Australian Dental Journal 1998;43:(2):117-27
Dental erosion and bruxism. A tooth wear analysis
from South East Queensland
F. Khan*†
W. G. Young*†
T. J. Daley*
Abstract
Tooth-tissue loss from erosion and attrition from
bruxism were associated findings in 104 patients
with excessive toothwear from South East
Queensland. Approximately one-third of these
subjects had been given a diagnosis of bruxism prior
to referral. After a structured interview and clinical
examination, the prevailing diagnosis was tooth
erosion associated with occupational or sports-
related dehydration, and one-third of the subjects
were provisionally classified as bruxers. Eight items
of clinical history and examination, designed to
differentiate bruxers from non-bruxers, were
analysed retrospectively from their records. These
clinical items, by which the diagnosis of bruxism
might be made, segregated the subjects into three
groups of equal size, ‘bruxers, possible bruxers and
non-bruxers,’ by a notional score for bruxism.
The presence of occlusal attrition or erosion on the
sextants of the dentitions was determined by
scanning electron microscopic criteria on epoxy resin
dental casts. The incidence of attrition versus erosion
was compared between the three groups. The
hypothesis was that attrition would be found on more
sextants of bruxers than non-bruxers. Erosion
predominated in virtually all sextants in all three
groups, to the virtual exclusion of attrition in the molar
sextants. The exception was the mandibular anterior
sextant, where more sextants in bruxers were
affected by attrition. Thus extrinsic or intrinsic acid
erosion was strongly associated with occlusal tooth
wear found in bruxers. Conversely, tooth-wear
patterns were unreliable indicators of a bruxing habit,
for attrition alone was often found on acid-exposed
teeth. Thus, even if a patient is suspected of having
bruxism, dental erosion is more likely the cause of
tooth-tissue loss than attrition, especially in the
dehydrating environment of South East Queensland.
Key words: Tooth wear, attrition, erosion, bruxism.
(Received for publication July 1997. Revised December
1997. Accepted December 1997.)
*Department of Dentistr y, The University of Queensland.
†F. Khan was the recipient of a 1995-96 Student Scholarship from
the Australian Dental Research Foundation. The ADRF also
supported this work by a Project Grant to W. G. Young.
Australian Dental Journal 1998;43:2.
Introduction
There are numerous indications in the literature
that the effects of erosion on the teeth must be
discriminated from tooth wear caused by
attrition/abrasion, in order that appropriate
prevention, patient management and therapy can be
instituted. This discrimination is essential when the
tooth clenching or grinding habit (bruxism) is also
suspected, for bruxism can exacerbate the tooth-
tissue loss from erosion. Moreover, a preconceived
‘diagnosis’ of bruxism can bias an objective
examination of the patient and neglect the indicators
of lifestyle that point to preventive strategies and
therapy to counteract dental erosion.
Bruxism has been defined as non-functional
(parafunctional) movements of the mandible, with
or without audible sound occurring during the day
or night. The incidence of bruxism seems to vary
according to the definition and diagnostic criteria
used, the population sampled and the design of
questionnaire employed.1 The indicator generally
used for this diagnosis is a history of clenching or
grinding the teeth reported by the subject, parent or
partner. Other associated signs are tongue indenta-
tions and linea alba on the buccal mucosa presumed
to be due to tongue thrusting and cheek-biting
habits concomitant with the bruxing habit.2
Excessive tooth wear is the most frequently cited
sign of bruxism, because a study of 15 bruxers and
15 non-bruxers found that tooth wear progresses
faster in bruxers than non-bruxers.3 However, it is
hazardous to infer that patients have the habit of
bruxism from the patterns of wear on their teeth.1
Although ‘bruxofacets’ have been defined as atypical
facets on teeth, with flat, smooth, shiny areas with
sharp edges that correspond with similar opposing
areas when the mandible is moved more than 3.5 mm
from centric occlusion in a lateral excursion,4
opinions differ as to when wear facets are due to
normal masticatory movements, to thegosis5 or to
117
bruxism.1 Wear facets were a very common feature
of the dentitions of Australian Aboriginals due to
dietary abrasion. 6 The range of mandibular occlusal
positions that produced these worn dentitions led to
the inference that tooth grinding, or bruxism, was a
very common feature of the dentitions of Australian
Aboriginals living an essentially non-industrial way
of life. 7 However the distribution of wear facets that
has been described and analysed on Western dentitions
can be accounted for by normal masticatory move-
ments.8 Caution has been expressed against inferring
bruxism from tooth wear patterns.8 Moveover, a
recent review on a possible relationship between
malocclusion and bruxism found that malocclusion
does not increase the probability of bruxism, and
