Tooth wear refers to loss of
tooth
A tooth ( : teeth) is a hard, calcified structure found in the jaws (or mouths) of many vertebrates and used to break down food. Some animals, particularly carnivores and omnivores, also use teeth to help with capturing or wounding prey, tear ...
substance by means other than
dental caries
Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating. Complicatio ...
.
Tooth wear is a very common condition that occurs in approximately 97% of the population.
This is a normal physiological process occurring throughout life; but with increasing lifespan of individuals and increasing retention of teeth for life, the incidence of non-carious tooth surface loss has also shown a rise.
Tooth wear varies substantially between people and groups, with extreme attrition and
enamel fracture An enamel fracture, or chip, is a complete fracture of the tooth enamel without the involvement of the dentine and pulp. A fracture occurs when a tooth contacts a hard object with enough force to break a section of enamel. Chips form with minimal pl ...
s common in archaeological samples, and
erosion
Erosion is the action of surface processes (such as water flow or wind) that removes soil, rock, or dissolved material from one location on the Earth's crust, and then transports it to another location where it is deposited. Erosion is distin ...
more common today.
Tooth wear is predominantly the result of a combination of three processes;
attrition
Attrition may refer to
*Attrition warfare, the military strategy of wearing down the enemy by continual losses in personnel and material
**War of Attrition, fought between Egypt and Israel from 1968 to 1970
**War of attrition (game), a model of agg ...
,
abrasion and
erosion
Erosion is the action of surface processes (such as water flow or wind) that removes soil, rock, or dissolved material from one location on the Earth's crust, and then transports it to another location where it is deposited. Erosion is distin ...
.
These forms of tooth wear can further lead to a condition known as
abfraction
Abfraction is a theoretical concept explaining a loss of tooth structure not caused by tooth decay ( non-carious cervical lesions). It is suggested that these lesions are caused by forces placed on the teeth during biting, eating, chewing and gri ...
,
where by tooth tissue is 'fractured' due to stress lesions caused by extrinsic forces on the enamel. Tooth wear is a complex, multi-factorial problem and there is often difficulty identifying a single causative factor.
However, tooth wear is often a combination of the above processes. Many clinicians, therefore, make diagnoses such as "tooth wear with a major element of attrition", or "tooth wear with a major element of erosion" to reflect this. This makes the diagnosis and management difficult.
Therefore, it is important to distinguish between these various types of tooth wear, provide an insight into diagnosis, risk factors, and causative factors, in order to implement appropriate interventions.
Tooth wear evaluation system (TWES) may help determine the most likely aetiology of tooth wear. Heavy tooth wear is commonly found on the occlusal (chewing) surface, but
non-carious cervical lesions
Non-carious cervical lesions (NCCLs) are a group of lesions that are characterised by a loss of hard dental tissue at the cementoenamel junction (CEJ) region at the neck of the tooth, without the action of microorganisms or inflammatory processe ...
from tooth wear are also common in some populations.
Multiple indices have been developed in order to assess and record the degree of tooth wear, the earliest was that by
Paul Broca
Pierre Paul Broca (, also , , ; 28 June 1824 – 9 July 1880) was a French physician, anatomist and anthropologist. He is best known for his research on Broca's area, a region of the frontal lobe that is named after him. Broca's area is involve ...
.
In 1984, Smith and Knight developed the tooth wear index (TWI) where four visible surfaces (buccal, cervical, lingual, occlusal-incisal) of all teeth present are scored for wear, regardless of the cause.
A more recent index Basic Erosive Wear Examination (BEWE) from 2008 by Bartlett et al., is now also in use.
Causes
Attrition
Attrition
Attrition may refer to
*Attrition warfare, the military strategy of wearing down the enemy by continual losses in personnel and material
**War of Attrition, fought between Egypt and Israel from 1968 to 1970
**War of attrition (game), a model of agg ...
is loss of tooth substance caused by physical tooth-to-tooth contact.
The word attrition is derived from the Latin verb ''attritium'', which refers to the action of rubbing against something.
Attrition mostly causes wear of the
incisal and
occlusal surfaces of the teeth. Attrition has been associated with
masticatory force and
parafunctional activity A para-functional habit or parafunctional habit is the habitual exercise of a body part in a way that is other than the most common use of that body part. In dentistry, orthodontics, and oral and maxillofacial pathology, the body part in question i ...
such as
bruxism. A degree of attrition is normal, especially in elderly individuals.
Abrasion
Abrasion is loss of tooth substance caused by physical means other than teeth.
The term is derived from the Latin verb ''abrasum'', which means ‘to scrape off’.
It tends to present as rounded ditching around the
cervical margins The cervical margin of a tooth is the surface above the junction of the crown of the tooth and the root of the tooth.
See also
* Dental terminology
This is a list of definitions of commonly used terms of location and direction in dentistry. Thi ...
of teeth, commonly described as ‘shallow’, concave or wedge shaped notches.
