RXIXSXKX AX SSESSMENT FOR WEAR IXSXAX VELLA KONTAXOPOULOU, SONIA ALAM Prim Dent J. 2 015; 4(2):2 x 5x--2x x9

ABSTRACT Tooth wear has an increasing prevalence in the UK population. The aetiology is commonly multifactorial, and the aetiopathology is through a combination of erosion, , and .

Erosion is associated with intrinsic or extrinsic acids, and therefore subjects with reflux disease and eating disorders are at increased risk. Fruit juice, fruits and carbonated drink consumption, frequency of consumption and specific habits are also risk factors.

Attrition is more prevalent in bruxists. Other habits need to be considered when defining the risk of tooth wear. Abrasion is usually associated with toothbrushing and , especially in an already acidic environment.

Patients with extensive that affect may be at higher risk, as well as those presenting with unstained lesions. Monitoring of the progress of tooth wear is recommended to identify those with active tooth wear. Indices for tooth wear are a helpful aid.

Definition Aetiology Tooth wear is defined as the loss of tooth As well as being physiological, the tissue by means other than bacteria. 1 progression of tooth wear can be It can be further classified into the modified by various internal and following categories: erosion, attrition, external circumstances. These can abrasion and abfraction. Tooth wear is include the type of food and drink usually a physiological aging process that ingested, the quality of tooth structure, has been affecting mankind for centuries. habit patterns and medical conditions. Evidence of this can be found in excavated It is important to highlight that the tooth human skulls where the dentition has wear process is multifactorial. Rarely remained fully or partially intact. are worn teeth the result of a single pathological factor, and clinicians KEY WORDS Prevalence need to consider that a variety of Tooth Wear, Erosion, Abrasion, The 2009 Adult Dental Health Survey aetiological factors are likely to be Attrition, Risk Assessment showed that the prevalence of anterior involved in most cases. tooth wear in the UK dentate population had increased from 66% in 1998 to Erosion AUTHORS 77% in 2009. While the incidence of Dental erosion can be defined as the Dr Isavella Kontaxopoulou, DipDS, severe tooth wear remains low, there loss of hard tooth structure by chemical MPros, MClin Dent seems to be an increasing number of means, notably acids. 2 The acids Specialist in Prosthodontics, Specialist Practice; Clinical Teacher, King’s College London Dental younger individuals (aged 16-34 years) involved in the erosive process are of Institute with moderate tooth wear which non-carious origin and may be intrinsic Dr Sonia Alam, BDS, MPros, MClin Dent indicates an alarmingly rapid rate of or extrinsic. Specialist in Prosthodontics, Specialist Practice; disease progression. Clinical Teacher, King’s College London Dental Institute

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Figure 1: Tooth wear associated with intrinsic erosion

incisors, as seen in Figure 1. In addition, the occlusal surfaces of molars 4,5 can be affected due to the way in which acids may be emitted from the gastro-intestinal tract. This can lead to ‘cupping out’ of the surfaces as seen in Figure 2.

However, ingested acids (such as fruit juices or sports drinks) in contact with the dentition may damage the entire dentition, or simply the anterior teeth. 3,6 This usually occurs along the labial and incisal aspects of the affected teeth and can also present with a smooth enamel surface, with loss of perikymata and Presentation period is essential to ensure that surface texture. 5 Early diagnosis of dental erosion can be suspected erosion is monitored and challenging to diagnose because early managed well. The presence of staining on tooth changes in the enamel surface can be surfaces may be suggestive of historic visually difficult to detect and patients The location of erosive lesions may help erosive potential, as the implication are usually asymptomatic. Although to identify the aetiology. 3 This is due to would be that there had been sufficient sensitivity is not common, when present, the origin of acid exposed to the teeth time for dietary chromogens to adhere to discomfort may occur from the (extrinsic or intrinsic) and also because the tooth surface without being worn off. application of thermal, mechanical or of the mode of exposure. For example, chemical stimuli. Careful history-taking, patients presenting with intrinsic acid- Intrinsic acids clinical examination and the related tooth erosion will often be Gastro-oesophageal reflux disease appropriation of a reasonable recall affected along the palatal aspects of (GORD) and dental erosion have been

