Professor Andrew Eder considers some of the risks associated with the identification and management of tooth wear and how to handle them.

Read the article below:

The public at large are relatively well informed about the importance of brushing and flossing to maintain a satisfactory level of oral health, embracing that message to various degrees.

What appears to be much less well known is that there can be tooth wear challenges posed by what one might call over-exuberant toothbrushing, in the form of abrasion.

Clinical signs that abrasion may be occurring include:

• Teeth may become less white as some of the outer surface is lost
• Front teeth may become sharp or chipped
• Chewing surfaces may wear flat and take on a shiny, pitted appearance.
• Restorations such as crowns and bridges may stand proud of the natural teeth.

 
An important preventive message to share with our patients, therefore, is the need for gentle but effective brushing. Experience has shown that many people mistake brushing hard for brushing well! It may also be appropriate for the dentist or hygienist to demonstrate the best brushing technique for the patient, and to recommend the use of a soft toothbrush and non-abrasive toothpaste.

If you would like help tackling this growing problem, The London Tooth Wear Centre® offers an evidence-based and comprehensive approach to managing tooth wear, using the latest clinical techniques and an holistic approach in a professional and friendly environment.

Earlier this year, a group of key opinion leaders published European Consensus guidelines on the management of severe tooth wear, focusing, in part, on the difference between physiological and pathological wear.¹

As Loomans and colleagues (2017) wrote, it is important to be able to differentiate between these two types of tooth wear, since physiological surface loss is to be expected with age, while pathological describes ‘unacceptable levels of progressive wear’.¹

To help dentists recognise which is which, the group merged the results of a number of studies into physiological tooth wear, revealing that over a time span of six decades the molars show the greatest level of wear (1740 μm), the mandibular incisors come next (1460 μm), then the maxillary incisors (1010 μm), and, lastly, the premolars (900 μm).¹

For dental professionals, the signs that indicate pathological tooth wear may be occurring and preventive action is, therefore, needed include:

• Tooth sensitivity
• Discolouration, including yellowing and loss of shine (where some of the outer enamel layer has been lost)
• Sharp or chipped anterior teeth
• Occlusal surfaces wearing flat and taking on a shiny, pitted appearance
• Altered occlusion as vertical height changes
• Restorations standing proud of the teeth
• Abfraction lesions developing cervically
• V-shaped notches or shallower cupping present cervically

Reference

Loomans B et al. Severe tooth wear: European consensus statement on management guidelines. J Adhes Dent 2017; 19: 111-119

The Oral Health Foundation recently raised concerns about teenagers bruxing in their sleep, because it can be a sign of being bullied.

According to a recent study (Serra-Negra et al, 2017), 65% of adolescents who were subjected to verbal bullying in school suffered from sleep bruxism, compared to just 17% in those who were not.

It would seem imperative, therefore, that dentists raise awareness of this indicator with parents, as well as offering advice on how what preventive measures can be taken to minimise damage to the dentition, whilst other parties address the social issues of the problem, to help maintain and build self-esteem.

If a patient presents with pain and/or tooth wear that can be attributed to bruxism, a three-step treatment plan may be appropriate:
1. Prescription of short term muscle relaxants, particularly if an acute situation
2. Treatment with a physiotherapist or osteopath with specialist knowledge of the temporomandibular joint
3. Nightly use of a mouthguard, primarily of the Michigan Splint design

It may also be a good idea to ensure patients are brushing effectively but gently with a relatively soft toothbrush and a toothpaste that is low in abrasivity where there is clear evidence of tooth wear, as well as suggesting they do something relaxing before bed such as reading or having a bath.

Reference
Serra-Negra J et al. Is there an association between verbal school bullying and possible sleep bruxism in adolescents? J Oral Rehabil. 2017; 44(5): 347-53

In anticipation of the first phase of the sugar tax, Professor Andrew Eder looks beyond the more commonly-associated topics of obesity and caries, and considers the effect of sugary drinks in terms of tooth surface loss.

Trends in relation to tooth surface loss, revealed by the most recent Adult Dental Health Survey (2009), suggest that erosion, abrasion and attrition are on the increase. Indeed, comparison between the 1998 and 2009 surveys reveal an increase of 10% in the incidence of tooth wear; when extrapolated, this is very concerning for the future.1

The good news is that some help is around the corner in the form of the so-called ‘sugar tax’, but it has predominantly been promoted as a tool in the fight against obesity and, to a lesser extent, caries. But in truth it also has a role to play in reducing the incidence of tooth wear, as the inherent acids have acidogenic potential, possibly resulting in erosion over time.

So, whilst this outcome is not directly linked to sugar, if the tax could be used as a tool to encourage patients to drink fewer carbonated beverages and high-sugar fruit juices, tooth surface loss beyond that expected as we age may be reduced, or even prevented.

