Tooth Surface Loss (TSL) can be carious and non carious. This article will
concentrate on non carious TSL. TSL is experienced throughout a patients’ lifetime,
but when it accelerates over the normal amount it can lead to functional and
cosmetic concerns. TSL can be considered pathological if the degree of wear
exceeds the level expected at any particular age1,2. TSL can be classified in 4 ways,
abrasion, erosion, attrition and abfraction.
Attrition due to TSL from tooth contact3. It includes TSL from restorations, eg. a
porcelain restoration can cause attrition of opposing natural teeth. Attrition also
includes wear of a restoration (Glass ionomer) due to the opposing natural tooth.
Common causes for attrition TSL:
1. Parafunction eg bruxism4
2. Medication/medical conditions eg autism.5,6
3. physiological eg group function7
Diagnosis is by exam and questionnaire enquiring about causes. Clinical exam
generally reveals flattened cusps/incisal tips with equal wear of dentine and enamel.
It is known to affect approximal surfaces less. Attrition is generalised or localised. If
localised it is likely due to an artificial cause such as porcelain restoration.
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Figure 18
Abrasion is TSL due to mechanical wear from a foreign object3, eg. Musical
instruments, floss, toothpicks, biting objects and excessive tooth brushing.
Diagnosis is by questionnaire and examination. Possible questions include about
habits and tooth brushing. Looking at the patient’s toothbrush, toothpaste and
brushing technique is helpful. This includes time and frequency spent brushing,
amount of force used, stiffness of brush/ bristles.
Clinically, teeth have facial cervical TSL if due to toothbrushing. The TSL are
notches/ grooves with sharp angles. TSL will be generalised to at least 2-3 or more
teeth. It is unlikely one tooth with cervical TSL will be due to abrasion. It may be
more evident on either left or right side depending on if the patient is left or right
handed. It may have also caused a decrease in the zone of attached mucosa.
Pipes, toothpicks, floss can cause localised TSL, especially if the object is repeatedly
placed in the same location.
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Figure 29
TSL due to acidic substances is erosion3,10.
There are different methods to classify dental erosion (see tables 1, 2 and 3).
Diagnosis is by questionnaire and examination.
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Table 1. Scores and criteria of the Basic Erosive Wear Examination Index and the
Simplified Tooth Wear Index.
B.E.W.E.
S-T.W.I.
Score
Criteria
Score
Criteria
0
No erosive tooth wear
0
No wear into dentine
1
Initial loss of surface texture
1
Dentine just visible (including cupping) or dentine
exposed for less than 1/3 of surface
2
Distinct defect, hard tissue loss
2
Dentine exposure greater than 1/3 of surface
3
Exposure of pulp or secondary dentine
<50% of the surface area
3
Hard tissue loss ≥50% of the surface
area
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Table 2. Pathognomic criteria of the Evaluating Index of Dental Erosion.
Clinical criteria
Score 0: no erosive tooth wear.
Score 1: shallow defects located coronal from the CEJ or cupping of cusps, no dentine involved
Score 2: shallow defects located coronal from the CEJ or cupping of cusps, dentine involved.
Smith and Knight tooth wear index [30]
Score Surface
Criteria
B/L/O/I No loss of enamel surface characteristics
0
C
No loss of contour
B/L/O/I Loss of enamel surface characteristics
1
C
Minimal loss of contour
B/L/O Loss of enamel exposing dentine for less than one third of surface
2
I
Loss of enamel just exposing dentine
C
Defect less than 1 mm deep
B/L/O Loss of enamel exposing dentine for more than one third of surface
3
I
Loss of enamel and substantial loss of dentine
C
Defect less than 1–2 mm deep
B/L/O Complete enamel loss–pulp exposure–secondary dentine exposure
4
I
Pulp exposure or exposure of secondary dentine
C
Defect more than 2 mm deep–pulp exposure–secondary dentine exposure
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Tables 1,2 and 311
Erosion pits develop with smooth enamel and little staining if active. They develop
on any surface. Translucency and loss of enamel with dentine exposure occurs.
Over time the pit becomes wider and deeper. Erosion commonly develops
incisally/occlusally. Dentine is lost quicker than enamel, as it is easily
demineralised. Cervical erosion looks differently from abrasion as it is generally
wider and shallower, giving them a cupping appearance. 'Perimylolysis' is erosion
of the palatal surfaces (figure 3) due to reflux or emesis (holst and Lange 1939)12.
Erosion around restorations cause marginal defects and the appearance of
restorations being higher than the tooth.
figure 313
Erosion TSL can be further classified by extrinsic and intrinsic acids.
Extrinsic Acids include food, drinks, medicines (eg Vitamin C/aspirin tablets), and
environmental/occupational acids. Increasing frequency of consumption, amount,
type (frozen, concentrated) and how it is consumed (less TSL if drunk quickly or
through straws) increases erosion.
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Environmental acids include poorly chlorinated swimming pools, illegal tooth
bleaching substances, occupational hazards such as fumes from work 14, wine15 or
food tasting.
