Toothpaste Abuse

The five major causes of pathologic, noncarious tooth wear according to Abrahamsen
Abrasion:
Bruxism
Toothpaste Abuse
Erosion
Regurgitation
Soda Swishing (Coke Swishing, Pepsi Swishing, etc.)
Fruit Mulling

The second most common cause of tooth wear is toothpaste abuse. As you may recall from the third page in this series, toothpaste abuse does NOT mean using too much toothpaste on the brush. It means using toothpaste in conjunction with very aggressive, prolonged, frequent, and hard brushing using a wide, back and fourth, "sawing" motion with the brush. This is most frequently done by patients on the occlusal and buccal surfaces of the teeth, and less aggressively on the lingual surfaces. This is a very common problem and is often engaged in by patients who do not like the color of their teeth and want to whiten them in the mistaken belief that aggressive use of the toothbrush/toothpaste will accomplish this.

Early research has shown that the toothbrush itself does not damage the teeth without additional abrasive, in spite of aggressive brushing. However, the addition of abrasive in the form of toothpaste DOES abrade away tooth structure. This is a bit like a lab ragwheel on a dental lathe. The ragwheel, by itself does little to the surface of the acrylic, but the addition of pumice will abrade the surface quickly. Furthermore, the coarseness of the pumice does not affect the final outcome. Even flour of pumice will abrade the denture away as surely as coarse pumice, given enough time and pressure.

The signs and symptoms of toothpaste abuse

Sandblasted teeth: The earliest sign of toothpaste abuse is the gradual elimination of the surface anatomy on the teeth, just as though the teeth have been sandblasted. See figures 7-10 on Dr Abrahamsen's paper for a great illustration of this phenomenon. This phenomenon is seen especially in younger adults who are very self conscious about the whiteness of their teeth.
Mandibular canines and premolars are the worst affected: The wear pattern is most pronounced on the cervical buccal surfaces of the mandibular premolars and canines, however the buccal surfaces of other teeth are often also affected. The reason that the damage from toothpaste abuse becomes worse the further anterior you go is because it is easier for the patient to be more aggressive with the toothbrush in the anterior regions.
Cupping or cratering on the mandibular molars is very common in cases of toothpaste abuse. In the image to the right, the cupping shows smooth, rounded enamel edges. The smoothness of the enamel around the craters is diagnostic of toothpaste abuse. Toothpaste on the brush is responsible for wearing the dentin below the level of the enamel and causing the smooth, rounded edges on the surrounding enamel.
Polished amalgams: Since very aggressive brushers are likely to brush the occlusal surfaces of their teeth, amalgam fillings may be highly polished.
Damage to the buccal tooth structure can be very severe: Until recently, I believed that abfraction was responsible for the damage seen in most of the images below. While biomechanical flexure of the teeth may be involved, I now believe that the major factor in producing these lesions is toothpaste abuse. (See also figures 11-14 on Dr Abrahamsen's paper)
Teeth that are very sensitive to cold. Often, patients who abuse toothpaste abrade away enough tooth structure at the cervix of their canines and premolars to cause serious tooth sensitivity. Overly agressive brushing is probably the major cause of tooth thermal hypersensitivity. Patients with this type of damage to their teeth also often complain of pain when eating or drinking sweet foods.






Confirming your diagnosis of toothpaste abuse

The damage from toothpaste abuse is worse on the buccal surfaces of the lower premolars and canines. There is often a stark difference between the damage on the right side of the dentition versus the left side due to the "handedness" of the patient.
Hand articulated diagnostic models show that upper and lower wear patterns do NOT coincide. It is very helpful to look at the occlusion from the lingual aspects to confirm this.
Ask the patient demonstrate their usual brushing technique. Give the patient a toothbrush (use their own if possible) and toothpaste and let the patient go to the sink to demonstrate. Stress that the technique they show you should be the same as the one they practice daily. You will be quite surprised to see how seriously aggressive they can be with their brush. Also, ask the patient how many times per day they practice this ritual. Quite often, they will tell you that they brush as often as they can in any given day.
Ask the patient if they like the color of their teeth!!! A vast majority of younger patients and middle age women exhibiting these lesions are dissatisfied with their tooth color, and they will tell you that they brush aggressively to make their teeth whiter.
The types of patients who damage their teeth with toothpaste abuse

Patients who dislike the color of their teeth and want to make them whiter. This applies to younger patients and women into late middle age. They will aggressively brush their teeth with the most abrasive toothpaste they can find, especially one that promises "whiter teeth". This habit becomes ingrained and continues even into older ages when the patient may care less about the color of their teeth.
Patients who learned aggressive horizontal brushing techniques when young and continue the habit throughout their lives. Childhood habits die hard! Children often begin brushing their teeth before developing the manual dexterity to anything more than horizontal strokes on the buccal surfaces.
Fearful patients. Many patients develop aggressive, horizontal tooth brushing techniques due to fear of retribution from their parents when they were children. Others are persons who are afraid of having to go to the dentist.
Treatment modalities for patients suffering the damage from toothpaste abuse

Offer to whiten the patient's teeth with bleaching techniques. In this instance, bleaching goes past cosmetic treatment into the realm of preventive treatment to prevent further serious damage to the teeth.
Repair the damage using standard treatment modalities. The patient should be made aware that composite restorations will not lighten along with their natural tooth structure, so sometimes it is wise to bleach before making this type of repair in order to match the color. Alternatively, the patient may wish to repair the damage with veneers (Lumineers work quite well), or crowns.
Council the patient about their tooth brushing technique, and explain the dangers of abrasives in toothpastes. Explain that aggressive brushing with toothpaste removes the white enamel from the surface of their teeth exposing the yellow color of the dentin underneath, causing their teeth to become even more yellow than they were before brushing. Suggest that the patient switch from using toothpaste to using mouthwashes such as Act which contains fluoride, or Listerine, which has been shown to kill plaque organisms.