Taking steps

It is anticipated that the tax on sugary beverages will come into being in April 2018,2 in form of a tiered tax on the drinks industry as follows:
• A high tax for drinks with >8 g of sugar per 100ml
• A moderate tax for 5g to 8g of sugar per 100ml
• No tax for <5g of sugar per 100ml.³

As Jeremy Rees, Professor of Restorative Dentistry at Cardiff University, told the British Dental Journal in 2015 regarding what was – at that time – a campaign to tax sugary drinks, ‘I believe that would be a step in the right direction because the average consumption of carbonated drinks in the UK (particularly for young people in their twenties and younger) is half a litre a day per person.’4

Responding to a question about what milestone he would like to see in preventive dentistry, he responded: ‘I think it’s making people more aware of the issues relating to acid erosion.’4

This is the key; educating patients about tooth surface loss. The public has been told repeatedly about the detrimental effect of sugar consumption on their oral health, and many have responded to this call to action by switching to sugar-free carbonated drinks and fruit juices. They genuinely think this is a healthy move, and, of course, in some ways it is.

Undeniably, telling a patient that they are suffering from tooth wear can come as something of a shock, especially for those in their 20s, 30s and 40s who are well educated and try to live a healthy lifestyle.

Whatever their age and status, patients need to be made aware that ill-considered drink choices can cause damage to the enamel and dentine. If you would like support in doing this, The London Tooth Wear Centre® offers an evidence-based and comprehensive approach to managing tooth wear, using the latest clinical techniques and an holistic approach in a professional and friendly environment.

References
1. Adult Dental Health Survey 2009. Health and Social Care Information Centre 2011
2. https://www.gov.uk/government/news/soft-drinks-industry-levy-12-things-you-should-know. Accessed 1 June 2017
3. Briggs ADM et al. Health impact assessment of the UK soft drinks industry levy: a comparative risk assessment modelling study. The Lancet Public Health 2017; 2(1): e15–e22
4. Rees J. ‘We ned to make people more aware of the issues relating to acid erosion.’ BDJ 2015; 219(4): 157-158

Did you know that missing teeth can contribute to excessive tooth wear of your remaining teeth?

So, not only might you be upset by the unsightliness of such a gap or gaps where teeth have been lost, you may also experience tooth sensitivity, as well as problems chewing. Your teeth may also begin to look shorter on smiling or when speaking. In addition:
• Teeth may become less white as some of the outer enamel surface is lost
• Front teeth may become sharp or chipped
• Chewing surfaces may wear flat and take on a shiny, pitted appearance.
• Restorations such as crowns and bridges may stand proud of the natural teeth.

One possible solution is that of dental implants, a permanent method of replacing missing teeth by inserting an artificial root – an implant – into the jaw to then support a new tooth on top. The issue is a simple one to understand; if you have a gap or gaps in your mouth where a tooth or teeth used to be, there is a possibility that the remaining teeth will come into greater contact than they would have before, when there was that extra ‘barrier’ in place.

If you want to know more about your personal suitability for dental implants, I would be delighted to offer advice if your own dentist is unable to assist and, in the meantime, I am happy to offer some further insight on tooth wear itself, because, as the adage goes, prevention is better than cure.

The good news is that there are some simple steps we can all incorporate into our everyday lives to reduce the risks, such as:
• Drinking still water or low-fat milk between meals
• Limiting fruit juice to once per day and avoiding fizzy drinks
• Rinsing the mouth with water for 15 to 30 seconds after consuming acidic foods or drinks
• Chewing sugar free gum or eating a piece of cheese after consuming acidic food or drink
• Waiting at least an hour to brush teeth after consuming any acidic foods or drinks
• Using toothpaste that contains fluoride but is low in abrasivity, with a relatively soft toothbrush.
• Using a fluoridated mouthwash every day at a different time to tooth brushing, as well as before or after acidic foods and drinks, to help limit the erosive potential.

If you are suffering from excessive tooth wear and no preventive action is taken, somewhere down the road you will be facing the possibility of extensive and expensive restorative treatment. You may think you are not affected by tooth wear but there is no doubt that it is on the increase; over three-quarters of adults and at least half of children show signs of tooth surface loss.

We are ideally placed to offer you tailored advice on dental implants and tooth wear. Please contact the London Tooth Wear Centre® which offers an evidence-based and comprehensive approach to managing tooth wear, using the latest clinical techniques and an holistic approach in a professional and friendly environment.

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

CAD/CAM assessment

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

Dentine hypersensitivity

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.

References

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

Many people would be surprised to learn that being stressed out may be affecting not only the health of their teeth but also how they look.

A type of tooth wear, known as ‘attrition’, involves contact between the teeth over and above normal use, as seen in patients who generally grind and clench their teeth at night (also known as bruxing), that has been linked to a stressful lifestyle.

To add insult to injury, when patients suffer from sensitivity as a result of tooth wear, how they react has the potential to make matters worse. For example, sufferers may avoid toothbrushing and flossing, plus make poor food and drink choices, in an attempt to avoid the pain these everyday tasks can cause.

Statistics gathered by the NHS suggest that over three-quarters of adults (permanent teeth) and more than half of children (primary teeth) are suffering from some type of tooth wear and, if we continue as we are, this is set to get worse.

Signs and symptoms

Those who do suffer from such grinding and/or clenching activity may experience tooth sensitivity, problems chewing, headaches and neck ache. If a dentist examined a bruxer’s mouth, they might find teeth that are:

• Sharp or chipped
• Broken
• Shortened
• Loose
• Wearing flat, and looking shiny and pitted

The dentist can help

Dentists are there to help, and will be able to make a diagnosis of attrition, provide preventive advice and care, or refer the sufferer on, if appropriate.

