|Other names: Non-carious tooth substance loss|
|Lower teeth shows signs of tooth wear likely caused by erosion|
Tooth wear refers to loss of tooth substance by means other than dental caries.
Tooth wear is a very common condition that occurs in approximately 97% of the population. This is a normal physiological process occurring throughout life; but with increasing lifespan of individuals and increasing retention of teeth for life, the incidence of non-carious tooth surface loss has also shown a rise. Tooth wear varies substantially between people and groups, with extreme attrition and enamel fractures common in archaeological samples, and erosion more common today.
Tooth wear is predominantly the result of a combination of three processes; attrition, abrasion and erosion. These forms of tooth wear can further lead to a condition known as abfraction, where by tooth tissue is 'fractured' due to stress lesions caused by extrinsic forces on the enamel. Tooth wear is a complex, multi-factorial problem and there is often difficulty identifying a single causative factor. However, tooth wear is often a combination of the above processes. Many clinicians, therefore, make diagnoses such as "tooth wear with a major element of attrition", or "tooth wear with a major element of erosion" to reflect this. This makes the diagnosis and management difficult. Therefore, it is important to distinguish between these various types of tooth wear, provide an insight into diagnosis, risk factors, and causative factors, in order to implement appropriate interventions. Tooth wear evaluation system (TWES) may help determine the most likely aetiology of tooth wear. Heavy tooth wear is commonly found on the occlusal (chewing) surface, but non-carious cervical lesions from tooth wear are also common in some populations.
Multiple indices have been developed in order to assess and record the degree of tooth wear, the earliest was that by Paul Broca. In 1984, Smith and Knight developed the tooth wear index (TWI) where four visible surfaces (buccal, cervical, lingual, occlusal-incisal) of all teeth present are scored for wear, regardless of the cause. A more recent index Basic Erosive Wear Examination (BEWE) from 2008 by Bartlett et al., is now also in use.
Attrition is loss of tooth substance caused by physical tooth-to-tooth contact. The word attrition is derived from the Latin verb attritium, which refers to the action of rubbing against something. Attrition mostly causes wear of the incisal and occlusal surfaces of the teeth. Attrition has been associated with masticatory force and parafunctional activity such as bruxism. A degree of attrition is normal, especially in elderly individuals.
Abrasion is loss of tooth substance caused by physical means other than teeth. The term is derived from the Latin verb abrasum, which means ‘to scrape off’. It tends to present as rounded ditching around the cervical margins of teeth, commonly described as ‘shallow’, concave or wedge shaped notches. Causative factors have been linked to this condition and include vigorous, horizontal tooth brushing, using toothpaste with a relatively high RDA value (above 250), pipe smoking or nail biting. It has also been shown that improper use of dental floss or Toothpicks can lead to wear on the interproximal (in-between) surfaces of the teeth.
Erosion is chemical dissolution of tooth substance caused by acids, unrelated to the acid produced by bacteria in dental plaque. Erosion may occur with excessive consumption of acidic foods and drinks, or medical conditions involving repeated regurgitation and reflux of gastric acid. It is derived from the Latin word erosum, which describes the action ‘to corrode’. This is usually on the palatal (inside) surfaces of upper front teeth and the occluding (top) surfaces of the molar teeth. Dental erosion is rarely seen in the archaeological record, but certain cases have been described which suggested acidic fruits and/or plants were regularly consumed.
- Gastroesophageal reflux disease (GERD)
- Vomiting, e.g. bulimia, alcoholism
- Eructation (burping)[medical citation needed]
- Dietary - liquids of low pH and high titratable acids.
Abfraction is loss of tooth substance at the cervical margins, purportedly caused by minute flexure of teeth under occlusal loading. The term is derived from the Latin words ab and functio meaning ‘away’ and ‘breaking’ respectively. Abfraction presents as triangular lesions along the cervical margins of the buccal surfaces of the teeth where the enamel is thinner and therefore, in the presence of occluding forces, is prone to fracture. Whether abfraction exists or not is debated.
Tooth wear indices are useful tools for carrying out epidemiological studies and for general use in dental practices.
