wear-of teeth-an update

8/7/2019 wear-of teeth-an update

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General Dentistry

An update on the etiology of tooth wear

Abstract Tocth wear is an ever-increasing problem, and younger patients are particularly

atrisL The pnM ein is likely to continue as patients' deman ds and expectations rise

atid as mownatural teeth are retained into old age. T he etiohigy of tooth wear

is reviewed, with emph asis on those factors that appear to be major cutitributiirs lo

the ptvblent at tiie tmiment. The clinical appearance of tooth wear is also discussed.

It would appear that erosive lactors ar e a significant c ause of tooth wear. The

prominence of acidic damage qf tooth tissue is probably a re/lection oj society's

coneern with heahhy eating and appearance. (Quintessence Int 1997:28:305-313.)

the cause of tooth wear is important for

the long-term prognosis of the dentition and

of the etiologic factors

may be diffieult to

entify and control because ofconfiicting priorities

the patient.

rious loss of tooth tissue is a normal physiologicand oceurs throughout life,' Problems arise,

if the rate of loss or the degree of destructionor esthetic

or sensitivity for the patient. Diagnosis ofve loss can be difficult if dec isions are based on

of limited

in Reslorallve Denlislry, Charles Clifford Dciilüi

Hospilal, Shafnekl, England,

in ResUirative Denlibtry, Kmgs Denial Inslinite. Lon-

don, Enelancl.

inRcsnirjiive Dtiilislry, <liiiries CiiiTiird Denial Hosni-

lal, Slicflield, Englimd.

Dr Karl Bishop, Senior Re¡:istrar in ResloraliveCh arle s Clifford Denial Hos pitói, Wellesly Road, Slieffieid,

Il4 27l7)j jû,

and confiicting data, Lamhrechls et al.- for example,

considered normal loss of enamel to be between 20 to

38 iim per year, while Xhonga' reported similar

figures for a 6-month period. Because it is difficult to

quantify normal loss. Smith and Knighf̂ suggested that

the rate of loss be considered patho logic if it is likely to

prejudice the survival of the teeth or is a source of

concern to the patient.

Traditionally, the terms erosion, abrasion, and

attrition are tised to describe noncarious, pathologic

loss of tooth tissue," These terms refiect the specific

etiologic factors that are associated with the loss of

tooth tissue, Eccles," however, suggested that tooth

surface loss be used to embrace all three individual

descriptions because a single etiologic factor is often

difficult to identify (Figs la and lb). Subsequently.

Smith and Knighf* contended ihat tooth surface losbelittles the severity of the problem and advocated the

use of the term tooth wear{T<N). For clarity's sake, TW

will be used throughout this article to describe the

pathologic, noncarious ioss of tooth tissue. However,

care should be taken in the tise of this term because it

may suggest an attritional or abrasive etiology and

diminish the importance of erosion, which appears to

bea ma jorcon tributorto the loss of tooth tissue,'^ The

terms erosion, abrasion, and attrition will be used,

however, lo describe specific etiologie factors.

The dental management of patients with TW ha

provided d illkultics for the dental profession for many



Bisflop et al

Figs la and 1 b Ma>;illary and mandibular teefh of a patienf wifh TW of unknown efiology The rTia;<illary leelh fiave a g"rounded" sfiape and have lost their surface characfenslics, suggesting tfie presence of erosive fac fors Howevemaxillary le fl cenfral and lateral incisors fiave a marked cervical "grooue" ffiaf corresponds wifh toothbrush abraston, whirnandibular incisors fiave tiatfened incisai edges, indicating an aftritional etiology.