Possible treatment options include prescribing muscle relaxants, fabricating a suitable mouthguard to be worn at night to relieve pressure on the jaw, or recommending care from a physiotherapist or osteopath with specialist knowledge of the muscles involved.

If there was one piece of advice above all others I would offer, it would be this – don’t delay in seeking help. If damage resulting from tooth wear is diagnosed and addressed in its early stages, tooth grinders can avoid the extensive and expensive dental treatment that would otherwise be necessary to correct the situation.

Making changes

The good news is that making a few simple lifestyle changes can be a big help, such as:

• Doing something relaxing before bed, such as yoga, reading or having a bath
• Learning to brush effectively yet gently with a relatively soft toothbrush and a toothpaste that is low in abrasivity (dentists can offer advice on this).

 
In addition, if someone is suffering from tooth sensitivity (which should be diagnosed by a dentist to ensure there is no underlying condition that needs treatment), using a fluoridated mouthrinse every day at a different time to toothbrushing is an effective first line of defence. A desensitising toothpaste can also be helpful in alleviating the pain caused by sensitivity.

Read the recent article on Toothbrushing below as published on Dental Supplies Magazine

“In this article, Professor Andrew Eder considers the damage that can be caused to the teeth if patients are too heavy-handed with their toothbrushing, as well as exploring other potential causes of abrasion and offering preventive advice to be passed on to patients.

The Oxford Dictionary of Dentistry defines ‘abrasion’ as: ‘The non-bacterial loss of tooth tissue due to frictional tooth wear by extrinsic agents. Common causes are toothbrushing, particularly with abrasive pastes, pipe smoking, and pencil chewing. The lesions produced by toothbrush abrasion are typically wedge-shaped and are most commonly associated with the labial and buccal surfaces of the premolars, canines, and incisors of the permanent dentition.’

These are not the only cause of abrasion – you can add to the list a diet rough in texture or using the teeth for a purpose other than nature intended, such as biting tags off new purchases, or cleaning between the teeth with tools not created for that purpose, for instance earring posts, keys and credit cards!

A patient suffering from tooth wear may report sensitivity, as well as problems chewing. Their teeth may also look shorter on smiling or when speaking. In addition:

• Teeth may become less white as some of the outer surface is lost

• Front teeth may become sharp or chipped

• Chewing surfaces may wear flat and take on a shiny, pitted appearance.

• Restorations such as crowns and bridges may stand proud of the natural teeth.

Patient awareness and education

Raising awareness and educating our patients about the potential for abrasive tooth wear is essential if we are to prevent further damage. Thus, for example, an important message to share is the importance of gentle but effective brushing – in my experience, many people mistake brushing hard for brushing well! It may be appropriate for the dentist or hygienist to demonstrate the best technique for the patient, and to recommend the use of a soft toothbrush and non-abrasive toothpaste.

Meanwhile, as already mentioned, foods with a rough texture will make matters worse, so it is worth having a discussion with patients about their diet. As a rule of thumb to share with them, if it’s tough to chew and/or fibrous, it may well be abrasive. Some of the more commonly consumed foods that can contribute to abrasion include celery, carrots, broccoli, apples, seeds and nuts.

It is also very important to make sure patients understand their teeth are not a handy tool, for example to tear labels off newly bought items or to rip open packets of sweets when their hands fail them! In addition, many people chew foreign objects such as pens and pencils, very often without realising. If a discussion with your patient brings such an issue to the fore, it might be worth suggesting they coat their chew-item of choice with a bitter-tasting solution designed for nail biters.

The reality of wear

As Wiegand and Schlueter (2014) wrote: ‘Although toothbrushing is considered a prerequisite for maintaining good oral health, it also has the potential to have an impact on tooth wear, particularly with regard to dental erosion. Experimental studies have demonstrated that tooth abrasion can be influenced by a number of factors, including not only the physical properties of the toothpaste and toothbrush used but also patient-related factors such as toothbrushing frequency and force of brushing. While abrasion resulting from routine oral hygiene can be considered as physiological wear over time, intensive brushing might further harm eroded surfaces by removing the demineralised enamel surface layer.’

Added to this, there is no doubt that tooth wear is on the increase; over three-quarters of adults show signs of tooth wear. Comparing the most recent Adult Dental Health Survey (ADHS) with its predecessor, figures suggest that in just 11 years the incidence of tooth wear in England has increased by 10%.

Our awareness of these issues – combined with proactive patient care – is key to helping the UK population achieve dental longevity, as well as keeping them pain-free. In addition, while this article has focused on abrasion, it is important to note that tooth wear is multi-factorial and should not be considered in isolation – abrasion, erosion, attrition and abfraction are rarely seen in isolation (if ever), and may affect people from all walks of life at any age.

The stark truth is that if patients remain unaware and uneducated about the potential for tooth damage through tooth wear, patients will continue with their destructive habits, which will have serious implications for their oral health in years to come.”

