Restorative Management of The Worn Dentition Pt1
Restorative Management of The Worn Dentition Pt1
Restorative Management of The Worn Dentition Pt1
AETIOLOGY
Abstract: In this, the first of a four-part series on the restorative management of the Toothwear has been defined as loss of
worn dentition, the aetiological factors, diagnosis of toothwear and preventive measures
tooth substance resulting from abrasion,
are summarized. Later papers will deal with the management of localized anterior and
attrition and erosion9 (Table 1) acting
posterior toothwear, the use of ‘Dahl type’ appliances as an effective means for the
restorations and the various treatment options for the management of the dentition singly or concurrently.10 When wear is
showing generalized wear. The series will discuss the relative merits of the treatment due to more than one predominant
strategies, clinical techniques and dental materials for the restoration of health, aetiological factor, special terms have
function and aesthetics for the dentition. been suggested to highlight the
multiplicity of causes. For example:
Dent Update 2002; 29: 162–168
Clinical Relevance: Management of patients with toothwear requires thorough ‘abrosion’ describes enamel
understanding of the causes and their prevention. This paper reviews the aetiological removed with a toothbrush after
factors and assists the readers in reaching a diagnosis. enamel has been softened by acid
(abrasion and erosion);
‘demastication’ refers to enamel
worn away by attrition (mastication)
after erosion (demineralization).11
lesions can be found on only one control of dental caries and periodontal
tooth in one segment; disease, it is likely that retention of
lesions found in subgingival natural teeth into older age will lead to a
regions; higher prevalence of worn dentition as a
the presence of such lesions in result of attrition.18
animals. Parafunctional habits such as bruxism
and clenching were also believed to be
An SEM study reported that the tip of important factors in causing
such lesions can be rounded or sharp, accelerated attrition. However, short-
Figure 1. Non-carious cervical lesions on buccal and the mesial and distal angles were term studies showed that toothwear
surfaces of 1/2. connected by one or more internal was not significantly different between
grooves. The rounded-tip lesion is bruxists and non-bruxists.19,20 The
and cementum are less wear-resistant thought to have an erosion component.16 difference between clinical impressions
than coronal enamel (Figure 1). Location and research reports may be because
of the abrasion (three-body wear) the effects of bruxism are slow and
lesions depends on tooth alignment Attrition short-term studies were not sensitive
and/or which hand is holding the Attrition resulting from tooth-to-tooth enough to detect the small changes.
toothbrush – more lesions occur on the contact (two-body wear) produces well Other factors predisposing to
left side with right-handed persons, and defined wear facets on the functional attrition include developmental dental
vice versa. Other habits causing surfaces of teeth in one jaw which match defects,21 coarse diet, natural teeth
abrasion include the misuse of dental corresponding lesions on teeth in the opposing coarse porcelain (Figure 3),
floss and toothpick, and pipe-smoking. other jaw (Figure 2). While ‘cupping’ of pseudo-Class III incisal relationship
Thread biting, and holding hair-grips the incisal edges (a shallow concavity of (Figure 4) and lack of posterior support
between the teeth can lead to abrasion the incisal edge surrounded by enamel) (Figure 5).
defects of incisal tooth edges in could also be due to acid attack on
seamstresses and hairdressers, dentine, it was postulated that this
respectively. appearance could be a result of three- Erosion
body wear or abrasion (as in the presence Erosion of tooth substance may be
of food) because dentine has lower wear caused by intrinsic or extrinsic acids,
Abfraction and erosion resistance than enamel.17 and modified by changes of salivary
Abrasion alone cannot satisfactorily With improved life expectancy and flow and constituents.
explain how every cervical non-carious
lesion occurs. The concept of ‘stress-
induced cervical lesions’ was introduced
a b
to explain how wedge-shaped Class V
lesions can be created by repeated
compression and flexure of the teeth
under occlusal loading. Dentine is more
elastic than enamel,12 and enamel rods
can be fractured in such situations. In
older adults, enamel crazing and
microfractures are more common. This
may explain why such lesions are more Figure 2. (a) Attrition of 321/ and 321/of a bruxist. (b) Right lateral view.
