Compiled from clinical pathology references. Medically reviewed by Dr Cristian Dunker, Principal Dentist at ArtSmiles Cosmetic Dentistry.
Quick summary
Also called | Tooth surface loss; the four subtypes, attrition, erosion, abrasion and abfraction |
How urgent? | 🟡 Worth assessing, mild wear is normal with age, but significant wear can lead to sensitivity, fractures and major reconstruction if not addressed |
Common or rare? | Common, and reportedly increasing, particularly in younger adults with acidic diets |
Who it affects | Adults of all ages, with rising prevalence in people who grind or clench their teeth, drink frequent acidic drinks, suffer from reflux, or use abrasive products too vigorously |
Who treats it | General dentist for diagnosis and management; sometimes in coordination with a GP for reflux or eating disorder care |
Based on | Neville, with cross-references in Cawson and Regezi |
What is it?
Tooth wear is the gradual loss of tooth surface from causes other than decay or trauma. The textbooks describe it as a normal physiological process that everyone experiences with age, but one that becomes pathological when the rate of loss begins to affect appearance, function or sensitivity. There are four main types of tooth wear, and most real-life cases involve a combination of more than one:
Attrition, wear from tooth-on-tooth contact during chewing and grinding.
Erosion, chemical loss of tooth structure from acid (food, drink, reflux, vomiting).
Abrasion, mechanical wear from a foreign object (toothbrush, pipe stem, fingernail).
Abfraction, small notches at the necks of teeth thought to relate to bending stresses, although the textbooks note debate about whether this mechanism really exists in the mouth.
Recognising which mechanism is dominant, and which combination of factors is at play, is the key to stopping further wear before extensive restoration is needed.
Who tends to get it?
The textbooks describe a fairly broad profile, since some degree of wear is universal:
Adults of all ages, wear becomes more visible with each decade.
People who grind or clench their teeth (bruxism), both daytime and nocturnal.
People with frequent or prolonged acid exposure, frequent acidic drinks, sour lollies, fresh fruits eaten between meals, reflux, vomiting.
People with reduced saliva flow, from medications, dry mouth conditions, dehydration during heavy exercise.
Heavy or vigorous toothbrushers, especially those using a hard-bristled brush with horizontal strokes.
People with certain occupations, sommeliers, bakers, swimmers in poorly buffered pools, industrial acid-exposure workers.
People with eating disorders, particularly bulimia, with chronic vomiting causing severe palatal erosion (erosion on the tongue-side of the upper front teeth, facing the roof of the mouth).
People with poor-quality enamel (the hard outer layer of the tooth), from fluorosis, hypoplasia, amelogenesis imperfecta or dentinogenesis imperfecta.
The textbooks note that tooth wear is increasing, particularly in younger adults, a trend many believe is driven by greatly increased consumption of acidic soft drinks (US figures cited in Neville show a 300% increase over 20 years).
What causes it?
Each of the four types has its own causes:
Attrition, wear from tooth-on-tooth contact:
Bruxism (clenching or grinding), often during sleep.
Edge-to-edge bite rather than the normal slight overbite.
Chronic chewing of abrasive substances between teeth.
Loss of back teeth placing greater load on the remaining teeth.
Erosion, non-bacterial chemical loss:
Dietary acids, soft drinks, citrus, vinegar, wine, sour lollies, energy drinks.
Gastric reflux (GORD), hiatal hernia, chronic alcoholism, pregnancy.
Voluntary vomiting in eating disorders such as bulimia.
Industrial acid exposure in particular occupations.
Some medications, including certain liquid medicines and chewable vitamin C.
Reduced saliva flow, saliva normally buffers acids and helps remineralise the enamel.
Abrasion, mechanical wear from a foreign object:
Hard-bristle toothbrush with heavy horizontal strokes, by far the most common cause.
Abrasive toothpaste used aggressively.
Habits such as biting fingernails, threads, pencils, pipe stems, or hairpins.
Inappropriate use of dental floss or toothpicks.