Professor Andrew Eder explores the significance of continuing education in relation to tooth wear to build on undergraduate knowledge, in order to meet the growing needs of patients suffering from pathological surface loss. The article was published in issue 42 of Dental Supplies Magazine below:

Read the full article below:

Professor Andrew Eder explores the significance of continuing education in relation to tooth wear to build on undergraduate knowledge, in order to meet the growing needs of patients suffering from pathological surface loss.

Professor Andrew Eder is a Specialist in Restorative Dentistry and Prosthodontics and Clinical Director of the London Tooth Wear Centre®, a specialist referral practice in central London. He is also Professor/ Honorary Consultant at the UCL Eastman Dental Institute and Pro-Vice-Provost and Director of Life Learning at UCL.

We’ve all been there. After five years of hard work (and some fun), there’s little to match the sense of achievement when you receive word that you’ve passed your final examinations and are ready to be let loose on the world, to contribute to the improvement of the nation’s oral health. For most of us, the next step came in the form of dental foundation training (DFT) and vocational training (VT) (or the equivalent at the time of your graduation), which is a steep learning curve to says the least!

It is at this point that reality of our patients’ needs really hit home and, whilst we all learned so much as undergraduates, there is still more to knowledge to absorb and apply in practice if we are truly to meet our career goals.

For me that, in part, came in the form of specialisation in restorative dentistry and prosthodontics, with a particular interest in tooth wear. You may ask – why? Because over the years, I have noticed an increase in tooth wear beyond that which would be expected in relation to my patients’ ages, and it’s something that needs to be addressed not only because it causes pain and an unsightly dentition, but also because the NHS can in no way can afford to meet the growing needs of these patients if left unchecked – with restorative treatment both extensive and expensive.

The facts and figures

Recognising that tooth wear has the potential to be a serious issue, its incidence and significance was recorded in the Adult Dental Health Survey (ADHS) for the first time in 1998, and repeated in the 2009 edition. In each, tooth wear was assessed at three stages:

1. Any wear
2. Moderate wear – wear that has exposed a large area of dentine on any surface
3. Severe wear – wear resulting in exposed pulp or secondary dentine.

Comparison of the two surveys shows that in just 11 years the incidence of tooth wear in England increased by 15% in those aged 16 to 24, 10% in the 25 to 34 cohort, and 13% between the ages of 35 and 44.

The trends identified in the last two surveys strongly suggest that those in the younger age groups need preventive treatment beyond what is generally already being offered if their dental health is to be secured over the long term.

This idea was further reinforced by the results of the 2013 Children’s Dental Health Survey, which indicated that just over a quarter of children in the UK aged 12 have tooth wear on their molars and on the buccal surfaces of their incisors. What’s more, by 15, 31% of children had tooth wear on the occlusal surfaces of molars (compared to 25% at 12 years old).

What needs to be done?

As a group of professionals dedicated to caring for our patients, clearly the increasing relevance of tooth wear does need to be addressed – preferably in its earliest stages. To be successful, preventive care and the ability to communicate effectively with patients – so that they can understand their responsibilities and be motivated to meet them – are essential.

For dental professionals, the key is to build on our undergraduate knowledge, not only to understand fully the care and treatment that these types of patients need, but also to be able to overcome any psychosocial impediments to patients acting on their own behalf to improve the situation.

There are online resources – both paid for and free of charge – such as GSK’s distance learner module on tooth wear and the Basic Erosive Wear Examination (BEWE), offering a valuable foundation.

To build upon this, check out what NHS Health Education England has to offer in your area. As just one example, Kent, Surrey
and Sussex offers a module entitled ‘BDA Clinical Management of Pathological Tooth Wear in General Dental Practice’, offering delegates the opportunity to ‘…attain a better understanding of tooth wear and will learn strategies to achieve a conservative solution avoiding further loss of healthy tooth structure in order to achieve a functional and predictable outcome.’

Also invaluable are hands-on courses, some privately run and others catered for by some NHS Health Education England providers, including HEKSS, with its day long event looking at the restoration of teeth worn down due to various types of erosion and attrition, using a range of techniques applicable to general practice. Not only that, but the psychology of care is also addressed, alongside record keeping, teamwork and when to refer.

Professor Andrew Eder explores the current situation regarding tooth wear in the UK in a recent interview with Private Dentistry. Andrew discusses the rise in tooth wear, its potential causes and offers advice to dentists dealing with patients who present with tooth wear.

Read the full interview with Professor Andrew Eder below:

Speaking exclusively to Private Dentistry, Professor Andrew Eder explores the current situation regarding tooth wear in the UK.

PD: In your view, what do the Adult and Children’s Dental Surveys indicate in terms of the situation regarding tooth wear in the UK?

Andrew Eder: In very broad terms, it’s two fold. If you look at the last two surveys, with 10 years between, they essentially demonstrate that tooth wear is on the increase in both adults and children.
Conversely, when considering tooth wear alongside tooth decay and gum disease, these have not shown the same increase and, in some cases, have even decreased.

PD: In real terms, what are you seeing in practice in relation to tooth wear?

AE: There are two elements of greatest concern to me at the moment. One is older patients who are living longer, and keeping their teeth for longer, but who are having problems with tooth wear. Some of their teeth are sharp, others are crumbling, fillings are falling out, and the dentition isn’t as effective as it used to be. Managing those sorts of problems is quite challenging. I’m also seeing younger patients with a lot of enamel loss due to attrition or erosion; the latter due mainly to the consumption of carbonated drinks and alcohol, as well as stomach acid regurgitation in patients with eating disorders.

