Unraveling the Impact of Tooth Wear on Oral Health

Tooth wear is a multifactorial phenomenon that can significantly impact oral health and overall quality of life. Pathological loss of tooth structure can lead to weakened tooth structure with exposed dentin. Exposure of dentin can lead to increased risk of dental caries and tooth sensitivity. Prolonged tooth wear can also compromise tooth integrity, leading to fractures and structural damage. Sometimes, irreversible pulpal inflammation can result. Impaired masticatory function can result when uneven occlusal wear patterns disrupt natural occlusal harmony and may also contribute to muscle fatigue and temporomandibular joint disorder. Tooth appearance may be affected with shortened crown length due to progressive wear and tooth discoloration can occur due to dentin exposure. Ultimately, the patient’s self-esteem, confidence, and quality of life may be negatively affected. Social withdrawal and limited nutrition intake may occur.

Although pathological loss of tooth structure can negatively impact oral health, it can also be a screening tool for mental health disorders such as depressive and eating disorders.¹ The incidence of bruxism is higher among those experiencing anxiety and/or stress, tobacco users, heavy alcohol users, and those who consume high amounts of caffeine.^2-6

Dental erosion is often present in patients with gastresophageal reflux disease (GERD).⁷ A secondary finding in GERD patients is nocturnal bruxism.⁸ Dental erosion can also occur in patients with anorexia nervosa and bulimia nervosa.^9,10 Erosion present on palatal surfaces of anterior and posterior teeth is a classic sign of bulimia.¹¹ Alcohol and drug use can directly and indirectly contribute to erosive wear.^12-14 In cases where intrinsic erosive pattern is observed, a referral to the patient’s primary care physician is recommended for evaluation and management. The physician may order an esophageal pH test to measure acidity in the esophagus.¹⁵

Identifying and understanding the etiology of tooth wear are important to prevention and management. A comprehensive, multidisciplinary treatment approach is needed to promote long-term oral health. Tooth wear is considered an age-related phenomenon and determining whether it is physiological or pathological is key.¹⁶ The physiological wear of enamel on occlusal surfaces is approximately 15 microns per year for premolars and 29 microns per year for molars.¹⁶

Tooth wear is a dynamic process influenced by a combination of mechanical, chemical, and biologic factors and can be identified as one of the following categories: attrition, abrasion, erosion, and abfraction.

Attrition

Attrition is the wearing away of a substance or structure through some unusual or abnormal mechanical process (Figure 1).¹⁷ Often, attrition refers to tooth-to-tooth contact during mastication or parafunctional activities. Increased or imbalanced occlusal forces can contribute to attrition. Malocclusion often exacerbates tooth wear.

The clinical presentation includes flat, polished occlusal and incisal surface wear pattern, wear facets and grooves in contact with opposing teeth, and possible enamel fractures. A diagnosis of attrition requires a visual inspection for wear facets, flattened surfaces, and fractures; presence of occlusal imbalance and occlusal interferences; formation of exostoses; and patient interview regarding parafunctional habits.

Treatment for attrition typically involves a thorough occlusal analysis and the restoration of worn tooth structure using direct or indirect dental materials. In some cases, it may be advisable to simply observe and maintain the teeth without immediate restoration.

When selecting materials for restoration, high-noble metals and ceramics are often preferred. It is crucial to evaluate the location of wear, etiology, and functional forces before proceeding with the restoration. Gold is generally recommended for molars in nonesthetic regions due to its low wear rate and minimal restorative space requirements. For patients who are more esthetically conscious, ceramic restoration is recommended for posterior molars. Although ceramics offer a more esthetic option, they may necessitate more tooth reduction compared to gold and could require additional dental procedures, such as crown lengthening. For the anterior region, ceramic or metal-ceramic restorations are often preferred for esthetic reasons.

Composite resins may also be used, though they may exhibit higher wear and a greater likelihood of fractures over time. These materials may be a viable option for patients who are unable to afford indirect restorations, with the goal of preserving the remaining tooth structure for as long as possible to allow for future definitive treatment.

