Introduction

With an ageing UK population, lifestyle and habit changes it is not uncommon to regularly encounter patients presenting with pathological tooth wear (TW) across the entire age spectrum.1

Due to the relatively slow pace and lack of symptoms with which this condition develops, patients will often not be aware of the presence of a wearing dentition. Consequently, they often present for treatment at an advanced stage, complaining of an impairment of aesthetics and/or function. For certain patients tooth sensitivity may become an issue, which may be indicative of an active and accelerated loss of mineralised tooth tissue. It is often challenging for the general dental practitioner to convey the diagnoses, whilst concomitantly emphasising the importance of disease management as well as the consequences of no care. Due to the loss of tooth substance (and therefore surface area) for restorative placement, treatment and management can prove to be difficult.

Aetiology, diagnosis and passive management

Tooth wear often has a multifactorial aetiology. Individual factors include erosion, abrasion, abfraction and attrition. It would appear erosion is a factor in the majority of patients with TW. A seven-fold increase in the rate of consumption of soft beverages in the UK between the 1950s and 1990s has been reported, with adolescents accounting for 65% of all purchases.2

The longer term, successful management of the patient will largely depend on the ability of the patient and the clinician to identify and prevent the causative factor(s) from inflicting further harm. A dietary analysis is often invaluable.

As part of preventative care for TW, habit changes should be encouraged. Topical fluoride application may also prove beneficial, as may sealant restorations to protect areas of exposed dentine. Where an underlying medical condition, such as a gastric reflux or bulimia, is suspected then referral to a medical colleague is required. Patients with xerostomia should also be managed appropriately.

To assess the efficacy of the preventative strategy, it is also important to monitor the condition of the worn surfaces.

The early recognition of localised TW is an important factor in its management and if tackled at this stage can be contributory towards preventing further generalised loss of tooth tissue. Figures 1 and 2 depict a 27-year-old female patient and a 14-year-old male patient respectively, with localised tooth wear.

Figure 1
figure 1

Shows a 27-year-old female patient in right lateral excursion with TW associated with the upper canine and premolar teeth

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Figure 2
figure 2

Shows a 14-year-old male patient in right lateral excursion with significant TW associated with the upper canine and lateral incisor

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The process of restoring canine guidance may be considered as a means of intercepting tooth wear. This form of restoration may be referred to as a 'canine riser or Stuart lift' which by altering the cuspal incline of the canine teeth will aim to provide a canine guided occlusion.3

In the presence of a 'canine-guided occlusal scheme', mandibular guidance during dynamic movements is provided by the canine teeth only, culminating in posterior teeth separation (disclusion). The anatomy and location of the canine teeth, commonly with a lengthy, bulbous root renders them suitable for this purpose.

In the cases of the patients shown in Figures 1 and 2, it can be extrapolated that without interceptive restorative management, this condition could continue to perpetuate into a more generalised problem.

Active restorative intervention

In all patients with TW a pragmatic approach should be taken towards instituting preventive measures, which should be regularly monitored and reinforced.

Whilst a significant proportion of pathological TW cases may be effectively managed using a passive-preventative approach for some patients, active restorative intervention will be indicated. Such cases may present with:4

  • Aesthetic concerns

  • Symptoms of pain and discomfort

  • Functional difficulties

  • The presence of an unstable occlusion

  • The rate of tooth surface loss may be of extreme concern to either the dental operator or patient, which if neglected may culminate in exposure of the dental pulp.

Five key aspects require consideration when restoring teeth affected by wear:

  • The pattern of tooth surface loss

  • Inter-occlusal space availability

  • Space requirements of the dental restorations being proposed

  • The quantity and quality of available dental hard tissue and enamel respectively

  • The aesthetic demands of the patient.5

It is vital that the clinician has a good working knowledge of the current concepts in occlusion, dental aesthetics and the available contemporary dental materials. It is of a significant advantage to plan the restoration of the worn dentition with techniques in which there is no requirement to remove further tooth tissue. Predetermination of the restorative end point from a functional and aesthetic perspective before commencing treatment has distinct benefits. Coupled with this, the patient's adaptive potential to the restored dentition should be carefully and meticulously evaluated. For the latter purposes, the use of resin composite applied directly offers a suitable option.6

It is generally accepted that resin composite restorations when applied to areas of high loading should be placed in the thickness range of 1.5–2.0 mm. Thus, in order to place this quantity of material, there is a need to provide the desired level of inter-occlusal clearance.

