Tooth Wear

Presented by
Dr Rinu Sharma
Dept. of Prosthodontics

“CURRENT CONCEPTS ON THE
MANAGEMENT
OF TOOTH WEAR”.

 BRITISH DENTAL JOURNAL VOLUME 212

Authors :
- S. B. Mehta, S. Banerji, B. J. Millar and J.-M. SuarezFeito

Current concepts on the
management of
tooth wear
1. Assessment, treatment planning and strategies for

the
prevention and the passive management of tooth
wear.
2. Active restorative care 1 : the management of

localised tooth wear
3. Active restorative care 2 : the management of

generalised tooth wear
4. An overview of the restorative techniques and dental

1. Assessment, treatment planning

and strategies for the
prevention and the passive
management of tooth wear.

. BRITISH DENTAL JOURNAL VOLUME 212 NO. 1 JAN
14 2012

CONTENTS  Introduction of tooth wear  Sub – classification of tooth wear & etiological factors  Assessment and diagnosis  Strategies of prevention  Passive management  Monitoring .

trauma or as a result of developmental disorders. vertical loss of enamel from physiological wear to be approximately 20-38 μm per annum . in 1989process estimated the normal  Normal physiological & irreversible. Lambrechts et al.Introduction  ‘Tooth Wear’ (TW) is a general term that can be used to describe the surface loss of dental hard tissues from causes other than dental caries.

Hattab. Int J Prosthodont 2000. Othmanvertical M.  Is disproportionate for the age of the patient  Symptoms of discomfort are present.  Faiez N.Pathological ?  Excessive to the extent that it is associated with functional or esthetic concerns by the dental patient or operator.13:101–107 . Yassin.dimension Etiology and Diagnosis of Loss of occlusal Tooth Wear: A Literature Review and Presentation of Selected Cases.

14% of surfaces examined showed marked enamel wear or dentinal exposure (Acta Odontol Scand 1988. Hugoson et al.46:255–265). (Community Dent Oral Epidemiol.Review of Prevalence studies There is growing evidence that erosion. in a Swiss population (aged from 26 to 30 years) it was 30%.to 29-year-olds. is the major cause of tooth wear. . reported that in 20. in a study of a group of Swedish adults.19: 286–290). The prevalence of dental erosion in adults in the United States was 25%. rather than attrition or abrasion.1991.

concluded that the percentage of adult patients presenting with severe tooth wear increased from 3% at the age of 20 years to 17% at the age of 70 years. (Shaw L. with a tendency to develop more wear with age. Erosion in children: An increasing clinical problem? Dent Update 1994.) Van’t Spijker et al. . Another study in the United Kingdom showed that almost half of children aged from 4 to 5 years exhibited some sign of erosion. Smith A. and 17% had exposed dentin.21:103–106.

Erosive tooth wear: diagnosis. Jaeggi T.5 years was identified. risk factors and prevalence. Zero D. . Erosion was included in the UK’s Children’s Dental Health Survey in 1993. Hellwig G. Am J Dent 2006. . 19: 319–325.5 years and 4.When reassessed in 1996/1997 a trend towards a higher prevalence of erosion in children aged between 3. Lussi A.

the term ‘tooth surface loss’ (TSL) was suggested by Eccles in 1982 to embrace all of the etiological factors regardless of whether the exact cause of wear has been identified. With life expectancy increasing .problems associated with tooth wear are likely to place greater demands upon dental professionals .  Difficult to isolate a single etiological factor.Tooth wear  Has a multi-factorial etiology.more people keep their natural dentition into old age .  So.

.There are four sub-classifications of tooth wear lesions:     Attrition Erosion Abrasion Abfraction.

.described as abfraction by Grippo Ronald G.Surface loss can be differentiated into 3 general causal categories: Mechanical loss .Erosion Biomechanical . 10: 224-233. Verrett.Attrition and Abrasion Chemical loss . J Prosthodont 2001. Analyzing the Etiology of an Extremely Worn Dentition.

(Eccles) Common occurrence – incisal and occlusal contacting surfaces .Attrition Attrition may be defined as the physiologic wearing away of tooth structure as a result of tooth-to-tooth contact. with possible abrasive substance intervention . as in mastication.

