Why talk about tooth wear? For some patients tooth wear is a significant problem and may result in tooth breakdown, loss of teeth, and decreased quality of life. In this article Dr. Alexander Shor discusses most important information about tooth wear!
What is tooth wear?
Tooth wear is an irreversible loss of hard tooth tissues (enamel and dentin) as a result of mechanical and chemical processes which occurs in the oral cavity. Tooth wear always starts on the outer surfaces of the teeth exposed to the oral environment.
What is the difference between normal (physiological) and abnormal (pathological) tooth wear?
Tooth wear is a normal or physiological process. As we age tooth enamel is slowly wearing down under mechanical and chemical processes which occur in the mouth.
Tooth wear can also be an abnormal or pathological. Dentists typically classify tooth wear into pathological process when it is excessive for the patient’s age, patient is experiencing discomfort, and/or there is a risk of tooth breakdown or tooth loss.
What are the different types of tooth wear?
Based on the processes which occur in the oral cavity dentists classify wear into 3 types.
Erosion- tooth wear which occurs as a result of low pH degradation from dietary, environmental or stomach acids. When source of acid is coming from diet or environment we call it Extrinsic Erosion. When acid is coming from the stomach we call it Intrinsic Erosion.
Abrasion– tooth wear which occurs as a result of tooth to foreign body contact. Examples of abrasion would be wear by food particles, tooth brushing, and biting on objects such as nails.
Attrition– tooth wear as a result of tooth to tooth contact. Examples of attrition would be nighttime tooth grinding (also called bruxism) and habitual tooth clenching.
How complex is tooth wear process?
Tooth wear is almost always a complex process where different types of wear contribute to the loss of tooth structure simultaneously. For example erosion makes teeth more susceptible to the abrasion and attrition and vice versa.
For some patients we can find one dominant type of tooth wear, but in many instance we cannot find one dominant factor and see different types of wear present simultaneously.
How do dentists diagnose tooth wear?
Diagnosis of tooth wear comes from clinical evaluation. Dentist performs a visual inspection of each tooth. If tooth wear is present, dentist make notes on the degree and site of wear. We may also supplement clinical evaluation with procedures such as dental x-rays, photographs, and study models (replicas of your teeth).
Part of evaluation also includes medical, dental, and behavioral history. This data is very helpful in making decision on the cause of tooth wear. When pathological wear is detected we may also do dietary assessment, salivary tests, and referral to medical specialists.
Another important aspect of tooth wear management is assessment of how aggressive is your tooth wear. This type of assessment is important because it may influence preventive and treatment regimen.
Is tooth wear evenly distributed among the teeth?
In most cases tooth wear is not evenly distributed between different teeth. For example in some instances tooth ware is more pronounced on the front teeth and less pronounced for the back teeth. In some instance tooth ear may affect top front teeth more than the bottom front teeth.
Tooth wear is also not evenly distributed between the different surfaces of the same tooth. For example on the same tooth wear can me more pronounced on the tongue side and much less pronounced on the front side of the tooth.
The uneven distribution of tooth wear occurs because of the different directions of the insulting factors as well as protecting effects of the tongue and saliva.
Location of the tooth wear is an important diagnostic finding in the determining the cause of wear.
What are the most common negative consequences of excessive tooth wear?
Cosmetic Changes and Short teeth
As tooth wear progresses over time, teeth can become short and unattractive. When there is loss of enamel, your teeth also become darker in color. These are some of the most common reasons patients seek reconstructive work for their worn down teeth.
Tooth sensitivity / Tooth Pain
As enamel and dentin of the tooth wears down, teeth can become sensitive and painful to temperature, touch and even inhaled air. For some patients tooth sensitivity can interfere with drinking, eating, and daily functions.
Tooth Chipping / Tooth Weakening
An enamel and dentist on the tooth gets thinner, remaining part of the tooth easily chips and breaks away. In some instances breaking of the enamel may create sharp edges which can cause discomfort in the mouth.
Root Canal Infections
In cases of advanced tooth wear, the internal chamber of the tooth called root canal can get infected by the oral bacteria. We call this root canal infections. Root canal infections can cause discomfort and pain and require costly treatment with root canal fillings.
Tooth Migration
The human teeth are naturally designed to keep up contact with each other and with the teeth in the opposing jaw. As tooth war progresses, teeth migrate in certain directions. This tooth migration can create unsightly appearance and make reconstructive work more complicated.
