TOPICS OF INTERESTAnalyzing the Etiology of an ExtremelyWorn DentitionRonald G. Verrett, DDS, MS

Patients requiring extensive restorative care frequently exhibit significant loss of tooth struc-

ture. Specific clinical findings in an extremely worn dentition may vary widely and are often

confusing. Severe wear can result from a mechanical cause, a chemical cause, or a combination of

causes. The location of the wear, the accompanying symptoms and signs, and information gained

from the patient interview are essential components in determining the etiology. A diagnostic

decision tree facilitates a systematic analysis and diagnosis of dental wear.

J Prosthodont 2001;10:224-233. Copyright © 2001 by The American College of Prosthodontists.

INDEX WORDS: tooth wear, diagnosis, abrasion, attrition, erosion

PATIENTS seeking complex restorative care of-ten exhibit clinical evidence of severe wear.

This may be related to an aging patient populationin which many individuals are retaining more teeth,but there is also compelling evidence to indicatethat the incidence of wear is increasing in youngerage groups.1

Tooth wear occurs as a physiologic process; nor-mal ranges for specific populations have been re-ported.2 Pathologic wear occurs when this normalrate is accelerated by unusual endogenous or exog-enous factors. Severe tooth wear is frequently mul-tifactorial and variable. To prevent further patho-logic change, it is essential that the etiology ofabnormal wear be determined, yet diagnosing thefactors responsible for a severely worn dentitionoften presents a clinical conundrum. The purposeof this report is to review the clinical manifestationsof tooth surface loss, to examine the predominantlocations and clinical signs that accompany thispathology, and to describe an orderly approach todiagnosis.

Initial AssessmentThe initial interview should include a thoroughreview of the patient’s health history, an evaluationof the wear history, a discussion of the patient’sdietary patterns, and an assessment of potentialoccupational factors and/or habits. The clinical ex-amination should include an evaluation of the pa-tient’s dental status, observation of specific wearpatterns, and, if possible, determination of the rateat which tooth structure has been lost. Serial bite-wing or other radiographs, made in earlier years,may provide objective evidence of the rate of toothsurface loss. Casts made in earlier years may alsoprove useful in determining the progression oftooth wear.

Observing the patient’s facial appearance pro-vides information such as an apparent decrease inocclusal vertical dimension. With the teeth in oc-clusion, the patient may exhibit a diminished facialcontour, thin lips with narrow vermilion borders,and drooping commissures (Fig 1).3 Interocclusalspace may appear excessive at the rest verticaldimension. Vertical dimension should be carefullyevaluated using one of several techniques previ-ously described.4-9

TerminologyFour types of surface loss have been identified,distinguished by the differing causes of loss. Attri-tion describes mechanical wear resulting from mas-tication or parafunction, and is limited to the con-tacting surfaces of teeth.10 Abrasion denotes thewearing away of structure through some unusual orabnormal mechanical process other than tooth-to-

Assistant Professor, Department of Prosthodontics, The University ofTexas Health Science Center at San Antonio, San Antonio, TX.

Accepted July 24, 2001.Presented at the annual meeting of the American College of Prostho-

dontists, New York, NY, October 22, 1999, and at the annual meeting ofthe American Academy of Restorative Dentistry, Chicago, IL, February 25,2001.

Correspondence to: Dr. Ronald Verrett, Department of Prosthodontics-MSC 7912, The University of Texas Health Science Center, 7703 FloydCurl Drive, San Antonio, TX 78229-3700. E-mail: Verrett@uthscsa.edu

Copyright © 2001 by The American College of Prosthodontists1059-941X/01/1004-0006$35.00/0doi:10.1053/jpro.2001.28264

224 Journal of Prosthodontics, Vol 10, No 4 (December), 2001: pp 224-233

tooth contact.10 Erosion indicates the progressiveloss of tooth structure through chemical processesthat do not involve bacterial action.11 Abfractionconnotes the pathologic loss of tooth structure at-tributed to mechanical loading and resulting inwedge-shaped defects in the cervical areas.12,13

Surface loss can be differentiated into 3 generalcausal categories: mechanical loss, which includesattrition and abrasion; chemical loss, which in-cludes erosion; and finally, a proposed biomechani-cal category, described as abfraction by Grippo.12

Abfraction lesions, in theory attributed to toothflexure, remain controversial12-14 and will not re-ceive further attention in this article. Althoughcategorization as mechanical or chemical consti-tutes a useful beginning toward understandingenamel wear, further exploration is necessary todetermine specific etiologies.

