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Abrasion: A Common Dental Problem Revisited

Article  in  Primary Dental Journal · April 2017

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 Abrasion: a common dental
problem revisited
Alex Milosevic
Prim Dent J. 2017;6(1):32-35
ABSTRACT
Dental abrasion is most commonly seen at the cervical necks of teeth, but can
occur in any area, even inter-dentally from vigorous and incorrect use of dental
floss. Acid erosion has been implicated in the initiation and progress of the
cervical lesion, while tooth-brush abrasion has long been held as the prime
cause of cervical abrasion. Identification of the risk factors is clearly important
in order to modify any habits and provide appropriate advice.
KEY WORDS
Toothwear, Tooth Surface Loss,
Dental Abrasion, Non-carious
Cervical Lesions
AUTHOR
Professor Alex Milosevic, BDS PhD
FDSRCS Ed DRDRCS Ed
Head of Prosthodontics, Hamdan Bin
Mohammed College of Dental Medicine
(HBMCDM), Mohammed Bin Rashid University
(MBRU) of Medicine and Health Sciences,
Dubai, UAE
32
individual. The gingivae are likely to
be inflammation free and possibly
hyperkeratinised from toothbrush trauma.
The defects are well delineated and deep
with pulpal exposure.
Various factors have been postulated
for toothbrush abrasion including using
a hard brush, too much pressure,
high frequency of brushing and an
inappropriate technique. The abrasivity
of the toothpaste has also been
D
ental abrasion is defined as the associated with cervical abrasion,
wear of teeth by any substance although most commercially available
other than tooth substance. The toothpastes meet stringent low abrasion
cervical is the most commonly abraded
site and the term non-carious cervical
lesions (NCCLs) is the appropriate term
to describe the lesions formed. Abrasion
can, however, occur on any area, even
inter-dentally from vigorous and incorrect
use of dental floss.1 Abrasion alone can
be difficult to distinguish from combined
erosion and abrasion.
NCCLs can have two quite distinct
clinical presentations:
• Flat, shallow, dish-shaped lesions. Figure 1: Unilateral abrasion in
• Deep, wedge-shaped lesions. the maxillary left quadrant, possibly
caused by a scrub technique
Both types of lesion may share common
aetiological factors. Acid erosion has
been implicated in the initiation and
progress of the cervical lesion, while
tooth-brush abrasion has long been held
as the prime cause of cervical abrasion.
Should acid erosion be suspected, then
questioning the patient regarding risk
factors (see paper on erosion, also in
this issue) is appropriate.
Non-carious cervical
lesions (NCCLs)
Figures 1 and 2 illustrate the presentation Figure 2: Cervical defects with wear
of NCCLs. In Figure 1, the unilateral labially in an older female. The presence
distribution in the upper left quadrant of gingivitis precludes tooth brush
may indicate an association with abrasion as an aetiology. There is incisal
horizontal tooth brushing or “scrub edge wear also. The aetiological factors
technique” in a right handed could not be identified
p r i m a r y d e n ta l j o u r n a l
 Figure 3: Deep V-shaped notch in an
elderly gentleman on the lone standing
maxillary second premolar. Another
cervical defect in present on the canine
(Image courtesy of Dr William Smith, Lecturer
in Conservative Dentistry, School of Dentistry,
The University of The West Indies, Trinidad)
Figure 4: Deep V-shaped notch buccal
cervical defects, possibly abfraction
Figure 5: Shallow dish-shaped lesions
in the maxillary right quadrant which
was associated with both acid erosion
and abrasion
Figure 6: Shallow and broad cervical
lesions and a very over-erupted maxillary
first molar which has cervical wear in the
mesio-buccal root. Probably associated
with abrasion
Vol. 6 No. 1 spring 2017
standards. Toothbrush hardness and
the teeth to which the brush and paste
are first applied are thought to be more
important in determining cervical wear.2
A greater percentage of subjects had
wear when brushing “Never, or less than
once a day” compared to “Twice a day”
according to the findings of the UK Adult
Dental Health Survey.3
Although right handedness is most
common, there is no evidence that left-
sided cervical wear predominates, or
that males exhibit more cervical wear
than females. It might be expected that
males exert greater tooth brushing force
than females, but no differences have
been reported.4
The prevalence and distribution of
cervical wear has been assessed in
several studies across the world. The
prevalence varies from 5% to 85%
and increases with age.5-7 NCCLs
have a high prevalence, with 62% in
Trinidad, 49% in Japan and 45% in
China having been reported.8-10 Some