Causative factors have been linked to this condition and include vigorous, horizontal
tooth brushing
Tooth brushing is the act of scrubbing teeth with a toothbrush, usually equipped with toothpaste. Interdental cleaning (with floss or an interdental brush) can be useful with tooth brushing, and together these two activities are the primary me ...
, using
toothpaste
Toothpaste is a paste or gel dentifrice used with a toothbrush to clean and maintain the aesthetics and health of teeth. Toothpaste is used to promote oral hygiene: it is an abrasive that aids in removing dental plaque and food from the teeth, a ...
with a relatively high
RDA value (above 250),
pipe smoking
Pipe smoking is the practice of tasting (or, less commonly, inhaling) the smoke produced by burning a substance, most commonly tobacco, in a pipe. It is the oldest traditional form of smoking.
Regular pipe smoking has been cited to carry seriou ...
or
nail biting
Nail biting, also known as onychophagy or onychophagia (or even erroneously onyhophagia), is an oral compulsive habit of biting one's fingernails. It is sometimes described as a parafunctional activity, the common use of the mouth for an activit ...
. It has also been shown that improper use of
dental floss
Dental floss is a cord of thin filaments used in interdental cleaning to remove food and dental plaque from between teeth or places a toothbrush has difficulty reaching or is unable to reach. Its regular use as part of oral cleaning is designed ...
or
Toothpicks
A toothpick is a small thin stick of wood, plastic, bamboo, metal, bone or other substance with at least one and sometimes two pointed ends to insert between teeth to remove detritus, usually after a meal. Toothpicks are also used for festive ...
can lead to wear on the interproximal (in-between) surfaces of the teeth.
Erosion
Erosion
Erosion is the action of surface processes (such as water flow or wind) that removes soil, rock, or dissolved material from one location on the Earth's crust, and then transports it to another location where it is deposited. Erosion is distin ...
is chemical
dissolution
Dissolution may refer to:
Arts and entertainment Books
* ''Dissolution'' (''Forgotten Realms'' novel), a 2002 fantasy novel by Richard Lee Byers
* ''Dissolution'' (Sansom novel), a 2003 historical novel by C. J. Sansom Music
* Dissolution, in mu ...
of tooth substance caused by acids, unrelated to the acid produced by bacteria in dental plaque.
Erosion may occur with excessive consumption of acidic foods and drinks, or medical conditions involving repeated regurgitation and reflux of gastric acid.
It is derived from the Latin word ''erosum'', which describes the action ‘to
corrode
Corrosion is a natural process that converts a refined metal into a more chemically stable oxide. It is the gradual deterioration of materials (usually a metal) by chemical or electrochemical reaction with their environment. Corrosion engin ...
’.
This is usually on the palatal (inside) surfaces of upper front teeth and the occluding (top) surfaces of the
molar teeth. Dental erosion is rarely seen in the archaeological record, but certain cases have been described which suggested acidic fruits and/or plants were regularly consumed.
*
Gastroesophageal reflux disease
Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases where stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/ ...
(GERD)
*
Vomiting
Vomiting (also known as emesis and throwing up) is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the Human nose, nose.
Vomiting can be the result of ailments like Food-poisoning, foo ...
, e.g.
bulimia
Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eate ...
,
alcoholism
Alcoholism is, broadly, any drinking of alcohol (drug), alcohol that results in significant Mental health, mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognize ...
*
Rumination
*
Eructation
Burping (also called belching and eructation) is the release of gas from the upper digestive tract (esophagus and stomach) of animals through the mouth. It is usually audible.
In humans, burping can be caused by normal eating processes, or as ...
(burping)
* Dietary - liquids of low pH and high titratable acids.
Abfraction
Abfraction
Abfraction is a theoretical concept explaining a loss of tooth structure not caused by tooth decay ( non-carious cervical lesions). It is suggested that these lesions are caused by forces placed on the teeth during biting, eating, chewing and gri ...
is loss of tooth substance at the
cervical margins The cervical margin of a tooth is the surface above the junction of the crown of the tooth and the root of the tooth.
See also
* Dental terminology
This is a list of definitions of commonly used terms of location and direction in dentistry. Thi ...
, purportedly caused by minute flexure of teeth under occlusal loading. The term is derived from the Latin words ''ab'' and ''functio'' meaning ‘away’ and ‘breaking’ respectively.
Abfraction presents as triangular
lesions
A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals.
Types
There is no designated classifi ...
along the
cervical margins The cervical margin of a tooth is the surface above the junction of the crown of the tooth and the root of the tooth.
See also
* Dental terminology
This is a list of definitions of commonly used terms of location and direction in dentistry. Thi ...
of the
buccal surfaces of the teeth where the enamel is thinner and therefore, in the presence of occluding forces, is prone to fracture.
Whether abfraction exists or not is debated.
Diagnosis
Tooth wear indices are useful tools for carrying out epidemiological studies and for general use in dental practices.
Basic erosive wear examination
The Basic Erosive Wear Examination was first described by Bartlett et al. in 2008.
