Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2012 39; 217–225

Review Article

Tooth wear and wear investigations in dentistry
of Otago, Dunedin, New Zealand Department of Oral Rehabilitation, Faculty of Dentistry, University


wear has been recognised as a major problem in dentistry. Epidemiological studies have reported an increasing prevalence of tooth wear and general dental practitioners see a greater number of patients seeking treatment with worn dentition. Although the dental literature contains numerous publications related to management and rehabilitation of tooth wear of varying aetiologies, our understanding of the aetiology and pathogenesis of tooth wear is still limited. The wear behaviour of dental biomaterials has also been extensively researched to improve our understanding of the underlying mechanisms and for the development of restorative materials with good wear resistance. The complex nature of tooth wear indicates challenges

for conducting in vitro and in vivo wear investigations and a clear correlation between in vitro and in vivo data has not been established. The objective was to critically review the peer reviewed Englishlanguage literature pertaining to prevalence and aetiology of tooth wear and wear investigations in dentistry identified through a Medline search engine combined with hand-searching of the relevant literature, covering the period between 1960 and 2011. KEYWORDS: tooth wear, wear in dentistry, wear studies, wear testing and worn dentition Accepted for publication 26 July 2011

Wear can be defined as the progressive loss of material from the contacting surfaces of a body, caused by relative motion at the surface (1, 2). Wear has been of interest in materials science and mechanical engineering for some time and wear testing is common practice for predicting the service time of a component. Wear has also been a topic of discussion in dentistry with several epidemiological studies indicating that tooth wear, especially erosion-related wear is increasing in the general population (3, 4). There have been a number of articles published regarding management and rehabilitation of the worn dentition of varying aetiologies (5, 6). Tooth wear is a complex, multifactorial phenomenon with the interplay of biological, mechanical, chemical and tribological factors (2). The amount of tooth wear depends on factors such as muscular forces, lubricants,
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patient diet habit and the type of the restorative material used (7). Of these, the dentist has the most control of the material selected (8) and thus a great deal of research has involved improving the wear properties of dental biomaterials and protecting natural teeth from excessive wear. The complex nature of tooth wear leads to difficulties in conducting wear studies. Although, in vivo wear studies would seem ideal to evaluate the wear behaviour of dental biomaterials, they are time-consuming, expensive (9) and the results scatter widely due to patient and dentist related factors (10). Most of all, the fundamental problem with the in vivo wear model is that it is impossible to isolate and vary key factors that may influence the wear process (11). On the other hand, an in vitro wear study allows precise control of the environment and variables, which influence the wear process of dental hard tissues and biomaterials (12). However, there is no universally accepted wear
doi: 10.1111/j.1365-2842.2011.02257.x

