Tooth wear

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Tooth wear
Oral Manifestation of Bulimia..jpg
Lower teeth shows signs of tooth wear likely caused by erosion
Classification and external resources
Specialty Dentistry

Tooth wear (also termed non-carious tooth substance loss) refers to loss of tooth substance by means other than dental caries or dental trauma.[1] Tooth wear is a very common condition that occurs in approximately 97% of the population.[2] This is a normal physiological process occurring throughout life, but accelerated tooth wear can become a problem.[3]

Tooth wear is majorly the result of three processes; attrition, abrasion and erosion.[3] These forms of tooth wear can further lead to a condition known as abfraction,[3] 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 difficulty identifying a single causative factor.[3] 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.[1] 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.[1]

Multiple indices have been developed in order to assess and record the degree of tooth wear, the earliest was that by Paul Broca.[4] 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.[4] A more recent index Basic Erosive Wear Examination (BEWE) from 2008 by Bartlett et al., is now also in use.[5]

Attrition[edit]

Attrition is loss of tooth substance caused by physical tooth-to-tooth contact.[2] The word attrition is derived from the Latin verb attritium, which refers to the action of rubbing against something.[2] Attrition mostly causes wear of the incisal and occlusal surfaces of the teeth. Attrition has been associated with masticatory force and parafunctional activity[2] such as bruxism. A degree of attrition is normal, especially in elderly individuals.[6]

Abrasion[edit]

Abrasion is loss of tooth substance caused by physical means other than teeth.[6] The term is derived from the Latin verb abrasum, which means ‘to scrape off’.[2] It tends to present as rounded ditching around the cervical margins of teeth, commonly described as ‘shallow’, concave or wedge shaped notches.[1] Causative factors have been linked to this condition and include vigorous, horizontal tooth brushing, using toothpaste with a too high RDA value, pipe smoking or nail biting. It has also been shown that improper use of dental floss or Toothpicks can lead to wear on the interproximal (in-between) surfaces of the teeth.[2]

Erosion[edit]

Erosion is chemical dissolution of tooth substance caused by acids, unrelated to the acid produced by bacteria in dental plaque.[1] Erosion may occur with excessive consumption of acidic foods and drinks, or medical conditions involving repeated regurgitation and reflux of gastric acid.[6] derived from the Latin word erosum, which describes the action ‘to corrode’.[2] This is usually on the palatal (inside) surfaces of upper front teeth and the occluding (top) surfaces of the molar teeth.

Abfraction[edit]

Abfraction is loss of tooth substance at the cervical margins, purportedly caused by minute flexure of teeth under occlusal loading.[7] The term is derived from the Latin words ab and functio meaning ‘away’ and ‘breaking’ respectively.[2] Abfraction presents as triangular lesions along the cervical margins of the buccal surfaces of the teeth where the enamel is thinner and therefore, in the presence of occluding forces, is prone to fracture.[1] Whether abfraction exists or not is debated.

Indices[edit]

Tooth wear indices are useful tools for carrying out epidemiological studies and for general use in dental practices.[5]

Basic Erosive Wear Examination (BEWE)[edit]

The Basic Erosive Wear Examination was first described in 2008 by Bartlett et al. 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) 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.[8]

Table 1: Basic Erosive Wear Examination Scoring
BEWE Score Clinical appearance description
0 No erosive tooth wear
1 Initial loss of surface texture
2 Distinct defect, hard tissue loss <50% of the surface area
3 Hard tissue loss ≥50% of the surface area

Tooth Wear Index (TWI)[edit]

Developed by Smith and Knight in 1984. TWI scores each visible surface (buccal/B, cervical/C, lingual/L and occlusal-incisal/I) (see Table 2).[9] This index has been widely used in epidemiological studies.[10]

Table 2: Tooth Wear Index Scoring
Score Surface Criteria
0 B/L/O/I No loss of enamel surface characteristics
C No loss of contour
1 B/L/O/I Loss of enamel surface characteristics
C Minimal loss of contour
2 B/L/O Loss of enamel exposing dentine for less than one third of surface
I Loss of enamel just exposing dentine
C Defect less than 1mm deep
3 B/L/O Loss of enamel exposing dentine for more than one-third of surface
I Loss of enamel and substantial loss of dentine
C Defect less than 1-2mm deep
4 B/L/O Complete enamel loss- pulp exposure- secondary dentine exposure
I Pulp exposure or exposure of secondary dentine
C Defect more than 2mm deep- pulp exposure- secondary dentine exposure

