Dento-legal considerations in the management of patients with tooth wear

Tooth wear is described as a complex multifactorial process that includes: erosion, abrasion, attrition and, theoretically, abfraction, potentially leading to the irreversible loss of enamel and dentine.¹ An ageing population, alongside improvements in dental health education, has meant the public are retaining their teeth for longer.² Thus, tooth wear is likely to be a growing concern in contemporary dentistry. Consequently, tooth wear patients will face a substantial time commitment and financial strain when dealing with the management of their tooth wear.

The prevalence of tooth wear increases with age.^3,4 We are seeing a rise in tooth wear in younger patients, which means they are exhibiting this condition for a longer duration of life. Dugmore and Rock studied a cohort of children in the UK aged 12. Their 2-year longitudinal study found that new or more advanced erosive lesions were seen in 27% of the children over the study period.³

Interestingly, Van't Spijker et al reported, in a systematic review, that 3% of 20 year olds and 17% of 70 year olds exhibited severe tooth wear.⁴ The Adult Dental Health Survey noted the decline of caries and periodontal disease while describing an increase in the prevalence of tooth wear.⁵ The report acknowledged the natural increase of tooth wear with age and suggested ‘mild’ to ‘moderate’ tooth wear would be expected in an older population, but raised the issue of public health concern in younger populations exhibiting ‘moderate’ to ‘severe’ wear.² A pan European study by Bartlett et al on over 3000 ‘young adults’ (18–35 years old), covering clinical data and questionnaires from seven countries, indicated that the UK exhibited a higher prevalence of ‘moderate’ scores for tooth wear (54.4%).⁶

Similarly to periodontal disease, this might be considered a ‘silent’ disease with its effects stretching out over time without the patient or dentist being aware of it. Recognizing it a long time into a practice–patient relationship can lead to awkward enquiries from the patient questioning why this had not been identified by the practice or individual dentist much earlier. There is every danger that tooth wear and its mismanagement may become the next big area of litigation.

Examination

A detailed dental examination allows dentists to understand a patient's oral health background, identify risk factors, and uncover potential issues that may impact treatment decisions. A comprehensive clinical assessment for tooth wear involves a meticulous examination of the tooth surfaces, investigating and screening for signs of erosion, attrition, and/or abrasion. A prudent dentist will note any structural changes, loss of tooth structure or characteristic wear patterns to accurately diagnose and plan appropriate interventions.

A popular screening tool used for tooth wear is the Basic Erosive Wear Examination (BEWE) index.⁷ Much like screening for periodontal disease and caries, tooth wear ought to be included as part of an overall risk assessment for every patient. A BEWE score of ‘3’ (Figure 1) is indicative of advanced wear and warrants appropriate diagnosis and management. This is also imperative from a medico-legal standpoint.

The difficulty with BEWE, or any index, is that they are subjective. However, it does provide a baseline assessment of the level of tooth wear for the busy general practitioner to record. Other methods to measure tooth wear include, but are not limited to: photography (Figure 2), serial study casts, silicone indices and, more recently, intra-oral scanners. It is the opinion of the authors that the practicality of retaining study casts and silicone indices in clinical practice may prove cumbersome. It is also quite difficult to compare study models, which are subject to their own distortion factors when manufactured and stored. Silicone indices are equally prone to distortion and will not identify the sort of minimal changes that can be identified and mapped using intra-oral scanners.

Diagnosis

The first key step is identifying the issue and conveying it to the patient. Given the multifactorial nature of tooth wear, diagnosing the root cause of the problem is oftentimes difficult (Figure 3). The importance of targeted questions and history taking is crucial to aid in the diagnostic process. It is tempting, in the hurried environment of general practice, for dentists to match patients' ambivalence towards their condition. However, patients may not have previously been aware of their tooth wear and a sense of empathy aids towards holistic, patient-centred care. A formal diagnosis, even when provisional, must be documented in the clinical records and conveyed to the patient. Identifying the extent of the tooth wear will help to motivate the patient. For example, if it is localized or generalized and how severe it is (assisted by a BEWE score).

Managing risk factors

Following a diagnosis, managing risk factors is the next pivotal step. This entails taking disease ownership in combating the condition. Once a diagnosis has been established, patients can be guided in identifying these risk factors through compassionate counsel on lifestyle modifications.

To facilitate this process, patients should be equipped with pertinent information and knowledge necessary for making substantial behavioural adjustments. For instance, if the erosion can be attributed to the consumption of acidic beverages, such as carbonated drinks, dietary guidance becomes paramount. Similarly, if the issue is related to aggressive mechanical toothbrushing, advising on brushing frequency, pressure, and toothbrush abrasivity becomes essential.

When providing patients with resources, such as information leaflets and diet sheets, it is wise to make a reference to these materials in the clinical records alongside the aetiology presented.

The dilemma: monitor or intervene?

Determining the appropriate timing for intervention can present a significant challenge for clinicians. Historically, clinicians were encouraged to monitor rather than intervene. After all, entering the restorative cycle signifies a commitment to lifelong care. However, simply monitoring can lead to substantial loss of tooth tissue, particularly in terms of reduced enamel and shortened clinical crowns. Sometimes, by the time patients themselves note aesthetic changes or hypersensitivity, the treatment modality may have already become complex, warranting time and a financial commitment for which the patient is unprepared (Figure 4).