Where desired inter-occlusal clearance is not readily present an overall increase in the occlusal vertical dimension (OVD) may be considered. A further approach is to place the material in supra-occlusion, hence the concept of 'relative axial movement', perhaps more commonly referred to as the 'Dahl concept',7 which, provided careful case selection is applied, can provide a predictable minimally invasive alternative to the removal of further tooth structure to produce the required space for restorations.

During the restoration of a generalised worn dentition it may be prudent to consider the rehabilitation of the anterior and posterior teeth with a direct composite material. This material is reversible and is well suited to establish the aesthetic and functional prescription as well as to determine a patient's tolerance to the planned changes. There is evidence to support the successful medium term use of direct resin to restore the worn anterior dentition; in the posterior segment(s) bulk fracture and wear are more likely to be encountered, particularly if the material is not used in its required thickness and with consideration to the occlusal forces which may be applied. However, composite resin is a material, which can be predictably repaired and added to. Once the prescription is confirmed the replacement of the posterior composite material with suitable indirect restorations can be considered. A staged approach to the rehabilitation of the generalised worn dentition also has the advantage of being able to spread the cost of this complex treatment for the patient.

Figures 3 and 4 show a patient with generalised TW where the dentition has been restored with a combination of anterior direct composite resin and posterior indirect cast gold alloy restorations without the removal of any further tooth tissue from the worn teeth.

Figure 3
figure 3

Smile view of a female patient with generalised tooth wear

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Figure 4
figure 4

Smile view of the patient depicted in Figure 3 following rehabilitation of the worn dentition

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It is important to acknowledge that TW also has a physiological component and this has to be accounted for during the rehabilitation process and material selection. Monitoring and recall are necessary and the provision of a well-fabricated hard occlusal stabilisation splint to protect the restorations and minimise further wear is desirable.

The presentation at the Conference will aim to focus on the clinical management of this commonly encountered condition in general dental practice.

Subir Banerji qualified with a Bachelor of Dental Surgery from The University of Newcastle Upon Tyne Dental School, UK. He gained his Masters in Clinical Dentistry (Fixed and Removable Prosthodontics) from the University of London. In addition to his private practice, he is the Programme Director for the MSc in Aesthetic Dentistry at King's College London Dental Institute. He lectures nationally and internationally and has several publications to his credit in peer reviewed International journals and books. He has conducted several postgraduate and master's level courses in prosthodontics, aesthetics, implants, tooth wear and occlusion and is an examiner for both undergraduate and postgraduate programmes. Along with Dr Shamir Mehta and others he authored the popular BDJ four-part series on Current concepts on the management of tooth wear and a BDJ series on the cracked tooth syndrome.

Shamir Mehta qualified with a Bachelor of Dental Surgery from King's College London. He gained his Masters in Clinical Dentistry (Fixed and Removable Prosthodontics) from the University of London. He is a senior clinical teacher and the Deputy Programme Director for the MSc in Aesthetic Dentistry at King's College London Dental Institute (KCLDI). He is also a partner in two practices in North-West London. He is an examiner for both undergraduate and postgraduate programmes at the KCLDI. Along with Dr Subir Banerji and other co-authors, he has published several peer-reviewed articles and learning resources, including the popular BDJ four-part series on Current concepts on the management of tooth wear and a BDJ series on the cracked tooth syndrome.

Subir Banerji will present a session on the subject of Clinical management of pathological tooth wear in general dental practice on Friday 27 May at the British Dental Conference & Exhibition 2016.

Venue: Manchester Central Convention Complex

Dates: 26-28 May 2016 www.bda.org/conference

For registration enquiries

Email bda@delegate.com or call 0844 3819 769 (overseas:+44 1252 771 425)