Tooth Wear Guidelines for the BSRD PDF

Tooth Wear Guidelines for the BSRD Part 1: Aetiology, Diagnosis and Prevention (June Dental Update) Part 2: Fixed Management of Tooth Wear (July/August Dental Update) Part 3: Removeable Management of Tooth Wear (September Dental Update) RestorativeDentistry...

Tooth Wear Guidelines for the BSRD Part 1: Aetiology, Diagnosis and Prevention (June Dental Update) Part 2: Fixed Management of Tooth Wear (July/August Dental Update) Part 3: Removeable Management of Tooth Wear (September Dental Update) RestorativeDentistry NEW Moisture levels vary. Our bond won’t. Prime&Bond active™ ©2016 Dentsply Sirona. All rights reserved. * Data on fi le Universal Adhesive Variations in moisture level can be difficult to detect, especially in the depths of a class II proximal box. Thanks to the new, patented Active-Guard™ Technology, Prime&Bond active adhesive provides reliable performance on over-wet and over-dried dentin, taking out some of the guess work and resulting in virtually no post-operative sensitivity*. For more information visit www.dentsplysirona.com/pbactiveuk 2 DentalUpdate July/August 2018  RestorativeDentistry Ken Hemmings Angharad Truman, Sachin Shah and Ravi Chauhan Tooth Wear Guidelines for the BSRD Part 1: Aetiology, Diagnosis and Prevention Dent Update 2018; 45: 3–10 Tooth wear (TW) is a common condition selected literature review covers three loss (TSL), can be described simply as ‘the affecting patients who often require advice sections: pathological non-carious loss of tooth and treatment from dentists. Physiological 1. Aetiology, diagnosis and prevention of tissue’.1 TW is normal and accepted by most tooth wear; The distinction between 2. Fixed management of tooth wear; pathological and physiological TW can patients. Pathological TW, by virtue of 3. Removable management of tooth wear. be difficult to determine. Wearing of the symptoms or rapid wear, will prompt the Each section is concluded with teeth is a normal physiological process. The need for dental care. It can range from a summary of key points which can act estimated normal vertical loss of enamel mild sensitivity from an abrasion lesion to as a quick reference checklist for the busy from physiological wear is thought to be gross destruction of the dentition. Similarly, practitioner. It is hoped that effective approximately 20−38 μm per annum.2 It is treatment can range from simple operative treatment or advice given at the right important to remember that just because a care to full mouth reconstruction with time can reduce the amount of long-term tooth has some element of wear this does crowns or complex dentures. Too little or maintenance care required in the future. not always necessitate treatment. Tooth too much treatment can lead to tooth loss However, it is acknowledged that some wear may be regarded as pathological if the and patient complaints. severe bruxist patients will always require rate of wear is greater than that expected These guidelines are designed regular repairs or replacement restorations. for the patient’s age, the patient has to help dentists manage tooth wear. A Guidelines become out of date concerns over the wear or the prognosis of immediately they are published. The society the tooth is compromised due to the wear. will review and update these guidelines on Tooth wear is often multifactorial Ken Hemmings, BDS, MSc, DRD RCS, MRD a 3-yearly basis. The work that the authors in nature and can be difficult to distinguish RCS, FDS RCS, ILTM, FHEA, Consultant in have put in to draft these guidelines is between, but it is often subdivided into: Restorative Dentistry, Eastman Dental Hospital gratefully received. The British Society of Attrition; and Institute, UCLH Trust and private practice, Restorative Dentistry (BSRD) Council and Erosion; Angharad Truman, BDS(Hons), MFDS RCPSG, members of the society are also thanked for Abrasion; and PGCME, FHEA, Specialty Registrar in Restorative their comments in improving the document. Abfraction (abfraction is often Dentistry, Bristol Dental Hospital, Sachin Shah, Effective treatment does exist and it is most described but, as yet, is not universally BDS, MFDS RCS, MClin Dent(Pros), MRD RCS, gratifying to make a dramatic difference to accepted as a true form of tooth wear). Specialist Prosthodontist in private practice/ patients with tooth wear when guidance is Clinical Teaching Fellow, Eastman Dental provided. Hospital and Institute, 256 Gray’s Inn Road, Attrition London, WC1X 8LD and Ravi Chauhan, MDDr, ‘The loss of tooth substance or MSc, MJDF RCS(Eng), MFDS RCS(Edin), Specialty Definition a restoration as a result of mastication or Registrar in Restorative Dentistry, King's College Tooth wear, or as it is also often contact between occluding surfaces of Dental Hospital, London, UK. referred to as non-carious tooth surface approximal surfaces’.1 July/August 2018 DentalUpdate 3 RestorativeDentistry Erosion 15%. Severe wear (exposing secondary to be the predominant pathological ‘The loss of tooth tissue by dentine) remained at 2%.9 cause of tooth wear in 11% of cases and chemical processes not involving bacterial Tooth wear in adults is a common reckoned that it accounted for two-thirds action’.3 clinical finding, with an increase in of the combined aetiology of TW. It is prevalence with increased age. A systematic important to acknowledge that a level of Abrasion review showed 3% of 20-year-olds and TW is normal, physiologically increasing ‘The physical wear caused by 17% of 70-year-olds exhibited severe tooth with age, but may become pathologically materials other than tooth contact’.4 wear.10 Furthermore, it has been suggested secondary to a parafunctional habit.14 that males tend to experience greater TW The diagnosis of parafunctional activity Abfraction than females, possibly due to increased is difficult and patients themselves are ‘Tooth wear located in the cervical tooth retention and greater occlusal forces often not aware of the condition. In fact, it area caused by flexural forces during in males.11 has been suggested that only half of the function and parafunction’.5 It is worth noting that prevalence population of bruxists are aware of the studies are somewhat lacking for adults and condition.15,16 Owing to this, the reported stricter guidelines are required for quality prevalence of bruxism varies between 5% Prevalence control.10 This may be attributed to the and 96%.3 Two popular theories have been difficulties in recruiting participants and proposed, but not confirmed, as the cause maintaining them, the varied study designs of bruxism, including parafunctional activity Prevalence in children and adolescents and terminology making comparisons as a manifestation of stress17 and as a result Epidemiological research across difficult. of premature contacts on mandibular Europe has shown an increasing prevalence in tooth wear in children over the last ten movement.18 years. An increased level of TW is found Aetiology At present, there is little evidence to be associated with increasing age, Clinical presentation and to support the theory that a reduced especially in the deciduous dentition.6 Tooth aetiology is usually subdivided into the number of occluding teeth leads to wear was reported to be between 0% and previously mentioned terms of attrition, increased tooth wear. Studies have reported 80% for children under seven years of age. erosion, abrasion and abfraction. Diagnosis no significant correlation between the This significant relationship of level of TW is often based on the clinical findings, loss of posterior teeth and anterior TW, to increase in age found in the deciduous which may suggest one causative factor. including the shortened dental arch.19,20 It is dentition did not appear to correspond to However, it is well known that the cause of suggested that the proprioceptive feedback the permanent dentition.6 tooth wear is multifactorial, making clinical mechanism and mutually protected In the UK, the Child Dental Health diagnosis difficult. Thus it is suggested that occlusion contribute to this finding.19,21 Survey has been undertaken decennially these single terms, which can be useful since 1973. The most recent survey, in 2013, when considering and describing the Erosion showed an increased incidence of tooth aetiology, may only describe the outcome It has been