Figure 2: Cupped out erosion lesions occlusally and abrasion lesions buccally

26 PRIMARY DENTAL JOURNAL linked to each other in numerous Extrinsic acids 40% of competitive swimmers training reports. 7-9 Some individuals may suffer Extrinsic acids contact enamel and dentine in a pool with a pH of 2.7. 15 However, with reflux without any GORD-related most commonly in the form of food and current UK guidelines states the symptoms (silent refluxers) so identifying drinks. 12 Citrus and sour items often recommended pH of a swimming pool this group of individuals may prove a contain vast amounts of acid in the form lies between 7.2 and 8.0. difficult task. 10 of citric acid. In contrast, most soft carbonated drinks contain phosphoric Environmental acid exposure from Historic or current treatment with proton- acid. Both acids can lead to tooth erosion industries where individuals were pump inhibitors, such as omeprazole, and with acidic beverages becoming a subjected to gaseous acids, such as may suggest a patient with increased major component of modern diets, a those emitted from battery acids and risk of dental erosion. higher prevalence of tooth wear in the gas-works, historically gave rise to tooth younger population is not wholly wear as an occupational hazard. Other causes include , which surprising. The importance of these acids However, tooth wear caused by these may be linked to stress, pregnancy, comes in the mode of consumption and forms of acids is becoming increasingly migraines, etc. Vomiting may also be frequency of intake, with a higher rare due to more stringent regulations self-induced, in the form of bulimia frequency of exposure (e.g. repeatedly on these industries. 16 nervosa. 11 sipping fruit juice) and direct contact with dental hard tissues causing increased tooth Other predisposing factors Rumination is a phenomenon where the wear (not drinking through a straw). Erosive lesions can be modified by lower oesophageal sphincter is relaxed, several factors, of which salivary flow allowing recently swallowed foodstuffs Peculiarly, adopting a healthy lifestyle is a key factor. 5 to re-enter the oral cavity, be re-chewed has the potential to present one with and swallowed once again. 12 Although dental erosion. Healthy diets, which are The oral soft tissue musculature is also rare in Western societies, rumination is considered to include more fruits and thought to play a role in protecting some a commonly occurring part of mealtimes vegetables, may lead to higher dental dental hard tissues from acid exposure in some cultures. Within Western erosion in some individuals. Sports or while others that are unprotected are cultures, the habit is more frequently energy drink consumers may also find affected. noted among professionals and their teeth at a higher risk of developing individuals with learning disabilities and erosive lesions and if consumed when Attrition has also been linked with psychological one is already dehydrated and with a This is the wear of teeth following illnesses including depression. 13 reduced salivary flow, the effects may contact with opposing teeth. 17 This is be even more significant. 5 a normal physiological action when Chronic alcoholism is a condition that teeth are grinding food together during has also been linked as a cause of Regular swimmers may be at a higher mastication, but in patients with a dental erosion 3,4,14 both intrinsically and risk of developing dental erosion if parafunctional habit such as , extrinsically. Many alcoholic beverages they exercise in pools with a low pH. attrition-related tooth wear can be very such as red wine are acidic in nature 3 Disinfection of swimming pools is significant. Individuals with a Class II/2 and have a direct erosive potential. performed using chlorinated gas and incisal relationship can also be at Excessive consumption of these sodium hypochlorite. It has been found greater risk of experiencing anterior beverages may lead to vomiting, which that dental erosion occurs in just under tooth wear. also exposes the oral cavity to highly acidic gastric juices.

Another side effect of long-term alcoholism may be a reduction in the buffering capacity of saliva, which is thought to protect against further hard tissue loss. 5

