A clinical reference for those who examine tooth wear chairside
Tooth wear: what it is, its three mechanisms, and when it stops being physiological
Dr. Guilherme Cabral
Tooth wear is the cumulative surface loss of mineralized tooth substance due to physical or chemo-physical processes not related to dental caries [1].
1. FDI World Dental Federation. Tooth wear. FDI policy statement. Int Dent J. 2024;74(1):163-164. PMID 38218598. PMCID PMC10829352. DOI 10.1016/j.identj.2023.10.007.
Enamel does not grow back, so every loss adds up over a lifetime. That is why some wear comes with age, and that much is physiological. In the chair, the question is whether a patient has lost more than their age explains. If they have, the next question is which mechanism is behind it.
Types of tooth wear: biocorrosion (erosion), tension (abfraction), and friction (abrasion, attrition)
Here, the four names fit into three mechanisms: acid dissolves tissue, load flexes the tooth, contact wears the surface. Each leaves a shape of its own on the tooth, and the reading starts from that shape.
Biocorrosion (erosion)
What it is
Biocorrosion (erosion) is mineral loss by chemical dissolution. The acid comes from the diet or from the stomach. Grippo proposed the term biocorrosion for this chemical action [2].
2. Grippo JO. Biocorrosion vs erosion: the 21st century and a time to change. Compend Contin Educ Dent. 2012;33(1):33-37. PMID 23268573.
How it happens
Hydrogen ions from the acid break down hydroxyapatite and release calcium into the saliva, on every surface they reach, with no preferred direction. Before any loss is visible, the surface softens. Saliva can still reharden that layer if nothing rubs it away; what has already dissolved does not come back.
How it presents
Dissolution leaves a rounded outline, wider than it is deep. The surface turns smooth and glossy. On posterior teeth, the cusps round off and the occlusal anatomy fades.
In the cervical region, the attack stops just short of the gingival margin and often leaves a thin band of intact enamel standing. Which surface is involved suggests the source: on the facial of anterior teeth, dietary acid; on the palatal of maxillary anterior teeth, gastric acid.
These are the usual sites, not the only ones.
Tension (abfraction)
What it is
Tension (abfraction) is loss of structure in the cervical region when load bends the tooth and the tensile stress from that flexure breaks down enamel and dentin.
How it happens
Load along the long axis becomes compression, which the tooth tolerates well. Oblique load bends the tooth like a cantilever anchored in bone, and tensile stress concentrates in the cervical third. The enamel there is thin, and enamel resists tension far less than compression. A single load leaves no mark; repeated, it fatigues the material until the crystals separate. Occlusion decides where the stress lands, and a clenching or grinding habit decides the dose.
How it presents
The lesion starts on the surface that flexure stretches, which depends on the cuspal incline taking the load. The shape tends toward a wedge, with a sharp internal angle, flat walls, and a straight margin. With a thick gingival phenotype, the lesion can grow below the margin, where acid and the toothbrush barely reach, and there the first suspicion is tension. With a thin phenotype, the same load can make the bone resorb and the margin recede, which leaves the exposed root within reach of the other mechanisms.
These are the usual sites, not the only ones.
Friction (abrasion, attrition)
What it is
Friction (abrasion, attrition) is loss from mechanical contact. There are two types, told apart by what touches the tooth.
Where friction weighs in
On tissue that acid has softened or load has flexed, contact speeds up the loss. In vitro, acid-softened enamel lost four times more to toothbrushing than sound enamel [4].
4. Wiegand A, Köwing L, Attin T. Impact of brushing force on abrasion of acid-softened and sound enamel. Arch Oral Biol. 2007;52(11):1043-7. PMID 17658454. DOI 10.1016/j.archoralbio.2007.06.004.
Attrition: tooth against tooth
In attrition, with nothing between the teeth, repeated contact flattens the spot where they touch. It comes from bruxism, during sleep or while awake. It usually shows where teeth meet: occlusal surfaces, incisal edges, cusp tips, and the tips of the canines. The mark is a flat, polished facet. In closure and excursions, the facet on one tooth fits the facet on its antagonist.
Abrasion: an outside agent against the tooth
In abrasion from toothbrushing, the particles in the toothpaste do the cutting; the brush only carries them. Fibrous food and objects held in the mouth abrade the tooth too. Abrasion usually shows on the facial surface and in the cervical region, along the path of the brush, as shallow, crisscrossing scratches on a rough, matte surface. On sound enamel, the brush removes little. Its direct damage is greater on the gingiva, which recedes and exposes the root.
