Attrition

Severe tooth wear of the lower front teeth (attrition)
Figure 1: Severe attrition of the lower front teeth. Despite the damage to these teeth, this patient was fortunate. He exhibited no TMJ symptoms, no cracked teeth, and no significant soft tissue problems. Wear on this patient's teeth was decelerated by making shallow box preparations into the exposed dentin and placing tooth-colored fillings, shown in Figure 2. Earlier intervention would generally be recommended.
Composite resin fillings in worn lower teeth can restore them cosmetically and functionally
Figure 2: Tooth-colored composite resin fillings placed to decelerate the wear on this patient's teeth had delivered several years of trouble-free service at the time of the photograph. Limited treatment such as this may not be successful in a patient with an ongoing tooth grinding ("bruxing") problem, and additional or alternative care may be needed.

Attrition is the term used to describe wear on the biting surfaces of natural teeth and dental restorations. The wear itself is a diagnosis that can be treated, but it's also a symptom of a larger problem which, if overlooked, can result in the failure of restorations performed to fix the wear. Common causes of attrition include tooth grinding (bruxism) and inappropriate alignment of the teeth (like gears that don't mesh properly), a condition known as malocclusion.

An attempt should be made to address the source of the bruxing if present (e.g. emotional stress, etc.), which may involve medical intervention as well. If the bruxing habit cannot be eliminated, it should also be treated. Orthodontics should be considered if improper tooth alignment is noted. In the case of severe malocclusion, maxillofacial surgery (orthognathic surgery) may be recommended.

Severe attrition like that shown in Figure 1 can be a serious problem. If all the teeth are involved, the jaws may rotate together more than they should. This is known as loss of vertical dimension of occlusion (bite collapse).

Bite collapse can result in damage to the jaw joints; severe pain or dysfunction in the jaw joints (TMJ dysfunction); excessive muscle contraction forces as the closing muscles of the jaw shorten (which can accelerate the destruction); cracked or chipped teeth; aggravation of periodontal disease (secondary occlusal trauma); shortening of the lower face height (which changes one's appearance); an inverted smile (corners of the mouth sag); frequent cracking or chapping at the corners of the mouth (angular cheilitis); and problems chewing.

Despite the obvious severe wear on the teeth, the patient in Figure 1 exhibited none of these conditions, as the back teeth had been crowned and prevented the bite from collapsing. If wear happens slowly enough, the teeth may continue erupting (moving into the mouth further) as the wear occurs, which can minimize or prevent bite collapse (and make fixing the problem more difficult, since there may be little or no room to add tooth structure). If the patient has periodontal disease, in which the tooth supporting bone is softened by the disease, some teeth may be lost, while others tip outward from the increased chewing forces applied to them. This can also lead to bite collapse, whether or not the teeth themselves become worn.

Last updated: 8/7/2013

Tooth enamel is the hardest substance in the body. It is very durable, and under normal conditions wears very little over a normal lifetime. It is becoming more common to see elderly patients with a complete set of natural teeth, that exhibit little if any visible wear.

Diagnosing attrition is easy, and amounts simply to observing visible wear planes (facets) on the teeth. What is less straightforward is determining whether the attrition is part of a larger problem (e.g. an ongoing bruxing habit, or malocclusion). If so, the attrition will likely get worse, and any treatment prescribed to repair the worn areas of the teeth may not hold up well over time unless the underlying cause is also successfully treated.

It's important to determine how long it took for the wear to occur. In general, excessive wear is a bigger problem on a younger patient because it has occurred in a shorter time frame, and the patient's life expectancy would normally be greater. Which teeth are involved also needs to be considered, so that the cause(s) can be identified and the most appropriate treatment(s) performed.

Last updated: 12/29/2013

Treatment options for severe attrition and bite collapse can be very costly, as it is sometimes necessary to place crowns or other types of dental restorations on several teeth to re-establish the proper "vertical dimension of occlusion" (the position the jaws are in relative to one another when the teeth are closed together fully).

If bruxing is suspected, your dentist may recommend bruxing appliances (also known as "occlusal guards", "night guards" or "bite splints") to help reduce stress and wear on the teeth. There are several types of occlusal guards, and they may also control chewing muscle forces, and forces applied to the temporomandibular joints (TMJs). In some cases tooth colored filling material bonded to the teeth may accomplish the same objectives as an occlusal guard, but crowns or onlays may be the only long term solution in severe cases of attrition. Often, it is appropriate for the patient to use an occlusal guard after the teeth have been restored, to protect the new dental restorations.

Whether or not attrition should be treated depends on several factors, including the age of the patient; the amount of tooth structure that has been worn away; and the length of time over which the wear occurred. Wear on primary teeth ("baby teeth") generally doesn't require treatment unless there is no permanent tooth in the jaw to eventually replace it, or the wear has contributed to decay (in which case restoring the cavities will usually solve the problem until the the teeth are lost naturally). Wear into the dentin of a permanent tooth on a person in their teens or twenties is severe, no matter how long it took. Wear that is just beginning to enter the dentin on an 80 year-old woman is relatively less serious.