PD: Is there anything about the pattern of tooth wear in the UK that surprises you?

AE: There is an issue that I’m keen to look into, so I don’t have all the answers yet. Some reports have suggested that thereis less erosive tooth wear in the US than in the UK. There is a suggestion that people in the US prefer their soft drinks much colder than we do in the in UK, normally putting ice in drinks or having them straight out of the fridge. When you do that, it may have a positive effect on the pH, in that it becomes less acidic. It’s early days on this but something that I’m keen to explore to see how we might be able to influence the potentially damaging effects of acidic drinks.

PD: Are you seeing anything new in practice that dentists might not yet be very aware about when it comes to tooth wear?

AE: One thing that I’m seeing more of in recent years is tooth wear related to recreational drug use. That’s most definitely something I’d like to make people more aware of. You’ll often see unusual patterns of tooth wear, particularly attrition as a result of grinding and clenching, because users may hold their mouth and face in what appears to be a very strained position. Finger application of drugs can also cause significant ulceration of the soft tissues.
If an unusual case of tooth wear presents, colleagues should explore all options, and a frank and open discussion with the patient may be required. However, if they are under the age of consent sometimes it can be more tricky. There is obviously preventive advice to share regarding drug use, but if there is tooth grinding then a mouthguard may be helpful although compliance is questionable.
Involving other healthcare providers where appropriate will also be critical to provide comprehensive assistance.

PD: In general terms, what can dentists do to help their patients prevent further wear damage going forward?

AE: The most important elements are the professional awareness and the ability to diagnose the various types of tooth wear based on the presentation. It isn’t uncommon for me to see a patient referred for an opinion and, on examination, it is clear that they present with a high level of tooth wear and yet no-one at their dental practice has mentioned this previously.
Early diagnosis is key because the sooner you diagnose any tooth wear, the sooner you can offer preventive advice and limit further progression. Also, at this point and where appropriate, patients can often be provided with simple, adhesively retained restorations to protect areas of tooth wear without further removal of otherwise healthy enamel or dentine.
Building on this approach, we – the profession – need to encourage and foster a conservative approach to management.

PD: What might the future hold for people susceptible to tooth wear if this challenge is not addressed appropriately and quickly?

AE: If tooth wear is not managed at the most optimal time and allowed to deteriorate, we may be limited in the treatment options available to help these patients. As a result, this might impact negatively on the quality of life experienced by, particularly, our older patients. If the wear progresses deep into the tooth, then patients can suffer from sensitivity and pain leading, possibly, to root canal problems and even tooth loss. In summary, we must do everything possible to avoid reaching the point where only extensive and complex treatment at one end or extractions at the other remain as viable options. Looking to a healthier future, it’s all about professional awareness, patient education, tackling the challenges of erosion in the young, and addressing wear and tear in the elderly.
It’s certainly an area in which the dental profession can make a big difference, and the sooner the better.

Professor Andrew Eder explores the effects of eating disorder bulimia on oral health, most specifically in terms of erosion as a result of self-induced vomiting, and how patients may be helped.

The piece as featured in Dental Nursing is shown below:

Read the article here:

With The Costs of Eating Disorders – Social, Health and Economic Impacts report estimating that more than 725,000 people in the UK are affected by an eating disorder, there is a very good chance that more than a few of your patients may need help in this area. The eating disorder that tends to have the greatest effect on oral health is bulimia nervosa, which involves the sufferer caught in a cycle of eating large quantities of food and then vomiting (known as purging), in order to prevent weight gain. This can result in severe damage to the teeth in the form of erosion, so it is certainly something that we, as dental care profesisonals, should be keeping an eye out for. Indeed, the extended periods of intentional vomiting suffered by bulimics can have considerable impact on the dentition and result in substantial oral health complications, including:

– The teeth can become rounded, smooth and shiny and lose their surface characteristics
– Incisal edges appear translucent
– Cupping forms in the dentine
– Cervical lesions are shallow and rounded
– Restorations tend to be unaffected by erosion and will therefore stand proud of the surrounding tooth tissue.

Advice is the first step

This can, of course, be a challenging issue to raise with a patient, as shame and denial are common features of an eating disorder. To
try to overcome such barriers, it is essential we do our very best to make the patient feel comfortable and not intimidated. Assure
them you have time to talk things through and ask questions in a non-judgemental way aimed at encouraging the patient to identify the origin of their oral health problems. One way that can help in this endeavour is to share your examination findings with the patient and explain how their symptoms may be linked. Advice rather than treatment features heavily during the initial stage of helping a patient suffering with bulimia. Diet analysis and general guidance on how to reduce the effect of acidic food and drinks should be
given, such as:

– Drinking water or low fat milk in preference to other liquids
– Using a straw positioned toward the back of the mouth when drinking acidic beverages
– Avoiding swishing acidic drinks around the mouth
– Rinsing the mouth with water or fluoridated mouthwash after consuming acidic foodstuffs.

