7. Tooth wear II Flashcards
LOs
why is looking at tooth wear important?
(IGNORE)
- Average Time in Treatment: 20.8 months (SD 9.6, Range 8–44 months).
- Average Number of Visits: 24.3 (SD 12.7; 8–48). Of these an average of 3.8 visits were treatment planning visits, often involving multiple disciplines.
- Money: The estimated cost of treatment provided by a specialist in private clinic was £13,353 (SD £6,905; £4,737–£31,224) per patient1.
- This is an average of $16,311 or range of $5,786 - $38,140 (Current Brexit exchange rates)
1
what is erosion?
2
main types + subtypes of erosion?
1
- Chemical dissolution of dental hard tissues by acids of non-bacterial origin
2
1. Extrinsic erosion
~ diet
~ environmental
- Intrinsic erosion
~ gastric contents in mouth
TIP
- identifying the acid is the most important part of tooth wear
- FREQUENCY of acid intake is 1of the most important factors in erosive tooth wear
- The more you have the higher your risk
- better to have acidic things with meals
causes of environmental erosion
VERY RARE
- acid fumes in factories
- inadequately maintained gas-chlorinated swimming pools
- this is very rare while dietary acid consumption is very common
diet info to ask patient?
- the specific dietary acids?
- how often they are having them (FREQUENCY)?
- when they are having it, with meal, between meals (TIMING)?
- how much of the acid they are having (QUANTITY)?
- how long they are having it (DURATION)?
- habits associated with intake (HABITS)?
specific acids to watch out for?
- these are all low pHs
- diet and sugar free drinks are just as acidic
- fruit infusion teas
- cordials
- juice
- fizzy drinks
- all alcohol
- herbal teas are fine as long as no fruit is added
- the pH for all of these are well below the dissolution rates of enamel
- when is the pH value most important
- what does erosive potential of an individual dietary acid depend on?
Don’t need to know table, understand concept
- pH value is most important for the early erosive challenge
- Erosive potential of an individual dietary acid depends on:
~ pH value
~ Titratable acidity
~ Calcium chelation properties
~ Buffering capacity
~ Mineral content - more Ca + P in teeth then those minerals will stay where they are = GOOD + relative damage to enamel = lower
frequency of dietary acid intake and how much it increases your likelihood of tooth wear compared to someone who doesn’t have that acid per day?
- One of the most important factors in erosive tooth wear
- 1 per day or less – not more likely to have tooth wear
- 2 per day = 2.33x more likely
- 3+ per day = 13.5x
- 4 dietary acids per day = high wear progression group
-2 citrus fruits per day = 33x
timing of dietary acid intake and risk likelihood?
FRUIT
- Fruit with meals = no increased risk
- Fruit outside meals did show a risk of erosive wear
1/day = 1.95x
2/day = 5.35x
ACIDIC DRINKS
- Acidic drinks with and outside meals showed increased risk of tooth wear
With meals
- 1/day OR 1.81
- 2/day OR 6.42
Outside meals
- 1/day OR 2.49
- 2/day OR 11.84
Quantity of dietary acid intake effects on tooth wear?
- Limited data on quantity vs frequency - unlike sugar consumption
- Increased quantity is generally associated with erosive tooth wear
- Is this due to increased quantity of the acid or increased contact time with teeth?
how does How Long is the Dietary Acid in Contact with the Teeth affect the risk?
- Intraoral salivary clearance rate of 2-15 minutes depending on drinking method
- > 10 minutes of contact time with acidic fruit increased risk by 12.8x
- > 10 minutes of contact time with acidic drinks increased risk by 2.9x
- Unusual ways of drinking 11x
~ Swishing or rinsing acidic drinks in the mouth
~ Holding drinks in the mouth
~ Sipping drinks slowly
~ Straw directed at the teeth instead of the back
of the mouth increased erosive wear
intrinsic erosion source types and subtypes
Gastric contents coming into the mouth
- INVOLUNTARY
~ Reflux
~ Rumination (bring food back up and chew it)
~ Chronic Alcoholism
~ Vomiting due to pregnancy/ pregnancy reflux
~ Heavy abdominal exercise - VOLUNTARY
~ Vomiting eating disorders
anatomy of oesophageal tract
- Muscular tube about 25cm long with a muscle sphincter at each end
- upper oesphageal sphincter is composed of striated muscle
- lower oesphageal sphincter is not a true phsyiological sphincter and is composed of the diaphragm and muscular folds
= As you descend there is a change from squamous cells to columnar cells – this junction is important as it is the most common site for malignant transformations
- heavy ab exercise can send up acid
gastro-oesphageal reflux
- lower oesphageal sphincter is not a tight sphincter- movement of gastric contents can occur
- Motility disorders
- Transient relaxations of the lower osephageal sphincter
- Incompetent sphincter
- Abnormalities of peristalsis
- Hiatus hernia
- Reflux occurs when the oesphageal pressure is lower than the intragastric pressure
1
what is gastro-oesophageal reflux?
