Tooth Wear

Question 1

Tooth wear also referred to as

Answer 1

Non carious tooth tissue loss (NCTTL)

Or

Non carious tooth surface loss (NCTSL)

Question 2

Describe tooth wear

Answer 2

• normal physiological process
• occurs throughout life
• pathological when rate of loss or degree of destruction is excessive (particularly in relation to pt age)
• may lead to problems with function, aesthetics or sensitivity

Question 3

Tooth wear due to a non carious process

Answer 3

Erosion, abrasion, attrition
Defined by;
- aetiology
- severity (mild, moderate, severe)
- distribution (localised, generalised)

Question 4

Dental health in the uk

Answer 4

• ageing dentate population with increasing evidence of cumulative effects of tooth wear
• erosion on the increase especially in the younger population
• NCTTL increasing in prevalence and occupying large amounts of practitioner time
• can be complex to manage in later stages but early treatment simple and effective

Question 5

Prevalence
2009 dental health survey

Answer 5

2009 dental health survey
- moderate tooth wear has increased from 11% in 1998 to 15% in 2009, although severe wear remains rare
- increase in moderate tooth wear in younger adults

Question 6

UK child dental health survey 2013

Answer 6

33% of 5yr olds had evidence of tooth surface loss (TSL) on 1 or more of the buccal surfaces of the primary upper incisors, 4% involving dentine or pulp

57% of 5yr olds had TSL of the lingual surfaces, 16% progressing to dentine or pulp

Question 7

Pathological loss of tooth tissue

Answer 7

Attrition

Abrasion

Erosion

Question 8

Define attrition

Answer 8

The loss of tooth substance or a restoration caused by tooth-to-tooth contact

Question 9

Define abrasion

Answer 9

The abnormal wearing away of tooth substance or a restoration by a mechanical process other than tooth contact

Eg, toothbrushing, restorations

Question 10

Define erosion

Answer 10

The irreversible, progressive loss of dental hard tissue by an acidic chemical process not involving bacteria

• due to acid not involved in the breakdown of sugars

Question 11

Clinical presentation - attrition

Answer 11

• enamel and dentine wearing at the same rate
• localised facets, flattened cusps/incisal edges
• worn surfaces ‘mate’ in closed eccentric movements (when pt bites together / moves jaw side to side - surfaces will meet)
• shiny amalgam in areas of contact
• attrition is a slow process so secondary dentine forms and usually not sensitive
• possible masseteric hypertrophy
• possible fractured cusps and/or restorations
• increased risk of tooth mobility (under force)

Question 12

Bruxism

Answer 12

Common para functional activity on response to stress
Associated tongue scalloping and/or cheek ridging in active cases
Masseteric hypertrophy in severe cases

Question 13

Abrasion causes

Answer 13

• tooth brushing (abrasive toothpaste)
• abrasive denitrifies (food particles)
• abrasive food particles
• piercings
• habits (eg, nail biting, tobacco chewing, pen chewing, pipe smoking, wire stripping)
• iatrogenic - unglazed porcelain / fractured porcelain - can cause abrasion of the opposing teeth

Question 14

Clinical presentation - abrasion

Answer 14

• mainly cervical
• sharply defined margins
• smooth, hard surface
• more rounded and shallow if associated with erosion

Question 15

Theory of abfraction

Answer 15

Theory of Abfraction (Grippo 1991) supposes that occlusal forces cause compressive and tensile stresses, which are concentrated at the cervical region of the tooth (Heymann et al, 1993) and cause micro fracture of cervical enamel rods

Question 16

Abfraction

Answer 16

• deep V shaped notch
• may be a single tooth affected
• toothbrush unable to contact base of defect
• defects may be subgingival

Question 17

How is erosion classified

Answer 17

Classified according to source of the acid
- Intrinsic
- Extrinsic

(Erosion is loss of tooth substance due to acid wear not bacterial acid or mechanical wear)

Question 18

Sources of acid involved in erosion

Answer 18

Intrinsic
- acid coming up (from stomach)

Extrinsic
- acid going in (from food / drink)

Question 19

Clinical presentation - erosion

Anterior teeth

Answer 19

Anterior teeth
- loss of surface anatomy, smooth enamel surface
- increased incisal translucency
- chipping of incisal edges
- palatal hollows
- areas where the enamel is absent
- exposure of the pulp
- intrinsic often affects the palatal surfaces, extrinsic the labial

