Professor Andrew Eder explores a handful of the most recently published research related to tooth wear, to help dental professionals stay ahead of this growing challenge being faced in everyday practice.
With the challenges posed by pathological tooth wear poised to affect many of our patients’ oral health if not addressed promptly, it is incumbent upon dental professionals to gather as much information as possible to help them take preventive steps before the problem becomes so bad that only restorative treatment offers an answer to their discomfort and aesthetic issues.
There is a growing body of evidence exploring the signs, symptoms and implications of tooth wear beyond that which we would expect as we age, ranging from exploration of the accuracy of various methods for assessing erosion to using CAD/CAM technology to monitor tooth wear in a clinical setting.
Physiological versus pathological
Loomans and colleagues (2017) recently published European expert consensus guidelines on the management of severe tooth wear, focusing on defining the difference between physiological and pathological damage, as well as recommending, ‘[…] diagnosis, prevention, counselling,
and monitoring aimed at elucidating the aetiology, nature, rate and means of controlling pathological tooth wear.’1
In terms of physiological tooth wear, one suggested scale is that a loss of around 15 μm per year for premolars and 29 μm per year for molars is ‘typical’, although others offer alternative indicators so it is important to consider a cross-section of the proposed measurements.1
The panel offered the following definition for pathological tooth wear: ‘Tooth wear which is atypical for the age of the patient, causing pain or discomfort, functional problems, or deterioration of aesthetic appearance, which, if it progresses, may give rise to undesirable complications of increasing complexity.’1
They also created a separate definition for ‘severe tooth wear’, relating to the level of tooth surface lost: ‘Tooth wear with substantial loss of tooth structure, with dentine exposure and significant loss (≥ 1/3) of the clinical crown.’1
The following guidelines were issued for the treatment of patients with severe tooth wear:
• ‘Priority should be given to the diagnosis of the aetiology of the wear and instigating appropriate preventive measures
• ‘Patients with moderate or severe tooth wear but without (functional or aesthetical) complaints should be advised to monitor the situation first to determine whether the tooth wear is progressive or not
• ‘Restorative treatment should be as conservative as possible, employing minimally invasive treatment strategies according to a dynamic restorative treatment concept
• ‘Direct and indirect minimally invasive techniques can be employed using adhesive materials. Traditional, invasive restorations remain an option in selected cases and under certain circumstances
• ‘Explanation of the possible treatment options and expected complications should be included in the informed consent.’1
Assessing erosive tooth wear
In 2016, Bliggenstorfer and Lussi reported on the accuracy of different methods for assessing erosive tooth wear, having acknowledged limitations in detection using the naked eye alone.2
They wrote: ‘[…] the aim of this study was to investigate if the accuracy of assessing exposed dentine by the naked eye could be improved by using a microscope, dyeing, or a combination of both. The collected data were compared with the assessment of histological sections, which was considered the gold standard.’2
Following assessment 4 times by 17 examiners of a total of 70 teeth demonstrating various levels of erosion, they concluded: ‘[…] the differentiation between enamel and exposed dentine of erosive tooth lesions was best performed using microscope magnification alone. The use of a dyeing agent alone provided no improvement in the visual assessment of the measured parameters. Even the combination of microscope magnification and dyeing did not show any further improvement compared with the microscope magnification alone. Therefore, the usage of an additional dye is superfluous for the detection of exposed dentine in teeth showing erosive tooth wear.’2
Ahmed and colleagues (2017) wrote about the clinical monitoring of tooth wear over a period of one year using CAD/CAM technology. Given the idea that current tooth wear indices offer only a subjective way of evaluating tooth surface loss, the authors of this study sought to assess CAD/CAM scanning as an objective assessment tool.3
They found: ‘[…] all patients presented anterior tooth wear ≥ 140 μm in depth. The most commonly and severely affected teeth were the maxillary central incisors. The clinical feasibility and applicability of the developed CAD/CAM methodology in monitoring tooth wear was demonstrated.’3
As the researchers admitted themselves, this study involved a small sample size, so the ability of statistical analysis was limited, and it would seem prudent, given the results, that further research is undertaken in the area in order to achieve more robust outcomes.3
Dental Update published guidelines for general dental practice, offering a new perspective on tooth sensitivity (Gillam A, 2017).
It was written: ‘[…] several investigators have suggested that DH [dentine hypersensitivity] may be a tooth-wear phenomenon characterized predominantly by erosion, which may subsequently expose the dentine surface and initiate the tooth wear lesions.’4
The guidelines continue: ‘[…] the treatment for tooth wear and DH may be more complex in restoring lost enamel and dentine than patients with DH associated with a well maintained dentition with relatively little tooth surface loss.’4
Offering overall management strategies for tooth sensitivity caused by tooth wear, in terms of clinical evaluation, Gillam (2017) suggests:
• ‘Identify cause of tooth wear (enamel loss)
• ‘Record severity of lesions, if possible, using a recognised index
• ‘Take study casts and clinical photographs to monitor condition over time
• ‘Check and monitor periodontal health.
• ‘Use of pain scores to assess and monitor DH (e.g., Visual Analogue Scores).’4
In relation to patient education and offering preventive advice:
• ‘Show patient the site(s) and explain probable cause of the tooth wear lesion(s)
• ‘Recommend an oral hygiene regimen to minimise risk of further tooth wear.
• ‘Where appropriate recommend reducing frequency of consumption of acidic food & drink.’4
Meanwhile, corrective treatment may involve:
• Provide high fluoride remineralising treatment (pre-emptive phase)
• ‘Provide professional desensitising treatment to relieve DH
• ‘Encourage patient to seek advice from medical practitioner, if tooth wear caused by working environment or reflux/excessive vomiting (Psychiatric evaluation may also be appropriate)
• ‘Restorative correction in the form of composite build up, crowns may also be appropriate.’4
The timing of acid intake
O’Toole and colleagues (2017) investigated the extent to which the timing of consuming acidic foods and drinks may affects erosive tooth wear, given that, as yet, there is no clinical threshold of what may be considered ‘safe’.5
Following completion of this single-centre, frequency-matched, case-control study, the authors offered the following summary: ‘In this large cohort of hospital-based patients, the predominant risk factors in the development of severe erosive tooth wear in this study were acid intake between meals, an alternate drinking method such as sipping, swishing or holding acidic drinks in the mouth prior to swallowing and eating fruit over an extended time period. Brushing after meals was not associated with erosive tooth wear suggesting universal preventive advice to delay brushing after meals is not substantiated.’5
Building on our knowledge
As with all areas of dentistry in the ever-changing and developing 21st century, new evidence, materials and methods are continuously coming to light and it is so important for us as dental professionals to remain up to date, if we are to succeed in safeguarding our patients from the potentially devastating effects of pathological tooth wear looming ahead in the not too distant future.
1. Loomans B et al. Severe tooth wear: European consensus statement on management guidelines. J Adhes Dent 2017; 19: 111–119
2. Bliggenstorfer SE, Lussi A. Accuracy of different methods for assessing erosive tooth wear. JDR Clinical & Translational Research 2016; 1(3): 218-225
3. Ahmed K et al. Clinical monitoring of tooth wear progression in patients over a period of one year using CAD/CAM technology. The International Journal of Prosthodontics 2016; 30(2): 153-155
4. Gillam A. A new perspective on dentine hypersensitivity – guidelines for general dental practice. Dental Update 2017; 44(1): 33-42
5. O’Toole S et al. Timing of dietary acid intake and erosive tooth wear: A case-control study. Journal of Dentistry 2017; 56: 99-104