and malocclusion (27. In early stages. The aim of this review is to provide an insight to prevalence and aetiology of tooth wear and to scrutinise wear studies in dentistry including the problems with these studies. with up to 97% of the study cohort experiencing some tooth wear (15). The severity of tooth wear was not significantly associated with dietary factors. ‘wear studies’. one longitudinal study has demonstrated an association between tooth wear recorded at age 5 and molar tooth wear recorded at age 12 (22). 28). the results are not easily comparable due to the wide range of tooth wear indices used and the variation in diagnostic criteria (23). Ayers et al. However. but instead describe clinical manifestations of a number of underlying events (6). Numerous wear simulation devices. ‘wear testing’ and ‘worn dentition’ between 1960 and the present. However. only 5–7% of 1007 adults in the study exhibited severe tooth wear. Although numerous epidemiological studies seem to indicate that tooth wear is prevalent and increasing in the general population. Clinically. indicating a tendency for accumulative wear with age (19). testing method (10). developed for research purposes use different wear testing concepts and variables such as force. but dentine involvement was rare (16). This may be due to an increasing dental awareness. the prevalence of tooth wear was high (57%) in adolescents aged between 11 and 14 years. indicating that tooth wear is a clinical finding in all age groups. It is related to aging. nor do they imply the causative factor. The retrospective study by Bartlett examined study models over a median time of 26 months and reported slow progression of tooth wear in the study sample. but appeared to be related to early weaning from the breast. However. for which interventive restorative treatment was justified. in a cross-sectional study observed that tooth wear is common in adults. conducted a cross-sectional study to investigate the prevalence and severity of tooth wear in the primary dentition of New Zealand school children aged between 5 and 8 (20). The peer reviewed English-language literature was searched through the Medline search engine with the key words. one systematic review on prevalence of tooth wear in adults reported that the predicted percentage of adults presenting with severe tooth wear increases from 3% at age 20 years to 17% at age 70 years. ‘tooth wear’. contact geometry and lubrication make comparative analysis of wear data difficult (10). traumatic occlusion in the partially edentulous dentition. A high percentage Aetiology The terms attrition. Currently there is no agreed consensus on a universally acceptable tooth wear index for quantifying tooth wear (24). with increased interest in retaining teeth as opposed to having them extracted (14). there appears a small polished facet on a cusp tip or slight flattening on an ª 2011 Blackwell Publishing Ltd .218 A . It was emphasised that tooth wear is a lifelong cumulative process and should be recorded in both the primary and permanent dentitions. These terms. Attrition is defined as a gradual loss of hard tooth substance from occlusal contacts with an opposing dentition or restorations (27). abfraction and erosion have been used interchangeably to describe the loss of tooth structure and dental biomaterials (2). A recent systemic review on prevalence of tooth wear in children and adolescents has indicated that the prevalence of tooth wear leading to dentine exposure in deciduous teeth increases with age. 13). but may be accelerated by extrinsic factors such as parafunctional habits of bruxism. (82%) of children had at least one primary tooth with dentine exposure. occlusal wear attributable to attrition will produce equal and matching wear facets on opposing teeth. Data from prevalence studies have demonstrated high levels of tooth wear in adults (15). adolescents (16) and children (17). ‘wear in dentistry’. while wear of permanent teeth in adolescents does not correlate with age (21). L E E et al. These factors complicate the evaluation of whether a true increase in prevalence is being reported (25) and therefore conclusion from prevalence studies should be considered with caution (26). abrasion. however are not in themselves descriptive of the wear process. In a study from the United Kingdom. Smith and Robb. Tooth wear Prevalence It has been recognised that tooth wear is a clinical problem that is becoming increasingly important in the aging population (2. suggesting that progression of tooth wear is not inevitable (18). A manual hand search was also conducted through the literature to identify relevant dental journals.

36). It was observed that patients with a flat condylar eminence tended to have significant posterior interferences. Erosive lesions present as a smooth concave defect in the early stage. while the mandibular teeth are protected from the erosive effect by the tongue and saliva (32). independent of occlusal contact (36). 30). Instead of occurring at the temporomandibular joints. 33). Abrasion is the loss of tooth substance through mechanical means. 34. causing flattening of posterior teeth. or exogenous from acidic foods and drinks (42). Dental erosion is defined as loss of tooth structure by a nonbacterial chemical process (29. it tends to produce significant tooth surface loss on the lingual and occlusal surfaces of teeth. In the case of the anterior open bite. which may result in an increased rate of wear (29. Tooth wear may involve the entire dentition (generalised) or be localised to anterior or posterior teeth. there have been no experimental studies that have confirmed the relationship between the angle of the condylar eminence and posterior teeth contact and moreover. the term erosion will be used to denote chemical dissolution of teeth or restoration. posterior occlusal contacts become the fulcrum point with greater forces applied to the anterior teeth. One longitudinal study demonstrated that increased incisal wear correlates with horizontal overjet and vertical overbite. 40. such as from gastric reflux. . Many authors agree that the aetiology is multifactorial and the term. time. the distribution and wear pattern of erosion is specifically associated with the origin of the acid and the posture of the head when the acid is present (32. while in the advanced stage. controversy remains regarding the relationship between functional occlusal contact and tooth wear (34. On the other hand. while severe attrition leads to dentine exposure. restorations may project above the occlusal surface and the cusps on premolars and molars exhibit concavities known as cupping (29). patients with bulimia or gastric reflux. One author has proposed that the steepness of the condylar eminence has a significant effect on the development and occurrence of posterior interferences during mandibular movement (32. Therefore. 34).TOOTH WEAR incisal edge. and the term ‘corrosion’ has been advocated to correctly describe the process of tooth surface loss due to chemical or electrochemical action (28. 36). The source of acid can be endogenous. 32). Some forms of abrasion may be associated with habit or occupation. where no occlusal contact exists between the maxillary and mandibular anterior teeth. such as a rounded ditch on the cervical aspects of teeth due to vigorous horizontal toothbrushing or incisal notching caused by pipe smoking or nail biting (28. the occlusal condition influences the quantity and distribution of the tooth wear pattern. As intrinsic acid enters the oral cavity from the eosophagus. the lingual surfaces of the maxillary anterior teeth are severely affected. depending on the causative factor of the tooth wear. The site and pattern of abrasion wear can be diagnostic as different foreign objects produce different patterns of abrasion wear (27). In attrition. 41). 33). greater wear is anticipated on the posterior teeth than on the anterior teeth (33). 39). and the ratio between these. For instance. However. 30). The most common cause of dental abrasion found in the cervical areas is toothbrushing and the severity and distribution of toothbrushing abrasion wear may be related to brushing technique. can be used as predictors of attrition tooth wear of the maxillary and mandibular incisors (43). patients with steep condylar eminences have minimal posterior interferences and hence little or no posterior wear. bristle design and the abrasiveness of the dentifrice (27. 41). extrinsic acid often results in erosive wear on facial and occlusal surfaces of teeth by its nature of entering the oral cavity from the anterior aspect. Some authors have proposed that tensile and compressive stresses from mastication and malocclusion play a major role in the formation and progression of wedge-shaped abfraction lesions (37). disagree with the term erosion due to its remarkably different meaning between dentistry and engineering tribology (13). the anterior guidance as determined by the overbite and overjet. However. non-carious cervical lesion (NCCL) is preferred to describe the loss of tooth substance at the cementum–enamel junction without bacterial involvement (38. the true aetiology of abfraction lesions has been controversial as other causative factors such as abrasion and erosion have been considered in the development of these lesions ª 2011 Blackwell Publishing Ltd 219 (38. On the other hand. It has been suggested that progressively greater loss of tooth structure occurs towards the anterior teeth. due to leverage changes produced by eccentric posterior interferences (31. 35). Abfraction is a relatively new term that describes loss of hard tooth substance in the cervical region as a result of crack formation during tooth flexure (11. Some authors however. frequency. In this review.

