TOOTH WEAR

TOOTH WEAR DR HSU ZENN YEW

DDS (UKMal), DCLINDENT (Adel)

TERMINOLOGY

‘Tooth surface loss/ TSL’ or ‘tooth wear’:

refers to the loss of tooth tissue by a disease process other than dental caries/ trauma. (Eccles, 1982)

VS

‘Early Enamel Caries’:

Subsurface mineral loss beneath relatively intact surface zone.

Caries

Caries

Tooth wear

Subsurface mineral loss

www.doctorspiller.com

Ungar et.al (2008)

Bailey S & Liu W (2010)

“…the human dentition is basically “designed” on the premise that extensive wear will occur…” Kaifu et al

BDJ 2006

CAVEMAN DIET.. BEST WAY TO SLIM DOWN?..

Is Tooth Wear Physiological or Pathological?

Physiological TSL:

Wear & tear process

Increased wear in older patient

Pathological TSL: Teeth are so worn that they affect-

Function: difficulty in mastication, speech

Aesthetics : seriously affect the appearance

Longevity / survival of teeth : whether tooth will survive until end of life span

Comfort: Exposed dentine -> dentinal sensitivity or pulpal symptoms

CLASSIFICATION

TOOTH WEAR

EROSION ABRASION ATTRITION ?

ABFRACTIONS

D.W. Bartlett and P. Shah (2006)

EROSION

Defined as loss of dental hard tissue as a result of chemical process NOT involving bacteria

Clinical features:

melted appearance (dull appearance)

cupping or grooving on occlusal/incisal surfaces

edges of restorations appear to rise above the level of the adjacent tooth

Lussi 2006

EROSION

silky-glazed appearance of the tooth shallow concavities coronal from the cemento-enamel junction

rounding of the cusps and grooves No occlusal morphology present

Lussi et 2006

Ana Carolina Magalhães et al J Appl Oral Sci. 2009;17(2):75-86

EROSION VS CARIES

CAUSES OF EROSION

ACID ATTACK PROTECTIVE MECHANISM

Biological:

•Saliva: flow rate, composition, buffering capacity and stimulation capacity

•Acquired pellicle: composition, maturation and thickness

•Type of dental substrate (permanent and primary enamel, dentin) and composition (e.g. fluoride content as FHAP or CaF2-like particles)

•Dental anatomy and occlusion Chemical factors

• pH and buffering capacity of the product

• Type of acid (pKa values)

•Citric acid caused more erosion than phosphoric acid

Occupation:

•Workers chemical industry

•Wine tasters

•Swimmers exercising in water with low pH

•Athletes consuming frequently erosive sport drinks.

Behavioural:

•Healthier diet style: diet high in acidic citrus fruits, fruit juices, vegetables

•Unhealthy life style: consumption of designer drugs

•Alcoholic

•Excessive consumption of acidic foods and drinks: soft drinks, wine, vinegar

EXTRINSIC INTRINSIC

Medical:

Common causes for the migration of gastric juice through the lower and upper oesophageal sphincters are • Gastroesophageal reflux disease, hiatus hernia, chronic indigestion •Eating disorders: Anorexia and Bulimia, ruminification •Chronic alcoholism •Pregnancy

Pickards’ Manual, Lussi 2006

ABRASION Defined as ‘the pathological wearing away of dental hard tissue through

abnormal mechanical processes involving foreign objects or substances other than by opposing teeth’.

‘Three- body wear’

Clinical characteristics:

Commonly present buccally

Cervical region

Disc shaped

??V-shaped notch (a/w abfractions)

Pickards’ Manual, Lussi 2006 http://www.teethforbetterhealth.com Badel et. Al 2007

ABRASION

Causes:

Abnormal habits:

Chewing pencils, cigar pipe, thread biting

www.mymuseum.org.uk

ABRASION

Causes:

Toothbrushing/ Oral hygiene habits

Depends on relative dentine abrasivity (RDA) of the toothpaste.

International Standards Organisation (ISO) laboratory test. ISO stipulates that the RDA of toothpastes should not exceed 250

Whitening toothpaste containing alumina may have high abrasivity.

“Normal toothbrushing habits with toothpastes that conform with the ISO standard will, in a lifetime’s use, cause virtually no wear of enamel and clinically insignificant abrasion of dentine (a figure of 1 mm in around 100 years is often cited)”

Addy et al 2003

ABRASION

Causes:

Toothbrushing/ Oral hygiene techniques

Modified bass and roll technique vs horizontal/scrub technique

The effect of acid on enamel and dentine makes the tooth more susceptible to abrasion.