Adjunctive at-home therapies can include the use of occlusal devices at night or clear retainers for individuals who clench during the day. In some cases, botox therapy may also be considered to manage symptoms associated with attrition.

Abrasion

Abrasion is an abnormal wearing away of the tooth substance by causes other than mastication or tooth-to-tooth contact (Figure 2).¹⁷ Abrasive wear can occur from external agents such as abrasive toothpaste and from foreign objects such as chewing on hard foods. Common etiologies include aggressive toothbrushing habits, professions involving abrasive materials, and lifestyle choices such as chewing tobacco.

Abrasion often presents clinically as cervical notches, typically characterized by a V-shaped defect. The loss of enamel leads to visible dentin, and in severe cases, the outline of the pulp chamber may also become visible. These defects are commonly localized to specific areas, depending on the etiology of the abrasion.

Diagnosis involves a visual inspection for cervical notches, as well as an interview with the patient to gather information about his or her lifestyle habits. Identifying the patterns and extent of tooth wear is also crucial in diagnosing abrasion. Treatment options include the restoration of worn tooth structure using either direct or indirect dental materials. Alternatively, the teeth may be observed and maintained without immediate restorative intervention.

For materials selection, conservative direct restorations using composite resin or resin-modified glass ionomer are recommended to restore the missing portion of the tooth structure. In more advanced cases, indirect restorations may be necessary to achieve optimal results.

Adjunctive at-home therapy includes modifications to lifestyle choices and changes to oral hygiene practices, such as using soft-bristled brushes and reducing the amount of force applied during brushing.

Erosion

Erosion is defined as the progressive loss of tooth substance by chemical processes that do not involve bacterial action (Figure 3).¹⁷ Etiology of erosion can be classified as intrinsic (such as acid reflux or vomiting) or extrinsic (such as citrus fruits and soda).¹⁸ Some medications can also contribute to erosion.¹⁸

Erosion is clinically presented as a smooth and shiny loss of enamel and/or dentin, giving the affected teeth a glossy appearance. Patients may experience increased sensitivity to hot, cold, or sweet stimuli. Additionally, concave depressions, known as cupping, may form on the occlusal surfaces, often accompanied by “islands” of restorative material where the erosion has worn away surrounding tooth structure.

Diagnosis of erosion involves a thorough visual inspection to identify smooth surfaces, cupping, and sensitivity. A comprehensive patient interview is essential to evaluate dietary habits, acidic exposures, and any underlying medical conditions that may contribute to erosion. Additionally, a salivary pH assessment can provide further insights into the potential causes of the erosion.

Treatment options include the restoration of worn tooth structure using direct or indirect dental materials, depending on the number of surfaces affected, the underlying etiology, and whether the etiology can be managed. In some cases, it may be appropriate to observe and maintain the teeth without immediate restorative intervention.

For materials selection, composite resins are suitable for managing small to moderate erosive wear conservatively with adhesively bonded restorations, provided the underlying etiology is addressed. High-noble metals and ceramics with subgingival margins are also an option, as subgingival margins help protect the remaining unprepared tooth by the gingiva.

Adjunctive at-home therapy can involve medical management of intrinsic factors and medications to stimulate salivary flow in patients with xerostomia. Other recommended measures include the use of oral rinses, nutritional counseling with a focus on reducing acidic and citrus foods, increased water consumption, and the use of custom fluoride trays.

Abfraction

Abfraction is the pathological loss of hard tooth substance caused by biomechanical loading forces.¹⁷ Often, these occur from tooth flexure due to occlusal stresses, which lead to microfractures of the tooth surface. High occlusal forces, occlusal interferences, and parafunctional habits can lead to abfraction (Figure 4).

Abfraction typically presents with cervical notches, often appearing as V-shaped defects. Patients may experience tooth sensitivity due to exposed dentin, and there may be uneven wear patterns along the cervical margin of the teeth.

