Tooth Surface Loss (TSL) can be carious and non carious. This article will

concentrate on non carious TSL. TSL is experienced throughout a patients’ lifetime,

but when it accelerates over the normal amount it can lead to functional and

cosmetic concerns. TSL can be considered pathological if the degree of wear

exceeds the level expected at any particular age1,2. TSL can be classified in 4 ways,

abrasion, erosion, attrition and abfraction.

Attrition due to TSL from tooth contact3. It includes TSL from restorations, eg. a

porcelain restoration can cause attrition of opposing natural teeth. Attrition also

includes wear of a restoration (Glass ionomer) due to the opposing natural tooth.

Common causes for attrition TSL:

1. Parafunction eg bruxism4

2. Medication/medical conditions eg autism.5,6

3. physiological eg group function7

Diagnosis is by exam and questionnaire enquiring about causes. Clinical exam

generally reveals flattened cusps/incisal tips with equal wear of dentine and enamel.

It is known to affect approximal surfaces less. Attrition is generalised or localised. If

localised it is likely due to an artificial cause such as porcelain restoration.

Post Graduate Diploma in Restorative DentistryPage 1

Figure 18

Abrasion is TSL due to mechanical wear from a foreign object3, eg. Musical

instruments, floss, toothpicks, biting objects and excessive tooth brushing.

Diagnosis is by questionnaire and examination. Possible questions include about

habits and tooth brushing. Looking at the patient’s toothbrush, toothpaste and

brushing technique is helpful. This includes time and frequency spent brushing,

amount of force used, stiffness of brush/ bristles.

Clinically, teeth have facial cervical TSL if due to toothbrushing. The TSL are

notches/ grooves with sharp angles. TSL will be generalised to at least 2-3 or more

teeth. It is unlikely one tooth with cervical TSL will be due to abrasion. It may be

more evident on either left or right side depending on if the patient is left or right

handed. It may have also caused a decrease in the zone of attached mucosa.

Pipes, toothpicks, floss can cause localised TSL, especially if the object is repeatedly

placed in the same location.

Post Graduate Diploma in Restorative DentistryPage 2

Figure 29

TSL due to acidic substances is erosion3,10.

There are different methods to classify dental erosion (see tables 1, 2 and 3).

Diagnosis is by questionnaire and examination.

Post Graduate Diploma in Restorative DentistryPage 3

Table 1. Scores and criteria of the Basic Erosive Wear Examination Index and the

Simplified Tooth Wear Index.

B.E.W.E. S-T.W.I.

Scor

e

Criteria Scor

e

Criteria

0 No erosive tooth wear 0 No wear into dentine

1 Initial loss of surface texture 1 Dentine just visible (including cupping) or dentine

exposed for less than 1/3 of surface

2 Distinct defect, hard tissue loss

<50% of the surface area

2 Dentine exposure greater than 1/3 of surface

3 Hard tissue loss ≥50% of the

surface area

3 Exposure of pulp or secondary dentine

Post Graduate Diploma in Restorative DentistryPage 4

Table 2. Pathognomic criteria of the Evaluating Index of Dental Erosion.

Clinical criteria

Score 0: no erosive tooth wear.

Score 1: shallow defects located coronal from the CEJ or cupping of cusps, no dentine involved

Score 2: shallow defects located coronal from the CEJ or cupping of cusps, dentine involved.

Smith and Knight tooth wear index [30]

Score Surface Criteria

0B/L/O/I No loss of enamel surface characteristics

C No loss of contour

1B/L/O/I Loss of enamel surface characteristics

C Minimal loss of contour

2

B/L/O Loss of enamel exposing dentine for less than one third of surface

I Loss of enamel just exposing dentine

C Defect less than 1 mm deep

3

B/L/O Loss of enamel exposing dentine for more than one third of surface

I Loss of enamel and substantial loss of dentine

C Defect less than 1–2 mm deep

4 B/L/O Complete enamel loss–pulp exposure–secondary dentine exposure

I Pulp exposure or exposure of secondary dentine

C Defect more than 2 mm deep–pulp exposure–secondary dentine exposure

Post Graduate Diploma in Restorative DentistryPage 5

Score Surface Criteria

Tables 1,2 and 311

Erosion pits develop with smooth enamel and little staining if active. They develop

on any surface. Translucency and loss of enamel with dentine exposure occurs.

