Tooth Wear E-Book

Débora R. Vilaboa

• Herausgeber: Quintessence Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 479

Veröffentlichungsjahr: 2023

Beschreibung

Tooth wear is a significant challenge. Progressive, irreversible, and multifactorial in nature, it requires a patient-centered methodology for successful treatment. In this impressive book, the authors advance an integrative and multidisciplinary approach to worn dentitions that promotes early detection, thorough assessment, and conservative modalities and also understands that comprehensive treatment can require surgery, implants, orthodontics, and indirect restoration to improve oral health and achieve esthetic results. Overall, this book effectively compiles all clinical aspects of tooth wear—from concept and diagnosis, treatment and communication, to prevention and long-term maintenance.

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ISBN: 978-1-78698-120-2

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Table of Contents

Foreword Alberto Álvarez Fernández

Foreword Jaime A. Gil

Preface

Dedicated to

Thank you

Authors

SECTION I. UNDERSTANDING TOOTH WEAR

CHAPTER 1. TOOTH WEAR: A MAJOR HEALTH ISSUE

1.The Global Burden of Tooth Wear

2.Physiologic Versus Pathologic Wear

3.Anthropologic and Contemporary Tooth Wear

4.Prevalence of Tooth Wear

5.Tooth Wear and General Health

6.The Quintessential Challenge of Tooth Wear

7.The Economy of Tooth Wear: The TW Curve Shape

8.The Geography of Tooth Wear

9.Key Points

References

CHAPTER 2. TOOTH WEAR AND SALIVA: THE FIRST LINE OF DEFENSE

1.The Oral–General Health Connection

2.Saliva and the Oral Microbiome: Defenders of Oral and General Health

3.Saliva, the Oral Microbiome, and Tooth Wear

4.The Importance of Unstimulated Salivary Flow for the TW Patient

5.Saliva and Erosion

6.The Critical pH

7.Bruxism and Saliva

8.Improving Salivation: The Invisible Guard

9.Key Points

References

CHAPTER 3. ETIOLOGY AND TYPES OF TOOTH WEAR

1.Tooth Wear: Classical Nomenclature

2.The Etiology of Tooth Wear

3.Tooth Wear and the Pediatric Patient

4.Tooth Wear in Adolescents and Adult Patients

5.Tooth Wear Indices

6.Following Tooth Wear Clues: Lifestyle and Health TW Questionnaire

7.Key Points

References

SECTION II. ASSESSING AND TREATING TOOTH WEAR

CHAPTER 4. DIAGNOSIS AND TREATMENT PLANNING IN TOOTH WEAR

1.Initial Visit of the Patient with TW

2.Anamnesis of the Patient with Tooth Wear

3.Informed Consent for the Patient with Tooth Wear

4.Patient-Centered Path in Tooth Wear Treatment

5.The Ideal Occlusal Scheme

6.Material Selection: When to Subtract and When to Add

7.Accuracy and the Preservation Principle

8.Traditional Acquisition of Data

9.Digital Acquisition of Data: Cross-Mounting in the Digital Era

10.Traditional and Digital: Hop-On, Hop-Off Workflow

11.Sequence of Reconstruction by Sector

12.Key Points: TW Treatment Flowchart

References

CHAPTER 5. INCIPIENT TOOTH WEAR

1.The Onset of Tooth Wear

2.Erosion and Caries: Is There a Link?

3.A Close-Up Look at the Incisal Edges

4.Anterior and Canine Guidance in Incipient Tooth Wear

5.Intercepting Tooth Wear with Orthodontics

6.Restoration of Canine and Anterior Guidance

7.Intercepting Incipient Erosive Damage

8.Key Points: Incipient TW Flowchart

References

CHAPTER 6. MODERATE TOOTH WEAR: TREATMENT STRATEGIES

1.Moderate TW: The Space Issue

2.Adhesion to Worn Surfaces

3.Composite for Moderate Tooth Wear: Direct versus Indirect

4.Palatal Restorations for Tooth Wear

5.Porcelain Laminate Veneers for Tooth Wear

6.Increasing VDO: A Tool More than a Target

7.Non-Carious Cervical Lesions

8.Key Points: Decision Making in Moderate/Severe TW

References

CHAPTER 7. SEVERE TOOTH WEAR: TREATMENT STRATEGIES

1.From Moderate to Severe Tooth Wear 215

2.Wax-Up: The Blueprint

3.Additive Approach with Porcelain Laminate Veneers for Anterior Guidance

4.Occlusal Scheme: Vertical Dimension of Occlusion and Centric Relation

5.Indirect Bonded Inlays/Onlays

6.Partial and Full Crowns for Single-Tooth Restorations: Occlusal Adjustment and Polishing

7.Key Points: Decision Making in Severe TW

References

CHAPTER 8. ORTHODONTICS IN TOOTH WEAR TREATMENT

1.Malocclusion and Tooth Wear

2.Orthodontics to Intercept Tooth Wear and Preserve Tooth Structure

3.Orthodontics to Provide Missing Space and Preserve Tooth Structure

4.Communication: A Key Player in the Tooth Wear Outcome

5.Timing of Orthodontic and Restorative Interventions

6.Key Points: TW Treatment Planning: Considerations for the Orthodontic-Restorative Team

References

CHAPTER 9. IMPLANTS IN PATIENTS WITH TOOTH WEAR

1.Biologic and Mechanical Considerations

2.Clinical Recommendations

3.Overload and Implant Failure in Patients with Tooth Wear

4.Implants and Occlusal Space in Patients with Severe TW: Management of Vertical Collapse

5.Digital Cross-Mounting and Advantages of Digital Protocols in TW Treatment

6.Maintenance Protocols in Patients with TW and Implants

7.Key Points: Implants in TW

References

SECTION III. PREVENTION AND LONG-TERM MAINTENANCE IN TOOTH WEAR TREATMENT

CHAPTER 10. ARE WE IN TIME TO FLATTEN THE TOOTH WEAR CURVE?

1.30 Years of Treating Tooth Wear: What have we learned?

2.Modern Lifestyle: Change what is possible

3.Targeting Nutritional Risk Factors: The Benefits of Erosion-Protective Foods

4.Parafunctional Habit Control and Ideal Occlusal Scheme: Keys to Long-Term Maintenance

5.Oral Hygiene and Tooth Wear

6.New Strategies in TW Prevention: Enhancing Healthy Saliva, The Day and Night Bodyguard

7.Long-Term Maintenance of the Patient with TW

8.Patient-Centered Long-Term Management of TW: Quality of Life, Prems, and Proms

9.Key Points: General Maintenance Guidelines for the Patient with TW

References

APPENDIX

APPENDIX 1 – Lifestyle and Health TW Questionaire

APPENDIX 2 – Informed Consent for the Patient with Tooth Wear (To Be Adapted to Local-Regional Legal Status)

Abbreviations

Foreword

Why is Tooth Wear the Quintessential Challenge?