Diagnosis of abfraction involves a clinical examination of V-shaped lesions with asymmetrical wear, along with an occlusal analysis. A patient interview is also conducted to gather information about parafunctional habits and any bite abnormalities.

Treatment begins with an occlusal analysis, followed by limited or complete occlusal adjustment if necessary. Restoration of the worn tooth structure can be achieved using direct or indirect dental materials. In some cases, it may be appropriate to observe and maintain the teeth without immediate restorative intervention.

For materials selection, conservative direct restorations using composite resin or resin-modified glass ionomer are recommended to restore the missing portion of the tooth structure. If alteration to the occlusal function is necessary to recreate proper guidance and occlusion, full or partial coverage restorations with high-noble metal and ceramics may be necessary.

Adjunctive at-home therapy may include the use of an occlusal device at night or clear retainers for individuals who clench during the day. Potential botox therapy may also be considered to help manage symptoms associated with abfraction.

Combined factors may enhance tooth wear. For instance, demineralized tooth structure by erosion may exhibit enhanced tooth wear due to attrition and abrasion. Some factors such as parafunction or uncontrolled mediators may greatly limit the prognosis of treatment. Treatment should be rendered based on complaints of the patient and clinical presentation.

Some common reasons patients seek dental care for tooth wear include tooth sensitivity or pain, compromised masticatory function, impaired esthetics, compromised integrity of teeth, and concerns for the long-term prognosis of their teeth.

When evaluating tooth wear, clinicians should consider several factors to decide whether to manage or treat the condition. These factors include the amount of tooth wear, the tooth surfaces affected, whether the wear is localized or generalized, the progression of the wear, the patient’s age, and the underlying etiology.

Tooth wear can be evaluated and tracked with radiographs, photographs, and casts or three-dimensional models.²⁰ Many intraoral scanners come with the capability to compare different scans at different times to evaluate changes including tooth wear. Photographs and casts to visualize tooth wear can be big eye-opener for patients and helps to explain why tooth wear should be monitored, maintained, or treated. Occlusal devices can be used to assess the extent of parafunctional habits (Figure 5). Treatment decisions should be made collectively with the patient.

First, the age of the patient should be considered. Significant tooth wear in younger patients is often pathological whereas in older patients, they are  physiological. Afterward, documentation of tooth wear as well as a risk assessment for etiological factors should be performed. Based on the findings, preventive strategies should be created with further monitoring of tooth wear. If the tooth wear causes concern for the patient and/or the dentist, treatment may be indicated.

Treatment and prevention strategies depend on the cause of tooth destruction and may involve a comprehensive oral and/or medical approach. The following are common prophylactic strategies to manage or prevent tooth wear:

• Aggressive toothbrushing can cause abrasion of the tooth surface. A gentle circular brushing motion with an extra-soft or soft-bristled toothbrush can help in the prevention of abrasion.
• Fluoride toothpaste can help strengthen enamel and reduce susceptibility to acid-induced erosion.¹⁸
• Reduced consumption of acidic and/or spicy foods and acidic and/or carbonated beverages may also help prevent erosion.¹⁸
• A calcium-rich diet supports enamel remineralization.
• The use of strategies to stimulate salivary flow is helpful.¹⁸
• For patients with parafunctional habits, nightguards can help prevent tooth-to-tooth contact while sleeping.
• Best preventive measures involve routine professional maintenance and early intervention when tooth destruction is observed.¹⁶

When tooth wear has occurred, clinicians can either maintain or treat the tooth. Minimally invasive intervention should be considered first before more aggressive modalities are discussed.¹⁶ Composite resin restorations may be used to recreate the lost tooth structure and to preserve the remaining tooth structure from further wear.

When moderate or aggressive tooth wear is present, more aggressive treatment must be taken. It may require a multidisciplinary approach including prosthodontics, orthodontics, endodontics, oral surgery, and periodontics. Treatment may range from equilibration to veneers and crowns to crown lengthening to implants. Patients may require full-mouth rehabilitation at an increased vertical dimension of occlusion.¹⁶ Uncontrolled etiological factors, especially bruxism and erosion, limit the successful prognosis of any restorative treatment.