In addition, oral health advice for a patient whose dentition is compromised by bulimia includes:

– Issuing a fluoride rinse or gel and prescribing a highly-fluoridated toothpaste and a soft toothbrush for daily use
– Not brushing immediately after vomiting or consuming acidic foodstuffs, but rinsing with a fluoridated mouthwash and chewing sugar-free, xylitol-sweetened gum afterwards.

Extra protection can be provided via calcium and phosphate ions, such as those found in GC Tooth Mousse, helping to restore the mineral balance, neutralise acidic challenges and stimulate saliva flow.

Extra protection

It will come as no surprise that patients with bulimia can find it extremely hard to overcome the disorder, which may mean that, ultimately, preventive oral care may not be enough to save the dentition. In such a situation, action beyond preventive advice alone may need to be taken to protect the remaining tooth structure. This may include the direct application of composite resin if at least an enamel halo exists or glass ionomer to sensitive areas, an occlusal guard to protect the teeth during purging, and an alkali or fluoride gel placed within the fitting surface of the guard to neutralise any acid pooling. Such mouthguards should not be worn
for prolonged periods without any such protective gels and when acids are present in the mouth to avoid these acids being held in direct contact with the teeth. Once any treatment has been completed, it is imperative that the patient attends for very regular check-ups so that the rate of wear can be monitored, further guidance provided, adjustments to lifestyle made, and motivation provided. As an aside, if you believe from a patient or their dentition that they may be bulimic, it may be prudent (with the patient’s permission) to make contact with their GP or other healthcare professional overseeing their care before beginning any course of treatment, as a team approach will normally help facilitate a course of action that will offer the best possible outcomes in the given circumstances.

Professor Andrew Eder explores the effect of bulimia on the dentition during Eating Disorders Awareness Week.

The piece as featured in the British Dental Journal outlines the impact bulimia has on dentition and oral health as well as suggest advice to offer patients on prevention and protection.

Read the full article below:

The Effect of Bulimia on the Dentition

During this year’s Eating Disorders Awareness Week, Andrew Eder explores the effects of bulimia on oral health, most specifically in terms of erosion as a result of self-induced vomiting, and how patients may be helped.

Eating Disorders Awareness Week took place between 27 February and 5 March 2017, focusing, in part, on early intervention. A leading charity in this area, BEAT (www.b-eat.co.uk) is looking to educate both healthcare professionals and the wider public about eating disorders, so that they are equipped to help if a patient or someone they know may be suffering.

Dental professionals are no exception, and with ‘The Costs of Eating Disorders – Social, Health and Economic Impacts’ report estimating that more than 725,000 people in the UK are affected by an eating disorder, there is a very good chance that more than a few of your patients may need help in this area.

The eating disorder that tends to have the greatest effect on oral health is bulimia nervosa, which involves the sufferer caught in a cycle of eating large quantities of food and then vomiting (known as purging), in order to prevent weight gain. This can result in severe damage to the teeth in the form of erosion, so it is certainly something that we, as dental professionals, should be keeping an eye out for. Indeed, the extended periods of intentional vomiting suffered by bulimics can have considerable impact on the dentition and result in substantial oral health complications, including:

– The teeth can become rounded, smooth and shiny and lose their surface characteristics
– Incisal edges appear translucent
– Cupping forms in the dentine
– Cervical lesions are shallow and rounded
– Restorations tend to be unaffected by erosion and will therefore stand proud of the surrounding tooth tissue.

Advice is the first step

This can, of course, be a challenging issue to raise with a patient, as shame and denial are common features of an eating disorder. To try and overcome such barriers, it is essential that we do our very best to make the patient feel comfortable and not intimidated. Assure them you have time to talk things through and ask questions in a non-judgemental way aimed at encouraging the patient to identify the origin of their oral health problems. One way that can help in this endeavour is to share your examination findings with the patient and explain how their symptoms may be linked.

Advice rather than treatment features heavily during the initial stage of helping a patient suffering with bulimia. Diet analysis and general guidance on how to reduce the effect of acidic food and drinks should be given, such as:

– Drinking water or low fat milk in preference to other liquids
– Using a straw positioned toward the back of the mouth when drinking acidic beverages
– Avoiding swishing acidic drinks around the mouth
– Rinsing the mouth with water or fluoridated mouthwash after consuming acidic foodstuffs.

In addition, oral health advice for a patient whose dentition is compromised by bulimia includes:

– Issuing a fluoride rinse or gel and prescribing a highly-fluoridated toothpaste and a soft toothbrush for daily use
– Not brushing immediately after vomiting or consuming acidic foodstuffs, but rinsing with a fluoridated mouthwash and chewing sugar-free, xylitol-sweetened gum afterwards.

Extra protection can be provided via calcium and phosphate ions, such as those found in GC Tooth Mousse, helping to restore the mineral balance, neutralise acidic challenges and stimulate salivary flow.

Extra protection

It will come as no surprise to dental professionals that patients with bulimia can find it extremely hard to overcome the disorder, which may mean that, ultimately, preventive oral care may not be enough to save the dentition.
In such a situation, action beyond preventive advice alone may need to be taken to protect the remaining tooth structure. This may include the direct application of composite resin if at least an enamel halo exists or glass ionomer to sensitive areas, an occlusal guard to protect the teeth during purging, and an alkali or fluoride gel placed within the fitting surface of the guard to neutralise any acid pooling.

