Arie van ’t Spijker Attrition, occlusion, (dys)function, and

Cees M. Kreulen
Nico H. J. Creugers
intervention: a systematic review

Authors’ affiliation: Key words: attrition, bruxism, (dys)function, occlusion, systematic review, TMD, tooth wear
A. van ’t Spijker, C. M. Kreulen, N. H. J. Creugers,
Department of Oral Function and Prosthetic
Dentistry, College of Dental Science, Radboud Abstract
University Nijmegen Medical Centre, Nijmegen, Objectives: Attrition and occlusal factors and masticatory function or dysfunction are
The Netherlands
thought to be related. This study aims to systematically review the literature on this topic
Correspondence to: with the emphasis to find evidence for occlusion-based treatment protocols for attrition.
Nico H. J. Creugers DDS, PhD
Materials and methods: Literature was searched using PubMed (1980 to 2/2006) and the
Department Oral Function and Prosthetic
Dentistry, Dentistry 309 Cochrane Library of Clinical Trials with the keywords ‘tooth’ and ‘wear’. Five steps were
Radboud University Nijmegen Medical Centre followed. Exclusion was based on the following: (1) reviews, case-reports, studies on non-
PO Box 9101
6500 HB Nijmegen human tooth material, and studies not published in English and (2) historical or forensic
The Netherlands studies. Included were (3) in vivo studies. Next, studies on (4) occlusal factors, function or
Tel.: þ 31 24 3614004
Fax: þ 31 24 36541971
dysfunction [temporomandibular disorders (TMD), bruxism], or intervention, and (5)
e-mail: n.creugers@dent.umcn.nl attrition were included. Two investigators independently assessed the abstracts; measure of
agreement was calculated using Cohen’s k; disagreement was resolved by discussion. Full-
text articles were obtained and correlation between outcomes on occlusal factors,
(dys)function, treatment, and attrition were retrieved. References in the papers included in
the final analysis were cross-matched with the original list of references to add references
that met the inclusion criteria.
Results: The search procedure revealed 1289 references on tooth wear. The numbers of
included studies after each step were (1) 345 (k ¼ 0.8), (2) 287 (k ¼ 0.87), (3) 174 (k ¼ 0.99), (4)
81 (k ¼ 0.71), and (5) 27 (k ¼ 0.68). Hand searches through the reference lists revealed six
additional papers to be included. Analysis of the 33 included papers failed to find sound
evidence for recommending a certain occlusion-based treatment protocol above another in
the management of attrition.
Conclusion: Some studies reported correlations between attrition and anterior spatial
relationships. No studies were found suggesting that absent posterior support necessarily
leads to increased attrition, though one study found that fewer number of teeth resulted in
higher tooth wear index (on the remaining teeth). Attrition seems to be co-existent with
self-reported bruxism. Reports on attrition and TMD signs and symptoms provide little
understanding of the relationship between the two.

To cite this article:
van ’t Spijker A, Kreulen CM, Creugers, NHJ. Attrition,
occlusion, (dys)function, and intervention: a systematic
review.
Clin. Oral Impl. Res. 18 (Suppl. 3), 2007; 117–126
doi: 10.1111/j.1600-0501.2007.01458.x
Extensive tooth wear is considered a poten-
tial threat to functional dentition. The
management of tooth wear, especially
from attrition, is becoming a subject of
increasing interest in the prosthodontic
literature, both from a preventive [how to
stop the progress of tooth substance loss
(TSL)] and from a restorative point of view
(how to replace the lost tooth substance
and to restore function).
By definition, attritional wear is the loss
of tooth tissue due to friction between