Intrinsic acids include physiological reasons of acids being produced internally and
coming into contact with the dentition. The reasons could be due to:
Anatomical defects like gastro oesophageal reflex disorders (GORD)/hiatus hernias.
Side effects of medicines like NSAIDS etc
Physiological conditions such as asthma can cause GORD. Diabetes can cause
gastroparesis which causes GORD. Pregnancy and progesterone increases affect
the function of the lower oesophageal sphincter, causing GORD. Xerostomia due to
old age, medication etc invariably means the acid environment of the oral cavity is
not neutralised.
Psychological issues like overeating, alcoholism, anorexia and bulimia nervosa all
cause acid reflux and erosion.
Intrinsic causes develop erosion on the palatal/lingual aspects. Extrinsic aetiologies
develop erosion labially/buccally.
Abfraction is controversial cause16,17 and is heavily debated. It is stress induced
TSL. Abfraction occurs cervically at the cement enamel junction (CEJ) as the tensile
and compressive forces concentrate here3,18.
Diagnosis is by elimination of other TSL and occlusal analysis for heavy/poor contact
points. Non working side interferences should be investigated. Signs and symptoms
of parafunction should be made. Abfraction is likely when there is a cervical lesion,
Post Graduate Diploma in Restorative Dentistry
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especially if v-shaped, subgingival and localised. Abfraction could be a sign of
occlusal disharmony. If the tooth is mobile with a class 5 TSL it is unlikely to be
abfraction, as the mobility dissipates the lateral forces which concentrate in the
cervical region.19 Darker sclerotic TSL lesions are usually not sensitive as the lighter
lesions.
Figure 4 20
Management
TSL management depends on the damage. Early TSL must be investigated,
diagnosed and treated of any pain/sensitivity.
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Identification of the disease process must be identified by starting with concise
questioning of habits, diet, medical history. Dietary factors should be identified with a
minimum 3 day diet sheet21. Diet analysis to control/reduce the causes can be
undertaken. Generic advice can be given, as most TSL is multifactorial3. A well
detailed questionnaire can be taken outlining possible habits, diet, parafunction,
medical history etc until diagnosis can be made22. It is important the patient
understands the cause and thus the possible treatment. This helps patient
compliance. The patient must seek a medical exam if there is history of a medical
condition. Suitable relevant specialists should be liased. For example if
bulimia/anorexia is diagnosed, psychiatric evaluation should be undertaken. If gastric
reflux is suspected, a general medical practitioner referral is appropriate.
Generic advice can be given until aetiology is identified:
Generic dietary advice:
Consume erosive beverages through wide straw.
Swallow immediately and not 'swish' around the mouth.
Teeth should not be brushed following erosive substance.
Finish meal with something neutral/alkaline (cheese/milk).
Chew xylitol gum unless attrition/parafunctional habits.
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Generic tooth brushing advice:
Avoiding excessive toothbrush time, frequency, pressure
Avoid abrasive toothpastes like natural or whitening/smokers toothpastes.
Avoid back and forth techniques but circular or Bass techniques.
Avoid hard bristled toothbrushes with no flexibility in the body.
Generic parafunctional/attrition advice:
Avoid chewy tough foods/objects in the mouth.
Avoid chewing gum
Provide hard acrylic splint
Reflux/emesis advice
Splints are useful in bulimics to protect their teeth during vomiting. Alkali (milk of
magnesia) or high fluoride can be applied to splints to neutralise any acid pooling.
Splints need extreme caution in use as there is a chance of acid being trapped
beneath.
High fluoride rinses, toothpastes like duraphat toothpaste (5000ppm sodium flouride)
and Tooth Mousse help remineralise teeth. Acidulated phosphate fluoride should be
avoided because of its acidity.
All risk factors associated with the different TSL should be addressed.
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If TSL is early then routine and regular monitoring can be undertaken. This is by
study models, silicone putty impressions23 and photos. The dexterity of the
photographer and ambient conditions affects the quality of photos and need to be
considered when comparing. Radiographs may be used if pulpal involvement is
suspected and possible periapical lesions. Tooth vitality tests can be undertaken.
If TSL has lead to irreversible pulpitis28, then extirpation/extraction must be
considered.
After a few months, reassessment should be undertaken to see how the response to
initial care. This should include whether the aetiology is still present or not. Patient’s
long term expectations/views could be addressed. If TSL is dramatic and
stabilisation is not slowing, restorative action should be undertaken, although
controversial24. Advantages/disadvantages should be outlined to the patient and
discussed in length. The restorations should be provided to protect existing dental
tissue25.
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If restoring the dentition has been decided, the treatment is dependent on the
amount of TSL, age and medical history. Some papers have attempted to provide a
classification for providing treatment depending on TSL types.26 (see Table 3)
TSL can be treated in the conventional way. Cervical lesions being treated with
composite, compomers and glass ionomer cements(GIC). Occlusal/incisal and
palatal lesions are treated with composites or if posterior could also include
amalgam. Exposed dentine in the occlusal and incisal areas can be be over-etched
(20–30s) to enhance opening of dentinal tubules and intratubular formation of resin
tags27. Composite is a good choice as it is not dissolvable by the acidic environment
like GIC which can be acid soluble28. However some authors have mentioned the
use of acid-etch when using composites actually exacerbates erosion TSL29,30.
