The Worn Dentition

Part 1: Identifying the problem
The human dentition is composed of some of the hardest substances in the human body. Teeth are very resistant to damage from the harsh outside environment. It’s a wonder constant hot, cold temperature changes, abrasive, acidic food and drinks don’t lead to more rapid deterioration. However given time, these challenges can lead to a gradual loss of tooth structure and function.

The contributing factors for tooth structure loss and wear are
1. Tooth decay and multiple restorations
2. Abrasion, such as from aggressive tooth brushing
3. Erosion, from acidic foods and drinks such as citrus and wines or from internal gastric reflux, bulimia.
4. Bruxism (night time tooth grinding and clenching)
5. Normal function

All these factors are considered in respect to time and in respect to a person’s age. This will have important implications in the treatments of such issues.

Signs and symptoms of dental wear:
1. Chipping and breakage of teeth, leading to jagged look.
2. Sensitivity to hot and cold
3. An endless (seemingly) constant cycle of dental fillings/restorations with no improvement to function and aesthetics.
4. Eventual loss of teeth.

Identifying dental tooth wear and loss is an important first step in the management of such issues. Knowing what these contributing factors are will better determine the necessary steps in prevention and restoration.

Part 2: Fixing the problem
After identifying the contributing factors for a worn (out) dentition the necessary treatment can and should be carried out.

Prevention:
Early problems leading to dental wear are commonly prevented by carrying out:
1. Correction of destructive diets
2. Change and personalize oral hygiene practices.
3. Monitor over time at regular intervals.

General dentistry:
In addition to prevention, Mild to Moderate dental wear can be managed by simple dental treatments such as:
1. Bonded dental fillings/facings to correct decay/chipping
2. Desensitizing exposed inner areas from erosion/abrasion

Reconstructive dentistry:
Moderate to Advanced wear can be treated by advance prosthodontic restoration of all lost tooth structure. The decision to do so must be done with great consideration in regards to:
1. Function
2. Aesthetics
3. Long term maintenance
4. Biological cost
5. Financial cost.

Planning:
Failing to plan is planning to fail. The following procedures may be carried out to plan a reconstructive case:
1. Examination
2. X-rays, large and small
3. Conebeam CT if implants are involved
4. Diagnostic models and wax templates, great for visualizing the final outcome. Good first step for discussing proposed changes.
5. Clinical photographs, great for seeing the smile and at rest postures. Good for digital smile designs.

Treatment:
Dental procedures are just a means to an end. Having a preconceived idea that reconstructive dentistry is expensive and involves a lot of crowns and veneers is just not correct. Often patients would ask for such, but what they really want is whiter, straighter and longer teeth.
In general, additive and minimally subtractive procedures are great for the worn dentition, because so much damage has already been done.

Examples of additive/minimally subtractive procedures:
1. Bonding, adding composite resin (filling material) in a defined purposeful manner to open bites and correct shape/form
2. No prep porcelain veneers and onlays. Ultra thin restorations can be made with the aid of CAD/CAM, bonded to the existing tooth structure without drilling.
3. Dental implants
4. Nightguards

A proper consultation and planning session is important to cover all these options, the pros and cons of such, the costs and the long term maintenance required.