2
prevalence % of western country?
3
potential causes?
1
- mild heartburn and/or regurgitation occurring at least 2 days per week
OR
- moderate/severe heartburn and/or regurgitation occurring at least 1 day per week
- should lead to a symptom based diagnosis of GERD
2
Western country (10-20% of the population will suffer from Gastro-oesphageal reflux disease)
3
Overweight
High alcohol and high fat diet
EG of reflux
MAKE Q’s
- gastric reflux
~ Stomach acid has a pH of 1-2 and is composed of strong hydrochloric acid. It affects 10-20% of the population and about 0.1% will not have symptoms
What we are increasingly becoming aware of is that it can enter the mouth and backtrack along the respiratory track, exacerbating symptoms such as asthma, chronic cough and hoarseness. This also goes the other way, asthma sufferers are more likely to have reflux which they think is due to bronchospasms and protective vagal reflexes. Furthermore, most inhalers result in a low intraoral pH which can make you more susceptible to any wear challenge. Let’s go down to this corner, obesity. We are just about to publish a paper showing the relationship between sugar sweetened acidic beverages, obesity and tooth wear. So ask carefully about the calories they may be drinking. We also know that obesity puts you at risk for reflux and sleep apneoa, both associated with tooth wear. Vomiting eating disorders are also associated with erosive tooth wear. They are more likely to drink diet carbonated beverages so it is easy to misdiagnose it as extrinsic acid sources. They can vomit up to several times a day and can have aggressive oral hygiene procedures. The primary treatment for bulimia are SSRI anti-depressants which can cause xerostomia and bruxism. A tooth wear cocktail. Alcoholics have frequent acidic drink consumption,and are more prone to vomiting and reflux. For all of these conditions, acidification of the oesophagus has been shown to induce bruxism. If we see erosive tooth wear we need to be vigilant.
toothbrush abrasion factors to think abot
- Dentifrice:
Amount
Fluoride concentration
Fluoride type
Abrasive concentration
Abrasive type
Other ingredients - Toothbrush:
Type (manual vs. electric)
Bristle stiffness
Design
Brushing technique - Patients’ Variation:
Force
Frequency
Duration
Technique - Tooth:
Enamel
Dentin
Erosion lesion
Caries lesion
EG of abrasions
abrasivity of toothpastes
the abrasivity = the greater the wear
- avoid whitening toothpastes as they can get very abrasive
- RDA = relative dentine abrasivity
what is attrition?
- Progressive loss of hard tooth substances caused by mastication or grinding between opposing teeth
- The extent of attrition will depend upon the use to
which an individual puts their teeth - Attrition is more apparent in people who clench or grind their teeth (bruxism) for example during sleep
- Clinically, it presents as a loss of cusp tips and incisal edges – this can lead to exposed dentine
- Teeth generally interdigitate before and after tooth wear
easy to spot as everything is flat
what is attrition?
- Progressive loss of hard tooth substances caused by mastication or grinding between opposing teeth
- The extent of attrition will depend upon the use to
which an individual puts their teeth - Attrition is more apparent in people who clench or grind their teeth (bruxism) for example during sleep
- Clinically, it presents as a loss of cusp tips and incisal edges – this can lead to exposed dentine
- Teeth generally interdigitate before and after tooth wear
easy to spot as everything is flat
what are the goals of intervention?
- prevent progression to this situation
- restoration of ETW should be a patient-driven process not dentist-driven (i.e. appearance, sensitivity or function)
how to differentiate active and inactive ETW (erosive tooth wear)
ACTIVE ETW
- Unstained – insufficient time to take up dietary stains
- Toothbrushing + acid removes stain
INACTIVE ETW
- Stained – sufficient time for teeth to take up dietary stains e.g. nicotine, caffeine
