Alyn Morgan breaks down the issues associated with tooth wear, both physical and beyond, and the potential for digital management.
Across the dental profession, dental caries has been the key disease we have treated for many years. More recently, tooth wear has been recognised as an increasing problem. It may become a much greater challenge for clinicians in the years to come.
Preventing and managing tooth wear and tooth surface loss (TSL) will be key to the conservative and holistic dentistry that we strive for. This means that we need effective ways to predict and monitor wear – could digital technologies help with this?
Impact of tooth wear
Tooth wear is a multifactorial condition that can be slow to progress. Therefore, symptoms may not appear until late in the disease process (Wetselaar et al, 2020). As colleagues will know, tooth wear is typically the result of attrition, erosion or abrasion – or a combination of these.
There are several possible chemical and mechanical causes. These include an acidic diet, gastric reflux, abrasive food or dental products, and parafunction. The data varies widely regarding the prevalence of moderate to severe tooth wear among the global population. However, it is estimated to be between 20% and 45% in adults (Schlueter and Luka, 2018).
Patients with tooth wear are nine times more likely to report dissatisfaction with their teeth (Al-Omiri et al, 2006). Higher levels of tooth wear have also been linked to a lower oral health-related quality of life (Mehta et al, 2023).
Severe versions of the condition have been linked to psychological discomfort and disability in patients. This is regardless of socio-demographic factors or specific clinical characteristics (Li and Bernabé, 2016).
As such, it is important that the dental team is able to help patients manage tooth wear. Through this, they can minimise its impact and prevent further progression.
Management of tooth wear
As is the case in many areas of dentistry, patients tend to be motivated to seek help for tooth wear primarily due to aesthetic concerns.
One study found this to be true for 59% of participants, compared with 40% complaining of sensitivity, 17% of function issues and 14% of pain (Wazani et al, 2012). Another study found similar results, despite endodontic treatment being indicated in 11% of tooth wear patients evaluated, all of whom presented with late-stage dental erosion and exposure of the pulp (Sivasithamparam et al, 2003).
Personally, I see an increasing number of patients present with fractures in the teeth due to prolonged wear. These are especially common in older people, and the fractures can be catastrophic for their natural dentition.
This, combined with the complex aetiology behind the development of the condition and an ageing population, means that effective preventive and clinical management of tooth wear is crucial, albeit challenging.
Where possible, a focus should be placed on prevention and early diagnosis to avoid potentially extensive treatment and rehabilitation. This requires ongoing assessment and recording of tooth surface levels. Additionally, collecting comparative data that can be utilised over time to evaluate TSL.
The Tooth Wear Evaluation System (TWES) 2.0 has been proven to be a reliable tool in the assessment of tooth wear severity (Roehl et al, 2022). It also contains a decision tree relating to the taxonomy of tooth wear to aid diagnosis.
Digital potential
There have also been developments in the digital techniques available to support management of tooth wear.
For example, intraoral scanners may be useful in the continuous monitoring of TSL, as they have shown promise in being able to detect minor tissue loss over time (Witecy et al, 2021). Comparing scans from consecutive patient appointments can provide a relatively easy way to measure the pace of TSL, and help clinicians to detect a potential issue and deliver early intervention.
These same images could also be used for digital models that facilitate occlusal management. This would help to prevent further wear in the future. Existing technologies are not yet capable of supporting this workflow efficiently, but this is definitely food for thought.
There is currently scope for digital solutions to be incorporated within the planning of restorative treatment following tooth wear diagnosis.
Face scanning, CBCT and intraoral scans may be combined to facilitate 3D planning that enables the design of restorations that are the most appropriate length, level, shape and colour for the patient’s face (Yar, 2023).
Additionally, digital solutions can be used to design and fabricate night guards to help protect new restorations and prevent further wear. The potential advantages of digital impressions and manufacturing processes in this area include shorter turnaround and chair times, as well as a simpler workflow for the dental team.
Prevention is better than cure
There is definitely still scope for improvement within all these digital workflows, but the early results are very encouraging.
Of course, prevention is always better than cure. Anything that can be done to avoid tooth wear in the first place must be prioritised. Digital technologies could help clinicians to risk assess for tooth wear, and restore dentition once the condition is under control. This would be a very valuable tool for the future.
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