Other indices[edit]

  • Eccles-Index [11]
  • Modified TWI [12]
  • Linkosalo and Markkanen [13]
  • O'Brien Index [14]
  • Lussi Index [15]
  • O'Sullivan Index [16]
  • Simplified Tooth Wear Index (STWI) [17]
  • Exact Tooth Wear Index [18]
  • Visual Erosion Dental Examination (VEDE) [19]
  • Evaluating Index of Dental Erosion (EVIDE) [20]

Active Intervention[edit]

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.[21]

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 this can first be tested using reversible method i.e. 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.[22]

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 different potential scenarios.[23]

  1. excessive wear with loss of OVD
  2. excessive wear without loss of OVD but with space available
  3. excessive wear without loss of OVD but with limited space available

Type 1 is relatively common, whereas type 2 is quite rare and tends to occur when the wear is rapidly occurring. Type 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.[23]

The options for restoring this loss in tooth height are the following [24]

  1. 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
  2. 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
  3. crown lengthening 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
  4. 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.

References[edit]

  1. ^ a b c d e f Kaidonis JA (August 2012). "Oral diagnosis and treatment planning: part 4. Non-carious tooth surface loss and assessment of risk". British Dental Journal. 213 (4): 155–61. doi:10.1038/sj.bdj.2012.722. PMID 22918343. 
  2. ^ a b c d e f g h Suchetha A (2014). "Tooth Wear - A Literature Review". Indian Journal of Dental Science. 5 (6): 116–120. 
  3. ^ a b c d Bhushan J, Joshi R (2011). "Tooth Wear - An Overview With Special Emphasis On Dental Erosion". Indian Journal of Dental Sciences. 5 (3): 89. 
  4. ^ a b López-Frías FJ, Castellanos-Cosano L, Martín-González J, Llamas-Carreras JM, Segura-Egea JJ (February 2012). "Clinical measurement of tooth wear: Tooth wear indices" (PDF). Journal of Clinical and Experimental Dentistry. 4 (1): e48–53. doi:10.4317/jced.50592. PMID 24558525. 
  5. ^ a b Lussi A, Ganss C. Erosive tooth wear : from diagnosis to therapy. 20 (2nd ed.). Basel. ISBN 9783318025538. OCLC 875630033. 
  6. ^ a b c Odell EW (Editor) (2010). Clinical problem solving in dentistry (3rd ed.). Edinburgh: Churchill Livingstone. pp. 285–287. ISBN 9780443067846. 
  7. ^ Sarode GS, Sarode SC (May 2013). "Abfraction: A review". Journal of Oral and Maxillofacial Pathology. 17 (2): 222–7. doi:10.4103/0973-029X.119788. PMC 3830231Freely accessible. PMID 24250083. 
  8. ^ Bartlett D, Ganss C, Lussi A (March 2008). "Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs". Clinical Oral Investigations. 12 Suppl 1 (Suppl 1): S65–8. doi:10.1007/s00784-007-0181-5. PMC 2238785Freely accessible. PMID 18228057. 
  9. ^ Smith BG, Knight JK (June 1984). "An index for measuring the wear of teeth". British Dental Journal. 156 (12): 435–8. PMID 6590081. 
  10. ^ Bardsley PF (March 2008). "The evolution of tooth wear indices". Clinical Oral Investigations. 12 Suppl 1: S15–9. doi:10.1007/s00784-007-0184-2. PMID 18228055. 
  11. ^ Eccles, J. D. (December 1979). "Dental erosion of nonindustrial origin. A clinical survey and classification". The Journal of Prosthetic Dentistry. 42 (6): 649–653. ISSN 0022-3913. PMID 292776. 
