Pathological abrasion of hard tooth tissues. Etiology, pathogenesis, clinic forms diagnostics. Orthopedic treatments pathological abrasion. Complications pathological abrasion of hard tooth tissues.

Tooth abrasion can be defined as the permanent loss of tooth structure that can occur on various tooth surfaces including the cutting surface outer enamel layer and even exposed root surfaces.

Tooth abrasion is not caused by one method alone but by numerous different activities. The main cause however can be due to brushing your teeth incorrectly. Brushing your teeth to hard to fast or even using the wrong toothpaste can lead to serious tooth abrasion. Other causes of tooth abrasion include grinding your teeth using your teeth as a cutting tool and chewing on hard objects.

Tooth abrasion can affect all types of people although the risk of tooth abrasion is higher amongst people who suffer with gum disease. Gum disease causes the teeth to pull away from the gum exposing the root of the tooth. This leaves the root area beneath the teeth exposed to water and other agents that the tooth enamel normally protects it against.

Definitions sometimes assume that all dental abrasion is pathological. For example, Imfeld defined abrasion as ‘the pathological wearing away of dental hard tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth’. However, it has been suggested that many dental health problems are caused or exacerbated by almost the complete lack of abrasive wear from the diet in modern Western populations and it is accepted that even normal tooth-cleaning practices produce some abrasion of dentine over a lifetime.

Given that tooth-cleaning habits are highly beneficial at the same time as being the most common cause of abrasion, it would seem reasonable to remove the words pathological and abnormal from the above definition. This is not to deny that abusive use of toothbrushes and toothpaste can produce pathological levels of abrasion, as parafunction can with attrition. In Western populations, the major abrasive agent is toothpaste, which affects dentine much more than enamel. The evidence identifying toothbrushing with toothpaste as the main agent in dentine abrasion is drawn from clinical data and studies in vitro. In toothbrushing abrasion, the toothbrush itself is merely the delivery vehicle, since brushing without paste has no effect on enamel and clinically minuscule effects on dentine. Nevertheless, features of the toothbrush, notably filament arrangement, density and texture, can modulate the abrasivity of toothpaste . Toothbrushing wear is time-dependent and appears to be influenced by many factors, including the frequency, duration and force of brushing . The sites of predilection for dentine wear seem to be correlated with toothbrushing habits; the sides, teeth and sites at most risk are those known to receive most attention during brushing. The major factor in dentine wear appears to be the relative dentine abrasivity (RDA) of the toothpaste, which is its abrasivity relative to a standard paste, which has an RDA set at 100, determined using an International Standards Organisation (ISO) laboratory test. ISO stipulates that the RDA of toothpastes should not exceed 250 but most toothpastes in developed countries have RDA _100. Difficulties arise in extrapolating RDA to clinical outcome. Only dentifrices with high relative enamel abrasivities (REA) cause appreciable rates of enamel wear, usually because they use non-hydrated alumina, which is harder than enamel. Dentifrices with relative enamel abrasivities _10 produce very little wear of enamel in vitro or in situ. It has been concluded that normal toothbrushing habits with toothpastes that conform with the ISO standard will, in a lifetime’s use, cause virtually no wear of enamel and clinically insignificant abrasion of dentine (a figure of 1 mm in around 100 years is often cited.

Abrasion, derived from the Latin verb abradere, nhrasi, ahrasum (to scrape off,), describes the wearing away of a substance or structure through mechanical processes, such as grinding, rubbing or scraping. The clinical term dental abrasion or abrasio dentium is used to describe the pathological wearing away of dental hard tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth. Depending on the etiology, the pattern of wear can be diffuse or localized. Based on the clinical observation of the frequent coincidence of smooth-surface and/or cervical abrasion and extensive oral hygiene, the latter has been incriminated to be a main etiological factor in dental abrasion . Both patient factors and material factors have been found to influence the prevalence of abrasion. Patient factors include brushing technique, frequency of brushing, time spent on brushing, force applied during brushing, where on the dental arch brushing is started, etc. Material factors refer to type of material, stiffness and end-rounding of toothbrush bristles, tufted sign of the brush, flexibility and length of the toothbrush grip, as well as abrasiveness, pH and amount of dentifrice used. Abrasion on proximal tooth surfaces may be caused by extensive use of interdental cleaning devices such as tooth picks or interdental brushes, especially when they are inserted along with toothpaste or toothpowder. Occupational abrasion, i.e. excessive tooth wear due to any professional cause such as abrasive dust at the work place, holding nails between the teeth biting thread, etc. are only rarely seen today.

CLASSIFICATION pathological abrasion of teeth

Classification of pathological abrasion of teeth. This classification includes various clinical aspects of functional and morphological character stage of development, depth, length, area damage and functional impairment.

Depending on the stage of development are distinguished:

1) physiological abrasion - within the enamel;

2) a transitional stage of development - within the enamel, partially dentin:

3) pathological stage of development - within the dentin (with reduced occlusal height and without reduction).

Depending on the severity and depth:

First degree- to the 1/3 height of the crown;

Second degree - from 1/3 to 2/3 the height of the crown:

Third degree -from 2/3 the height of the crown to the gums.

Depending on the duration of lesions:

1) limited pathological abrasion;

2)general pathological abrasion.

Depending on changes in dentin sensitivity:

1) in the normal range;

2) with hyperesthesia.

Interaction of Dental Abrasion with Erosion

Exposure of enamel to acid renders it more vulnerable to abrasion. Rats drinking an acidic drink instead of water showed occlusal and lingual wear of the molars, whether they were consuming soft or hard food . In vitro, softened enamel is more susceptible to abrasion, not only by toothbrush and paste , but even by such mild challenges as toothbrushing without paste or friction from the tongue . Thus, whereas enamel is scarcely abraded by normal toothbrushing, it becomes vulnerable to toothbrush abrasion after erosive challenge. There is a gradient of mineral loss in softened enamel and the outer extremities of the crystals are thinned and would be extremely vulnerable to mechanical forces. A physical challenge probably removes only the outer, more demineralised part of the softened enamel to leave the inner, less demineralised part . It can be conjectured that abraded softened enamel surfaces would be more susceptible to fresh acid challenges, but this has yet to be tested experimentally. It was found that brushing simultaneously with exposure to citric acid enhanced wear by about 50% compared with brushing after acid exposure . The increase is probably due to a primarily increased rate of mineral dissolution because of increased fluid movement , which will result in more rapid creation and breakage of thinned crystal extremities. Several studies have shown that acid-softened dentine is also vulnerable to toothbrush abrasion.