Basic erosive wear examination
The Basic Erosive Wear Examination was first described by Bartlett et al. in 2008. The partial scoring system is based on the surface area affected. Within a sextant (i.e. teeth in mouth divided into 6 parts), the most severely affected tooth surface (buccal, occlusal or lingual/palatal)(see dental terminology) is recorded according to the severity of the wear (see Table 1). A cumulative score is then matched to a risk level and guidance for its management by a clinician. The management includes steps which identify and eliminate main aetiological factors, preventative treatment and also any operative and symptomatic intervention required by the patient. The frequency of repeating the index ranges from 6–12 months depending on the risk level of patients.
|BEWE Score||Clinical appearance description|
|0||No erosive tooth wear|
|1||Initial loss of surface texture|
|2||Distinct defect, hard tissue loss <50% of the surface area|
|3||Hard tissue loss ≥50% of the surface area|
Tooth wear index
The Tooth Wear Index (TWI) (see Table 2) was developed by Smith and Knight in 1984. TWI scores each visible surface (buccal/B, cervical/C, lingual/L and occlusal-incisal/O/I) (see dental terminology). This index has been widely used in epidemiological studies.
|0||B/L/O/I||No loss of enamel surface characteristics|
|C||No loss of contour|
|1||B/L/O/I||Loss of enamel surface characteristics|
|C||Minimal loss of contour|
|2||B/L/O||Loss of enamel exposing dentine for less than one third of surface|
|I||Loss of enamel just exposing dentine|
|C||Defect less than 1mm deep|
|3||B/L/O||Loss of enamel exposing dentine for more than one-third of surface|
|I||Loss of enamel and substantial loss of dentine|
|C||Defect less than 1-2mm deep|
|4||B/L/O||Complete enamel loss- pulp exposure- secondary dentine exposure|
|I||Pulp exposure or exposure of secondary dentine|
|C||Defect more than 2mm deep- pulp exposure- secondary dentine exposure|
- Eccles-Index 
- Modified TWI 
- Linkosalo and Markkanen 
- O'Brien Index 
- Lussi Index 
- O'Sullivan Index 
- Simplified Tooth Wear Index (STWI) 
- Exact Tooth Wear Index 
- Visual Erosion Dental Examination (VEDE) 
- Evaluating Index of Dental Erosion (EVIDE) 
Once the cause of tooth wear has been identified and a preventative regime has been put in place, the patient should be reviewed for 6–12 months to establish that the intervention has been successful before any active management is carried out. Once this has been achieved a decision needs to be made whether or not it is necessary to carry out restorative treatment or if it can simply be managed by non-invasive methods.
Where restorative treatment is necessary, it must be decided whether to conform to the existing occlusion (typically for moderate wear, where only a few teeth are affected) or reorganise the occlusion (severe wear, unstable occlusion). Where the occlusion is reorganised, it can first be tested using a reversible method (i.e. a hard occlusal splint). A decision is made after full occlusal assessment including assessment of contacts in intercuspal position (ICP) and retruded contact position (RCP) as well as analysing casts articulated in a semi-adjustable articulator to use for a diagnostic wax up of any proposed restorative work.
Active restorative management depends upon the location of the wear (localised or generalised), the severity of the wear, and the patient's occlusal vertical dimension (OVD), which may have changed as a result of tooth wear. There are three potential scenarios of tooth wear:
- Excessive wear with loss of OVD
- Excessive wear without loss of OVD but with space available
- Excessive wear without loss of OVD but with limited space available
Scenario 1 is relatively common, whereas scenario 2 is quite rare and tends to occur when the wear is rapidly occurring. Scenario 3 occurs due to a phenomenon called dentoalveolar compensation whereby the dentoalveolar tissues compensate for wear of teeth by increasing the bony support in order to maintain a constant OVD. This makes things difficult as there is no room to build the teeth back up to their original height without increasing the OVD.
The options for restoring this loss in tooth height are: 
- Increasing the OVD - this is the traditional approach and involves restoring all teeth to an increased height in order to create a new ICP at an increased OVD
- Occlusal adjustment - this is typically used for anterior teeth only, whereby the patient's occlusion is reorganised into the RCP position to utilise increased space in this position
- Crown lengthening or orthodontic extrusion - this is useful when crowns are to be placed in a worn dentition but there is inadequate crown height and you do not want to change the OVD
- Relative axial tooth movement - this is the most commonly used method and can be used for localised or generalised wear, the idea is to prop the bite open thereby causing the extrusion of worn teeth to provide extra crown height for restoration, this can be done using simple direct restorations or more complex indirect restorations, this idea was first established by Dahl and is often referred to as the Dahl effect
Pulp vitality must also be taken into consideration prior to treatment, when teeth have severe wear it is possible that they have become non-vital.
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Kaidonis JA (August 2012). "Oral diagnosis and treatment planning: part 4. Non-carious tooth surface loss and assessment of risk". British Dental Journal. 213 (4): 155–61. doi:10.1038/sj.bdj.2012.722. PMID 22918343.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Suchetha A (2014). "Tooth Wear - A Literature Review". Indian Journal of Dental Sciences. 5 (6): 116–120.