Appearance of a small polished facet on the cusp or ridge. Progressive lesion .Tendency towards the reduction of the cusp height and flattening of the occlusal inclined planes.Clinical manifestation Early manifestation .there may be a marked shortening of the clinical crown height of the affected tooth/teeth respectively . with concomitant dentine exposure. or the slight flattening of an incisal edge.  Severe lesion .

wear.wear facets with An example of pathological tooth sharply defined line angles. has a significant etiological role asymptomatic teeth. .Mechanical wear . where attritional wear rate as adjacent enamel. and histories that include para-functional habits. with a multi-factorial restorations that wear at the same etiology.

Erosion Erosion has been defined as the loss of tooth surface by a chemical process that does not involve bacterial action.  It is caused by the chronic exposure of dental hard tissues to acidic substrates which may be of an intrinsic or extrinsic source .

 Perimolysis .  Intrinsic Erosion .often seen to occur on the labial surfaces of maxillary anterior teeth. typically in the form of scooped out depressions .Extrinsic Erosion .The classical lesions seen as a result of chronic vomiting. . localised to the palatal surfaces of the maxillary anterior teeth.most often seen on the palatal surfaces of the maxillary anterior teeth. resulting in a concave depression of the entire palatal surface.

resulting in a shallow. Progressive lesion . glazed surface that usually lacks developmental ridges and stain lines and are usually free from plaque deposit. smooth.Clinical manifestation Bilateral concave defects without the chalkiness or roughness  Early lesions .Dentine exposure will occur and the lesion may take on a rather dulled appearance.May be evidence of ‘cupping’ of both the occlusal surface of posterior teeth and the incisal edges of anterior teeth .Affects enamel layer. Severe lesion .

Example of a case showing erosive wear resulting from chronic gastric reflux affecting the palatal surfaces of the upper anterior teeth Chronic regurgitation related to alcoholism causing severe erosion of the maxillary teeth with minimal surface loss on the mandibular teeth. .

elevated islands of restorative material. such as amalgam. and unstained but frequently hypersensitive teeth. .Chemical wear has distinctive characteristics: occlusal cupping and cratering with rounded margins. erosion lesions that do not articulate with opposing surfaces.

habit of overzealous tooth brushing. Common cause . . The site and pattern of lesion is usually determined by the offending object.Abrasion Physical wear of tooth surface through an abnormal mechanical process independent of occlusion It involves a foreign object or substance repeatedly contacting the tooth ..

Maxillary Incisors : Habits such as the biting of nails.Clinical manifestation Lesions are typically rounded or ‘V’ shaped ditches seen on the buccal/labial surfaces in the region of the cement-enamel junction.Canine & Premolars : tooth brushing . • Common site : . threads. hair pins or a wind instrument . a pipe stem. pins.

Note the ‘V’ shaped appearance of these lesions .Selection of views to demonstrate tooth wear by abrasive tooth brushing habits.

abrasion being the most likely major component .Lesions on the cervical areas of the lower teeth.

Abfraction Abfraction has been defined by (Imfeld) as the loss of hard tissue from eccentric occlusal loads leading to compressive and tensile stresses at the cervical fulcrum area of the tooth. which has the effect of producing classical wedge shaped defects with sharp rims at the cement-enamel junction . Tensile stresses weaken the cervical hydroxyl- apatite.

but are often typified by the presence of recurrently failing cervical restorations The extent of the lesions is dependent on the size. direction.Lesions are less commonly seen amongst teeth which may display signs of mobility. frequency and location of the forces concerned. duration. .

Two examples of wear seen on the cervical area of the 24 which are also in occlusal contact on excursion .

Assessme nt .

of any preventative . if any. in order to prevent or reduce non-carious destruction of tooth substance it is important to: Recognize that the problem is present Grade its severity Diagnose the likely cause or causes  Monitor progress of the disease in order to assess the success.According to Holbrook and Arnadottir.

Less commonly.PATIENT HISTORY  Chief complaint .Difficulties with function. comfort (pain and sensitivity) . unattractive teeth/restorations or tooth discoloration) .  Common complaints associated with tooth wear include concerns relating to: .must first be evaluated. .Aesthetic impairment (fractured. such as the efficiency of mastication or lip/cheek or tongue biting.

 Medication : . Bricanyl powder form  Others associated with dental erosion are : .Iron preparations . .Chewable Vitamin C ( ascorbic acid) .31 to 9.Asthma inhalers : contributes to dental erosion.Aspirin (salicylic acid) .g.Asthma medication : PH range from 4.30 e.Medical history  May reveal underlying condition which preclude complex treat plan  Insight into etiology of wear pattern observed.

