Discussion on the contemporary
management of tooth wear
13/12/13
Student:
Christopher Barley
Student number:
CDB275
Epidemiology
Tooth wear is an increasing problem for the population on a whole. In the adult
dental health survey of 2009, (1), it was found that moderate tooth wear had
increased from 11% in 1998 to 15% in 2009. Although severe tooth wear is low,
it is increasing and there are an increasing proportion of young adults with tooth
wear.
The percentage of tooth wear has been shown to increase markedly with age. In
adults age 18-24, 52% showed some tooth wear compared with 95% of 75-84
year olds.
Diagnosis/Measurement
The diagnosis of tooth wear would be made clinically and has been measured
historically with the use of stone models following impressions.
The diagnostic process would include
 A full medical history
 Social/family history and any obvious areas of stress
 Diet analysis
 Full clinical examination
Clinical features of erosion would include the loss of surface anatomy, the
“cupping” of surfaces of anterior teeth along with chipped incisal
edges/incisal translucency, and loss of palatal enamel
Clinical features of attrition would be flattening of surfaces on the
anterior teeth
This approach is not ideal due to the difficulty in reproducibilty and so other
methods of record taking such as photography and the BEWE (Basic Erosive
Wear Examination) can now be useful tools(2). BEWE is a scoring system, which
aims to simplify the measurement of tooth loss by means of looking at the
sextants of the mouth with their corresponding tooth loss and allowing a
reproducible transferable diagnostic aid.
Aetiology
There are three aspects to tooth wear, with the problem becoming greatest when
two or more are present at the same time.
Triad of:
1. Erosion-defined as, “the chemical or mechanicochemical destruction
of tooth substance, the mechanism of which is incompletely known,
which leads to the creation of concavities and many shapes at the
cementoenamel junction of teeth. The surface of the cavity, unlike
dental caries, is hard and smooth”.
Aetiology of erosion;
 Extrinsic-wines, soft drinks, heavily chlorinated swimming pools
 Intrinsic-gastrointestinal reflux, bulimia, anorexia nervosa
 Idiopathic
The erosive process can be influenced by factors including;
 Saliva.ie Flow rates, buffering capacity, reparative ions. Reduced flow rate
leads to increased possibility of erosion…i.e. surgery/Sjorgens
 Tooth composition and structure. i.e. hardness of an individuals
enamel/dentine, response to erosive attack
 Dental anatomy. i.e. shape and contour of teeth, parafunction, tooth
flexure (abfraction)
 Occlusion
 Soft tissue movements. i.e. increasing/decreasing acid contact with teeth
2. Attrition, which is defined as “the normal loss of tooth substance
resulting from friction caused by physiological forces”. This would be
the rubbing of tooth surfaces against each other and includes also
parafunctional habits of bruxism and clenching. Also included here
would be the commonly seen situation of a porcelain restoration
opposing a natural, unrestored tooth.
3. Abrasion-“The grinding or wearing away of tooth substance by
mastication, incorrect brushing, bruxism or similar causes” (Mosby’s
dental Dictionary 2004). This would normally be associated with
foreign objects, which most commonly would be tooth-brushing
action with abrasive toothpaste.
Prevention/Advice
Patients suffering erosion should be educated regarding the erosive components
of their diet. Avoiding sugary/fizzy drinks, reducing the overall intake of acidic
foods and drinks and to cool drinks where possible, and not brushing within 30 –
60 minutes of consumption of these items. The consumption of acidic foods
and/or drinks can cause weakening of the tooth surface which will lead possibly
to 10 times the rate of wear at the time of consumption.
Anorexia Nervosa or Bulimic patients should be advised regarding not brushing
their teeth after vomiting but instead to use an antacid mouthwash, and should
be referred to their GP or GIT consultant for treatment.
This is also the case for those suffering with Gastro-Oesophageal Reflux Disorder.
The only symptom of this may be the patient being aware of sometimes having
an acidic taste at the back of the mouth.
A treatment, which can be very effective, is the use of a protein pump inhibitor
prescribed by the patient’s general medical practitioner.