- ↑ 3.0 3.1 3.2 3.3 3.4 Bhushan J, Joshi R (2011). "Tooth Wear - An Overview With Special Emphasis On Dental Erosion". Indian Journal of Dental Sciences. 5 (3): 89.
- ↑ Towle, Ian; Irish, Joel D.; Groote, Isabelle De (2017). "Behavioral inferences from the high levels of dental chipping in Homo naledi" (PDF). American Journal of Physical Anthropology. 164 (1): 184–192. doi:10.1002/ajpa.23250. ISSN 1096-8644. PMID 28542710. Archived (PDF) from the original on 2019-03-06. Retrieved 2022-01-09.
- ↑ Smith, B. Holly (1984). "Patterns of molar wear in hunter–gatherers and agriculturalists" (PDF). American Journal of Physical Anthropology. 63 (1): 39–56. doi:10.1002/ajpa.1330630107. hdl:2027.42/37625. ISSN 1096-8644. PMID 6422767. Archived (PDF) from the original on 2012-09-05. Retrieved 2022-01-09.
- ↑ Wetselaar, P.; Lobbezoo, F. (January 2016). "The tooth wear evaluation system: a modular clinical guideline for the diagnosis and management planning of worn dentitions". Journal of Oral Rehabilitation. 43 (1): 69–80. doi:10.1111/joor.12340. PMID 26333037. Archived from the original on 2022-05-27. Retrieved 2022-01-09.
- ↑ 7.0 7.1 Towle, Ian; Irish, Joel D.; Elliott, Marina; De Groote, Isabelle (2018-09-01). "Root grooves on two adjacent anterior teeth of Australopithecus africanus" (PDF). International Journal of Paleopathology. 22: 163–167. doi:10.1016/j.ijpp.2018.02.004. ISSN 1879-9817. PMID 30126662. S2CID 52056962. Archived (PDF) from the original on 2021-04-29. Retrieved 2022-01-09.
- ↑ 8.0 8.1 López-Frías FJ, Castellanos-Cosano L, Martín-González J, Llamas-Carreras JM, Segura-Egea JJ (February 2012). "Clinical measurement of tooth wear: Tooth wear indices". Journal of Clinical and Experimental Dentistry. 4 (1): e48–53. doi:10.4317/jced.50592. PMC 3908810. PMID 24558525.
- ↑ 9.0 9.1 Lussi A, Ganss C (2014-06-24). Erosive tooth wear : from diagnosis to therapy. Vol. 20 (2nd ed.). Basel. ISBN 9783318025538. OCLC 875630033.
- ↑ 10.0 10.1 10.2 Odell EW (Editor) (2010). Clinical problem solving in dentistry (3rd ed.). Edinburgh: Churchill Livingstone. pp. 285–287. ISBN 9780443067846.
- ↑ Shellis, R. Peter; Addy, Martin (2014), Lussi, A.; Ganss, C. (eds.), "The Interactions between Attrition, Abrasion and Erosion in Tooth Wear", Monographs in Oral Science, Basel: S. KARGER AG, 25: 32–45, doi:10.1159/000359936, ISBN 978-3-318-02552-1, PMID 24993256, archived from the original on 2020-05-06, retrieved 2021-07-23
- ↑ Sarode GS, Sarode SC (May 2013). "Abfraction: A review". Journal of Oral and Maxillofacial Pathology. 17 (2): 222–7. doi:10.4103/0973-029X.119788. PMC 3830231. PMID 24250083.
- ↑ 13.0 13.1 Bartlett D, Ganss C, Lussi A (March 2008). "Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs". Clinical Oral Investigations. 12 Suppl 1 (Suppl 1): S65–8. doi:10.1007/s00784-007-0181-5. PMC 2238785. PMID 18228057.
- ↑ Smith BG, Knight JK (June 1984). "An index for measuring the wear of teeth". British Dental Journal. 156 (12): 435–8. doi:10.1038/sj.bdj.4805394. PMID 6590081. S2CID 35419496.
- ↑ Bardsley PF (March 2008). "The evolution of tooth wear indices". Clinical Oral Investigations. 12 Suppl 1: S15–9. doi:10.1007/s00784-007-0184-2. PMC 2238784. PMID 18228055.
- ↑ Eccles, J. D. (December 1979). "Dental erosion of nonindustrial origin. A clinical survey and classification". The Journal of Prosthetic Dentistry. 42 (6): 649–653. doi:10.1016/0022-3913(79)90196-3. ISSN 0022-3913. PMID 292776.