These are the usual sites, not the only ones.
| Mechanism | What acts | Where it usually shows | What it looks like |
|---|---|---|---|
| Biocorrosion (erosion) | Acid from the diet or the stomach, not from bacteria, that dissolves tissue | Facial of anterior teeth (dietary acid), palatal of maxillary anterior teeth (gastric acid), occlusal of posterior teeth | Rounded outline, wider than it is deep; smooth, glossy surface; cervically, often a thin band of intact enamel at the gingival margin |
| Tension (abfraction) | Oblique load that bends the tooth; the tensile stress from that flexure breaks down enamel and dentin | Cervical third, on the surface that flexure stretches; with a thick gingival phenotype, it can grow below the margin | Wedge: sharp internal angle, flat walls, straight margin |
| Friction (abrasion, attrition) | Attrition: tooth against tooth, from bruxism. Abrasion: an outside agent (toothpaste particles, fibrous food, objects) | Attrition: where teeth meet (occlusal surfaces, incisal edges, cusp tips). Abrasion: facial and cervical surfaces, along the path of the brush | Attrition: a flat, polished facet that fits the one on its antagonist. Abrasion: shallow, crisscrossing scratches on a rough, matte surface |
These are the usual sites, not the only ones.
One lesion, more than one mechanism
Goodacre and colleagues describe non-carious cervical lesions (NCCLs) as multifactorial in etiology [3]. Take a patient who sucks on oranges through the day. The citric acid softens the cervical surface, and the fiber of the fruit, chew after chew, carries away what the acid softened. Two mechanisms, one lesion. Which one leads changes from patient to patient: in one it is load, in the next it is acid.
3. Goodacre CJ, Roberts WE, Munoz CA. Noncarious cervical lesions: morphology and progression, prevalence, etiology, pathophysiology, and clinical guidelines for restoration. J Prosthodont. 2023;32(2):e1-e18. PMID 35920595. DOI 10.1111/jopr.13585.
Within one lesion, read it wall by wall. Is the outline rounded, or does it narrow into a wedge? Look at where the walls meet, and note whether the angle is sharp or soft. Then check the surface inside the concavity for scratches.
The shape raises a suspicion about the mechanism. The consultation confirms it: the history you take, and the reasoning you work through with the patient.
BEWE: the index that grades the extent of loss
The Basic Erosive Wear Examination (BEWE) scores each surface from 0 to 3, first by the texture of the surface and then by the fraction of its area lost [5]. Its job is to compare the same surface from one visit to the next. Two surfaces with the same area lost get the same score, whatever the mechanism and however long the loss took.
5. Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clin Oral Investig. 2008;12(Suppl 1):S65-S68. PMID 18228057. PMCID PMC2238785. DOI 10.1007/s00784-007-0181-5.
Tap a score for its criterion.
No erosive tooth wear. The surface is intact.
Initial loss of surface texture. There is no defect with a defined outline yet: what has changed is the texture.
Distinct defect: hard tissue loss of less than 50% of the surface area. Dentin is often involved, but area sets the score, not dentin.
Hard tissue loss of 50% or more of the surface area. Here too dentin is often involved, and the score still comes from area.
Time and the person separate physiological from pathological wear
Loomans and colleagues, in the European consensus on severe tooth wear, pose the deciding question: is the wear consistent with the patient's age, or atypical for it [6]?
6. Loomans B, Opdam N, Attin T, et al. Severe tooth wear: European consensus statement on management guidelines. J Adhes Dent. 2017;19(2):111-119. PMID 28439579. DOI 10.3290/j.jad.a38102.
Take two patients with the same loss of structure on the same surface. One is 60, the other 24. At 60, decades of function can account for that loss, and the wear is consistent with age, unless an active cause turns up. At 24, the same loss built up in less than half the time: the wear has advanced faster than age explains, and that is where it reads as pathological.
Consistent with age: physiological
Atypical for age: pathological
Frequently asked questions
What causes tooth wear?