well documented wear. In children aged five, 33% had some of a number of underlying events rather that demineralization of dental hard tissue evidence of TW on the buccal surfaces, than the cause or process involved in the leading to dental erosion occurs following with 4% involving the dentine or pulp and wear. the drop in pH of the oral cavity below 57% on the lingual, with 16% involving It is important to acknowledge, critical pH, ie 5−5.5.22 Smith and Knight13 the dentine or pulp.7 In the permanent even if one single contributing factor found an erosive aetiology as part of the dentition, 31% of 15-year-olds showed signs appears to be involved, that other cause in almost 89% of patients referred for of TW on the occlusal surfaces of the first damaging factors may be present. Failure to severe wear. Erosion is often subcategorized permanent molars and 44% on the palatal acknowledge this may lead to insufficient into ‘extrinsic’ or ‘intrinsic’, depending on the surfaces of the maxillary incisors.8 advice, failure of treatment and progression nature of the acidic causative agent.23 of the condition. A thorough patient history A wide range of diseases and Prevalence in adults is essential to help aid understanding of the syndromes are associated with erosion: causative factors. In the UK, NHS Information Various medications, such as the frequent Occasionally, patients may have Centre commission surveys are undertaken use of asthma inhalers containing steroid inherited dental conditions that may decennially to assess the dental health or effervescent medication, which have a increase the severity of tooth wear, such status of adults to capture trends over time. pH value ranging from 4.3 (Bricanyl, powder as dentinogenesis imperfecta and dentine The most recent survey, in 2009, showed an form) to 9.3 (Ventolin, aerosol form);24 dysplasia, to name but two. It is important increased incident of tooth wear from 66% Reduced quantity and quality of saliva to inform these patients of their increased to 76% since the 1998 survey. Tooth wear (including drug-induced, salivary gland risk of wear.12 into dentine was found to be higher than agenesis, Sjögren’s syndrome); and previously, at 77% in the anterior teeth. Reduced motor function (including Moderate TW (extensive into dentine) also Attrition cerebral palsy), affecting the clearing of showed an increase from 11% in 1998 to Smith and Knight13 found attrition acidic food and drink from the teeth, may 4 DentalUpdate July/August 2018  RestorativeDentistry enhance intrinsic and extrinsic factors chlorinated swimming pool water.35 Due anorexia nervosa. The most common sign leading to erosion.25 to this, improvements in health and safety of this condition is perimolysis lesions, It has been noted that, for have been developed, such as wearing which are erosive lesions on the palatal children of all socio-economic backgrounds, protective airways masks, to reduce the surfaces of maxillary incisors.40 The effects tooth wear is most common on the effects of environmental erosion from the of such disorders leading to self-induced palatal surfaces of the maxillary incisors. work place.36 vomiting in the development of dental Furthermore, cross-sectional studies Chronic alcoholism is a source of erosion are well documented.41,42 The report a high prevalence of erosion, 53%26 both extrinsic and intrinsic dental erosion, incidence of bulimia has rapidly increased, and 77%27 in adolescents and adults, Extrinsically, the alcohol consumed has with 14 per 100,000 affected and respectively, in the UK. The prevalence of an acidic component, resulting in erosion approximately 7 per 100,000 individuals dental erosion in children and adolescents alongside the effects of regurgitation, in the population now thought to be is believed to be due to the increased vomiting and gastritis.4 affected by anorexia. This increase may be susceptibility of demineralization of the due to increased exposure to the media newly formed dentition, the time taken portraying the ‘ideal’ body shape and Intrinsic erosion for maturation and the reduced salivary size.43,44 It is worth noting that the male Intrinsic erosion results from the buffering capacity at night. to female ratio is approximately 1:10. gastric content entering the oral cavity.25 However, males are less likely to seek This can be from a variety of voluntary or Extrinsic erosion medical attention so may be at equal risk involuntary habits and diseases. Vomiting Extrinsic sources of acid of eating disorders.45 can be both voluntary and involuntary as may include acidic food and drinks and Rumination predominately a result of pregnancy, as a side-effect of medications, from the environment or affects patients with mental disabilities. some medications, through alcoholism, industrial processes. Medications, such It involves GORD combined with alimentary tract disorders, as well as as Aspirin (a salicylic acid), iron tonics, voluntary or involuntary regurgitation of psychosomatic conditions including eating chewable vitamin C and replacement swallowed food into the oral cavity, which disorders. hydrochloric acid, may lead to erosive tooth is then re-chewed and re-swallowed. Involuntary regurgitation of wear.3 Unfortunately, this condition is poorly gastric acids may be a result of gastro- Epidemiological studies have understood and the prevalence of erosion intestinal disturbances, such as during observed a correlation between acidic diets associated is not fully known.42 pregnancy, gastro-oesophageal reflux and the development of erosive TW.28,29 disease (GORD), vomiting, hiatus hernia or Acidic food and drink intake has increased rumination. Abrasion on a population level, furthermore, there Approximately half of patients The prevalence of abrasion has been an increase in population trends with localized anterior tooth wear report is reported in a range from 5%−85%, of leading a healthy lifestyle with increased having gastric reflux. GORD results in depending on the inclusion criteria.46 consumption of diet drinks and ‘juicing’, gastric content moving from the stomach Abrasion can often result from over leading to increased erosion. A strong link into the oesophagus due to a laxity in the enthusiastic toothbrushing with abrasive between the increased consumption of lower oesophageal sphincter.37 It is now toothpastes, improper use of interdental carbonated drinks, citrus fruits, fruit juices, recognized as a more common condition cleaning aids, or patient habits such as herbal tea and erosion is well known.23,28,30 for children/adolescents than previously nail-biting, pen-chewing or having a Both carbonated and non-carbonated thought. Stomach acid has a pH of tongue piercing. It is also suggested that drinks exhibit a similar erosive potential.31,32 approximately 2, which is highly erosive to there is an occupational hazard associated The acids commonly found in these foods the dentition. The effect can be particularly with some jobs, such as dress-making, include phosphoric, citric and malic acid, damaging to the dentition, especially the glassblowers and musicians.14 Dental however, there are many other acids with palatal surfaces, when continual episodes treatment may cause attrition if improper erosive potential in food. It has been are involved.38 Silent reflux can occur materials are utilized, for example, accepted that titratable acidity, which is a whereby patients are unaware of having unpolished ceramic restorations against a measurement of the total acid content, is longstanding, asymptomatic GORD leading natural tooth.1 a more important indicator than actual pH to dental erosion. Referral to a general It has also been highlighted that value in determining erosive potential of medical practitioner to assess this may be the present day ‘healthy diets’ may be beverages.22 beneficial to the patient as repeated soft contributing to an increase in tooth wear,1 Exposure to acid in the work tissue harm can lead to strictures, ulceration especially if there is high erosive content place can lead to environmental erosion. of the oesophageal lining and, in some from ‘juicing’, alongside an increase in It has been reported in those working cases, malignant changes, in particular abrasive foods such as nuts and seeds. It in industries such as wine tasting33 and Barrett’s oesophagus.39 is important