studies had small sample sizes and
expressed results as a proportion of teeth
rather than subjects. There are conflicting
results regarding which teeth are the most
commonly affected. Maxillary premolars
and mandibular premolars have both
been found to be most often affected
by cervical wear.
TAble 1
Behaviours, activities and foods with
abrasive potential
Betel nut chewing
Chewing pens, other objects as part of a nervous displacement behaviour
Gnawing on bones
Occupational (eg. workers in cement factory)
Pica – the chewing and possible ingestion of non-edible items (eg. stones)
Pipe smoking
Eating stone-ground bread
Eating unwashed food with sand or grit still present
Using teeth as tools (eg. electricians stripping wire, seamstresses holding needles
between teeth)
Apart from tooth brushing, other possible
factors associated with cervical wear
include bruxism, as determined from
wear facets. Some studies reported
NCCLs to be more prevalent in bruxism
and others did not find any differences
between bruxers and normal control
groups.11-14 The increased load on teeth,
either during bruxism or from an occlusal
interference, has led to the concept of
tooth flexion resulting in the pulling apart
or breaking off of the cervical enamel
prisms resulting in a deep wedge shaped
lesion, termed abfraction.15
Presentation
NCCLs are either deep V-shaped notches
or shallow dish-shaped lesions. Deep
notches are regarded as less likely to
be caused by tooth brushing as the
toothbrush filaments cannot contact the
deepest part of the lesion. Figures 3
and 4 illustrate the deep lesions with a
narrow opening preventing toothbrush
heads from entering the deepest part of
the defect. Shallow dish-shaped lesions
are shown in Figures 5 and 6. Sensitivity
and unacceptable appearance were the
main patient complaints.
Abrasion of non-cervical sites
As stated previously, abrasion can occur
on any tooth surface. Table 1 gives a
list of behaviours and foods which are
potentially damaging.
33
 Abrasion: a common dental
problem revisited
7a
7b
Figure 7:
a Wear caused by chewing betel
nut over decades. The height of the
crowns is reduced and the occlusal
surfaces are cupped
b Close-up view of the mandibular
molars
The general abrasion produced by betel
nut chewing is shown in Figures 7a and
7b. The patient was a male medical
practitioner aged 63 years old from the
Indian sub-continent. The wear is severe
and generalised, resulting in widespread
dentine exposure. Figures 8a and 8b
show local abrasion on the incisal edges
in an electrician who stripped insulation
from wire by biting into the plastic
insulation.
The Inuit, natives of Greenland, use teeth
as tools, resulting in marked abrasive
34
8a
8b
Figure 8:
a Incisal edge abrasion in an electrician
who stripped electrical wire between
teeth to remove the insulation
b Teeth in ICP illustrating the perfect
notch formed by the wire
Figure 9: Image of mandibular cast
showing significantly more buccal
wear compared to lingual wear in
a native from Greenland. This presents
as a reverse curve of Monson
wear of occlusal surfaces. The pattern
of wear is distinctive with the lower
buccal and upper palatal supporting
cusps (functional cusps in a normal
bucco-lingual relationship) being worn.
Figure 9 illustrates the reverse curve of
Monson on a mandibular study cast of
a Greenland native (the image is taken
from a publication that assessed wear but
termed it attrition rather than abrasion).16
10a
10b
Figure 10:
a Palatal view of abraded occlusal
surfaces secondary to chewing bones,
a common practice in parts of SE Asia
b Occlusal view of the mandibular teeth
showing cupped occlusal surfaces on
molars with exposed dentine similar
to the presentation of erosion
A middle aged male from Hong Kong
attended with the presentation as shown
in Figures 10a and 10b. Initially, a
diagnosis of erosion was made. On
questioning the patient, however, dietary
acid intake was low and there was no
history of gastric reflux or vomiting.
A more detailed analysis revealed that
the patient chewed chicken bones, which
he broke between his teeth in order
to suck the marrow from leg bones,
as marrow is highly nutritious. This
is dietary abrasion occurring mainly
on the occlusal surfaces.
Occupational abrasion has also been
reported in several studies, mainly in
the Scandinavian literature. Cement
factory workers in Tanzania, iron ore
miners in Sweden and granite workers in
Denmark were all reported to have high
abrasive wear.17-19 Although the studies
tended to have small sample sizes,
air-borne particles were nevertheless
thought to contribute to greater wear
p r i m a r y d e n ta l j o u r n a l
 NOTE: all pic yet to be ACTiffed (converted/lightened etc - to be done
later)

