Not only is the prevalence of tooth surface loss (TSL) increasing, but clinicians increasingly find themselves facing criticism and challenges regarding its diagnosis and management.
A clinician’s failure to investigate TSL adequately, perhaps leading to an incorrect diagnosis and inappropriate treatment (especially where such treatment is unnecessarily interventive) are the most common problem areas encountered. A clinician’s ability to withstand such challenges will rely in part at least upon the extent to which the clinical records can demonstrate each of the stages in the diagnostic and treatment process. Excluding tooth tissue loss through trauma, caries or interventive procedures, TSL can arise from three main factors either alone or (as often occurs) in combination. These are erosion, attrition and abrasion.
The 10-point checklist below serves to highlight key questions and key areas to consider when diagnosing and treating TSL. Use it to assess and improve the quality of your own clinical records, next time you are treating a patient who has presented with TSL. Remember also that TSL may not be static; a review appointment following initial assessment and treatment is an ideal opportunity to build upon whatever information you have gathered previously, and this may also lead you to explore additional or alternative etiological factors or different treatment approaches.
1. Medical history
Where the TSL primarily affects the palatal surfaces of the maxillary (especially anterior) teeth, the records should demonstrate specific enquiries regarding any acid regurgitation resulting from hiatus hernia or gastric conditions (such as ulcers). Any eating disorders such as anorexia or bulimia should be considered as a possibility, especially if the patient’s body weight and physique supports this. Any medication currently (or recently) taken by the patient also needs to be discussed and recorded.
2. Dental history
Patients may or may not be aware of TSL. Where symptoms are reported, the history of the presenting complaint can be important in establishing the rate at which the TSL is occurring. Try to distinguish between teeth which are symptomatic, and those which are not and make this clear in the records. It is relevant to establish whether TSL has been discussed with any previous clinician and if so, when, and what diagnosis and treatment was suggested. Has any treatment been successful?
3. Social history
Occasionally, a patient’s occupation or hobbies may be a relevant contributory factor. Sporting activities may be associated with the consumption of sports drinks or even with dehydration (depriving the tooth surface of the buffering capacity of saliva). Recreational drugs can sometimes induce bruxing with an associated loss of tooth tissue.
4. Examination and charting
In cases of TSL it is important to establish a baseline against which the subsequent progression (or otherwise) of the condition can be compared. Record the affected teeth, the surface(s) involved, and the severity of any TSL. Also relevant here is the surface profile - a dull, matt surface, rounded edges of any lesion, and a general loss of surface anatomy will often be suggestive of erosive TSL. On the other hand, a highly polished/burnished appearance, and lesions with sharper edges are suggestive of attrition and abrasion (sometimes exacerbating an underlying erosive element by accelerating the rate of tooth tissue loss).
5. Investigations
It is arguably in this area, in particular, that the clinical records need to be sufficient to demonstrate the reasonable skill and care that the clinician has exercised when assessing, diagnosing and monitoring TSL. The relevant investigations might include:
- Study models (providing a definitive record of the surface profile and characteristics of the affected teeth, and also the occlusion at different moments in time). These are particularly valuable when comparing the situation from one visit to the next.
- Clinical photographs.
- Dietary assessment - especially where the TSL is generalised, or limited to the buccal surface of anterior teeth.
- Tooth vitality.
- Radiographs where periapical involvement is suspected.
- Toothbrushing (enquiries regarding the type/hardness of toothbrush and toothpaste, and the technique used).
6. Diagnosis
The records should show the differential diagnosis considered by the clinician, as well as the conclusion reached, and be consistent with the records of the preliminary stages outlined above.
7. Preventive advice/counselling
In the initial stages of treating TSL, it is not unusual for the clinician to give the patient advice regarding the preventive management of the TSL through alterations in diet, toothbrushing etc or perhaps the use of fluoride or alkaline solutions in certain situations. It is important to record the details of what advice was given, and when, and what response this elicited from the patient. If the patient seems reluctant or unwilling to follow a course of action recommended by the clinician (for example, discontinuing the use of sports drinks), this fact should similarly be recorded in the clinical notes.
If anything is done to protect the at-risk surfaces (for example, the topical application of fluoride), this needs to be recorded on each occasion. The same applies where the patient is advised to return at a specified interval for such treatment to be repeated.
8. Consent
When treating TSL, it is important that the patient understands its cause, and the reasoning behind the treatment approach adopted, as well as agreeing to any specific treatment that is proposed. Where the success of any treatment will depend to a large extent upon patient compliance/co-operation, the patient must be told this and fully understand the consequences of not following the advice given. Such discussions need to be clearly recorded in a dated entry in the patient’s notes.
9. Provisional treatment
Where palliative or provisional treatment is carried out, perhaps in order to protect surfaces at risk while a diagnosis is confirmed and/or a definitive treatment plan is agreed and embarked upon, the records should make clear both the temporary nature of the treatment provided, and also the fact that this has been explained to and understood by the patient
10. Definitive treatment
In recent years, thinking has changed regarding the management of TSL. As a general rule, minimum intervention procedures should be tried before considering a more radical or interventive approach. If in doubt, and/or when faced with complex cases, it may be sensible to consider, or suggest to the patient, a second opinion from a specialist in restorative dentistry or from a more experienced colleague. Any such consideration or discussion with the patient should be recorded in the notes, and copies of any relevant referral correspondence retained safely.
Summary
Any failure to recognise or manage TSL in an appropriate fashion, which then results in the condition deteriorating unnecessarily, can leave a clinician open to criticism. Where TSL has been present for some time, and is not progressing, it is sufficient in most cases to record the fact that it has been recognised and pointed out to the patient, and is being kept under observation. On the other hand, proceeding too hastily - or with insufficient prior assessment and investigation - with extensive restorative treatment, can be difficult to justify and defend if this treatment subsequently proves to be unsuccessful.