Dental wear: a problem that is becoming more common

Clinical Assessment

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.

Treatment

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

Treatment:

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.

Active Treatment:

Loss of dental tissue from wear may require active treatment for the following reasons:

– Sensitivity

– Aesthetics

– Function

– 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.

Conclusions:

An early diagnosis of the signs related to tooth wear is extremely important so that corrective, preventive and even restorative measures can be taken.