Figs 2a and 2b fvlaxillary anterior teeth of a f6-yea r-old girl wifh marked TW The palienf adm itted fo consuming 2.5carbonafed "diet" scfl drinks a day. Note fhe sfiorf crown heights and visible pulps Occlusal contact is mainfaineintercuspal position despite substanfial TW Nofe also tfie "cupped" lesion affecfing the incisai edge of fhe maxillary canine and the unaffected enamel at the gingival margins of fhe teefh

years, and it is generally agreed that tfie profilcm is

increasing," This can partly be explained by tfie factthat the population is retaining more natural leeth into

old age."'""'' Hovvever. it ¡s not only the middle-agedand e lderly populations thai suffer but also younger age

groups'' (Rgs 2a and 2bl. Robb,'" for example,observed greater TW in individuals younger than 26

years of age than in many older age groups. Similarly,the Child Dental Health Survey ( 1994 ) " reported that

32% of 14 year olds in the United Kingdom hadevidence of damage to the palatal surfaces of their

permanent incisors. These observations cannot be

explained as an age-related phenomenon but mayreflect changing lifestyles and soeial pressures that

have led to the increased prominence of partic

etiologic factors.The aim of this article is to provide an overview

the etiology of TW„ with emphasis on factors that

currently thought to be major contributors to problem.

Erosion

Dental erosion is the progressive loss of hard de

tissnes by a chemieal process not involving bact

action," Acid is probably the most common causerosion and leads to demineralization o fthe inorgmatrix ofthe tooth, Mannerberg,'- in an in vivo st



Bishop et a

Total Soft Drinks Sales (VK\.Peicentage MaiketShare for

^Diet 'Soft Drinks.

g 3 Total Suit drink sales (United Kingdom ), Fig 4 Market share for diet sott drinks.

bed two distinct erosive lesions; active lesions, in

It wotild appear that erosion either by itself or in

TW, Smith and Kjiighl.''^ for example, could

11% ofthe

Acidic foods and drinks are now widely available

gnificant com ponent of many diets. This is

65% of sales, and 42% of fruit drinks are

2 and 9

years.** '̂ It has been suggested that theconsu tnp tion ofsoft drink s by the yo ting, in particular, accounts for thehigh incidence of TW observed in the United King-

dom." Hccles-' confirmed the impoHance of softdrinks when he reported that they are implicated as

etiologic factors in 40% of patients with TW,

Societal concern with slimncss and "healthy eatitig"has lead to an Increase in consumption of "diet" foods

and beverages. For example, diet drinks now accountfor a large share ofthe market in the United Kingdom

(Fig 41 , These low-calorie beverages are also acidicand hav econ stituentssim ilarto those of the traditional

beverages. It is unclear whether diet drinks are more

destructive of tooth tissue than the sugar-containingalternatives, although there is some evidence to

suggest that carbonated drinks are less destructive thannoncarbonated drinks,'''-" Unfortunately, unlike the

sugar-containing drinks, the potential for erosivedamage by these diet beverages may not be well

understood by the public,

A healthy diet may also contain substantial acidic

foods,-'"-'' which also have the potential to cause lossof tooth tissue. Furthermore, the abrasive nature of

many ofthe components of these diets may accelerateTW,

Another source of dietary acids is associated with

orally adm inistered medicines and drugs, such as irontonics, chewable vitamin C tablets, and replacement

hydroc hloric acid used by patients with gastric achlor-

Régurgitation ero.'iion

Régurgitation is the return of gastric contents to the

mouth and is usually described as involuntary or



Bishop et al

Fig 5 Maxillary teeth of a professional pck ey who usedrégurgitation as a method to control his weight. Note thedistribution of the looth surface loss; the palatal surfaces ofthe maxillary leeth are predominantly affected (perimolysisl.The rounded appearance ol the leelh suggests an erosiveetiology.

voluntary,'' •'' The gastric environment is highly acidic(approximately pH 2), and régurgitation can expose

the teeth to highly erosive facfors. Although isolatedincidents are unlikely to cause long-term problem s, the

teeth may be severely affected by repeated o r con tinualepisodes of régurgitation.-^ -'

Involuntary régurgitation

Involuntary régurgitation, or gastroesophageal refiux.is a common complication of gastrointestinal prob-

lems, such as hiatus hernia, or as a consequence of

pregnancy. Some dietary components, such as spicyfoods and onions, can aiso promote refiux as can

smoking and certain types of exercise.-**-''