The Ancient Greeks believed a certain type of air could be found in the upper section of heaven, a type of air that was purer and more splendid than the air inhaled by mere mortals. This dazzling substance, or essence, inhaled by the Gods was known as ether.

Aristotle classified ether as the fifth natural element. To the four natural elements that had previously been identified by the Ionic philosophers—earth, water, air, and fire—Aristotle added a new, completely different element in his theory of nature.

When faced with the traditional four elements that made up the sublunar world, corruptible and subject to change—and given to imperfect, rectilinear movements—ether, the element that occupied the superlunary layers of the cosmos, the element from which the celestial spheres housing the planets and stars were made, was incorruptible, moving eternally and perfectly in circles, presenting characteristics that brought them closer to the divine.

Medieval philosophers gave ether the Latin name of “quintessence” for its aforementioned characteristic of being the fifth element that made up the Universe. The concept of quintessence gained significant importance in alchemy both in the Middle Ages and in the Early Modern Period.

In traditional alchemy, quintessence came to be identified as the Philosopher’s Stone (elixir of life), an essence that could transform any metal into gold. Alchemists searched for quintessence on Earth, but, believing that they would find very limited quantities here given its celestial origins, they mainly tried to find a formula to obtain ether by combining the other elements.

They had hoped to use quintessence as medicine in the form of an elixir. Given the purity and the divine quality of quintessence, alchemists believed that by taking the elixir an individual would remain free of any type of impurity and sickness, and they would even become young again (rejuvenate). Quintessence began to be identified with a spiritual energy that could unite and dissolve the other four elements; the soul of the world. Paracelsus maintained that quintessence was the element that would bring new life to the body and the soul. Inspired by the archaic Pythagorean doctrine, alchemists considered quintessence to be the spark of the divine in the human, of the heavenly in the earthly, of the infinite in the finite.

In this book, the problems associated with tooth wear (TW) are approached from four different aspects, elements, or basic dimensions: physical, functional, psychologic, and social, to which is added a fifth dimension, fifth element, or fifth essence, so to speak. As with alchemy, the preservation of the teeth involves a series of elements and combining these in the best way possible to achieve quintessence.

The esthetic dimension could be considered as the fifth element of those contributing to dental well-being. Just as quintessence, or ether, was the purest natural element, or essence, for the ancient philosophers, the esthetic dimension is the purest element, or essence, when facing the challenge of TW.

As the essence of the alchemists was centered around an element that offered the perfect combination of the other elements, it is important to clarify that we consider here a wider sense of the concept of esthetics, in its Greek meaning. In this way, we understand esthetics in its deepest and most profound state.

Esthetics is connected to feelings and how those feelings are perceived: the outside world, the world we see, what we hear, what we taste, what we smell, and what we touch. While esthetics can be approached according to the relationship each individual has with the world around them, it can also be approached according to the relationship each one of us has with others. Esthetics is the domain of the senses and perception. It encapsulates both the perception we have of others and the perception others have of us, and in turn the perception that we have of the perception that others have of us.

The teeth occupy a fundamental position in personal esthetics; the mouth is one of the principal and primary ways we present ourselves: a personal cover letter. Dental esthetics are a fundamental pillar for self-esteem and an individual’s confidence; therefore, through our mouth, teeth, and smile we are able to communicate a lot about ourselves, our personality, and our moods. The perception others have of us is very much related to the appearance of the mouth and teeth.

How do others perceive me? What image do I present of myself? Do I give off a youthful image, do I come across as a healthy person, confident in myself, and what in turn is of interest to others?

The response to these questions involves the teeth and the mouth as fundamental components. A person with a deteriorated mouth seems aged, in a bad state of health, and is going to feel as though others see them in this way too. Therefore, people may feel their self-esteem is undermined, and this in turn projects an even more deteriorated self-image; it is a vicious circle.

Think on this deterioration, of how it is perceived by others and how it is going to continue, affecting the different areas of the mouth in an itinerant, constant, and progressive way. This thought will lead you to be aware of your finiteness and that the Universe, with its huge regions where the ether dwells, will continue its course without you being able to do anything to prevent it. The divine quintessence in its eternal and perfect movement is unconnected to this suffering.

Alberto Álvarez Fernández

Spanish philosopher and economist, childhood friend of the authors

Foreword

Drs Debora and Beatriz Vilaboa have a passion for dentistry that has pushed them to search for better ways to deliver treatment while respecting the benefits of tooth preservation. Their enthusiasm for and dedication to this work is transmitted to their students and their team. In this book, they now share their vision with a wider audience.

After medical and dental school, Drs Vilaboa wanted to address the need for dental restoration with a legitimate desire to improve smiles, and they pioneered with other colleagues in esthetic dentistry. They believed in restoring worn dentitions and anterior guidance with porcelain laminate veneers and worked to overcome the general reluctance toward adhesive restorations in a time when traditional prosthodontics seemed preferable.

They have always described their career as a “journey,” and I have been honored to count myself as a companion on that journey. Not only have they attended every continuing education seminar and congress that I have organized, but I was proud to mentor them as they became active members of the European Academy of Esthetic Dentistry and have remained an active part of their family since then. I had the pleasure of knowing their father and mother and brilliant brother Jorge. In addition, the parallelism between Debora’s and my family has been a matter of joy for all of us, and in both families, the next generation (Jose Manuel and Alfonso, through surgical and restorative disciplines and Debora and Jaime as orthodontists) has also chosen to devote their lives to dentistry. The torch is being passed on.

The Vilaboa family is one of business talent. Their group practice is well structured and patient centered and a source of inspiration to us. It has flourished because they understood how a multidisciplinary approach and the fluent use of the newest digital tools could enhance the patient experience and the treatment processes.

Inside this book, readers will find an integrative and multidisciplinary approach to tooth wear, which covers surgery, implants, orthodontics, and restorations (both direct and indirect), with the goal of improving oral health and achieving esthetic dentistry. In addition, the economic burden of tooth wear is softened with well-supported protocols that help make treatment accessible in all cases.

Overall, this is a comprehensive book for tooth wear that is easy to read and that effectively compiles all clinical aspects—from the concept and diagnosis to treatment and communication. Enjoy the reading and we will continue to meet along the journey.

Professor Jaime A. Gil

President International Federation of Esthetic Dentistry (IFED)

Preface

The appetite for new restorative paths continues apace. At the same time, the digital evolution of the dental industry continues to thrive, with unprecedented possibilities for a more precise and predictable outcome.