c 2007 The Authors. Journal compilation

c 2007 Blackwell Munksgaard 117
van ’t Spijker et al . Attrition, occlusion, (dys)function and intervention
opposing teeth and is thus related to dental
occlusion. In a classical paper on attrition,
Berry & Poole (1976) considered TSL to be
a normal ageing process, in which depos-
itioning of secondary dentine, alveolar
growth, muscle adaptation, and attrition
are all part of a compensation mechanism.
They stated that ‘if this concept is right,
then attrition, whatever its extent, can
never be excessive’ (Berry & Poole 1976).
However, loss of tooth tissue usually affects
the dental occlusion and it is still disputed
whether a changing occlusion could be
ignored in the management of dental pro-
blems such as ‘extensive’ attrition or tem-
poromandibular disorders (TMD).
The role of occlusion as a key factor in
the treatment of mutilated dentitions is
less disputed. Although almost completely
empiric-based, occlusal concepts are will-
ingly used in both conservative dentistry
and prosthodontics to compass the restora-
tive process of broken down or worn teeth
and dentitions. The scientific evidence of
the use of occlusal concepts and the knowl-
edge regarding the role of occlusal factors in
(the management of) tooth wear is frag-
mented and ambiguous, as is the relation-
ship between (management of) tooth wear
and (dys)function.
In the management of tooth wear, the
prosthodontist has to make decisions re-
garding the need for treatment, treatment
procedures, materials’ choice, and occlusal
concepts. With regard to treatment need it
has been advised that tooth wear should be
diagnosed early and treated timely ‘to pre-
vent the tooth from wear beyond a point of
acceptable restoration’ (Dawson 2007). In
contrast, careful monitoring has been ad-
vised above early treatment because the
progress of tooth wear might fluctuate
(Seligman & Pullinger 1995; Smith &
Robb 1996). Regarding treatment proce-
dures and materials’ choice, a wide varia-
tion of options has been proposed in the
dental literature, most of it in textbooks,
case reports, or clinically oriented reviews.
Besides the traditional prosthodontic re-
storations used in oral rehabilitation, direct
and indirect composite restorations (Briggs
et al. 1994; Yip et al. 2003), bonded cast
metal restorations (Watson 1997; Chana
et al. 2000), implant-supported removable
partial dentures (Briggs & Bishop 1997),
orthodontic treatment (Evans 1997), and
(protective) splints (McIntyre 2000) have
118 | Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 117–126
been proposed. Yet, no evidence is available
for choosing one of these treatment options
above another.
The purpose of the present study was to
systematically assess relationships, if any,
between attrition and occlusal factors and
oral (dys)function in terms of management
of attrition. More specifically, the aims were
(1) to find and assess evidence from the liter-
ature for patients with attrition and TMD
regarding choice of intervention, (2) to map
evidence addressing occlusion-based protocols
and occlusal factors in the management of
attrition, and (3) to find evidence for defining
a certain threshold, at which interventions
are indicated in subjects with attrition.
The null-hypothesis was the literature
provides no sound evidence justifying the
qualification of certain occlusion-based in-
terventions above others in the manage-
ment of attrition.
Material and methods
This systematic review is characterized by
four major elements: literature search, in-
clusion/exclusion of papers, extraction and
grouping of study outcomes, and outcome
analysis.
Literature search
The literature was searched using PubMed
with limitation of publication year from
1980 up to February 2006 as well as the
Cochrane Library of Clinical Trials. Key
words used in the literature search were:
‘tooth’ in combination with ‘wear’.
Inclusion/exclusion of papers
From this dataset, references were selected
with ‘wear of human tooth tissue’ as the
study subject. Two independent readers (A.
V. S., N. H. J. C.) selected references to be
included on the basis of abstracts. The
search was not limited to randomized-
controlled trials (RCTs). Excluded were
reviews, case reports, comments, and
references in which wear other had mean-
ings than loss of tooth tissue. References to
non-English articles were also excluded. If
abstracts were not available in PubMed,
original published articles were obtained.
Observer agreement was analysed and dis-
agreements were resolved by discussion.
Second, references that were identified
as ‘historical studies or forensic’ were ex-
cluded. A reference was considered ‘histor-
c 2007 The Authors. Journal compilation