Occlusal Wear

Several studies have found that occlusal wear may be related to a variety of factors, including occlusal variations, dusty environments, salivary variables and intake of acidic foods and drinks. These observations suggest that erosion, abrasion or both probably contribute to occlusal wear. From detailed observation of tooth surfaces it was concluded that erosion was a major factor in heavy occlusal wear in one Australian sample, except in anterior teeth of positively-identified bruxers .The limited in vitro data suggest that erosive softening of dental tissues is likely to increase abrasive wear but not attritional wear. This is consistent with the finding that the total amount of wear on molars of rats drinking an erosive liquid did not depend on the hardness of the food. Persons subsisting on a raw-food diet, which was both fibrous and with a high acid content, developed marked occlusal wear, with cupping of the exposed dentine . The similarity of the pattern of wear to that in a mediaeval population with an abrasive diet suggested that an erosive diet softens the occlusal surfaces and makes them vulnerable to wear even by weakly abrasive materials, such as raw vegetables, which would not affect sound dentine. An index for assessing clinical wear and for predicting the future rate of wear would be useful. Information on tooth wear in relation to age exists for various populations, mostly historical . Richards et al. used such data to develop a mathematical model of the normal progression of wear with age. While this approach has great potential, its successful application in a particular population requires that the wear data on which it is based are derived from the same population or one very like it.

Cervical Wear

The most common sites for abnormal tooth wear are the buccal cervical regions and there has been considerable interest in the aetiology of this wear process, thoroughly reviewed by Levitch et al. . Obviously, a direct role for attrition in creation of these lesions can be ruled out. Recognition of the synergy between erosion and mechanical wear has led most researchers to consider these to be erosion/abrasion lesions rather than the often-described cervicalAddy/Shellis 26 abrasion lesions. Erosion must be a factor in any lesion involving enamel since, as discussed above, most modern dentifrices produce very little wear of enamel. The abfraction hypothesis has drawn attention to the possibility that unusual occlusal loads, resulting from tooth misalignment or heavy muscular force, may be associated with non-carious cervical lesions, but the evidence for this is not conclusive. Studies which considered cervical lesion characteristics in relation to occlusal wear or malocclusion suggest that the proportion of lesions possibly due to abfraction was 15–38%. Khan et al. found saucer-shaped lesions to be associated strongly with occlusal erosion, while wedge-shaped lesions were associated equally with occlusal erosion and attrition.

Cervical lesions of all kinds were much more prevalent in persons eating an erosive rawfood diet than in controls, but were absent in a sample of mediaeval dentitions with heavy occlusal wear . However, the latter could be due to reduced eccentric loading or other causes . In a case-control study , only variables considered to be related to abrasion were significant risk factors for cervical lesions in a subject-level model, while variables related to tooth flexure and erosion were also significant risk factors in a tooth-level model. In summary, the evidence suggests that non-carious cervical lesions have a multifactorial aetiology, with combined erosion and abrasion probably playing the dominant role.

Saliva and Tooth Wear

The importance of saliva as a lubricant has been alluded to above. Saliva is also the source of the acquired pellicle, which reduces the amount of mineral loss in short-term erosion. However, during acid exposure, the pellicle is removed except for the dense basal layer and its protective effect is lost.

Thus, to determine whether pellicle protects against repeated erosive and abrasive challenges it is important to determine how quickly the protective effect is re-established. In vitro tests indicate that a significant protective effect is achieved after exposure to saliva for 2 min for dentine and 1 h for enamel. The pellicle seems to show some resistance to brushing, since the basal pellicle layer survives 10 s brushing with saliva alone . Brushing with hydrated alumina or saliva/silica slurry was reported to leave a thin pellicle layer on enamel and Hannig suggested that this layer could modify wear. However, brushing with these abrasives would cause no significant wear of sound enamel and this hypothesis needs to be tested using softened enamel. Moreover, the finding that brushing removes the outer pellicle substantiates the suggestion that brushing immediately before eating or drinking might reduce the protective effect of the pellicle against erosion. Softened enamel exposed to a remineralising solution or to saliva for an adequate time can regain mineral and thus re-acquire mechanical strength.

In vivo saliva could thus reduce the vulnerability of softened dentalhard tissues to mechanical wear. In vitro, resistance to toothbrush abrasion or to ultrasonication was restored after exposure to artificial saliva for 4and 6 h, respectively. In vivo results over times that would be useful in terms of reducing abrasion of softened enamel have been less encouraging. In one in situ experiment, only partial resistance to brushing abrasion was acquired after 60 min exposure to saliva while in another the decrease in abrasion after the same time was not significant The discrepancy between the in vitro and in situ results might be due to the presence in saliva of proteins (e.g. statherins) known to inhibit hydroxyapatite crystal growth, and their absence from the artificial salivas used in in vitro experiments. As regards dentine, exposure to saliva seems to be ineffective in restoring abrasion resistance within a useful time. In vitro exposure to artificial saliva for up to 2 h or for 24 h produced no improvement in resistance to subsequent mechanical challenge. One in situ study showed no effect on abrasion resistance after exposure to saliva for 1 h . In another there was a numerical decrease in abrasion resistance after 30 and 60 min remineralisation but in neither case was the tissue loss significantly different from that in specimens brushed immediately after erosion. While artificial caries lesions of dentine can be remineralised in vitro , it is not complete even after 20 weeks, and remineralisation of such lesions seems to take place by re-growth of residual mineral crystals. In erosive dentine lesions, the superficial layer seems to be completely demineralised and Clarkson et al. showed that dentine demineralised by organic acids does not remineralise because it retains phosphoproteins which may act as inhibitors.

Longevity of Restorative Materials and Acidic Conditions

The longevity of dental restorations depends on the durability of the material per se and its wear resistance , the durability of the interface between tooth substance and restoration, the level of tooth destruction, its location and load.

In a study, three glass-ionomer restorative materials used for cervical erosion/abrasion lesions were evaluated clinically after 10 years. The authors concluded that when a noninvasive approach is desired, glass-ionomer materials are the restorative material of choice for this kind of lesion because of their longterm retention values . It has to be kept in mind that at the time of this study total-etch dentinal adhesive systems were still improving and hardly any system showed, clinically, restoration margins free of microleakage for an extended time Gaengler et al. evaluated the longevity of posterior glass-ionomer

cement/composite restorations after an examination period of 10 years. They found that the early risk of failure was attributed to bulk fractures and partial loss of filling material. The maximum longevity was a maximum of 74% over 10 years. It was concluded that this form of posterior restoration was clinically appropriate because a high percentage of restorations had correct anatomical form and demonstrated a low secondary caries rate. Future treatment regimes have been made possible by the development of sophisticated preparation techniques, improved adhesive systems and restorative materials that will result in the therapy of more small-sized lesions rather than large restorations. Indirect inlay techniques will shift towards direct restorative techniques. As the cavities become smaller, it is to be expected that the use of improved direct restorative materials will provide excellent longevity even in load-bearing situation.

