What is the recommended treatment for pathological tooth wear versus physiological tooth wear?

Management of Pathological vs Physiological Tooth Wear

Pathological tooth wear requires restorative intervention with a minimally invasive approach, while physiological tooth wear typically only needs monitoring and preventive measures. 1

Distinguishing Physiological from Pathological Tooth Wear

Physiological Tooth Wear

• Normal, expected tooth surface loss that occurs throughout life at a slow rate without causing functional, aesthetic, or sensitivity problems 2, 3
• Typically age-appropriate and does not require restorative intervention 4

Pathological Tooth Wear

• Characterized by excessive destruction or rapid rate of loss causing functional, aesthetic or sensitivity problems 2
• Considered pathological when moderate/severe/extreme tooth wear is present with one or more clinical signs and symptoms 4
• Often requires preventive and/or restorative intervention 1

Diagnostic Approach

Clinical Assessment

• Evaluate extent of tooth wear in relation to patient's age 4
• Document signs and symptoms including:
  • Pain or discomfort 5
  • Functional problems 5
  • Aesthetic impairments 5
  • Tooth sensitivity 2

Radiographic Assessment

• Intraoral radiographs are indicated to assess periapical and pulp health conditions of affected teeth 6
• Follow-up radiographic examinations should be performed at three months, six months, one year, and then annually for three years for teeth with significant wear requiring treatment 6

Treatment Recommendations

For Physiological Tooth Wear

• Monitoring and preventive measures 1
• Patient education on oral hygiene practices 6
• Regular dental check-ups to assess progression 4

For Pathological Tooth Wear

Conservative/Preventive Approach

• Identify and address etiological factors (erosion, attrition, abrasion, abfraction) 2
• Implement preventive measures before considering restorative treatment 5
• Dietary counseling if erosion is a factor 2

Restorative Approach (when indicated)

• Use a diagnostic wax-up (DWU) to determine new occlusal plane and vertical dimension of occlusion (VDO) 5
• Create a diagnostic mock-up to evaluate esthetics and function before definitive treatment 5
• Consider minimally invasive restorations:
  • Lithium disilicate occlusal onlays to stabilize VDO 5
  • Anterior veneers (lithium disilicate or feldspathic) 5
  • Direct composite restorations where appropriate 5

Treatment Planning Algorithm

1. Assessment Phase

   • Determine if tooth wear is physiological or pathological 4
   • Identify etiological factors 2
   • Document extent and rate of progression 1

2. Decision Phase

   • If physiological: implement monitoring and preventive measures 3
   • If pathological: proceed to intervention planning 1

3. Intervention Phase (for pathological wear)

   • Create diagnostic wax-up and mock-up 5
   • Evaluate new VDO/esthetics/function through therapeutic mock-up 5
   • Perform minimally invasive restorative procedures 1

4. Follow-up Phase

   • Radiographic follow-up at three months, six months, one year, and then annually for three years 6
   • Monitor for complications such as pulp necrosis 6

Important Considerations and Pitfalls

• Delaying restorative intervention as long as possible is typically recommended for pathological wear 1
• When intervention is indicated, a conservative, minimally invasive approach should be prioritized 1
• Underlying medical conditions may contribute to tooth wear progression and should be identified 2
• Moderate to severe tooth wear poses significant clinical challenges and may require complex treatment 2
• Preventive measures should always complement restorative approaches 1