Determining EtiologyThe diagnosis of severe wear is frequently cloudedby the presence of multiple etiologic agents. Thediagnostic challenge is to first correctly identify thesigns of a severely worn dentition and then, usingan orderly evaluation process, to arrive at an un-derstanding of the etiology. It will be useful to beginthe discussion of this process with a review of thegeneral kinds of surface loss, including the develop-mental dysplasias that may contribute to the pro-cess.

First, it is important to distinguish between me-chanical and chemical wear. Each has distinctive

characteristics. Mechanical wear occurs between 2or more moving surfaces. This type of surface lossoccurs as teeth contact each other, or are abradedby another source (Fig 2). With mechanical wear,restorations tend to wear at the same rate as adja-cent tooth structure. Wear facets display sharplydefined peripheries that can be matched on articu-lated diagnostic casts. Teeth with severe mechani-cal wear are frequently asymptomatic, and patientsmay report parafunctional habits.

Chemical erosion occurs when tooth surfacesexperience prolonged exposure to acidic solutions(Fig 3), resulting in loss of structure and restora-tions that appear elevated, often termed “amalgamislands.” Occlusal surfaces display cupping and cra-

Figure 1. The appearance of the patient’s face when theteeth are in maximum intercuspation may suggest a lossof vertical dimension. Diminished vermilion borders anddrooping commissures are indications of a decreasedocclusal vertical dimension.

Figure 2. Mechanical wear has distinctive characteris-tics: wear facets with sharply defined line angles; resto-rations that wear at the same rate as adjacent enamel;asymptomatic teeth; and histories that include parafunc-tional habits.

Figure 3. Chemical wear has distinctive characteristics:occlusal cupping and cratering with rounded margins;erosion lesions that do not articulate with opposing sur-faces; elevated islands of restorative material, such asamalgam; and unstained but frequently hypersensitiveteeth.

225December 2001, Volume 10, Number 4

tering with rounded margins.15 Such findings arepathognomonic for erosion. The teeth are fre-quently hypersensitive and, in most instances, arenot stained. The cupping and cratering from ero-sion cannot be matched on opposing articulateddiagnostic casts. The causative acid may come fromwithin the body, from the diet, or from the environ-ment, and a detailed history will often reveal thesource.

Many reports have confirmed a multifactorialetiology associated with tooth surface loss. Whenconsidered as a single factor, location has not beenshown to reliably indicate the cause of surfaceloss.16 Limited population studies have attemptedto identify factors associated with high-weargroups.17-20 Johansson and co-workers21 examined59 high-wear patients and found that men showedsignificantly more wear than women. Increased biteforce was also positively correlated with increasedwear. Analysis of saliva showed that a low bufferingcapacity and a diminished rate of secretion alsowere related to high wear rates.

An efficient diagnostic approach involves deter-mining whether the cause of the surface loss ischemical or mechanical or a combination of both.The location of the loss and an interpretation of theaccompanying signs and symptoms may then beused to guide the differential diagnostic process.

Finally, it must be noted that hereditary dyspla-sias, such as amelogenesis imperfecta and dentino-genesis imperfecta, compromise wear resistanceand predispose teeth to accelerated surface lossfrom mechanical or chemical causes.22 Amelogene-sis imperfecta, a local, systemic, or hereditary dys-plasia affecting the quantity of enamel or the qual-ity of calcification, results in enamel that is thinnerand/or more friable, thus more susceptible to chem-ical erosion and mechanical wear.

