Tooth Wear

Tooth structure is more valuable than gold. Dentists actually did use gold in the past to restore teeth. Today, some of the most advanced computerized technologies are used to fabricate micron-precision restorations. Currently, dentistry benefits from 3D cameras and laser-guided milling machines to create biocompatible ceramics that reinforce the tooth structure and protect the nerve inside from mechanical injuries and temperature variations. Dental caries is notorious in destroying tooth structure but could it be another one that is even more dangerous?

Tooth Wear – Slow and irreversible loss of tooth structure.

Tooth wear is probably today the most undiagnosed disease of the mouth and “has been recognized as a major problem in dentistry”. (“Tooth wear and investigations in dentistry” Lee A., He LH, Lyons K., Swain MV. in Journal of Oral Rehabilitation, 2012) We assume teeth are strong (after all, enamel is hardest organic substance in the body) and last a lifetime but when muscles bring teeth in contact – enamel on enamel – way too often and too hard (Bruxing or Clenching), valuable tooth structure gets lost. Muscles “listen” to posture, joints, body chemistry, nutrition, stress… so it becomes important to understand what is causing them to be hyperactive. In many situation, verifying and equilibrating the bite can remove the trigger that causes grinding. In other instances, the trigger lies with other functional issues such as snoring, OSA – Obstructive Sleep Apnea, inadequate bite guards…

Why is tooth wear one of the most under-diagnosed diseases of the body?! – because it does not hurt and it happens very slowly. We might think that since it does not hurt and the body can adapt by over-erupting the teeth, everything is okay. Actually, when one or more teeth get worn so much that dentin (secondary layer of the tooth) is exposed that means the biting surface is getting closer to the nerve chamber. When we try to repair the teeth and cover the worn parts, there is no space left to build the tooth back up. To repair worn teeth, we need to “make space” for the covering restoration either by preparing more tooth structure – getting us even closer to the nerve – or use braces to push the teeth back in the bone – where they used to be before they got slowly worn. Either option is invasive! There is a third option: so called Raising the VDO (Vertical Dimension of Occlusion) – capping all the teeth in the mouth – but that is even more invasive than the first two options.

How much wear is too much?! – when we wore a tooth through enamel and dentin.

Dentin is Not capable of withstanding chewing forces nor can resist for long the mouth acids and enzymes. Changes in tooth size or position can also lead to joints, muscles and periodontal problems, which are even more difficult to treat than teeth. Tooth Wear is considered pathological when we lose more than 20-38 µm of vertical tooth structure per year / 1.6 – 3.04 mm in 80 years. (“Current concepts on the management of tooth wear: part 1. Assessment, treatment planning and strategies for the prevention and the passive management of tooth wear” Mehta S. B., Banerji S., Millar B. J., Suarez-Feito J.-M. in British Dental Journal, 2012)

What does it take to diagnose it and treat it early? – first of all, Knowledge … enhanced by newer diagnostic technologies.

“We see only what we know”, therefore we treat only what we see. Old-fashion dentistry focused on tooth decay and soft tissue inflammation often overlooks the developing tooth wear. Diagnosing tooth wear not matching one’s chronological age makes the difference between preserving the original tooth structure for a lifetime or developing the need for extensive restorative dentistry. No matter how sophisticated the current dental materials are, they are inorganic and cannot get remineralized like the human enamel can. (Maintaining the integrity of the enamel surface: the role of dental biofilm, saliva and preventive agents in enamel demineralization and remineralization” Garcia-Godoy F., Hicks MJ. in Journal of American Dental Association, 2008)

Distinguishing between different forms of wear – Attrition, Abrasion, Erosion and Abfraction or a combination of any of them – might also hold the key to identifying contributory systemic  factors. At your next visit to the dentist, ask if you can benefit from a functional bite analysis (preferably with a computerized technology) and a digital photographic evaluation of your teeth wear level. It is better to reach the AHA moment sooner rather than later.

Costin Marinescu
Dr.-medic stom., D.D.S. (USA)

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