c 2007 Blackwell Munksgaard
ical’ if the material studied was a non-
living human material (e.g., skulls). In a
third step, references to in vivo studies
were included while in vitro and in situ
studies were excluded. The fourth step
emphasized on including studies that in-
vestigated relationships of tooth wear with
either (1) occlusal factors (including ‘occlu-
sal designs for oral reconstruction’), (2)
function or dysfunction (TMD, bruxism),
and (3) intervention or dental treatment
history. Also, studies investigating indica-
tion thresholds for restorative vs. non-re-
storative intervention were included. In the
fifth step, only studies providing outcome
data on attrition were included to the final
dataset. References in the papers included
in the final analysis were cross-matched
with the original list, adding further refer-
ences that met the inclusion criteria. Ob-
server agreement was analysed for each
step and again disagreements were resolved
by discussion.
Grouping and extraction of study
outcomes
From the papers that resulted after step 5,
full-text versions were obtained and read.
The reviewers classified the papers inde-
pendently according to the different study
topics in four categories: (1) occlusal para-
meters, (2) functional parameters (includ-
ing TMD or bruxism), (3) intervention or
treatment history, and (4) threshold values
for treatment of attrition. Information re-
garding study design, research questions,
populations under investigation, measure-
ment methods, and study outcomes were
extracted. Final classification was based on
consensus between reviewers and in case of
disagreement a third reviewer (C. M. K.)
was the mediator.
Assessment of study outcomes and
statistical analysis
For all steps, Cohen’s k coefficient was
used as a measure of agreement between
the two reviewers. Study outcomes were to
be pooled, but only a qualitative assess-
ment was achievable. Correlations be-
tween parameters and outcome (attrition)
were retrieved.
Results
The PubMed search resulted in a list of
1289 references. A total of 345 references
 van ’t Spijker et al . Attrition, occlusion, (dys)function and intervention

et al. 1987; Ekfeldt et al. 1990; Carlsson

Dataset Pubmed search 1289 et al. 2003) dealt with both occlusal and
functional parameters and were therefore
Step 1 Kappa = 0.80 ± 0.02 included in both sub-sets. Another two
944 Excluded: reviews, comments,
case reports, non-English articles studies (Bauer et al. 1997; Witter et al.
2001) addressed research questions related
Included: wear of human to occlusal parameters in dental situations
tooth tissue 345
resulting from active dental treatments.
For practical reasons, these studies were
Step 2 Kappa = 0.87 ± 0.04
58 Excluded: historical and forensic studies allocated to the occlusal parameters group
only. No papers were identified investigat-
ing threshold values of TSL, at which
287
interventions are indicated in subjects
with attrition.
Step 3 Kappa = 0.99 ± 0.01
113 Excluded: in vitro and in-situ studies The studies selected for the category
occlusal parameters showed large heteroge-
neity in study design, sample composition,
Included: in vivo studies 174
research question, and measurement
method (Table 1). As a result, pooling of
Step 4 Kappa = 0.71 ± 0.05 Excluded: studies not dealing with outcome data was not possible. Only few
93 occlusion, TMD, bruxism, or intervention
correlations between attrition and occlusal
parameters were reported. No correlation
Included: occlusion, TMD,
bruxism, and intervention 81 between anterior attrition and absent pos-
terior teeth was reported; only some statis-
Step 5 Kappa = 0.68 ± 0.08 tical correlations were found for specific
53 Excluded: no outcome data on attrition
sub-samples (Smith & Robb 1996; Witter
et al. 2001). However, differences were
Included: outcome data on attrition 27 small and considered clinically irrelevant.
One study found a correlation between
reduced number of teeth and increased
10 Papers via hand search of reference lists
tooth wear on the remaining teeth (Ekfeldt
et al. 1990) Associations between attrition
4* Excluded: no outcome
and anterior (spatial) relationships were
data on attrition reported in several studies, although some
of them appear to be contradicting (Table 1).
Studies included in the analysis 33 6 Included: outcome data on attrition The studies investigating functional
parameters in relation to attrition also
showed large heterogeneity, making mean-
ingful aggregation of outcome data impos-
sible (Table 2). Kim et al. (2001) was the
11 21 4 0 only report addressing ‘normal’ function.
All other reports in this category dealt with
Occlusal parameters Functional parameters Intervention/others Threshold values for intervention TMD or bruxism and as such they were
considered addressing dysfunction. A few
Fig. 1. Flowchart describing the results of each step in the selection procedure. *Excluded papers: Krogstad
trends could be distinguished. Seven stu-
et al. (1985), De Boever et al. (1987), Agerberg et al. (1989), Poynter et al. (1990).
dies reported positive correlations between
were entered in the tooth wear dataset them dealing with functional parameters attrition and self-reported bruxism. Two
containing studies addressing wear of hu- and attrition (Droukas et al. 1984; De studies including self-reported bruxism re-
man tooth tissue. Search of the Cochrane Laat et al. 1986; Seligman et al. 1988; ported no such correlation. Another study
Library of Clinical Trials did not reveal Runge et al. 1989; Ekfeldt et al. 1990; reported no significant correlation between
further relevant papers. The complete Pintado et al. 1997). Finally, 11 articles attrition and clinically diagnosed bruxism.
selection procedure resulted in the inclu- reporting data on attrition and occlusal Nine studies reported relationships be-
sion of 27 articles (Fig. 1). Observer agree- parameters, 21 articles with data on attri- tween attrition and clinically diagnosed
ments ranged from 0.68  0.08 (fair) to tion and functional parameters, and four TMD, of which three demonstrated posi-
0.99  0.01 (very good). Hand search articles evaluating intervention or treat- tive correlations and one reported a nega-
through the reference lists revealed six ment effects were subjected to further ana- tive correlation. Four studies reported no
additional papers to be included, all of lysis. Three studies (Egermark-Eriksson such correlations. Another study presented