The partial scoring system is based on the surface area affected. Within a sextant (i.e. teeth in mouth divided into 6 parts), the most severely affected tooth surface (buccal, occlusal or lingual/palatal)(see
dental terminology
This is a list of definitions of commonly used terms of location and direction in dentistry. This set of terms provides orientation within the oral cavity, much as anatomical terms of location provide orientation throughout the body.
Terms
...
) is recorded according to the severity of the wear (see Table 1). A cumulative score is then matched to a risk level and guidance for its management by a clinician. The management includes steps which identify and eliminate main aetiological factors, preventative treatment and also any operative and symptomatic intervention required by the patient. The frequency of repeating the index ranges from 6–12 months depending on the risk level of patients.
Tooth wear index
The Tooth Wear Index (TWI) (see Table 2) was developed by Smith and Knight in 1984. TWI scores each visible surface (buccal/B, cervical/C, lingual/L and occlusal-incisal/O/I) (see
dental terminology
This is a list of definitions of commonly used terms of location and direction in dentistry. This set of terms provides orientation within the oral cavity, much as anatomical terms of location provide orientation throughout the body.
Terms
...
). This index has been widely used in epidemiological studies.
Other indices
* Eccles-Index
* Modified TWI
* Linkosalo and Markkanen
* O'Brien Index
* Lussi Index
* O'Sullivan Index
* Simplified Tooth Wear Index (STWI)
* Exact Tooth Wear Index
* Visual Erosion Dental Examination (VEDE)
* Evaluating Index of Dental Erosion (EVIDE)
Treatment
Once the cause of tooth wear has been identified and a preventative regime has been put in place, the patient should be reviewed for 6–12 months to establish that the intervention has been successful before any active management is carried out. Once this has been achieved a decision needs to be made whether or not it is necessary to carry out
restorative treatment or if it can simply be managed by non-invasive methods.
Where restorative treatment is necessary, it must be decided whether to conform to the existing occlusion (typically for moderate wear, where only a few teeth are affected) or reorganise the occlusion (severe wear, unstable occlusion). Where the occlusion is reorganised, it can first be tested using a reversible method (i.e. a hard occlusal splint). A decision is made after full occlusal assessment including assessment of contacts in
intercuspal position (ICP) and
retruded contact position (RCP) as well as analysing casts articulated in a
semi-adjustable articulator to use for a diagnostic wax up of any proposed restorative work.
Active restorative management depends upon the location of the wear (localised or generalised), the severity of the wear, and the patient's
occlusal vertical dimension (OVD), which may have changed as a result of tooth wear. There are three potential scenarios of tooth wear:
# Excessive wear with loss of OVD
# Excessive wear without loss of OVD but with space available
# Excessive wear without loss of OVD but with limited space available
Scenario 1 is relatively common, whereas scenario 2 is quite rare and tends to occur when the wear is rapidly occurring. Scenario 3 occurs due to a phenomenon called
dentoalveolar compensation whereby the dentoalveolar tissues compensate for wear of teeth by increasing the bony support in order to maintain a constant OVD. This makes things difficult as there is no room to build the teeth back up to their original height without increasing the OVD.
The options for restoring this loss in tooth height are:
# Increasing the OVD - this is the traditional approach and involves restoring all teeth to an increased height in order to create a new ICP at an increased OVD
# Occlusal adjustment - this is typically used for anterior teeth only, whereby the patient's occlusion is reorganised into the RCP position to utilise increased space in this position
#
Crown lengthening
Crown lengthening is a surgical procedure performed by a dentist, or more frequently a specialist periodontist. There are a number of reasons for considering crown lengthening in a treatment plan. Commonly, the procedure is used to expose a greate ...
or orthodontic extrusion - this is useful when crowns are to be placed in a worn dentition but there is inadequate crown height and you do not want to change the OVD
# Relative axial tooth movement - this is the most commonly used method and can be used for localised or generalised wear, the idea is to prop the bite open thereby causing the extrusion of worn teeth to provide extra crown height for restoration, this can be done using simple direct restorations or more complex indirect restorations, this idea was first established by Dahl and is often referred to as the
Dahl effect
Pulp vitality must also be taken into consideration prior to treatment, when teeth have severe wear it is possible that they have become non-vital.
See also
*
Attrition
Attrition may refer to
*Attrition warfare, the military strategy of wearing down the enemy by continual losses in personnel and material
**War of Attrition, fought between Egypt and Israel from 1968 to 1970
**War of attrition (game), a model of agg ...
*
Abrasion
*
Erosion
Erosion is the action of surface processes (such as water flow or wind) that removes soil, rock, or dissolved material from one location on the Earth's crust, and then transports it to another location where it is deposited. Erosion is distin ...
*
Abfraction
Abfraction is a theoretical concept explaining a loss of tooth structure not caused by tooth decay ( non-carious cervical lesions). It is suggested that these lesions are caused by forces placed on the teeth during biting, eating, chewing and gri ...
*
Bruxism
References
External links
{{Oral pathology
Dentistry
Acquired tooth pathology