13). suggested that the aetiology of clinical wear may be considered in terms of site.e. The total duration of the masticatory cycle was reported to be approximately 0Æ70 s (49. Some testing devices incorporate unidirectional sliding movement of mastication. where the specimen slides in one direction for a specified duration. in which the teeth are brought close together and the food particles become trapped between the tooth surfaces. (2)]. lubricant. 51). Although research into tooth wear has grown considerably over recent years. smoking. Tooth wear mechanisms and their interactions [from Mair et al. 50). load. originally established to sharpen teeth (46). This method uses a simple relative movement between the wear pair and gives relatively quick results (53). timing and underlying wear mechanism rather than nomenclature (Fig.220 A . and these conditions occur during non-masticatory movement in the mouth (11. antagonist. and these periods amount to 15–30 min of contact loading each day (11. rougher surfaces are more likely to trap food particles than smooth tooth surfaces. Among the many geometric designs. L E E et al. the open phase and the closed phase (2). 48). the teeth approximate from an open position to a position of a near contact (open phase). erosion and abfraction is difficult. it does not properly simulate the oral environment (48) and repeatability of results using the same condition (i. However. Bruxism is the action of grinding teeth without the presence of food (11). contact pressure. More complex in vitro wear testing devices have been developed to provide a more accurate simulation of the masticatory movement (55–57). Mastication is the action of chewing food and is composed of two phases. Wear investigation in dentistry In vitro wear testing Numerous wear testing devices have been developed to predict the clinical performance of many dental biomaterials. grinding occurs either with tooth-foodtooth contact (indirect) or direct tooth–tooth contact of the opposing teeth surfaces (47). This is followed by a closed phase. since these aetiological factors may act synchronically or additively with other entities masking the true nature of tooth wear (29). . etc. cultural. our understanding of its aetiology and pathogensis is still lacking (45). Masticatory parameters such as the magnitude of the force and duration of the masticatory cycle vary widely among individuals and depend largely on the food type. contact geometry. Thegosis is defined as the action of sliding teeth laterally and it has been proposed that this is a genetically determined habit. and some simulation devices include abrasive slurries to replicate this as three-body wear (12. The occurrence and pattern of tooth wear is closely associated with educational. dietary. sliding speed) is poor (54). abrasion. 12). whilst the mean duration of the occlusion is about 0Æ10 s. Following compression and crushing of the food bolus. displacement. a pin-on-disk wear-test rig has been commonly used to simulate twobody wear between the sample and the antagonist (52. Differentiation among attrition. Mair et al. DeLong and Douglas in the early 1980s developed an ‘artificial oral environment’ which simulates the physiological movement of the oral cavity through two ª 2011 Blackwell Publishing Ltd Thegosis Bruxism Mastication (closed phase) Habits (pipe. 1. Initially. During mastication. 1) (2). but they differ in the degree of complexity and use different variables including force. Most of the wear simulation devices are used for two-body wear testing. and the abrasive particles are suspended and free to move in the food (slurry). However. and cycles (12. in which the surfaces move against each other in direct contact. after which it is repositioned to its original position (55). and thus no single occlusion-based treatment protocol can be recommended in the management of attrition (44). a correlation between attrition and other occlusal parameters has not been reported. occupational and geographic factors in the population (27).) Mastication (opened phase) Toothbrushing Direct tooth contact Indirect Contact (trapped particles) Slurry effects (suspended particles) Wear at sites of occlusal contact Wear at contact free sites Chemical effects Fig. food particles present in the mouth play an important role in the wear of teeth and dental biomaterials. Entrapment of food particles is largely influenced by textural characteristics of the surfaces. size of food bolus and chemical and physical action of saliva (13. 13). 53).