c 2007 The Authors. Journal compilation

c 2007 Blackwell Munksgaard 119 | Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 117–126
120 |
Table 1. Studies investigating relationships between attrition and occlusal factors
Correlations between tooth wear and
Overbite Number Occlusal Others

values
r/r/OR
Level of

Number
of teeth guidance

Remarks

ðcontrolsÞ

ðcontrolsÞ
% female

risk factor
Age group

of subjects

Anticipated

References
Tooth wear
Tooth wear
scheme

significance

Study design
scale ðlevelsÞ

measurement

Subject selection
+/++
Carlsson L Population-based Bruxism, oral 320 52 YA I 5 w w 1 þ1 OR 0.26 Less anterior tooth wear with non-working
et al. (2003)n parafunctions side contacts. More posterior tooth wear
with more horizontal overjet
Witter L Dental school Shortened 74 (72) 60 (51) A I 4 w 0 w w No overall differences between shortened
et al. (2001) patients dental arche dental arches and complete dental arches.

Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 117–126

Shortened dental arches existing over 15
years show more wear in premolars
w ++
Bauer C Orthodontically Anterior 85 38 YA þ A I þ II 4 w 1 w Unspecified Less posterior tooth wear with anterior
et al. (1997) treated guidance guidance
for anterior
van ’t Spijker et al . Attrition, occlusion, (dys)function and intervention

wear
Smith & C Population-based Absent posterior 1007 ? YA þ A þ E I 5 w þ1 w w r ¼ 0.2–0.51 ? Only small, clinically not significant
Robb (1996) teeth differences between subjects with or
without absent posterior teeth
+
Seligman & C Dental school Canine attrition 148 32 YA þ A II 5 w w w þ1 r ¼ 0.45–0.58 Correlations between canine wear and total
Pullinger patients þ posterior tooth wear for ageso50 years; not

(1995) private for  50 years
practice
patients
Abdullah C Dental students Excursive contact 64 47 YA I þ II 4 w w 0 w Correlations between posterior þ anterior
et al. (1994) schemes tooth wear and anterior guidance were not
significant
+
Johansson C Dental students Excursive contact 80 44 YA I þ II 4 w w  1/0/ þ 1 w Unspecified With anterior protrusive guidance: more
et al. (1994) schemes anterior tooth wear and less posterior tooth
wear. No correlations between wear and
lateral excursive schemes
+++
Silness L Dental school Vertical overbite 51 45 O þ YA II 3 þ1 w w w Unspecified More incisal tooth wear with more vertical
et al. (1993) patients and horizontal overbite
overjet
Crothers & C Referrals wear Vertical 35 (40) 23 (55) YA þ A III mm w w w 0 No relation between tooth wear and total

