Tooth Wear: Clinical Detection and Management

Tooth Wear Lectures and Assessments

• Tooth Wear 1 is pre-recorded and has a workbook.
• Tooth Wear 2 is pre-recorded and has a quiz.
• Tooth Wear 3 is live and uses case studies to apply the theory.
• Formative assessments include a workbook, quiz, and case studies.
• Summative assessments involve e-assessment and/or cases.

Intended Learning Outcomes

• It is important to describe the clinical signs and symptoms of tooth wear and how to detect them.
• Describe the BEWE screening tool.
• Outline preventive management strategies.
• GDC Learning Outcomes: 1.1.2, 1.1.4, 1.1.8, 1.7.7, 1.10.1, 1.10.2, 1.10.3, 1.10.4, 1.10.6

Clinical Detection

• Clinical signs, BEWE, and patient history are important to consider.
• Detection = clinical examination (signs) + patient factors (symptoms & history)
• Preparation for clinical detection includes a mirror, dry surface, 3 in 1 OR, and cotton wool rolls.
• Examine the occlusal, palatal/lingual, and buccal clinical signs.

Tips To Detect Clinical Signs

• Using existing knowledge of normal tooth morphology is important.
• Subtle changes in tooth morphology may indicate tooth wear.
• Most adults show signs of tooth wear due to normal physiological processes.
• Assess the rate of wear relative to patient age.

Basic Erosive Wear Examination (BEWE) Index

• Score 0 indicates no erosive wear.
• A score of 1 indicates initial loss of surface texture, such as brightness loss, opaque surface, or 'frosted glass' appearance.
• Score 2 indicates a distinct defect, hard tissue loss (less than 50% of the surface area), with possible dentine involvement.
• A score of 3 indicates hard tissue loss of more than 50% of the surface area, with possible dentine involvement.
• The cumulative BEWE score (maximum 18) is achieved by adding each sextant score and informing risk and clinical management strategies.
• The BEWE is used to record tooth wear regardless of the aetiology.

BEWE 0

• This score indicates no signs of erosive tooth wear, although staining is evident.
• Hypoplasia could be present.

BEWE 1

• This score indicates early signs of erosive tooth wear with small, discrete erosive lesions or a discrete area of wear on the buccal surface and incisal edge.

BEWE 2

• Less than 50% loss is observed with signs of erosive tooth wear on the buccal (facial) surface, incisal edge loss, and dentine exposure.
• Loss of the clinical crown height is less than 50%.

Cuspal Changes

• Healthy cusps are pointy with steep inclines similar to a mountain top.

BEWE 3

• More than 50% of the palatal surface is affected.
• Exposed dentine is visible, especially at the gingival margins and incisal edges.
• A 'halo effect' is visible.
• Dentine hypersensitivity may be present, depending on whether the tooth wear is active.
• Erosive tooth wear covers more than 50% of the tooth surface.

BEWE In Clinical Notes

• A cumulative BEWE score of 3 is used to inform the level of intervention.

Patient Factors To Consider In Risk Assessment

• Age affects the rate of wear.
• Verbal history reveals aetiological factors.
• Consider past and current exposure to internal and external acids.
• Other factors include occupation, medical history, fluoride exposure, stress, habits, and dietary choices.
• Patient symptoms or concerns include sensitivity and noticed changes.
• Saliva is a significant modifying factor.

Interventions

• Risk assessment is followed by preventive care and advice.
• Further interventions include restorative care or referral, and review and monitor.

Management Guidance

• Use the opportunity to raise awareness regarding tooth wear.
• Oral hygiene and dietary advice are helpful management tools.
• Routine maintenance and recommending low-abrasion toothpaste products assist in managing tooth wear.
• Monitoring with study casts, clinical photographs and silicone impressions provide data for ongoing management.

Preventative Treatment

• Home care advice consists of tailored education for each patient.
• Non-abrasive brushing techniques and medium/soft toothbrushes are recommended.
• Using a low abrasive toothpaste and avoiding brushing after acidic foods or vomiting episodes is helpful.
• Fluoride toothpaste and spit with no rinse is advised.
• Dietary advice includes tailored advice for each patient.
• Eliminating or reducing the frequent intake of acidic foods and drinks is beneficial.
• Limiting acidic drinks to meal times and once per day is recommended.
• Buffering/neutralizing with water and not omitting essential fruits can reduce tooth wear.
• Maximizing fluoride exposure can be achieved with prescription toothpaste (2800/5000ppm) and fluoride mouthrinse at a different time to brushing

Fluoride Toothpaste

• 5% w/v Sodium Fluoride Varnish requires a prescription with 22600ppm.

Monitoring

• Take impressions for study models to monitor change over time.
• Take clinical photographs.

Occlusal Splint

• Occlusal splints involve impressions and preparation of a splint and stress management.
• Referral may be required; only proceed when erosion is under control.

Restorative Options

• Restorations may be necessary once the tooth wear is stable, although bonding materials can be difficult to use.
• Treatment options include the building up of bonding materials, veneers, and crowns, and may require a specialist referral, depending on complexity.

Referrals

• Refer if cases are beyond the scope, including severe tooth wear, bruxism, complex restorative care, eating disorders, or GORD.