Figure 3: Tooth wear with elements of erosion and attrition

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Bruxism is a habit developed often as a function opposing these restorations. noted in the areas of stress concentration coping mechanism for stress and as a An occlusal examination is a useful which, similar to abrasion, tend to collect result may go through periods of activity diagnostic aid and it can highlight along the cervical margins. 17 and quiescence. However, the initial attrition that manifests as matching trigger for this could be due to changes wear facets. Quality of tooth tissues in the occlusal surfaces of oral hard The inherent quality and nature of the tissues, such as following the placement Abrasion dental hard tissues will also determine of a new restoration or the loss of a Abrasion is the loss of tooth surface the extent to which tooth wear occurs. 5 tooth, which also could also alter the material caused by friction against the For instance, those suffering hereditary position of remaining teeth. 18 Another tooth with an extrinsic agent, e.g. dysplasias such as amelogenesis possible cause has been highlighted as toothbrush bristles, dentifrices, foodstuffs, imperfecta, which affects the enamel being psychosocial, such as one’s stress . 17 The characteristic and the extent of calcification, can be adaptive capacity. Pathophysiological appearance of abrasion-induced cavities more susceptible to dental erosion. 23 causes for bruxism, which are largely is their location along the cervical associated with sleep disorders, may margins of the teeth along the labial, Clinical diagnosis play an important role too. 19 buccal and interdental regions. The of tooth wear lesions are often associated with the type When faced with the clinical scenario Attrition may lead to loss of occlusal of brush bristle, amount of force used, of a patient suffering with tooth wear, vertical dimension. 20 Patients presenting frequency of brushing and abrasiveness making a diagnosis is often challenging with tooth wear as a result of attrition of . as the process is usually multifactorial. 24 often have flat incisal and occlusal For instance, erosion may result in the surfaces with a loss of surface texture However, a synopsis of clinical in situ and ‘softening’ of dentine and enamel, and morphology on the affected in vivo studies 21 concluded that tooth wear which may then undergo abrasion surfaces, as seen in Figure 3. There may associated with toothbrushing only reaches and attrition. 2 be chips or fractures along these pathological levels in cases of abuse or surfaces, giving an indication towards when is also present. A diagnosis can only be as definitive the cause of tooth wear. Attrition may as the history and examination obtained present in a localised or generalised Abfraction from a patient. 25 The location, extent fashion affecting some or all of the Abfraction is also often cited as a form and severity of tooth wear can help occlusal and incisal surfaces of the teeth. of tooth wear but is a largely defunct to identify the primary cause whilst the It can be apparent as wear caused by term in the UK. It is a phenomenon surface characteristics of the enamel and occlusal ceramic restorations and as thought to be induced from occlusal dentine also play a part in identifying such, it is observed in the areas that stresses. 22 Microstructural fractures are the severity. Equally, the presence or

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28 PRIMARY DENTAL JOURNAL TABLE 1 TABLE OF RISK PARAMETERS

Medical history Reflux, Gastro-oesophageal reflux disease (GORD), Rumination, Eating disorders, Alcoholism, Healthy diets Diet Fruit, Fruit juices, Carbonated drinks, Frequency of consumption, Manner of consumption Other acids Occupational, Swimming and habit modification. Attrition may Habits Bruxism, Toothbrushing, Other objects progress at a slower rate with the use of Exam Extent of lesions, Presentation, an occlusal splint. 27 The management of Index Basic Erosive Wear Examination (BEWE) abrasion would take into consideration the adaptation of oral hygiene habits and the elimination of acidic challenges. absence of patient symptoms such as strong similarities to the commonly used The role of fluoride in the prevention dentine hypersensitivity or tenderness Basic Periodontal Exam (BPE). Sextants of tooth wear has been explored, and of the facial musculature may help the are scored the worst of possible scores. could be beneficial, but the number of identification of the cause. The scores are all added together to studies is still limited. 28 provide a management solution based The use of clinical photographs to act as a on a clearly defined protocol. In the clinical scenarios where restorative baseline to compare future tooth wear and management of the worn dentition is the use study models have been advocated Management of appropriate, various clinical modalities too but both offer a retrospective approach the risk factors can be considered. These can be in on the monitoring of tooth wear. Matrices The first and the most important step in either a conformative occlusal approach constructed of putty can be of similar use. the management of the risk factors is the or in a Dahl concept with raising the accurate diagnosis of the cause of tooth occlusal vertical dimension. Depending Tooth wear indices wear. 12 The aetiopathologic elements of on the clinical presentation, composite Various indices have been proposed the tooth wear need would need to be build ups, metal backings, onlays or to record tooth wear. Although only managed. Intrinsic erosive tooth wear crowns can be prescribed. 29 applicable for tooth wear where erosion may need to be managed with habit is the primary causative agent, the Basic modification and appropriate referrals A suitable aid memoire to assessing the Erosive Wear Examination (BEWE) 26 could be considered. Extrinsic erosive risk parameters for tooth wear can be offers an efficient and simple tool with tooth wear would require diet advice found in Table 1.

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