Tooth Loss
In most severe cases of tooth wear, teeth are at risk of being lost. There are so little tooth left that reconstructive work is not able to restore the tooth to the desired functional and cosmetic state. Also tooth loss may occur as a result of root canal infection.
What are the most common health and oral conditions which contribute to tooth wear?
Tooth Grinding / Bruxism
Tooth grinding may result in wear of the teeth. Tooth grinding manifests as a habit during the day. It can also be an uncontrolled grinding of the teeth during night. Night time grinding is called Bruxism and is classified as sleep disorder.
Bulimia /Anorexia
Bulimia Nervosa and Anorexia Nervosa are eating disorders. Bulimia is binge eating which is followed by attempts to rid the body of the consumed food (purging). Anorexia includes food restriction, unhealthy eating habits and distorted body image. Patient with bulimia and anorexia quite often engage in self-induced vomiting. The stomach content is very acidic and chronic vomiting over time may result in erosive tooth wear as well as accelerate other types of wear.
Gastroesophageal Reflux Disease(GERD)
GERD is a chronic leakage of the acid from the stomach into esophagus. However acid can also leak into throat, larynx, and mouth. GERD is caused by the failure of the valve (sphincter) between the stomach and esophagus. Patient who experience stomach acid leakage into the mouth may experience severe tooth wear.
Dry Mouth (Xerostomia) and Low pH (Acidic) Saliva
Dry mouth also called Xerostomia is reduction in the amount of saliva. Dry mouth most commonly caused by side effects of medications and radiation in the head and neck area. Dry mouth can also be caused by some autoimmune disease which affect salivary glands. Since saliva lubricates and re-hardens the teeth with minerals, dry mouth can be a risk factor for tooth wear. Some patients may also have acidic low pH saliva which is a risk factor for tooth wear.
Bite and Multiple Missing Teeth
Under certain condition your bite can contribute to wear of the teeth. For example patients with uneven bite may have only several teeth which touch against each other in the mouth. These teeth will experience higher rate of tooth wear. Also patients with multiple missing teeth may experience more wear on the remaining teeth.
What are the other factors which contribute to tooth wear?
Acidic (low pH) Drinks
Repetitive and high consumption of acidic / low pH drinks can cause dental erosion and tooth wear. Some of the beverages with low pH include colas, sport drinks, fruit and vegetable juices, wine, and flavored waters and flavored teas.
Acidic Food
Repetitive and high consumption of low pH foods can cause dental erosion and tooth wear. Some of the foods with low pH includes citrus fruits, tomatoes, apples, fermented food such as pickles and vinegar.
Tobacco Chewing
Due to its abrasive nature, chronic tobacco chewing may result in tooth wear.
Occupational Exposure to Acid Fumes
There have been reports that factory workers with exposure to acid fumes may experience a higher rate of tooth wear.
What are the preventive measures against tooth wear?
The best way to deal with tooth wear is prevention. It is critical to find the cause of tooth wear and try to eliminate it or reduce its severity on the teeth. For example if patient is having GERD than treatment of GERD will be important in prevention of tooth wear.
Patient may also be advised on the behavioral and dietary changes which may help to reduce tooth wear.
Preventive approach may also include remineralization therapy, which aims at strengthening of tooth so it can resist better against wear. Dentist may prescribe professional grade fluoride and calcium formulas which are used as tooth pastes or applied to the teeth in the form of gels.
Patient may also be advised to use mouthguard to protect the teeth against grinding or during vomiting episodes.
What are the restorative treatment options for tooth wear?
In some instance restorative treatment is indicated for the treatment of tooth wear. Goals of reconstructive treatment may include replacement of lost tooth structure, strengthening of the tooth against mechanical and chemical insults, prevention of root canal infections, and smile enhancement.
Restorative treatment includes placement of artificial dental restorations which mimics natural tooth and may include composite fillings, composite bonding, inlays/onlays, veneers and crowns.
In a number of instances in addition to dental restorations, worn down teeth may need root canal treatment, orthodontic treatment, and gum surgery to expose more tooth structure.
Conclusion
For some of the patients, tooth wear is a serious oral health problem. The best strategy in dealing with tooth wear is prevention. In some instances reconstructive treatment is indicated to extend longevity of the teeth, and improve comfort and appearance.
Before and After Examples of Restorative Treatment for Advanced Tooth Wear performed by Seattle Prosthodontist Dr. Alexander Shor.