c 2007 The Authors. Journal compilation

Sandham clinic dimensional facial height. Vertical dimension of
(1993) responses occlusion compensated by vertical dento-
alveolar height change
+++
Ekfeldt C Population-based Number 87 (133) ? YA þ A þ E IV 4 w 1 w w r2 ¼ 0.29 The fewer number of teeth, the higher the
et al. (1990) of teeth tooth wear index. Number of occluding
teeth was measured but not reported

c 2007 Blackwell Munksgaard

 van ’t Spijker et al . Attrition, occlusion, (dys)function and intervention
positive correlations for some sub-samples
wear; unilateral contact in RCP: more tooth
More vertical deviation RCP-IP: more tooth of TMD, but not for others. Five studies in
this category were based on self-reported
TMD symptoms. Of these, two reported a
positive correlation between attrition and
TMD pain; one reported no such correla-
tion in their results. One study reported a
relationship between attrition and tempor-
omandibular joint (TMJ) clicking and an-
other reported no correlation between
attrition and symptoms of TMD.
wear
From the intervention/treatment studies
(Table 3), only one had a prospective study
Tooth wear measurement: I, clinical examination; II, cast examination; III, cephalometric lateral skull radiographs; IV, clinical examination þ validation by casts.
+++
design reporting less attrition in subjects
(young children) wearing bites plates com-
r ¼ 0.24
pared with subjects who did not wear these
Age-groups: Ch, children ( 11 years); O, adolescents (12–18 years); YA, young adults (19–30 years); A, adults (31–64 years); E, elderly ( 65 years).
devices (Hachmann et al. 1999). This find-
ing was affirmed by Carlsson et al. (1985)
who followed subjects with severe attrition
and found splint treatment in these sub-
þ1
jects to slow down the rate of tooth wear.
Two studies were retrospective analyses
reporting on relationships between tooth
w
wear and treatment history. Orthodontic
treatment history was not associated with
attrition (Dahl et al. 1989), whereas exten-
w
sive restorative treatment and treatments
including extraction of teeth seemed to
þ 1, positive correlation; 0, no correlation;  1, negative correlation; +Po0.05; ++Po0.01; +++Po0.001.
increase the risk for tooth wear (Dettmar
w
& Shaw 1987). No studies were found
addressing interventions at certain thresh-
5
old values of attrition. One of the included
papers (Smith & Robb 1996) mentioned
I
threshold values, but only in relation with
Ch þ O
the prevalence of tooth wear.
49
Discussion
240
The papers included in this review demon-
strated that research on tooth wear is a
complex undertaking. It appeared that it
factors/TMD/
is difficult to quantify the amount of TSL
bruxism
Occlusal
Study design: L, longitudinal; C, cross-sectional.
in a practical way for larger groups of
subjects; hence, there is no consensus on
Reports based on same (original) samples.
?, not described, unknown, unspecified.
how to measure tooth wear clinically. The
L Population-based
studies included made use of tooth wear
scales ranging from two to eight levels.
Very few studies actually measured wear.
Relating attrition to other dental factors
appeared to be even more complex.
wNot investigated.
The measurement methods determining
mm, millimetre.
et al. (1987)n
occlusal factors as well as the diagnosis of
functional and dysfunctional ‘use’ of the
Egermark-
Eriksson
dentition as described in the studies
showed extensive variation. For example,
n
some studies used anamnestic criteria
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c 2007 Blackwell Munksgaard 121 |
while others used research diagnostic cri-
teria (RDC/TMD) to diagnose TMD. In
other cases, the used measurement meth-
ods were not validated. Moreover, it seems
to be impossible to isolate specific antici-
pated risk factors from others, which hin-
ders proper investigation of the multi-
factorial phenomenon of TSL.
The literature on attrition does not pro-
vide clear evidence for the efficacy of parti-
cular occlusal designs in the management
of attrition. No intervention studies addres-
sing this topic were found. Some support
was found in cross-sectional studies, indi-
cating that anterior (spatial) relationships
and attrition were related. As could be
expected, anterior guidance, which is par-
tially determined by vertical overbite and
horizontal overjet, seems to reduce the risk
for posterior attrition, but increases the risk
for anterior attrition. Clinically, canine
protection is advocated to ensure anterior
guidance with the purpose of diminishing
posterior TSL. In this review, one study
addressed this variable, demonstrating an
association between canine wear and pos-
terior wear (Seligman & Pullinger 1995). It
has to be emphasized that this was the case
for unrestored teeth and was therefore not
directly applicable for restored teeth. Based
on the literature though, a treatment strat-
egy to create canine guidance thus remains
unproven. The literature provides no data
regarding the amount of lost tooth tissue
due to attrition for different occlusal
schemes. Whether the occurrence of ante-
rior TSL is more or less a threat to the
dentition or its function than posterior TSL
remains a subjective issue.
The articles addressing the relationship
between attrition and the level of posterior
support found that decreased support does
not lead to more wear. Hence, there is no
justification for tooth replacement to pre-
vent TSL in the remaining dentition.
Nevertheless, the multi-factorial aetiology
of TSL is a too complicated a factor to draw
such conclusions.
Most studies identifying relationships
between attrition and functional or dys-
functional parameters, addressed the ques-
tion whether these parameters could be the
cause for attrition. Bruxism was identified
as an associative factor in dental attrition in
most of the studies. However, as all of
these associations were based on self-
reported bruxism, they are lacking a sound
Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 117–126
 Table 2. Studies investigating relationships between attrition and function, dysfunction (TMD) or bruxism