Gastritis and acid régurgitation can also occur as aconsequence of chronic alcoholism, although patients

may not be aware of the problem,'"" Often the

individual is secretive about the habit, and confirma-tion can be difficult. Some patients, for example, some

young adulls, have frequent atid repeated alcoholbinges. These binges are often associated with epi-

sodes of vomiting but, unlike alcoholics, the patientstend to be less secretive. Soft drinks, which are

frequently used as mixers with alcoholic drinks, mayalso contribute to TW,

Refiux can also occur in the absence of any clinicalsigns and symptoms normally associated with the

problem,-^-'- It has been suggested that this couldaccount for some situations in which TW occurs in the

absence o fan iden tifiable c tio logic f a ^ ' '

Voluntary régurgitation

Voluntary régurgitation is usually associated wi

underlying psychological problem, such as an edisorder."--'"' However, there is a group of pa

who repeatedly regurgitate in the absence of anypathologic or psychoiogical disorder. T hese indivi

after deliberately returning food to the mouth, usexpel some of the contents prior to swallowin

remainder. This habit, termed nuiünuiion. hasdescribed in institutionalized individuals with lea

difficulties,-'' Gihnour and Beckett,'^ however

ported similar practices in highly motivated, intelprofessional people who use the habit as a respo

stress. Voluntary régu rgitation in the absence opsychological problems may also occur in indivi

whose occupations depend on control of body wefor example, professional jockies (Fig 5).-''*

The eating disorders most commonly assoc

with TW are anorexia nervosa and bulimia nerThese problems, a feature ofa body-conscious so

ofien begin in early adolescence, frequently runnchronic course with substantial complications.''

prevalence of eating disorders in the general potion is unclear, although studies suggest the incid

of anorexia and bulimia nervosa are 0,1% to Ù.T

1% to 2X, respectively. However, patients with e

disorders may actively avoid detection or be relu

to disclose deta ils, and the true prevalence munderestimated,'^-"' It is generally agreed tha

problem is increasing and that groups such as dandieticians, and Asian females are particularly at

Although studies indicate that eating disordermore prevalent in fetnales, males may be equally

but do not necessarily seek medical help.

The effect of acid régurgitation in bulimia ne

patients has been well documented.'^'"" The common sign is peritnolysis—erosive lesions loca

to the palatal aspect of the maxillary teeth (F

These lesions are thought to result because the todirects gastric contents forward during voluntaryprepared vomiting and the lateral spread of the to

protects the mandibular teeth."-'' ' However,idiosyncratic distribution of lesions may also oc

The pattern of TW in patients with eating disomay also be affected by othe r etiologic factors, su

consumption of erosive diet beverages and hefoods as patients strive to control their w

xerostomia, caused by vomit-induced dehydratidrugs such as diuretics, appetite suppressants

antidepressants; and long-term co mp lications, s

gastric ulcers and hiatus hernia,-^



5ishop et al

enisinn

the risk o fth is type ofdatiiage.•*-•*' A high

ed in Germ any and Finland in studies of workers

Environmental erosion predominaiitiy atlects the

and the degree of destruction is intluenced by

used by mastication or contact between occluding or

s traditionally are classified as canine guided or

ally associated with greater wear. However, contro-

Tooth wear can be particularly significant in patients

The prevalence of bruxism is unclear; reports

cate that between 5% and 96% of th e populationy be affected.''^ "̂ The occlusal forces involved may

e et al''' studied the electromyo-

age, five episod es occurred a night, with a mean

a wide variation. Xh on ga ' observed a fourfold

nctioning subjects over a 6-month period .

Loss of occlusal tooth tissue does not necessarily

restilt in changes in the occlusal vertical dimension or

development of interocciusül space, because compen-

satory alveolar growth may occur, particularly when

the loss of tooth tissue is localized to one area ofthe

den tition '' (see Fig 2a}. The re is little evidence to

support the wideiy held view that a reduction in the

number of teeth causes increased TW."^-

Abras ion

Abrasion is the loss, by wear, of tooth substance or a

restoration caused by factors other than tooth con-

tact.̂ It is usually caused by abnormal rubbing oftoothtissue or restorations by a nondenta! object, such as

pipes, hairclips, musical instrument mouthpieces,

etc. '-''-'''' However, probably the most comm on cause is

incorrect or overvigorous tooth brush i tig, resulting inlesions at the neck ofthe tooth (see Fig Ib). This

association is supported by studies that have reportedan increase in cervical abrasive lesions in individuáis

who brush their teeth tiiore often, for longer, and use ascrubbing technique rather than a less damaging

method.''' Lesions are more common in the maxilla,

and canines, premolars, and first molars are patiic-ularly susceptible.''' This is thottght to be the result of

thin buccal bone in these regions.