Wear has been exacerbated by a recent history of xerostomia. Right: Palatal/occlusal view .such as diuretic agents and antidepressant drugs. Left: Facial view. with major attritional and erosive components. . Advanced generalised.Other drugs through inducing xerostomia may also be causative of tooth wear. pathological tooth surface loss in a 79-year-old female.

oesophagitis. (and volume)  Cyclic vomitting syndrome  Pregnancy (regurgitation & morning sickness) . sphincter incompetence.Medical conditions Presence of a gastro-oesophageal reflux as seen in : - anorexia nervosa. or Erosion occurring on the lingual increased gastric pressure surfaces of the maxillary teeth is evidence of chronic regurgitation. bulimia nervosa hiatus hernia.

history of .the intensity .the type of toothbrush used.  For tooth wear. frequency and timing of tooth brushing . .the abrasivity of the dentifrice being used.Past dental history Provides useful information as to the patient’s previous level and experience of dental care.  previous experience of removable appliance/prosthesis wear experience .

.Social history Can reveal further insight into the etiology eg. . lifestyle stresses or occupational details which may also have a bearing on their ability to attend for treatment plans.

.amongst copper mine workers.Occupation history Erosive tooth wear . who may be exposed to ambient sulphuric acid used in the mining of this metal. Amongst frequent swimmers as a consequence of being exposed to chlorine in swimming pools.Affecting the labial surfaces of maxillary anterior teeth . .

cola. (Shaw and Smith. coarse food. . fruit juices and carbonated drinks. pickles.Diet history Of particular relevance are . 1994) .copious consumption of citrus fruits. with a reported per capita intake of 15 litres per person. vinegar (acetic acid).The consumption of soft drinks in the UK has increased seven fold between 1950s and 1990s with adolescents and children accounting for 65% of all purchases.

.

as binge drinking is often followed by vomiting. and holding objects between .  Pen/pencil biting.significant role in cases of pathological erosive wear.HABIT  Alcohol consumption .  Smoking especially pipe – smoking.

.PATIENT EXAMINATION Extra – oral examination  TMJ . clicking.Presence of any joint or muscle tenderness.  Maximum jaw opening ( less than 40 – restricted)  Parotid gland enlargement – seen in bulimic patient. crepitation. mandibular deviation on opening or closure or any associated aches/ pain should be noted. .bilateral muscle and joint palpation.

Facial vertical proportions should also be carefully examined.The use of electrical muscle stimulation techniques . . .Use of phonetic assessments (particularly the sibilant sounds) .Jaw tracking and .Facial soft tissue contour analysis.Assessment of the freeway space (FWS) .

Demonstrates a typical appearance resulting from loss of occlusal vertical dimension. note the presence of an ‘inverted lip profile’ .Fig.

abrasions and erosive lesions. fractures. detailing the presence or absence of teeth.restorations.  Level of oral hygiene should be assessed Dental chart should be completed.Intra – oral examination Detailed soft tissue assessment. . dental caries. failed restorations. Presence of buccal keratoses. Scalloping of the tongue Signs of xerostomia may give clues to the possible etiology.

anterior/posterior or generalised) and Severity of the tooth surface loss should be recorded (as being restricted to enamel only.The location of tooth wear (localised. into dentine or severely affecting the teeth or series of teeth). The Tooth Wear Index of Smith and Knight is most commonly described in literature. .

.

(no wear).• • BEWE (Basic Erosive Wear Examination) • • • • records the severity of wear on a scale from 0 to 3 for each sextant.(initial loss of surface texture).(greater than 50% loss of surface) . 0 . 1 .(less than 50% loss of surface) and 3 . 2 .

 Examination of the general alignment of teeth        Of importance are the presences (or absence) of: Crowding Rotations Tilting Drifting Spacing Over-eruption Mobility. .Intra – Oral examination contd… Comprehensive occlusal assessment is mandatory.

Overbite and over jet should also be measured and recorded.  Ease with which the patient can be manipulated into their retruded arc of closure should also be established. and tooth contacts in the intercuspal position (ICP) described. .  The presence of a stable centric occlusion (CO) should be determined.

The use of deprogramming devices should be considered. .the use of cotton wool rolls and wood spatulas. .  Commonly used examples of such deprogramming devices range from .More elaborate appliances such as anterior bite planes (Lucia jig) or full coverage stabilization splints.If patient cant be manipulated to CR due to protective neuromuscular reflexes.

hence the retruded contact point (RCP) should be identified and the presence of any ‘slides’ (and the direction of the latter) from CR to CO established.  If present.The first point of tooth contact in CR. any working side/non-working side occlusal interferences should be described. .  Tooth contacts during lateral excursive (canine guidance or group function) and protrusive movements of the mandible should be determined.