- ↑ Millward, A.; Shaw, L.; Smith, A. J.; Rippin, J. W.; Harrington, E. (September 1994). "The distribution and severity of tooth wear and the relationship between erosion and dietary constituents in a group of children". International Journal of Paediatric Dentistry. 4 (3): 151–157. doi:10.1111/j.1365-263X.1994.tb00124.x. ISSN 0960-7439. PMID 7811669.
- ↑ Linkosalo, E.; Markkanen, H. (October 1985). "Dental erosions in relation to lactovegetarian diet". Scandinavian Journal of Dental Research. 93 (5): 436–441. doi:10.1111/j.1600-0722.1985.tb01336.x. ISSN 0029-845X. PMID 3864217.
- ↑ Maureen., O'Brien (1994). Children's dental health in the United Kingdom, 1993 : a survey carried out by the Social Survey Division of OPCS, on behalf of the United Kingdom health departments, in collaboration with the Dental Schools of the Universities of Birmingham and Newcastle. Great Britain. Office of Population Censuses and Surveys. Social Survey Division., University of Birmingham. Dental School., University of Newcastle upon Tyne. Dental School. London: H.M.S.O. ISBN 978-0116916075. OCLC 32250617.
- ↑ Lussi, A. (April 1996). "Dental erosion clinical diagnosis and case history taking". European Journal of Oral Sciences. 104 (2 ( Pt 2)): 191–198. doi:10.1111/j.1600-0722.1996.tb00067.x. ISSN 0909-8836. PMID 8804886.
- ↑ O’Sullivan, EA (2000). "A new index for the measurement of erosion in children". Eur J Paediatr Dent. 1: 69–74.
- ↑ Bardsley, P. F.; Taylor, S.; Milosevic, A. (2004-10-09). "Epidemiological studies of tooth wear and dental erosion in 14-year-old children in North West England. Part 1: The relationship with water fluoridation and social deprivation". British Dental Journal. 197 (7): 413–416, discussion 399. doi:10.1038/sj.bdj.4811722. ISSN 0007-0610. PMID 15475904. S2CID 2186540.
- ↑ Fares, J.; Shirodaria, S.; Chiu, K.; Ahmad, N.; Sherriff, M.; Bartlett, D. (2009). "A new index of tooth wear. Reproducibility and application to a sample of 18- to 30-year-old university students". Caries Research. 43 (2): 119–125. doi:10.1159/000209344. ISSN 1421-976X. PMID 19321989. S2CID 46065628.
- ↑ Mulic, A.; Tveit, A. B.; Wang, N. J.; Hove, L. H.; Espelid, I.; Skaare, A. B. (2010). "Reliability of two clinical scoring systems for dental erosive wear". Caries Research. 44 (3): 294–299. doi:10.1159/000314811. hdl:10852/34967. ISSN 1421-976X. PMID 20516691. S2CID 21372549.
- ↑ Margaritis, Vasileios; Mamai-Homata, Eleni; Koletsi-Kounari, Haroula; Polychronopoulou, Argy (January 2011). "Evaluation of three different scoring systems for dental erosion: a comparative study in adolescents". Journal of Dentistry. 39 (1): 88–93. doi:10.1016/j.jdent.2010.10.014. ISSN 1879-176X. PMID 21035516.
- ↑ Mehta, S. B.; Banerji, S.; Millar, B. J.; Suarez-Feito, J.-M. (January 2012). "Current concepts on the management of tooth wear: part 1. Assessment, treatment planning and strategies for the prevention and the passive management of tooth wear". British Dental Journal. 212 (1): 17–27. doi:10.1038/sj.bdj.2011.1099. ISSN 1476-5373. PMID 22240686.
- ↑ Mehta, S. B.; Banerji, S.; Millar, B. J.; Suarez-Feito, J.-M. (February 2012). "Current concepts on the management of tooth wear: part 3. Active restorative care 2: the management of generalised tooth wear". British Dental Journal. 212 (3): 121–127. doi:10.1038/sj.bdj.2012.97. ISSN 1476-5373. PMID 22322760.
- ↑ 28.0 28.1 Dyer, K.; Ibbetson, R.; Grey, N. (April 2001). "A question of space: options for the restorative management of worn teeth". Dental Update. 28 (3): 118–123. doi:10.12968/denu.2001.28.3.118. ISSN 0305-5000. PMID 11819971.
- ↑ Ibbetson, R (June 1999). "tooth surface loss: Treatment planning". British Dental Journal. 186 (11): 552–558. doi:10.1038/sj.bdj.4800167. ISSN 1476-5373. PMID 10405470. S2CID 11008538.