This may well be a pivotal moment for the practice of dentistry with the advent of full digital workflows and the intermediate traditional-digital hybrid to suit all practitioners.

Whether the dental practitioner is a digital flow purist or a believer in traditional chairside dentistry, the patient always remains analog, reminding us that the mouth truly is a live test bench with the patient headlined for comfort, well-being, and a pleasing result.

As in any other field, flexible and prepared human power leads to productivity and efficiency improvement.

Sticking strictly to only one flow, be it CAD/CAM or manual, may be holding the overall process back from time-saving and precise outcomes both in the diagnostic and restorative phases.

The approach of treating only to repair diseased tissue associated with lesions may prove a limited perspective, while the trend to treat in a primarily esthetically driven way may leave the patient unprotected as a concomitant shift in lifestyle can be devastating in already demineralized tissue.

Perhaps one can be tempted by a self-content attitude, delivering restorations in the same manner as with any other dental condition. But in doing this there is not much space to ask oneself why. Why has this happened? Why has the patient lost the protection of saliva? Why are the lesions different in every patient, and even within the same mouth? Why is there no pain? Why is there no space? Why is the patient oblivious of so much tooth structure loss? Why are we more prepared to choose our preferred treatment option? Why are we doing that? Why is it necessary? Why should the patient with TW have the same regular checkups as other patients?

In asking yourself why, you will serve the patient better, as many procedures that initially would have been deemed necessary will probably be left out after questioning whether the principles of maximum tooth preservation are still present, making the overall treatment more accessible and acceptable for the patient. Nonetheless there should be general rules or protocols as in any other field of medicine, as any decision will have an impact not only on the treatment outcome but on the overall tooth survival.

Artificial intelligence and facial and surface recognition will most probably deliver treatment tools unimaginable today.

The recognition that preventing TW and intercepting further TSL may be less hazardous than imitating nature has made a quantum leap in recent years. All disciplines of modern dentistry and medicine, when focused on early detection and minor intervention, may demonstrate a shortcut to flatten the TW curve.

When reading this book, the authors hope you have a feeling of a déjà vu, as this is intended to be a reader-friendly compilation of observation, study, and clinical work that surely you too have experienced. If so, we hope it inspires clinicians who wish to treat TW patients.

Embark, and enjoy your journey¡

Dedicated to

Our families with love.

My son, José Manuel, whom I admire.

My daughter, Débora, who fills my life with joy.

With gratitude to both of them for following in my professional steps.

Laura, who has enriched our family.

Manuel, a source of joy and strength.

My husband, José, who always believed in me.

Diego, the sunshine of my life.

My husband, Jesus, for thinking I am the one.

Our brother George, the leader of our family; Marta, the love of his life; Clara, the new orthodontist in our family; Bea; and Paula.

In loving memory of Manuel and Pilar, our parents whose love inspired us all.

Débora and Beatriz R. Vilaboa

Manu, you are my world. My mother Débora and my aunt Beatriz, my role models.

My father, the most positive person I have ever met. My brother, the best working partner I could ever have.

The women in my family, Patricia, Marta and Eva for their generous and incondiotional support. To Manuel and Jose for your love to Manu and me.

Clara, Beatriz, Paula and Diego we have grown together with an unbreakable bond.

S. Ochandiano, D. Martin, M. Pulido, B. Mateo, E. McLaren, R. Romano, De Rossa and D. de Franco, my true inspiration.

Débora Reuss

Laura, my love, my everything.

My mother and father, sister, and aunt, for their endless love and support.

My mentors, Drs Martínez Corriá, Gil, and Moy. Your input in my professional life is priceless.

José M. Reuss

Thank you

This is a dedication to those who have accompanied us throughout our professional and personal lives. Thank you to our patients for blessing us with their confidence.

Thank you to our team for believing in our project. Thank you to Drs Mercedes Pulido, Borja Mateo, Amparo Llorente, and Maria Araujo; we have sailed many seas. Thank you to Dr Marta Lago; your father would be proud of you. Thank you to Drs Veronica Rubio, Laura Peix, Cristina Fernandez, Jaime Fernandez, and Beatriz de Lujan for enriching our restorative mission. Thank you, Julia, Veronica, Adina, Juana, Sandra and Marisa. We need you so much. Thank you, Angel, Karmel, and Andrea, you landed in the middle of the storm. Thank you, Carmen Fernandez and Jess Ride-Out, continuing our writing during the weekends was easier with your help. Thank you Silvia Muriel, you have been an asset.

Thank you to Laura Cifuentes; we knew from the beginning we were in good hands. Thank you, Rocio Perez Durias, you inspire us. Thank you, Paloma, for taking the torch. Thank you Marc Romea for the support and input.

Thank you to Elena Perez, you said you would do it, and you did it. Thank you for being with us. By the way, yes, you are kidnapped and the ransom payment will be high.

Thank you to Carlos Barja, Gonzalo Medina, Santiago Dalmau, and your team. Thank you to Stefano and Fernando Tonarelli; God bless our lecture in Warsaw. Thank you to the Rutten brothers. Thank you to Javier Rubio and to Arturo Calvo.

Thank you to our family from the European Academy of Esthetic Dentistry for your friendship and support.

Thank you to Jaime Gil for your lifelong mentorship. Thank you to our colleagues from BQDC. You are the best.

Thank you to Alberto Alvarez for your reflections. Thank you to Gonzalo Rada for your drawings. Thank you to Ines Castellanos for your lifestyle photography.

Thank you to the Haase family. You are not just our editors; you are much more than that.

Débora and Beatriz R. Vilaboa,

Jose Manuel and Débora Reuss

Authors

DEBORA R. VILABOA

Dr Debora R. Vilaboa graduated from the Complutense University Faculty of Medicine and Surgery in Madrid. The same year, she was accepted at the Seville School of Dentistry, where she obtained her dental degree. Later on she chose to attend the Advanced Pediactric Dentistry Program at the University of Southern California in Los Angeles.

After establishing the Vilaboa Clinic in 1987, she found that some cases could not be explained by caries nor periodontal disease and began gathering data. She lectured on tooth wear as early as 1992, both in Spain and the United States. Understanding how to approach the treatment of young children helped Dr Deborah Vilaboa in her work with tooth wear patients, many of whom had a fear of dentistry. As a pioneer in the field of porcelain laminate veneers, she treated such cases with a novel adhesive concept.