to take into consideration manufacturing battery acid.34 Leisure Voluntary regurgitation is dietary, social and demographic patterns activities, such as swimming, may also increasing due to increasing incidence associated with time to determine what be a causative agent due to low pH gas- of eating disorders, such as bulimia and is acceptable for physiological wear.47 This July/August 2018 DentalUpdate 5 RestorativeDentistry makes the diagnosis between physiological and pathological a little more difficult to determine as it is ever changing. Abfraction Abfraction has caused much debate as to whether it is an accepted form of tooth wear. Much research has developed from finite element studies with little clinical evidence.48,49,50 As TW is Figure 1. Tooth wear presenting as mainly Figure 2. Tooth wear mainly presenting as often multifactorial in nature, it is debated attrition. The lack of posterior support may have erosion from frequent vomiting in a patient with that abfraction is a manifestation of a contributed to this appearance. anorexia bulimia. Note how the crown has been combination of erosion, abrasion and spared from the erosive wear. attrition.46 Erosive processes may lead to subsurface mineral loss, which leads to a softening of the tooth surface. Abrasion and results in loss of the cusp tips or incisal attrition may lead to an acceleration of the edges which generally interdigitate with the tooth wear processes in the cervical region. occluding dentition.53 Initial presentation may involve localized occlusal cusp tips and Clinical presentation the palatal surfaces of the maxillary anterior Due to the multifactorial aetiology teeth showing loss of tooth structure. tooth wear can present in a variety of As the process progresses, dentine may clinical appearances, making a diagnosis become exposed, leading to flattening of may be difficult. Occasionally, one causative incisal edges and cusp tips. The matching Figure 3. Tooth wear mainly presenting as opposing surfaces wear at the same rate abrasion with the prominent teeth being affected factor may be dominant and indicative and so the teeth continue to interdigitate most. of the main cause, but often the clinical appearance is the result of cumulative (Figure 1). damage over a period of time. Tooth wear may present as localized or generalized Erosion observed on the buccal cervical surfaces of loss off tooth substance, depending on the Often, early erosive lesions are the maxillary teeth and the occlusal surfaces number of teeth affected. not noticed by the patient. The cause of the of the mandibular posterior dentition.13 Patients may be unaware of erosion can determine, to some extent, the It has been suggested that erosive and the presence of tooth wear, especially in clinical presentation as the location and abrasive TW can be differentiated, in the the early stages of the process. However, severity may differ.5 If the erosive process is cervical region, as erosive wear tends to often patients present complaining of currently active, there is often no staining of create broader dished-out shallow lesions in reduced aesthetics. Occasionally, patients the teeth. If dentine is exposed and stained, complain of the appearance of reduced comparison to the sharply defined margins often the erosive element is no longer associated with abrasion.55 lower facial height, however, due to alveolar occurring. compensation, this is not often a presenting In intrinsic erosion, TW tends In general, erosive lesions present to present on the palatal surfaces of the feature. Dentists may note a reduced clinically when in enamel only as rounded interocclusal space for restorations. Enamel maxillary dentition. The lingual surfaces and and smooth lesions with loss of surface lower anterior teeth are often not affected may fracture and the teeth appear shorter.23 contour. Once the enamel layer has been Loss or thinning of the enamel may lead due to the protective nature of the tongue lost, exposed dentine is more susceptible to shine through or exposure of the covering them from exposure to the acid to the acidic attack and the accumulation underlying dentine, changing the optical attack41 (Figure 2). of tooth wear factors, leading to a more properties and colour of the teeth.45 rapid loss of tooth substance. This can lead Patients may complain of symptoms to cupping or dished out lesions. Teeth Abrasion of dentine sensitivity and impaired Clinical presentation is dependent may appear translucent, due to thinning of function.51 Other reported symptoms of on the causative factor and will affect the enamel anteriorly, or darker due to the burning mouth syndrome, oral ulceration the severity and distribution of the wear. exposed dentine. Anterior teeth may chip or and parotid gland enlargement may be fracture and restorations may stand proud Localized lesions may be the result of a provided.52 from the teeth. A chamfer margin of enamel habit such as pen-chewing, nail-biting, is often observed.54 pipe-smoking, or present as an occupational Attrition In extrinsic erosion, for example issue, such as builders holding screws Attrition, as previously defined, from dietary intake, tooth wear is often between their teeth. The tooth wear pattern 6 DentalUpdate July/August 2018  RestorativeDentistry will fit the shape of the object causing the of oral hygiene should be recorded together suggestions have been proposed to wear. with the undertaking of a Basic Periodontal improve the TWI, including modifying Overenthusiastic toothbrushing Examination (BPE). An occlusal assessment the threshold values for pathological often presents as rounded grooves in may be required for moderate to severe wear, expanding the scoring criteria and the cervical region of teeth; again this wear. creating another scoring level for secondary can present as a localized problem, often dentine and pulpal exposure. Millward with the canines and premolars being Measuring and monitoring et al60 modified the TWI to study erosion most affected, or as a more generalized tooth wear in primary and secondary dentine by condition dependent on the patient’s grouping TWI scores into categories of A large number of indices have toothbrushing technique. Of note, right- ‘Mild’, ‘Moderate’ and ‘Severe’. Again, there is been developed over the years, including handed individuals tend to create more potential for overestimation of tooth wear. the more popular Tooth Wear Index (TWI)13 wear on the left side and vice versa (Figure Fares et al61 undertook the most recent and the Basic Erosive Wear Examination 3). modification of the TWI to produce the (BEWE).58 However, at present, a single Exact Tooth Wear Index. This index scores universally accepted method of quantifying wear for enamel and dentine separately. It Abfraction and recording tooth wear is yet to be has the potential for scores to be converted Abfraction lesions can present adopted.59 This can make recording and into the original TWI for research purposes similarly to toothbrushing abrasion cavities, documenting TW difficult. for comparison and review. but tend to be more angular and undercut Some indices record wear based The above indices tend to be at the coronal aspect where enamel on the aetiology; however, the majority quite comprehensive and often used for overhangs the defect. of indices that have been developed are research. Bartlett et al58 designed The Basic based on the diagnosis and monitoring of Erosive Wear Examination (BEWE). It is a the wear. These indices tend to distinguish simple index, based on the principles of Examination of the tooth wear severity of the wear and are often numerical the Basic Periodontal Examination (BPE) as patient in nature. Measuring wear in vivo is difficult a screening tool for tooth wear. The BEWE For patients presenting with for a clinician as indices can only provide is a partial scoring system recording the tooth wear, the extra-oral examination the prevalence of wear at the point of time most severely affected surface for each should include an assessment of their of recording as there is a lack of reliable sextant. This can then be utilized to guide temporomandibular joints and associated natural reference points for continuity. management of the condition, much like musculature. The presence of any clicking, The majority of indices rely subjectively