Over time the pit becomes wider and deeper. Erosion commonly develops

incisally/occlusally. Dentine is lost quicker than enamel, as it is easily

demineralised. Cervical erosion looks differently from abrasion as it is generally

wider and shallower, giving them a cupping appearance. 'Perimylolysis' is erosion

of the palatal surfaces (figure 3) due to reflux or emesis (holst and Lange 1939)12.

Erosion around restorations cause marginal defects and the appearance of

restorations being higher than the tooth.

figure 313

Erosion TSL can be further classified by extrinsic and intrinsic acids.

Post Graduate Diploma in Restorative DentistryPage 6

Extrinsic Acids include food, drinks, medicines (eg Vitamin C/aspirin tablets), and

environmental/occupational acids. Increasing frequency of consumption, amount,

type (frozen, concentrated) and how it is consumed (less TSL if drunk quickly or

through straws) increases erosion.

Environmental acids include poorly chlorinated swimming pools, illegal tooth

bleaching substances, occupational hazards such as fumes from work14, wine15 or

food tasting.

Intrinsic acids include physiological reasons of acids being produced internally and

coming into contact with the dentition. The reasons could be due to:

Anatomical defects like gastro oesophageal reflex disorders (GORD)/hiatus hernias.

Side effects of medicines like NSAIDS etc

Physiological conditions such as asthma can cause GORD. Diabetes can cause

gastroparesis which causes GORD. Pregnancy and progesterone increases affect

the function of the lower oesophageal sphincter, causing GORD. Xerostomia due to

old age, medication etc invariably means the acid environment of the oral cavity is

not neutralised.

Psychological issues like overeating, alcoholism, anorexia and bulimia nervosa all

cause acid reflux and erosion.

Intrinsic causes develop erosion on the palatal/lingual aspects. Extrinsic aetiologies

develop erosion labially/buccally.

Post Graduate Diploma in Restorative DentistryPage 7

Abfraction is controversial cause16,17 and is heavily debated. It is stress induced TSL.

Abfraction occurs cervically at the cement enamel junction (CEJ) as the tensile and

compressive forces concentrate here3,18.

Diagnosis is by elimination of other TSL and occlusal analysis for heavy/poor contact

points. Non working side interferences should be investigated. Signs and symptoms

of parafunction should be made. Abfraction is likely when there is a cervical lesion,

especially if v-shaped, subgingival and localised. Abfraction could be a sign of

occlusal disharmony. If the tooth is mobile with a class 5 TSL it is unlikely to be

abfraction, as the mobility dissipates the lateral forces which concentrate in the

cervical region.19 Darker sclerotic TSL lesions are usually not sensitive as the lighter

lesions.

Figure 4 20

Management

TSL management depends on the damage. Early TSL must be investigated,

diagnosed and treated of any pain/sensitivity.

Post Graduate Diploma in Restorative DentistryPage 8

Identification of the disease process must be identified by starting with concise

questioning of habits, diet, medical history. Dietary factors should be identified with a

minimum 3 day diet sheet21. Diet analysis to control/reduce the causes can be

undertaken. Generic advice can be given, as most TSL is multifactorial3. A well

detailed questionnaire can be taken outlining possible habits, diet, parafunction,

medical history etc until diagnosis can be made22. It is important the patient

understands the cause and thus the possible treatment. This helps patient

compliance. The patient must seek a medical exam if there is history of a medical

condition. Suitable relevant specialists should be liased. For example if

bulimia/anorexia is diagnosed, psychiatric evaluation should be undertaken. If gastric

reflux is suspected, a general medical practitioner referral is appropriate.