therefore the early treatment of occlusal conditions
to prevent bruxism is not scientifically justified.9
There is clinical evidence that erosion predisposes
to severe attrition, and that the two mechanisms
often act in tandem to cause tooth tissue loss.
Erosion from industrial acids has been repeatedly
associated with severe dental attrition.10,11 The latter
study attributed a high prevalence of attrition on
adult posterior teeth to abnormal ‘fragility’ due to
acid exposure. It has also been emphasized that the
severe attrition found in young patients is commonly
due to erosive factors in their diets.12 Ultrastructural
studies on experimental animals have shown that the
dental hard tissues are more susceptible to
attrition/abrasion when softened by erosion, for the
reduced microhardness of acid-affected enamel
makes it more susceptible to attrition. 13 Hence, even
physiologic tooth-to-tooth interactions are likely to
accentuate the occlusal manifestations of acid-
challenge on enamel and dentine. Moreover, if the
parafunctional habit of bruxism is superimposed, it
may accelerate tooth-tissue loss in an erosive
environment.14 Erosion can be overlooked in cases of
marked attrition. Several patients, referred for the
treatment of temporomandibular joint dysfunction
because of their attrition, were found to have erosion
only after particularly careful examination.15
Accordingly, the examination of patients who present
with a history of bruxism, or temporomandibular
joint pain dysfunction syndrome, must be directed
toward ascertaining if acid demineralization is the
underlying cause of their tooth wear.
Tooth wear from attrition can readily be
discriminated from tooth-tissue loss by erosion on
teeth worn into the dentine using scanning electron
microscopic criteria. These criteria can be used to
characterize the predominant pattern of wear at
individual tooth-sites and within the anterior,
premolar and molar sextants of the dentition.16
Simplistically, the habit of bruxism may produce
wear patterns characteristic of attrition on occluding
tooth surfaces which are different from the patterns
118
of occlusal tooth-tissue loss associated with dental
erosion. Hence, it might be possible to discriminate
‘bruxers’ from ‘non-bruxers’ using tooth wear
criteria. Conversely, because occlusal wear from
bruxism has been found to be frequently associated
with cervical erosion,3 the effects of bruxism on the
teeth could be enhanced by enamel demineralization
in the acidic environment and hence bruxers would
have a higher rate of wear than non-bruxers.3 Some
lesions would be attritional, but a high incidence of
erosional lesions might also be found on occlusal
surfaces. It was therefore deemed necessary to
examine the teeth of suspected bruxers for evidence
of acid attack, which may manifest as occlusal
attrition or as erosion, in order not to miss what may
be the underlying cause of their tooth wear.
To this end, the clinical and examination records
of 104 patients, referred to a toothwear clinic at the
University of Queensland Dental School between
1991 and 1995 by dental practitioners for the
investigation of tooth wear, were analysed and
scored for bruxism. Casts of 102 dentitions of these
subjects were examined by light microscopy for wear
patterns based on scanning-electron microscopy
(SEM) criteria. The objectives of this study were to
discriminate lesions produced by attrition from
those produced by erosion, to analyse dentitions of
the subjects, and to describe the incidence of these
patterns of wear, analysed by sextant partitioned by
items, and by scores for bruxism, to determine if the
perceived aetiology matched the patterns of wear.
The significance of this investigation is that when
bruxism was indicated by clinical criteria in patients,
the predominant patterns of occlusal tooth-tissue
loss found were erosive rather than attritional.
Patterns of tooth wear were thus inconsistent with
the diagnosis of bruxism. Erosion is of greater
importance in tooth wear of this South East
Queensland population, although bruxism may
contribute by exacerbating attrition at certain sites.
Materials and methods
Clinical items
The structured interview and examination of each
patient allowed positive or negative responses to be
established for eight items of history and examination
pertaining to bruxism (Table 1). Item 1, Clenching
or grinding during the day was generally ascertained
by a question such as Are you conscious of clenching or
grinding your teeth when concentrating or stressed during
the day? A positive response to this item was
weighted 4 points, as was a positive response to Item
2, Clenching or grinding during the night. This
required, in the case of young adults, confirmation
by the parent present. In the case of adults, the
unequivocal question was asked Has your partner told
Australian Dental Journal 1998;43:2.
Table 1. Incidence of positive responses to
Item 1 to 8 and the notional point value for
these items
Question from patient record n Points
(1) Grinding or clenching during the day 32 4 Possible bruxers
(2) Grinding or clenching during the night 23 4 Non-bruxers