Dr Debora Vilaboa soon became a member of the Spanish Society of Stomatological Prosthetics (SEPES) and the Spanish Society of Periodontology (SEPA). Her passion for treating patients and continuing education was rewarded in becoming an active member of the European Academy of Esthetic Dentistry (EAED). She was then able to pursue her restorative and prosthodontic interests, thanks to a truly collaborative and generous exchange of knowledge among the active members that is still a driving force for the team at Vilaboa Clinic. She is also an active member of the Italian Academy of Esthetic Dentistry (IAED).

Dr Debora Vilaboa was invited by the San Pablo CEU University to create an undergraduate Esthetic Dentistry Department that she co-directs with her sister, Dr Beatriz Vilaboa. She lectures worldwide in esthetic dentistry, with a focus on tooth wear. She was a contributor to Esthetics in Dentistry (Quintessence, 2016). Given her medical background, Dr Deboarh Vilaboa is devoted to understanding and treating conditions arising from medical and oral imbalances, and through her research, she has obtained several patents related to her work. She is an active member of the American Academy of Oral Medicine (AAOM), a fellow member of the International College of Dentists (ICD), and an academic at the Pierre Fauchard Academy.

BEATRIZ R. VILABOA

Dr Beatriz R. Vilaboa received her degree in medicine and surgery with honours from the Complutense University of Madrid from which she also attained her specialty in stomatology. She joined Clinica Vilaboa in Madrid soon after her sister Dr Debora R. Vilboa founded it in 1987. She enjoys her private practice at the Vilaboa Clinic, dedicated to esthetic and restorative dentistry.Her devotion to treating patients using the most conservative approach possible motivated her to embrace the adhesive-additive concept to provide solutions to the tooth wear patient. Her interest in tooth wear culminated with a PhD from San Pablo CEU University Faculty of Medicine in Madrid, where she is now Co-Director of the undergraduate Esthetic Dentistry department. Dr Beatriz Vilboa’s passion for teaching is also evident in the many courses that she and her sister have given over the last 30 years.

Dr. Beatriz Vilaboa has the honour of being an active member of the European Academy of Esthetic Dentistry (EAED) and the Italian Academy of Esthetic Dentistry (IAED). She is also founding member of the International Academy of Adhesion (IAA). Her desire to better help patients suffering from cancer and other major medical conditions pushed her to become a member of the American Academy of Oral Medicine (AAOM). She is also a member of the Spanish Society of Stomatological Prosthetics (SEPES) and Spanish Society of Periodontology (SEPA), as well as a fellow member of the International College of Dentists (ICD) and an academic from the Pierre Fauchard Academy. She lectures worldwide on esthetic and restorative dentistry and especially on tooth wear.

Dr Beatriz Vilaboa treasures friendship with colleagues worldwide and believes that the common passion for dentistry goes beyond borders.

JOSE MANUEL REUSS

Dr Jose Manuel Reuss graduated in dentistry from the University Complutense of Madrid, where he also obtained a Master’s Degree of Science. As a postgraduate in surgical implant dentistry at the University of California at Los Angeles, he was a recipient of a grant from the American Academy of Implant Dentistry for preclinical and clinical research. During his postgraduate research, he focused on bone regeneration with growth factor technologies.

Dr Jose Manual Reuss’s clinical background both in implant surgery and prosthodontics has led him to develop a facially guided restoration concept. In particular, severe tooth wear or highly dysfunctional cases can benefit from the combination of digital protocols and a more traditional classical workflow. His current clinical and research foci relie on the integration of facial scanners into guided surgery systems, restorative protocols, and clinician-technician communication.

As an affiliate member of the European Academy of Esthetics Dentistry, he is an enthusiast of multidisciplinary thinking and is therefore also a member of the Spanish Society of Prosthodontics (SEPES), the Spanish Society of Periodontics (SEPA), the Academy of Osseointegration (AO), and the European Academy of Osseointegration (EAO).

Dr Jose Manuel Reuss is a Collaborating Professor in the Postgraduate Prosthodontics Department in the field of implant and restorative dentistry at the University Complutense of Madrid, the University of Leon, and at the Esthetic Dentistry Department at the University San Pablo CEU of Madrid. His current focus of research is digital implant dentistry and severe tooth wear with the aim to optimize diagnostic and treatment phases and engage the working team in research. His goal to simplify the communication between the team members of an integrated multifaceted treatment plan challenges Dr Reuss almost as much as his passion for sports in his personal life.

DEBORA REUSS

Dr Debora Reuss obtained her Master’s Degree in Orthodontics at the European University of Madrid, 4 years after graduating as a dentist from San Pablo CEU University of Madrid. Having completed several postgraduate specialty courses (including Damon self-ligating and Invisalign systems), she joined the Spanish Orthodontics Society (SEDO) and the Spanish Society of Aligners (SEDA). As a Member of the American Association of Orthodontics (AAO), she is a firm believer in facial- and profile-guided orthodontics.

Dr Reuss trained in occlusion at the Pankey Institute of Miami and believes that a classical concept of occlusion must be a driving force in treating orthodontic patients.

Her passion for treating patients within a multidisciplinary approach has inspired her to attend continuing education courses on occlusion, restorative, and prosthodontic topics and is the reason behind her affiliation with the Spanish Society of Stomatological Prosthetics (SEPES) as well as the reason why she became affiliate member of the European Academy of Esthetic Dentistry (EAED) and the Italian Academy of Esthetic Dentistry (IAED). Dr Reuss teaches at the Esthetic Dentistry Department at San Pablo CEU University of Madrid.

Multidisciplinary thinking led her to join the Vilaboa Team in Madrid to help treat tooth wear patients with a minimally invasive philosophy to prevent further wear and to ensure conservative performance of the required restorations. An education in three-dimensional thinking as an orthodontist is key in leading the tooth wear team to a facially guided restoration as an architect of the oral complex.

SECTION I

UNDERSTANDING TOOTH WEAR

„Teeth talk; you just need to watch.

CHAPTER 1

TOOTH WEAR: A MAJOR HEALTH ISSUE

„The Perfect Storm: A critical or disastrous situation created by a powerful concurrence of factors.

—definition from the Merriam-Webster dictionary

Tooth wear (TW) understood as non-carious surface loss is damage to teeth—independent of trauma or bacteria and not explainable by the patient’s age—that can compromise tooth survival.

TW may well be one of the biggest challenges posed to both the dental professional and the patient today.

Progressive, irreversible, multifactorial, and insidious in nature, it ideally requires a comprehensive approach and a trained team with the ability to recognize TW at its earliest onset and establish preventive measures and a patient-centered treatment path.

Conversely, a wait-and-see attitude is not desirable as wear progression may prove devastating even in young dentitions over a short period of time. The course and cycle of TW is closely interrelated with general health conditions and lifestyle, with a documented negative impact in four dimensions: physically, functionally, psychologically, and socially.