In patients with severe tooth surface loss on more than two surfaces per tooth and extended loss of vertical dimension, a complex reconstruction with indirect restorations (ceramic crowns, bridges) is often inevitable. This measure should be restricted to very advanced erosion cases .As in other patients with erosive tooth wear adequate preventive measures and recall intervals must be executed.

Dental occlusion is the manner in which the top and bottom teeth come into contact with one another, whether at rest or while chewing. That is, whether you're resting or chewing, dental occlusion has to do with how your teeth touch and whether or not they are in a healthy alignment with one another.

Static Occlusion

Static occlusion refers to the relationship between the bottom and top teeth when the jaw is still and stationary. Static occlusion is observed and measured when the mouth is at rest.

Centric Occlusion

Centric occlusion is the way the teeth fit together when the jaw is closed; it's the way the teeth align during normal and comfortable biting. Centric occlusion in which all the teeth are correctly aligned is desired, with no overbite, cross-bite or underbite.

Malocclussion

Malocclusion is characterized by teeth that are misaligned and do not fit together properly. This can result in an over bite, underbite or an incorrect bite, which can cause numerous health problems that extend beyond the dental realm.

Malocclusion-Related Problems

Malocclusion can cause problems involving the teeth and gums. Fillings and crowns can break or wear out quicker than normal, or teeth are generally sore and gums recede. Temporomandibular joint or TMJ problems can also result, causing clicking, grinding and pain in the jaw joint. Some people experience buzzing in the ear. When undue strain is placed on the jaw muscles, people with malocclusion can experience fatigue in their muscles. This can translate into headaches, sinus problems, neck and shoulder pain and muscle spasms.

Occlusal Trauma

When poor dental occlusion or malocclusion is experienced, occlusal trauma can result. This trauma is made apparent in several ways including pain, the movement of teeth including crowding, the feeling that the teeth are always mobile and the wearing down of the facets of the teeth on inappropriate areas.

HARD TISSUE OF TEETH

We know that throughout life there is abrasion of enamel and dentin. Under normal conditions, this process is physiological in nature and begins immediately upon the teeth in contact with each other physiological abrasion of hard tooth tissue occurs in two planes - horizontal and vertical. Clearing in the horizontal plane is observed on the cutting edge of incisors and canines as well tubercles molars and premolars. This reduction bite can be explained as adaptive reaction. In the case of vertical abrasion abrasion of hard tissue occurs on the contact surfaces, which eventually leads to the formation of contact points to the pads. Physiological wear off expressed in different people in different ways. Some patients younger than 50 years of clinical wearing off identify difficult-pathological abrasion of hard tooth tissues characterized by rapid and progressive decrease in size of natural teeth. This process, once begun, practically stops. and constantly progressing.

Pathological wearing off teeth observed in the case of bruxism . Bruxism - the unconscious (often nightly) compression or conventional automatic movements lower jaw, accompanied by grinding teeth. Bruxism refers to parafunction of the group distorted features. With one of the reasons for the emergence and development of a generalized pathological abrasion of teeth. Treatment developed enough. Patients require a comprehensive examination of the dentist, a neurologist and psychiatrist. With the use of orthopedic occlusive caps for the entire dental series of hard or soft plastic base plate .

One of the causes of abnormal abrasion of teeth is their acid necrosis. It is observed in the chemical industry workers who have contact with hydrochloric, nitric and other acids. If spilled acid on the teeth with the flow of air as vapor and subsequent dissolution in saliva is decalcification of enamel especially front teeth. Immediate action devastating acid on the tooth appears primarily on organic substances.

In the case of vertical abrasion abrasion of hard tooth tissues occurs at the contact surfaces that eventually leads to the formation of contact points to the pads. Physiological stertist expressed in different people in different ways. Some patients younger than 50 years of clinical stertist difficult to determine.

Pathological abrasion of hard tooth tissues characterized by rapid and progressive decrease in size of natural teeth. This process, once started, almost stops, and continually progresses.

Pathological wearing off teeth has polyetiological form of the disease. The occurrence of this disease involves both endogenous and exogenous factors. Not exclude the role of disturbances of mineral metabolism, which is basically concomitant somatic disease. Of great importance are also factors such as the effect of chemical agents, particularly extended time. Pathological abrasion fo tooth develops from mechanical overload, which is usually the result of loss of teeth.

Another clinical picture observed by a generalized form of pathological abrasion of teeth. Patients with this form of abrasion are divided into two groups. The first group includes patients with generalized abrasion whoch covers all teeth, but reduce the height of the lower third of the face is not happening due to a compensatory increase in alveolar ridge and collar pieces that are massive and increasing in volume. Do not change position of the head and lower jaw in articular hollow.

The second group includes patients with generalized form of pathological abrasion which is not compensated by the growth and increase in the amount of alveolar bone and, as a result there is a marked reduction of the lower third of the face. Reducing the distal face is characterized by shortening of the upper lip, nasolabial folds and under chin pronounced, corners of his mouth dropped, his face in such patients become senile specific look.

Due to the fact that this pathology is changing the position of the mandible relative to the top and head position of the mandible to the articular hollow, they are shifted backwards and down. This placement heads mandible leads to redistribution and functional overload joint, which may be the cause of deforming arthritis and related pathological symptoms (tinnitus, hearing loss, nasal tinnitus, dry mouth, etc.).

Due to the decrease in the height of the lower third of the face and reduces the distance between the points of attachment of the masticatory muscles, which negatively affects their work and eventually leads to a decrease in chewing efficiency.

Pathological abrasion teeth often combined with partial loss of teeth, secondary deformities, distal displacement of the mandible, manifested complex clinical picture.

Orthopedic treatment in case of pathological abrasion of hard tissue teeth

Before drawing up a plan of orthopedic treatment of the patient with abnormal abrasion of teeth should be examined in detail. In a study to determine the most likely causative factor in abnormal abrasion, shape and degree of (localized, generalized, compensated, decompensated), clinical and radiological status crowns and periodontal tissues of the teeth, pulp condition they may change the appearance of the patient, the condition of temporomandibular joint.

In the process of collecting medical history to find out whether there was a similar disease in close relatives. Older people interpret, whether this disease in their children. Particular attention should be paid to the interpretation of conditions.

Clinical and radiological examination of oral tissues facilitates treatment plan and the optimal method.

Preparing patients for orthopedic treatment must include rehabilitation of the mouth. Tooth extraction is carried out after a thorough examination of bone and periodontal tissues of the inclusion complex survey electro excitability of pulp, which in this disease is usually reduced. Removing teeth be amended near the apex tissues, impassable canals, teeth that have no functional value, which can not produce stump tab.

