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WEAR, OH WEAR!
BY RICHARD GIBSON
Richard Gibson, Principal of Wallasey Orthodontics and Consultant
to Liverpool University Dental Hospital talks to us about dentistry.
Wear is a massive 21st Century issue but it’s not a new problem. It may
have evolved but it still causes significant challenges to dentists in terms of
its management and more crucially its prevention. Wear of the teeth can be
broken down into 3 components, which can have an impact individually or
synergistically on the dentition. As professionals we talk about attrition,
abrasion and erosion – the cause of the wear being the discerning factor.
Attrition is tooth surface loss associated with tooth to tooth contact. We
probably all are or know a grinder and will be aware that this is a trickier issue
because it has a strong association with stress levels and the subconscious
– most of it occurring whilst you’re asleep. It is a normal physiological
process and is commonly seen in association with ageing. Abrasion is
the pathological loss of tooth surface usually associated with some sort of
mechanical process whether that b e your hygiene with your toothbrush or
whitening toothpaste, from dental appliances or indeed some habits – like
nail biting or chewing objects. Finally, erosion is irreversible tooth surface
loss associated with contact with an acid (not of bacterial origin).
Historically, dentists have had to deal with attrition and indeed the body has
been used to managing this from a functional perspective anyway. Attrition
tends to be, in isolation, a slow process with decades of wear and tear resulting
in shortening of front teeth and flattening of the back teeth. In the face of
these low grade chronic changes the teeth are able to lay down additional
material on their inside resulting in the nerve of the tooth shrinking which
frequently means that people experience less symptoms than you might
expect. There are, of course, exceptions and parafunction where the attritive
element is present persistently and for long periods of time can cascade into
more acute episodes with cracked teeth, chips, fractures and sensitivity –
potentially even resulting in loss of vitality of the teeth. The most common
presenting complaint may be aches of the jaw joint or headaches associated
with the muscles that work your jaw. If the symptoms persist then your
dentist may consider discussing with you exercises to normalise the way you
open and close your jaw or even providing you with a soft mouthguard to
sleep in.
Abrasion again has been a challenge for a number of centuries – initially
related to a coarse diet and then with the advent of current oral hygiene
regimes. There has been such a range of dentifrices used over the centuries
from coal to modern fluoridated toothpastes – all of which have the potential
to abrade the surface of the tooth based on their physical makeup but also
the frequency of use. Abrasion is most commonly seen on the necks of the
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side teeth where the hard enamel outer layer meets the soft covering of the
root (dentine/ cementum). The differential resilience of the dental materials
becomes starkly apparent as the dentine/ cementum wears at a much faster
rate, causing grooves at the gum margin. Because of the shorter timescales
these areas are frequently sources of sensitivity and probably were the major
factor in the development of sensitive toothpastes. These toothpastes work
by blocking the freshly opened channels in the dentine of the roots which
are directly connected to the cells lining the nerve of the tooth (the pulp).
Erosion, however, has exploded in the late 20th and now 21st centuries and
is a problem for the young and old alike. As I mentioned above – it is related
to acids coming into contact with the teeth through a non-bacterial cause i.e.
not through the process of tooth decay or periodontal disease. Bacteria in
the mouth ferment sugars in the absence of oxygen and produce acids as a
by-product. This is the process by which we get tooth decay. Non-bacterial
acids tend to come from dietary factors or from the stomach. We see signs of
erosion in people with gastro-oesophageal regurgitation (reflux) where the
acidic contents of the stomach makes its way into the mouth but also where
vomiting is a regular occurrence – whether self-induced or for another
reason. The pattern of wear tends to be different depending on which side
the acid is coming from so when dietary related we would tend to see it on
the front surface of the incisor teeth and on the back when it is coming from
the stomach.
This explosion, in an adolescent age group, of problems they will need
to live with for the rest of their lives is concerning and largely related to
the massive consumption of carbonated/ fizzy drinks. A relative increase
in the prevalence of eating disorders certainly complicates the matter and
creates its own challenges in terms of finding a solution. The fizzy drink
phenomenon is an easier fix because these drinks have to be purchased. By
simply taking them off the table as a choice we help protect ourselves and
our children from the potentially debilitating consequences. Using a straw
to drink through and having them with a meal certainly helps but is not a
substitute for complete removal. By raising awareness of dental erosion and
its consequences hopefully we can motivate ourselves and others to finally
burst the bubble on the popularity of fizzy drinks!
For more information on the types of treatment we offer or the results we can
achieve, please visit www.wallaseyorthodontics.co.uk