122 |
Remarks

ðcontrolsÞ
ðcontrolsÞ
diagnosis

% female

risk factor
Age-group

Anticipated
Tooth wear
Tooth wear

References
r/OR values

Study design
scale ðlevelsÞ
TMD/bruxism
TMD/bruxism

measurement
Correlation with

Subject selection
Number of subjects
Level of significance
Hirsch C Population- TMD 1011 52 Ch þ O I 3 S 0 No correlation between anterior tooth
et al. based wear and TMD pain
(2004)
Baba C Bruxers and Bruxism activity 8 (8) 50 YA II 8 D 0 No significant relationship between
et al. matched tooth wear and current bruxism
(2004) controls
++
Carlsson L Population- Bruxism, oral 320 52 YA I 5 S þ1 OR 12,5 Anterior tooth wear at 15 years of age
et al. based parafunctions predicts reported tooth grinding at
(2003)n night 20 years later

Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 117–126

Pergamalian C TMD History of 84 84 YA II 4 D 0 No correlation between tooth wear and
et al. diagnosed self-reported TMD pain. Tooth wear not correlated
(2003) subjects bruxism with reported bruxism
+++
Carlsson L Population- TMD signs and 320 52 YA I 5 S þ1 OR 4.3 Tooth wear at 15 years of age predicts
et al. based symptoms TMJ clicking 20 years later
van ’t Spijker et al . Attrition, occlusion, (dys)function and intervention

(2002)n at young age

John C Dental TMD 154 (120) 75 (63) O, YA, A, E II 6 D 0 Anterior tooth wear not significantly
et al. school associated with TMD
(2002) patients
with

diagnosed
TMD and
controls
+
Kim et al. C Dental Chewing 15 (15) 33 (33) YA I þ II 4 Grinding type more posterior tooth wear
(2001) students pattern than chopping type, no difference for
(grinding vs. anterior tooth wear
chopping)
+
Pintado L Dental Gender, 18 ? YA II mm/mm3 S þ1 D ¼ 0.05 Bruxers show more volume loss per time
et al. students diagnosed mm3 per period than non-bruxers
(1997) TMD year
+
Magnusson L Population- TMD signs and 84 45 YA I 5 S þ1 r ¼ 0.39 Tooth wear correlated with subjective
et al. based symptoms reports of nocturnal tooth clenching.
(1994)n Degree of tooth wear correlated with
TMJ pain on palpation and subjective
difficulties in mouth opening