Unlike caries, tooth wear has no single agent such as bacteria: it is shaped by the patient's habits, lifestyle and health. Among 3,187 adults aged 18 to 35 in seven European countries, Bartlett and colleagues found wear associated with heartburn or acid reflux, repeated vomiting, snoring, and fresh fruit and juice [7]. None of these can be confirmed from the tooth alone; they come out in the history. To see how The Tooth Wear Workup teaches that history, visit the program page.
7. Bartlett DW, Lussi A, West NX, Bouchard P, Sanz M, Bourgeois D. Prevalence of tooth wear on buccal and lingual surfaces and possible risk factors in young European adults. J Dent. 2013;41(11):1007-13. PMID 24004965. DOI 10.1016/j.jdent.2013.08.018.
What should be done about tooth wear lesions? Isn't restoring them enough?
Restoring is one part of managing tooth wear lesions, and typically a late one. The European consensus guidelines on severe tooth wear recommend diagnosis, prevention, counseling and monitoring, to clarify the cause of the wear and how to control it, and advise delaying restorative intervention as long as possible [6]. When a restoration is indicated, the same guidelines favor a conservative, minimally invasive approach, backed by preventive measures.
6. Loomans B, Opdam N, Attin T, et al. Severe tooth wear: European consensus statement on management guidelines. J Adhes Dent. 2017;19(2):111-119. PMID 28439579. DOI 10.3290/j.jad.a38102.
Aren't non-carious cervical lesions caused by occlusion?
Occlusion can add to a non-carious cervical lesion (NCCL), but on its own it rarely explains one. Duangthip and colleagues reviewed 69 studies: 81% found an association between occlusal stress and NCCLs, yet no clinical study showed a lesion caused by stress alone [8]. In the mouth, load works alongside acid and contact and the loss comes from the combination. An occlusal finding opens the history; it does not close it.
8. Duangthip D, Man A, Poon PH, Lo ECM, Chu CH. Occlusal stress is involved in the formation of non-carious cervical lesions. A systematic review of abfraction. Am J Dent. 2017;30(4):212-220. PMID 29178704.
Isn't cervical wear just from brushing too hard?
No single brushing factor, hard brushing included, has been established as the primary cause of cervical abrasion. Reviewing the evidence, Litonjua and colleagues found the studies on force, technique, bristle stiffness and toothpaste too limited and conflicting to single one out, and concluded that brushing may act together with biocorrosion (erosion) and, possibly, occlusal load [9]. Hard brushing still belongs in the history, alongside the questions about acid and load.
9. Litonjua LA, Andreana S, Cohen RE. Toothbrush abrasions and noncarious cervical lesions: evolving concepts. Compend Contin Educ Dent. 2005;26(11):767-8, 770-4, 776 passim. PMID 16300231.
Isn't a healthy diet good for the teeth?
A diet that is healthy for the body can still be hard on enamel and dentin. In a systematic review, Smits and colleagues found the vegetarian diet associated with higher odds of biocorrosion (erosion) (odds ratio 2.40), though most included studies were of poor quality [10]. That diet tends to spread fruit and vegetables across many meals and snacks, so acid reaches the teeth more often. The risk follows the eating pattern more than any single food.
10. Smits KPJ, Listl S, Jevdjevic M. Vegetarian diet and its possible influence on dental health: a systematic literature review. Community Dent Oral Epidemiol. 2020;48(1):7-13. PMID 31571246. PMCID PMC6972589. DOI 10.1111/cdoe.12498.
Isn't biocorrosion (erosion) about what the patient drinks?
In biocorrosion (erosion), what the patient drinks matters, and so does how they drink it. Johansson and colleagues compared young men with high and low levels of it: the high group kept a cola-type drink in the mouth for 71 seconds, against 40, while the pH after drinking did not differ between the groups [11]. The study was small, 19 men in all, but it adds a question to the history: how each drink is taken.
11. Johansson AK, Lingström P, Birkhed D. Comparison of factors potentially related to the occurrence of dental erosion in high- and low-erosion groups. Eur J Oral Sci. 2002;110(3):204-11. PMID 12120705. DOI 10.1034/j.1600-0447.2002.11211.x.
How do you treat a tooth wear lesion?
You treat a tooth wear lesion through the host first: the patient, and what their routine keeps doing to the tooth. The lesion is the part of the disease that has already happened, so the working rule is to control the host, not the lesion. For biocorrosion (erosion), the European Federation of Conservative Dentistry includes screening for early signs and evaluating all etiological factors in effective management [12].
