Severe erosive tooth wear: prevention versus immediate full-mouth veneers
A 55-year-old woman attends asking for veneers on all her teeth. She reports cold sensitivity in both upper quadrants and thinks her teeth are getting shorter. She drinks two cans of cola a day, often sipping over several hours, and has gastro-oesophageal reflux for which she takes omeprazole 20 mg daily. She grinds at night and wakes with a dull ache in the masseters. Examination shows generalised loss of enamel with cupping of the occlusal surfaces, exposed dentine on the palatal surfaces of the upper anterior teeth, and shortened clinical crowns. Her Basic Erosive Wear Examination score is 14. There is no caries, no mobility and no periapical tenderness; sensibility testing is normal on all teeth. She has a healthy periodontium and no restorations. She is adamant she wants the whole lot done before her daughter's wedding in four months.
1. What is your diagnosis and what would you do to establish the cause and severity?
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Diagnosis: generalised erosive tooth wear, with a mixed aetiology - extrinsic acid (frequent cola sipping), intrinsic acid (reflux) and attrition from bruxism. A BEWE cumulative score of 14 or more places her in the high-risk category requiring full assessment and management, not simply monitoring. Sensitivity is consistent with exposed dentine; normal sensibility and no periapical signs make pulpal pathology unlikely.
Establishing cause and severity:
- A 3–7 day diet diary focused on acidic food and drink frequency and timing, especially before bed.
- Detailed reflux history, and liaison with her GP about whether the reflux is controlled; refer back if symptoms are poorly controlled.
- Salivary flow (unstimulated and stimulated) and review of medication-related dry mouth.
- Photographs, study casts and sextant BEWE charting as a baseline for comparison.
- Ask about eating disorders, alcohol and occupational acid exposure.
- Assess the occlusion: freeway space, occlusal contacts, and evidence of parafunction and splint wear.
- Judge whether wear is active (sharp, unpolished enamel margins) or arrested (smooth, stained dentine).
2. Justify a non-restorative first phase and set out what it would include.
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Why not restore first: restorations placed on actively worn, eroded teeth fail; the underlying acid challenge continues; the wear may be slow and can be monitored; and restorative treatment is irreversible, additive and will need repeated replacement over her lifetime.
First phase (3–6 months):
- Diet: reduce cola frequency, use a straw, substitute water, and avoid acidic drinks at bedtime or between meals; rinse with water rather than brushing immediately after acid exposure, and chew sugar-free gum.
- Fluoride: 5,000 ppm fluoride toothpaste twice daily, plus 22,600 ppm fluoride varnish on sensitive or eroded surfaces at least twice a year.
- Desensitisation: potassium nitrate or arginine-calcium toothpaste; seal exposed dentine with a bonding agent if needed.
- Reflux: confirm the GP has reviewed control; advise not to lie down soon after meals.
- Parafunction: a hard, well-adjusted occlusal splint for night-time grinding.
- Monitoring: repeat BEWE, photographs and casts at 3–6 months to document whether wear is progressing.
Make clear to her that this phase is treatment, not delay - a point she is likely to resist given the wedding deadline.
3. Under what circumstances would you restore, and how would you plan the restoration given the four-month deadline?
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Restore when: there is persistent sensitivity or pain not controlled by prevention; function is compromised (reduced freeway space, loss of occlusal stops, unstable occlusion, difficulty eating); aesthetics are unacceptable to her after a preventive phase; or progression is documented despite good prevention. Her wish for a change before the wedding is legitimate but not sufficient on its own.
Planning if restoring:
- Stabilise first: splint, preventive regime and controlled reflux for at least 3 months.
- Choose an additive, minimally invasive approach: direct composite overlays on worn palatal and occlusal surfaces, which can be used to raise the occlusal vertical dimension (Dahl principle) and adjusted over a few weeks - reversible and repairable.
- Sequence posterior support first, then anterior guidance, with even contacts in centric relation and smooth excursions.
- If the vertical dimension is increased, do it provisionally with composite, review for a month, and consider ceramic onlays or veneers as the definitive phase once the occlusion and parafunction are controlled.
Four months: a provisional additive composite phase is realistic; definitive ceramics are better planned for 6–12 months later. Say so explicitly and agree the staged plan in writing.