Only your dentist can tell you for sure whether, and how, the attrition should be treated. Sometimes the dentist will take photographs showing the extent of the wear, and monitor a particular landmark (e.g. the tip of a canine tooth) at checkups. Stone casts of the teeth may also be used. If treatment is recommended, it will probably involve one or more of the following options: crowns; inlays; equilibration (adjusting the way teeth fit together); fillings; core buildups; occlusal guards; onlays; orthodontic treatment. Other treatment may be recommended.

Last updated: 12/29/2013

Attrition (wear of the teeth) is often a sign of – or accompanied by – other dental health problems. Among these are bruxism, cracked or chipped teeth, lost vertical dimension of occlusion, malocclusion, primary occlusal trauma, and temporomandibular joint dysfunction (TMJ).

Last updated: 12/29/2013
This page contains links to external websites. Full-text articles are linked to, when available. Some links lead to content requiring payment. ToothIQ is not compensated by the organizations or authors whose articles are linked to. The links are intended only as a means of ToothIQ users to learn more about topics related to dental diagnoses and procedures.
Background information

The following articles are intended to provide you with background information on the topic. These articles may or may not influence your decisions about care.

The treatment of painful temporomandibular joint clicking with oral splints—A randomized clinical trial
Conti, Paulo Cesar Rodrigues, DDS, et al.
The Journal of the American Dental Association
2006 137 (8): 1108-1114

Minimally invasive dentistry
Murdoch-Kinch, Carol Anne, DDS, PhD, and McLean, Mary Ellen, DDS
The Journal of the American Dental Association
2003 134: 87-95

Abfraction
McCubbin, James, BDS
The Journal of the American Dental Association
2002 133 (6): 690-691

Examining the prevalence and characteristics of abfractionlike cervical lesions in a population of U.S. veterans
Piotrowski, Bradley T., DDS, MSD, et al.
The Journal of the American Dental Association
2001 132 (12): 1694-1701

Study shows link between antidepressants, bruxism
The Journal of the American Dental Association
2000 131 (3)
Editor's notes: Article in JADA's "News" column.

Case Report: Antidepressant-induced bruxism successfully treated with Gabapentin
Brown, E. Sherwood MD, PhD and Sunhee C. Hong, DDS
The Journal of the American Dental Association
1999 130 (10): 1467-1469

Diagnosis and Management of Dental Erosion
Gandara, Beatrice Kay, DDS, MSD and Truelove, Raymond L., DDS, MSD
The Journal of Contemporary Dental Practice
1999 1 (1): 16-23

Dental erosion and bruxism. A tooth wear analysis from South East Queensland (PDF, 177K)
Khan, F., et al.
Australian Dental Journal
1998 43 (2): 117-127

Restoring Lost Vertical Dimension of Occlusion Using Dental Implants: A Clinical Report
Balshi / Wolfinger
International Journal of Prosthodontics
1996 9 (5): 473-478

Dental Splint Prescription Patterns: A Survey
Pierce, Calvin J. DMD, PhD, et al.
The Journal of the American Dental Association
1995 126 (2): 248-254

Bruxism/Teeth grinding
MayoClinic.com web site
Last viewed: 9/23/2010

The TMJ Association
The TMJ Association web site
Last viewed: 9/23/2010

Read before treatment

The following articles, if read before treatment, may influence your decisions about care.

Occlusal splints for treating sleep bruxism (tooth grinding)
Macedo CR, et al.
Cochrane Database of Systematic Reviews
2007 4
Notes: Art. No.: CD005514
Editor's notes: This review found insufficient evidence in the literature to conclude that occlusal guards reduce sleep bruxism; however, the study design was not intended to evaluate whether they reduce wear on the teeth, and was not suggesting that they are ineffective for that purpose.

Treatment of localized anterior tooth wear with a glass-fiber-reinforced composite resin: A clinical report
Akar, Gulcan Coskun, DDS, PhD and Dundar, Mine, DDS, PhD
The Journal of Prosthetic Dentistry
2007 97 (3): 133-136

A Critical Review of Non-carious Cervical (Wear) Lesions and the Role of Abfraction, Erosion, and Abrasion
Bartlett, D.W. and Shah, P.
Journal of Dental Research
2006 85 (4): 306-312

Clinical measurement and evaluation of vertical dimension
Toolson, L. Brian, and Smith, Dale E.
The Journal of Prosthetic Dentistry
2006 95 (5): 335-339

Facing the challenges of ceramic veneers (PDF, 208K)
Christensen, Gordon J., DDS, MSD, PhD
The Journal of the American Dental Association
2006 137 (5): 661-664

Interdisciplinary management of anterior dental esthetics
Spear, Frank M., DDS, MSD, et al.
The Journal of the American Dental Association
2006 137 (2): 160-169

Minimally invasive operative techniques using high tech dentistry (PDF, 148K)
Brostek, Andrew M. Dr., et al.
Dental Practice
2006: 106-106
Editor's notes: Online publication date September/October 2006.