Wear of Functional Tooth Surfaces

In situations where the wear pattern is present on the functional surfaces of teeth (Figure 1 and 3, pages 42 and 43), choosing dental materials that are durable and have lower wear rate, such as metal (gold or high noble alloy) or ceramic over composite resin is important. When extensive tooth loss has occurred, a full or partial coverage indirect restoration may be necessary to re-establish proper occlusal relationship. However, not all patients are able to afford full-mouth rehabilitation. Situations with limited wear of the functional surface of teeth (Figure 6) may be treated with more conservative treatment modalities such as composite resin and management of etiology.

Many patients present with Class V non-carious cervical lesions (noncarious cervical lesion [NCCLs], Figures 2 [page 43] and 4). Clinicians must determine whether there are any etiologies that need to be managed. Next, deciding between monitoring and treatment is necessary based on the patient’s age, etiology, risk factors, and patient desires.²¹ Generally, NCCLs progress slowly with etiology management. Routine monitoring at periodic examinations is required. Treatment should occur when dentinal hypersensitivity, caries, inability to maintain hygiene due to plaque traps, extensive tooth structure loss that may compromise the integrity of the tooth or proximity to the pulp, abutment for removable prosthesis, or esthetic demand is present.²¹ Restoration with resin-modified glass ionomers or composite resins is recommended unless significant tooth loss has occurred in which an indirect restoration is indicated.

Conclusion

Identifying and understanding the etiology behind tooth wear are vital to formulating a predictable treatment plan. Early intervention of tooth wear can help prevent more severe dental outcomes. Although conservative treatment modalities are available, the patient’s desired treatment outcome and/or the goal to provide the best long-term outcome may necessitate more aggressive treatment. Case Report

A 47-year-old man presented with the request that he wanted to be able to chew more effectively. He reported limited financial resources. No significant medical and dental findings were noted except acid reflux managed by a proton pump inhibitor. He reported grinding habits that have progressively gotten worse over the years as he lost more teeth. He also reported enjoying foods such as peanuts and crackers.

Extraoral examination revealed normal mouth opening, low Frankfort mandibular plane angle, no temporomandibular disorder symptoms, and reverse smile curvature. Intraoral examination revealed periodontal health, generalized recession on posterior teeth, no teeth mobility, edge-to-edge anterior articulation in maximum intercuspation, and slight compensatory supraerpuption on the mandibular anterior segment (Figures 7 to 9).

He was assessed as Turner Classification I. Teeth #10 and 29 had existing endodontic therapy and # 14-D, 15-M/D, 20-D, and 30-D had caries. Tooth #29 was a nonrestorable root tip. Treatment plan included full mouth rehabilitation with extractions of # 29 and 30 and crowns on #6, 7, 8, 9, 10, 11, 14, 15, 20, 21, 22, 27, and 28 with incisal composites on #23, 24, 25, and 26 followed by maxillary and mandibular metal-acrylic partial dentures and occlusal device.

After diagnostic wax-up and planning at an opened vertical dimension of occlusion after extractions of #29 and 30, polymethyl methacrylate provisional shells and maxillary and mandibular acrylic partials were fabricated prior to the patient’s tooth preparation appointment. Maxillary and mandibular were prepared for full coverage restorations and #23, 24, 25, and 26 were built with incisal composites (Figures 10 and 11). The patient was provisionalized and the new teeth design was tested for 2 months (Figure 12). After the patient reported satisfaction and no problems with esthetics, phonetics, and function, definitive restorations were placed on all the prepared teeth and definitive metal-acrylic removable partial dentures were provided (Figures 13 to 15). He reported his high satisfaction with the treatment rendered and stated that he could chew and smile again. An occlusal device was provided.

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From Decisions in Dentistry. August/September 2024; 10(5):42-45