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Eeny Meeny Miny Moe – Which Type of Tooth Wear?

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Dental Revelations Blog-3877

There are four types of tooth wear that we diagnose from patients’ mouths. Erosion, abrasion (I’m sorry for a missing link – I did not agree with any of the images of abrasion), abfraction and attrition. The easiest ones from these to diagnose are the erosion and attrition. You can’t go wrong with them. But it is completely different case with abfraction and abrasion.

When a dentist or a hygienist sees tooth wear on the neck of the tooth they diagnose it by default as abrasion caused by too vigorous brushing. If there are also receding gums on the same teeth as where the tooth wear is, the dentist makes a wrong conclusion easily. They recommend softer toothbrush and this silly brushing technique called Bass (it is so silly that I think I am going to dedicate one post entirely to this technique).

This normally leads into a situation where patient begins to be too careful with the brushing because she doesn’t want to cause further damage to the teeth. That’s when the plaque starts to build up to the gum line, gum gets inflamed because of the plaque and the patient begins to notice bleeding when brushing. Now she’s even more careful with the brushing as in her mind bleeding means she’s doing something wrong – brushing too hard like the dentist said she is. She’s afraid that the bleeding means her gums are receding.

But what if the dentist/hygienist misdiagnosed the tooth wear? What if the correct diagnosis was the abfraction?

Tooth wear – What to Check?

When you see a tooth wear that you are tempted to diagnose as abrasion, stop for a moment before you proceed giving advice on brushing. Instead do the following:

1. Check if there is mobility on the teeth affected by tooth wear

2. Check if there are interferences on side movements and protrusion

3. Check if there are shiny facets on occluding surfaces

4. Check if the gums have receded on affected sites.

If you get positive answer to even one question the chances are great for the tooth wear to be an abfraction. And in this case telling patient that the tooth wear is caused by her brushing can be damaging in many ways:

  1. It is hard to convince a patient that they are not actually brushing too hard and that they have not damaged their teeth by it. I have my ways of convincing the patient but life would be soooo much easier if I didn’t have to.
  2. The dentin will decay very easily (as I’m sure you know) and plaque accumulating and staying there undisturbed for longer period of time because of too careful brushing will very quickly cause decay. And we all know that these fillings in the cervical area can be pain in the butt. Somehow they always seem to have overhangs or they come off when scaling. Sound familiar?
  3. The teeth where the surface of the root (dentin) has been exposed by receding gums will get sensitive if the plaque builds up.
  4. If the tooth is mobile and has already bone loss the plaque building up to the gum line and inflaming the gum can be disastrous. Please memorise that

MOBILITY + PLAQUE = RAPID BONE LOSS

The Cause for Abfraction Needs to Be Dealt With

When a tooth interferes with full closure, it will trigger deflective interferences6-8 and cause any of the 7 signs and symptoms of occlusal disease such as hypersensitivity, abfractions, mobility, excessive wear or fractures, and muscle or temporomandibular (TM) pain.

There is no consensus amongst the dental professionals over the right approach to occlusion. Is this the reason why signs of interferences on occlusion are ignored or unchecked and the tooth wear is so easily made as patient’s fault?

The quote above is from an article The Three Golden Rules of Occlusion in dentistrytoday.com and you can read a full article here.

But by Whom?

To be honest – and like I have expressed in my previous post – I would not let just anyone touch my occlusion. I would love if the dentists would refer patients to the specialist in prosthodontics because they have the best knowledge and skills to treat the occlusion. And that’s something every patient is entitled to.

Guilt Is a Heavy Load to Carry

I have often noticed that patient feel unnecessarily guilty over damaging their teeth. They feel guilty and desperate over the fact that the damage done by brushing is irreversible. And that they are not sure if their brushing technique is still damaging their teeth hence too careful brushing to make sure they are not.

I believe that guilt does not lead us forward in life, it does not bring anything positive into our lives. Therefore I always try to relieve my patient’s guilt whenever it is possible.

In the case of tooth wear and some dental professionals way of putting the blame on patients’ brushing technique I always have the same conversation with a patient. It goes like this.