Such mouthguards should not be worn for prolonged periods without any such protective gels and when acids are present in the mouth to avoid these acids being held in direct contact with the teeth. Once any treatment has been completed, it is imperative that the patient attends for very regular check-ups so that the rate of wear can be monitored, further guidance provided, adjustments to lifestyle made, and motivation provided.

As an aside, if you believe from a patient or their dentition that they may be bulimic, it may be prudent (with the patient’s permission) to make contact with their GP or other healthcare professional overseeing their care before beginning any course of treatment, as a team approach will normally help facilitate a course of action that will offer the best possible outcomes in the given
circumstances.

Professor Andrew Eder explores the current situation regarding tooth wear in the UK. Read below as featured in Private Dentistry:

This month Professor Andrew Eder’s article ‘Key to wearing well whatever your age’ features in The Jewish Chronicle. The piece looks at how Tooth Wear is increasingly affecting people of all ages, the affect it has on our teeth, it’s causes and what can be done limit tooth wear.

Read the full article below:

Tooth Wear is no respecter of age; in fact, it is increasing across the UK among both the young and the old. But why does it matter? After all, it is a natural part of ageing. True — but lifestyle can accelerate and exacerbate this process. The result may be tooth sensitivity and an unsightly smile due to teeth becoming short and unattractive, while rough tooth edges can harm the lips, tongue and inside of the cheeks.

More than three-quarters of adults and more than half of children show signs of tooth wear. What is more, sadly, 35 per cent of 12-year-olds and 28 per cent of 15-yearolds are too embarrassed to smile or laugh due to the condition of their teeth.
Without doubt, tooth wear has the potential to affect a person’s self-esteem for life. And that is not something any of us want for ourselves or for our children. What can be done to minimise and prevent tooth wear that might otherwise require expensive and extensive dental treatment further down the line?

Particularly common among children and young adults, tooth erosion is caused by consuming acidic foods and drinks; the acid attacks the outer surface of the teeth. Culprits include fruit juices, smoothies, sports beverages and fizzy drinks (including sugar-free). Where possible, drink still water or low-fat milk between meals, limit fruit juice to once per day and avoid fizzy drinks.

Another significant cause of tooth erosion is bulimia nervosa, which involves eating large quantities of food and then deliberately vomiting, bringing up stomach acid that can damage the teeth.

Young women, particularly those aged 12 to 20, are the most likely to develop an eating disorder but older women and men of all ages can also have an eating disorder.

Where acid is damaging teeth, you can use these preventative measures following consumption of something acidic or an episode of vomiting:

– Rinse the mouth with water for 15 to 30 seconds.
– Chew sugar-free gum or eat a piece of cheese.
– Wait at least an hour to brush teeth.
– Use a toothpaste that contains at least 1,400ppm fluoride and a non abrasive toothbrush.
– Use a fluoridated mouthwash every day at a different time from tooth brushing, as well as before or after an acidic event

In addition, if wear is linked to tooth grinding brought on by stress, it may help to do something relaxing before bed, such as yoga, reading or having a bath. In addition, if you are worried that you may be brushing your teeth too hard — which can also lead to tooth wear — ask your dentist or hygienist to demonstrate how to brush your teeth without being too vigorous and perhaps use a softer toothbrush and a minimally abrasive toothpaste. If you have any concerns about your oral health, or that of your children, call your dental practice without delay. Do not suffer in silence; dentists and hygienists are here to help.

Professor Andrew Eder comments on the increase in Tooth Wear across the young and old. Read below as featured in the Jewish Chronicle:

This month Professor Andrew Eder features in Dental Practice Magazine with his article ‘Facing the Future of Tooth Wear’. The piece looks at what we mean by Tooth Wear and its increasing occurrence among both adults and children. He also discusses the signs and symptoms and considers the future of tooth wear and its prevention.

Read the full article below:

Read the recent blog post on Eating Disorders Awareness Week below as published on the British Society of Dental Hygiene and Therapy website:

“Eating Disorders Awareness Week will take place between 27th February and 5th March 2017, focusing, in part, on early intervention. A leading charity in this area, BEAT (www.b-eat.co.uk) is looking to educate both healthcare professionals and the wider public about eating disorders, so that they are equipped to help if a patient or someone they know may be suffering.

Dental professionals are no exception, and with The Costs of Eating Disorders – Social, Health and Economic Impacts report estimating that more than 725,000 people in the UK are affected by an eating disorder, there is a very good chance that more than a few of your patients may need help in this area.

The eating disorder that tends to have the greatest effect on oral health is bulimia nervosa, which involves the sufferer caught in a cycle of eating large quantities of food and then vomiting (known as purging), in order to prevent weight gain. This can result in severe damage to the teeth in the form of erosion, so it is certainly something that we, as dental care professionals, should be keeping an eye out for.

Indeed, the extended periods of intentional vomiting suffered by bulimics can have considerable impact on the dentition and result in substantial oral health complications, including:
– The teeth can become rounded, smooth and shiny and lose their surface characteristics;
– Incisal edges appear translucent;
– Cupping forms in the dentine;
– Cervical lesions are shallow and rounded;
– Restorations tend to be unaffected by erosion and will therefore stand proud of the surrounding tooth tissue.

