Tooth Wear–Abrasion page

Tooth wear pages–1234567

The five major causes of pathologic, non carious tooth wear:

  • Abrasion:
    • Bruxism
    • Toothpaste Abuse
  • Erosion
    • Regurgitation
    • Soda Swishing (Coke Swishing, Pepsi Swishing, etc.)
    • Fruit Mulling

Toothpaste Abuse

The second most common cause of tooth wear is toothpaste abuse.  As you may recall from the first page in this series, toothpaste abuse does NOT mean using too much toothpaste on the brush.  It means using toothpaste in conjunction with very aggressive, prolonged, frequent, and hard brushing using a wide, back and fourth, “sawing” motion with the brush.  This is most frequently done by patients on the occlusal and buccal surfaces of the teeth, and less aggressively on the lingual surfaces.  This is a very common problem and is often engaged in by patients who do not like the color of their teeth and want to whiten them in the mistaken belief that aggressive use of the toothbrush/toothpaste will accomplish this.

Early research has shown that the toothbrush itself does not damage the teeth without additional abrasive, in spite of aggressive brushing.  However, the addition of abrasive in the form of toothpaste DOES abrade away tooth structure. This is a bit like a lab rag wheel on a dental lathe.  The rag wheel, by itself does little to the surface of the acrylic, but the addition of pumice will abrade the surface quickly.  Furthermore, the coarseness of the pumice does not affect the final outcome.  Even flour of pumice will abrade the denture away as surely as coarse pumice, given enough time and pressure.

All toothpastes contain some form of abrasive (usually varying amounts of silica) in order to “polish” the teeth. In most cases, this is an absolute necessity in a toothpaste in order to clean off persistent stains caused by coffee, tea, tobacco and other items commonly used by modern people. Without these abrasives, many people would not be satisfied with their toothpaste.

However, not all toothpastes show the same degree of abrasiveness. The American Dental Association has done tests on popular brands of toothpaste using a laboratory test. Extracted natural teeth are stripped of their enamel and the remaining dentin is then exposed to strong radiation. This causes some of the molecules to become radioactive. These radioactive teeth are then subjected to prolonged brushing using standard toothbrush bristles and various brands of toothpaste. The amount of radioactivity in the water after this procedure is correlated to the abrasiveness of the toothpaste used. This test is called the Relative Dentin Abrasivity (RDA) test. The table below shows the results:

RDA      Tested Toothpaste

04      Toothbrush with plain water
07      Plain baking soda
15      Weleda Salt Toothpaste
91      Aquafresh Sensitive
93      Tom’s of Maine
30      Elmex Sensitive Plus
30      Weleda Plant Tooth Gel
35      Arm & Hammer Dental Care
40      Weleda Children’s Tooth Gel
42      Arm & Hammer Mentadent Advance Whitening
44      Squiggle Enamel Saver
45      Weleda Calendula Toothpaste
45      Weleda Pink Toothpaste with Ratanhia
45      Oxyfresh
48      Arm & Hammer Dental Care Sensitive
49      Tom’s of Maine Sensitive
52      Arm & Hammer Peroxicare Regular
80     Amway Glister
53      Rembrandt Original
53      Closys
54      Arm & Hammer Dental Care PM Bold Mint
57      Tom’s of Maine Childrens
62      Supersmile
63      Rembrandt Mint
68      Colgate Regular
70      Colgate Total
70      Arm & Hammer Advance White Sensitive
70      Colgate 2-in-1 Fresh Mint
78      Biotene
79      Sensodyne
80      AIM
80      Close Up
82      Under the Gum
83      Colgate Sensitive Max Strength
87      Nature’s Gate
94      Rembrandt Plus
95      Oxyfresh with Fluoride
95      Crest Regular
97      Oxyfresh Powder
101     Natural White
103     Mentadent
103     Arm & Hammer Sensation
104     Sensodyne Extra Whitening
106     Colgate Platinum
106     Arm & Hammer Advance White Extreme Whitening
107     Crest Sensitivity Protection
110     Colgate Herbal
113     Aquafresh Whitening
117     Arm & Hammer Advance White Gel
117     Arm & Hammer Sensation Tartar Control
120     Close Up with Baking Soda
124     Colgate Whitening
130     Crest Extra Whitening
133     Ultra Brite
144     Crest Multicare Whitening
145     Ultra Brite Advanced Whitening Formula
150     Pepsodent
165     Colgate Tartar Control
168     Arm & Hammer Dental Care PM Fresh Mint
176     Nature’s Gate Paste
200     Colgate 2-in-1 TartarControl/Whitening

200     FDA recommended upper limit
250     ADA recommended upper limit

  • Any toothpaste with an RDA below 70 is considered to be low abrasive.
  • Any toothpaste with an RDA between 70 and 150 is considered to be moderately abrasive
  • Any toothpaste with an RDA over 15o is considered highly abrasive except for occasional use to remove severe stains

The signs and symptoms of toothpaste abuse

Sandblasted teeth:

The earliest sign of toothpaste abuse is the gradual elimination of the surface anatomy on the teeth, just as though the teeth have been sandblasted.  This phenomenon is seen especially in younger adults who are very self conscious about the whiteness of their teeth.  Note in the model below that the surface anatomy of the teeth has virtually been erased and the beginning of toothbrush abrasion is visible around the cervix of nearly all the posterior teeth.