Me: Have you been told that you brush too hard?
Patient: Yes I have.
Me: I thought you might have. You see when a patient is told this, she starts to be too careful and then the plaque starts to build up and there is actually plaque in the gum line of your teeth. (I take a mirror and show the plaque to the patient)
Patient: Eww..
Me: I personally try not to tell patients that they are brushing too hard because this leads to too careful brushing which will cause more problems like decaying and gingivitis. Instead I interview the patients about how they brush their teeth and correct it if necessary. You see the tooth wear can be caused by other things than just vigorous brushing… 

Prior to this conversation – in the beginning of the treatment – I have interviewed the patient and asked about her oral hygiene habits. Which brush she uses? How often? How often does she replace the brush head/brush? How does the brush head look like before replacing it? Spread or still like new apart from colour fading? This is why I can continue the above conversation like this.

Me: In your case I doubt it that the tooth wear is caused by your brushing but I will just in case show you the right technique. I will first just check couple of things…

And then I check the mobility, the interferences and the occluding surfaces. I feel great satisfaction when the teeth affected by tooth wear have mobility on the side movements. I am on the right path!

The patient is visibly relieved when they can stop worrying about their brushing. Well who wouldn’t be! There is enough to worry about in life even without worry over brushing.

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Don’t Let Just Anyone Touch Your Occlusion

Dental Revelations14 Comments

Dental Revelations Blog-3878

Grinding or clenching of the teeth is a very common problem. It is a nasty problem for its bearer as it causes pain in the muscles and in the jaw joint, headache, toothache and even disturbed sleep at night. If nothing is done to the problem the teeth will eventually suffer from the grinding especially if the occlusion is imbalanced. There will be a recession in the gum, worn enamel, chipped enamel and periodontal problems to start with.

So if you do know that you grind or clench your teeth at night – or even more so if you clench your teeth during the day which is a definite sign that you do it also at night – go to see your dentist. But here’s an important advice:

Do not go to see just any dentist. Find a specialist in that has done 3 extra years of stuyding to gain the title prosthodontics (even better if one has a PhD).

Why? I will tell you the reasons from my own experience.

My First Mouth Guard Or Should I Say Bite Block

I am a dental professional and in my early career I was quite naive and thought that all the dentist can do all the stuff they are taught at school. I was so wrong.

In my first year after graduation I had a bite guard made by a regular dentist in my practice. I soon realised it wasn’t perfect and sought help from a specialist in prosthodontics who was working in our practice.

The first thing the specialist did was that he filed away about 0,7 cm (0,28 inches) of the hight of the bite guard without fitting it in the middle of the filing. Once he was done with the filing he started to adjust it to my occlusion. He was covered with acrylic dust and he did lots of eye rolling and head shaking.

He told me that the bite guard is not ideal and it would be better to have it redone. I never really used it after that and I carried on suffering from the grinding and clenching of the teeth.

My Second Mouth Guard – When Desperate You Accept Anything

Couple of years later I lived in another country and once again sought help from a dentist for the grinding. She recommended me an anterior night guard (also known as NTI or MCI) which she did routinely for every patient suffering from grinding.

Now I tried to find you a web site that had a photo and impartial info about anterior night guard but wasn’t able to find one. So I took a photo of mine. I must apologise that the device is not in a mint condition anymore. There is my current mouth guard (that I will tell you more about later in this post) in the photo for comparison.

Dental Revelations Blog-2
NTI/MCI/anterior night guard on the left

I felt this anterior night guard – I will call it MCI from now on – relieved the symptoms I had. I was very happy about the dentist and the MCI. Until I spoke to a former colleague of mine, a very good dentist.

He warned me that I was in risk of developing an anterior open bite due to a use of MCI. I did not second guess him once he explained the reasons.

With MCI the back teeth do not make contact. And when the teeth don’t make a contact with the opposite side they will erupt while the front teeth are kept in place by MCI. The over-erupted back teeth cause the open bite in the front. Simple as that.

We’ve all seen what happens to a tooth that lacks an opposing partner in occlusion. It over-erupts!

So I got an advice to use the MCI for 2 weeks and then keep 2 weeks break to avoid the over-erupting back teeth. So I did. But it did not keep the symptoms of grinding at bay.