the BPE for periodontal disease. This index crepitation, mandibular deviation on on visual assessment of the wear severity, has been found to be easy to use by general opening or closure, maximum jaw opening which can lead to a conflict of opinions dental practitioners and researchers alike. (less than 40 mm is considered restricted) from different clinicians. Furthermore, the Studies have found the BEWE to be an and any associated muscle tenderness/ vast number of indices available makes acceptable method for scoring erosion aches/pain should be recorded.56 It is also comparison and aggregation of data with good inter-examiner reliability when worth noting the presence of parotid gland challenging.6 scoring sound surfaces and TW into dentine, enlargement, which is often seen in bulimic The Tooth Wear Index, developed but more discrepancies were recorded patients. by Smith and Knight,13 is the most widely when scoring enamel lesions.62 Severe tooth wear patients utilized. It was designed to be of use in A new classification, proposed may present with a reduced lower facial research into the aetiology, prevention, by Vailati and Belser,63 the Anterior Clinical height due to over closure from loss of management and monitoring of tooth Erosive classification (ACE), aims to provide vertical tooth height. Due to this, the facial wear and epidemiology. It was the a tool that is easier to use than the BEWE vertical proportions should be noted. first index of its kind to measure and for clinicians. Patients are grouped into six This can be examined by assessing the monitor multifactorial tooth wear. It is a classes based on five parameters relevant to freeway space (FWS), by determining the comprehensive index whereby the four the treatment and the prognosis: patient's resting vertical dimension (RVD) surfaces of a tooth are scored according 1. The dentine exposure in the contact and occlusal vertical dimension (OVD). to clinical findings based on the level areas; Callipers or a Willis gauge can be used for of enamel lost, level of dentine lost and 2. The preservation of the incisal edges; this. Other simple techniques include the change of the contour of the surface. 3. The length of the remaining clinical use of phonetic assessments (particularly Smith and Knight13 proposed a distinction crown; the sibilant sounds) and facial soft tissue of pathological levels of wear based on a 4. The presence of enamel on the vestibular contour analysis.57 The patient’s smile patient’s age. surfaces; and aesthetics may also be examined looking at However, there are several 5. The pulp. the smile line and lip line. limitations to this index.11 The thresholds A dental treatment plan is A full intra-oral examination for each age group have been criticized suggested for each class.63 Much like the should be undertaken including a detailed with subsequent underestimation aforementioned BEWE and the well-known soft and hard tissue assessment. The level of pathological wear.59 A number of Basic Periodontal Examination (BPE) utilized July/August 2018 DentalUpdate 7  RestorativeDentistry for assessing periodontal disease, the Prevention example, in cases of acid erosion, avoidance most severely affected tooth is used The increase in incidence of tooth of further exposure of the tooth to acid is to decide the classification. It is worth wear, especially in children, is concerning paramount.66 A reduction in the quantity noting that the classification is specifically as, without appropriate prevention, this and frequency of the consumption of for the anterior maxillary dentition, is likely to continue into adulthood.64 The acidic food/drinks would be beneficial. however, assessment and treatment of the correct diagnosis is essential for successful Patients should also be advised to limit posterior dentition must also be planned prevention and management. Even though their consumption of acidic foods/drinks as an integral part of the definitive oral prevention is of utmost importance, there to meal times. A change of habit, so that rehabilitation, which is a limitation of this is little high quality evidence about the when acidic drinks are consumed they classification. clinical effectiveness of most preventive are drunk through a wide bore straw, plus The difficulty with all the measures.65 Furthermore, it is difficult to avoidance of swishing beverages in the indices is that they are subjective and mouth, will help to reduce the rate of dental predict which individuals will be affected by potentially insensitive to small changes. erosion. It has been found that consuming TW, making primary prevention difficult to Some, such as the TWI, may be time dairy products, including hard cheese or achieve. consuming in a general dental practice chewing gum after the ingestion of an The decision to treat arises when setting when compared with the BEWE acidic substances, is beneficial in promoting the extent of the tooth wear and potential and ACE. However, both are good for the re-hardening of enamel, stimulating for progression may affect the prognosis of assessing the level of tooth wear and saliva flow and increasing the saliva pH and the tooth, or the patient expresses a want how best to manage the condition. reducing the effects of the erosive source.69 for treatment, or there is the presence of Alternative methods to measure TW Appropriate toothbrushing symptoms. In the absence of functional and include using intra-oral three-dimensional advice and habit avoidance or counselling aesthetic issues, monitoring and counselling laser scanners; sequential photographs; will also be of benefit to the patient, may be the preferred treatment option.66 periodic accurate study casts; sectional including the avoidance of overzealous It is reported that, once TW has silicone index and radiographs, which toothbrushing and the use of less abrasive been diagnosed, wear progression appears have all been utilized in clinical settings toothpastes such as those marketed for to occur at a relatively slow rate whilst with varying results. Furthermore, tooth whitening. Toothbrushing shortly the enamel is still present, particularly in assessing the patient clinically and for after acid exposure (commonly practised cases where preventive advice has been after vomiting or after drinking citrus juice changes in reported symptoms, ie the successfully implemented.66,67 However, in the morning) should be avoided. Studies patient begins to notice increased tooth a change in lifestyle and personal have shown that remineralizing toothpastes wear or sensitivity, should also be utilized circumstances, including an increase in increase the surface hardness of teeth for measuring TW. stress, may be associated with sporadic exposed to acidic substances and have a bursts of wear activity amongst these greater effect than conventional fluoride- Diagnosis patients, which may have the potential containing toothpastes alone.70 However, The difficulty in distinguishing to produce severe wear. Therefore, early topical fluoride application has been shown between the clinical presentations and preventive advice is paramount to success to protect against subsequent tooth wear often multifactorial nature of tooth in preventing ongoing wear leading to following an acid challenge. A neutral wear can make diagnosis difficult. It is possible highly restored dentitions with sodium fluoride mouthrinse or gel should important to take into consideration long-term management requirements. Most be recommended. whether the wear is physiological or research into the efficacy of preventive Furthermore, fluoride application pathological. A detailed history of the strategies has focused on the prevention of can also aid in prevention of symptoms chief complaint should be ascertained erosive wear. Preventive advice should be of sensitivity. Toothpastes containing and documented. Alongside this, also structured in relation to cause. potassium and Tooth Mousse ACP (GC) record an accurate and up-to-date medical Preventive advice may be centred are also considered to be appropriate for history assessment of the clinical signs and on medical management with referral to a the management of dentine sensitivity.56 symptoms and the location of the wear medical practitioner or psychiatrist.68 This Such agents may be applied with the aid (generalized or localized) when