Recommendation : delay at least 1 hour after acidic meals

Addy et al 2003

ABFRACTION

Controversial

Defined as fracture of dental tooth structure caused by occlusal loads of functional and parafunctional force producing stress concentrations around the cervical margin of the crown.

Occlusal forces produce the flexion of the teeth both axially and paraaxially.

The destructive effect on teeth will be intensified by effects of erosion and abrasion

?V-notched at cervical area

Pickards’ Manual, Lussi 2006 http://www.teethforbetterhealth.com Badel et. Al 2007

ATTRITION

Attrition is defined as the loss of enamel, dentin, or restoration by tooth-to-tooth contact (Pindborg, 1970).

Physical wear as a result of the action of antagonistic teeth with no foreign substances intervening (two body wear)

It occurs primarily on occlusal surfaces of teeth or interproximal areas.

Clinical features:

Flat surfaces

Glossy areas with distinct margins

Correspond to antagonistic teeth

Pickards’ Manual, Lussi 2006, Badel et al 2007

ATTRITION

Mechanical loss or in combination with erosion

Affects non-contacting occlusal

Causes:

1. ? Diet: Abrasive diet (e.g vegetarian)

? contemporary diet


ATTRITION

Causes:

2. Bruxism: diurnal and nocturnal parafunctional activity that includes clenching, bracing, gnashing, and grinding of teeth

But..

“Tooth wear is a poor indicator of bruxism..” -> Patients with tooth wear may not have bruxism

“Even if a patient is suspected of having bruxism, dental erosion is more likely the cause of tooth-tissue loss than attrition.”

Khan et al 1998


ATTRITION

Causes:

3. Iatrogenic:

If the restorative material has a greater abrasiveness than enamel (for example, ceramic bridges and crowns and ceramic pontics in dentures), only the antagonist teeth surfaces will undergo tooth wear

Materials which are softer than tooth enamel (composite fillings, acrylic pontics in dentures, acrylic facets and occlusal planes in crowns and bridges, etc.) will wear out to a greater extent whereas enamel of antagonist teeth will remain intact.


CLASSIFICATION

TOOTH WEAR

EROSION/ COROSSION

Chemical wear

ATTRITION

Physical wear: tooth-tooth

surfaces

ABRASION

Physical wear

? ABFRACTIONS

Flexion of tooth

Lussi 2006, D.W. Bartlett and P. Shah (2006)

“It is challenging to distinguish between the influences of erosion, attrition or abrasion during a clinical examination.” “..They may occur simultaneously with sometimes similar shape.”

Although there are known situations where only one single process causes tooth wear (e.g. nocturnal teeth grinding produces wear by attrition alone), the clinical presentation often results from a combination of tooth wear processes.

Combination of erosion, abrasion and attrition Abrasion, abfraction and erosion

MANAGEMENT

DIAGNOSIS

PREVENTION

STABILIZATION

RESTORATION/ REHABILITATION – Phase 3

REVIEW / MONITORING

Phase 2

DIAGNOSIS

Although a combination of factors is usually involved, it is feasible in most cases to identify a perceived major factor

Assessment of possible causative factors should include a systematic history and a methodical approach to the clinical examination.

Johansson et al 2008

CLINICAL EXAMINATION

Quantify the severity and progression of wear

Location of wear: enamel, dentine or pulpal

Alteration in morphology

Changes in the height of tooth


MEDICAL REFERRAL

Refer patients or advise them to seek appropriate medical attention gastroenterologist and/or a psychologist) when intrinsic causes of erosion are involved.

OHE

• Reduce acid exposure by reducing the frequency, and contact time of acids (main meals only). Do not hold or swish acidic drinks in your mouth. Avoid sipping these drinks.

OHI

•Avoid tooth brushing immediately after an erosive challenge (vomiting, acidic diet). •Use a fluoride containing mouth rinse, a sodium bicarbonate (baking soda) solution, milk or food such as cheese or sugar-free yoghurt. If none of the above are possible, rinse with water. •Use a soft toothbrush and low abrasion fluoride containing toothpaste. & proper technique

PROFESSIONAL INTERVENTION

•Night guard for bruxism

•Stimulate saliva flow with chewing gum or lozenges.

•Remineralization:-

•Topical fluoride (NaF, APF, SnF)

•ToothMousse® (CPP-ACP/ Casein Phosphopeptide -amorphous calcium phosphate

PREVENTION

TOOTH WEAR PROTECTIVE MECHANISM

PROFESSIONAL INTERVENTION

•Night guard for bruxism

•Stimulate saliva flow with chewing gum or lozenges.