My Third Mouth Guard Was Almost What It Should Be

Five years later I was back in my home country where I was advised to have a mouth guard done by a dentist in my practice. I did and she removed my upper wisdom teeth so that it was easier to have the mouth guard done. Once I received the mouth guard I didn’t feel it was helping me at all.

At this point I had had enough of the dentists in this matter and decided to see a specialist in prosthodontics. One that was known to be a good one.

The specialist did a careful examination on my teeth and the mouth guard. He said the mouth guard was ok’ish and that he just needed to adjust it. I also showed him my MCI which he advised to use only as emergency basis and only 4-5 days in a row.

I told to the specialist that I have a feeling that only my last molars were in contact. He checked it and said there was no imbalance – meaning that my bite was as it should be. I also asked if I should do the exercise for the jaw muscles. The specialist said there is no benefit of it.

I had to return to see the specialist every 6 months and every time he adjusted the mouth guard and charged quite a lot even compared to the specialist’s fares.

After 3 years of using the mouth guard there was a hole in it. I had apparently “bitten” through it. It was time to have a new mouthguard done.

My Fourth And Current Mouth Guard

For one reason or another I did not completely trust the specialist I had been seeing so I asked for recommendations of specialists from my colleagues. Based on the recommendations I went to see a specialist in prosthodontics and stomatognathic physiology – she had PhD too!

I was kinda shy when mentioning that I have a feeling that only my last molars were in contact – well hell yeah, one specialist had told me I was imagining things.

Only this time I was told I was right. She also told me that I have a partial anterior open bite. I was flabbergasted. I knew that not all the dentist master the matters of occlusion but even the specialists get it wrong!

And once she had done her magic about my occlusion by balancing it I felt the difference immediately.

By the way – my intact upper wisdom teeth were unnecessarily removed by the dentist who made my third mouth guard. A mouth guard can be done with the wisdom teeth in place as long as they are nicely positioned as mine were.

So after I had my occlusion sorted out I got my new bestest of the best mouth guard. It is amazing I must say. It brought me an immediate relief. But I was only half way through the treatment.

I was booked to see a dental hygienist who did massage for the muscles of the jaw in 3 separate visits and gave instructions (based on the specialist’s recommendations) on how to exercise the muscles by stretching and strengthening them. I realised that having a mouth guard is not enough. It won’t take away the root cause of the grinding which in my case was the weak muscles that did not support the jaw.

The MCI I was not allowed to use again. I did not argue with that.

Conclusion

I, a dental professional had three mouth guards (including the MCI) done until I got a proper one. None of the dentists I saw for the mouth guard had a clue about occlusion or what is the best treatment for it. The second specialist was only concentrating on the mouth guard and did not find the imbalance in my bite. Naughty naughty. I guess he was concentrating in money making – I sense these things as I am HSP – and that was probably one reason I didn’t go back to see him.

I worry over the patients who do not have an understanding of what is right treatment for grinding and clenching of the teeth. There are lots of people using MCI every night and they have been using it for years and years. Do they realise that the open bite they have developed is caused by the use of MCI? No they don’t as the dentist won’t necessarily tell them – especially if the patient is seeing the same dentist who recommended the MCI (see my previous post about this phenomenon). And it is not guaranteed that another dentist will tell either.

Also very commonly the treatment dentists offer for the grinding is the mouth guard. And only the mouth guard. But that is never enough! The best thing any dentist can do for the patient who is suffering from the grinding is to REFER to a specialist.

Important information for the patients: You can make a self referral to a specialist by simply booking an appointment. They will not say no to the new patients. Be prepared to pay more for the mouth guard but it is money well spent.

The occlusion is a delicate thing. I always advice patients not to let just anyone adjust the bite. It can go from bad to worse. You are in better hands when seeing a specialist in prosthodontics. The higher educated one the better – in any health matter.

I learned my lesson the hard way. I suffered from the grinding for many years. I lost two intact wisdom teeth unnecessarily. And I can’t help but think that the malocclusion on my back teeth and the partial anterior open bite were caused by the MCI. There was a dreadful moment when the specialist was thinking that I might need crowns for my intact canine teeth to fix the open bite and to get enough support for the side movements of the jaw. So I can count myself as lucky that the malocclusion could be fixed by simply filing the teeth.

Phew!

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Eeny Meeny Miny Moe – Which Type of Tooth Wear?