Abfraction, debated as a mechanism:
Eccentric occlusal forces (bite forces that hit the tooth at an angle rather than straight down) that cause the tooth to flex, with the cervical area (the neck of the tooth, near the gum line) as the point of greatest stress.
The textbooks specifically note that systematic reviews have found little evidence that occlusal forces alone are responsible for these cervical defects. Many lesions originally labelled abfraction may be combined erosion-abrasion.
In practice, the textbooks emphasise that most cases of tooth wear are multifactorial, pure attrition, pure erosion or pure abrasion is unusual. Each mechanism makes the surface more vulnerable to the others, so they tend to combine and accelerate together.
How does it develop?
Each subtype has a recognisable pattern of development, but they overlap in real patients. Attrition slowly flattens the chewing surfaces. Erosion softens the surface, making it more vulnerable to even gentle abrasion. Abrasion at the gum line exposes the softer dentine (the softer layer beneath the enamel), which then erodes and abrades faster than the surrounding enamel. Abfraction, where it occurs, creates wedge-shaped defects at the necks of teeth that can deepen with continued occlusal stress.
Importantly, the pulp of the tooth tries to keep up with the slow loss by laying down extra dentine on the inside of the pulp chamber (reactionary dentine). This is why teeth can wear down considerably without becoming painful, the pulp protects itself by retreating from the advancing wear.
What might you notice?
What it looks like
Attrition:
Flat, shiny, polished facets on the chewing surfaces and biting edges.
Shorter front teeth, often with thinner edges that may chip.
Matching wear patterns on opposing teeth.
Erosion:
Cupped lesions on the tips of cusps (the pointed peaks on the chewing surface of back teeth), with elevated rims of enamel and a depressed dentine centre.
Spoon-shaped depressions on the front surfaces of upper front teeth, typical of dietary acid.
Yellow appearance of teeth as the white enamel thins and the underlying dentine shows through.
Fillings standing higher than the surrounding tooth, a useful diagnostic clue.
Smooth, polished palatal surfaces of upper front teeth in patients with chronic vomiting (perimolysis).
Abrasion:
Sharp-edged horizontal notches on the gum-line side of teeth, particularly canines and premolars.
Notches on incisal edges (the biting edges of the front teeth) in pipe smokers or thread biters.
Loss of tooth structure on the side of the dominant hand.
Abfraction:
Deep, narrow, V-shaped notches at the gum line.
Often affecting a single tooth with healthy neighbours.
Sometimes subgingival (below the gum line), where a toothbrush could not reach.
What it feels like
Sensitivity to cold or sweet foods, particularly with erosion, where the dentine is exposed.
Sharp pain when biting if the wear has reached deep dentine.
Aesthetic concern, shorter, yellow or chipped teeth.
Difficulty chewing when much of the chewing surface has been lost.
Jaw discomfort in heavy bruxers.
No symptoms at all in many slow cases, where the pulp's reactionary dentine has kept the nerve protected.
What an X-ray might show
X-rays may show:
Reduced crown height in advanced attrition.
Pulp chamber narrowing from reactionary dentine.
Cervical defects in abfraction lesions.
Loss of enamel thickness in erosion when severe.
What happens at the dentist?
Tooth wear is most often picked up at a routine dental check-up and clean at ArtSmiles. The dentist will typically:
Examine each tooth surface under good light, photographing and documenting the pattern.
Take a careful history, diet, drinks, reflux, vomiting, brushing technique, smoking, occupational exposures, jaw discomfort, sleep partner reports of grinding.
Take impressions or scans to compare the current surfaces with future visits, wear is often easier to spot by comparison than at a single visit.
Test for sensitivity with a small puff of air or cold spray.
Identify which mechanism is dominant based on the pattern, and which factors are reversible.
Discuss preventive measures before any restorative work, restoring teeth while wear is still active rarely succeeds.
Coordinate with a GP for reflux, eating disorders or other systemic causes.
Is this serious?
🟡 Mild tooth wear is normal with age. Significant wear is a serious long-term issue because it eventually leads to sensitivity, fracture, loss of biting height, jaw discomfort and the need for major restoration. The good news is that with early identification and management of the underlying factors, the rate of wear can be dramatically slowed.