Generic advice can be given until aetiology is identified:

Generic dietary advice:

Consume erosive beverages through wide straw.

Swallow immediately and not 'swish' around the mouth.

Teeth should not be brushed following erosive substance.

Finish meal with something neutral/alkaline (cheese/milk).

Chew xylitol gum unless attrition/parafunctional habits.

Post Graduate Diploma in Restorative DentistryPage 9

Generic tooth brushing advice:

Avoiding excessive toothbrush time, frequency, pressure

Avoid abrasive toothpastes like natural or whitening/smokers toothpastes.

Avoid back and forth techniques but circular or Bass techniques.

Avoid hard bristled toothbrushes with no flexibility in the body.

Generic parafunctional/attrition advice:

Avoid chewy tough foods/objects in the mouth.

Avoid chewing gum

Provide hard acrylic splint

Reflux/emesis advice

Splints are useful in bulimics to protect their teeth during vomiting. Alkali (milk of

magnesia) or high fluoride can be applied to splints to neutralise any acid pooling.

Splints need extreme caution in use as there is a chance of acid being trapped

beneath.

High fluoride rinses, toothpastes like duraphat toothpaste (5000ppm sodium flouride)

and Tooth Mousse help remineralise teeth. Acidulated phosphate fluoride should be

avoided because of its acidity.

All risk factors associated with the different TSL should be addressed.

Post Graduate Diploma in Restorative DentistryPage 10

If TSL is early then routine and regular monitoring can be undertaken. This is by

study models, silicone putty impressions23 and photos. The dexterity of the

photographer and ambient conditions affects the quality of photos and need to be

considered when comparing. Radiographs may be used if pulpal involvement is

suspected and possible periapical lesions. Tooth vitality tests can be undertaken.

If TSL has lead to irreversible pulpitis28, then extirpation/extraction must be

considered.

After a few months, reassessment should be undertaken to see how the response to

initial care. This should include whether the aetiology is still present or not. Patient’s

long term expectations/views could be addressed. If TSL is dramatic and

stabilisation is not slowing, restorative action should be undertaken, although

controversial24. Advantages/disadvantages should be outlined to the patient and

discussed in length. The restorations should be provided to protect existing dental

tissue25.

Post Graduate Diploma in Restorative DentistryPage 11

If restoring the dentition has been decided, the treatment is dependent on the

amount of TSL, age and medical history. Some papers have attempted to provide a

classification for providing treatment depending on TSL types.26 (see Table 3)

TSL can be treated in the conventional way. Cervical lesions being treated with

composite, compomers and glass ionomer cements(GIC). Occlusal/incisal and

palatal lesions are treated with composites or if posterior could also include

amalgam. Exposed dentine in the occlusal and incisal areas can be be over-etched

(20–30s) to enhance opening of dentinal tubules and intratubular formation of resin

tags27. Composite is a good choice as it is not dissolvable by the acidic environment

like GIC which can be acid soluble28. However some authors have mentioned the

use of acid-etch when using composites actually exacerbates erosion TSL29,30.

Restoring advanced TSL becomes more difficult and depends on a number of

factors. Crown lengthening surgery, orthodontics and Dahl appliances can be utilised

if there is a large TSL with insufficient room for the preparation of teeth for

crowns/onlays.

If there is a large amount of TSL with loss stable intercuspal position (ICP) then a

reorganised approach may need to be investigated. This could include occlusal splint

therapy to check stability of a new ICP (from a retruded position) and facebow

analysis. The teeth are then temporised with long term provisionals restorations.

Once occlusion is stable, permanent lab-based restorations are provided.

If TSL is beyond restoring the teeth with laboratory restorations then overdentures

can be considered.

Post Graduate Diploma in Restorative DentistryPage 12

If beyond overdentures, then extractions with provision of implants and dentures

maybe the only option left.