Figure 11: Cervical foils or matrices.

These are available malleable, come
in different sizes and are placed over
the glass ionomer immediately after
placement into the defect

of the posterior teeth compared to the
anterior teeth. Recent studies have also
found increased wear in olivine miners.20
Strict adherence to health and safety
rules should hopefully reduce the risk of
microparticulate atmospheric pollutants
being inhaled through the mouth.
The chewing of snuff or tobacco has
been reported to increase the risk of
masticatory surface wear although a
later study found that salivary flow and
lubrication mitigated against abrasion
and that snuff chewing was not a risk for
occlusal wear.21,22
Management of abrasion
Identification of the risk factor(s) is
clearly important in order to modify any
habits and provide appropriate advice.
Questioning patients about acidic diet
is covered elsewhere. Oral hygiene
habits will involve detailed analysis of
technique, frequency, types of brush and
toothpaste. Certain pastes or powders
are abrasive, such as smoker’s powders.
The distribution of abrasion defects
will help the clinician diagnose the
risk factors. If the only complaint is of
dentine sensitivity, then advice to use de-
sensitising toothpastes or application of
de-sensitising resin as appropriate. When
applying resin, it is important to clean
the surface with an oil-free prophylaxis
paste and to follow the manufacturer’s
guidance. Self-etch resins such as Seal
and Protect™ (Dentsply) require two to
three surface coats for maximal benefit.
Such resins have good retention and
protect against wear in situ.23
NCCLs are relatively common and
usually managed by restoration. There
are various aesthetic restorative materials
indicated for such cases, including
glass-ionomer cements, composites and
hybrids of these materials. The choice
of material will depend upon clinical
experience, the need to maximise
aesthetics and whether fluoride release
is important. Glass-ionomer cements are
inherently adhesive, whereas composite
systems require an etching and bonding
stage. The release of fluoride is very
advantageous. Glass-ionomers provide
a sustained release over years and can
absorb fluoride from the oral cavity for
later release, thus acting as a storage
reservoir. Composites do not have this
ability, although the polyacid-modified
resin composites or compomers have
hydrophilic monomers, which allows
water diffusion into the set material
and fluoride ions out of the matrix. For
anterior cervical lesions, where aesthetics
needs to be optimal, a composite or
compomer are appropriate. Since neither
material is bulk set, light curing is needed
through a transparent matrix, which will
help provide the desired contour and
reduce finishing time.
Glass ionomers have the advantage
of bulk placement and longer fluoride
release, but they have low wear
resistance, low toughness and dissolve
in acids. If acid erosion is not controlled,
then a composite or compomer may
be better. Furthermore, the handling
characteristics of glass ionomers are
inferior to composite, with short working
times and long setting times. This has
been overcome to some extent by the
development of resin-modified glass
ionomers which can be command set by
light and have improved resistance to
dessication and acid attack.
The technique for placement of a glass
ionomer restoration is shown in Figures
12a to c. Syringing the glass ionomer
from a capsule directly into the cavity,
followed by placing a matrix such as
a metallic foil over the surface while it
sets, reduces finishing time. The cervical
matrices or foils are malleable and can
be adapted across the buccal convexity
to provide a good contour (Figure 11).
Light cured materials cannot be used with
these matrix foils. Initial finishing removes
marginal excess, but final polishing is
best left until complete set has occurred
(after 24 hours). During this phase, the
surface should be coated with a varnish
or resin immediately after removal of
the matrix to prevent contamination or
dehydration. Finishing after 24 hours is
carried out with yellow or white ring fine
diamond high speed burs or 12-fluted
tungsten carbide high speed burs under
water spray to avoid dessication. At least

