Would you agree that the results of bruxism, attrition, or erosion can be seen every day in your practice? How severe does tooth loss need to be before you inform the patient? If you inform the patient, does he have a sense of urgency to have treatment rendered? How many patients, when informed of these conditions, turned down treatment? And if this has happened, does informing the next patient of his condition create any anxiety for you?
These are important questions because any patient not informed of tooth surface loss is put at risk of having no choice in treating what can become a severe condition. What happens if the dentist ignores the problem? This article presents examples of tooth surface loss, how the patients were educated regarding this condition, and the resulting treatment of their missing tooth structure.
BRUXISM, ATTRITION, EROSION, OR ABFRACTION?
|Figure 1. Bruxism and attrition.||Figure 2. Abfraction.|
Patients appear every day in my practice with some degree of tooth surface loss. For years, there has been controversy regarding the definition of this condition. In his educational course on occlusion, Dr. John Kois points out that not all wear is the result of bruxism. It may be attrition following bruxism because of chewing using only the anterior teeth (Figure 1) or abrasion because of a habit. Bruxism may initiate a problem, but other factors may also be involved. According to Dr. Kois, abfraction (Figure 2) is caused by “biomechanical loading forces that are thought to be because of flexure and ultimate fatigue of enamel and/or dentin.” This is a relatively new term for surface loss on the sides of the teeth, replacing the commonly surmised cause of toothbrush abrasion alone, which can still be a contributing factor. Erosion is caused by the diet or stomach juices. An example would be lingual surface loss on upper incisors because of bulimia.
Regardless of the causes and labels used to describe tooth surface loss, the purpose of this article is to focus on treating the result of this condition.
|Figure 3. Teenage bruxism.||Figure 4. Incisal view of Figure 3.|
Patients with bruxism may be seen first as teenagers if one is looking with the aid of an intraoral camera. Figures 3 and 4 show a teenager who has lost considerable enamel. Would you want to inform the parents of this condition? If allowed to continue, could the patient someday look like Figures 1, 2, or 5?
I routinely examine carefully each patient on an ongoing basis for signs of anterior and posterior wear. Figure 6 shows the teenager with worn cusps on teeth Nos. 19 and 20. When a teenager shows these signs, the parent and patient are shown what is occurring using a 28x intraoral camera. They are then shown pictures like those depicted in Figures 1, 2 and 5, then asked, “If I could prevent your child from looking like these patients, would you like me to do so?” (Remember, these cases started as minimal wear at some point.) Never has a parent refused the prevention option (usually utilizing a night guard as initial care).
|Figure 5. Bruxism and attrition of long standing.||Figure 6. Teenage posterior bruxism.|
An explanation is provided about the parafunctional habit and its inability to be controlled except by keeping the teeth apart and rebuilding lost cuspid-protected rise. (Yes, occlusal equilibration is a possible need.) Parents are usually in favor of this, but the reality of a teenager wearing an appliance is dependent on the motivation the dentist or team member can instill. We relate it to the patient’s goal of how he would like the status of his teeth to be in the future. Photos such as Figures 1, 2, or 5 can be great motivators. Most teenagers do not want a bad outcome regardless of their parents’ opinion.
ADULT TOOTH SURFACE LOSS
|Figure 7. Loss of cuspid rise.||Figure 8. Attrition and chemical erosion.|
|Figures 9 and 10. Excessive mandible excursion.|
The next population of bruxism or attrition patients is obviously adults with various amounts of tooth loss. Have you ever observed incisor wear, brought it to the patient’s attention, and found the patient response to be the following: “It never bothers me. The other dentist never mentioned it. I’m not interested in fixing that.” Figures 7 and 8 show cases of long-standing destruction. Some tooth surface loss results from excessive mandible movement, as seen in Figures 9 and 10. If the wear is just beginning or if it is obviously severe, how is treatment rendered, especially for those who need it most? Asking questions of the patient seems to be the best direction toward understanding his goals. The treatment then follows the goals. The majority of my patients elect to have care rendered to repair the damage and then protect it.
|Figure 11. Abfraction restored.|
Tooth structure loss related to occlusal trauma (abfraction) may result in the request for treatment if sensitivity becomes an issue. Figure 2 shows a classic case before treatment. Figure 11 shows the restoration of the abfraction.
How much tooth loss is required before a dentist should bring it to the patient’s attention? With minimally invasive preparation using air abrasion, I believe early abfraction should be treated to prevent greater loss, which often continues as a result of chemical (acidic) erosion and/or toothbrush abrasion.