62). Heintze et al.TOOTH WEAR servo-hydraulic units that control horizontal and vertical movements (58). The composition of food simulation slurry varies widely in different studies. and in the specification. However. contact area and contact geometry. 68). using the Hertz theory in contact mechanics. structural integrity and patient satisfaction after a certain period of use (70). temperature. to investigate the influence of food particles on wear behaviour of dental biomaterials (51. Some authors have also incorporated abrasive discs or slurries in the wear testing devices. subjective performance assessment of the material and quantitative measurement of wear (9). have investigated the wear resistance of 10 restorative dental materials (eight composite resins. intraoral photographs and tooth wear indices that can be used alone or in combination to identify morphological changes of teeth over time (71. In vivo wear testing An in vivo wear investigation of dental biomaterials usually encompasses two parts. This includes the factors that influence the wear of dental biomaterials. In 2001. Numerous indices have been developed for use in clinical studies and most are based on numerical grades to quantify the amount of hard tissue loss (25). The authors suggested that varying the wear simulation device settings results in measuring different wear mechanisms and thus care must be taken when interpreting and comparing the results of in vitro wear data. and artificial saliva. material wear can be influenced by various factors including load. The Smith and Knight tooth wear index is the most frequently used index in the dental literature (19) and it records wear on all four surfaces (buccal. This is accompanied with quantitative wear measurement using various methods including study casts. Some indices such as the Basic Erosive Wear Examination (BEWE) or the classification for dental attrition investigate one aetiological factor. a universally acceptable tooth wear index has yet to be found (24) and new indices are continually being designed and applied in clinical . combined with the various methª 2011 Blackwell Publishing Ltd 221 ods used in the past makes it difficult or even impossible to compare in vitro wear data. gingival health. cornmeal grit and wholemeal flour in distilled water (63) and polymethyl methacrylate beads (62). The lack of an internationally acceptable in vitro method for evaluating wear behaviour of dental biomaterials. For example. attrition or abrasion (75–77). the specification did not provide any information about validity or accuracy of the testing methods and whether the testing devices with which the methods were conducted were qualified for that purpose. an amalgam and a ceramic) using five different wear simulation methods in order to validate the compatibility of different wear simulation devices (64). They compared their simulative wear data on amalgam. Physiological conditions of the oral cavity are reproduced by controlled setting of the biting force. that produces physiological movements or a force pattern similar to the oral environment. such as ground rice in phosphate buffer (51). 66). 12).and ⁄ or three-body contact’. However. the ballon-disk experimental design is becoming popular to investigate and compare the wear mechanisms of dental biomaterials (67. Tooth wear indices are the most popular method of quantifying wear over a long period of time as they are readily available and do not require special equipment (73). The limitations and issues of in vitro wear studies in dentistry have been addressed elsewhere (10. The relative ranking of the tested materials varied significantly between the different wear testing methods. The clinical performance of a restoration is assessed based on specified criteria such as marginal adaptation. The current trend with in vitro wear studies has shifted from developing a physiological wear simulator to identifying the underlying wear mechanisms. using some of the concepts used in mechanical engineering (tribology) and physics (65. Understanding the in vitro wear propensity of a dental restorative material will help researchers and clinicians predict the response of a particular material in a clinical setting (69). cervical. eight different wear testing methods were described (10). Also. composite resin and dental porcelain with clinical data and found a good correlation between them (59–61). lingual and incisal–occlusal). Despite the development of sophisticated and complex wear simulators. however there are no standard oral conditions (48). 72). specific for erosion. the International Standard Organisation (ISO) published a technical specification termed ‘wear by two. Sajewicz and Kulesza argued that the emphasis in previous in vitro wear studies has been on the development of a wear simulator. a clear correlation between in vitro and clinical data has not been established (11) and the clinical performance of dental biomaterials cannot be precisely predicted. irrespective of the aetiology of tooth wear (Table 1) (74).

