– Attrition

– Abrasion

– Erosion (corrosion)

– Abfraction

– Internal inflammatory

– Internal replacement

– Idiopathic

– Secondary to other pathology

– Resorption of roots of deciduous teeth

– Secondary dentin

– Reparative dentin

– Dead tracts

– Reticular atrophy of pulp

– Pulp calcifications

– Cementicles

– Hypercementosis.

Radiographic findings

Radiographically the morphology of the crowns is lost and the occlusal and incisal edges of teeth are bereft of the radiopaque enamel cap. The curved cuspal edges are reduced to single flat plane. The incisocervical length of the crown is shortened. Owing to the secondary dentin formation, the size of the pulp chambers are reduced. In severe cases, the pulp chamber and the pulp canals may be obliterated. Occasionally, hypercementosis may be seen associated with attrited teeth.

Clinical significance

Attrition of teeth leads to esthetic and functional disturbances. Dentinal hypersensitivity is usually the most common complaint. Severe attrition leads to pulpal exposure (Figure 2), non-vital teeth and periapical pathology. The razor sharp cuspal or incisal edges of teeth may cause traumatic ulcers.

It is often believed that generalized attrition will also result in a reduction in occlusal face height (vertical dimension of occlusion). However, it has been often noticed that in spite of the extensive loss of tooth surface the resting facial height appears to remain unaltered primarily because of dentoalveolar compensation. Bruxism-associated attrition may be associated with temporomandibular dysfunction.

Management

Patients should be educated regarding the consequences of attrition. Sharp edges of teeth can be smoothened. Desensitizing toothpastes will help patients presenting with dentinal hypersensitivity. A soft bite guard will help break the habit of bruxism and prevent further loss of tooth structure.

Teeth with pulpal exposure warrant endodontic treatment. Finally, crowns may be fabricated for restoring esthetics.

Clinical features

It is seen frequently on exposed root surfaces and in cervical regions of labial and buccal surfaces due to overzealous toothbrushing in horizontal manner. Maxillary teeth are involved more than mandibular teeth, and left side is affected commonly in case of right-handed persons and vice versa. It appears as a V-shaped or a wedge-shaped ditch on the root side of the cementoenamel junction in teeth with some gingival recession (Figure 3). The exposed dentin appears highly polished (Figure 4). Improper use of dental floss and tooth picks may also produce such lesions on the exposed proximal root surfaces.

In habitual pipe smokers, notching of teeth can be seen that conforms to the shape of the pipe stem. It can also be seen as occupation-related oral finding in carpenters and tailors who hold objects against the teeth during work. Exposure of dentinal tubules and the consequent irritation of odontoblastic processes stimulates the formation of secondary dentin.

When tooth wear is accelerated by chewing an abrasive substance between opposing teeth, the process is termed demastication and it exhibits the feature of both attrition and abrasion.

Grippo et al (2004) described a term, ‘masticatory abrasion’ to refer to tooth wear on the occlusal or incisal surfaces due to friction from the food bolus. They reported that the masticatory abrasion can also occur on the facial and lingual aspects of teeth as coarse food is forced against these surfaces by the tongue, lips and cheeks during mastication.

Radiographic features

Radiographically, abrasive lesions caused by toothbrush are seen as half-moon shaped, well-defined radiolucent areas in the cervical regions of the teeth. These defects are usually seen involving the maxillary premolar teeth.

However, abrasive lesions caused by dental floss are usually slender half-moon-shaped radiolucent areas in the proximal regions of the neck of the teeth. Owing to the normal flossing pattern, the distal surface of teeth exhibit relatively deeper radiolucent areas compared to the mesial surfaces of teeth. Pulp chambers may be obliterated.

Radiographically, these radiolucent areas mimic cervical carious lesions, root surface caries and cervical burn out.

Management

Patients should be educated regarding the correct brushing and flossing technique. They should be advised to discontinue any deleterious habits associated with their occupations. Use of abrasive dentifrices should be strongly discouraged.

Pulpal exposure is rarely a complication of cervical abrasion as the formation of secondary dentin protects the pulp from being involved. Dentinal hypersensitivity when present can be managed with the use of desensitizing toothpastes and mouthrinses.

Clinical features

Erosive lesions are usually smooth surface lesions evident on the buccal and labial surface of teeth. Occasionally, proximal surfaces may be involved.

Clinically, erosions appear as wide, polished and smooth areas on the enamel approximating the cervical margin of the tooth (Figure 5). The erosive areas are almost always shallow and exhibit ‘scooped-out’ architecture. The common teeth to be affected by erosion are the anterior teeth.

Typically, when the occlusal surfaces of posterior teeth with restorations are eroded, the margins of the restorations appear higher than the level of the eroded enamel.

1. Endogenous/intrinsic causes

Frequent episodes of vomiting as seen in pregnancy, acid reflux or regurgitation, anorexia nervosa and bulimia cause corrosion of teeth. Bodecker (1945) showed that the gingival crevicular fluid is acidic and may cause corrosion when in contact with the cervical regions of the teeth.

Typically, the enamel is translucent and thin. The common sites for erosion are the palatal surfaces of anterior teeth and occlusal surfaces of posterior teeth. Occasionally other sites that may be affected include the areas of pooling of the contents of the gastric reflux.

The erosion occurs from the action of hydrochloric acid and the proteolytic enzyme pepsin that is contained in gastric juice.

Erosion of the lingual or palatal surface of teeth due to regurgitation of the acidic contents of the stomach, aggravated by the circular movement of the tongue is termed perimolysis (Figure 6).

Another term used with regards to regurgitation of the acidic contents is stress reflux syndrome. This syndrome typically affects young working adults. The acidic reflux usually occurs during the working hours at day. The regurgitated acidic contents are held in the mouth before being swallowed again. This syndrome produces erosion of the buccal surfaces of mandibular posterior teeth.