Although the location of some cervical lesions canbe attributed to toothbrushin g. some lesions canno t beexplained by this activity. For this reason, other TW

factors, such as erosion, may contribute to theproblem.*'**' Recently, interest has grown in the role of

occlusal stresses in the developtnent of cet^ical abra-sive lesions, and the term abfructioti has been used to

describe such lesions.'" Advocates of this conceptsuggest that tooth flexure causes tensile and com pres-

sive forces at the necks ofthe teeth, resulting in cracksin the enamel and eventual loss oftooth tissue.'^•^^•^''

Evidence has been put forward to support thisassociation:

1. The number of lesions is greater in bruxists and inolder individuals.

2. Bruxists are m ore likely to lose cervical re storations.

3. Lesions can progress around existing cervicalrestorations and extend subgingivally.

4. Lesions are rarely seen on the lingual surfaces of

mandibular teeth.

5. Lesions can be observed in animals.

6. Cervical flexure can be generated by occlusalforces.



Bishop et al

7, Often adjacent teeth are not affected.8, Lesions ate less common if the tooth is mohilc.

Prevalence

Assess tuet It

It is generally accepted that the prevalence of TWincreases with age,'"'*''"'^'' However, the exact prev-alence is unclear, primarily because of differing assess-ment crite ria,'" For exam ple. Hugoson etal-''̂ reportedthat 13% and 24% of surfaees show evidence ofocclusal wear, while other studies observed thatbetween 25% and 50% of subjects have evidence ofTW," Some loss of tooth tissue is normal during apatient's lifetime, as a result of wear and tear. The lossis likely lo be a problem only when the degree exceeds

what would be considered normal for a particular age.Studies that consider only "pathologic" TW may,therefore, be more relevant to clinical dentistry. TheTooth Wear Index'' attempted to achieve relevance hyproposing maximum acceptable tooth tissue loss foreach decade of life. Tooth surface joss in excess ofthese figures is considered pathologic. When thisindex was nsed, between 4,5% and 5,7% of surfacesexamined exhibited TW,''-'"

Contriinning factorsAlthough the actual prevalence of TW is unknown,there is general agreement that the problem is in-creasing, particularly in the young.''"" The exactreason for this is unclear, but several factors may beimplicated.

Body image

Fashion designers and image makers have promotedthe concept that siimness equates with attractiveness

or success. This concept is supported by role models,who may significantly influence perceptio n of the idealbody shape. In an attempt to control body weight,patients may consume acidic foods, such as fruit anddiet drmks, rather than high-calorie alternatives. Thisstruggle to achieve the ideal body shape may also partlyaccount for the increased prevalence of eating dis-orders.

Soft drinks

The soft drink industry is a muitimillion dollarbusiness. Coea-Cola, for example, is the secondbiggest brand label in the world, with an estimated

brand value of nearly $ 9.00 0 million. M arketing odrinks is often directed to the young aduassociating the beverages with peer group accepity. More recently, the drinks have been protnothealthy and linked to high-profile sports figuresconsumption of acidic beverages following ex

may be particularly dangerous because of dehydand lack of salivary buffering.