(3) Muscle or TMJ tenderness in the morning 14 1
(4) Muscle or TMJ tenderness upon palpation 27 1
(5) Tongue indentations 20 1
(6) Buccal mucosa: linea alba 34 1 this score and segregated into three equal groups of
(7) Bruxism – diagnosed/suggested 37 2
(8) Bruxism treated – splint made 15 2 34 subjects; bruxers, possible bruxers and non-
Patient sample=104 patients.
you that they hear or see you grinding or clenching when
you are asleep?. A positive response was recorded for
this item if, for any other reason, the subject was
certain they had the habit. Recollection of stiffness
or tenderness of the muscles of mastication or of the
temporomandibular joints on waking in the
morning, particularly if under stress, was taken as a
positive indicator for Item 3. During the clinical
examination of each patient, three signs were looked
for, which have been associated with bruxism. These
were: Item 4, pain, clicking or tenderness on bilateral
palpation in the muscles of mastication or temporo-
mandibular joints on opening and closing17; Item 5,
indentations of the tongue, impressions of teeth on
the tongue and lips2; and Item 6, bilateral prominent
linea alba, cicatricial thickening of the buccal
mucosa near the occlusal surfaces of the posterior
teeth’.2 Items 3-6 were weighted 1 point each, as
each was deemed to be a symptom or sign, partially,
but not necessarily correlated with the condition.
Most patients, prior to referral, had been asked,
often repeatedly, about grinding their teeth at night.
This was not sufficient evidence that bruxism was
positively diagnosed or suggested (Item 7). How-
ever, the structured interview allowed a determination
to be made as to whether the patient had been given
a diagnosis, or an explanation in the past, that his or
her tooth wear was the result of an unconscious
nocturnal grinding or clenching habit. In most
cases, the actual referring dentist was sceptical about
this ‘diagnosis’. The term ‘bruxism’ was, almost
exclusively, unfamiliar to these patients in South
East Queensland. A point weighting of 2 was
assigned to Item 7. However, as two additional points
were given when a dentist in the past had diagnosed
and treated these subjects for bruxism, they received
a combined score of 4 points. Item 8 recorded the
number of subjects who had received treatment in
accordance with this diagnosis, and this was generally
occlusal adjustment and/or splint therapy.
Point weightings, assigned to positive findings on
each item of clinical history and examination, were
totalled to give a notional score for bruxism for each
patient (Table 1). The subjects were rank-ordered by
Australian Dental Journal 1998;43:2.
Table 2. Distribution of subjects by rank order
point score in three groups
Group Size Point range
Bruxers n=34 6 to 16 points
n=34 3 to 5 points
n=34 0 to 2 points
bruxers on the basis of score ranges (Table 2). The
limits of the ranges were chosen as follows.
Subjects with scores of 0 to 2 points were grouped
as non-bruxers. Thus a subject with up to two signs
or symptoms, which only possibly correlated with
bruxism (Item 3-6) was not designated as a possible
bruxer. Similarly, a subject to whom the suggestion
of bruxism had been given (Item 7) but who had no
other history, symptom, sign or treatment would not
be classified as a possible bruxer in accordance with
the scepticism expressed above. Subjects with scores
of 3 to 5 points were designated possible bruxers.
Thus a subject with three or more possibly
correlated signs or symptoms (Item 3-6) was so
designated. Subjects without such signs or symptoms
but with 4 points for a confirmed history of
clenching or grinding (Item 1 or 2) or who had been
treated for bruxism (Item 7 and 8) were classified as
possible bruxers. Possible bruxers might have one
additional sign or symptom, and score 5, without
being classified as a bruxer. However if subjects had
in addition two or more signs or symptoms (score 6)
they were classified as bruxers. This cutoff reflected
the clinical perception that if a subject said the
muscles of mastication were tender on waking (Item
3) and if these muscles were tender to palpation (Item
4), then the validity of the historical items (1 or 2 or
6 and 7) was reasonably established. Similarly, the
combination of tongue indentations and linea alba
(Item 5 and 6) strongly suggested that a
parafunctional habit existed.
Wear patterns
It was hypothesized that wear patterns on the
teeth might be used to discriminate patients with
bruxism from those with other aetiologies. Epoxy
resin replicas of the dentitions of 102 subjects were
used to discriminate different wear patterns on teeth
worn to dentine on the basis of SEM criteria of tooth
microwear. No attempt was made to subclassify facets
into ‘bruxofacets’ as was done by other authors.4,7
Discrimination between wear facets due to attrition
and tooth-tissue loss due to erosion on occlusal
surfaces can readily be made when the facets, or
eroded areas, are worn into dentine.16 Consequently,
this study is not based on the positions of shiny wear
facets in enamel as used in other studies, and shown
119
 LE