ACE CLASSIFICATION31 Table 3

PALATAL ENAMEL

PALATAL DENTINE

INCISAL EDGE LENGTH

FACIAL ENAMEL

PULP VITALITY

SUGGESTED TREATMENT

CLASS I REDUCED NOT EXPOSED PRESERVED

PRESERVED PRESERVED

NO TREATMENT

CLASS II LOST IN CONTACT AREAS

MINIMAL EXPOSED

PRESERVED

PRESERVED PRESERVED

PALATAL COMPOSITES

CLASS III LOST DISTINCTIVELY EXPOSED

LOST <2.1mm

PRESERVED PRESERVED

PALATAL COMPOSITES

CLASS IV LOST EXTENSIVELY EXPOSED

LOST>2MM PRESERVED PRESERVED

SANDWICH APPROACH (EXPERIMENTAL)

CLASS V LOST EXTENSIVELY EXPOSED

LOST>2MM DISTINCTIVELY REDUCED/LOST

PRESERVED

SANDWICH APPROACH (EXPERIMENTAL)

CLASS VI LOST EXTENSIVELY EXPOSED

LOST>2MM LOST LOST SANDWICH APPROACH (HIGHLY EXPERIMENTAL)

There is no clear TSL index which accounts all causes like age. TSL is only

pathological if it exceeds the normal amount of wear. So TSL it is difficult to

quantify/qualify32,33,34. Studies on the U.K. population TSL should only be considered

with tooth wear indices which account factors such as age.

Post Graduate Diploma in Restorative DentistryPage 13

The actual prevalence of TSL is unclear but it is increasing in the UK population35.

Some evidence was seen in 25% of over 11 years old and on average between 5-

8% of all age groups34,36,37. This could be attributed to a few reasons34.

There has been an increase in bruxism from occupational38,39 and student work

related stress38,40. This can increase attrition and TSL.

Another reason is an increase in the marketing of slim men and women. This has led

to an increase in body dysmorphia and eating disorders41,42,43,44,45. As such there has

been an increase in bulimia/anorexia and erosion/perimylolysis. Increases in

juice/sports drinks cause erosion as people become more physically fit

conscious46,47,48. Sports drink consumption can have a 2 fold problem as it is drunk

during dehydration of a sports activity. Saliva buffering will be lower and erosion will

increase. Refrigeration is now widely available and fruit production is plentiful

throughout the year. Availability of fruit juice means they can be consumed

throughout the year and is not limited to seasons. Public health messages now are

focused on healthy eating of more vegetables and fruit. Patients are unlikely to be

aware of the damage the acid erosion could do to their dentition. Parents feel “no

added sugar” options are healthier and think young babies and children are at no

harm from drinking copious amounts. Erosion is being seen in younger children.

As the population becomes healthier, people are living longer and having their teeth

longer. There is an increasing trend of restoring the dentition of the elderly, who

obviously have a more worn set of teeth.

Patients are increasingly having more aesthetic treatment, bleaching, composites,

porcelain restorations, even in the posterior region of the mouth. They all can

increase TSL. Porcelain causes attrition, phosphoric acids for composite and

Post Graduate Diploma in Restorative DentistryPage 14

bleaching can cause erosion. So called “whitening” toothpastes are generally

abrasive.

The UK has a changing population. Since the 1950’s there has been an influx of

different cultures and diets. There is TSL prevalence in some communities than

others. Some communities use various traditional abrasive methods to clean their

teeth (miswaak49). Certain communities eat a highly abrasive diet, like high fibre

rice50.

Recreational drug use has been on the increase. From studies52 we are aware that

that this increases TSL.

If TSL is not prevented it will lead to early loss of teeth and occlusion, sensitivity and

pain, loss in face height, psychological effects of a poor dentition25.

Management of TSL is important. Early recognition/interception of TSL before further

damage is priority. Education to patient, dentist and doctor is vital. If severe TLS is

present patients should be educated on all the options. Without greater public health

education there will be increasing further TSL.

Post Graduate Diploma in Restorative DentistryPage 15

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Post Graduate Diploma in Restorative DentistryPage 16

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