creating a is considered appropriate when an eating of a custom-fabricated tray (containing diagnosis. disorder or reflux disease is suspected. reservoirs akin to bleaching trays). For The diagnosis of a patient Medication, such as antacids, omeprazole patients experiencing sensitivity this may presenting with tooth wear should include and ranitidine can be used to reduce be prevented by the application of dentine- a description of the type(s) of lesions gastric reflux and acid production. Where bonding agents, and fissure sealant to observed, together with an account of xerostomia may have an underlying role, erosive lesions may be of some benefit. the extent/location (localized, anterior/ referral to a specialist in oral medicine However, studies have shown the longevity posterior or generalized) and severity may be considered; or discussing with of dentine-bonding agents applied to teeth (restricted to enamel only, into dentine or the medical practitioner an alternative displaying severe wear to be relatively severely affecting the teeth involving the medication if xerostomia is a side-effect short lived.71 Glass ionomer cements can pulp) of the condition. of a current medication regimen. For also be readily applied to worn surfaces for 8 DentalUpdate July/August 2018  RestorativeDentistry a a may be aware or unaware of their tooth wear. If it is of concern and they have symptoms (pain, poor function or poor appearance) they may request treatment. If possible, the dentist should advise prevention or minimal intervention treatment to prevent symptoms from occurring. 5. The exposure of dentine and presentation of thin or unsupported enamel should b prompt a discussion with the patient about b the tooth wear. The rate of TW is likely to increase when dentine is exposed. 6. Preventive management of tooth wear may include any of the following: (a) Dietary advice; Figure 4. (a, b) Soft or bilaminar splints are cheap (b) Medical referral; to provide but not as durable as a hard acrylic (c) Oral hygiene instruction and correction splint. of damaging habits; (d) Fluoride application; Figure 5. (a, b) A maxillary hard acrylic splint involves more clinical and laboratory time to (e) Alkaline solutions; make. It can be more durable and effective when (f ) Remineralizing solutions; the purposes of sensitivity and tooth wear treating severe tooth wear, TMJ dysfunction and (g) Desensitizing agents; prevention. reducing muscle dysfunction. (h) Occlusal splints; Advising patients to change (i) Composite or glass ionomer restorations habits, such as that of pen/pencil-biting, to cover dentine. nail-biting or holding or opening objects 7. In early or mild presentations of tooth with the teeth, such as bottle tops, hair on wear/usage must be precise, so that wear, in the absence of symptoms, grips, sewing needles, pipes, will also help the splint does not become a reservoir for monitoring and prevention may be most prevent ongoing wear. the acid produced. In erosive tooth wear appropriate. In cases of tooth wear, splint a soft vacuum-formed appliance modified 8. Occlusal splints may be soft, bilaminar therapy is beneficial in order to prevent to include reservoirs is beneficial. Neutral (hybrid) or hard and can be placed in either the loss of tooth structure from attrition. fluoride gels, desensitizing agents and also jaw. The selection will depend on the The use of a night guard is recommended acid neutralizers, ie sodium bicarbonate severity of tooth wear and cost involved. for nocturnal bruxists. This may be a soft solution, can be applied, respectively.56 Hard acrylic splints are expensive but are splint, but this will not be durable in the more effective in managing severe TW, long term. A bilaminar splint may be more Key points severe TMJ dysfunction and establishing cost-effective72 (Figure 4). However, for an a reproducible retruded contact position established bruxist patient, a full coverage 1. Making a diagnosis in tooth wear (RCP) in pre-restorative treatment. hard acrylic occlusal splint should be is a fundamental starting point for constructed (ie a Michigan splint or a Tanner managing TW. It should be expressed in terms of aetiology, severity, whether it is References appliance). The splint should be fabricated 1. Kelleher M, Bishop K. Tooth surface loss: tooth to provide an 'ideal occlusion' (Figure 5). physiological or pathological, localized surface loss: an overview. Br Dent J 1999; 186: It is important to take precautions when or generalized and compensated or non- 61−66. 2. Lambrechts P, Braem M, Vuylsteke-Wauters M, providing splints to patients with an erosive compensated. This should be explained to Vanherle G. Quantitative in vivo wear of human factor, in the cause of the tooth wear, patients in terms that they can understand. enamel. J Dent Res 1989; 68: 1752−1754. 2. Monitoring tooth wear is best carried 3. Bishop K, Kelleher M, Briggs P, Joshi R. Wear especially if night reflux is a causative factor. now? An update on the etiology of tooth wear. Advice should be given to the patient out with study casts or photographs. In the Quintessence Int 1997; 28: 305−313. future, digital scanning methods are likely 4. Smith BG, Robb ND. Dental erosion in patients accordingly, as the acidic substances may with chronic alcoholism. accumulate within the splint and further to be available in daily practice. The most J Dent 1989; 17: 219−221. exacerbate the rate of wear, and regular useful indices58,63 have not gained universal 5. Lee WC, Eakle WS. Possible role of tensile stress in the etiology of cervical erosive lesions of maintenance is required. Splints may be acceptance as yet. teeth. J Prosthet Dent 1984; 52: 374−380. used to protect teeth during episodes of 3. Tooth wear usually has a mixed aetiology 6. Kreulen CM, Van’t Spijker A, Rodriguez JM, of attrition, erosion and abrasion. Abfraction Bronkhorst EM, Creugers NH, Bartlett DW. vomiting for the bulimic patient, which Systematic review of the prevalence of tooth are worn during the vomiting period only is not a universally accepted entity. wear in children and adolescents. Caries Res and after vomiting should be removed and 4. Patients’ attitude will dictate whether 2010; 44: 151−159. 7. Pitts NB, Chadwick B, Anderson T. Children’s cleaned. Again precautions and instructions prevention or treatment is advised. They Dental Health Survey 2013 Report 2: Dental July/August 2018 DentalUpdate 9  RestorativeDentistry Disease and Damage in Children England, Wales 29. Lussi A. Erosive tooth wear − a multifactorial 51. Addy M, Pearce N. Aetiological, predisposing and Northern Ireland. Health and Social Care condition of growing concern and increasing and environmental factors in dentine Information Centre, 2015. knowledge. Monogr Oral Sci 2006; 20: 1−8. hypersensitivity. Archiv Oral Biol 1994; 39: S33− 8. Murray JJ, Vernazza CR, Holmes RD. Forty years 30. Phelan J, Rees J. The erosive potential of some S38. of national surveys: an overview of children's herbal teas. J Dent 2003; 31: 241−246. 52. Milosevic A. Tooth wear: an aetiological and dental health from 1973−2013. Br Dent J 2015; 31. Kitchens M, Owens B. Effect of carbonated diagnostic problem. Eur J Prosthodont Rest Dent 219: 281−285. beverages, coffee, sports and high energy 1993; 1: 173−178. 9. White DA, Tsakos G, Pitts NB, Fuller E, Douglas drinks, and bottled water on the in vitro erosion 53. Mair LH. Wear in dentistry − current GV, Murray JJ, Steele JG. Adult Dental Health characteristics of dental enamel. terminology. J Dent 1992; 20: 140−144. Survey 2009: common oral health conditions J Clin Pediatr Dent 2007; 31: 153−159. 54. Bartlett DW. The role of erosion in tooth wear: and their impact on the population. Br Dent J 32. Al-Dlaigan Y, Shaw L, Smith A. Dental erosion in aetiology, prevention and management. Int Dent 2012; 213: 567−572. a group of British 14-year-old school children J 2005; 55: 277−284. 10. Spijker AV, Rodriguez JM, Kreulen CM, Part II: Influence of dietary intake. Br Dent J 55. Levitch LC, Bader JD, Shugars DA, Heymann HO. Bronkhorst EM, Bartlett DW, Creugers NH. 2001; 190: 258−261. Non-carious cervical lesions. J Dent 1994; 22: Prevalence of tooth wear in adults. Int J 33. Mulic A, Tveit AB, Hove LH, Skaare AB. Dental 195−207. Prosthodont 2009; 22. 35−42. erosive wear among Norwegian wine tasters. 56. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. 11. Donachie MA, Walls AW. Assessment of tooth Acta Odont Scand 2011; 69: 21−26. Current concepts on the management of tooth wear in an ageing population. 34. Tuominen ML, Tuominen RJ, Fubusa F, Mgalula wear: part 1. Assessment, treatment planning J Dent 1995; 23: 157−164. N. Tooth surface loss and exposure to organic and strategies for the prevention and the 12. Barron MJ, McDonnell ST, MacKie I, Dixon MJ. and inorganic acid fumes in workplace air. passive management of tooth wear. Hereditary dentine disorders: dentinogenesis Community Dent Oral Epidemiol 1991; 19: Br Dent J 2012; 212: 17−27. imperfecta and dentine dysplasia. Orphanet J 217−220. 57. Rivera-Morales WC, Mohl ND. Restoration of the Rare Dis 2008; 3: 31. 35. Geurtsen W. Rapid general dental erosion by vertical dimension of occlusion in the severely 13. Smith BG, Knight JK. An index for measuring the gas-chlorinated swimming pool water. Review worn dentition. Dent Clin North Am 1992; 36: wear of teeth. Br Dent J 1984; 156: 435−438. of the literature and case report. Am J Dent 651−664. 14. Grippo JO, Simring M, Schreiner S. Attrition, 2000; 13: 291−293. 58. Bartlett D, Ganss C, Lussi A. Basic Erosive Wear abrasion, corrosion and abfraction revisited: a 36. Kim HD, Douglass CW. Associations Examination (BEWE): a new scoring system for new perspective on tooth surface lesions. J Am between occupational health behaviors and scientific and clinical needs. Clin Oral Investig Dent Assoc 2004; 135: 1109−1118. occupational dental erosion. 2008; 12: 65−68. 15. Agerberg G, Carlsson GE. Functional disorders J Public Health Dent 2003; 63: 244−249. 59. Bardsley PF. The evolution of tooth wear indices. of the masticatory system II. Symptoms in 37. Mahoney EK, Kilpatrick NM. Dental erosion: part Clin Oral Investig 2008; 12: 15−19. relation to impaired mobility of the mandible 1. Aetiology and prevalence of dental erosion. 60. Millward A, Shaw L, Smith AJ, Rippin JW, as judged from investigation by questionnaire. NZ Dent J 2003; 99: 33−41. Harrington E. The distribution and severity Acta Odont Scand 1973; 31: 335−347. 38. Bartlett DW, Evans DF, Smith BG. The of tooth wear and the relationship between 16. Helkimo M. Studies on function and relationship between gastro‐oesophageal reflux erosion and dietary constituents in a group of dysfunction of the masticatory system: IV. disease and dental erosion. J Oral Rehabil 1996; children. Int J Paediatr Dent 1994; 4: 151−157. Age and sex distribution of symptoms of 23: 289−297. 61. Fares J, Shirodaria S, Chiu K, Ahmad N, Sherriff dysfunction of the masticatory system in Lapps 39. Reid BJ, Weinstein WM, Lewin KJ, Haggitt M, Bartlett D. A new index of tooth wear. Caries in the north of Finland. Acta Odont Scand 1974; RC, VanDeventer G, DenBesten L, Rubin CE. Res 2009; 43: 119−125. 32: 255−267. Endoscopic biopsy can detect high-grade 62. Mulic A, Tveit AB, Wang NJ, Hove LH, Espelid 17. Budtz‐Jørgensen EJ. Occlusal dysfunction and dysplasia or early adenocarcinoma in Barrett's I, Skaare AB. Reliability of two clinical scoring stress. J Oral Rehabil 1981; 8: 1−9. esophagus without grossly recognizable systems for dental erosive wear. Caries Res 2010; 18. Ramfjord SP. Bruxism, a clinical and neoplastic lesions. Gastroenterology 1988; 94: 44: 294−299. electromyographic study. J Am Dent Assoc 1961; 81−90. 63. Vailati F, Belser CU. Classification and treatment 62: 21−44. 40. Schmidt U, Treasure J. Eating disorders and the of the anterior maxillary dentition affected 19. Smith BG, Robb ND. The prevalence of dental practitioner. by dental erosion: the ACE classification. Int J toothwear in 1007 dental patients. Eur J Prosthodont Rest Dent 1997; 5: 161−167. Periodont Restor Dent 2010; 30: 559. J Oral Rehabil 1996; 23: 232−239. 41. Robb ND, Smith BG, Geidrys-Leeper E. The 64. Chadwick BL, White DA, Morris AJ, Evans D, Pitts 20. Witter DJ, Creugers NH, Kreulen CM, De Haan distribution of erosion in the dentitions of NB. Non-carious tooth conditions in children in AF. Occlusal stability in shortened dental arches. patients with eating disorders. Br Dent J 1995; J Dent Res 2001; 80: 432−436. 178: 171−175. the UK, 2003. Br Dent J 2006; 200: 379−384. 21. Bartlett D, Phillips K, Smith B. A difference 42. Milosevic A. Tooth surface loss: eating disorders 65. Kelleher MG, Bomfim DI, Austin RS. Biologically in perspective − the North American and and the dentist. Br Dent J 1999; 186: 109−113. based restorative management of tooth wear. European interpretations of tooth wear. Int J 43. Monteath SA, McCabe MP. The influence of Int J Dent 2012; 2012: 742509. Prosthodont 1999; 12: 401−408. societal factors on female body image. 66. Bartlett DW, Palmer I, Shah P. An audit of study 22. Singh S, Jindal R. Evaluating the buffering J Soc Psychol 1997; 137: 708−727. casts used to monitor tooth wear in general capacity of various soft drinks, fruit juices and 44. Hawkins N, Richards PS, Granley HM, Stein DM. practice. Br Dent J 2005; 199: 143−145. tea. J Conserv Dent 2010; 13: 129. The impact of exposure to the thin-ideal media 67. Bartlett DW. Retrospective long term monitoring 23. Eccles JD. Tooth surface loss from abrasion, image on women. Eat Disord 2004; 12: 35−50. of tooth wear using study models. Br Dent J attrition and erosion. Dent Update 1982; 9: 45. Bishop K, Briggs P, Kelleher M. The aetiology 2003; 194: 211−213. 373−374. and management of localized anterior tooth 68. Treasure J, Schmidt U, Troop N, Tiller J, Todd 24. O’Sullivan EA, Curzon ME. Drug treatments for wear in the young adult. Dent Update 1994; 21: G, Keilen M, Dodge E. First step in managing asthma may cause erosive tooth damage. 53−60. bulimia nervosa: controlled trial of therapeutic Br Med J 1998; 317(7161): 820. 46. Bartlett DW, Shah P. A critical review of non- manual. Br Med J 1994; 308(6930): 686−689. 25. Johansson AK, Omar R, Carlsson GE, Johansson carious cervical (wear) lesions and the role of 69. Imfeld T, Birkhed D, Lingström P. Effect of urea A. Dental erosion and its growing importance in abfraction, erosion, and abrasion. J Dent Res in sugar-free chewing gums on pH recovery clinical practice: from past to present. Int J Dent 2006; 85: 306−312. in human dental plaque evaluated with three 2012; 2012: 632907. 47. Crothers AJ. Tooth wear and facial morphology. different methods. Caries Res 1995; 29: 172−180. 26. Bardsley PF, Taylor S, Milosevic A. J Dent 1992; 20: 333−341. 70. Muňoz CA, Feller R, Haglund A, Triol CW, Epidemiological studies of tooth wear and 48. Rees JS. The role of cuspal flexure in the Winston AE. Strengthening of tooth enamel by dental erosion in 14-year-old children in North development of abfraction lesions, a finite a remineralizing toothpaste after exposure to an West England. Part 1: The relationship with element study. Eur J Oral Sci 1998; 106: acidic soft drink. water fluoridation and social deprivation. Br 1028−1032. J Clin Dent 1999; 10(1 Spec No): 17−21. Dent J 2004; 197: 413−416. 49. Rees JS. The effect of variation in occlusal 71. Bartlett D, Sundaram G, Moazzez R. Trial of 27. Daly B, Newton TJ, Fares J, Chiu K, Ahmad N, loading on the development of abfraction protective effect of fissure sealants, in vivo, on Shirodaria S, Bartlett D. Dental tooth surface lesions: a finite element study. J Oral Rehabil the palatal surfaces of anterior teeth, in patients loss and quality of life in university students. 2002; 29: 188−193. suffering from erosion. Prim Dent Care 2011; 18: 31−35. 50. Rees JS, Hammadeh M. Undermining of enamel J Dent 2011; 39: 26−29. 28. Jarvinen VK, Rytomaa II, Heinonen OP. Risk as a mechanism of abfraction lesion formation: 72. Longridge NN, Milosevic A. The bilaminar (dual- factors in dental erosion. J Dent Res 1991; 70: a finite element study. Eur J Oral Sci 2004; 112: laminate) protective night guard. Dent Update 942−947. 347−352. 2017; 44: 648−654. 10 DentalUpdate July/August 2018  RestorativeDentistry #&