  12. ^ Millward, A.; Shaw, L.; Smith, A. J.; Rippin, J. W.; Harrington, E. (September 1994). "The distribution and severity of tooth wear and the relationship between erosion and dietary constituents in a group of children". International Journal of Paediatric Dentistry. 4 (3): 151–157. ISSN 0960-7439. PMID 7811669. 
  13. ^ Linkosalo, E.; Markkanen, H. (October 1985). "Dental erosions in relation to lactovegetarian diet". Scandinavian Journal of Dental Research. 93 (5): 436–441. ISSN 0029-845X. PMID 3864217. 
  14. ^ Maureen., O'Brien, (1994). Children's dental health in the United Kingdom, 1993 : a survey carried out by the Social Survey Division of OPCS, on behalf of the United Kingdom health departments, in collaboration with the Dental Schools of the Universities of Birmingham and Newcastle. Great Britain. Office of Population Censuses and Surveys. Social Survey Division., University of Birmingham. Dental School., University of Newcastle upon Tyne. Dental School. London: H.M.S.O. ISBN 0116916079. OCLC 32250617. 
  15. ^ Lussi, A. (April 1996). "Dental erosion clinical diagnosis and case history taking". European Journal of Oral Sciences. 104 (2 ( Pt 2)): 191–198. ISSN 0909-8836. PMID 8804886. 
  16. ^ O’Sullivan, EA (2000). "A new index for the measurement of erosion in children". Eur J Paediatr Dent. 1: 69–74. 
  17. ^ Bardsley, P. F.; Taylor, S.; Milosevic, A. (2004-10-09). "Epidemiological studies of tooth wear and dental erosion in 14-year-old children in North West England. Part 1: The relationship with water fluoridation and social deprivation". British Dental Journal. 197 (7): 413–416; discussion 399. doi:10.1038/sj.bdj.4811722. ISSN 0007-0610. PMID 15475904. 
  18. ^ Fares, J.; Shirodaria, S.; Chiu, K.; Ahmad, N.; Sherriff, M.; Bartlett, D. (2009). "A new index of tooth wear. Reproducibility and application to a sample of 18- to 30-year-old university students". Caries Research. 43 (2): 119–125. doi:10.1159/000209344. ISSN 1421-976X. PMID 19321989. 
  19. ^ Mulic, A.; Tveit, A. B.; Wang, N. J.; Hove, L. H.; Espelid, I.; Skaare, A. B. (2010). "Reliability of two clinical scoring systems for dental erosive wear". Caries Research. 44 (3): 294–299. doi:10.1159/000314811. ISSN 1421-976X. PMID 20516691. 
  20. ^ Margaritis, Vasileios; Mamai-Homata, Eleni; Koletsi-Kounari, Haroula; Polychronopoulou, Argy (January 2011). "Evaluation of three different scoring systems for dental erosion: a comparative study in adolescents". Journal of Dentistry. 39 (1): 88–93. doi:10.1016/j.jdent.2010.10.014. ISSN 1879-176X. PMID 21035516. 
  21. ^ Mehta, S. B.; Banerji, S.; Millar, B. J.; Suarez-Feito, J.-M. (January 2012). "Current concepts on the management of tooth wear: part 1. Assessment, treatment planning and strategies for the prevention and the passive management of tooth wear". British Dental Journal. 212 (1): 17–27. doi:10.1038/sj.bdj.2011.1099. ISSN 1476-5373. 
  22. ^ Mehta, S. B.; Banerji, S.; Millar, B. J.; Suarez-Feito, J.-M. (February 2012). "Current concepts on the management of tooth wear: part 3. Active restorative care 2: the management of generalised tooth wear". British Dental Journal. 212 (3): 121–127. doi:10.1038/sj.bdj.2012.97. ISSN 1476-5373. 
  23. ^ a b Dyer, K.; Ibbetson, R.; Grey, N. (April 2001). "A question of space: options for the restorative management of worn teeth". Dental Update. 28 (3): 118–123. ISSN 0305-5000. PMID 11819971. 
  24. ^ Ibbetson, R (June 1999). "tooth surface loss: Treatment planning". British Dental Journal. 186 (11): 552–558. doi:10.1038/sj.bdj.4800167. ISSN 1476-5373.