Editorial status: Evidence-informed draft for clinician review. Tooth wear is multifactorial; diagnosis requires examination, history and documented progression before irreversible restoration.

Tooth wear describes tissue loss

Tooth wear is loss of enamel and dentine not primarily caused by dental caries or trauma. Erosive tooth wear involves chemical softening by non-bacterial acids followed by mechanical removal. Attrition, abrasion and abfraction-like stress descriptions may overlap clinically. A single tooth often shows several processes. The useful diagnosis identifies pattern, activity, severity and likely drivers instead of forcing one label onto every surface.

Physiological versus pathological wear

Some slow wear occurs through life. It becomes pathological when the rate or extent is unusual for age, threatens teeth or restorations, causes pain or functional and aesthetic problems, or requires complex care. Severity alone does not reveal speed. An older patient with stable wear may need monitoring, while a younger patient with modest but rapidly progressing loss requires active prevention.

Erosion is chemical-mechanical

Acid softens the surface and makes it more vulnerable to contact, brushing and chewing. Dietary acids and gastric acid are common sources. Bacteria produce acid in caries, but erosive wear is defined as non-bacterial. Caries and erosion can coexist, especially with dry mouth and frequent sweet acidic drinks. Prevention must distinguish them because plaque control alone will not remove an intrinsic or dietary acid source.

Clinical appearance

Early erosion may produce a smooth silky surface and loss of fine anatomy. Progression can cause shallow concavities, cupping of cusps, raised restoration margins and shortened or thinned edges. Dentine exposure may appear yellow and increase sensitivity. Appearance varies with saliva, tooth position and mechanical forces. Photographs and models help track change more reliably than memory.

Pattern recognition

Palatal upper-tooth wear may raise suspicion of gastric exposure, while facial surfaces may reflect dietary acids, but patterns are not diagnostic alone. Lower teeth can be protected by the tongue and saliva. Occlusal cupping may reflect erosion plus contact. Record which surfaces are affected and which are spared, then compare the pattern with history without claiming a medical diagnosis from location alone.

Dietary history

Ask about frequency, timing and method of consuming soft drinks, citrus, juices, sports drinks, energy products, vinegar, wine, sour sweets and supplements. Sipping, swishing and holding a drink prolong contact. Sugar-free products can remain highly acidic. A several-day diary often reveals exposures missed by a broad “healthy diet” question. Focus on achievable frequency and technique changes.

Gastric acid exposure

Reflux, recurrent vomiting, pregnancy-related vomiting, eating disorders and some gastrointestinal conditions can expose teeth to strong acid. Dental findings may be the first clue, but dentists should not diagnose the medical cause. Ask sensitively about heartburn, regurgitation, morning symptoms and vomiting and refer appropriately. Eating-disorder conversations require privacy, compassion and coordinated medical support.

Saliva

Saliva dilutes and buffers acid and forms a protective pellicle. Dry mouth from medicines, disease or radiotherapy can accelerate damage. Assess symptoms, salivary pooling and medication history. Hydration and stimulation may help where glands function, while severe hyposalivation requires a broader prevention plan. Normal flow does not neutralise frequent concentrated acid exposure.

Occupational and lifestyle exposures

Competitive swimming in poorly controlled pools, wine tasting, battery or industrial acid exposure and repeated inhaler use have been reported in particular settings. Do not assume causation from occupation alone. Clarify duration, protective equipment and pattern, and involve occupational health where relevant. Lifestyle details such as holding citrus during exercise can be more important than job title.

Brushing timing

Acid-softened surfaces are vulnerable to abrasion, but advice to delay brushing must not reduce twice-daily fluoride use or plaque control. Rinse with water after an acid event, avoid aggressive scrubbing and use a soft brush and low-abrasive fluoride toothpaste. Individualise timing around reflux, vomiting and meals. Do not recommend brushing immediately after vomiting with an abrasive product.