Health care workers

Health care worke rs, such as physicians and dietiadvocate fresh fruit as A component of a balancedThese foods are, therefore, promoted as a heoption to harmful alternatives. Patients are unlikebe warned of the potential damage associated such foods. Dentists may indirectly support

concept by advising their patients to avoid Patients may further perceive that foods and dthat do not contain sugar must, therefore, bedamaging to their teeth. Dentists often advise pato hrush their teeth after exposure to foods and dcontaining stigar or acid, which may accelerate T

One of the major roles of saliva is to dilutehufler acid that enters the mouth. Saliva also actlubricant during mastication. If the salivary fioreduced, the potential for erosive, attritional,

abrasive damage increases,-'''^ As medieal scadvances and life expectancy grows, the use of within the population is more widespread,^^ Mathese drugs cause a dry m outh, and the associateproblems are likely to become more prevalent,^"^problem may be compounded if patients conacidic drinks in an attempt to alleviate the sympand stimulate salivary flow.

Restorative materials

Dentists often use esthetic re storatio ns, irrespectwhether the restoration is visible. Many of malerials have the potential to accelerate TW, pularly if used on occluding surfaces in parafunc

patients. Potentially less destructive matesuch as "softer" porcelains and fine-particle composites, have been developed but have not clinically evaluated, particularly in TW patientsFor this reason, metal occlusal surfaces are thechoice in patients w ith extreme TW. particularly w

an attritional etiology is suspected. However, pamust be aware that all restorative materials



Bishop et al

Flattening of the cusp tips or incisai edges and

and movement ofthe oppo sing too th. If the

a\' occur as ilie dentin is lost m ore quickly

he surrounding enam el. This unsupported enam-

Erosive lesions eause cupping or grooves to form in

unlike attritional lesions, the base

an irregular appea rance because of fractures ofthe

differential loss of the soffer

ral area of exposed dentin surroun ded by a border

This feature has been attributed to the buffering

Traditionally, cervical lesions caused by abrasion

the lesion is more rounded and shallower (see

Fig C V'vo"i -.- .KK Pia n-tui '='n-lü nvXal tr i invns in a bru^in g

pat ient These restoiat ian s v jcrc place d 2 years previouslybecause of TW. The pat ient had nof been provided witb an

occlusal spl inf

Fig 2 ), Lesions assoeiated with toothbrushing are also

thought to have rounded internal angles, while those

caused by abfraction are more angular and may initially

have a corrugated appearance , '''

The clinical appearance of restorations may also

reflect the major cause of TW, Amalgam and resin

composite restorations, for example, tend to be

unaHeeted by erosive factors and remain "proud" ofthesurrounding tooth tissue. However, both restorative

materials show evidence of faceting if attrition is the

major etiologic factor,''

Despite exp osure of extensive areas of dentin, acute

sensitivity is rarely a problem. This is probably due to

the developtnent of sclerosed dentin and smear layers

on the surface of the toofh. Pain can be a problem,

however, when the TW is rapid and ongoing and is

common when erosion is a major etiologic factor.

Conclusion

The management of TW is a major challenge to the

denfal profession, and this is likely to continue as

changing lifestyles highlight particular etiologic factors

to which younger individuals are especially sus-

ceptible. It is important that these causes be identified

and, if possible, eliminated before restorative therapy

is initiated. Failure to eliminate the cause may com-

promise the long-term survival of restorations andfurther deterioration ofthe dentition.



Bishop et al

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David Korson

Aesthetic Designfor Ceramic Restorations

The most

Hi) tu r a l ,

cstheric restilts

in dental

ceramics cati

be achieved

with contem-

r a r } ' techniques—and this book describes

how. Investigated arc the cha racteristics of

natural dctitition, tissue martagemetit, impres-

sions, occlusal rec ords, waxing techniques ,

color, and laboratory- techniques, including

methods for an aesthetic ceramic margin,

opalescence, and development of the dentine

ma melo n. Filled with practical tips, this book

is ideal for dentists and technicians.

US$7fi

159 pages; 292 color illus; ISBN 1-85097-ÍI34-3

Contents

1 Studies of Natniral Dentitio n

2 Dcntist-Technician-Patjenr Commi.inication

3 Tissue Managem ent for Aesthetic

and Biological Harmony

4 Impressions and Occlusai Records

5 Aesthetic Wii\ Diagnostic Control

6 Accurate Registration and Communicationof Colour Characteristics

7 Advanced Laboratory Techniques

8 Case Studies

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O r d e r N o w

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