TE

D
D

Fig. 1. – Maxillary left second incisor viewed from the palatal aspect, showing attrition (Pattern A1). On the incisal
edge, well-defined contiguous facets (F) have formed against the mandibular second incisor and canine teeth.
Shallow interface from the facial enamel onto dentine contrasts with the hollowed and chipped dentine-enamel
junction with the palatal enamel. These interfaces are consistent with the leading edge (LE) and trailing edge (TE):
the Greaves effect. 18 A shelved attritional facet is present on the cingulum (C). [Bar=1 mm.]
Fig. 2. – Maxillary left first incisor showing erosion on the incisal edge and on the palatal surface (Pattern B). Facial
incisal enamel is chipped (E) and the incisal dentine (D) is deeply hollowed out. Palatal enamel is mostly eroded,
even into the gingival sulcus (S). Palatal dentine is finely striated. This tooth was from a patient with Bulimia
nervosa. [Bar=1mm.]

120 Australian Dental Journal 1998;43:2.

 TE
D

LEE

Fig. 3. – Maxillary left first molar from the distal aspect showing attrition and abrasion on the occlusal surface
(Pattern A) wear. Greaves effect18,19 is shown particularly on the heavily-worn palatal cusps; and leading edges (LEE)
and trailing edges (TE) can be identified. The palatal cusps were worn by a phase of the occlusal stroke when the
buccal faces wore against the lingual faces of mandibular molar buccal cusps moving in the direction of the arrows.
A reciprocal wear pattern was found on opposing mandibular molars. [Bar=1mm.]
Fig. 4. – Maxillary right first molar viewed from the mesial aspect showing a shallow cupped lesion on the mesio-
buccal cusp (B) as evidence of mild occlusal erosion. The occlusal amalgam restoration (R) has slightly raised
margins. [Bar=1 mm.]

Australian Dental Journal 1998;43:2. 121

 D

D D

Fig. 5. – In contrast to Fig. 4 from the same subject, the opposing mandibular right first molar is
markedly eroded occlusally. There is extensive loss of enamel and cupped lesions in dentine (D) on all
cusps and marginal ridges (pattern B). The edges of an amalgam restoration (R) are raised above the
cupped lesions. [Bar=10 mm.]

in most instances to be due to mastication.8 Instead,
the type of wear into dentine on the occlusal surfaces
was taken as representative of the principal mode of
tooth wear occurring in that sextant.
Two different patterns of microwear were
discriminated on the occluding surfaces of teeth
worn into dentine. Attritional facets on anterior
teeth were characterized by flat planes of wear with
well-defined margins in enamel of incisal edges or as
step-like areas on palatal aspects (Fig. 1). In
contrast, erosion lesions damaged dentine more
deeply (Fig. 2). In general, attritional tooth wear,
Pattern A, was characterized by planar enamel wear
and shallow dentine wear, on molars often
contoured in the direction of relative tooth-to-tooth
movement in accordance with the Greaves effect and
with equivalent facets being found on all opposing
teeth (Fig. 3).18,19 Mild tooth-tissue loss due to
erosion, Pattern B, was characterized by cupped
lesions (Fig. 4). Advanced erosion was found as
deeply cupped dentine-loss on occlusal surfaces
(Fig. 5). The enamel/dentine interfaces in cupped
lesions are generally not contoured in accordance
with the Greaves effect (Fig. 2 and 5). These series
of wear patterns were essentially those used in other
studies,12,15 as qualified by the above SEM criteria.16
The presence or absence of the predominant
pattern (either A or B) was recorded for each of six
sextants of all 102 dentitions. These sextants were:
the maxillary and mandibular anteriors (incisors and
122
canines), maxillary and mandibular premolars and
the maxillary and mandibular molars. These data
were expressed as the percentages of subjects who
showed either pattern A or B per sextant, partitioned
by groups of subjects classified as bruxers, possible
bruxers or non-bruxers, based on their scores from
clinical items. A third category of no wear (No W/I)
was used if the wear in the sextant did not extend
into dentine. The results are mostly reported as
descriptive statistics and the Chi-squared analysis
was applied where appropriate.
It must be stressed that the subjects had been
investigated by many additional items in the
structured interview concerning other aetiologies of
attrition, abrasion and erosion.20,21 From these
additional data, the clinical impression had been
gained that the subjects had mostly been exposed to
dental erosion from dietary or intrinsic acids.16,22
Moreover, the climate and lifestyle in South East
Queensland makes it likely that occupation and/or
sports-activities induce dehydration and salivary
hypofunction which contribute to lack of salivary
protection against extrinsic and intrinsic acids.22
This clinical impression of these subjects has been
substantiated by an as yet unpublished case-control
study21 which has been discussed elsewhere.23 Thus,
the division of bruxers from non-bruxers did not
imply that the bruxer and possible bruxer groups
had not also been exposed to erosion.
Australian Dental Journal 1998;43:2.
 % K Type A % K Type A
60 - K Type B 70 - K Type B
K No W/I 60 - K No W/I
50 -
50 -
40 - 40 -
30 -
30 - 20 -
20 - 10 -
0
10 - 10 -
20 -
0
30 -
Bruxers Possible Non-
bruxers bruxers 40 -
50 -
Fig. 6. – The percentages of sextants which showed attritional
pattern (Type A), erosional pattern (B), or no wear (No W/I) in 102 60 -
subjects, partitioned into equal groups of 34 from their clinical scores 70 - Bruxers Possible Non-
for bruxism. Erosion was found equally commonly in bruxers as in bruxers bruxers
non-bruxers. However, the difference between the incidence of Fig. 8. – Incidences (%) of premolar sextants affected by wear or no
attritional wear in bruxers and non-bruxers was significant. wear. Whereas the incidence of erosion (Type B) on the premolar
sextants of all groups was high and equivalent; attrition was
commoner on the premolars of bruxers than non-bruxers.
Results Conversely, the premolars of non-bruxers were commonly unworn
(No W/I).
Clinical items
Table 1 shows that the commonest positive item of
clinical history was that the diagnosis/suggestion of muscles of mastication was elicited by palpation in
bruxism, or of a tooth grinding habit, had been 27 subjects (Item 4). Linea alba on the buccal
given to 37 of the 104 patients (Item 7). However, mucosa was found in 34 subjects (Item 6). Tongue
less than half that number had received splint indentation (Item 5) was a less frequent sign
therapy (Item 8). Items 1 and 2 are worthy of encountered (20 subjects). When the subjects were
contrast. Thirty-two subjects were conscious of rank-ordered by notional score for bruxism from
grinding or clenching their teeth during the day these clinical items, they segregated by the score
when stressed or concentrating (Item 1). In only 23 range into three groups of subjects as shown in Table
instances were the subjects certain, or a parent or 2. Positive responses to each of the Items 3-6 were
partner had confirmed that they ground or clenched found in subjects of the group which scored as non-
their teeth at night when asleep. The least number of bruxers. However, in no instance did a positive
subjects (14) reported tenderness or stiffness in the response to Item 7, the prior diagnosis of bruxism,
temporomandibular joint or muscles of mastication alone result in a subject being classified as a non-
on awakening in the morning (Item 3). However, bruxer. In two subjects, incomplete records of their
tenderness of temporomandibular joint or the dentitions excluded them from the wear pattern
analysis.
% K Type A
70 - K Type B % K Type A
60 - K No W/I 100 - K Type B
50 -
80 - K No W/I
40 -
30 - 60 -
20 - 40 -
10 -
20 -
0
0
10 -
20 - 20 -
30 - 40 -
40 - 60 -
50 -
80 -
60 -
70 - 100 -
Bruxers Possible Non- Bruxers Possible Non-
bruxers bruxers bruxers bruxers
Fig. 7. – Percentages of anterior sextants showing that attrition wear Fig. 9. – Percentages of molar sextants affected by wear showing the
(Type A) occurred more commonly than erosion (B) in the anterior virtual absence of attrition (type A) in the non-bruxer group. Erosion
mandible and was equivalent in the maxilla (Mx) and mandibles (B) affected substantially more mandibular than maxillary sextants,
(Md) of the two bruxer groups, but not in the non-bruxer group. affected all three groups equally much more than did attrition. There
Erosion was much commoner in the maxilla than mandible, in all was a high incidence of maxillary sextants of the non-bruxer group
groups. unaffected by wear into dentine (No W/I).

