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Dr. Khalid AletaibiConservative Dentistry · Dubai

FUNCTIONAL DENTISTRY

Tooth wear, the damage you don't notice until it matters.

Teeth wear. That much is normal. But when wear is rapid, asymmetric, or acid-driven, it is pathological, and it will not slow down on its own. The distinction between physiological ageing and destructive wear is a clinical judgement, and catching it early is the difference between monitoring and a full rehabilitation. Most of the damage I see in practice could have been managed conservatively if it had been identified one stage sooner.

QUICK ANSWER

Tooth wear has three mechanisms, attrition (grinding), erosion (acid dissolution), and abrasion (mechanical wear), and most clinical cases involve a combination [^3]. The European consensus on severe tooth wear recommends a stepped approach: identify and control the cause first, monitor mild wear, and intervene conservatively with adhesive restorations only when structural integrity or function is threatened [^1]. Early detection using standardised scoring systems like the Basic Erosive Wear Examination allows risk-based management before the damage requires complex treatment [^2].

What tooth wear actually is, and why the cause matters more than the damage

Tooth wear is the progressive loss of tooth surface that occurs through three distinct mechanisms. Attrition is tooth-on-tooth contact, typically from grinding or clenching. Erosion is chemical dissolution by acid, from dietary sources like citrus and carbonated drinks, or from gastric acid in patients with reflux. Abrasion is mechanical wear from external sources, most commonly aggressive toothbrushing. Shellis and Addy's review of these interactions demonstrated that the three mechanisms rarely act in isolation: erosion softens the enamel surface, making it dramatically more vulnerable to attrition and abrasion, a synergy that accelerates wear far beyond what any single mechanism would produce alone [3].

This is why the clinical assessment begins not with measuring how much tooth has been lost, but with understanding why it was lost. A patient whose wear is driven primarily by nocturnal bruxism needs a different management strategy from a patient whose wear is driven by daily dietary acid exposure, even if the visible damage looks identical. Gastroesophageal reflux, in particular, is an underdiagnosed driver of erosive tooth wear, Lechien and colleagues' systematic review found a significant association between reflux disease and dental erosion, with many patients unaware of their reflux until the dental damage prompts investigation [5].

How wear is measured and monitored, and when monitoring is enough

The Basic Erosive Wear Examination, introduced by Bartlett, Ganss, and Lussi, provides a standardised, reproducible scoring system that grades erosive wear on a four-point scale across all sextants of the mouth [2]. Its value is not in the score itself but in what it enables: risk stratification. A low BEWE score with an identifiable, controllable cause, a dietary acid habit, for example, can be managed with behaviour change, protective fluoride strategies, and serial monitoring rather than immediate restoration. A high score, or a score that is increasing between visits, signals that the wear is outpacing the body's protective mechanisms and that intervention is needed.

Prevalence data confirms that erosive tooth wear is not rare. Dallavilla and colleagues' systematic review of risk group patients, including those with gastric reflux, eating disorders, frequent acid exposure, and medication-related dry mouth, found erosive wear rates significantly higher than in the general population [4]. These patients benefit most from early, systematic screening because their wear is progressive and, without intervention at the cause level, will continue regardless of any restorations placed on top of it.

How tooth wear is managed, and why the European consensus changed the approach

The European consensus statement on the management of severe tooth wear, authored by Loomans, Opdam, Bartlett, and an international panel, established the modern stepped approach that has replaced the old reflex of crowning every worn tooth [1]. The consensus recommends three tiers: first, prevention and monitoring for mild wear where the cause can be controlled; second, conservative adhesive restorations, direct composite buildups, indirect composite or ceramic overlays, for moderate wear where function or structure is compromised; and third, indirect restorations with greater coverage only when the tooth structure is too diminished for adhesive approaches. At every tier, the principle is the same: do the least that achieves stability, and do not restore what can be monitored.

Direct composite resin, in particular, has become the first-line restorative material for managing tooth wear conservatively. Vajani, Tejani, and Milosevic's systematic review confirmed that direct composite performs reliably as both a definitive and a long-term transitional restoration in wear cases, with the added advantage that it can be repaired, adjusted, and added to without removing sound tooth structure [6]. This repairability is not a weakness, it is the material's greatest strength in a wear case, because wear management is an ongoing process, not a one-time fix. The teeth may need adjustment as the bite settles, and composite allows that without re-preparing the tooth.

The most important intervention in tooth wear management is often not a restoration at all, it is identifying and controlling the cause. A night guard for a bruxist. Dietary counselling for a patient with high acid intake. A referral to a gastroenterologist for a patient with undiagnosed reflux. These steps do not appear on a treatment plan as line items, but without them, every restoration placed on a worn tooth is fighting a losing battle. The teeth I restore for wear last longest in the patients who understand what caused the damage and have taken steps to prevent it from recurring.

COMMON QUESTIONS

What patients ask most.

How do I know if my tooth wear is normal or a problem?
Some flattening of the biting surfaces over decades is physiological and expected. Wear that is rapid, uneven, associated with sensitivity, or that has exposed the darker dentine underneath the enamel is likely pathological. I assess this during your examination using a standardised scoring system and, when needed, serial photographs to track whether the wear is progressing. If it is stable and mild, monitoring is appropriate. If it is progressing, we need to understand the cause and act before the damage becomes complex to repair.
Can acidic food and drink really damage my teeth?
Yes, and more easily than most patients expect. Citrus fruits, vinegar-based dressings, carbonated drinks, including sparkling water, and sports drinks all have a pH low enough to dissolve enamel over time. The damage is cumulative and often painless until it is advanced. Frequency matters more than quantity: sipping an acidic drink throughout the day is far more damaging than drinking it with a meal. Simple changes, reducing frequency, using a straw, rinsing with water after acidic foods, can significantly slow the process.
I grind my teeth. Will that cause wear?
Grinding, bruxism, is one of the primary causes of attritive tooth wear. The forces involved in nocturnal grinding can be many times greater than normal chewing forces, and over years they flatten the biting surfaces, chip enamel, and fracture restorations. A well-fitted night guard is the most effective way to protect the teeth from grinding damage. But the guard alone does not address the underlying cause, which may involve stress, sleep quality, airway issues, or medications. I assess all of these as part of the management.
Can worn teeth be repaired without crowns?
In many cases, yes. Direct composite bonding can rebuild worn surfaces by adding material to what remains of the tooth, rather than cutting the tooth down further for a crown. This additive approach preserves all remaining tooth structure and is repairable if it chips or wears over time. Crowns are reserved for teeth where the remaining structure is too compromised for adhesive techniques, which, with modern materials and methods, is fewer teeth than you might expect.
Does tooth wear always get worse?
Not necessarily. If the cause is identified and controlled, bruxism managed with a guard, dietary acid reduced, reflux treated, wear can stabilise. The key is early identification and monitoring. Wear that has been stable for years rarely needs restoration. Wear that is progressing despite conservative measures needs intervention before it reaches a stage that requires complex treatment. This is why regular examination and documentation of wear patterns matters.
Should I stop brushing so hard?
Aggressive brushing with a hard-bristled brush is a recognised cause of abrasive wear, particularly at the gum line where the enamel is thinnest. A soft-bristled brush with gentle pressure is effective at removing plaque without damaging the tooth surface. Timing also matters: brushing immediately after consuming acidic food or drink, when the enamel is temporarily softened, can accelerate wear. Waiting twenty to thirty minutes, or rinsing with water first, reduces this risk considerably.

Concerned about tooth wear?

If your teeth are visibly shorter, more sensitive, or showing yellow dentine through thinning enamel, let's assess the cause and the severity before it progresses further.

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