Parafunction and contact

Bruxism and heavy contact can shape wear after chemical softening. Wear facets alone do not prove current sleep bruxism. Ask about clenching, muscle symptoms, fractures and partner reports and assess occlusion and restorations. An appliance may protect selected patients but does not control acid. A polished guard surface can also wear and needs periodic review.

Basic Erosive Wear Examination

The BEWE records the most severely affected surface in each sextant and supports screening, risk communication and monitoring. It is not a complete restorative design or a measure of exact tissue volume. Record score, date and examiner and supplement it with site-level photographs or scans when decisions depend on progression. Different moisture and viewing conditions can affect scoring.

Study casts and digital scans

Serial casts, photographs and intraoral scans can compare morphology over time. Digital colour maps may help visualise change, but scanner accuracy, alignment and software thresholds matter. Keep original datasets and document the interval. A dramatic colour image without quantified uncertainty should not alone justify full-mouth treatment. Clinical symptoms and function remain important.

Sensitivity

Dentine exposure can cause short sharp pain to cold, touch or air, but cracks, caries, pulp disease and restoration problems can mimic it. Test teeth individually. Desensitising toothpaste, fluoride, bonding agents or restoration may help according to cause. Persistent spontaneous or lingering pain requires pulpal assessment rather than repeated surface treatment.

Loss of vertical dimension

Severe wear does not always mean the bite has collapsed; eruption and alveolar adaptation can maintain facial height. Assess facial proportions, interocclusal space, speech, joint and muscle symptoms and restorative space. Increasing vertical dimension is a treatment decision that should be tested provisionally, not inferred from short teeth alone.

Aesthetic and functional impact

Patients may notice short edges, translucency, darkening, sharpness, food trapping or reduced chewing. Their concern and adaptation influence timing. Photographic mock-ups can support communication but should not promise tissue-free treatment. The biological cost of creating ideal proportions may exceed the benefit when wear is stable and function is acceptable.

Prevention comes before restoration

Identify acid source, reduce frequency and improve saliva and fluoride before extensive reconstruction. Otherwise new restorations and remaining teeth continue to be exposed. Prevention may include medical referral, diet changes, water or neutral rinsing, safe saliva stimulation and protective toothpaste. Document whether activity falls before finalising a complex restorative plan.

Dietary modifications

Reduce frequency, consume acidic drinks with meals where appropriate, avoid swishing, use a straw positioned away from teeth when practical and finish exposure rather than sip for hours. Water and non-acidic alternatives can replace some events. Do not advise eliminating nutritious foods without considering medical and dietary needs; a dietitian can help when nutrition or eating disorder risk exists.

After reflux or vomiting

Rinse gently with water or a professionally advised neutral solution and avoid immediate abrasive brushing. Seek medical evaluation for recurrent symptoms. Do not treat reflux solely with dental products or encourage unsupervised bicarbonate ingestion. The dental team protects surfaces while the medical team evaluates the source. Urgent dehydration, bleeding or severe systemic symptoms require prompt care.

Fluoride and protective products

Fluoride toothpaste supports enamel and dentine resistance and caries prevention. Higher-fluoride or stannous products may be considered according to local guidance and individual risk. Evidence for many marketed “enamel repair” claims varies. Select products by active ingredient, abrasivity, tolerance and clinical goal rather than advertising language.

Monitoring stable wear

When disease is controlled and there is no unacceptable symptom or functional loss, active monitoring can avoid unnecessary tooth preparation. Define photographs, index scores, scans or measurements and the interval. Monitoring is meaningful only if the clinic can detect change and has a threshold for intervention. “Come back if worse” is inadequate for a young patient with established wear.

Direct composite options

Bonded composite can add tissue with little or no preparation, test a new shape or vertical dimension and be repaired. It can stain, chip and wear and requires maintenance. Success depends on isolation, load, available enamel and control of acid. A staged additive approach may preserve options but should not be described as permanent or maintenance-free.