prevalent in older age groups. The term
abfraction was used to describe this
‘stress corrosion’ mechanism (Table 1). a b
However, the physiochemical effects of
an acidic environment may also be
responsible.13
The ‘stress corrosion’ theory has been
supported by a number of observations:
Flow of Saliva
Reduced salivary flow following surgical
excision of one or more major salivary
glands, Sjögren’s syndrome, drug intake
(e.g. antidepressants, sedatives,
Figure 4. (a, b) Attrition of incisal edges of 1/1 and pseudo-Class III incisal malocclusion. tranquillizers), or radiotherapy in the
head and neck region predisposes not
only to rapid caries development but
also to dental erosion. In addition to its
a b diluting and flushing effects, changes in
flow rate of saliva may also affect its
buffering capacity, and concentrations
of secreted ions available for
remineralization.
Figure 8. Examination form for assessing patients with toothwear. 1. To document and record the
recommended for protecting the anterior Harrington E. The distribution, severity of tooth 42: 339–348.
wear and the relationship between erosion and 19. Johansson A, Fareed K, Omar R. Analysis of
teeth. Correct polishing procedures can
dietary constituents in a group of children. Int J possible factors influencing the occurrence of
reduce the surface roughness of Paediatr Dent 1994; 4: 151–157. occlusal wear in a young Saudi population. Acta
abrasive porcelain restorations.27 8. Milosevic A, Young PJ, Lennon MA. The prevalence Odontol Scand 1991; 49: 139–145.
Orthodontic treatment is recommended of tooth wear in 14-year-old school children in 20. Anderson GC, Pintado MR, Beyer JP, DeLong R,
Liverpool. Community Dent Health 1994; 11: 83– Douglas WH. Clinical enamel wear as related to
to correct Class II division 2 and Class 86. bruxism and occlusal scheme. J Dent Res 1993;
III incisal malocclusion during 9. Watson IB, Tulloch EN. Clinical Assessment of 72: 303 [Abstract 1601].
adolescence. cases of tooth surface loss. Br Dent J 1985; 159: 21. Licht WS, Leveton EE. Overdentures for
144–148. treatment of severe attrition. J Prosthet Dent
10. Bader JD, McClure F, Scuria MS, Shugars DA, 1980; 43: 497–500.
Heymann HO. Case-control study of non-carious 22. Eccles JD. Erosion affecting the palatal surfaces of
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implications and even considerations have been better placed at the end of
BOOK REVIEW for female patients. The editors rightly each chapter.
highlight the need for precise Despite the prominent disclaimer
Antibiotic and Antimicrobial Use in strategies and guidelines governing about the differences in suggestions
Dental Practice, 2nd ed. M.G. Newman the use of antibiotics, however, I was between chapters – I feel this text has
and A.J. van Winklehoff, eds. unable to detect either of these in the lost an opportunity for consensus
Quintessence Publishing Co. Ltd., text. between such a distinguished group
New Malden, 2001 (304pp., £27.00 There are 21 contributors to the text of contributors with some clear and
p/b). ISBN 0-86715-397-0. and this has probably contributed to concise guidelines for practitioners.
some confused messages and The book has a distinct North
Superbugs and antibiotic resistance inconsistencies, for example, the use of American feel to it which may or may
are rarely out of the headlines these tetracyclines in the prophylaxis of not appeal to the reader. As a result,
days and the dental profession, in line bacterial endocarditis. The layout of the many of the drugs, for example,
with other prescribers, have a duty to text with key facts, clinical insights and ciprofloxacin and dosages are either
prescribe antibiotics judiciously. A important principles lost their impact on not in the Dental Practitioners
text on antibiotics and antibiotic use in reading each chapter. Some important Formulary or do not comply with
dental practice should therefore be a messages, although eloquently written, current UK practice guidelines, for
welcome addition to the practitioners seemed to get lost in the text, for example ‘loading doses of penicillin
bookshelf. This second edition, edited example, ‘Antibiotics should be used VK of 1000mg’. In view of these
by Newman and Winklehoff, is very selectively in the treatment of issues, I would find this text difficult
certainly comprehensive. There are periodontal disease. Narrow indications to recommend to UK dental
chapters on new and evolving clinical should replace the indiscriminate practitioners.
issues such as oral malodour, repeated use advocated by some Andrew Smith
paediatrics, implant dentistry, legal manufacturers.’ These key facts would University of Glasgow Dental School