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flossing. Dent Update 2003;
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2 Radentz WH, Barnes GP, Cutright
DE. A survey of factors possibly
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of the multi-factorial aetiology The prevalence and severity of non- 11 Bader JD, McClure F, Scurria MS,
of abfractions. J Oral Rehabil carious cervical lesions in a group Shugars DA, Heymann HO. Case-
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toothbrushing and dental abrasion. 9 Takehara J, Takano T, Akhter R, 12 Shah P, Razavi S, Bartlett DW.
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6 Levitch LC, Bader JD, Shugars DA, factors determined by using other causes of wear. J Prosthodont
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7 Borcic J, Anic I, Urek MM, Ferreri S. 10 Jiang H, Du MQ, Huang W, Peng B, Tobias TS. Effects of occlusal load
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NOTE: no Figure 11a to c captions supplied, but mentioned in text.

Vol. 6 No. 1 spring 2017 Only one Figure 11 image supplied. Figure 12a to c caption & 35
images supplied, but not mentioned in body copy
 Abrasion: a common dental
problem revisited

12a Figure 12: Finally, a few words regarding

a Close-up view of combined abrasion
and erosion cervical defects on the
maxillary right hand teeth
b Placement of glass ionomer in 14
and 15 showing gingival bleeding
which often cannot be avoided. The
cervical matrix is still in place on 15
and shows the matrix has been bent
to conform to the convexity of the tooth
c Removal of the matrix has resulted
in an acceptable marginal finish and
contour avoiding the need to carry out
12b extensive finishing post-placement
60.5% of cervical restorations placed
in general dental practice in the UK
survived for five years, with factors such
as the dentist, cavity size, use of glass-
ionomers as compared to composite,
moisture contamination and patient
age affecting survival.24
Restoration of abrasion lesions on
non-cervical and cervical areas will
12c depend on the extent of the defect.
Composite has the advantage of
conserving remaining tooth structure,
reversibility, widespread availability
and good durability, even in load
bearing situations, and restorations
of composite have better survival
compared to restorations of glass
ionomer. Both composites and glass
ionomers, however, are technique
sensitive materials.
abfraction. There is no widespread
consensus that abfraction is a separate
clinical problem. The theory that tooth
flexion under abnormal loads results in
the breaking apart of cervical enamel
has not been proven. Finite-element
studies have shown stress concentration
can occur cervically, but other studies
have not found occlusal loading can
lead to the progress of narrow cervical
lesions. Nonetheless, should cervical
restorations repeatedly fail, it may not
be the fault of the clinician, as flexure
will break the bond between restoration
and tooth. In such situations the clinician
needs to check the occlusal contacts for
any interference and remove this prior
to restoration.25-27
Conclusion
Abrasion is mainly associated with
the cervical area and thus amenable
to restoration using widely available
aesthetic materials. Its association and
possible initiation by acid dissolution
means patients should be questioned
about dietary acid and other erosive
risk factors which should be controlled
prior to restoration.

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