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JMMVNJOBUJPO W&H (UK) Limited Park Street, St Albans t + 44 1727 874990 [email protected] July/August 6 Stroud2018 Wood Business Centre Hertfordshire AL2 2NJ, United Kingdom f + 44 1727 874628 wh.com DentalUpdate 11 RestorativeDentistry Ken Hemmings Angharad Truman, Sachin Shah and Ravi Chauhan Tooth Wear Guidelines for the BSRD Part 2: Fixed Management of Tooth Wear Dent Update 2018; 45: 11–19 The management of tooth wear (TW) of life. Significant tooth structure loss can life, affecting patients’ satisfaction with may often present a dilemma to the also lead to difficulties with any potential their dentition, in particular; aesthetics, clinician. The clinical decision-making rehabilitation.1 Patients often only become oral comfort and/or mastication.5 Correct process between monitoring and active aware of their TW when the appearance diagnosis is therefore critical for successful management can be difficult. Thorough of their teeth begins to deteriorate or they management of TW. The predominant history-taking and clinical assessment become symptomatic. Enamel may appear aetiology should be determined and the are essential parts of gathering sufficient thin or discoloured, begin to fracture and patient concerns identified.6 Although the information to allow the clinician and the the teeth may appear shorter.2 Exposure rehabilitation of worn teeth is common patient to make these treatment decisions. of dentine can lead to transient pain in clinical practice, there appears to be a Uncontrolled tooth wear response to chemical, thermal, tactile or can lead to poor aesthetics, dentine osmotic stimuli. This is commonly known stark absence of documented outcomes. hypersensitivity and functional problems, as dentine hypersensitivity and may occur It has been identified in numerous reviews ultimately resulting in a reduced quality following loss of enamel with dentinal that there is no strong published evidence exposure secondary to tooth wear.3 This on management strategies.6,7 To date, pain can often be unsettling for the patient most recommendations are based on and may lead to limitation of the types of published, evidence-based, expert opinion Ken Hemmings, BDS, MSc, DRD RCS, MRD food or beverage ingested. or observational studies, with a lack of RCS, FDS RCS, ILTM, FHEA, Consultant in Loss of tooth structure can high quality research supporting individual Restorative Dentistry, Eastman Dental Hospital have many restorative implications. The restorative measures for the replacement of and Institute, UCLH Trust and private practice, need to conserve tooth structure, in tooth tissue.7 Angharad Truman, BDS(Hons), MFDS RCPSG, particular enamel, remains vital to the PGCME, FHEA, Specialty Registrar in Restorative The decision to treat arises when predictability of adhesive restorations Dentistry, Bristol Dental Hospital, Sachin Shah, the patient’s needs, severity of the wear and which are indicated, where possible, to BDS, MFDS RCS, MClin Dent(Pros), MRD RCS, potential for progression are of concern. avoid removal of more tooth structure, as Specialist Prosthodontist in private practice/ There is a lack of evidence to suggest that is required with conventional crown and Clinical Teaching Fellow, Eastman Dental bridge work.4 Further restorative difficulties the presence of TW will predictably lead to Hospital and Institute, 256 Gray’s Inn Road, can be encountered as TW causes loss of severe wear.6 In the absence of aesthetic London, WC1X 8LD and Ravi Chauhan, MDDr, interocclusal space, thereby leaving limited or functional issues, monitoring of the MSc, MJDF RCS(Eng), MFDS RCS(Edin), Specialty space for the restorative material. TW and preventive advice, including diet Registrar in Restorative Dentistry, King's College Uncontrolled tooth wear may counselling, may be preferable.8,9 Dental Hospital, London, UK. ultimately result in decreased quality of The preservation of tooth 12 DentalUpdate July/August 2018  RestorativeDentistry structure is critical. In cases of intrinsic and removable restorative approach. wax-up can be carried out at the desired erosion, prevention of further exposure Disadvantages of restorative treatment vertical dimension. This diagnostic preview to the damaging gastric contents is of revolve around the patient entering forms the foundation for future treatment paramount importance.10 The management the restorative maintenance cycle, thus and can be transferred to the patient in strategy should be centred around medical rendering both the restorations and the order to assess proposed changes in the management, and psychiatric evaluation teeth susceptible to fracture or even failure. vertical dimension and aesthetics and if eating disorders are suspected.11 The consequences of failures and their function. Parafunctional habits may exert highly subsequent management must all be taken destructive forces and are difficult to into consideration prior to embarking on a restorative management strategy. Occlusal splints prevent in comparison to erosive wear.12 Despite prevention being the foundation A hard heat-cured full coverage for successful management, there is a lack Preliminary investigations acrylic splint can be used in the diagnostic of high quality evidence about the clinical The initial investigations should phase. The ideal splint should provide effectiveness of most preventive measures.13 involve thorough assessment of the even contact along the retruded arc of patient in order to identify the cause of closure, with anterior guidance on anterior wear, if possible, and correlate the clinical teeth with posterior disclusion and canine Indications for fixed symptoms resulting from such wear. The guidance in lateral excursions with no management of tooth wear relevant aesthetic, restorative, periodontal interferences from the posterior dentition.15 Generalized/localized tooth and endodontic examinations should They can provide the following benefits: wear in dentate patients with associated: be carried out along with any necessary Protect worn teeth from any further wear, Pain/discomfort; radiographic investigations. This should be especially if the original cause is attrition; Aesthetic concern; accompanied with a set of mounted study Disrupt the habitual path of closure into Functional disturbance; casts. intercuspal position (ICP) by separating the Compromised structural integrity of On conclusion of the teeth; tooth/teeth; assessments, the clinician will be able to Testing tolerance to the planned changes Alveolar compensation with resulting lack draw conclusions on the overall state of the in occlusal vertical dimension.16-18 This is of interocclusal space for restoration. dentition, the complexity of the problem, probably unnecessary, since proprioception individual and general prognosis and makes tolerance highly likely when occlusal Contra-indications for fixed potential treatment options available. loads are directed through the periodontal management of tooth wear ligament (PDL), as with fixed restorations; Contra-indications include: Diagnostic phase Pre-restorative stabilization to ensure a Worn teeth compromising periodontal reproducible jaw relationship is established Mounted study casts disease and/or extensive caries; prior to embarking on a re-organized A set of articulated study Unrestorable teeth − vertical root approach. This is thought to be achieved by casts can be used to assess the overall fractures, horizontal/oblique fractures dentition, occlusal relationship, contacts breaking the proprioceptive feedback from to bone crest, caries to bone crest, failed and interferences, and restorative space periodontal mechanoreceptors, resulting endodontics; available. The mounted casts can also in muscle relaxation that will facilitate the Concurrent soft tissue defects; be used to assess the effect of changing accurate recording of the retruded axis The additional time and cost involved occlusal contacts (trial equilibration), position (RAP);17 which may be prohibitive for some patients; diagnostic repositioning of teeth14 and to Protection of new restorations from Worn dentitions with extensive create a diagnostic preview. occlusal forces in parafunction; edentulous spans or insufficient posterior If it is determined that Management of temporomandibular support and dental implants are not reconstruction is required, treatment dysfunction through a true therapeutic considered. should aim to restore the worn dentition to effect or potential placebo effect.19,20 a determined occlusal vertical dimension Partial coverage splints should Aims of fixed management of needed to create space for restoration of be avoided due to potential selective tooth wear lost tooth tissue, avoiding sound tooth