c 2007 The Authors. Journal compilation

Pullinger & C Dental TMD 270 (148) 89 (32) YA þ A II 5 D Various Various Occlusal etiology role for attrition in TMD
Seligman school subgroups subjects remains questioned
(1993) patients þ
private
practice
patients
Goho & C School Wear facets in 50 (50) ? Ch I 3 D 0 No correlation between wear facets and
Jones children primary teeth clinical signs of TMD
(1991)

c 2007 Blackwell Munksgaard



Steele C Referrals Migraine 72 (31) 71 (71) All age groups I þ II 5 D 0 Migraine group not significant more
et al. pain patients wear than control group
(1991) clinic and
controls
+++
Ekfeldt C Population- Bruxism 87 (133) ? YA þ A þ E IV 4 S þ1 r2 ¼ 0.03 Higher prevalence of bruxisme in subjects
et al. based with tooth wear compared with
(1990) subjects without
+
Runge C Orthodontic TMJ sounds 226 54 OþA I 4 D þ1 Unspecified Association between reciprocal clicking
et al. patients and moderate to severe dental wear
(1989)
+
Seligman C Dental TMD 222 46 YA þ A II 5 D 0 Z0 ¼ 2.78– Dental attrition not associated with TMJ
et al. students symptoms S þ1 3.69 clicking. In male: attrition of canines
(1988) and premolars associated with
reported bruxism
+
Szentpetery C Population- TMD 600 53 All age groups I 2 D, S þ1 Unspecified Correlation between excessive tooth

c 2007 The Authors. Journal compilation

et al. based wear and dysfunction signs and
(1987) between excessive tooth wear and
reported bruxism
Roberts C Referrals Occlusal 205 ? ? I 4 D 0 No difference between tooth wear in
et al. TMD clinic factors for arthrogenic TMD diagnosed subjects
(1987) arthrogenic and subjects without arthrogenic TMD
TMD
+
Egermark- L Population- Occlusal 240 49 Ch þ O I 5 S þ1 r ¼ 0.23 Tooth wear correlated with reported
Eriksson based factors/TMD/ bruxism for ages 11 and 15 years. No
et al. bruxism correlation between tooth wear and

c 2007 Blackwell Munksgaard

(1987)n TMD
++
De Laat C Dental Occlusal 121 41 YA I þ II 2 S þ1 Unspecified More dental wear in subjects with
et al. students parameters reported bruxism. Dental wear
(1986)n for TMD correlated with muscle pain
+
Lieberman C Population- Dysfunction 369 49 Ch þ O I 3 D þ1 Unspecified Correlation between excessive wear and
et al. based symptoms dysfunction symptoms
(1985)
+
Droukas C Dental Occlusal 48 48 YA þ A I 4 D 1 r ¼  0.33 Negative correlation between attrition of
et al. students factors for S 0 premolars and clinical dysfunction
(1984) dysfunction index. No correlation between attrition
symptoms in and reported bruxism

123 |
a non-patient
group
n
Reports based on same (original) samples.
?, not investigated.
Not described, unknown, unspecified; study design: L, longitudinal; C, cross-sectional; S, self-reported; D, clinical diagnosis.
Age-groups: Ch, children ( 11 years); O, adolescents (12–18 years); YA, young adults (19–30 years); A, adults (31–64 years); E, elderly ( 65 years).
þ 1, positive correlation; 0, no correlation;  1, negative correlation; tooth wear measurement: I, clinical examination; II, cast examination.
+
Po0.05; ++Po0.01; +++Po0.001.
TSL, tooth substance loss; TMD, temporomandibular disorders; TMJ, temporomandibular joint.

Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 117–126

van ’t Spijker et al . Attrition, occlusion, (dys)function and intervention
van ’t Spijker et al . Attrition, occlusion, (dys)function and intervention

methodological basis (Lavigne et al. 1996).