•Remineralization:-

•Topical fluoride (NaF, APF, SnF)

•ToothMousse® (CPP-ACP/ Casein Phosphopeptide -amorphous calcium phosphate

MEDICAL REFERRAL

Refer patients or advise them to seek appropriate medical attention gastroenterologist and/or a psychologist) when intrinsic causes of erosion are involved.

Pickards’ Manual, Lussi 2006 OHI

•Avoid tooth brushing immediately after an erosive challenge (vomiting, acidic diet). •Use a fluoride containing mouth rinse, a sodium bicarbonate (baking soda) solution, milk or food such as cheese or sugar-free yoghurt. If none of the above are possible, rinse with water. •Use a soft toothbrush and low abrasion fluoride containing toothpaste. & proper technique

OHE

• Reduce acid exposure by reducing the frequency, and contact time of acids (main meals only). Do not hold or swish acidic drinks in your mouth. Avoid sippingt hese drinks. Avoid parafunctional/ abnormal habits

J L Wickens. British Dental Journal 186, 371 - 376 (1999)

Prescription of night guard

Prescription of Michigan splint

Prescription of Tanner appliance

STABILIZATION

Observation, monitoring and palliative strategies

Study cast

Intraoral photographs

computerised software

It is recommended that serial observations be performed at approximately 6–12 monthly intervals (depending on the perceived rate of progression) and comparing the recordings


Serial casts recorded over a period of 7 years showing the value of using models to judge the extent of tooth wear. J L Wickens. British Dental Journal 186, 371 - 376 (1999)

What is a pathological wear rate?

Exceeds physiological wear rates: 10–30 µm on occlusal and 7.5 µm on palatal surfaces annually

A sectional silicone index formed from the initial cast can be used as a reference guide

STABILIZATION

Monitor preventions strategies: monitor progression of tooth wear

OHE reinforcement.

Address symptoms and prevent further damage

Eg: dentine hypersensitivity: bonding agent / topical desensitizing agent may be placed temporarily or semi-permanently over exposed dentine.

RESTORATION/ REHABILTATION

ONLY NECESSARY IF TOOTH WEAR IS PATHOLOGICAL

Degree of wear relative to the age of the patient,

the aetiology,

the symptoms and the patient’s wishes

Patient complaint/ presented with:

Function deficit: diificulty in mastication, speech

Aesthetics problems: seriously affect the appearance

Longevity: threat to the strength of tooth

Cause discomfort/ pain/ sensitivity

Function Aesthetic Longevity Comfort

RESTORATIVE CHALENGES

Adhesion of the restorative material.

resin bond strengths to noncarious sclerotic cervical dentine are lower than bonding to normal dentine.

This is thought to be a result of tubule occlusion by mineral salts, preventing resin tag formation.


Loss of vertical dimension – increased in free way space

S. B. Mehta, S. Banerji, B. J. Millar & J.-M. Suarez-Feito. BDJ 212, 17 - 27 (2012)


Compensatory eruption: lack of restorative space


Restorability of tooth

DoctorSpiller.com

Localized tooth wear

Adequate restorative space

Direct restoration

Direct composite resin

Localized tooth wear

Adequate restorative space

Indirect restoration

Crowns /Veneers

Onlays

Generalized tooth wear

Proper planning: diagnostic mock-up

Interdisciplinary management: periodontal ( surgical crown lengthening), endodontics ( RCT/ elective endodontics), surgery ( extractions, alveolaplasty)

Need to consider referral to restorative specialist or prosthodontist

Combination of various restorative methods

Direct and indirect

Fixed and removable (+ implants)

PBM crowns made on 34, 35, 44,45

Upper full clearance and moditication of existing RPD

Lower wax up at increase OVD

Composite build ups and FGC on 47,36

MAINTENANCE PHASE

Cases should be reviewed at least annually when new study casts, and photographs should be taken

A careful clinical and radiographical examination of abutments should be performed: caries, failed retention, wear facets, porcelain integrity, etc., must be checked, recorded, and treated as necessary.

Assess progression of tooth wear.

Reinforcement of preventive measures

Tooth wear is a multifactorial process, which makes it difficult to identify a single cause.

Definitive restorative procedures should not be performed without identification of aetiological factors, in conjunction with adequate preventive measures and advice.

‘Tooth wear is a natural process that normally does not require specific treatment. Even patients with more extensive tooth wear do not necessarily require oral rehabilitation if the adaptation is good’

Carlsson GE, Magnusson T. 1999

TOOTH WEAR

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