Yet there is a fifth dimension when facing the challenge of TW connected to feelings, well-being, self-esteem, and self-image.

Understanding TW, finding better treatments for our patients, and contributing to a flattening of the TW curve is a team task.

1. The Global Burden of Tooth Wear

Over the last decades, TW has trespassed beyond the boundaries of anthropology, gradually invading the pages of peer-reviewed journals, congresses and webinars of the restorative and prosthodontics fields of dentistry.

Traditionally, the wearing of the dentition has been considered a consequence of aging. Even though TW can occur at any stage of life, it is in adulthood and beyond where TW is most prevalent. The world is seeing an unprecedented growth in its aging population throughout all countries and regions, an effect of globalization. It is only a matter of time before this growing group of patients with worn dentitions will include everyone of us, if it has not already. While longevity is a success story, not preparing protocols and services according to growing needs will negatively impact our practices in the long run and may exclude wide sectors of our society from the benefits of the aftermath of development and well-being.

Life expectancy has also been stated to be responsible for the deterioration of the dentition, as well as other aspects of the oral cavity such as salivary function. Other parameters like general health and lifestyle of the individual are key to oral health and a well-maintained tooth structure. Today oral health is regarded as an integral part of general health, especially after multiple studies have linked oral health to major health conditions (Fig 1-1).

Fig 1-1 This image shows that worn enamel caused by grinding or tooth clenching can facilitate further tooth loss with the onset of acidic attack. This 62-year-old male patient was diagnosed with GERD at the age of 60. The acidic attack onset will meet with an already worn, flattened tooth that lacks enamel protection and is therefore more susceptible to erosion.

TW is undoubtedly a challenge for the dental profession in the current decade.

Commonly undiagnosed and unfortunately underestimated during the initial stages, TW, when left untreated, leads to anatomical loss of valuable tooth structure, increased permeability of pathogens, functional impairment, psychologic impact, social disability, and esthetic changes. Pain, high risk of tooth fracture, and eventually premature tooth loss will follow long-term untreated severe TW.

TW is also responsible for facial and dentoalveolar compensation that is unfortunately unable to overcome the bone consequences of premature tooth loss.

TW is common in patients throughout the world, in some cases associated with habits like acidic diets. Strikingly, young adults and even children may experience TW to a noticeable amount by the time they are diagnosed. It is often asymptomatic for many years until an issue such as a fracture, restoration failure, or abscess brings the patient to the office (Fig 1-2).

Fig 1-2 The radiographic exam of this young adult revealed both low incidence of caries and periodontal compromise (a). Single tooth–oriented treatments have not been able to prevent TW from progressing. Hard tissue loss is seen in the form of disappearance of occlusal and facial anatomy and topography of cusps and occlusal fossae. Note the remaining composite restorations resisting erosive attack. Photos were taken before any hygiene and prophylaxis was performed, and the low presence of biofilm is noticeable (b to d). (See more on this case in chapter 7.)

The wait-and-see approach can have unprecedented consequences as TW is multifactorial, cyclic, and progressive. Even in the absence of the original etiologic factor, it can lead to further tooth loss in the original site of TW or distant sites of the mouth (Fig 1-3).

Fig 1-3 A 55-year-old male patient with exposed dentin as a result of prolonged exposure to an acidic environment. Patient was free of symptoms despite the obvious erosive lesions (a). Progression of tooth structure loss of untreated lesions over an 8-year time period (b).

In the 2020s, TW is defined by irreversible tooth surface loss (TSL) affecting either enamel or enamel and dentin by factors different to the ones responsible for caries or trauma.1 This loss of tooth structure comprises damage to the macro and micro aspects of teeth. The different clinical presentations include attrition, abrasion, abfraction, and erosion, or a combination of all of these.

The increasing number of papers on TW and erosion serve as evidence of the exponential growth of awareness of dental practitioners and researchers regarding this topic. This comes as no surprise since both the occurrence and severity of TW has been growing rapidly over recent decades.

Furthermore, escalating occurrence in the young population today predicts an avalanche of worn dentitions, dramatically changing the scenario to one in which dentists will have to perform and deliver restorations susceptible to more failure2 (Fig 1-4).

Fig 1-4 Multifactorial TW in a 38-year-old male patient. Note distinctive vestibular defects in relation to a combination of abrasion, erosion, and abfraction, together with generalized manifest erosive damage (a). Capricious occlusal anatomy evocative of an erosive skyline landscape (b). Roller coaster incisal profile (c).

Moreover, the geriatric challenge for dental medicine associated with a still-lengthening life expectancy comes from the fact that preventive strategies in the adult, plus better hygiene and nutrition, as well as preventive and treatment strategies of comorbidities of dental diseases (eg, caries and diabetes, periodontitis and cardiovascular conditions), have provided the opportunity for more people to keep their teeth even in the later decades of their life.

Some authors have anticipated that edentulism will be present in only 2.6% of people by 2050, mostly in the oldest and poorest demographic groups3 (Fig 1-5).

Fig 1-5 Note in the panoramic radiograph periapical lesions in relation with extreme TW (a). A 68-year-old male patient with multifactorial TW lesions such as attrition, abrasion, abfraction, and erosion (b). Most of the enamel and dentin is gone, exposing pulp chambers and root canal filling materials with severe TW and premature tooth loss (c).

On the other hand, the emerging number of people diagnosed and treated for cancer, and very recently those with secondary effects of the COVID-19 virus, pose a challenge as erosion will be present in dentitions even in the absence of high acidic affluence. Polypharmacy, chemotherapy, and noncommunicable general health conditions will course with salivary gland dysfunction, be it hyposalivation or alteration of the composition of saliva, a hidden cause and potentiator of TW, as will be discussed in chapter 2.

Dental professionals will have to do a quantum leap in their understanding of TW and have a cascade of possible treatment strategies to be able to care for their patients in this prospective future (Fig 1-6).

Fig 1-6 Erosive wear in a 27-year-old woman with noticeable absence of bacterial plaque and distinctive perimolysis pattern with exposed dentin and intact enamel at the gingival margin. Generalized loss of palatal anatomy leads to breakage of incisal edges and crown shortening. (See more on this case in chapter 7.)

While caries and periodontal diseases are plaque-related conditions, TW is independent of the level of plaque accumulation. In fact, caries and erosion cannot happen simultaneously on the same tooth surface at the same time.4

While innate defense mechanisms against caries are multiple and effective in healthy patients to contain progression of or even revert the lesion, erosion and attrition—and the combination of both—are progressive and do not encounter a remineralizing parallelism.