Long-term monitoring is essential for assessing the effectiveness of preventive measures taken and any further progression of the wear before embarking on interventive treatment. incisal loss of enamel. diet and parafunctional habit is crucial for diagnosis and treatment planning (27). a lifelong approach to management should be undertaken rather than short-term interventive treatment measures (85). and occlusal loss of enamel. severity of wear and potential for progression of the wear (86).222 A . lingual. 3D laser scanning can be used to scan the surface of a replica to construct a 3D image for quantifying the wear more accurately (81). L E E et al. exposing dentine for less than 1 ⁄ 3 of the surface. Study casts are a valuable diagnostic tool for monitoring progression of tooth wear and quantifying the amount of wear (18). each individual represents a variable and this confounds the interpretation of wear results (11). exposing dentine for more than 1 ⁄ 3 of the surface. Since tooth wear is a progressive phenomenon that affects the dentition throughout life. Al-Omiri et al. compared the reliability of three different methods to detect incisal wear over a 6-month period. a tool maker microscope for micromeasurement applications and a conventional tooth wear index (Smith and Knight wear index) (73). Silicone impressions of teeth or restorations are taken at regular intervals to make replica models in stone or epoxy resin. claimed that many of the deviations in the results occur due to an inaccurate replica technique. restricting their use in everyday dental practice (82). in a recent review claimed that there are too many indices with a lack of standardisation in terminology. If the cause of tooth wear is related to medical conditions such as severe erosive tooth wear induced by eating disorders. occupation. Tooth wear index [from Smith and Knight (74)] Criteria 0 1 2 No loss of enamel surface characteristics Loss of enamel surface characteristics Buccal. substantial loss of dentine Buccal. and occlusal loss of enamel. The methods used were a CAD–CAM laser scanning machine. the medical management of these causes must be coordinated by the general medical practitioner in concert with dental treatment (45). a thorough clinical examination including a medical and dental history. uncontrolled wear is occurring that is altering the occlusal vertical dimension with functional and aesthetic deficit (85). measurements can be taken to standardise the testing conditions among the participants. Therefore. However. lingual. The quantity and positional wear pattern are pathognomonic of the causative factor and thus the clinician should carefully observe the wear patterns on diagnostic casts in order to differentiate various causes and confirm the diagnosis (31). or progressive. repositioning problems and restrictions of the measuring devices (84). resulting in difficulty in interpreting and comparing the results of many of the epidemiological studies (25). which are then compared for quantitative analysis (9). incisal pulp exposure or exposure of secondary dentine 3 4 regime and toothbrushing. In addition. studies (78). the sensitivity of measurement and replica techniques are an important consideration (11). Restorative treatment is indicated when the patient presents with clinical symptoms such as tooth sensitivity or pain that cannot be controlled conservatively. With advancement in measuring techniques. Table 1. Measurements can be recorded by using a number of methods including stylus or laser profilometry (79) and stereomicroscopy images and computerised image fitting (80). Bardsley. Although. The articulated study casts and a diagnostic ª 2011 Blackwell Publishing Ltd . lingual. However. pulp exposure. It was found that the tooth wear index was the least sensitive for tooth wear quantification and was unable to identify wear progression in most cases. such as the dietary Clinical management of worn dentition Considering the multifactorial nature of the tooth wear process. minimal dentine exposure Buccal. gastric problems or alcoholism. and occlusal complete loss of enamel. new sophisticated measuring tools are costly and require specialised hardware and software. or exposure of secondary dentine. Early diagnosis and appropriate prevention measures can avoid the complicated restorative treatment in the future (18). Lambrechts et al. the fundamental problem with in vivo wear studies is the inherent patient factor (83). The restorative treatment decisions should be based on the patients’ needs. despite improved accuracy and reliability. appropriate training and calibration are important to minimise subjective errors and a combination of methods should be used for a more reliable quantitative analysis. incisal loss of enamel.

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