During the compilation of the previous treatment plan should be carried out differential diagnosis occlusal disturbances caused by tooth-collar extending from strains with different pathogenesis. In case of loss of chewing teeth front group performs a mixed function, which leads to a shortening of their clinical crowns due to abrasion of enamel and dentin.

Orthopaedic treatment in the event of abnormal abrasion of teeth has both therapeutic and prophylactic purpose. At first realize improved chewing function and appearance of the patient, in the second - to prevent abrasion of hard tooth tissue and disease prevention TMJ. Specific tasks in the orthopedic treatment of a particular patient depends on clinical features.

Before drawing up a plan of orthopedic treatment of the patient with abnormal abrasion teeth necessary to analyze the clinical situation to determine how to restore intercoronal height, taking into account data study of height in the lower third of the face of a state of physiological rest and the central value of the jaws.

You must pay attention to the X-ray data TMJ.

In the case of localized and generalized forms of abrasion without changing the height of the lower third of the face can be used such methods are the most common orthopedic care. If abnormal abrasion caused changes in the aesthetic sense, then you need to plan measures include orthopedic prosthesis hard tooth tissue cores inset piece and structures with facing modern materials depending on the prosthesis.

In severe cases, when the process started, except to prevent further progression of the patient return appearance by restoring anatomical shape of crowns. In this case it is necessary to increase coronal height in the anterior or throughout the dentition. In the first clinical case to the front group of teeth made removable plate or metal caps, parting bite in lateral parts, which leads to regression of alveolar bone and parts in the front. This approach is effective in younger patients, in elderly restructuring collar bone and part of it may not happen, then you need to increase the height coronal if it can make a fortune TMJ. Increasing coronal height necessary to carry out the restructuring miostatic reflexes in several stages. In the extreme case, when all the applied methods are ineffective, it is necessary to remove the front of the teeth if they are cult at gingival margin.

If abnormal abrasion, accompanied by a decrease in the lower third of the face, the task is much more complicated prosthesis. In this case, it is necessary not only to improve the function of mastication, but also to prevent further tooth wear. At the same time we have to increase the height coronal that will change the appearance of the patient and to normalize the position of the head of the mandible in the articular fossa.

Increasing coronal height achieved restoration of form and height erased crowns of natural teeth, which requires use piece design, since all the others on this disease are ineffective and short-lived.

Partial loss of teeth can occur against the backdrop of an existing pathological abrasion of teeth. On the other hand, the loss of molars and premolars can cause abnormal wear of the front group of teeth from a mixed function that they have to perform. The clinical picture in this case is complicated, because the abnormal abrasion attached clinic partial loss of teeth. The tasks that need to be addressed during the prosthesis when abnormal abrasion of teeth, added more problems and partial replacement of defects of teeth. Orthopedic design dentures, which are used to solve the latter problem, conditioned by the particular clinical picture. If included defects without reducing distal face can be used fixed-piece prostheses. If reduction of distal face prosthetics provides restoration of dentition defects and mandatory in coronal height in all surviving teeth. This can be achieved fully if used piece prosthetic appliances.

In the presence of end defects as unilateral and bilateral, shows the use of different designs of removable dentures.

Tooth abrasion can occur gradually over a period of time or very quickly. Gradual tooth abrasion allows the body to reduce the severity of tooth abrasion as the body has sufficient time to repair itself. The body does this by allowing a new layer of dentin (the layer immediately under the outer tooth enamel layer) to be deposited over the damaged areas of the tooth. This new layer of dentin prevents the nerves blood vessels and connective tissue inside the tooth known as the pulp from being damaged further and therefore enables the tooth to heal.

Quick tooth abrasion on the other hand can cause irreversible damage to the pulp and lead to the consequences of tooth abrasion which not only include crocked teeth but also increased tooth sensitivity infection and ultimately loss of the tooth.

CLASSIFICATION:

class 0 - no abrasion,

class 1 - abrasion of enamel,

class 2 - abrasion with revealed dentine,

class 3 - abrasion of dental occlusion,

class 4 - abrasion of a tooth’s crown to the point of

revealed tooth’s neck,

class 5 - abrasion with the tooth’s chamber opened.

One of the most common types of damage that occurs in the mouth is called Toothbrush Abrasion. I see it in about 8 out of 10 people. Toothbrush abrasion is an innocuous problem stemming from a bad habit that can lead to receded gums, sensitive teeth, holes cut into teeth, strange esthetics and tooth loss.

Introduction

For starters, take your toothbrush and move it back and forth along your skin. If you rub it like this enough times in the same area and with enough pressure, you will cause your skin to turn red and it may hurt. If you kept up this pace, your brush may eventually cause damage to your skin, cause a little bleeding, and hurt a lot. Now, please don’t try this for real, but you get the idea.

Fortunately, brushing the skin is not something most of us do, even though the outer skin is a tough layer of protection and will stand up pretty well against a toothbrush.

However, brushing the teeth is a daily exercise that all of us must do. When you take your toothbrush and carry it to the mouth, it is going to meet two things: something very hard (your teeth) and other things very soft (your gums, your tongue, etc.).

The enamel of teeth is the hardest substance in the human body, almost like rock, and very hard to break or otherwise do damage to. Enamel in adult teeth has years to form, which partly explains where this strength comes from. Enamel makes up the outermost layer of teeth when you look in the mirror.

Teeth are encircled by a fragile, thin, easy to damage layer of skin called the gums. Their most fragile spot than at that junction where the teeth meet the pink of the gums (called the gumline). It is at this point that toothbrush abrasion comes into the picture, because this is precisely the area in your mouth that is most vulnerable to damage from brushing one’s teeth too hard, leading to what is called toothbrush abrasion.

The Cause of Toothbrush Abrasion

We all brush our teeth every day. The goal of brushing is to remove food particles from around the teeth to render them clean and our breath feeling fresh. Food usually collects in the form of “plaque”, which is that whitish material that likes to hang around the gumline. So when you take your toothbrush, you are carrying it around the teeth, but often also against the gumline and maybe a little bit higher onto the gums themselves. So you brush and you brush and you brush and you’re done, great.

However, if you put too much force on the toothbrush as you go around, your gums don’t like it (remember the skin example). Keeping in mind that the gums are very fragile and weak, they really can’t stand up to this excessive force for too long. What happens over time is that the gums will actually recede- (in protest?) and you will have given yourself a receded gumline.

Gum Recession from Toothbrush Abrasion

Gum recession caused by toothbrushing is not the same thing gum disease, which is caused by bacteria and infection. This recession is caused by you. You have brushed too hard, too frequently, with too much force, too much on the gums, for too long, and now it is too late, your gum has disappeared. Maybe you pushed too hard because you were stressed or not paying attention. No matter what the reason, once the gum is gone, it is gone and it “‘aint ever gonna grow back”. You have receded gums and- you’re (gasp!) only 25, or 30 or 35 or whatever and you thought all your life that gum recession was only a problem for “old people”. As you can see, if the cause of the recession is toothbrushing, it can occur at any age, young and old.