ADVICE IS THE FIRST STEP

This can, of course, be a challenging issue to raise with a patient, as shame and denial are common features of an eating disorder. To try and overcome such barriers, it is essential that we do our very best to make the patient feel comfortable and not intimidated. Assure them you have time to talk things through and ask questions in a non-judgmental way aimed at encouraging the patient to identify the origin of their oral health problems. One way that can help in this endeavour is to share your examination findings with the patient and explain how their symptoms may be linked.

Advice rather than treatment features heavily during the initial stage of helping a patient suffering with bulimia. Diet analysis and general guidance on how to reduce the effect of acidic food and drinks should be given, such as:
– Drinking water or low fat milk in preference to other liquids;
– Using a straw positioned toward the back of the mouth when drinking acidic beverages;
– Avoiding swishing acidic drinks around the mouth;
– Rinsing the mouth with water or fluoridated mouthwash after consuming acidic foodstuffs.

In addition, oral health advice for a patient whose dentition is compromised by bulimia includes:
– Issuing a fluoride rinse or gel and prescribing a highly-fluoridated toothpaste and a soft toothbrush for daily use;
– Not brushing immediately after vomiting or consuming acidic foodstuffs, but rinsing with a fluoridated mouthwash and chewing sugar-free, xylitol-sweetened gum afterwards.

EXTRA PROTECTION

It will come as no surprise to dental professionals that patients with bulimia can find it extremely hard to overcome the disorder, which may mean that, ultimately, preventive oral care may not be enough to save the dentition.

In such a situation, action beyond preventive advice alone may need to be taken to protect the remaining tooth structure. This may include the direct application of composite resin if at least an enamel halo exists or glass ionomer to sensitive areas, an occlusal guard to protect the teeth during purging, and an alkali or fluoride gel placed within the fitting surface of the guard to neutralise any acid pooling. Such mouthguards should not be worn for prolonged periods without any such protective gels and when acids are present in the mouth to avoid these acids being held in direct contact with the teeth.

Once any treatment has been completed, it is imperative that the patient attends for very regular check-ups so that the rate of wear can be monitored, further guidance provided, adjustments to lifestyle made, and motivation provided.

As an aside, if you believe from a patient or their dentition that they may be bulimic, it may be prudent (with the patient’s permission) to make contact with their GP or other healthcare professional overseeing their care before beginning any course of treatment, as a team approach will normally help facilitate a course of action that will offer the best possible outcomes in the given circumstances.

Pathological Tooth Wear (also known as tooth surface loss) is on the increase, as indicated by the most recent Adult and Children’s Dental Health Surveys.

Recognising that tooth wear has the potential to be a serious issue in the UK in the future if preventative action is not fully embraced, its incidence and significance was recorded in the Adult Dental Survey (ADHS) for the first time in 1998, and this exercise was repeated in the latest offering. Comparison of the two surveys shows that in just 11 years the incidence of pathological tooth wear in England has increased by 10%.
As for the Children’s Dental Health Survey, it tells us, for example, that 33% of five-year-olds demonstrated tooth surface loss (TSL) on one or more of the buccal surfaces of the primary upper incisors, while a quarter of 12-year-olds were reported to have TSL on the molars and the buccal surface of the incisors. In addition, 15-year-olds were shown to be more adversely affected than 12-year-olds when TSL on the occlusal surface of molars was measured (31% compared to 25%).

LOOKING AHEAD

Commenting on this worrying trend, Professor Andrew Eder, clinical director of the London Tooth Wear Centre, said, ‘Irrespective of age and circumstance, patients need to be aware that, amongst other issues, poor drink and food choices, eating disorders, stress-related bruxism and traumatic oral hygiene measures can all cause considerable tooth wear.

If we are to have any chance of subverting the oral health outcome that the statistics indicate, it is incumbent upon all dental professionals to meet this challenge head-on.’

The London Tooth Wear Centre offers an evidence-based and comprehensive approach to managing pathological tooth wear, using the latest clinical techniques and an holistic approach in a professional and friendly environment.

This article was published in Private Dentistry, December 2016.

With New Year’s Eve and its associated celebrations fast approaching, Professor Andrew Eder considers the erosive potential of alcohol, and offers both preventive and treatment solutions.

As we prepare to chink glasses and celebrate the New Year with a kiss from our nearest and dearest, it is important that our patients realise there’s a ‘hidden’ danger from too much imbibing of the merry stuff! I write ‘hidden’ because there appears to be a worrying lack of public awareness when it comes to tooth wear, which we dentists know has the potential to wreak havoc, resulting in pain, sensitivity and, ultimately, expensive and extensive restorative treatment if not prevented as early on as possible.

Alcohol, of course, tends to be high in sugar – an ingredient that many of our patients will associate with causing tooth decay and resulting in fillings. But it’s also acidic (and excessive drinking leading to vomiting contributes additionally, of course) – with long-term consumption contributing to tooth erosion; and that’s what many patients fail to realise.

Read preventive advice and how to remedy the damage in the full article on the erosive potential of alcohol below: