Attrition (Fig. 4.3) is common (especially in males), where the diet is very coarse, where there is bruxism, or where the teeth are defective, as in dentinogenesis imperfecta or Ehlers–Danlos syndrome. Furthermore, tooth wear may be more common in individuals with intellectual disabilities. Restorative procedures may be needed, including composites and advanced restorative techniques.

Higher levels of dental caries may be present in some individuals with special needs (Fig. 4.4), with the level of risk dependent on a complex interrelationship between socioeconomic factors and access to oral health care, concurrent illness and its treatment. Examples of factors which may increase caries risk include: xerostomia due to Sjögren’s syndrome, radiotherapy, or secondary to the use of tranquilisers or other psychoactive anticholinergic drugs medications containing sugar special diets, including those that require frequent snacking poor motor control of the cheeks, lips and tongue dysfunction in the arms and hands general debilitation/poor motivation due to concurrent illness or chronic depression.

Measures that may be used to help in caries prevention include the use of fluorides, chlorhexidine and xylitol gum.

Frequent exposure to acidic substances may result in the loss of enamel from the tooth surface by chemical erosion (Fig. 4.5). Erosion may be the result of intrinsic or extrinsic sources of acid.

The intrinsic sources include: gastro-oesophageal reflux, which may be due to sphincter incompetence, increased gastric pressure (due to obesity) and increased gastric volume vomiting (due to pregnancy, eating disorders) rumination.

The extrinsic sources include: dietary acids, such as carbonated beverages, alcoholic drinks and citrus foods medication such as vitamin C and iron preparations, ecstasy, anti-asthmatic medication and excessive aspirin some mouthwashes and saliva substitutes that are also acidic environmental contact with acids as part of work or leisure activities.

Immediate management includes desensitisation through the use of fluoride toothpaste and mouthwashes, and implementation of appropriate preventive strategies aimed at reducing the acid exposure. Interim and long-term treatment includes the provision of temporary diagnostic restorations, ongoing monitoring of disease, definitive restorative work where appropriate, and modification and reinforcement of preventive advice.