As such, adhesive dentistry may be deemed less predictable and more conventional, subtractive methods are required. The literature suggests approximately 63–72% of the coronal tooth structure is removed when teeth are prepared for all-ceramic and metal–ceramic crowns.⁸ This biological cost is made worse with worn teeth. Hence, delaying treatment can result in more severe issues, potentially avoidable through earlier intervention.

Ultimately, decisions regarding treatment should be in patients' best interests. The importance of active patient involvement in the decision-making process is paramount. Patients should undergo a thorough assessment to understand the treatment rationale and costs associated with management plans customized to their circumstances. Patients must be provided with comprehensive and relevant information to enable them to make informed decisions in collaboration with the clinician. Shared decision-making as part of the consent process represents the dialogue between patients and healthcare clinicians alike, leading to mutually agreed-upon options.

Communication with indifferent patients

Clinicians can often encounter limited enthusiasm and indifference from patients. This is often because the patients are not experiencing any signs and symptoms of the condition being explained to them and, if they do, they may simply dismiss it as a natural ageing process or ‘wear and tear’. To engage indifferent patients, it is important to explain the ‘why’ behind the treatment, granting them a sense of control and participation.

Encouraging questions, providing information gradually, and offering alternatives enables patients to make informed decisions about their dental care. Conveying the consequences of inaction and creating a supportive atmosphere, dental professionals will encourage patients to foster a sense of ownership in their oral health.

Patients have an absolute autonomous right to refuse treatment, even if it is offered in their best interests, but that must be an informed refusal. The patient should be left in no doubt about the consequences of a refusal to accept treatment, the risks and concomitant consequences and clinical records should accurately reflect the refusal and the reasons for it, for example financial.

In some cases, particularly for new patients, it is not always easy to predict a timeline or speed of progression and that unpredictability should be shared with the patient. They might be happy with a ‘wait and see’ approach, as does the treating clinician.

The risks of not doing anything and more complex treatment later

A dental professional who lacks confidence or expertise in treating tooth wear may opt for a cautious approach, advising the patient that monitoring of their tooth wear represents the best course of action. However, this approach also carries its own set of challenges, as refraining from treatment may potentially jeopardize the predictability of future interventions. This may result in patient dissatisfaction or, even worse, a breakdown of trust.

Referral

In line with General Dental Council (GDC) standards, dentists should recognize their own limitations. Treating extensive tooth wear is seldom simple. Seeking a second opinion, and providing a referral, to determine the appropriate treatment for tooth wear is worthwhile. As per GDC standards:⁹

• 6.3.3 You should refer patients on if the treatment required is outside your scope of practice or competence. You should be clear about the procedure for doing this.
• 7.2.2 You should only deliver treatment and care if you are confident that you have had the necessary training and are competent to do so. If you are not confident to provide treatment, you must refer the patient to an appropriately trained colleague.

By making judicious referrals, we not only enhance patient outcomes but also safeguard ourselves from potential legal and ethical issues that might arise from attempting treatments beyond our scope of practice.

Record keeping

Good record keeping plays a pivotal role in shaping the strength of a defence against any complaints or allegations of substandard care.

The key aspects, regarding tooth wear, that dental teams need to record are:

• Tooth wear has been identified;
• Tooth wear risk status (high, medium, low) for patients at the same time as the caries and periodontal disease risk assessment;
• The location and severity of tooth wear;
• That this finding has been communicated to the patient;
• A diagnosis has been made and relevant prognoses;
• A care plan is set out and agreed with the patient;
• Tooth wear and/or its management are reviewed periodically;
• That the patient has been communicated all clinical findings.

Whether a patient accepts or declines treatment should be recorded in the clinical records.

The benefits and risks of all treatment options, including doing nothing, should be noted. For example, the longevity of restorations will depend on the aetiology of the tooth wear. Patients need to be made aware of the clinical benefits and limitations of different materials. For instance, composite materials can provide good aesthetics and be minimally invasive. However, composites may readily wear, discolour and chip over time. This will result in further costs and clinical time, which patients will need to be aware of beforehand. Minimally invasive dentistry is clearly a key element of managing tooth wear early to avoid unnecessary destruction later. However, placement of composite restorations is technique sensitive, requiring good isolation with rubber dam, high-quality bonding techniques, especially with large areas of exposed dentine, and sandblasting where appropriate.

The general dentist should have a basic understanding of the treatment options available. For example, patients should be informed in advance of any planned occlusal changes as part of their tooth wear treatment (i.e. reorganization of the occlusion at an increased OVD). This avoids the embarrassment of them finding out after treatment has commenced. Most patients adapt positively to changes in their occlusion; however, some do not, and clinicians can safeguard themselves through sound documentation and record keeping.

Conclusions

Tooth wear is a significantly rising concern in dentistry. Patients often seek treatment mainly for aesthetic reasons. But here's the thing – by the time they notice it, their teeth might already be severely worn down. So, catching it early and preventing it is the way to go to avoid costly and extensive treatments later on. Dentists play a crucial role in educating patients and asking about any risk factors.