Risk Assessment of Tooth Wear
Tooth wear is a multifactorial, complex process involving erosion, attrition, abrasion. Erosion is defined as the chemical dissolution of hard tissues due to acids of non-bacterial origin. Attrition is defined as the mechanical removal of dental hard tissues through tooth-to-tooth contact and abrasion is defined as the mechanical removal of dental hard tissues with anything else. Erosive tooth wear has recently been defined as the chemical–mechanical process resulting in a cumulative loss of hard dental tissue not caused by bacteria. It is a relatively new term used to highlight that an acidic component often underlies severe tooth wear and knowledge of this is essential to proper risk assessment of tooth wear. Epidemiological evidence suggests that the prevalence of erosive tooth wear is increasing, particularly in younger age groups. The reason for this is unknown but the change in snacking habits of the population, anxiety and stress levels and the prevalence of gastro-oesophageal reflux and vomiting eating disorders may be influencing factors. A trans-European study on over 3000 young adults aged 18–35 years observed the prevalence of moderate to severe wear to range from 17 to 54%. The outcome of this research suggests that erosive tooth wear is common.
A patient with erosive tooth wear may be unaware of their condition, particularly in the early stages. Initially, erosion produces an altered surface texture on the tooth as the higher mineral content of enamel makes it more susceptible to acids. Incisors lose their perikymata and molars the defined morphology of their ridges and the cusp tips become rounded. As wear progresses, distinct defects may be observed. On the occlusal surfaces of molars, these results in small cupped or cratered lesions often where the cusp tips used to be. On the buccal surfaces, the smooth surface may become slightly uneven. Ridges or grooves may start to form and there may be a distinct step in the hard tissue adjacent to the gingival margin, possibly from the protection of the crevicular fluid. As the wear progresses, these defects may grow in size or link up until they affect the entire surface of the tooth and the crown shortens. Once this occurs the changes become visible to patients and they complain of thinning, shorter and “translucent” incisal edges.
For all patients in the amber and red categories, monitoring with study models or clinical photography is indicated. As digital methods of assessing wear improve, this will improve our diagnostic capacity. Active prevention methods such as effective preventive advice, fluoride application measures and mouth guards should be a continuous intervention. Restorative intervention is rarely indicated until the diagnosis of all aetiological factors is confirmed. Monitoring the patient while you are determining the activity of the aetiological factors and risk assessing is not supervised neglect. Lack of restorative intervention for 1–2 years will rarely leave you with a poorer disease outcome, but it may lead you to an improved risk assessment and diagnosis.
Journal of Oral Hygiene and Health