Australian Dental Journal 1998;43:2. 123

Table 3. Differences in % between A and B type wear for yes findings to the items
Sextant Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8

L anterior % +38.1 +22.7 +50.0 +44.5 +15.0 +18.1 +63.9 +60.0

**** *** **** **** **** ****
L premolar % +6.4 -26.1 +28.6 -7.4 -25.5 -8.8 +8.3 +33.3
**** **** *** ****
L molars % -54.8 -76.2 -78.6 -77.8 -90.0 -82.4 -70.6 -93.3
**** **** **** **** **** **** **** ****
U anterior % 0 -22.7 +13.3 +11.2 -25.5 +23.6 +20 -6.6
** **** *** ** **
U premolar % -30.0 -27.3 +14.3 -33.3 -38.9 -30.1 -11.4 -53.3
**** **** *** **** **** **** ****
U molar % -27.6 -45.4 -30.8 -43.5 -47.0 -46.7 -22.8 -46.7
**** **** **** **** **** **** *** ****
The levels of significance of differences between the % incidence of pattern A(+) and B(-) wear for mandibular (L) and maxillary (U) sextants for positive findings
to eight items of clinical information relating to bruxism [as detailed in Table 1].
– p values calculated using chi square methods.
– Negative percentage values represent B type wear being more common than A type.
– Values in bold signify significant results (p<0.05). * p<0.05. ** p<0.025. *** p<0.01. **** p<0.005.
– Values in italics signify nonsignificant results.