Special tests
Radiographs

- Good Quality periapical radiographs for teeth
displaying signs of wear or where active restorative
intervention is considered.
 Assessment of :
- signs of alveolar bone loss
- root surface morphology
- anatomy of pulp chambers of affected teeth
- pre-existing endodontic treatment, dental caries
- widening of lamina dura
- retained roots or signs of peri-apical pathology.

Articulated study casts
Casts poured in vacuum mixed die-stone should be mounted on

at least a semi-adjustable articulator in centric relation.
 Assessment of

- the occlusion in the absence of soft tissue/muscular
interferences.
- Impact of tooth over-eruption can be more readily assessed
- Tooth contacts in CR, during lateral excursive and protrusive
movements, and the presence of occlusal interferences can
be
more easily determined.
-

. The space gained by manipulating the mandible

into
CR can be noted and the effect of ‘opening the
bite’ on
the articulator on the residual dentition is also
seen, along with the effect of any trial occlusal
adjustments.
- The vertical and horizontal components of the
slide
from CR to CO can also be examined at this
stage.

Study casts of a patient displaying tooth
wear, mounted in centric relation on a semiadjustable articulator (left); right: diagnostic
wax up fabricated in accordance with an
accurate occlusal-aesthetic prescription

warmed gutta percha or electric stimuli to the tooth.Sensibility test Loss of vitality is often seen amongst teeth which display signs of severe wear. Involve the application of ethyl chloride. .  More appropriately ‘true’ vitality status of a tooth can strictly be established with the use of Doppler flow techniques.

Images should be appropriately stored Salivary analysis This can be undertaken for both stimulated and un-stimulated secretion rates and respective buffering capacities . posterior (left/right) views and occlusal views of both arches are very important.Intra-oral photographs Including anterior.

length. to assist in the evaluation of aesthetics. and inclination the wax up once duplicated by the means of a stone model can be used to fabricate a vacuum formed PVC matrix that can initially be used to demonstrate the proposed changes intra-orally by the application of a provisional crown and bridge material into the vacuum . tooth shape.Diagnostic wax mock-ups They form a useful visual aid and communication tool.

or used to form a polyvinylsiloxane (PVS) index.The wax mock-up can used as an aid to help form tooth reduction guides. assist with the fabrication of provisional restorations. which helps form direct resin .

Simple adjustment of a sharp cusp or incisal edge. .Application of a de-sensitising agent or glass ionomer cement over an area of exposed dentine. which will require immediate attention. . a composite resin bandage can be provisionally applied.Treatment Plan 1. . The first step involves the management of any acute conditions : .In some cases where aesthetics may have been compromised. .Pulpal extirpation or in severe cases a dental extraction. . an acute exacerbation of temporomandibular joint pain dysfunction may exist.Where there may be an underlying parafuctional tooth grinding habit.

such as caries control. .2. the management of active periodontal disease and oral mucosal lesions. Teeth of hopeless prognosis will need to be .Stabilisation of any underlying dental pathology should be subsequently undertaken. The next stage is of Prevention.

.Similar results have been reported by in vitro studies involving the addition of fluoride and xylitol to orange juice. particularly in cases where preventative advice has been successfully implemented. Fluoride .Addition of fluoride to potentially erosive beverages reduced their erosive potential. .Prevention  Wear progression appears to occur at a relatively slow rate.

Neutral sodium fluoride mouth rinse or gel should be advised & low ph rinses shouldn’t be recommended. . . The avoidance of toothbrushing shortly after acid exposure (commonly practised after vomiting) will also help to reduce the rate of tooth surface loss. .Colgate and Gel-kam.Fluoriguard mouthrinse.

4% stannous fluoride has been shown to be clinically beneficial  Potassium containing toothpastes Tooth Mousse ACP (GC). contains ‘Recaldent’ which is an ingredient derived from casein (part of a protein found in . Desensitizing agents .7% fluoride solution followed by the home application of 0.Use of a 0.

Beverage modification/dietary counselling . has the effect of increasing their respective erosive potential (in vitro) Reduction in the quantity and frequency of the consumption of fruits.shown to reduce the erosive potential of Coca Cola addition of citric acid – i. fruit juices.Addition of calcium lactate . carbonated drinks or any other acidic substrate would be beneficial advice .e Pepsi Cola with a ‘twist of lime’.