Introduction

Fortunately, brushing the skin is not something most of us do, even though the outer skin is a tough layer of protection and will stand up pretty well against a toothbrush.

The Cause of Toothbrush Abrasion

Gum Recession from Toothbrush Abrasion

Sensitivity in The Teeth

If a recession of the gumline has occurred, most people will first take notice of a sensitivity when something cold or sweet touches the side of the affected tooth while eating, drinking or breathing air. Sometimes also a pain occurs during toothbrushing as the bristles move across the side of the tooth. Why is this related?

As the gumline recedes due to excessive toothbrushing forces, it begins to expose a part of the tooth which is normally kept covered up by the gums. This part of the tooth is called the dentin, which is where the nerve endings are. As a result of the dentin being exposed, the nerve endings contained within also become exposed and the result is the sensitivity to cold, sweet or touching of the area.

The dentin is a layer underneath the enamel, but as you go down into the root of the tooth, the enamel slowly gets thinner and thinner until it stops about 1/3 of the way down. This is where the underlying dentin starts to show through and takes it the rest of the way down the root to the tip of the tooth. Where the enamel has stopped and the dentin takes over is called the dentin-enamel junction, which usually happens to be just below the gumline. If the gumline has receded, however, this junction becomes exposed and the dentin sensitivity becomes apparent.

If the gumline recession is minor, de-sensitizing materials can be placed over the exposed dentin to seal the nerve endings and make the patient comfortable. One popular material is potassium nitrate, contained in “sensitivity” toothpastes. Upon using a toothpaste containing it, it blocks the nerve endings, but it takes two weeks for enough to build up to give a noticeable result. Indeed if the person stops using the product, the material goes away and they are sensitive again. The other downside is that the toothpaste itself may not be what is needed in the rest of the mouth (maybe the person needs a tartar control toothpaste, or an anti-gingivitis formula), so it means a lot of toothpaste in the house. Finally, the overzealous person will attempt to brush the sensitivity toothpaste into the tooth vigorously, causing further gumline recession and worsening the problem.

A better solution is a desensitizing solution that is applied in the dental office directly to exposed sensitive dentin areas only. The chemical is then sealed into place, completely blocking the nerve endings. It is invisible, works instantly, offers long-lasting protection and is cheaper than buying tube after tube of special toothpaste.

Holes cut into teeth

As the gumline recedes and the dentin is exposed, not only does sensitivity become a problem, but the dentin itself can be literally cut away by the toothbrush if a bad forceful brushing technique is continued to be used.

The dentin is softer compared to enamel. While toothbrushing cannot easily cause harm to enamel, the dentin however, is quite easily damaged. Once a receded gumline has exposed enough dentin, the toothbrush can easily start to cut a hole into the tooth at this point. After a months of abuse, the hole will have grown to resemble a notch.

A smaller notch, if caught early, may not need any treatment other than desensitizer to keep the patient comfortable from the exposed dentin. However, a deeper notch will always require treatment to fill in the notch.

If the notch is left exposed, food and bacteria become trapped in hidden corners and this will lead to tooth decay (a cavity). Decay that occurs in the dentin notch will quickly eat away and destroy the tooth, resulting in pain and more complicated treatment like a root canal becoming necessary.

To treat a deeper notch, the treatment consists of a filling, usually of tooth-colored filling material applied directly to the notch to fill it in. This not only gives the tooth its correct contour back, but it covers up all exposed dentin, shutting off any sensitivity. This is a very common treatment.

Tooth Loss

A deeper notch, sometimes cutting as much as halfway into the tooth like a lumberjack saws a tree before it is about to be felled, will eventually weaken the tooth so much that just like the tree, the tooth will break, cracking out of the mouth when the person bites hard.

Yet even continued brushing too hard, with continuing recession of the gumline without necessarily any notching, will cause more and more of the tooth to be exposed. As the gum shrinks towards the tip of the root, the tooth loses support from the gums. Eventually the tooth may get loose and fall out due to simply not having enough gum around it to hold it up.

Esthetics due to Toothbrush Abrasion

Patients often ask why there is a yellow part of the tooth at the gumline. That is the dentin, it is always yellow. If the patient has brushed too hard and gumline has receded due to toothbrush abrasion, more of the dentin will be exposed, causing a “yellow teeth” esthetic problem. Sometimes tooth-colored filling material can be placed as a “patch” to cover up the yellow areas.

Treatment for Toothbrush abrasion

First and foremost is to stop the bad brushing habit. Keep brushing, but do so with a soft toothbrush, a light touch and with an up and down motion against the teeth to minimize destruction. It doesn’t matter if the toothbrush is manual or electric, both types can cause the same problem.

Since the gum doesn’t grow back, as long as the patient is comfortable, without sensitivity or deep notches, it can be left like that.

Some patients with high esthetic requirements opt to have plastic surgery on the gums to reposition the gums back into place or to cut out gum from another part of the mouth in order to cover up the teeth where the gumline has receded.

Information contained is generalized. Sensitivity of any kind may be an indicator of more a serious dental and/or overall health condition. This advice is not intended to be self-diagnostic nor may it be relevant to your particular condition and cannot be used to replace a dental examination.

Treatment of dental erosion depends on the severity of the damage. If the loss of tooth enamel is moderate without affecting the patient’s appearance, there is no need of restorative treatment. The dentist may recommend certain fluoride treatments and de-sensitizing toothpastes to control the tooth sensitivity symptoms caused by teeth erosion. Enhancing the re-mineralization process by providing minerals such as fluoride may be enough for natural tooth enamel restoration. The dentist may also apply a fluoride varnish on the affected teeth for further protection and repair of tooth enamel.

Restorative cosmetic treatments become necessary if the tooth enamel damage is extensive. Depending on the degree of tooth wear, restorative treatment can range from placement of bonded composites (tooth bonding) in a few isolated areas of teeth erosion, to crowns, dental porcelain veneers, bridges or even full mouth reconstruction in the case of severe tooth enamel damage. A cosmetic dentist has to evaluate the situation and recommend the best cosmetic treatment to restore teeth function and appearance.

Treatment of beginning form of pathological abrasion without TMJ disorders:

Production of metal inlays, or cast metal crowns on the molars & premolars and their antagonists on both sides.

Treatment of gyperesthesia ( desensitizing substances, pastes with fluoride, electrophoresis of 10% solution of CaCl, calcium gluconate)

Forms of pathological abrasion of the teeth:

Vertical

Horizontal

Mixed

0123

Types of pathological abrasion of the teeth:

Local

0117

Generalized

І group – patients with the whole teeth row abrasion, but without decreasing of the lower third of the face. It is compensated with alveolar bone growing.