Could it be something else?
Several conditions can produce loss of tooth structure or similar symptoms. The textbooks list these as the main differentials:
Dental caries, bacterial decay, usually with discoloration and a soft cavity rather than a polished smooth surface.
Enamel hypoplasia, defective enamel from the time of tooth formation, present from eruption.
Enamel hypoplasia and dental fluorosis, mottling and pitting from excessive fluoride during development.
Amelogenesis imperfecta, hereditary defective enamel formation.
Dentinogenesis imperfecta, hereditary defective dentine formation.
External or internal resorption, softer dentine loss visible on X-ray.
How is it treated?
Treatment depends on which mechanisms are at play and how much damage has occurred. The textbooks emphasise prevention first, restoration second.
At-home measures and habits:
Reduce frequency of acidic foods and drinks, sip them at meals rather than between meals, use a straw positioned at the back of the mouth, finish with water.
Wait before brushing after acid exposure if you have just eaten or drunk something acidic, although evidence on the optimal interval is mixed, very vigorous brushing immediately after acid is best avoided.
Use a soft-bristled toothbrush with gentle, small circular strokes rather than horizontal scrubbing.
Use a low-abrasivity toothpaste if you are prone to abrasion.
Treat reflux with your GP, diet, position, and where needed, medication.
Manage bruxism, stress reduction, sleep hygiene, and a custom night splint.
Stop biting fingernails, pencils or pipe stems.
Stay well hydrated during exercise to maintain saliva flow.
Consider sugar-free gum to stimulate saliva after meals or between exposures.
Professional steps your dentist may consider:
Detailed diagnosis using photographs, impressions or digital scans, with comparison over time.
Desensitising treatments, fluoride varnishes, stannous fluoride, strontium chloride or potassium nitrate toothpastes.
Custom occlusal splint (night guard) for bruxism.
Composite ("white") restorations for early cervical defects or worn cusps, see also dental fillings.
Onlays, veneers or crowns for more extensive wear, restoring shape and function.
Bite reconstruction in severe generalised wear, often as part of a staged restorative plan.
Coordination with a GP or dietitian when reflux, vomiting or dietary factors are central.
Long-term follow-up, since tooth wear is rarely a "one and done" problem.
A patient-centred approach is particularly important here. Tooth wear is rarely the patient's fault in any simple sense, the modern diet, common medications, reflux, and stress all conspire. Calm, unhurried discussion of which factors apply to each person and what change will give the biggest return is itself part of effective care, values that sit at the heart of our clinical philosophy.
What's the long-term outlook?
The outlook depends heavily on early diagnosis and on whether the contributing factors can be modified. With prompt identification and good preventive care, even teeth showing significant wear can usually be stabilised and protected for many years. Where wear is left to progress, the eventual restoration is more invasive and more expensive. The single most important factor across all cases is early dental review and consistent management of the everyday habits that drive wear.
A note on this article
This article is for educational purposes only and does not constitute a clinical diagnosis. Please consult a registered dental practitioner for assessment and treatment advice.
The cover image above is an AI-generated illustration based on the most common visible features of this condition described in clinical pathology references. It is not a photograph of a real case and should not be used to diagnose or rule out the condition in your own situation. If you are concerned about something you have noticed, please book an assessment with a registered dental practitioner.
References
Neville, B. W., Damm, D. D., Allen, C. M., & Chi, A. C. (2023). Oral and maxillofacial pathology (5th ed.). Elsevier. Chapter 2, Abnormalities of Teeth: Postdevelopmental Loss of Tooth Structure (Attrition, Abrasion, Erosion and Abfraction), with detailed clinical features and treatment, pp. 58-62.
Cawson, R. A., & Odell, E. W. (2017). Cawson's essentials of oral pathology and oral medicine (8th ed.). Elsevier. Cross-reference for tooth wear management and the role of saliva, fluoride and bruxism.
Regezi, J. A., Sciubba, J. J., & Jordan, R. C. K. (2017). Oral pathology: Clinical pathologic correlations (7th ed.). Elsevier. Cross-reference for postdevelopmental loss of tooth structure.