Mandibular canines and premolars are the worst affected:

The wear pattern is most pronounced on the cervical buccal surfaces of the mandibular premolars and canines, however the buccal surfaces of other teeth are often also affected.  The reason that the damage from toothpaste abuse becomes worse the further anterior you go is because it is easier for the patient to be more aggressive with the toothbrush in the anterior regions.

Cupping or cratering

AttritionCupping on the mandibular molars is very common in cases of toothpaste abuse.  In the image to the right, the cupping shows smooth, rounded enamel edges.  The smoothness of the enamel around the craters is diagnostic of toothpaste abuse.  Toothpaste on the brush is responsible for wearing the dentin below the level of the enamel and causing the smooth, rounded edges on the surrounding enamel.

Polished amalgams:

Since very aggressive brushers are likely to brush the occlusal surfaces of their teeth, amalgam fillings may be highly polished.

Damage to the buccal tooth structure can be very severe:

Until recently, I believed that abfraction was responsible for the damage seen in most of the images below.  While biomechanical flexure of the teeth may be involved, I now believe that the major factor in producing these lesions is toothpaste abuse.


Teeth that are very sensitive to cold.

Often, patients who abuse toothpaste abrade away enough tooth structure at the cervix of their canines and premolars to cause serious tooth sensitivity.  Overly aggressive brushing is probably the major cause of tooth thermal hypersensitivity.  Patients with this type of damage to their teeth also often complain of pain when eating or drinking sweet foods.


Confirming your diagnosis of toothpaste abuse

The damage from toothpaste abuse is worse on the buccal surfaces of the lower premolars and canines.  There is often a stark difference between the damage on the right side of the dentition versus the left side due to the “handedness” of the patient.

Hand articulated diagnostic models show that upper and lower wear patterns do NOT coincide.  It is very helpful to look at the occlusion from the lingual aspects to confirm this.

Ask the patient demonstrate their usual brushing technique.  Give the patient a toothbrush (use their own if possible) and toothpaste and let the patient go to the sink to demonstrate.  Stress that the technique they show you should be the same as the one they practice daily.  You will be quite surprised to see how seriously aggressive they can be with their brush.  Also, ask the patient how many times per day they practice this ritual.  Quite often, they will tell you that they brush as often as they can in any given day.

Ask the patient if they like the color of their teeth!!!  A vast majority of younger patients and middle age women exhibiting these lesions are dissatisfied with their tooth color, and they will tell you that they brush aggressively to make their teeth whiter.

The types of patients who damage their teeth with toothpaste abuse

Patients who dislike the color of their teeth and want to make them whiter.  This applies to younger patients and women into late middle age.  They will aggressively brush their teeth with the most abrasive toothpaste they can find, especially one that promises “whiter teeth”.  This habit becomes ingrained and continues even into older ages when the patient may care less about the color of their teeth.

Patients who learned aggressive horizontal brushing techniques when young and continue the habit throughout their lives.  Childhood habits die hard!  Children often begin brushing their teeth before developing the manual dexterity to anything more than horizontal strokes on the buccal surfaces.

Fearful patients.  Many patients develop aggressive, horizontal tooth brushing techniques due to fear of retribution from their parents when they were children.  Others are persons who are afraid of having to go to the dentist.

Treatment modalities for patients suffering the damage from toothpaste abuse

Offer to whiten the patient’s teeth with bleaching techniques.  In this instance, bleaching goes past cosmetic treatment into the realm of preventive treatment to prevent further serious damage to the teeth.

Repair the damage using standard treatment modalities.  The patient should be made aware that composite restorations will not lighten along with their natural tooth structure, so it is wise to bleach before making this type of repair in order to match the color.  Alternatively, the patient may wish to repair the damage with veneers (Lumineers® work quite well), or crowns.

Council the patient about their tooth brushing technique, and explain the dangers of abrasives in toothpastes.  Explain that aggressive brushing with toothpaste removes the white enamel from the surface of their teeth exposing the yellow color of the dentin underneath, causing their teeth to become even more yellow than they were before brushing.  Suggest that the patient switch from using toothpaste to using mouthwashes such as Act which contains fluoride, or Listerine, which has been shown to kill plaque organisms.

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