12. Carvalho TS, Colon P, Ganss C, et al. Consensus report of the European Federation of Conservative Dentistry: erosive tooth wear diagnosis and management. Swiss Dent J. 2016;126(4):342-346. PMID 27142130. DOI 10.61872/sdj-2016-04-143.
Doesn't a night guard stop bruxism?
A night guard protects the teeth during bruxism; the evidence does not show that it stops the bruxism itself. In a Cochrane review, Macedo and colleagues found insufficient evidence that occlusal splints treat sleep bruxism, and noted that they may bring some benefit for tooth wear [13]. The patient may go on grinding with the same intensity and frequency, with the acrylic wearing in place of the enamel. So the splint protects while you look for what drives the grinding.
13. Macedo CR, Silva AB, Machado MA, Saconato H, Prado GF. Occlusal splints for treating sleep bruxism (tooth grinding). Cochrane Database Syst Rev. 2007;(4):CD005514. PMID 17943862. PMCID PMC8890597. DOI 10.1002/14651858.CD005514.pub2.
Why is exposed dentin sensitive in one patient and not in another?
Exposed dentin becomes sensitive when its tubules are open at the surface and reach the pulp, and not every worn surface has open tubules. Absi and colleagues compared exposed cervical dentin under the electron microscope: sensitive teeth had about eight times more tubules per area, about twice as wide, as non-sensitive teeth [14]. Addy and Pearce consider biocorrosion (erosion), which opens tubules, the probable main initiator of dentin hypersensitivity [15].
14. Absi EG, Addy M, Adams D. Dentine hypersensitivity. A study of the patency of dentinal tubules in sensitive and non-sensitive cervical dentine. J Clin Periodontol. 1987;14(5):280-4. PMID 3475295. DOI 10.1111/j.1600-051x.1987.tb01533.x.
15. Addy M, Pearce N. Aetiological, predisposing and environmental factors in dentine hypersensitivity. Arch Oral Biol. 1994;39(Suppl):33S-38S. PMID 7702465. DOI 10.1016/0003-9969(94)90186-4.
Is abfraction accepted?
Tension (abfraction) is recognized as one factor in non-carious cervical lesions, and debated as an explanation for them. Goodacre and colleagues include occlusal stress among the factors that contribute to these lesions, and note that publications have both supported and challenged the concept of abfraction [3].
3. Goodacre CJ, Roberts WE, Munoz CA. Noncarious cervical lesions: morphology and progression, prevalence, etiology, pathophysiology, and clinical guidelines for restoration. J Prosthodont. 2023;32(2):e1-e18. PMID 35920595. DOI 10.1111/jopr.13585.
Managing tooth wear: what to do, and in what order
Across all three mechanisms, management follows the same order. It starts with the person, and the patient carries out much of it.
Tap a step to read it
Start with the person
Before you touch a tooth, ask about their routine, diet, reflux, sleep, stress and medication, and take dated photographs. The shape of the wear tells you what to ask; only the patient can answer it.
Let the patient see it
Show them their own photographs and where the wear is heading if nothing changes. Then they decide how far to take treatment.
Control the cause, with the patient
The patient changes what is theirs to change; the rest goes to another clinician, with the dated photographs, as part of the treatment.
With acid, frequency is what counts: they space out the exposures, and right after one they rinse with water instead of brushing. Acid from within is not yours to treat: it gets referred.
With load, the patient learns to notice daytime clenching, and anxiety or poor sleep is referred. Canine guidance takes lateral load off the posterior teeth. Subtractive occlusal adjustment to treat the lesion is not supported by the evidence.
With contact, the patient changes how and when they brush, never how much: a soft brush and a low-abrasivity toothpaste.
Protect the tooth in the meantime
Once sleep apnea has been screened for and night reflux ruled out, a hard stabilization splint takes the contact in place of the enamel and spares the surfaces that meet. Acute pain, an impending fracture or an exposed pulp is treated at once, alongside cause control. When the cause does not give way, protection becomes the strategy.
Restore last
A restoration gives back form and distributes load, but it does not treat the cause. Place it to give back function and structure, alongside cause control or after it.
Follow up without discharge
At each recall, photograph the same surface, compare it with the first record and revisit the habits with them. If the cause you targeted is under control and the wear has not slowed, the reading was wrong: reorder the plan.