Restoring advanced TSL becomes more difficult and depends on a number of
factors. Crown lengthening surgery, orthodontics and Dahl appliances can be utilised
if there is a large TSL with insufficient room for the preparation of teeth for
crowns/onlays.
If there is a large amount of TSL with loss stable intercuspal position (ICP) then a
reorganised approach may need to be investigated. This could include occlusal splint
therapy to check stability of a new ICP (from a retruded position) and facebow
analysis. The teeth are then temporised with long term provisionals restorations.
Once occlusion is stable, permanent lab-based restorations are provided.
If TSL is beyond restoring the teeth with laboratory restorations then overdentures
can be considered.
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If beyond overdentures, then extractions with provision of implants and dentures
maybe the only option left.
ACE CLASSIFICATION31
Table 3
PALATAL
ENAMEL
PALATAL
DENTINE
INCISAL
EDGE
LENGTH
FACIAL
ENAMEL
PULP
VITALITY
SUGGESTED
TREATMENT
CLASS I
REDUCED
NOT EXPOSED
PRESERVED
PRESERVED
PRESERVED
NO TREATMENT
CLASS II
LOST IN
MINIMAL
PRESERVED
PRESERVED
PRESERVED
PALATAL
CONTACT
EXPOSED
COMPOSITES
AREAS
CLASS III
CLASS IV
LOST
LOST
DISTINCTIVELY
LOST
EXPOSED
<2.1mm
EXTENSIVELY
LOST>2MM
PRESERVED
PRESERVED
PALATAL
COMPOSITES
PRESERVED
PRESERVED
EXPOSED
SANDWICH
APPROACH
(EXPERIMENTAL)
CLASS V
LOST
EXTENSIVELY
LOST>2MM
EXPOSED
DISTINCTIVELY
PRESERVED
REDUCED/LOST
SANDWICH
APPROACH
(EXPERIMENTAL)
CLASS VI
LOST
EXTENSIVELY
LOST>2MM
LOST
LOST
EXPOSED
SANDWICH
APPROACH
(HIGHLY
EXPERIMENTAL)
There is no clear TSL index which accounts all causes like age. TSL is only
pathological if it exceeds the normal amount of wear. So TSL it is difficult to
quantify/qualify32,33,34. Studies on the U.K. population TSL should only be considered
with tooth wear indices which account factors such as age.
The actual prevalence of TSL is unclear but it is increasing in the UK population 35.
Some evidence was seen in 25% of over 11 years old and on average between 58% of all age groups34,36,37. This could be attributed to a few reasons34.
Post Graduate Diploma in Restorative Dentistry
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There has been an increase in bruxism from occupational38,39 and student work
related stress38,40. This can increase attrition and TSL.
Another reason is an increase in the marketing of slim men and women. This has led
to an increase in body dysmorphia and eating disorders41,42,43,44,45. As such there
has been an increase in bulimia/anorexia and erosion/perimylolysis. Increases in
juice/sports drinks cause erosion as people become more physically fit
conscious46,47,48. Sports drink consumption can have a 2 fold problem as it is drunk
during dehydration of a sports activity. Saliva buffering will be lower and erosion will
increase. Refrigeration is now widely available and fruit production is plentiful
throughout the year. Availability of fruit juice means they can be consumed
throughout the year and is not limited to seasons. Public health messages now are
focused on healthy eating of more vegetables and fruit. Patients are unlikely to be
aware of the damage the acid erosion could do to their dentition. Parents feel “no
added sugar” options are healthier and think young babies and children are at no
harm from drinking copious amounts. Erosion is being seen in younger children.
As the population becomes healthier, people are living longer and having their teeth
longer. There is an increasing trend of restoring the dentition of the elderly, who
obviously have a more worn set of teeth.
Patients are increasingly having more aesthetic treatment, bleaching, composites,
porcelain restorations, even in the posterior region of the mouth. They all can
increase TSL. Porcelain causes attrition, phosphoric acids for composite and
bleaching can cause erosion. So called “whitening” toothpastes are generally
abrasive.
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The UK has a changing population. Since the 1950’s there has been an influx of
different cultures and diets. There is TSL prevalence in some communities than
others. Some communities use various traditional abrasive methods to clean their
teeth (miswaak49). Certain communities eat a highly abrasive diet, like high fibre
rice50.
Recreational drug use has been on the increase. From studies52 we are aware that
that this increases TSL.
If TSL is not prevented it will lead to early loss of teeth and occlusion, sensitivity and
pain, loss in face height, psychological effects of a poor dentition25.
Management of TSL is important. Early recognition/interception of TSL before further
damage is priority. Education to patient, dentist and doctor is vital. If severe TLS is
present patients should be educated on all the options. Without greater public health
education there will be increasing further TSL.
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50
Nutrition and Oral Medicine
Nutrition and Health, 2005, III, 107-127
Oral Consequences of Compromised Nutritional Well-Being
Paula J. Moynihan and Peter Lingström
Post Graduate Diploma in Restorative Dentistry
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