Wear patterns between groups
When comparisons were made between the three
groups, bruxers, possible bruxers and non-bruxers;
overall, the preponderance of occlusal erosion
(Pattern B) in all groups was striking (Fig. 6). No
significant difference was found between the
incidence of erosion in bruxers versus non-bruxers.
However, comparing the percentages of attrition
(Pattern A) wear within each group, more attritional
wear was detected in bruxers. Moreover fewer
sextants in the bruxers had no wear (Fig. 6).
When sextants were analysed independently,
further differences between the bruxers and non-
bruxers emerged. Figure 7 illustrates these comparisons
as found in the anterior sextants. When wear on
incisor and canines was considered (Fig. 7), more
attrition than erosion was found on mandibular sextants
in all treatment groups. More maxillary anterior
sextants were affected by erosion in all treatment
groups. However wear, due to attrition, was found
equally on the mandibular and maxillary teeth of the
bruxer and possible bruxer groups, but less so in the
non-bruxer group. Wear not extending into dentine,
the no wear category, was relatively uncommon in the
anterior sextants of the entire sample.
Figure 8 details these comparisons for the
premolar sextants. Erosional wear was found more
frequently than attritional wear in all groups in all
mandibular and maxillary premolar sextants.
Attritional wear was commoner on the mandibular
premolars in the bruxer and possible-bruxer groups.
However, the non-bruxer group showed less
maxillary than mandibular attrition, and had a
greater incidence of no wear on premolar sextants
than possible bruxers and non-bruxers (Fig. 8).
Figure 9 examines the incidences of the two
patterns in the molar sextants. Lesions due to
attrition were uncommon on molar teeth regardless
of bruxism status, for less than 20 per cent of
124
sextants were affected in bruxers and possible
bruxers. Notably, virtually no attritional wear was
found in the non-bruxer group. Erosional wear was
found in approximately 50 per cent of maxillary
sextants of all groups. However, the mandibular
sextants were more severely affected by erosion; as
high as 80 per cent of sextants in non-bruxers being
affected. In contrast, no wear to dentine was
frequently found on the maxillary molars especially
on those of non-bruxers (Fig. 9).
Wear patterns within items
Table 3 compares the relative incidences of
attrition and erosion found in the sextants of the
subjects with positive findings for each item of
clinical information relating to bruxism given in
Table 2. In those subjects with positive responses to
all items, with the notable exceptions of tongue
indentations (Item 5) and linea alba (Item 6),
significantly more attrition than erosion was found
in the mandibular anterior sextants. The highest
difference of attrition over erosion at this site was
found in subjects given a diagnosis of bruxism (Item
7). Paradoxically, the lowest difference was found in
subjects confirmed to have had nocturnal grinding
or clenching (Item 2). In contrast to mandibular
anterior sextants, for maxillary anterior sextants,
significant differences of attrition over erosion were
only found in subjects confirmed to have had muscle
tenderness in the morning (Item 3), linea alba (Item
6) and the diagnosis of bruxism (Item 7) (Table 3).
The premolar sextant comparisons for each item
clearly indicated that erosion was significantly more
common in positive respondents to all items with
one exception: the lower premolar sextants showed
more attrition than erosion in the 15 subjects for
whom treatment had been given (Item 8).
Paradoxically, erosion was much commoner in
upper premolar sextants of the same subjects.
Australian Dental Journal 1998;43:2.
 The within-item comparisons between attrition
versus erosion on the molar sextants showed that
both upper and lower molar sextants were
significantly more affected by erosion in the subjects
who confirmed positive for all items of clinical
i n f o rm ation. Specifically, in the lower molar
sextants, greater than 90 per cent more erosion than
attrition was found in subjects positive for tongue
indentations (Item 5) and if treated (Item 8).
Discussion
Overall, this study shows that tooth wear patterns
are unreliable indicators of bruxism, that dental
erosion is strongly associated with perceived
bruxism, and that where attrition is found in
association with bruxism it may well be an indicator
that acid demineralization is softening the teeth
making them more susceptible to the forces from the
bruxing habit.
One-third of the subjects had been given the
suggestion/diagnosis that their condition was due to
a parafunction/habit. In order to make this diagnosis,
the clinician had to rely on the presence of
symptoms and signs. The cardinal sign of bruxism is
clenching or grinding of the teeth when asleep,
particularly if obser ved by a partner or parent (Item
2). This item was only positively confirmed for 23
subjects, whereas 37 subjects had been given this
diagnosis (Item 7). This raises two questions: how
reliably can an ‘unconscious’ habit be reported by a
patient if not confirmed by a partner or parent?
Secondly, why was the diagnosis of bruxism given to
37 subjects without positive verification of this sign
(Item 2) in 14 of them? It may be that other items,
symptoms or signs, were elicited, but the inference is
that wear on the occlusal surfaces of the teeth was
taken as the main indicator of bruxism. If nocturnal
bruxism is the primary cause of occlusal attrition,
then attrition would be the predominant wear
pattern found in subjects who present with signs and
symptoms indicative of bruxism. However, this was
not the finding in this study.
A notional score derived from positive, weighted
