From a Dawson perspective, I always start with the complete exam, which then leads into your full diagnostic records and a full occlusal analysis. A full wear case should never be treated, unless the cause can be identified or all other options have been exhausted and treatment must move forward. (this sentence doesn't seem to flow, but I'm not quite sure what is being conveyed.
First, understand the root cause
If we don't understand the root cause of the problem, we cannot properly form a plan in order to prevent it from happening again. We must understand what has led to the loss of tooth structure, and then must know how to prevent it from recurring. If we cannot prevent the tooth-loss, is it possible to slow its progression? In the Dawson philosophy, you will hear it stated many times that 'our goal is to have our patients get worse at the slowest possible pace'. There are high functional risk patients that, no matter what we do, will have major wear on their teeth and any restorations that are placed. The end goal is planning to either prevent the same issue from continuing, or minimize the impact moving forward.
Start with a full history and make no assumptions
Our diagnostic process starts with obtaining a full history and patient interview followed by a complete exam and full records. It is also important to understand that not all wear is from parafunction. I think a common misconception is that anytime we observe wear, it is always from parafunction. When I first graduated from dental school, anytime I saw exposed dentin, I assumed the patient was grinding. Now we know that is not the case and that it could be from attrition due to an unstable occlusion.
Wear can also result from abrasion, erosion, corrosion, etc. Does the patient have acid reflux? Are there sleep disturbances? What habits or dietary factors could be contributing to the loss of tooth structure? There are many different factors that could cause their wear. If we do not have a full understanding of all possible contributing factors, it is going to be very hard to achieve optimal treatment results and prevent the same breakdown from recurring in the future. The patient pictured above presented to my office only 12 months after his maxillary arch was reconstructed with an implant supported fixed hybrid denture. Do you think the practitioner who completed his maxillary arch planned to fail? Or do you think the practitioner failed to plan?
The more information, the better
I always tell my patients that I want to know every little detail even if they feel it is insignificant. Sometimes those little, insignificant details can be the most important inmaking an accurate diagnosis. It is extremely important that during the interview with the patient to make your own observations as well. Be sure to look intraorally, and obtain facebow mounted models on a semi-adjustable articulator. If you use un-mounted models or even models mounted on a hinge articulator, it will be impossible to make an accurate diagnosis and treatment plan, because you will not be able to obtain an accurate replication of the masticatory system.
Finally, once you have obtained a full patient history and have your diagnostic models, you have to make sure everything makes sense. Does the patient’s reported history match up with what you are observing intraorally and on your mounted models? If it doesn’t, then you either need to go back to the patient or back to your models to find out what information is missing.
Understand how to identify and treat occlusal wear in Functional Occlusion - From TMJ to Smile Design.