Plaque-removing strategies and fluoride together with hygiene measures can change the course of carious disease. Unfortunately, such preventive measures do not stop TW.5

Caries is a classic condition that is easily recognized and managed by dentists and their teams when compared to TW. The decline in caries incidence and rate of progression in some countries has shifted caries intervention toward a less invasive approach.

However, the type of restorative approach is far more dependent on the professional ability and background of the dentist than on the disease of the patient. In fact, both the treatment strategies and the diagnosis vary widely between dentists who do not make an individual diagnosis and evaluation but rather respond automatically towards caries.6

Many factors have been accounted for in the variability of treatment decisions between dentists when confronting caries. These include dentist education, oral hygiene status, financial considerations, workload, number of years in practice, school attended, and the dentist’s feeling on the speed of progression of the lesion, all of them leading to false-positive and false-negative interventions.7

The decisions on why, how, and when to intervene on a tooth are going to affect its life cycle and survival as well as the oral status of the patient.

2. Physiologic Versus Pathologic Wear

Experts agree upon the fact that a certain degree of TW is physiologic with the passing of the time. However, excessive or premature wear cannot be related to age. In other words, premature TW that occurs in the younger patient cannot be attributed to the patient’s age.

Notwithstanding the above, the acceptance of a normal amount of TW should be taken into consideration relative to the patient’s age. For example, incisal edge wear in the absence of other findings like insufficient guidance protection in a 62-year-old patient is reasonably compatible with good oral health and may only need consideration from an esthetic point of view (Fig 1-7).

Fig 1-7 Note incisal edge wear in a 62-year-old man associated with a long-standing malocclusion in an otherwise healthy and functioning mouth. (See more on this case in chapter 8.)

Conversely, in a teenager, incisal or canine cusp wear should raise concerns as parafunctional habits may lead to exponential damage in future years. The insidious character of TW causes a subtle change in the anatomy that goes unnoticed to the untrained eye (Fig 1-8).

Fig 1-8 Teenager with incipient TW affecting incisor edges and canine cusps due to a parafunctional habit (lip biting). (See more on this case in chapter 5.)

Despite the existing debate around the definitions and terminology in the universe of TW, there seems to be agreement that while attrition or abrasion to a certain extent can be physiologic, erosive damage should always be considered to be pathologic (Figs 1-9 and 1-10).

Fig 1-9 Erosive damage in a young female patient. Incisal wear due to palatal erosion. Note translucency due to palatal structure loss. (See more on this case in chapter 7.)

Fig 1-10 Acid erosion dissolution of tooth structure in a young woman. Note the characteristic remaining enamel halo at the gingival margin.

3. Anthropologic and Contemporary Tooth Wear

The story of human evolution, where we come from and who we are, has been explained through morphologic study and more recently with the aid of the genome of fragmented human fossils. The anthropologic study of the human dentition, more than any other part of the body, has contributed to our knowledge about our primitive ancestors.

Attrition and abrasion have existed since the beginning of humanity. Teeth were utilized as tools to soften, blend, and tear raw materials like animal skins, branches, and hunting devices.

Interestingly, in specimens from our ancestors dating back to the early medieval ages, erosion seems almost nonexistent (Figs 1-11 and 1-12). Similarly, anthropologists are not familiar with the emerging phenomenon of erosion, as no signs of erosion are seen in prehistorical fossils.

Fig 1-11 Attrition and abrasion signs in this specimen from the Middle Ages before the advent of the modern “erosive era.” (Courtesy of the Anthropological Collection of the Museum of the School of Legal Medicine at Complutense University of Madrid.)

Fig 1-12 Note the caries- and erosion-free dentition despite the primitive oral hygiene regimen in the Middle Ages. The absence of fast food or cariogenic drinks and the presence of a local, non-industrialized diet explain the lack of caries and erosion signs. Harsh and coarse food ingredients such as in hunted meat and/or raw vegetables and grasses support the attrition signs. (Courtesy of the Anthropological Collection of the Museum of the School of Legal Medicine at the Complutense University of Madrid.)

Biologic anthropology considers that human functional evolutionary adaptation starts in climate and environmental changes that in turn dictate the form, size, and characteristics of humans.

The concept “form follows function,” originally coined for industrial design, can be applied to the adaptation of teeth throughout human evolution. When humans of the Homo genus started to eat fruits and meat and later were able to cook with the discovery of fire, teeth proved unnecessarily wide and large and consequently started to evolve to a smaller size.

The canine of hominids diverged in form from the ape’s, losing prominence in the arch. By the time the humans of the Homo genus settled down, their canines were essentially like ours today, drawing a slightly curved line in harmony with the row formed by the incisors.

The increased thickness of the human enamel appears to be an adaptation to a longer life expectancy of humans, who benefit from a reservoir of wear-resistant, non-shedding tissue for the years to come.8

Rapidly occurring extensive wear in the short life span of prehistoric humans of the Australopithecus genus found in specimens of South African fossils are a manifestation of very abrasive diets in otherwise caries-free and erosion-free individuals, as acid erosion is an unseen phenomenon until modern times.9 For many decades, anthropologists did not distinguish between the three major terms abrasion, attrition, and erosion, even though erosion was almost absent in anthropologic libraries borrowing the term from geologists.

It is only recently that dentistry has differentiated clearly between these three mechanisms that affect modern dentition. Nevertheless, complexity lies ahead as they can be overlapping, subsequent, or concomitant10 (Fig 1-13).

Fig 1-13 The accuracy that photography and new technologies provide today, together with the increasing understanding of TW, enables a better differentiation of the mechanisms behind TW. However, the concomitant and alternant course of the different origins of TW pose challenges, both to the patient and the dental team, in the everyday practice.

4. Prevalence of Tooth Wear

Several difficulties lay behind the ample variation of results when assessing TW prevalence. First was the lack of a universally accepted case definition. Second was the difficulty in accepting a unified TW index. When using the TW term and its different subcategories, some authors refer to TW as a synonym to erosion, whereas others clearly separate erosion and TW into different categories.

Lifestyle and contemporary habits have created the actual TSL scenario (Fig 1-14).

Fig 1-14 Lifestyle and dietary habits with acidic fruits and beverages are behind many cases of TW in young patients today.

Double-digit figures of the prevalence of TW, ranging from 70% in primary dentition in German children11–13 to 78% in the same age group of Australian children,14 reveal a reason to worry.

Prevalence of TW in permanent dentition ranges from 8% to 31% in 14-year-old children in the United Kingdom, while other teenager populations show an overall prevalence of 10% to 90%15,16 (Fig 1-15).

