Tooth wear
First, do no harm F
John Craig and Martin Kelleher argue that addition beats subtraction when it comes to the management of tooth wear
or for many years we have written and spoken out against some of the destruc- tive excesses of
modern, supposedly ‘restor- ative’ or ‘cosmetic’ dental practice, one as a concerned Scottish GDP, and the other as a consultant in restorative dentistry. We had thought that such destructive methods were becoming less prevalent in modern dentistry, but appar- ently not so. We, therefore, write to challenge several of the points expressed in a recent article. This peculiar article demonstrated mild upper anterior tooth surface loss with a mild postural class three adaptive position, which is often found when the loss of upper incisor height has been due to chemical erosion. We disagree strongly that this picture showed ‘severe wear’ as was stated in that article. As a general rule in tooth
wear assessment, if the crown heights of the upper anterior teeth have been preferentially shortened, but the height of the lower teeth have not been equivalently affected, experi- enced clinicians can usually be fairly sure that the upper tooth surface loss has been caused mainly by chemical erosion. This is because the lower teeth are generally spared from most of the damage caused by the damaging erosive acid fluids, during either extrinsic or intrinsic acid attacks, by the protective action of the tongue. The tongue lies over the
lower teeth during the swal- lowing of acidic fluids, or during any sort of regurgitation and thereby keeps most of the
48 Scottish Dental magazine
erosive acids away from the lower teeth but allowing the damaging acids to attack the top teeth and thereby short- ening them so that their height to width ratios are reduced disproportionately and they then look ‘short and wide’. In the recently published
case report, the heights of the upper anteriors appeared to have been preferentially reduced to the extent of them being about the same as their width. By way of contrast, the opposing lower teeth still appeared to be a normal shape and have a significantly greater height than their width – which is usually the case in healthy unworn lower incisor teeth. This contrast in the opposing
dental arches clearly pointed to chemical erosion as being the most likely explanation for this particular case presentation, because, if the tooth surface loss had been due to phys- ical attrition, then the much smaller lower incisors would have been worn preferentially, or at the very least equivalently, to match the tooth surface loss apparent at the upper inci- sors. By way of illustration of this important differential diagnostic point, two images
from a different case, this time actually showing severe preferential tooth surface loss caused by Coca Cola erosion are shown in Figures ıa and ıb. Sadly, in our view, it is not
infrequent to still see this sort of failure of accurate diagnosis of the probable aetiology for shortened upper teeth before then proceeding as shown in that recent case report with what, in our sincerely held opinion, was an unnecessarily destructive treatment plan involving multiple ceramic veneered full coverage crowns for this mild wear problem. Many of these cases appear
to us to be sometimes done for rather questionable ‘cosmetic’ benefit or to conform to some unproven, or unscientific, occlusal belief system some- times involving articulators of varying complexity being used in order to treat tooth surface loss problems. Parts of the Hippocratic
Oath include: “Firstly, or most importantly, do no harm”, but also exhort that: “Extreme remedies should be reserved for extreme diseases.” Mild tooth surface loss is not an extreme disease. Elective removal of much residual
sound tooth tissue undoubt- edly does structural and other biologic harm, often involving processes that are not benign, not trivial and not reversible. High speed drills with diamond burs are dental weapons of mass destruction and every seriously destructive preparation of an already worn tooth will probably shorten its life. Although the ceramic veneered crowns may well look pretty at the start of their life, that aesthetic or biologic picture will probably look worse in 20 or 30 years time with a poor ‘fall back position’, sadly, for the patient. We honestly believe that
most experienced dentists when treating mild wear would not remove vast amounts of residual sound tooth tissue from their own daughter’s teethı, from a colleague’s teeth, nor indeed have it removed voluntarily from their own teeth. There is no articulator system in the world that can compensate a tooth for hazarding its pulpal health with an elective full coverage crown preparation2, or for the loss of 62-73 per cent of it’s load bearing structure, which has been shown by Edelhof and
Fig 1a & b
The tooth surface loss is greater at the upper teeth so that they appear shorter and wider. The lower incisors have a normal height-to-width ratio. This problem was caused by chemical erosion rather than by attrition
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