Indirect restorations

Onlays, veneers and crowns may be appropriate when structure, aesthetics and load demand them, but preparation removes tissue and can affect pulp. Adhesive partial coverage often allows more conservation than full crowns. Material thickness, bonding substrate, occlusion and repairability matter. Severe wear does not automatically justify crowning every tooth.

Provisional testing

Mock-ups, overlays or provisional restorations can test speech, appearance, bite, muscle comfort and cleaning before definitive work. Record the proposed vertical change and patient response. A short symptom-free trial does not guarantee long-term success, but it reveals obvious problems and allows adjustment. Transfer approved contours digitally or physically to the laboratory.

Full-mouth rehabilitation

Extensive reconstruction needs a diagnosis, stabilised causes, restorative-space analysis and phased consent. Define which teeth need treatment and which can be monitored. Plan failure and repair pathways. International travel schedules should not compress diagnostic and provisional stages merely to deliver a full arch quickly; wear rehabilitation is a long-term system, not a one-visit cosmetic package.

Follow-up

Review acid exposure, medical management, sensitivity, photographs or scans, restoration condition, bite and appliances. Continue prevention after restoration because exposed natural surfaces and margins remain at risk. New chips may signal load, design or uncontrolled acid rather than a defective material alone. Adjust the maintenance interval to activity and complexity.

Distinguishing active from historical wear

A smooth worn surface does not reveal when tissue was lost. New sensitivity, changing photographs, scan differences, fresh sharp margins or repeatedly fractured additions can support activity, while unchanged serial records support stability. Ask whether dietary or medical circumstances have changed. When no baseline exists, create one and avoid declaring rapid progression from appearance alone.

Worked example: acidic sipping

A patient may drink one sports beverage daily yet expose teeth for three hours by repeated sipping. The priority is not simply counting one drink; it is shortening contact, choosing a less acidic alternative, using water and protecting surfaces with fluoride. Serial photographs and sensitivity records show whether behaviour change is sufficient before restorative additions are considered.

Worked example: suspected reflux

Palatal wear, morning sour taste and hoarseness may justify medical referral, but they do not prove gastro-oesophageal disease. The dentist records the pattern, protects teeth and monitors change while the medical clinician investigates. Full crowns should not be rushed to hide damage while acid exposure remains uncontrolled. New severe chest, swallowing or bleeding symptoms require prompt medical care.

Second-opinion comparison

Ask each clinic to identify active evidence, likely causes, planned monitoring and the minimum restorative map. Compare how vertical dimension will be tested and which teeth can remain untreated. A plan based only on ideal smile length may overlook stable adaptation; a prevention-only plan may overlook structural failure. The documented rate and patient impact should connect diagnosis to intervention.

Questions for the clinic

Is my wear active, stable or uncertain?
Which surfaces and patterns support the suspected causes?
How will progression be measured?
Which medical or dietary factors need referral?
Can treatment be additive and repairable?
How will a bite change be tested before final restorations?

Records to request

Request dated photographs, BEWE or other index, scan or cast files, diet and reflux history, salivary findings, sensitivity tests, occlusal assessment, prevention plan and proposed restorative map. For complex care, retain diagnostic wax-up, provisional design, material and bonding records and post-treatment baseline.

Common errors

Calling all tooth wear acid erosion.
Diagnosing reflux from tooth pattern alone.
Restoring before controlling active exposure.
Assuming severe wear always means lost vertical dimension.
Using a digital colour map as exact proof without method details.
Crowning every worn tooth when additive options exist.
Monitoring without reproducible baselines.

Evidence summary

Erosive tooth wear is cumulative chemical-mechanical loss. Diagnosis combines site pattern, severity, activity, dietary and gastric history, saliva, load and serial records. Control sources and monitor progression before major restoration. When intervention is necessary, consensus guidance favours minimally invasive, repairable care supported by prevention and provisional testing, with full-mouth reconstruction reserved for defined functional or structural need.

Sources

Prepared as general educational information. Individual diagnosis and care require examination by qualified dental and medical professionals.

Erosive Tooth Wear: Diagnosis, Prevention and Restoration