Dental wear: a problem that is becoming more common
The loss of tooth surface can be simply physiological as a natural aging consequence. Nevertheless, this loss of tooth structure can be pathological due to phenomena such as erosion, abrasion and friction.
Dental wear is a pathology with different causes.
Behavioral changes, an unbalanced diet (acidic beverages), different medical or drug conditions that induce gastric reflux or influence the composition of saliva or its flow rate, all these elements can trigger tooth erosion.
Daytime or nighttime bruxism induces attrition and abrasion.
Classification of tooth surface loss
There are 3 reasons behind the loss of tooth structure (with no cariogenic relationship), nevertheless, abfraction can also be regarded as a cause of non-cariogenic tooth surface loss.
1- Erosion – this is a chemical process that takes place on the tooth surface without bacterial plaque. The associated factors may be intrinsic (gastroesophageal reflux and eating disorders) or extrinsic (natural fruit juices, carbonated beverages, alcoholic drinks and some particular foods).
2- Abrasion – external factors such as hard-bristled toothbrushes or dietary causes.
3- Attrition – attrition is a process during which the tissue is lost as a result of contact with the tooth surfaces of the opposing teeth during their function or parafunction. This contact takes place mainly in the proximal areas, supporting cusps and on the guide surfaces during chewing.
4- Abfraction (stress injuries) – this is a consequence of forces and eccentric movements applied on natural teeth. Abfraction is a source of fatigue, flexion and deformation of teeth, caused by the biomechanical loads of the tooth structure, particularly in the cervical regions. The extension of the injury depends on the size, duration, direction, frequency and location of the forces. Abfraction injuries are caused by flexing and fatigue of the teeth in areas that are normally distant from the load point.
There are several dental consequences of abrasion and erosion:
· Loss of enamel with progressive exposure of tooth surfaces.
· Loss of occlusal, buccal and lingual anatomy
· Decreased tooth size affecting the aesthetic and functional aspects
· Discoloration of the exposed dentin surfaces
· Tooth sensitivity and pulp-related issues
· Increased risk of cavities
· Loss of marginal adaptation of restorations, as well as their fracture
The clinical assessment must allow:
– to distinguish between loss of physiological and pathological tooth surface;
– to analyze all the characteristics capable of identifying the etiology involved;
– to verify whether or not treatment is necessary;
– to anticipate the difficulties that may take place during the treatment.
Differentiating a physiological loss and a pathological loss of tooth surface
The pathological loss of tooth structure results in a change in tooth appearance and is deemed excessive when taking into account the patient’s age.
These characteristics can include:
– Temperature sensitivity
– Loss of vertical dimension
– History of recurrent fracture teeth and fillings
– Hypermobility and positional change
Analyzing all the characteristics capable of identifying the etiology involved
Wear affecting the cusps or incisal edges and wear facets affecting the palatal or occlusal surfaces may indicate an etiology related mainly to friction.
Cervical injuries caused only by abrasion are properly delimited with sharp edges and a polished and hard surface. The injury may become rounder and shallow when an erosion element is present.
If the wear is caused mainly by attrition, the dentin often shows the same wear as the surrounding enamel.
The erosive injuries wear the dentin away. When erosion reaches the palatal surfaces of maxillary teeth, a central area of exposed dentin often emerges surrounded by an unaffected enamel edge.
What are the effects of tooth surface loss?
These are the effects of tooth surface loss: The surface loss of the physiological tooth is normal and results in a reduction in the height (vertical) and the width of the tooth (horizontal).
In the physiological loss of the tooth surface, the vertical dimension is kept by the remodeling of the alveolar bone, resulting in an elongation of the alveolar process, likewise the proximal wear is counterweighed by a constant pressure to maintain the tooth-on-tooth contact.
If the case is related to a vertical pathological tooth surface loss, it is possible that the compensatory growth (dental-alveolar compensation) may have occurred to some extent.
Verifying whether or not treatment is necessary
As in every clinical exercise, it is necessary to carefully take into account the patient’s anxieties and desires, as well as the clinical characteristics, before providing treatment advice.
A modern treatment model is based on 3 stages:
1 – Understanding the etiology through a clinical investigation
2 – Outlining the treatment plan and its implementation
3 – Maintenance
There are no immutable and quick-paced rules and the need for treatment must be established after proper ponderation of the following:
• The degree of wear in relation to the patient’s age
• The etiology
• The symptoms
• The patient’s desires.
Treatment may be passive or active
Monitoring – Only monitoring allows the assessment of the wear of tooth surfaces, defining them as active or static. In most situations, the patient must undergo a monitoring period before submitting to active treatment.
Prevention – this approach intends to prevent future loss of tooth surfaces in order not to allow the patient to reach a situation where they would need a restorative treatment.
When the cause of tooth surface loss is erosive fluids, the patient must receive diet-related advice, use sugar-free bubblegum and an oral mouthwash with fluoride.
When abrasion is the main source of tooth wear, the patient must be re-educated on oral hygiene.
If dental wear is associated with the attrition, the patient may have bruxism. A mouthguard is recommended.
Loss of dental tissue from wear may require active treatment for the following reasons:
– Loss of vertical dimension
When we opt for restorative treatment, we have to rely on the preexisting dental conditions, as well as the extent and location of the loss of tooth tissue.
Restoration maintenance in conservative treatment
Preventive measures must be adopted in patients suffering from erosion and abrasion injuries with the intent to reduce contact between the acids and the teeth and protect the latter from mechanical stress.
It was found that patients suffering from moderate to severe erosion often had a high degree of parafunctional habits as well, which impaired treatment maintenance.
In addition to diet control and other medical conditions related to erosion, all patients must receive a night mouthguard, which appears to be the most effective measure, knowing that occlusion is neither the cause nor the treatment of parafunctional habits.
The night mouthguard has an important protective effect, but its therapeutic action in the treatment or improvement of temporomandibular disorders is controversial.
The strong forces related to night and daytime bruxism, and the fact that patients rarely use a night mouthguard or follow the recommendations provided by the professionals, lead to problems or mechanical failures.
An early diagnosis of the signs related to tooth wear is extremely important so that corrective, preventive and even restorative measures can be taken.
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