ІІ group – decompensated form.

0121

Sensitivity in The Teeth

Holes cut into teeth

Tooth Loss

Esthetics due to Toothbrush Abrasion

Treatment for Toothbrush abrasion

Since the gum doesn’t grow back, as long as the patient is comfortable, without sensitivity or deep notches, it can be left like that.

Dental Erosion: A challenge for the 21st century! This monograph offers a guide towards better oral health in the future. Erosive tooth wear is a multifactorial condition of growing concern to the clinician and the subject of extensive research – a view supported by the literature and impressions from many international conferences over recent decades. However, until now, no attempt has been made to collect and organize the available information in a single book. This volume of onographs in Oral Science is the first book dealing solely with erosive tooth wear. The thirteen chapters of the book present a broad spectrum of views on dental erosion, from the molecular level to behavioral aspects and trends in society.

The multifactorial etiological pattern of erosive tooth wear is emphasized and is a strand connecting the different chapters of the book. It starts with the definition of erosion and describes the interaction of attrition, abrasion and erosion in tooth wear. The chapters on diagnosis of erosion, and prevalence, incidence and distribution of the condition are followed by a chapter on the chemistry of erosion. Under the heading extrinsic causes of erosion, several factors are analyzed and illustrated, amongst which are the consequences of our changing life styles and the effects of oral hygiene products and acidic medicines. The chapter on intrinsic causes of erosion focuses on gastroesophageal reflux disease and related issues. A separate chapter is devoted to dental erosion in children. Methods of assessment of dental erosion are presented and critically evaluated, concluding that the complex nature of erosive mineral loss and dissolution might not readily be encompassed by a single technique: a more comprehensive approach combining several different methods is recommended. The last three chapters cover dentinal hypersensitivity, risk assessment and preventive measures, and, finally, restorative options for erosive lesions.

Each chapter has a comprehensive list of references, encouraging the reader to consult the original articles for more details. Instructive intraoral photographs illustrate the text and guide the reader. An unusual step is that every chapter was reviewed not only by the editor, but also by two external reviewers, ensuring the highest of standards. This monograph describes current concepts of dental erosion and presents an overview of the literature, with special reference to clinically relevant implications. It is not only suitable for faculty members and researchers, but may also be recommended for dental students, practitioners and other dental professionals who are committed to preventing and treating dental erosion.

Erosive Tooth Wear – A Multifactorial Condition of Growing Concern and Increasing Knowledge

Abstract

Dental erosion is often described solely as a surface phenomenon, unlike caries where it has been established that the destructive effects involve both the surface and the subsurface region. However, besides removal and softening of the surface, erosion may show dissolution of mineral underneath the surface. There is some evidence that the presence of this condition is growing steadily. Hence, erosive tooth wear is becoming increasingly significant in the management of the long-term health of the dentition. What is considered as an acceptable amount of wear is dependent on the anticipated lifespan of the dentition and, therefore, is different for deciduous compared to permanent teeth. However, erosive damage to the permanent teeth occurring in childhood may compromise the growing child’s dentition for their entire lifetime and may require repeated and increasingly complex and expensive restoration.

Therefore, it is important that diagnosis of the tooth wear process in children and adults is made early and adequate preventive measures are undertaken. These measures can only be initiated when the risk factors are known and interactions between them are present. A scheme is proposed which allows the possible risk factors and their relation to each other to be examined.

Change of Perception

Erosive tooth wear has for many years been a condition of little interest to clinical dental practice or dental public health. Diagnosis was seldom made, especially in the early stages, and there was little if anything that could be done to intervene in the early stages. However, perceptions are now changing.

‘Etiology, mechanisms and implications of dental erosions’ was published. It was stated in the preface that dental erosion is an area of research and clinical practice that will undoubtedly experience expansion in the next decade. Indeed,in the last decade erosion has attracted a great amount of research, with subsequent progression in the field. Whilst in the 1970s less than 5 studies per year were published about erosion, this number was still below 10 in the 1980s and has nowadays increased to about 50 studies per year. (Erosive) tooth wear is becoming increasingly significant in the long term health of the dentition and the overall well-being of those who suffer its effects. Following the decline in tooth loss in the 20th century, the increasing longevity of teeth in the 21st century will render the clinically deleterious effect of wear more demanding upon the preventive and restorative skills of the dental professional. Awareness of dental erosion by the public is still not widespread, and dental professionals worldwide are sometimes confused by its signs and symptoms, and its similarities and differences from the other categories of tooth wear namely abrasion, attrition and abfraction. In its earl y stages, and for the vast majority of the population, the changes seen in tooth erosion are of only cosmetic significance. In a survey in England, 34% of the children were aware of tooth erosion but only

8% could recall their dentist mentioning the condition. Forty percent of children believed incorrectly that the best way to avoid erosion was regular toothbrushing which shows some lack of information or misunderstanding. In addition, the awareness of dentists was considered low.

Change of Consumption of Acidic Foods and Beverages

As lifestyles have changed through the decades, the total amount and frequency of consumption of acidic foods and drinks have also changed. Soft drink consumption in the USA increased by 300% in 20 years, and serving sizes increased from 185 g (6.6 oz) in the 1950s to 340 g (12 oz) in the 1960s and to 570 g (20 oz) in the late 1990s. Around the year 1995, between 56 and 85% of children at school in the USA consumed at least one soft drink daily with the highest amounts ingested by adolescent males. Of this group, 20% consumed four or more servings daily. Studies in children and adults have shown that this number of servings per day is associated with the presence and progression of erosion when other risk factors are present. It becomes obvious that with the increased popularity of soft drinks the consumption of milk may decrease in children and adolescents, which could result in calcium deficiency, thus jeopardizing the accrual of maximal peak bone mass at a critical time in life.