Fig 1-15 Incipient TW in an adolescent clinically diagnosed during a checkup for hygiene and prophylaxis with a hygienist (a). Detail of flattening from incipient TW lesions affecting incisal edges as well as canine cusps (b).

Although epidemiologic studies have predominantly studied children and the younger population, research has shown a high incidence of TW in adults that may affect up to 77% of their anterior teeth.17 Sex distribution has shown a significantly higher occurrence of TW in males with ratios such as 2.3:118 and 1.7:1.19

Lifestyle, dietary habits, and stress, together with higher masticatory forces, may explain the higher occurrence in men. Severity of wear has also been found to be higher in men than in women.20

An exception is TW found predominantly in women suffering from eating disorders.

5. Tooth Wear and General Health

The modern concept of general health is inseparable from oral health. TW when left untreated evolves into an oral condition that impacts negatively on quality of life.TW is commonly present in cases of premature tooth loss.

Failure to detect moderate to severe cases of TW and treat them with restorative, noninvasive approaches, leaves the patient and the dentist victims of repeated tooth-oriented treatments that unfortunately will not change the evolution of TW.

In order to understand comorbidity of TW, it should be taken into consideration that the oral cavity is part of both the digestive and respiratory tracts (Fig 1-16). Therefore, any condition that affects the respiratory apparatus may cause damage in the oral cavity and vice versa. Pneumonia, pulmonary fibrosis, and asthma can be triggered or caused by poor oral hygiene, a shift in the oral microbiome, or a definite oral dysbiosis. This has been acknowledged recently as the oral-lung axis.20

Fig 1-16 Erosive wear with enamel dissolution in a male patient in his 60s with chronic unspecific digestive complaints compatible with the presence of gastric reflux and an active social life (a and b).

Conversely, patients with mouth breathing, obstructive sleep apnea (OSA), pulmonary insufficiency, chronic obstructive pulmonary disease, or pulmonary fibrosis and patients on an oxygen regimen exhibit varying grades of TW.

Similarly, patients with gastroesophageal reflux disease (GERD) have a higher incidence of dental erosion with a reciprocal negative effect. It has been found that patients with GERD have a low salivary flow.21 In another study by Correa et al, while there was no significant difference between patients with GERD and a control group when it came to salivary flow, the results showed a significant difference in the salivary buffering capacity, with it being lower in the GERD group22 (Fig 1-17).

Fig 1-17 A 21-year-old male patient with generalized TW that has eliminated anatomical and morphologic features. The “cleansing effect” of acids removes all biofilm and impedes the adhesion of the acquired pellicle with the result of an immaculate mouth that should not hinder the diagnosis of premature wear. A presumptive silent reflux diagnosis needs to be confirmed in this very young adult.

On the other hand, patients with worn dentitions and impaired mastication are at higher risk of esophageal and gastric disease, which can be the origin of the TW, and in a vicious cycle the worn dentition can aggravate and perpetuate the digestive problems (Fig 1-18).

Fig 1-18 A 40-year-old male patient with severe wear nearing pulp exposure.

Saliva is the most important biologic factor affecting the progression of dental erosion.23 Medication-induced salivary gland dysfunction (MISGD), specifically a decreased salivary flow or a change in the salivary composition, is a common comorbidity of many conditions and diseases and their associated medication. In the 2014 World Workshop on Oral Medicine, clear conclusions arose identifying the strong connection between medication and xerostomia, with xerostomia occurring in almost 50% of patients taking antihypertensives. This percentage increased to 71% in patients taking antidepressants.24 Intake of prescribed medications follows a growing pattern as stated by the data collected by health organizations such as the Center for Disease Control in the United States.

Another growing group of patients in whom premature, devasting TW can be seen is in those suffering from eating disorders. The prevalence of bulimia nervosa in young women reaches 5%, while anorexia, with an onset during early adolescence, has a prevalence of 2%.25,26

6. The Quintessential Challenge of Tooth Wear

TW has implications for the patient in all aspects physical, functional, psychologic, social, and esthetic.

The TW treatment team should shift from restorative thinking to tooth structure thinking and spare no occasion to educate the patient in line with structure-preserving strategies. The challenge is larger today as more people remain active for longer periods of life, and the evidence is strong showing that TW, as a threat to oral health, will impact all aspects of well-being—physical, psychologic, and social—throughout a lifetime27,28 (Fig 1-19).

Fig 1-19 Tooth wear as the quintessential challenge. As explained in the front pages of this book, treating the worn dentition is the quintessential challenge to the dentist as the patient’s functional, biologic, psychologic, social, and esthetic disability calls for immediate action.

All attempts to safe and effectively improve hyposalivation will provide better chances for our TW patients.

Another aspect that should not be overlooked is the significant expense that repetitions of restorations incur for a patient. Controlling the overall cost of the patient’s present treatment and most importantly considering right from the start the expenditure that will be needed in the future should be part of the treatment strategy.

3D technologies were first marketed as a promise to render high-end restorations to more people at reasonable cost. Unfortunately, the trend is to make things more expensive and not more affordable.

The challenge remains in the hands and mind of the dentist, who needs to apply practical and accessible protocols in order to serve the goal of saving resources for the patient and to bring the treatment closer to the patient.

TW affects all spatial dimensions and planes of the dentition. 3D tools and 3D workflow when used in a patient-centered modus operandi may be of great help, even if it requires a jump from digital to analog domains to serve patients better. This aspect, described in this book as “hop-on, hop-off” from digital to analog and vice versa is further explained in chapter 4.

7. The Economy of Tooth Wear: The TW Curve Shape

The social science of economics explains through graphs and curves not only principles but also trends.

The COVID-19 sanitary crisis has increased the interest and the knowledge of the general population in terms of understanding how the economy will recover from the COVID-19 impact. Digitalization together with education and a sustainable economy are three of the recommended measures to recover and stabilize a system.

In the same manner as economists represent the market’s health drop in a crisis by a downward chart, TW and its impact in oral health can follow a downhill course, implying a progressive decrease in oral and general health. How and when we intervene as a TW treatment team, depending on the treatment type and timing, will mark the recovery pattern and the future resilience to relapse.

As in economics, digitalization, sustainable treatments, and patient education in healthy lifestyle choices are key to managing TW in a dental practice, as there is no single factor that can reduce the challenge of TW both to the dentist and to the patient.

Eventually there will be recessions, some exogenous and some intrinsic, both in economics and in health that cannot be avoided nor prevented.

In times of repeatable relapses or recessions, easy-to-implement noninvasive interventions have proven effective for dealing with TW in a clinical environment.

V-Shape Recovery

This is the ideal recovery shape and the most optimistic one. The V-shape recovery curve implies a fast and effective recovery (Fig 1-20).

