F E AT URE D E N TAL RIS K
Professor Andrew Eder considers some of the risks associated with the identification and management of tooth wear and how to handle them
MANAGING TOOTH WEAR
T
OOTH wear – encompassing erosion, abrasion and attrition – is usually multifactorial and is increasing in the UK, especially in younger people. There are a myriad of causes, ranging from the much-publicised effects of smoothies, fruit juices and drinks to issues around which there is, perhaps, less awareness, such as stress (resulting in bruxism) and disorders like bulimia. Just as in every area of oral health and dental care,
prevention is preferable to treatment, especially since patients with severe tooth wear may require extensive restorative treatment – but more on that later. Signs and symptoms of tooth wear (images page opposite), which may or may not be what one would expect for a patient’s specific age (i.e. chronological or pathological), include: • teeth becoming rounded, smooth and shiny and losing surface characteristics
• incisal edges becoming short and appearing translucent • cupping forming in the dentine • cervical lesions which are shallow and rounded • restorations standing proud of the surrounding tooth tissue (as they tend to be unaffected by erosion).
Patients are often shocked to be told they have a tooth
wear problem. This revelation may be especially upsetting for those who have been regular attenders and never been made aware previously, and also for those who have embraced a ‘healthy eating’ regimen that inadvertently encourages the consumption of acidic – and therefore potentially tooth- damaging – foods and drinks. Some of the less well-known culprits include dried fruits, spinach and certain cheeses; all are favourites amongst the health conscious. It is, therefore, very important that a diagnosis be handled sensitively, and especially so in cases where there is an underlying emotional issue, for example bulimia. Denial and shame are strong features of eating disorders, so emphasise to the patient that you and your team members are there to help. A staged approach, beginning with a non- judgmental and sympathetic discussion, is ideal. As with any patient, it is important to share examination findings with them and explain how their signs and symptoms are linked. Aim to make the patient feel comfortable and not intimidated, assure them you have time to talk things through and gently ask questions aimed at encouraging the patient to identify the origin of their oral health problems. Advice rather than treatment features heavily during the initial stage of helping a patient suffering with bulimia.
14 / MDDUS INSIGHT / Q3 2018
KNOWING WHEN TO REFER Of course, it is always important to treat the problem in front of you, but clinicians also need to know their limits. If you do discover that a condition beyond the usual scope of dental practice is contributing to tooth wear, it would be prudent to seek the patient’s permission to liaise with their GP or medical specialist before taking further action. This does not just apply to patients with eating disorders – drug or alcohol addicts, for example, may need extra help too. Even in general terms, referral to a specialist may be
appropriate as tooth wear can be challenging to manage and/or restore. A dentist has a duty of care to refer patients for further advice if they have any concerns about their ability to carry out treatment to an appropriate standard. In addition, if a patient asks for a referral, for example for a second opinion, the dentist must fulfil that request. When a referral is made, whether through the NHS
or privately, it is important to have a process in place to track its progress, and to follow up if a response is not forthcoming from the specialist.
SHARED DECISION-MAKING Modern dentistry requires any prevention and/or treatment decisions to be made in partnership with an informed patient. To help patients choose how to best move forward in terms of managing their tooth wear (and, indeed, any form of dental treatment), they need to be involved in a number of decision-making steps. In order to secure valid consent, the dentist must communicate the following effectively (NB: this list is not comprehensive): • the problem • any treatment options and their material risks • costs and the basis for treatment provision (NHS v private) • benefits and limitations • the evidence base.
These discussions should be confirmed by, at the very
least, a written treatment plan/cost estimate. Dentists also need to understand each patient’s expectations, values, preferences, understanding and any other personal circumstances that may be relevant. At the heart of this process remains patient safety and clinical suitability.
IT’S ALL IN THE NOTES
One fundamental tenet of managing risk in dentistry is keeping high-quality records. Accurate, contemporaneous,
REFERENCES 1 Clinical Examination and Record-Keeping: Good Practice Guidelines www.
fgdp.org.uk; May 2016 2 Worn’ing: Tooth Wear Ahead. Slater L, Eder A. and Wilson, N Prim Dent J. 2016; 5(3): 38-42
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