Dentinogenesis imperfecta, a hereditary dyspla-sia of the dentin affecting both primary and perma-nent dentitions,22 results in teeth with a character-istic gray or brown opalescent appearance. A weakenamel-to-dentin bond results in the early loss ofthe enamel, rapid attrition, and increased suscepti-bility to caries.

Determining the Cause ofMechanical Wear

Once the mechanical nature of wear has beenidentified, the location or locations of surface lossshould be analyzed. Several individual patterns of

mechanical wear can be identified that tend tooccur at predictable locations. In the first, wearoccurs primarily on the incisal surfaces of the an-terior teeth. A second pattern displays occlusalwear throughout the arch, with progressivelygreater structural loss as one proceeds from theposterior teeth to the anterior teeth. A third wearpattern tends to occur on the facial surfaces ofcuspids and premolars. Each of these patterns ex-hibits specific associated clinical signs and symp-toms.

Pattern: Anterior Tooth Wear Greater ThanPosterior Tooth Wear

Inadequate or unstable posterior support has beenidentified as a factor in severe anterior attrition anddecreased occlusal vertical dimension.23 The loss ofposterior teeth has been reported as a major factorin the development of a traumatic anterior occlu-sion.24 Posterior occlusal prematurities also maycause increased function on anterior teeth, result-ing in increased wear (Fig 4).

Pattern: Progressively Greater Wear on theAnterior Teeth

Mechanical wear resulting from bruxism often re-sults in progressively greater wear toward the an-terior teeth (Fig 5). An exception to this findingoccurs in individuals with anterior open bite. Vari-ations in mandibular movement may result in awide variety of wear patterns in bruxing patients.As might be expected, bruxism produces surfaceloss, which is related to the duration and force ofparafunction. A definitive diagnosis may be made

Figure 4. Mechanical wear affecting primarily the ante-rior teeth may result from posterior tooth loss, malposi-tion, or interferences.

226 Analyzing an Extremely Worn Dentition ● Verrett

by hand articulating diagnostic casts and matchingwear facets. Additional intraoral findings may in-clude grooving of the lateral borders of the tongue,evidence of cheek biting, and the presence of frac-tured porcelain restorations. Cupping or crateringof the occlusal surfaces can occur once the enamelhas been perforated.

Pattern: Wear on Facial Surfaces of theCuspids and Premolars

Excessive tooth brushing may produce noticeablewear on the facial surfaces of the cuspids andpremolars, sometimes resulting in a “sandblasted”appearance with reduced anatomic detail (Fig 6).25

Depending on the patient’s oral hygiene habits,tooth brushing abrasion also may result in bizarrepatterns of wear with notching or grooving of theteeth. The amount of surface loss will be affected by

the individual’s tooth brushing technique, theamount of time spent in brushing, the mechanicalproperties of the toothbrush, and the abrasivenessof the dentifrice.26 A definitive diagnosis may bemade by asking the patient to demonstrate his orher brushing technique. This may confirm that thelocation of the wear correlates with the source ofthe abrasion.

Pattern: Wear in Variable Locations,Primarily Occlusal and Incisal Surfaces

Variable wear on occlusal and incisal surfaces sug-gests some type of parafunctional habit as a causalfactor. Such habits may be related to job require-ments, habitual behaviors, or stress. Case reportsdocument the destructive effects of foreign objectssuch as pipe stems, pins, needles, paper clips, sun-flower seeds, and soft drink cans.27 Wear is foundprimarily on the occlusal and incisal surfaces of theteeth (Fig 7).

Diagnostic Algorithm for Mechanical Wear

Mechanical wear can be unusual in appearance anddifficult to diagnose. Using a 3-tier decision tree canassist in categorizing the wear (Fig 8). First, iden-tify the character of the pathologic wear, then thelocation, then evaluate the clinical signs and symp-toms and discuss habit possibilities with the pa-tient.