intrusion and extrusion of teeth. The Restorative management of destruction, whilst ensuring acceptable resulting malocclusion can be difficult tooth wear may be necessary in order function and aesthetics. In most patients to correct and a potential source of to achieve the aims of restoring the who are fully or mostly dentate, where medicolegal litigation. appearance, function and/or speech of restorations will be tooth borne, such patients with worn dentitions, conserving changes are well tolerated. The occlusal remaining tooth structure and reducing vertical dimension should ideally be Planning strategies sensitivity or pain associated with captured with a jaw registration at or close Management strategies will be worn teeth. This may be by means of to the desired vertical dimension, which is influenced by the following factors that fixed, removable or a combined fixed then used to mount the casts. A diagnostic should all be considered during the July/August 2018 DentalUpdate 13  RestorativeDentistry material is of far less importance by way of shown to perform better than the older comparison to survival of the tooth and the microfilled resins. dentino-pulpal complex.13 In a series of studies assessing Modern resin-based restorative direct and indirect composite resin materials have risen in popularity due restorations in predominantly erosive to their use being less destructive to the cases, Gow and Hemmings found an remaining tooth tissue whilst serving the annual failure rate of 6.9% in a relatively functional requirements, bringing into short follow-up of two years for indirect question traditional fixed prosthodontic palatal ceromer veneers.26 The indirect approaches.9 restorations did not offer any advantages Figure 1. Adhesive metal backings and onlays are durable but can have poor aesthetics. over direct composites. Gulamali et al found Localized tooth wear a similar annual failure rate when assessing indirect and direct hybrid composites in The vast majority of studies the management of localized TW, with are centred around management of median survival times of 7 years for major planning phase: localized tooth wear. Huge variations in 1. The aetiology and pattern of failures and 5.8 years when assessing all outcomes exist in the reported success and failures.27 Despite more than 50% of all tooth wear; survival of direct and indirect restorations. 2. Occlusal vertical dimension, restorations suffering some form of failure, There has been a gradual evolution the authors concluded that composite resin dento-alveolar compensation in restorative methods when it comes and available restorative space; restorations offer a viable medium-term to the management of TW. Traditional management strategy for TW, in view of the 3. The remaining available tooth methods revolved around full coverage tissue; fact that they are non-destructive of tooth cast restorations. Rochette’s introduction tissue when compared with conventional 4. Space requirements of the of a method for cementation of metal indirect restorations and treatment can proposed restorative materials; alloy castings to enamel without relying be repeated. Despite the huge variation in 5. The patient expectations primarily on macromechanical resistance clinical situations posed and the variety of and retention resulted in significant approaches used to rehabilitate dentitions, Aetiology and pattern of tooth wear advances within restorative dentistry.22 The which limits comparison among different The aetiology of tooth wear adhesive techniques proposed allowed studies, annual failure rates of composite and wear resistance of restored and natural for a more conservative approach to be resin restorations appear to be within an teeth should be considered. Although adopted, whereby individual cast-metal acceptable range. some aetiologies can be controlled, some veneers cemented to the palatal surfaces of may be beyond the control of the patient anterior maxillary teeth. Further advances or the clinician. It is essential to establish in the physical properties of resin-based Generalized tooth wear whether the restored dentition is likely to restorations have resulted in a further Traditional treatment methods be exposed to such causes of wear prior to development of management techniques for patients with severe generalized tooth making material choices. Behaviour under involving the sole use of composite resin- wear involved full mouth rehabilitation with normal and excessive loads will have an based restorations. cast indirect restorations, However, there influence on decision-making, especially The success and survival rates is a lack of well-designed clinical studies in parafunctional patients. Given the of the newer adhesive techniques have assessing performance and outcomes for complex nature of the oral environment, gradually improved with the evolution of this method.6,7 This, combined with high both mechanical and biological failures materials. Nohl et al, reported an overall cost and an invasive technique, rendered are possible. Biological failures have been success rate of 89% in a retrospective survey this approach less favourable when shown to be primary or secondary (often of 48 patients treated with 210 metal palatal compared to the newer more conservative following a mechanical failure), and are veneers for anterior palatal TW for periods treatment strategies. Despite rehabilitation more probable.21 Laboratory-based trials of up to 5 years.23 They recommended the of severely worn teeth being common have shown the wear resistance of gold and combination of metal palatal veneers with practice, there appear to be deficiencies ceramic materials to be similar, whereas resin composite luting agent restoring the in the evidence in support of specific resin-based materials have demonstrated functional surfaces of maxillary anterior techniques or materials.28 three to four times more material wear teeth affected by acid erosion (Figure 1). The limited data shows that than gold or ceramics. In cases of high Direct composite resin rehabilitation of TW with direct composite load conditions, traditionally, metal or restorations have been extensively studied resin can offer good clinical results, whilst metal-ceramic restorations have been and vary significantly in annual failure being less invasive than preparations for an recommended as the material of choice,6 rates from 0.7%24 to 26.3%.25 Variations in indirect approach. Direct hybrid composite however, under extreme conditions material properties have been suggested as restorations have been reported to perform there is no material that is likely to last. contributory factors to this wide variation. well, even in larger posterior restorations. A Nevertheless, survival of the restorative Microhybrid composite resins have been number of studies have suggested that 14 DentalUpdate July/August 2018  RestorativeDentistry a 1010 restorations in 164 patients, Milosevic results. Parafunctional activity can result and Burnside suggested that direct in devastating forces resulting in the hybrid composite resin restorations offer increased risk of mechanical failure at both a predictable option in the management the restoration and tooth level. Numerous of generalized TW, with relatively low clinical studies on the management of failure rates.31 The study highlighted the severe TW exclude high risk subjects such detrimental impact of attrition and the lack as bruxists.28 As such, interpretations of posterior support on survival outcomes. of these studies should be carried out Within the current literature, with caution. Research into the use of very few studies are available assessing composite resin in such cases have shown b the management of generalized TW, with mixed results. A few studies have shown even fewer comparing the use of direct and good outcomes supporting its use,31,34 indirect restorative techniques. however, these were over a relatively short Vailati assessed the observational period, whilst others have management of severely eroded dentitions shown poorer outcomes.25,35 It is clear that with a combination of indirect palatal further high-quality research is required to composite restorations and labial porcelain aide material choice in such cases. veneers.32 The study concentrated upon observations on the restored anterior teeth, whilst t