responses to eight items of symptomatology or
treatment characterized one-third of the subjects as
a group of bruxers. When these eight items were
analysed independently some interesting associations,
and lack of associations, with patterns of tooth wear
emerged. The 37 subjects who had been given the
suggestion/diagnosis that their condition was due to
a parafunctional habit (Item 7) were found to have
more upper and lower incisor and canine attrition
than those not so diagnosed (Table 3). However, on
the upper and lower molars of the same subjects,
considerably more sextants were found to be
affected by erosion and very little by attrition (Fig.
9). Clearly, the diagnosis of bruxism may be
Australian Dental Journal 1998;43:2.
sustainable by anterior attrition, but is an inadequate
explanation for the erosion and lack of reciprocal
wear in the molar regions. The 32 subjects who
responded positively that they ground or clenched
their teeth when stressed or concentrating during the
day (Item 1) showed no appreciable differences in
anterior tooth wear patterns (Table 3; Fig. 6). The
molar and upper premolar sextants of subjects with
this symptom were more affected by erosion than
attrition (Table 3). These findings suggest that this
symptom is not reliably associated with attritional
tooth wear. More attrition than erosion was found
on lower incisors and canines in nocturnal grinders.
However, the presence of equal amounts of erosion
and attrition on the upper anterior teeth of these
subjects (Table 3) did not substantiate that
reciprocal incisal and canine attrition could be a
cardinal sign of bruxism.
In the absence of confirmation of the nocturnal
habit of bruxism (Item 2), the symptom of muscle or
TMJ tenderness or stiffness on waking (Item 3)
seems good supportive evidence, as does the sign of
tenderness on palpation (Item 4). Although only 14
of the subjects complained of this symptom (Item
3), attrition rather than erosion was more prevalent
on the upper and lower anterior teeth and on the
upper and lower premolars in these subjects. More
attrition was also found in these sextants in bruxers
compared with non-bruxers as scored by all items.
Thus, it can be inferred that this reciprocal attrition
on the upper and lower incisors, canine and
premolar teeth is associated with a nocturnal
clenching habit which gives rise to the symptom of
muscle stiffness or joint tenderness on waking.
However, tenderness on palpation of the muscles
and joints at presentation (Item 4), did not seem to
link bruxism with reciprocal attrition on the teeth.
This sign was only associated more commonly with
lower anterior attrition.
What can be said of the soft tissue signs of tongue
indentations (Item 5-20 subjects) and linea alba of
the buccal mucosa (Item 6) found in 34 subjects?
Erosion was found more commonly than attrition on
all sextants of subjects with tongue indentations, and
in all sextants with the exception of the upper
anterior, in subjects with linea alba. If these are
reliable soft tissue signs of nocturnal parafunctional
habits, there is a stronger association of erosion with
bruxism than of attrition with bruxism in these
subjects.
The finding that attrition affected the anterior
sextants more than posterior sextants in the bruxer
group may suggest that the forces of bruxism
produce more pronounced effects on the anterior
than in the molar sextants. Moreover, as attrition
was roughly equally distributed in all three groups, it
is clear that attrition on lower incisors alone cannot
125
be used as a reliable discriminator of bruxism from
erosion.
Attrition, and less often erosion, was found in the
mandibular anterior sextant. This is consistent with
the concept that saliva protects lower incisors against
erosion and thus attrition would be more commonly
found in this sextant in all three groups. The findings
that both mandibular and maxillary anterior sextants
are affected equally by attrition, but unequally by
erosion, are in accordance with the findings from
other studies that maxillary teeth are less well
protected by saliva from the effect of acid erosion.12,15
The distribution of the patterns of wear on the
premolar sextants can be interpreted as follows. The
maxillary premolars of the sample experienced
equivalent exposure to erosion as did the maxillary
incisors and canines with 50-60 per cent of sextants
being affected in all groups (Fig. 8). Bruxism played
a part, for more attrition was encountered in the
b ru xer group. The occlusal surfaces of the
mandibular premolars appeared to have less salivary
protection against acid demineralization than did the
mandibular incisors because more erosion than
attrition was encountered. Subjects with no wear no
premolar occlusal surfaces tended to be non-bruxers,
with equivalent lack of wear in the mandibles and
maxillae, unlike the molar sextents.
How can the data for the molar sextants be
interpreted? The occlusal surfaces of mandibular
molar sextants in the subjects, unlike their maxillary
counterparts, were commonly affected by erosion.
The absence of attritional wear, the relative absence
of erosion on maxillary molars, and the numbers of
maxillary molar sextants which were devoid of wear
in non-bruxers (Fig. 9), suggest that the occlusal
surfaces of maxillary molars are better protected by
saliva than the occlusal surfaces of mandibular molars.
The preferential effects of erosion on mandibular
versus maxillary molars has been noted in other
studies.15,16 Ultrastructurally, attritional wear facets
can be found on occluding surfaces adjacent to cupped
lesions of erosion on mandibular molar teeth. How-
ever, the opposing maxillary teeth may be relatively
unaltered by erosion, and attrition is minimal (Fig.
4). This suggests that maxillary molar teeth,
