All of the above plus poor diet.
It usually takes a combination of factors to start the erosion but things like carbon, high bacterial load in the water, or even hexamita protozoans can be present without causing hith.
I was just reading a day or so ago about a study where hith lesions were swabbed and cultured and every case had hexamita present while a strong majority also had necrotic bacteria present. since it takes seperate meds to cure these that might explain why it is so hard to cure.