Figure 5. Mechanical wear that is progressively greatertoward the anterior teeth and is characterized by exten-sive occlusal and incisal wear facets suggests chronicbruxism.

Figure 6. Mechanical wear that occurs primarily on thefacial surfaces of cuspid and bicuspid teeth is often re-lated to toothbrush/dentifrice misuse. Teeth may exhibita loss of surface detail and a “sandblasted” appearance.

Figure 7. Mechanical wear can occur as a result of avariety of parafunctional habits, including biting on nee-dles, pipe stems, hairpins, or paper clips, often resultingin notch-like defects at the occlusal or incisal surfaces.

227December 2001, Volume 10, Number 4

Determining the Cause ofChemical Erosion

Pindborg28 described “erosion” as loss of toothstructure resulting from a chemical process and notmediated by bacteria. Chemical erosion has beenidentified as a major cause of tooth surface loss. Ina study of 100 patients referred for evaluation oftooth wear, 89% were determined to have erosionas a contributing cause.29 Several population stud-ies have shown an increasing prevalence of dentalerosion in children. The largest of these studies, theUnited Kingdom Child Dental Health Survey of1993, reported that 52% of the 5-year-olds surveyedshowed evidence of significant erosion.1 Awarenessof the problem of erosion has increased in both thedental profession and in the general population forthe past 3 decades.

The risk of dental erosion has been shown toincrease with certain dietary habits, with gastricregurgitation or reflux, and in individuals withchronic self-induced vomiting.12,30 Once the chem-ical cause of surface loss has been identified, thelocation should be assessed. Patterns of erosionwith anterior tooth surface loss greater than poste-rior tooth surface loss or vice versa can occur.

Pattern: Anterior Surface Loss Greater ThanPosterior Surface Loss

Chemically mediated surface loss has been observedto occur in stages.31 Lesions begin as smoothly glazedenamel and progress to concavities. As the erosionprocess continues, islands of restorative material be-come evident, and cupping of the enamel occurs.Chronic vomiting is the most common cause of severe

erosion of the lingual surfaces of the maxillary ante-rior teeth, although hiatal hernia and gastric refluxare also possible causes. Chemical erosion of the max-illary anterior teeth has been correlated with self-induced vomiting since 1937.33 A diagnosis relating tochronic vomiting may be difficult to confirm becausepatients with eating disorders frequently deny suchbehavior.32

Chronic regurgitation can be recognized by thevery specific pattern of surface loss (Fig 9).33 Asgastric contents, with a mean pH of 3.8,34 rush pastthe teeth, the lingual surfaces of the maxillaryanterior teeth are most severely affected. There isprogressively greater erosive damage from poste-rior to anterior. Eroded palatal surfaces are verysmooth, with the defects beginning at the gingivalmargins. The maxillary molars and premolars mayhave chamfer-like defects on the lingual surfaces.Mandibular teeth tend to be minimally affectedbecause of the protection afforded by the tongueand the buccal mucosa.

Gastric reflux has also been shown to causeerosion on the lingual surfaces of the maxillaryanterior teeth.35-37 Erosion may occur as a localizedphenomenon at other locations if the hydrochloricacid reflux solution is permitted to pool, as mayhappen, for example, when the patient is sleeping.Gastroesophageal reflux differs from vomiting bothin the volume of acidic material to which the teethare exposed, and in the lack of forceful expulsion,because muscular contraction of the diaphragmdoes not occur. Identification of gastroesophagealreflux disease, or GERD, is often suggested by thesymptoms of belching, acidic tastes in the mouth,stomachaches on awakening, heartburn, and hyper-

Figure 9. Erosion occurring on the lingual surfaces ofthe maxillary teeth is evidence of chronic regurgitation.The lingual surfaces of the maxillary premolars andmolars may display chamfer margins.

Figure 8. The etiology of pathologic wear resulting frommechanical causes can be determined by correlating thelocation of wear, other signs and symptoms, and informa-tion obtained during the patient interview.