.to promote flow. Xerodent has the added benefit of containing fluoride. such as Proflyin (Propylactor AB.Alpharma.  Xerostomia . which may assist in reducing the effect of the erosive agent. Chewing gum containing carbamide can provide a rapid rise in salivary pH. Sweden) and Xerodent (Dumex. Denmark) to promote salivation.Consuming hard cheese or dairy products after the ingestion of an acidic beverage has also been suggested to be beneficial in promoting the re-hardening of enamel.

A change of habit. . such as drinking acidic beverages through a wide bore straw and the avoidance of swishing beverages in the mouth. The avoidance of overzealous tooth brushing. The use of less abrasive toothpastes and refraining from habits such as that of pen/ pencil .Habit changes . will help to reduce the rate of dental erosion. .

Splint therapy – . a full coverage hard acrylic occlusal splint should be constructed.Where nocturnal bruxism is confirmed. .g. e.A canine guidance to provide posterior tooth separation during lateral excursive and protrusive mandibular movements and .An even/shared anterior guidance on protrusion (provided by an anterior ramp) with posterior teeth disclusion . Michigan splint or a Tanner appliance The splint should be fabricated to provide an ‘ideal occlusion’ incorporating the presence of even centric stops .

.It is hoped that the splint therapy will permit muscle activity to return to normal function by disrupting the habitual pathway of closure into centric occlusion by removing the unwanted guiding effects of cuspal inclines and also by causing tooth separation.

An example of a Michigan splint Example of a lower Tanner appliance .

into which neutral fluoride gels or alkali in the form of milk of magnesia or sodium bicarbonate solution can be applied respectively.  The splint can be given in the form of a soft vacuum formed appliance modified to include reservoirs.Patients with erosion from gastric reflux.Acidic substances may accumulate within the splint and further exacerbate the rate of tooth wear. . .

The application of dentine bonding agents and fissure sealant to eroded areas may be helpful in providing some level of protection and reduce dentinal hypersensitivity Glass ionomer cements can be readily applied to worn surfaces for the same purposes. .Sealant restorations – .

.Referral to a medical practitioner – .Where xerostomia may have an underlying role. referral to a specialist in oral medicine may be considered.When the dental operator suspects a case of bulimia or reflux disease or other medical condition .

so the wear rate may ultimately return to that of a physiological rate Avoid restorative intervention where possible.Prevent further pathological wear. as this will undoubtedly commit the patient to costly. long term maintenance care .Monitoring Strategies Primary goal .

Sectional silicone index formed from the initial cast can be used as a reference guide.Monitoring can be undertaken .High quality sequential clinical photographs .Periodic study casts at approximately 6-12 monthly intervals .More precisely with use of computerised software to map changes in tooth surface profiles . .

.

.

It is vital to accurately assess and diagnose a patient presenting with tooth wear. there will undoubtedly be a small proportion of such cases which will require active restorative intervention.  However.Summary Tooth wear is a condition being frequently encountered by general dental practitioners. requiring long term monitoring and maintenance. preventative measures. . The majority of such cases can be successfully treated by passive.

4. pp 7476. Lambrechts P. 13: 101–107. 1994. Kreulen C. Int J Prosthodont 2000. Vanherle G. J Dent Res 1989. Vuylsteke-Wauters M. Tooth surface loss from abrasion. Int J Prosthodont 2009. literature review and presentation of selected cases. attrition and erosion. London: HMSO. Bartlett D. 3. Van’t Spijker A. 5. Etiology and diagnosis of tooth wear: a 2. 22: 35–42. Quantitative in vivo wear of human enamel.References 1. O’Brien M. Children’s dental health in the UK 1993. Prevalence of tooth wear in adults. Yassin O. . 68: 1752–1754. Braeme M. Hattab F. Dent Update 1982. Eccles J. 9: 373–381.

Qualtrough. Davies. Omar R. Verrett. 9.54:369–378. Acta Odontol 1996. Shaw L.21:103–106. Ronald G. Baghdadi S. 1 january 12 2002 . Gray and A. S. J Prosthodont 2001. Johansson A. 8. M. J. Analyzing the Etiology of an Extremely Worn Dentition. E. and the development of a system for assessing erosive anterior tooth wear. Management of tooth surface loss. Dental erosion. Erosion in children: An increasing clinical problem? Dent Update 1994. and oral health in young Saudi men. Carlsson GE. R. J. 10: 224-233 10. J. Johansson A-K. British dental journal volume 192 No.7. Smith A. soft-drink intake. Birkhed O.

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