The protocol for each measure, and the cases where a measure backfires, are taught in depth in The Tooth Wear Workup. One example: in a patient whose gastric acid rises at night, the bruxism splint holds that acid against the enamel.
See the programWe do not treat only the wear. We treat the person it happened to.
Start with the next case of tooth wear in your chair. Before you commit to any procedure, find the real cause of the wear, so you are not putting your work on the line.
Dr. Guilherme Cabral
References
- FDI World Dental Federation. Tooth wear. FDI policy statement. Int Dent J. 2024;74(1):163-164. PMID 38218598. PMCID PMC10829352. DOI 10.1016/j.identj.2023.10.007.
- Grippo JO. Biocorrosion vs erosion: the 21st century and a time to change. Compend Contin Educ Dent. 2012;33(1):33-37. PMID 23268573.
- Goodacre CJ, Roberts WE, Munoz CA. Noncarious cervical lesions: morphology and progression, prevalence, etiology, pathophysiology, and clinical guidelines for restoration. J Prosthodont. 2023;32(2):e1-e18. PMID 35920595. DOI 10.1111/jopr.13585.
- Wiegand A, Köwing L, Attin T. Impact of brushing force on abrasion of acid-softened and sound enamel. Arch Oral Biol. 2007;52(11):1043-7. PMID 17658454. DOI 10.1016/j.archoralbio.2007.06.004.
- Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clin Oral Investig. 2008;12(Suppl 1):S65-S68. PMID 18228057. PMCID PMC2238785. DOI 10.1007/s00784-007-0181-5.
- Loomans B, Opdam N, Attin T, et al. Severe tooth wear: European consensus statement on management guidelines. J Adhes Dent. 2017;19(2):111-119. PMID 28439579. DOI 10.3290/j.jad.a38102.
- Bartlett DW, Lussi A, West NX, Bouchard P, Sanz M, Bourgeois D. Prevalence of tooth wear on buccal and lingual surfaces and possible risk factors in young European adults. J Dent. 2013;41(11):1007-13. PMID 24004965. DOI 10.1016/j.jdent.2013.08.018.
- Duangthip D, Man A, Poon PH, Lo ECM, Chu CH. Occlusal stress is involved in the formation of non-carious cervical lesions. A systematic review of abfraction. Am J Dent. 2017;30(4):212-220. PMID 29178704.
- Litonjua LA, Andreana S, Cohen RE. Toothbrush abrasions and noncarious cervical lesions: evolving concepts. Compend Contin Educ Dent. 2005;26(11):767-8, 770-4, 776 passim. PMID 16300231.
- Smits KPJ, Listl S, Jevdjevic M. Vegetarian diet and its possible influence on dental health: a systematic literature review. Community Dent Oral Epidemiol. 2020;48(1):7-13. PMID 31571246. PMCID PMC6972589. DOI 10.1111/cdoe.12498.
- Johansson AK, Lingström P, Birkhed D. Comparison of factors potentially related to the occurrence of dental erosion in high- and low-erosion groups. Eur J Oral Sci. 2002;110(3):204-11. PMID 12120705. DOI 10.1034/j.1600-0447.2002.11211.x.
- Carvalho TS, Colon P, Ganss C, et al. Consensus report of the European Federation of Conservative Dentistry: erosive tooth wear diagnosis and management. Swiss Dent J. 2016;126(4):342-346. PMID 27142130. DOI 10.61872/sdj-2016-04-143.
- Macedo CR, Silva AB, Machado MA, Saconato H, Prado GF. Occlusal splints for treating sleep bruxism (tooth grinding). Cochrane Database Syst Rev. 2007;(4):CD005514. PMID 17943862. PMCID PMC8890597. DOI 10.1002/14651858.CD005514.pub2.
- Absi EG, Addy M, Adams D. Dentine hypersensitivity. A study of the patency of dentinal tubules in sensitive and non-sensitive cervical dentine. J Clin Periodontol. 1987;14(5):280-4. PMID 3475295. DOI 10.1111/j.1600-051x.1987.tb01533.x.
- Addy M, Pearce N. Aetiological, predisposing and environmental factors in dentine hypersensitivity. Arch Oral Biol. 1994;39(Suppl):33S-38S. PMID 7702465. DOI 10.1016/0003-9969(94)90186-4.