How do you clinically distinguish between pathological and physiological wear in the dentition?

Distinguishing Pathological from Physiological Tooth Wear

Tooth wear is pathological when moderate, severe, or extreme wear is present in combination with functional problems, pain/discomfort, aesthetic impairments, or sensitivity—otherwise it should be considered physiological age-appropriate wear. 1, 2

Clinical Assessment Framework

Define the Severity of Wear

Visual examination should assess:

• Extent of tooth substance loss relative to patient age 1, 2
• Pattern of wear across the dentition (localized vs generalized) 2
• Presence of excessive wear facets indicating bruxism 3
• Dentin exposure causing sensitivity to air, food, or beverages 3

Identify Signs and Symptoms of Pathology

Pathological wear is confirmed when ANY of the following are present alongside moderate-to-severe wear: 2

• Functional impairment: difficulty chewing, altered occlusion, or inability to fully interdigitate posterior teeth 3
• Pain or sensitivity: discomfort with hot/cold exposure, prolonged chewing, or spontaneous pain 3
• Aesthetic concerns: visible tooth shortening, loss of tooth contour, or patient dissatisfaction 4
• Rapid progression: excessive wear inappropriate for patient's age 1, 5

Determine Etiological Factors

Assess for chemical causes (erosion): 2, 5

• Dietary acids (citrus, carbonated beverages, wine)
• Gastric acid exposure (GERD, vomiting disorders, bulimia)
• Environmental acid exposure (occupational)

Assess for mechanical causes: 2, 6

• Attrition: tooth-to-tooth contact from bruxism or clenching 3
• Abrasion: toothbrush trauma, abrasive dentifrices, occupational factors 5, 6
• Abfraction: stress-related cervical lesions 5

Radiographic Evaluation

Obtain intraoral radiographs to assess: 7

• Periapical health of affected teeth
• Pulp chamber size and proximity to wear
• Secondary dentin formation

Key Clinical Pitfalls

Do not assume all wear is physiological in young patients—pathological wear can occur at any age and requires intervention when symptomatic. 1, 2

Do not overlook underlying medical conditions—gastroesophageal reflux, eating disorders, Sjögren's syndrome, and medication-induced xerostomia can accelerate erosive wear without patient awareness. 3, 5

Do not confuse localized trauma-related wear with generalized pathological wear—isolated fractures or luxation injuries have distinct management protocols. 3

Management Decision Algorithm

If physiological wear (age-appropriate, asymptomatic):

• Patient education on prevention 7
• Monitoring at routine intervals 1

If pathological wear (symptomatic or progressive):

• Institute preventive measures immediately (dietary counseling, fluoride, management of underlying medical conditions) 1, 5
• Delay restorative intervention as long as possible 1
• When restoration is necessary, use minimally invasive adhesive techniques 1, 4
• Follow-up radiographs at 3 months, 6 months, 1 year, then annually for 3 years 7