Oral hygiene advice regarding tooth brushing technique and the timing of tooth
brushing with regards to eating/drinking, the management of dental plaque with
its associated acids is another important patient education.
Clinical Treatment
Treatment of tooth wear needs to have a multidisciplinary approach. Following
appropriate diagnosis, this should consist of prevention, patient advice, clinical
treatment (restorative/non-restorative) and referral where necessary.
The active treatment of tooth surface loss should be aimed at protecting worn
and wearing surfaces from further tooth loss first and foremost.
 Fluoride. The use of a CPP-ACP compound as found in the likes of “GC
Tooth Mousse”, can be encouraged. This has been shown (3) to aid the
remineralization of enamel and as such should help to reduce enamel loss
 Composite restorations. The bonding to enamel is straightforward and
effective whilst bonding to dentine is less so. It can be argued that the
treatment of tooth surface loss is best initiated early while the enamel
surface area is greatest.
 Dahl appliance.
 Crowning teeth or other laboratory-based treatments should be avoided.
The preparation necessary to create such restorations is far too
destructive to be deemed necessary. It has been shown that crowned
teeth have a 15% likelihood of becoming non-vital after 10 years(4)
The Dahl Appliance
The “Dahl Principle” of treating worn teeth has been around since 1962. The
principle relies on obtaining space for the restoration of worn teeth. Evidence
shows that it is an effective treatment that can be confidently used (5).
The Dahl Principle works on the basis of building onto the anterior teeth and
then allowing the eruption of the posterior teeth to increase the occlusal vertical
dimension.
This will now be carried out ideally with the use of directly bonded composite to
the palatal surfaces of the upper anterior teeth.
The initial phase should be the bonding of composite to the upper anterior
palatal surfaces and then 1 week later followed by thorough occlusal
equalization. The review then following the initial bite equalization should be at
three months.
Over a period of 1 to 4 months, the posterior teeth will erupt into occlusion.
Patient Communication Regarding Restorations
Patients need to be aware that composite restorations will need occasional
repolishing and that composite will wear approximately at the same rate as
enamel.
Patients need to understand that the reason for the initial treatment is to correct
the problem with the occlusion. It may be the case that the initial treatment also
works on an aesthetic level but this is not necessarily always going to be the case
and further aesthetic treatment may be required.
Longevity
Studies show that the long term success of anterior composites (6) is sufficient
for this to be a recommended treatment for the treatment of tooth wear.
References
(1)White DA, Pitts N, Steele J, Cooke P, et al. 2011. NHS Information centre
(2) B. Dixon, M. O. Sharif, F. Ahmed, A. B. Smith, D. Seymour & P. A. Brunton.(2012),Evaluation of the basic erosive wear
examination (BEWE) for use in general dental practice. British Dental Journal vol:213 iss:3
(3) Ferrazzano, G. F., Amato, I., Cantile, T., Sangianantoni, G. and Ingenito, A. (2011), In vivo remineralising effect of GC
Tooth Mousse on early dental enamel lesions: SEM analysis. International Dental Journal, 61: 210–216.
doi: 10.1111/j.1875-595X.2011.00059.x
(4) Cheung, G. S. P.; Lai, S. C. N.; Ng, R. P. Y. (2005) Fate of vital pulps beneath a metal-ceramic crown or a bridge
retainer. International Endodontic Journal Vol. 38 Issue 8 Page Numbers: 521-530
(5) Poyser, N. J., Porter, R. W. J., Briggs, P. F. A., Chana, H. S., & Kelleher, M. G. D. (2005). The dahl concept: Past, present
and future. British Dental Journal, 198(11), 669-76; quiz 720. doi:http://dx.doi.org/10.1038/sj.bdj.4812371
(6) Burke, F. J. T., Kelleher, M. G. D., Wilson, N. and Bishop, K. (2011), Introducing the Concept of Pragmatic Esthetics, with
Special Reference to the Treatment of Tooth Wear. Journal of Esthetic and Restorative Dentistry, 23: 277–293.
doi: 10.1111/j.1708-8240.2011.00462.x