Change of Prevalence of Erosion

National dental surveys are not routinely undertaken and when conducted seldom have included measures of tooth wear, specifically erosion. Erosion was first included in the UK childrens’ dental health survey in 1993 and is repeated periodically. The prevalence of erosion was seen to have increased from the time of the children’s dental health survey in 1993 to the study of 4- to 18-year-olds in 1996/1997. There was a trend towards a higher prevalence of erosion in children aged between 3 1/2 and 4 1/2 years, and in those who consumed carbonated drinks on most days, compared with toddlers consuming these drinks less often. In another UK study, 1,308 children were examined at the age of 12 years and 2 years later. Five percent of the subjects aged 12 years and 13% 2 years later had deep enamel lesions. Dentinal lesions were found in 2% of the examined subjects at the age of 12 years and rose to 9% 2 years later. The incidence of new cases also increased. Twelve percent of 12-year-old children who demonstrated no evidence of erosion developed the condition over the subsequent 2 years. New and more advanced lesions were seen in 27% of the children over the study period. Active erosive lesions will progress when no adequate preventive measures are implemented (figs. 1–3). To determine the progression of erosive defects 55 persons were examined twice on two occasions six years apart. All persons were informed about the risk of erosive tooth wear but no active preventive care during the study period was performed. A distinct progression of erosion on occlusal and facial surfaces was found. The occurrence of occlusal erosions with involvement of dentine rose from 3 to 8% (26–30-years-old at the first examination) and from 8 to 26% (46–50-years-old at the first examination). The increase in facial erosions was smaller but again more marked for the older group. In this longitudinal study, the subjective evaluation of dentine hypersensitivity remained unchanged despite the marked increase of erosive and wedgeshaped defects. Dentine hypersensitivity is a relatively common phenomenon and tooth wear, specifically erosion, has been implicated as a predisposing factor. However, no conclusive data are available which would show an increase of dentine hypersensitivity with increasing acidic consumption or erosive tooth wear. Clearly, more research is needed in this field.

Early Diagnosis

Early diagnosis is important. Dental professionals will typically ignore or overlook the very early stages dismissing minor tooth surface loss as a normal and inevitable occurrence of daily living, being ‘within normal limits’ and thus not appropriate for any specific interventive activity. Only at the later stages in which dentine has become exposed and possibly sensitive, and the appearance and shape of the teeth altered that the condition becomes evident at routine examination. There is no device available for the specific detection of dental erosion in routine practice. Therefore, the clinical appearance is the most important feature for dental professionals to diagnose dental erosion. This is of particular importance in the early stage of erosive tooth wear. The appearance of a smooth silky-glazed appearance, intact enamel along the gingival margin, change in color and cupping and grooving on occlusal surfaces are some typical signs of early erosion. However, it is difficult to diagnose erosion at an early stage and it can be very difficult to determine if dentine is exposed or not. Even if a clinician is able to diagnose tooth wear, the differential diagnosis of erosion, abrasion or attrition may be a challenge either through lack of awareness of the multifactorial and overlying etiologies. It is possible to use disclosing agents to render dentine involvement visible. Only a dentist with the diagnostic capability of distinguishing early erosion from the other noncarious defects will be in a position to deliver timely preventive measures. Indeed, these conditions may occur simultaneously. In children, the most commonly reported areas with wear are occlusal surfaces of molars (fig. 3) and incisal surfaces of incisors. These surfaces are also associated with attrition and it can be difficult to separate what is being caused by erosion from what is being caused by other tooth wear factors. For these and other reasons the terms ‘erosion’ and ‘erosive tooth wear’ are used in this book interchangeably demonstrating the overlapping nature of this condition.

Occlusal erosive tooth wear with involvement of dentine with a composite filling rising above the level of the adjacent tooth surface. Age of the patient: 30 years. Known risk factors: soft drinks (sip-wise), gastroesophageal reflux.

Same patient as in figure 1 (5 years later). The progression on the premolars and on the first molar is clearly visible.

Occlusal erosive tooth wear of a child aged 14 years. He suffered from dentine hypersensitivity. Known risk factors: gastroesophageal reflux, ice tea, acidic beverages. Same patient 2 1/2 years later. Progression is clearly visible.

Change of Knowledge and Risk Factors

Erosion is often described solely as a surface phenomenon, unlike caries where it has been established that the destructive effects are both on the surface and within the subsurface region. However, the pathophysiology of erosion is more complex. When a solution comes in contact, with enamel, it has to diffuse first through the acquired pellicle and only thereafter can it interact with enamel. The acquired pellicle is a biofilm, free of bacteria, covering oral hard and soft tissues. It is composed of mucins, glycoproteins and proteins, amongst which are several enzymes. On the surface of enamel, the acid with its hydrogen ion (or a chelating agent) will start to dissolve the enamel crystal. First, the prism sheath area and then the prism core are dissolved, leaving the well-known honeycomb appearance. Fresh, unionized acid will then eventually diffuse into the interprismatic areas of enamel and dissolve further mineral underneath the surface, in the sub-surface region. This will lead to an outflow of ions and subsequently to a local pH rise in the tooth substance and in the liquid surface layer in close proximity to the enamel surface. The events in dentine are in principle the same but are even more complex. Due to the high content of organic material, diffusion of the demineralizing agent (i.e. acid) deeper into the region and the outward flux of tooth mineral are hindered by the organic dentine matrix. It has been assumed that the organic dentine matrix has a sufficient buffering capacity to retard further demineralization and that chemical or mechanical degradation of the dentine matrix promotes demineralization.

These erosive processes are halted when no new acids and/or chelating substances are provided. An increase in agitation (e.g. when a drink is swished around the mouth) will enhance the dissolution process because the solution on the surface layer adjacent to enamel will be readily renewed. Further, the amount of drink in the mouth in relation to the amount and flow of saliva present will modify the process of dissolution. There are many more factors which are involved in and interact with erosive tooth wear. Figure is an attempt to reveal the multifactorial predisposing factors and etiologies of the erosive condition, which seems to be steadily rising in western societies. Many biological, behavioral and chemical factors are interacting with the tooth surface, which over time, may either wear it away, or indeed protect it depending upon their fine balance. Hydrogen ion concentration (pH) alone does not explain erosive potential of a foodstuff; titratable acidity, calcium, phosphate, luoride levels and other factors must also be considered. The interplay of all these factors is crucial and helps explain why some individuals exhibit more erosion than others, even if they are exposed to exactly the same acid challenge in their diets. In the initial stage a certain degree of repair should be possible as there is a subsurface component of the process which is symbolized with the short (back reaction) arrow in figure 4. As known in the carious process the factors listed in the outer circle will influence the whole process of erosion development or defense further. Comprehensive knowledge of the different risk and protective factors is a prerequisite to initiate adequate preventive measures. People who show signs and symptoms of erosion are often not aware of, and may easily be confused by, the erosive potential of some drinks and foodstuffs. Only when a comprehensive case history is undertaken will all the risk factors be revealed. However, a thorough knowledge of the erosive potential of drinks and foodstuffs is needed by the dentist, to determine the patient’s risk and to bring it in to context with the behavioral and biological factors. Knowing these factors, the reported symptoms (thermal or tactile sensitivity) and signs evident on clinical examination, and putting them in relation to the wishes, hopes and possibilities of the individual patient enables the dentist to initiate adequate preventive (noninterventive) and therapeutic (interventive) measures. When a restoration becomes inevitable, in all situations, the preparations have to follow the principles of minimally invasive treatment. In no case may early diagnosis of erosive tooth wear be an excuse for a restoration. Instead preventive measures must be initiated to reduce the erosive challenge and to increase the protective and defensive factors thus bringing this equilibrium back to the oral environment.

