More Than Just Cosmetic

The incidence of tooth wear is growing, causing lasting damage to the tooth structure and very often painful dentinal hypersensitivity. The condition can be difficult to identify in its early stages, but becomes increasingly apparent as it worsens.

Signs of Tooth Wear

The first factors affected are the luster and texture of teeth— as enamel wears away, teeth become smooth-looking and may take on a dull appearance. Further thinning of the enamel may affect the color of the teeth, as underlying dentin shows through with a yellowish tint. Next in the progression, incisors may display an increased translucency. Following these stages, the structure and form of teeth may be irreversibly damaged.

The effects of tooth wear can be more than just cosmetic. As enamel wears, it can leave patches of dentin exposed and more susceptible to dentinal hypersensitivity. Additionally, even a small number of acidic beverages can remove the smear layer from dentin. In this way, acid erosion delivers a one-two punch to teeth, by dissolving enamel and stripping away the smear layer. For patients who don’t make the connection between their dietary habits and dentinal hypersensitivity, the effects can only grow worse over time.

TABLE 1. CAUSES OF TOOTH WEAR

1. Some fruits and vegetables, wine, and diet soda all come with dangerously low pH levels, which can soften enamel and leave teeth more susceptible to erosion and abrasion.
2. The diet trend of grazing—eating small meals every few hours during the day—poses a risk by decreasing the amount of time between meals in which saliva can help remineralize teeth.
3. Brushing more than twice a day, after consuming acidic foods/drinks, and aggressive brushing may compromise the tooth surface.

HELPING PATIENTS MANAGE TOOTH WEAR

Dental hygienists should look for the signs of tooth wear in their patients and then initiate a conversation about habits that may contribute to the condition. See Table 1 for causes of tooth wear. When evaluating eating habits and toothbrushing, dental hygienists can explain the risks posed by tooth wear and help patients think through alternatives and new behaviors to modify their diet and oral care habits. A patient with a habit of drinking several cans of diet soda every day may be convinced to alternate water with the soda. Patients who like to brush directly after meals can be encouraged to chew sugarfree gum instead. Small lifestyle habits can make a difference in minimizing tooth wear and thus the resulting dentinal hypersensitivity. Dentinal hypersensitivity is a common patient complaint and should be addressed at the dental appointment. However, patients at risk for tooth wear are likely to experience dentinal hypersensitivity in concert with the tooth wear. If patients remark that they avoid hot, cold, sweet, or spicy foods and beverages, then they may be suffering from dentinal hypersensitivity as a result of exposed dentin.

The severity of sensitivity can range from an occasional twinge to a daily nuisance, thus patients should be reminded that even occasional sensitivity is important to mention during a dental appointment. As the enamel surface wears on the occlusal, incisal, or facial surfaces, the tooth becomes more vulnerable because the dentin is either exposed or the enamel layer is so thin, it loses its protective ability. The dental hygienist needs to identify the source of the assault on the tooth and determine appropriate methods to reduce the sensitivity. An assessment of the patient’s oral habits should be made, including nutritional intake and oral hygiene. If necessary, diet modification should include a reduction of acid and sugar containing beverages and food. Along with this recommendation, the dental hygienist should suggest reducing the number of times per day the patient consumes these products. If the tooth sensitivity is a result of thermal extremes such as hot and cold, there are several options the dental hygienist may suggest (see examples below). Assuming that the dentist has ruled out any pathology and the cause is tooth wear, the hygienist should modify the preventive care as needed and suggest a product that focuses on reducing dentinal hypersensitivity.

ADDRESSING DENTINAL HYPERSENSITIVITY

Many treatment modalities are available to address dentinal hypersensitivity. One of the most effective is to use a dentifrice containing potassium nitrate, which affects the pulpal sensory nerves directly.¹ It works by depolarizing the sensory nerve fiber membranes, relieving pain.² Patients should be advised to make sure the dentifrice also contains fluoride to strengthen dental enamel and protect against caries.³ The addition of amorphous calcium phosphate (ACP) to products may also help reduce dentinal hypersensitivity. Some ACP products contain casein phosphopeptide (CPP) to stabilize the ACP. This combined product is called Recaldent^®. ACP is thought to remineralize the tooth structure by filling microscopic tooth surface defects.⁴ Dentifrice containing calcium, phosphate, and fluoride ions may help harden softened tooth enamel and provide protection against acidic foods and beverages.

ACP is also available in chewing gum, mouthrinses, and topical pastes.⁵ Calcium sodium phosphosilicate (NovaMin^®), an ingredient initially used for regenerating the hip bone after hip replacement surgery, is another tool in the dentinal hypersensitivity armamentarium. It forms a protective barrier of hydroxycarbonate apatite through the releasing of calcium and phosphate ions on the tooth surface.⁶ NovaMin is available in a variety of delivery systems from prophy paste to prescription dentifrice. Professionally applied strategies are also helpful. Fluoride varnish applied chairside is effective, particularly when combined with the at home use of a desensitizing dentifrice. The application of fluoride varnish may reduce the solubility of dentin, thus boosting the stability of the dentin surface.⁷ Dentist applied treatments such as copal varnish, dental bonding systems, and iontophoresis may also be effective if less invasive methods have proven ineffective.⁶ While patients today are keeping their dentition longer than ever, dental hygienists are faced with a new set of challenges in keeping those teeth as healthy as possible. Even our most conscientious patients are not immune to the effects of tooth wear and dentinal hypersensitivity, but early intervention and treatment recommendations can help these patients prevent unnecessary damage and pain.

REFERENCES

1. Pray WS. Oral care and dentinal hypersensitivity. US Pharm. 2001;26:7.
2. Schiff T, Dos Santos M, Laffi S, et al. Efficacy of a dentifrice containing 5% potassium nitrate and 1500 PPM sodium monofluorophosphate in a precipitated calcium carbonate base on dentinal hypersensitivity. J Clin Dent. 1998;9:22-25.
3. Mandel ID. The new toothpastes. J Calif Dent Assoc. 1998;26:186-190.
4. Tung MS, Eichmiller FC. ACP for tooth mineralization. Compendium Cont Educ Dent. 2004;25(Suppl 1):9-13.
5. Westphal C, Hays RD. A new tool in the caries armamentarium. Dimensions of Dental Hygiene. 2008;6(2):20-22.
6. Tillis T. A closer look at dentin hypersensitivity. Dimensions of Dental Hygiene. 2005;3(9):30-32.
7. Olusile AO, Bamise CT, Oginni AO, Dosumu OO. Short-term clinical evaluation of four desensitizing agents. J Contemp Dent Pract. 2008;9:22-29.

From Dimensions of Dental Hygiene. June 2008;6(6): 36-37.