The increasing prevalence of erosive tooth wear across all generations is often overlooked by general practitioners, according to a leading New Zealand dentist Dr Andrea Shepperson.
'Erosive tooth wear is a multifactorial condition of increasing concern to the clinician. The consequence is a worn dentition with an aetiology often labelled “bruxism” when the primary aetiology for wear may often be an acid source,' says Dr Shepperson.
While a certain amount of tooth wear is the consequence of attrition, it has been estimated to be approximately 11 microns of enamel per year. Wear beyond these levels is not commensurate with age and usually stems from other causes.
A careful history, including an assessment of intrinsic and extrinsic sources of acid, needs to be part of a thorough clinical assessment in cases of tooth wear.
Erosive wear can lead to significant loss of vertical height in the dentition as cusp tips are worn and a changing anterior tooth relationship develops. Posterior cusp loss impacts on the envelope of function anteriorly, often creating associated anterior wear. This creates restorative challenges for dentists who are uncomfortable increasing vertical dimension.
Occlusal concepts have long been considered the domain of the prosthodontist and an understanding of occlusion has carried an air of mystique for the general dentist. Shepperson believes that all general practitioners need to recognise when the OVD needs to change to improve force management strategies and enhance the life of natural teeth and restorations.
Dr Shepperson frequently sees treatment planning that overlooks loss of occlusal vertical dimension (OVD) and its impact on the overall dentition.
'I see implants placed and restored posteriorly to a worn and altered occlusal plane while the patient continues to have erosive and associated wear across the remaining arch. The patient presents with concerns about appearance, usually related to loss of tooth display or chipping and fracture of anterior teeth. They are often distressed to find that the OVD needs to change, and this requires dismantling
implant supported crowns which are providing inadequate posterior support.'
Developing treatment strategies to manage OVD changes requires knowledge, experience and systems built around good clinical evidence.
'I work with general practitioners who understand the need to have a healthy functioning occlusion, and seek the steps to create it clinically, before embarking on occlusal reconstruction. Helping dentists to visualise an end point for the dentition before embarking on major treatments such as implant dentistry or crown and bridgework involves recognising occlusal risk factors, as well as one’s own clinical
Dr Shepperson has developed a special interest in restoring dentitions affected by erosive wear. There is an opportunity to be involved in rewarding care at a comprehensive level, often resulting in significant improvements in the quality of life for many patients. Initial diagnosis, implementing preventive strategies with a hygiene team, conservative minimally invasive restorative options, and reconstruction of the smile and restoration of the entire arch are all aspects of her work. She works closely with gastro-enterologists in patients suspected of having gastric reflux disease.
'We use ambulatory pH monitoring to determine the proximal extent of acid reflux. The patient is often surprised and grateful for the role we play in contributing to their oral health,' says Shepperson.
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Dr Shepperson will be in London discussing Dental Erosion: Restorative Management of the Worn Dentition in a full day lecture on Friday 22 March at Chandos House, London.
Further information is available at www.sheppersoneducation.com/London.html.