Diagnosis of Erosive Tooth Wear

Abstract

The clinical diagnosis ‘erosion’ is made from characteristic deviations from the original anatomical tooth morphology, thus, distinguishing acid induced tissue loss from other forms of wear. Primary pathognomonic features are shallow concavities on smooth surfaces occurring coronal from the enamel–cementum junction. Problems from diagnosing occlusal surfaces and exposed dentine are discussed. Indices for recording erosive wear include morphological as well as quantitative criteria. Currently, various indices are used making the comparison of prevalence studies difficult. The most important and frequently used indices are described. In addition to recording erosive lesions, the assessment of progression is important as the indication of treatment measures depends on erosion activity. A number of evaluated and sensitive methods for in vitro and in situ approaches are available, but the fundamental problem for their clinical use is the lack of re-identifiable reference areas. Tools for clinical monitoring are described.

Current Approach to Erosive Tooth Wear

‘Diagnosis is the intellectual course that integrates information obtained by clinical examination of the teeth, use of diagnostic aids, conversation with the patient and biological knowledge. A proper diagnosis cannot be performed without inspecting the teeth and their immediate surroundings’. This definition formulated for caries is also true for erosive tooth wear. It means that a grid pattern of criteria is pelted over the patient and thereafter the signs and symptoms are first ordered and then classified in the second step. In the same process, the native tooth anatomy and morphology memorized engram-like is compared with the actual appearance. The different chemical and physical insults on teeth cause loss of dental hard tissue with some characteristic patterns. The classification of wear is made from clinically observed morphological features. However, some indices do assume information as to the etiology such as attrition, abrasion and erosion. This approach is open to debate for two reasons: (1) an association between defect morphology and the respective etiological factors has not been validly established, and (2) the presumed etiology predetermines scientific strategies and could introduce bias. It has therefore been argued that assessing wear as the super ordinate phenomenon disregarding the shape of lesions would overcome these disadvantages. It is, however, important to note that the tissue loss ceases from progression when the cause is eliminated. Therefore, on a patient level it is a prerequisite to detect the condition early, to distinguish it from other defects and to search for the main cause in order to start the adequate preventive measures. From a clinical as well as from a scientific point of view, it would be necessary to have differentiating diagnostic criteria available.

Morphology and Differential Diagnosis of Erosive Tooth Wear

The early signs of erosive tooth wear appear as a smooth silky-shining glazed surface. In the more advanced stages changes in the original morphology occur. On smooth surfaces, the convex areas flatten or concavities become present, the width of which clearly exceeds its depth. Undulating borders of the lesion are possible. Initial lesions are located coronal from the enamel–cementum junction with an intact border of enamel along the gingival margin. The reason for the preserved enamel band could be due to some plaque remnants, which act as a diffusion barrier for acids or due to an acid-neutralizing effect of the sulcular fluid, which has a pH between 7.5 and 8.0. Further acid attacks can lead to pseudo-chamfers at the margin of the eroded surface.

Erosion can be distinguished from wedge-shaped defects, which are located at or apical to the enamel–cementum junction. The coronal part of wedge-shaped defects ideally has a sharp margin and cuts at right angles into the enamel surface, whereas the apical part bottoms out to the root surface. The depth of the defect clearly exceeds its width. The initial features of erosion on occlusal and incisal surfaces are the same as described above. Further progression of occlusal erosion leads to a rounding of the cusps, grooves on the cusps and incisal edges, and restorations rising above the level of the adjacent tooth surfaces. In severe cases the whole occlusal morphology disappears. Erosive lesions have to be distinguished from attrition. They are often flat and have glossy areas with distinct margins and corresponding features at the antagonistic teeth. Much more difficult is the distinction between occlusal erosion and abrasion/demastication, which sometimes are of similar shape. Whenever possible, the clinical examination should be accomplished by a thorough history taking with respect to general health, diet and habits and by the assessment of saliva flow rates.

Facial erosive tooth wear. Note the intact enamel along the gingival margin and the silky-glazed appearance of the tooth. Age of patient: 28 years. Known etiological factors: acidic drinks, gastroesophageal reflux.

Facial erosive tooth wear. No intact enamel along the gingival margin, but a silky-glazed appearance of the surface. Age of patient: 35 years. Known etiological factors: acidic fruits (lemon, orange) and fresh squeezed lemon and orange juice.

Severe facial erosive tooth wear. Age of patient: 25 years. Known etiological factors: lemon slices under the lip, fruit juices.

Occlusal erosive tooth wear. Note rounding of the cusps and grooves. Age of patient: 29 years. Known etiological factors: soft drinks, sipping of 0.5-l acidic sports drinks per day.

Occlusal erosive tooth wear. Age of patient: 29 years. The signs of erosive tooth wear are more pronounced. Known etiological factors: soft drinks, sipping of 0.5-l acidic sports drinks per day

Severe occlusal erosive tooth wear. No occlusal morphology present. Age of patient: 29 years. Known etiological factor: gastroesophageal reflux.

Severe oral and occlusal erosive tooth wear. Note the worn oral cusps and the amalgam filling rising above the level of the adjacent tooth surface. Age of patient: 29 years. Known etiological factor: gastroesophageal reflux.

Indices

Erosive tooth wear from a clinical view is a surface phenomenon, occurring on areas accessible to visual diagnosis. The diagnostic procedure is therefore a visual rather than instrumental approach. A number of indices for the clinical diagnosis of erosive tooth wear have been proposed, which more or less are modifications or combinations of the indices published by Eccles and Smith and Knight. All erosion indices include diagnostic criteria to differentiate erosions from other forms of tooth wear, and criteria for the quantification of hard tissue loss. The size of the area affected is often given as the proportion of the affected to the sound tooth surface. The depth of a defect is estimated by using the criterion of dentine exposition. Thereby, a relation between exposed dentine and amount of substance loss is implicated. Most working groups have developed their own index modifications which had not yet reached broader use. Frequently used indices with particular regard to erosions are the indices used in the British Children’s National Health and National Diet and Nutrition Surveys and the index suggested by Lussi.

Two items included in the erosion indices are currently under discussion: The morphological criteria for occlusal/incisal surfaces are not strongly associated with erosive tissue loss. A study including subjects with substantially different nutrition patterns (an abrasive, an acidic, and an average western diet.

Severe oral erosive tooth wear. Note the intact enamel along the gingival margin. Age of patient: 28 years. Known etiological factor: gastroesophageal reflux.

Severe oral erosive tooth wear. Note the intact cervical enamel band and the pulp shining through. No endodontic complications or dental complaints. Age of patient: 29 years. Known etiological factor: Eating disorder (free from chronic vomiting for a couple of y ears).