228 Analyzing an Extremely Worn Dentition ● Verrett

sensitivity of the affected teeth.38 However, manypatients with this disorder report no subjectivesymptoms, and ambulatory pH monitoring may berequired to confirm this diagnosis.38

Alcoholism may lead to erosion resulting fromchronic vomiting and regurgitation associated withgastritis. The lingual surfaces of the maxillary an-terior teeth are primarily affected, with mandibularteeth minimally affected (Fig 10). Alcoholism is arelatively common condition in western countries,with an estimated incidence of as high as 10% inmen.39 Robb and Smith40 found evidence of chem-ical erosion in 92% of a clinical sample of 37 inpa-tients admitted for the treatment of chronic alco-holism. They observed more severe wear in thosewho drank regularly as compared with binge drink-ers (ie, heavy alcohol consumption for up to 2 weekswith intervals of sobriety).

Citrus fruit sucking results in erosion on thefacial surfaces of the maxillary anterior teeth (Fig11). Severe erosion related to a prolonged history ofeating or sucking lemons has been reported.41 Thelocation and severity of erosion is directly related tothe manner in which the acidic food is consumed,the degree of its acidity, and the duration of expo-sure. In most instances, posterior teeth are sparedthe effects of the acid, and a marked transitionfrom the eroded anterior teeth to the unaffectedposterior teeth can be observed.

Pattern: Posterior Surface Loss GreaterThan Anterior Surface Loss

The dietary causes of dental erosion have receivedwidespread attention in case studies,42-44 popula-

tion surveys,14,28,45,46 and in vitro testing.47-50 Asacidic food and drinks are consumed, the occlusalsurfaces of the posterior teeth tend to displaygreater wear than the anterior teeth. Erosion re-sulting from extrinsic causes has been correlatedwith excessive consumption of low-pH carbonatedbeverages as well as fruits and juices with high citricacid contents. A study of 106 patients referred forevaluation of erosion, indicated a significant risk ofsurface loss occurred in patients who consumedcitrus fruits more than twice a day or soft drinks atleast once a day.15

Acidic beverages are widely consumed in oursociety. Larsen and Nyvad51 studied the erosivepotential of 18 acidic beverages and observed 3distinct groupings: carbonated flavored soft drinksincluding colas; orange juices; and mineral waterdrinks. In general, enamel erosion was found toincrease logarithmically as the pH decreased. Car-bonated mineral waters were found to increase inpH by almost a half unit as they were poured, andthe erosive effects on enamel were found to beminimal.

Chemical erosion in which posterior tooth sur-face loss is greatest at mandibular first molar andsecond premolar areas has been associated withholding carbonated soft drinks in the mouth and/orswishing (Fig 12). Erosion resulting from holdingcarbonated soft drinks in the mouth until the car-bon dioxide bubbles have dissipated has been de-scribed.52,53 Holding a low pH solution in the man-dibular posterior area tends to produce a specificpattern of tooth surface loss. The buccal mucosaand the lateral borders of the tongue tend to limit

Figure 10. Chronic regurgitation related to alcoholismcauses severe erosion of the maxillary teeth with minimalsurface loss on the mandibular teeth.

Figure 11. Citrus fruit sucking typically causes erosionon the facial surfaces of the maxillary anterior teeth,whereas the posterior teeth remain unaltered. The teethcontacted by the fruit and the manner of consumptiondetermine the clinical presentation.

229December 2001, Volume 10, Number 4

the effects to the occlusal surfaces with the resultthat amalgam restorations on mandibular molarsmay appear as elevated islands. Cupping or crater-ing of the occlusal surface also may be present andmay be severe. Maxillary teeth and mandibularanterior teeth are usually not affected.