Low incidence of severe tooth

results in more tooth wear
than in untreated subjects
yes/no orthodontic history
Heavily restored/extractions/
orthodontic þ extractions
Less tooth wear in children
The information on bruxism attained from

slow down rate of tooth

Tooth wear not related to

wear in general, splints

treated with bite plate
the subjects might not be reliable, because
many individuals are not aware of their
Outcome parafunctions (Magnusson et al. 1985).
One study concluded that attrition was
not increased in subjects with diagnosed

wear
bruxism (Baba et al. 2004), but due to the
small sample size and the short experimen-
tal period covered, this study might have
been insufficient for this conclusion.
Intervention study on efficacy

severe tooth wear patients

extractions) on tooth wear
With regard to possible associations
Effect of treatment history
(restorative/orthodontic/

Wear rate for moderate/

of nocturnal biteplate

between attrition and TMD signs and

Effect of orthodontic

symptoms, synthesis of study outcomes

is even more difficult. As time goes by,
Study purpose
TMD symptoms may vary. TSL on the
treatment

other hand has a cumulative character:

lesions do not heal but will stay constant
even if (some of the) aetiological factors
disappear. Comparing TMD patients with
non-patients in studies on TSL is therefore
mm2

Tooth wear
less accurate than often assumed. More-
2

scale ðlevelsÞ
Age-groups: Ch, children ( 11 years); O, adolescents (12–18 years); YA, young adults (19–30 years); A, adults (31–64 years).

over, the ‘degree of dysfunction’ is often

I þ II þ III

not measured, in contrast to the ‘degree of

Tooth wear TSL’. It is therefore very difficult (if not
II

II

measurement
I

impossible) to combine data from different

studies using subjective and objective
O þ YA

YA þ A

Age-group TMD-criteria with data from studies using

Ch

different tooth-wear scales (varying from

Table 3. Studies investigating effects of intervention or treatment history on tooth wear

two to eight levels) in an attempt to calcu-

55 (40)

late relative risks for TSL in case of TMD.

% female
33

50

ðcontrolsÞ Elements of the healthy dentition have

?

Tooth wear measurement: I, clinical examination; II, cast examination; IV, photographs.

been described as absence of pathology,

Number of subjects
5 (4)

51 (47)

ðcontrolsÞ sufficient oral function, variability in forms

and function, and the ability to adapt to
36

18

changing function or environment (Mohl

et al. 1988; Ash & Ramfjord 1995). If
Oclusal splints

attrition is hypothesized as a mechanism

Orthodontic
treatment

treatment

to adapt to changing function or environ-

Bite plate

Anticipated ment, it might explain the weak correla-

Dental

risk factor
tion between attrition and TMD; lack of
ability to adapt is claimed to cause TMD.
However, the two selected studies that
Study design: L, longitudinal; C, cross-sectional.
Private practice

Orthodontially

investigated attrition as possible cause for

Selected cases
Unspecified

dysfunction are ambiguous in this respect.

Subject selection
treated

In one study, wear facets in primary teeth

did not predict clinical signs of TMD
(Goho & Jones 1991). In contrast, the other
study (Carlsson et al. 2002, 2003) pointed
Study design out that attrition at young age predicts TMJ
C

C
L

clicks and night grinding 20 years later.

Dahl et al. (1989)

Dettmar & Shaw

Hachmann et al.

Unfortunately, we found only one inter-

?, not described.
Carlsson et al.

vention study relevant to our topic. This

study (Hachman et al. 1999) reported on
(1999)

(1987)

(1985)

References
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retrospective studies (Dettmar & Shaw

124 | Clin. Oral Impl. Res. 18 (Suppl. 3), 2007 / 117–126 c 2007 The Authors. Journal compilation


c 2007 Blackwell Munksgaard

1987; Dahl et al. 1989) cannot be consid-
ered intervention studies. They did not
compare the true effects of one treatment
to another, but merely looked at TSL as a
side effect of variable treatments in the
past.
It is possible that another search strategy,
e.g., using the keyword ‘bruxism’ in com-
bination with ‘intervention’ or ‘treatment’,
would have revealed more intervention
studies. However, most probably TSL
would not have been included as a research
variable in those studies designs.
Nevertheless, some remarks can be
made regarding our search strategy. The
additional hand search on the basis of the
full text articles revealed that six relevant
papers had to be included instead of their
exclusion on the basis of abstracts and
titles. Three of them (Seligman et al.
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