Noncarious cervical lesions in adults: Prevalence and occlusal aspects
Pegoraro, Luiz Fernando, DDS, PhD, et al.
The Journal of the American Dental Association
2005 136 (12): 1694-1700

Attrition, abrasion, corrosion and abfraction revisited—A new perspective on tooth surface lesions
Grippo John O. BS, DDS, et al.
The Journal of the American Dental Association
2004 135 (8): 1109-1118

Physiologic vertical dimension and centric relation
Shanahan, Thomas E. J.
The Journal of Prosthetic Dentistry
2004 91 (3): 206-209

Brief communication: Study of noncarious cervical tooth lesions in samples of prehistoric, historic, and modern populations from the South of France
Aubry, M., et al.
American Journal of Physical Anthropology
2003 121 (1): 10-14
Editor's notes: This article states that off-axis stresses on teeth in prehistoric times may not have been as great because the abrasive diet eaten at that time quickly reduced the occlusal cusp anatomy, such that the teeth became flat on the biting surfaces, and slid on each other without generating sideways forces.

Noncarious cervical lesions and abfractions: A re-evaluation
Litonjua, Luis A., DMD, MS, et al.
The Journal of the American Dental Association
2003 134 (7): 845-850

The Effect of Increasing Occlusal Vertical Dimension on Face Height
Gross, Martin D., BDS, LDS, RCS, MSca, et al.
International Journal of Prosthodontics
2002 15 (4): 353-357

A common-sense approach to splint therapy
Dylina, Tim J., DDS
The Journal of Prosthetic Dentistry
2001 86 (5): 539-545

The speaking method in measuring vertical dimension
Silverman, Meyer M.
The Journal of Prosthetic Dentistry
2001 85 (5): 427-431

Using the neutral zone to obtain maxillomandibular relationship records for complete denture patients
Alfano, Stephen G., DDS, LCDR, USNR and Leupold, Richard J., DDS, CAPT, USN
The Journal of Prosthetic Dentistry
2001 85 (6): 621-623

Clinical Indications for Altering Vertical Dimension of Occlusion
Harper, Richard P., DDS, PhD, FRCD(C) and Misch, Carle E., DDS, MDS
Quintessence International
2000 31 (4)
Notes: Quintessence Publishing

Managing incomplete tooth fractures
Ailor, J. Edward Jr., DDS
The Journal of the American Dental Association
2000 131 (8): 1168-1174

Porcelain Laminate Veneers. A Retrospective Evaluation After 1 to 10 Years of Service: Part II—Clinical Results
Dumfahrt, Herbert, Dr med and Schaffer, Herbert, Univ-Doz Dr med
International Journal of Prosthodontics
2000 13 (1)
Editor's notes: Findings in this study were generally positive, and provide evidence in support of porcelain veneers.

Tooth wear treated with direct composite restorations at an increased vertical dimension: Results at 30 months
Hemmings, Kenneth W., BDS, MSc, et al.
The Journal of Prosthetic Dentistry
2000 83 (3): 287-293

Treating Bruxism and Clenching
Christensen, Gordon J., DDS, MSD, PhD
The Journal of the American Dental Association
2000 131 (2): 233-235

The 5-year clinical performance of direct composite additions to correct tooth form and position: II. Marginal qualities
Peumans, M., et al.
Clinical Oral Investigations
1997 1 (1)

Stress-induced cervical lesions: Review of advances in the past 10 years
Lee William C., DDS, MA; Eakle W. Stephan, DDS
The Journal of Prosthetic Dentistry
1996 75 (5): 487-494

A New Technique for Restoration of Worn Anterior Teeth—1995 (PDF, 565K)
Christensen, Gordon J., DDS, MSD, PhD
The Journal of the American Dental Association
1995 126 (11): 1543-1546

Noncarious dental "abfraction" lesions in an aging population
Owens BM, Gallien GS
Compendium of Continuing Education in Dentistry
1995 16 (6): 552, 554, 557-8 passim
Notes: Quiz 562

Abfractions: a new classification of hard tissue lesions of teeth
Grippo, J.O
Journal of Esthetic Dentistry
1991 3 (1): 14-19

BiteStrip® Home Screening_Test for Sleep Bruxism
Therapy Control Products Inc.
NoSnoreZone.com web site
Last viewed: 9/24/2010
Editor's notes: Manufacturer's web site. Sells a home test for assessing whether a patient clenches or grinds their teeth while sleeping. Symbyos does not have firsthand experience with the test, and is unaware of scientific studies verifying the manufacturer's claims.

Treating Bruxism and Clenching (Letter #1) CLENCHING
The Journal of the American Dental Association
Editor's notes: Editorial comment re: Dr. Christensen's recommended treatments for bruxing- discusses mandibular rest and isokinetic stretching, used successfully for 40 years, by Dr. James H.Quinn, DDS.

Treating Bruxism and Clenching (Letter #2)
The Journal of the American Dental Association
Editor's notes: Editorial comment re: Dr. Christensen's recommended treatment for bruxing in young patients- discusses possible orthodontic complications from splint use in growing patients, by David J. Harnick, DDS, MSD (orthodontist).

Last updated: 7/10/2011