Chemical erosion with surface loss evenly dis-tributed on the occlusal surfaces of the maxillaryand mandibular posterior teeth has been associatedwith chewing the pulp of citrus fruits (Fig 13).Eating citrus fruits more than twice a day has beenobserved to increase the risk of erosion 37-fold,15

producing a specific pattern of wear similar to thatresulting from habitually holding a carbonated softdrink in the mandibular posterior area. As the

acidic citrus fruit pulp is mulled between the teeth,surface loss tends to occur on both maxillary andmandibular occlusal surfaces. Cupping and crater-ing with smooth and rounded enamel edges is ob-served. This type of dental erosion has been associ-ated with the increased intake of fruits in health-conscious individuals such as vegetarians.43

Pattern: Variable Locations, MiscellaneousCauses

Any medication that has an acidic pH and that is infrequent contact with tooth surfaces can cause ero-sion. Chewable vitamin C tablets,54 chewable aspi-rin tablets,55 and aspirin powders56 have been asso-ciated with erosion on the occlusal surfaces ofposterior teeth. Abuse of the illicit amphetaminedrug, Ecstasy (3,4, methylene dioxy-methamphet-amine), has been associated with significant wear ofthe posterior occlusal surfaces when compared withage-matched, non-drug users.57 In addition, the ap-plication of cocaine to the oral mucosa has beenreported to produce cervical erosion on the facialsurfaces of maxillary anterior and first premolarteeth.58

It should be noted that saliva plays an essentialrole in minimizing tooth surface loss from chemicalerosion. Saliva dilutes, buffers, and neutralizes in-gested acids and aids in remineralization by provid-ing calcium and phosphate.59 Therefore, xerosto-mia should be considered in evaluating the factorscontributing to dental erosion.

Case reports and epidemiologic studies docu-ment erosion in factory workers related to occupa-tional exposure to acidic fumes and aerosols.60

Severe erosion affecting the facial surfaces of the

Figure 14. The etiology of pathologic wear resultingfrom chemical causes can be determined by correlatinglocation of wear, the presenting signs and symptoms, andinformation obtained during the patient interview.

Figure 12. Chemical erosion occurring predominantlyin the mandibular posterior region has been associatedwith holding and swishing soft drinks in the mouth. Thelow pH affects the occlusal surfaces of this area becauseof tongue position and gravity.

Figure 13. Uniform erosion of all posterior segmentshas been associated with the mulling of citrus fruits. Theacidic fruit pulp contacts the opposing posterior occlusalsurfaces and produces a wear pattern that may indicate acombination of mechanical and chemical wear.

230 Analyzing an Extremely Worn Dentition ● Verrett

anterior teeth has also been reported in profes-sional wine tasters61 and competitive swim-mers.62,63

Because erosion lesions present a wide variety ofappearances, a decision tree can be helpful in iden-tifying chemically mediated surface loss patterns(Fig 14).

ConclusionOrganizing the evaluation of a severely worn den-tition involves determining whether the characterof the surface loss is chemical, mechanical, or both.In turn, identification of surface loss locationsshould be made and accompanying clinical signsand symptoms identified. These observations, alongwith information gained from the patient interview,can then be combined to guide the diagnostic pro-cess.

It is important to remember that surface lossmay result from a combination of chemical andmechanical factors. Attrition from bruxism oftencan be identified in association with other causes.Patients may remain secretive about eating disor-ders and dietary habits. Establishing a diagnosisrepresents a challenge, but analysis and identifica-tion become more manageable if an orderly system

of information gathering and analysis (Fig 15) isused to guide the process.

AcknowledgmentThe author expresses gratitude to his mentor, Dr.Thomas C. Abrahamsen, who introduced the conceptsand applied an orderly algorithm to understand the eti-ology of severe tooth wear. A special thanks is alsoextended to numerous prosthodontic colleagues whoshared their clinical experiences and patient documenta-tion resources.

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Figure 15. The chemical and mechanical branches of the diagnostic decision tree can be combined to provide amethodical framework for analyzing an extremely worn dentition.

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232 Analyzing an Extremely Worn Dentition ● Verrett

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