Tooth wear–Attrition page

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Tooth wear Introduction

If you have been in practice long enough, you will have run into something like this eventually.  This is a 76 year old farmer who has fairly obviously been “grinding his teeth”.  In fact, you would be making a correct assumption.  Note that the tooth wear is much worse anteriorly than it is in the posterior.  As we will eventually see, this is diagnostic of abrasion from bruxism.  But notice a few other less obvious things.  You see no occlusal amalgam fillings in the posterior teeth.  You see no plaque or redness around the gingiva.  You see no active decay anywhere.  Furthermore, the patient has no periodontal bone loss in spite of a serious bruxing habit.  On the other hand, you do see a few buccal composite fillings along with severe buccal-cervical wear.  We can conclude the following from these observations:

This patient has probably never used too much sugar.  We conclude this by the lack of amalgam fillings in the intact molars and the occlusal of #4, the one “surviving” premolar.

The patient has had good oral hygiene for most of his life.  We conclude this by the lack of periodontal disease, in spite of severe bruxing, and the current state of health of the gingiva and supporting structures.

Note, however that he does have severe lesions on the buccal surfaces of his premolars and canines, but they are as clean as a whistle.  These lesions were not caused by tooth decay.  They were caused by a process called abfraction, which is fully explained on the next page in this series.


Dr Abrahamson has come to believe on the basis of studies carried out by WD Miller in 1917 and G. Sanges in 1975 that the term toothbrush abrasion is inaccurate and should be discarded in favor of the following terms:

Toothbrush recession:

Studies have shown that the toothbrush, regardless of the stiffness of the bristles or the way the ends are shaped does NOT cause abrasion of the tooth structure.  The toothbrush itself DOES cause injury to the gingiva, with consequent recession, and the extent of this injury is dependent on the stiffness of the bristles and the way the bristles are shaped at the tip.  The most damage to the gingiva is caused by stiff bristles which are shaped with rough, sharp edges.  The least recession is caused by soft bristles with milled, rounded ends.

Toothpaste Abrasion:

Although the toothbrush does not damage the teeth by itself in spite of aggressive brushing, the addition of abrasive, in the form of toothpaste DOES abrade away tooth structure, a bit like a rag wheel with pumice on it will abrade away the acrylic on a denture.  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 effect the final outcome.  Even flour of pumice will abrade the denture away as surely as coarse pumice, given enough time and pressure.

Toothpaste Abuse:

This term means nearly the same thing as toothpaste abrasion, defined above, but it requires some further explanation.  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.  It’s a very common problem and is often engaged in by patients who do not like the color of their teeth.   They mistakenly believe that aggressive brushing with toothpaste will whiten them.  Instead, they wear away the white enamel allowing more yellow from the underlying dentin to show through.

The following terms are defined in fairly standard fashion except for the concept of attrition which now has an expanded definition to include both abrasion and erosion:


Attrition is now a generic term defined as the pathologic wear of teeth from abrasion and/or erosion.  Everyone wears down their teeth in one way or another during a lifetime, and thus everyone suffers at least some attrition.


Abrasion is defined as the pathologic wear of teeth from mechanical rubbing; either on occlusal surfaces from bruxing or from the misuse of toothpaste on virtually any surface exposed to toothbrush bristles and toothpaste.


Erosion is defined as the pathologic wear of teeth from a chemical-dissolving process such as those cases in which stomach acid is regurgitated into the mouth in bulimia, or Acid Reflux Disease (formerly known as GERD).  Erosion also happens because of acidic solutions and foods kept in the mouth for prolonged periods.


Cupping or Cratering:

This diagnostic finding is one of the most obvious and easily discernible characteristics of erosive and abrasive attrition.  When the practitioner sees cupping on molar cusp tips, its characteristics will go a long way toward helping with the diagnosis.

Cupping happens on the cusp tips of molars and premolars  and incisal edges of incisors and canines.  Cupping on molars has less to do with bruxing than with erosion caused by acids, while cupping on anterior teeth is more likely due to bruxing in older patients.

Diagnostic Models:

Doctor Abrahamson correctly notes that the diagnosis of all forms of attrition are facilitated by the use of hand articulated diagnostic models.  In fact, all erosive and abrasive tooth stigmata are more easily seen on well made stone models, and the ability to hand articulate them has the added benefit of making it possible to inspect the occlusion from the lingual to see if occlusal wear on maxillary teeth actually coincides with the occlusal wear on the mandibular teeth.  Many practitioners assume that all occlusal wear is from bruxing, but are surprised to see that the wear facets on opposing teeth do not coincide.

The five major causes of pathologic, non carious tooth wear according to Abrahamsen

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

The following pages will examine each of these five causes of tooth wear and give the pathognomonic wear pattern associated with them.  Images will follow in time, however in the meantime I refer you directly to the relevant figures in Dr. Abrahamsen’s paper.  I will give you the diagnostic features of each pattern of wear, as well as various questions you can ask the patient in order to confirm your diagnosis.

Next page–attrition 2–The theory of abfraction>>

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