Toothwear ; An emerging trend in Sri Lanka
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Toothwear; An emerging trend in Sri Lanka
Dr. Manil Fonseka BDS, LDSRCS (Eng) MS (Restorative Dentistry)
Department of Restorative Dentistry11th September 2014
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Historical Perspective
• Normal physiologic process• Some tooth-wear essential for efficient
function of teeth which is seen in many herbivores
• Important to establish unhindered guidance during mastication
• However the level of tooth wear minimal
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Rates of tooth-wear
• 2500 years for 1mm of enamel wear with normal function
• Estimated the level of tooth wear to be 29µm for molars and 15µm for premolars (Lambrechts et al, 1989)
• Physiological wear poses minimal problems• If the rate of wear challenges the viability of
teeth TSL considered pathologic
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Factors precipitating wear
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Factors precipitating tooth-wear
• Multi-factorial aetiology• Increase in life expectancy
Increased functional demandLonger exposure to erosive foodsRecession and exposure of relatively weaker
cementumIncreased use of medicationQuantitative and qualitative reduction in salivary flowLoss of teeth increases demand on the
remaining teeth
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Diet
• Dietary changes have resulted in the diets being less abrasive
• Should theoretically reduce the levels of tooth-wear
• Excessive consumption of erosive beverages and foods has had a potentiating effect on the increased prevalence of NCTSL
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Implicated foods• Fizzy drinks (pH 2.2 – 3.8)• Fruit juices (pH 3.0 – 4.0)• Wines (pH 3.2 – 4.8)• Cider and Beer (pH 3.5 – 4.0)• Citrus fruits
• Increased prevalence among children and adolescents in the UK (35%)
• Condition of affluent in Sri Lanka (Ratnayake N & Ekanayake L. 2010)
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Extrinsic Acid Erosion
Intrinsic Acid Erosion
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Intrinsic Acid
• pH of Gastric acid is 1-2Gastric RegurgitationBulaemia and anorexiaVomitting
Classically presents as palatal/lingual erosive defects
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Para-function
• Stress induced parafunction• Bruxism• Object biting
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Problems of para-function
• 700 times the normal masticatory load• Force used is considerably greater than during
normal mastication• Seen as wear in non functional cusps
Molars may be severely affectedProminant massetersMarked antigonial notchingTenderness of muscles of
mastication
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Other factors contributing to tooth surface loss
• Defective enamel and dentine deposition and maturation ( E.g AI, DI, Hypoplasias)
• Abrasive restorative material (Unglazed porcelain)
• Abrasive dentifrices and hard brushing in horizontal strokes
• Habits – Instrument biting, Needles etc
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Defective enamel formation
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Scale of the Problem
• 98% of individuals in the UK have some amount of tooth wear
• Increased prevalence among children, deciduous teeth
• 30% of individuals in the UK have severe tooth wear (Tooth Wear Index scores of 3 & 4)
• Problem of affluent in Sri Lanka
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Types of tooth-wear
• Erosion - Intrinsic or Extrinsic acid• Attrition - Tooth to tooth contact • Abrasion - Due to foreign objects• Abfraction - Repeated cyclic flexion of
teeth
• Mostly multi-factorial thus cannot home-in on one cause
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Erosion
• Due to intrinsic or extrinsic acid• Intrinsic acid regurgitation due to gastric reflux
disease (Bullaemia, Anorexia, Gastritis, GORD)• Extrinsic acid consumption (Coke, Fizzy drinks,
Fruit juices, tamarind)• Increasingly seen in young due to change in
lifestyles
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Extrinsic Acid Erosion•Buccal and Labial surfaces•Lingual and palatal spared
Intrinsic Acid Erosion•Palatal and lingual surfaces•Lower incisors spared•Etched like appearance•Cupping•Discoloured if historical•“Proud” restorations
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Attrition
• Tooth to tooth contact• Accelerated due to para-function• Wear on non-functional cusps• Seen in anterior teeth when posteriors are lost• No loss of OVD due to dento-alveolar
compensation• Erosion potentiates attrition (De-mastication)
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Attrition
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Abrasion
Overzelous brushingHorizontal StrokesAbrasive Dentifrices and Brushes
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Effects of NCTSL
• Sensitivity of teeth• Pulpal and Periodontal complications• Poor aesthetics• Impeded function• Prone to fracture• Low self esteem (OHRQoL)
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Aides to Diagnosis
• Detailed history – Occupation, Social, Dietary analysis, Medical history
• Examination– Masticatory apparatus, Wear facets and their
location, “proud” restorations
• Investigations– Radiographs, Photographs, Dated study casts
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Strategies in the management of NCTSL
• Psycho-social support• Medical referrals (GERD)• Habit intervention• Reduction in consumption of erosive
beverages• Using a straw• Soft mouth guards to protect teeth during
gastric regurgitation (Addition of Fluoride gel)• Michigan splints to reduce effects of bruxism
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Soft bite guards/ Michigan splints
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Challenges in management
• Lack of vertical space due to dento-alveolar compensation mechanisms
• Excessive loading of restorations• If the cause continues tooth-wear would continue• Frequent recall and maintenance
Primary aim in treatment prevent/reduce the causes and replace what is lost and maintain available
tooth tissue for adequate function and aesthetics
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Management of Localized tooth wear
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Re-organisation
• Should be well planned not haphazard• Based on sound prosthodontic principles• In dentate patients a raise of 11mm of OVD
could be tolarated• Anterior and canine guidance maintained
without posterior interference• Try with a splint first and go for definitive
restorations if patient tolarates
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Re-organization of occlusion Case 1
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Re-organization of occlusion Case 2
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Re-organization Case 3
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Re-organization Case 4
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Thanks