Fig 1-20 V-shape recovery.

Once the treatment and preventive measures have been applied, no lasting TW sequelae will impact negatively on the health of the patient.

Chances to achieve V-shape recovery are higher in cases where TW is detected, intercepted, and treated in its incipient/moderate stages. Implementing preventive measures is key to long-term recovery (Fig 1-21).

Fig 1-21 Early treatment enables interception of TW damage provided the patient receives correct coaching regarding lifestyle habits (lip biting in this particular case). For the patient to remain free of further damage, patient-dentist communication is indispensable (a and b). (See more on this case in chapter 5).

U-Shape Recovery

Patients who draw a U-shape curve in their recovery pattern sustain lower oral health for a variable period of time (Fig 1-22).

Fig 1-22 U-shape recovery.

This is normally the case in severe cases that require sustained patient commitment as well as a coordinated multidisciplinary treatment approach. Patients can lose their motivation as they lose sight of “the light at the end of the tunnel.” A U-shape recovery is sometimes unavoidable such as with implant or orthodontic therapy, which take time and have a complex provisionalization period and compromised occlusal support in the worst scenarios. It should be anticipated that patients can also lose their confidence in the professional team taking care of them. Furthermore, a concomitant challenge may appear (such as a new medical condition) that impedes a total recovery (Fig 1-23).

Fig 1-23 Severe TW has destroyed all the occlusal anatomy and enamel barrier on this patient with a hopeless tooth due to extensive TW. Patient commitment is mandatory to recover and maintain the restored health (a and b). (See more on this case in chapter 9.)

W-Shape Recovery

The W-shape curve has also been described in economy as a “double dip” (Fig 1-24).

Fig 1-24 W-shape recovery.

This is the case where the patient has an initial good and effective recovery but before regaining health, relapses into another downturn or even drops out of treatment, which might endanger a good and prompt outcome. In these cases, a reevaluation should be done, and a new treatment should be discussed (Fig 1-25).

Fig 1-25 Tobacco-related complications arose in the surgical phase, with the onset of a new surgical procedure and a demotivation process that represented a risk for the final outcome. Empathizing with the patient while reemphasizing the general treatment goal is usually helpful to regain patient’s trust (a and b).

K-Shape Recovery

This happens when part of the team performs well but in an isolated manner. Despite the fact that part of the treatment plan can be a success for a certain amount of time, the overall success is challenged as there is no true multidisciplinary approach (Fig 1-26).

Fig 1-26 K-shape recovery.

In such cases, the generalized TW will progress and endanger the apparently successful part of the treatment, bringing back the patient to the original status (Fig 1-27).

Fig 1-27 Even though excellent osseointegration was achieved, the underestimation of the overall TSL led to occlusal implant overload and implant failure. See the loss of tooth structure in the interval between the radiographs. Erosion eliminated the occlusal support of adjacent and contralateral teeth. The occlusal porcelain of the screw-retained implant crown had suffered from occlusal prematurities with repeated chipping and screw dislodgment, signs that had alerted the dentist to the issue. In this case the patient rejected any TW restorative treatment, resulting in progression to implant loss (a and b). (See more on this case in chapter 9.)

L-Shape Recovery

This is the least desirable scenario (Fig 1-28).

Fig 1-28 L- shape recovery.

Patient lacks motivation to undergo the treatment and to further follow preventive measures, or the dental team lacks the required experience to effectively treat the TW condition that is negatively impacting the patient’s oral and general health. This also occurs when patients are treated “one tooth at a time” without a general concept and protocol and a comprehensive diagnosis and treatment plan to address TW.

Years ago, when TW was far from being understood, it was not unusual to find patients that had been treated exclusively on the labial aspect of the anterior teeth, taking only the esthetic appearance into consideration. An example would be patients seriously affected by medical conditions producing acid erosion (eg, eating disorders, GERD) with extensive dissolution of the palatal aspect of maxillary teeth that were only treated with direct or indirect labial restorations of the maxillary anterior teeth. Even though those patients were satisfied with the treatment, the TW damage continued to advance with devastating effects over the years (Fig 1-29).

Fig 1-29 Buccal restorations of anterior teeth performed decades ago were not able to free the patient from the TW cycle that continued to challenge tooth structure. Facially driven 3D-planned orthodontic treatment will in many cases provide the required space to allocate palatal restorations with no further tooth reduction.

8. The Geography of Tooth Wear

Tooth wear is found today throughout the world and linked mainly to lifestyle and contemporary dietary habits. Globalization is like a tsunami, diluting traditional idiosyncratic culinary patterns and leaving teeth buffeted by a merciless acidic challenge.

A review coming from Freiburg University in 2017 shows a large variation in global prevalence of erosion ranging from 0% to 100%. The lack of homogeneous study design and the fact that data are only available from certain countries, with close to zero information from the continents of Africa, South America, Asia, and many countries from southeastern Europe, explain this huge variation. As per the aforementioned review, estimating the global prevalence is complex as comparison between local studies is a complicated task due to the variation of study designs29 (Table 1-1).

Table 1-1 Global mean erosion prevalence as per the review by Schlueter and Luka.29

Global mean erosion prevalence

1%–100%

Global mean erosion prevalence in primary teeth

30%–50%

Global mean erosion prevalence in permanent teeth

20%–45%

This review points out differences in data between the primary and permanent dentition.29 For the ease of the reading, data of erosive TW both in children and adults have been summarized in Table 1-2.

Table 1-2 Prevalence of erosion in children and adults in various countries.

CHILDREN

ADULTS

Australia

0%–33%

Brazil

1%–62%

China

6%–15%

44%

Denmark

2%

Finland

18%–75%

France

26%

Germany

32%–71%

24%–40%

Great Britain

28%–50%

3%–100%

India

29%

Israel

37%–62%

Italy

21%

Japan

26%

Norway

20%–38%

Saudi Arabia

31%

28%

Switzerland

100%

8%–82%

USA

25%

The effects of characteristic, proprietary habits in certain cultures such as drinking vinegar beverages along with the use of komesu (fermented rice vinegar) and kurosu (unpolished rice vinegar) in Japan have turned out to be mild in comparison to the worldwide expansion of branded carbonated soft drinks that are cited as predominant risk factors in most of the epidemiologic studies regarding erosion prevalence and etiology.30 The use of fermented and acidic food and drink in diets seems to be increasing, with the potential to change the oral microbiome in the same manner as a cariogenic diet changes the oral microbiota to acid-resistant and acid-generating bacteria such as Streptococcus mutans. The shift of the microbiota to a population of acidic bacteria that are adapted to an acidic environment and are themselves a source of acetic metabolites may have unprecedented consequences.31