protected by saliva, are harder than the opposing
mandibular teeth softened by erosion. There is
evidence from this study that the superimposition of
bruxism produced attrition in the molar sextants, for
some 20 per cent of sextants were affected by
attrition in bruxers and possible bruxers (Fig. 9).
The findings agree with previous statements in the
literature that reliance on tooth wear as a diagnostic
indicator of bruxism is not recommended.1,8 In
contrast, the combination of absence of attrition or of
erosion on maxillary molars of non-bruxers (Fig. 4),
with a predominance of erosion on mandibular
126
molars found in the non-bruxers (Fig. 5), is an
excellent indicator of a solely extrinsic or intrinsic
acid aetiology.
Conclusion
The comparisons of tooth wear patterns between
three notional groups of bruxers, possible bruxers
and non-bruxers showed that the wear pattern which
predominated in all sextants in all groups was that
associated with dental erosion. This reaffirms
Xhonga’s observation3 that the tooth wear found in
bruxism has a strong association with dental erosion.
Further, the clinical impression is confirmed that it
is dental erosion that affects most of this South East
Queensland sample selected by referral for tooth
wear, although one-third could be classified as
bruxers. However, as attrition was found more
commonly in certain sextants in the bruxers and
possible bruxers, it is probable that the forces of
parafunctional habits exacerbate wear in teeth
moderately softened by acid demineralization.
It is an interesting reflection that the historical
indigenous peoples of Australia experienced
considerable occlusal attrition/abrasion which was
not considered to be due to bruxism.6 In a more recent
study using ‘bruxofacets’ as criteria, indigenous
tooth wear was inferred to arise in part from
bruxism.7 This present South East Queensland non-
indigenous sample which was referred for tooth wear
was largely affected by erosion with, in some
instances, superimposed attrition ascribable to
bruxism. This emphasizes that in current dental
practice in Queensland at any rate, clinical
examination and history-taking of patients with
tooth wear should range widely over the life-style
factors which cause erosion rather than be narrowly
focused on indicators of bruxism.
Acknowledgements
The vigilance of the many dentists who referred
the patients for differential diagnosis of tooth wear is
gratefully acknowledged. Informed consent was
obtained from the patients for the use of their
records and study models in this project, which was
conducted in accordance with National Health and
Medical Research Council ethical guidelines. The
Australian Dental Research Foundation
Incorporated is thanked for supporting Mr Farid
Khan through a Student Scholarship and by Project
Grant No. 96 ADRF004G.
References
1. Pavone BW. Bruxism and its effect on the natural teeth. J
Prosthet Dent 1985;53:692-6.
2. Wigdorowicz-Makowerowa N, Grodzki C, Panek H, Maslanka
T, Plonka K, Palacha A. Epidemiological studies on prevalence
and etiology of functional disturbances of the masticatory
system. J Prosthet Dent 1979;41:76-82.
Australian Dental Journal 1998;43:2.
3. Xhonga F. Bruxism and its effect on the teeth. J Oral Rehabil
1977;4:65-76.
4. Lindquist B. Bruxism in twins. Acta Odontol Scand
1974;32:177-87.
5. Every RG. Sharpness of teeth in man and other primates. Postilla
1970;143:1-30.
6. Barrett MH. Dental observations on Australian Aborigines.
Continuously changing functional occlusion. Aust Dent J
1958;3:39-52.
7. Kaidonis JA, Townsend GC, Richards LC. Nature and
frequency of dental wear facets in an Australian Aboriginal
population. J Oral Rehabil 1993;20:333-40.
8. Woda A, Gourdon AM, Faraj M. Occlusal contacts and tooth
wear. J Prosthet Dent 1987;57:85-93.
9. Vanderas AP, Manetas KJ. The relationship between malo-
cclusion and bruxism in children – Review. Paediatr Dent
1995;17:7-12.
10. Bruggen Cate HJ ten. Dental erosion in industry. Br J Industr
Med 1968;25:249-66.
11. Petersen PE, Gormsen C. Oral conditions among German
battery factory workers. Community Dent Oral Epidemiol
1991;19:104-6.
12. Eccles JD, Jenkins WG. Dental erosion and diet. J Dent
1974;2:153-9.
13. Meurman JH, ten Cate JM. Pathogenesis and modifying factors
of dental erosion. Eur J Oral Sci 1996;104:199-206.
14. Lewis KJ, Smith BGM. The relationship of erosion and attrition
in extensive tooth-tissue loss. Br Dent J 1973;135:400-4.
Australian Dental Journal 1998;43:2.
15. Järvinen VK, Rytomaa I, Heinonen OP. Risk factors in dental
erosion. J Dent Res 1991;70:942-7.
16. Teo C, Young WG, Daley TJ, Sauer H. Prior fluoridation in
childhood affects dental caries and tooth wear in a South East
Queensland population. Aust Dent J 1997;42:92-102.
17. Kampe T, Hannerz H. Five-year longitudinal study of adoles-
cents with intact and restored dentitions: signs and symptoms of
temporomandibular dysfunction and functional recordings. J
Oral Rehabil 1991;18:387-98.
18. Greaves WS. The inference of jaw motion from tooth wear
facets. J Palaeontol 1973;47:1000-1.
19. Rensberger J. An occlusion model for mastication and dental
wear in herbivorous mammals. J Palaeontol 1973;47:515-28.
20. Imfeld T. Dental erosion, definition, classification and links. Eur
J Oral Sci 1996;104:151-55.
21. Sauer H. The epidemiology of tooth wear in southern
Queensland. Brisbane: The University of Queensland, 1994. B
Dent Stud thesis.
22. Zero DT. Etiology of dental erosion – extrinsic factors. Eur J
Oral Sci 1996;104:162-77.
23. Young WG. Diet and nutrition for oral health: advice for patients
with tooth wear. Aust Dent Assoc News Bulletin 1995;224:8-10.
Address for correspondence/reprints:
Associate Professor W. G. Young,
Department of Dentistry,
The University of Queensland,
Brisbane, Queensland 4072.
127