Only when the patient sees value in having treatment completed can clinical skills be utilized. Bruxism or other tooth surface loss often is not treated because of lack of perceived value by the patient or the treating dentist. However, when questions are asked about the patient’s long-term goals, the patient has control and—feeling in control—trust can develop. The following examples illustrate the treatment that was accepted because the patients perceived value for treatment of a problem, which facilitated a sense of urgency.
|Figure 12. Teenager with bruxism.|
Figure 12 shows Melissa, a teenager with early bruxism. (Figures 3 and 4 show her bruxed teeth.) When questioned about how she would like the status of her teeth to be in 20 years, she described a nice, healthy smile. When shown her teeth close-up, she was taken aback with the destruction. When shown pictures of how her teeth could deteriorate without care, she was motivated to prevent such additional destruction. It was decided to offer her (1) a restored cuspid rise to regain the protection she had lost and (2) a night guard.
|Figure 13. Preparing a long bevel.||Figure 14. Air abrasion for added retention.|
|Figure 15. Reestablished cuspid disclusion.|
Figure 13 shows preparation of a bevel of tooth No. 27 with a beveled diamond. The more tooth structure beveled, the stronger the bond. Figure 14 shows the use of air abrasion to prepare the tooth for enhanced bonding. The resulting rebuilt composite anatomy provides the needed cuspid protected occlusion, as seen in Figure 15. The exposed dentin in Figure 4 was air-abraded and filled with a microfill to slow chemical and attrition loss. A night guard was delivered a week later.
Often a patient presents with a problem that he thinks is not serious, or he has no sense of urgency regarding its treatment. However, with a supportive approach over time, this same patient may develop a desire to have treatment.
|Figure 16. Tooth surface loss of long standing.||Figure 17. Restored tooth surface and vertical.|
James was “eating” his lower incisors away. Again, this is a case where Dr. John Kois would point out that bruxism is no longer the only cause of the disappearing tooth structure; attrition is also involved. Figure 16 shows tooth surface loss that will continue if nothing is done. James had been a patient for many years and had been shown his lower tooth structure loss at recare visits. Finally, he decided he wanted to preserve his disappearing teeth. James was asked what he would like the status of his teeth to be in 10 years, and he said he wanted them to be “at least as good as they are now if I can keep them.” It was explained to him that in 10 years, the teeth in question would be in much worse condition than they are now. He understood, made a request for a treatment plan, and was offered 2 treatment options: (1) veneers or bonding and a new lower partial denture; or (2) implants. Because of financial conditions, James chose bonding. Figure 17 shows the results. (Crowns on teeth Nos. 21 and 28 were left in place, and the clasps on the new partial denture were fabricated using an acetyl resin called Aesthetic Perfection [Cosmetic Dental Materials]).
James’ long-standing condition of tooth structure loss will now cease. With the understanding that the bonding may require repair now and then, his condition is better than it would be with no treatment.
SAVING THE FOUNDATIONS
Charlotte came as a new patient adamantly wanting a new lower denture, meaning teeth Nos. 21 through 28 would require extraction. She also stated that she had limited funds. Upon examination of her severely worn teeth due to chewing on only those teeth (Figure 1), I found that her periodontal condition was sound (as is often the case with bruxism). I decided not to accept her case, since I did not want to remove perfectly sound teeth that could support a partial denture. I told her that her remaining teeth were “worth” about $12,000 (the cost of implants to replace them). Their value in terms of serving as the foundation for a partial denture was substantial.
After hearing this, her attitude changed, and I proceeded to propose restoring her lower teeth. She accepted the treatment plan of veneers and a new partial denture. Her new perception of the proposed care resulted in her finding the money to pay for it. (Money that she claimed was not initially available.)
|Figure 18. Severe attrition.||Figure 19. The composite that increased the patient’s vertical dimension.|
|Figure 20. The final restoration.|
Figure 18 shows the breakdown of the remaining mandibular teeth. In order to develop a new bite, I decided to temporarily build up her bite with composite. Figure 19 shows the composite that increased her vertical dimension, which was tested for 2 weeks. Once she felt comfortable with the improvement and feel of the trial care, we proceeded to complete the case with veneers and a new lower partial denture, again using Aesthetic Perfection clasps. Figure 20 shows the final result.
Tooth surface loss due to the conditions of bruxism, attrition, erosion, or abfraction presents the dentist with the choice of offering the patient information about the condition and its consequences or not offering any information at all. It would seem that these conditions are the least treated of all dental conditions, possibly because of the dentist’s concern that the patient will not be receptive to treatment for which they may have no sense of urgency or value. That may be the patient’s view, but without the patient having the option to make the decision, the patient has no control over his treatment.
Asking questions of any patient who shows signs of tooth surface destruction due to any of the conditions mentioned allows the patient to control his goals. Helping patients develop these goals is what I believe I need to do as their dentist. Once these goals are developed, the treatment follows. When patients receive the optimal care to meet their goals, they have appreciation for your level of service.
The conditions leading to tooth surface loss are common (if observed). Treatment can be as basic as a night guard, or it may involve opening the bite and placing veneers or crowns. The earlier these conditions are diagnosed, the earlier patient is informed, and the earlier treatment is accepted, the less chance there will be additional tooth surface loss.
Dr. Whitehouse practices in Castro Valley, Calif. He is currently treasurer of the World Congress of Microdentistry and holds fellowships with the International Congress of Oral Implantology and the World Congress of Microdentistry. One of very few dentists with a master’s degree in counseling, he is available for speaking engagements concerning communication skills and cosmetic dentistry and will be speaking at the fourth World Congress of Microdentistry meeting Aug.13-16 in Vancouver, BC, Canada. Dr. Whitehouse is founder of the Dental Learning Center, which provides communication skill workshops and cosmetic dentistry hands-on courses.
Disclosure: Dr. Whitehouse is on the board of directors of Cosmetic Dental Materials.