Question 20

Clinical presentation - erosion

Posterior teeth

Answer 20

Posterior teeth
- loss of surface anatomy
- cuspal cupping
- proud restorations - restorations haven’t worn away but the tooth around them has
- darkening of colour - due to secondary dentine being laid down
- pulpal exposure rare in permanent teeth

Question 21

Clinical presentation - erosion

General

Answer 21

Worn surface not in contact in closed eccentric movements

Question 22

How does erosion differ from caries

Answer 22

In caries - plaque acid leads to demineralisation but the organic matrix is not affected

In erosion - extrinsic / intrinsic acid leads to demineralisation and loss of the organic matrix

Question 23

Intrinsic acid: regurgitation erosion

Answer 23

Gastro oesophageal reflux (GOR)

Vomiting (voluntary / involuntary)
- eating disorders
- pregnancy
- metabolic / endocrine
- GI disorders
- drug induced (eg, chemotherapy)
- alcoholism (reflux / vomiting)

Question 24

Gastro oesophageal reflux (GOR) symptoms

Answer 24

• heartburn
• retro sternal discomfort
• epigastric pain
• dysphagia
• chronic cough
• sore throat
• hoarseness
• sour taste at back of throat

However may be silent

Question 25

Eating disorders

Answer 25

- over 700,000 people in uk - 90% female - underestimate as not all cases are presented to health services - can develop at any age but risk of onset is highest for adolescents - atypical eating disorders are most common, followed by binge eating disorders - anorexia nervosa is the least common

Question 26

Eating disorders - anorexia nervosa

Answer 26

- aversion to food - restricting and bing/purging types - highest incidents in age 15-19 years - female : male ration 10 : 1 - more than 15% below ideal body weight

Question 27

Eating disorders - bulimia nervosa

Answer 27

- over eating followed by inappropriate compensatory behaviour (eg purging) - prevalence in Europe less than 1-2% - peak age onset 15-25yrs - female to male ratio 10:1 - within 10% of ideal body weight or grossly overweight

Question 28

Dietary acid sources

Answer 28

Acidic drinks and food - soft drinks - alcohol - fresh fruit, pulp, dried fruit - pickles, vinegar, acetic acid added to crisps - yoghurts, sauces - fruit/herbal teas - energy / sport supplements

Question 29

Dietary erosion - important factors

Answer 29

- amount - frequency - method of consumption - timing of consumption

Question 30

Other potential contributors to erosion

Answer 30

Oral hygiene products - mouthwash - saliva substitutes Medications - vitamin c - asthma inhalers - those affecting saliva quality/quantity Low saliva flow is a risk factor for erosion

Question 31

Dry mouth - xerostomia cause

Answer 31

Results from reduced saliva secretion Caused by… - drugs - dehydration - anxiety - Sjögren’s syndrome - affects salivary glands - head / neck radiotherapy

Question 32

Initial management

Answer 32

- identify presence and severity of tooth wear - identify aetiology - monitoring - prevention

Question 33

Severity of toothwear

Answer 33

- symptoms - affecting enamel/dentine/pulp - loss of crown height - structural integrity compromised? - aesthetic concern?

Question 34

Clinical consequences of NCTTL (non carious tooth tissue loss)

Answer 34

One or more of the following - change in appearance - pain and/or sensitivity - loss of OVD and/or lack of occlusal stability - functional difficulties

Question 35

Aetiology - what to ask / look for

Answer 35

Patient history - food / drink - medication - medical history - habits Diet sheet may be helpful Clinical appearance

Question 36

The severely worn dentition What are the main difficulties / issues with these patients?

Answer 36

- lack of tooth tissue - hard to build up tooth - pulpal problems - aesthetic compromise - lack of space for restoration - occlusal changes - soft tissue changes - habitual / aetiological factors

Question 37

Habitual / aetiological factors

Answer 37

Aetiological factors ongoing may cause - damage to restorations - further wear of teeth

Question 38

Is the toothwear progressing (and at what rate?)

Answer 38

Clues - sensitivity - indicates that it is progressing because the tooth hasn’t had time to lay down secondary dentine to protect the pulp therefore creating sensitivity due to the exposed dentinal tubules - staining - indicates that its not progressing because there has been time for staining to accumulate on the surface and if there was progression, the stain would be removed Monitoring

Question 39

Is the toothwear progressing (and at what rate?) Monitoring tooth surface loss

Answer 39

Initial review 4-6 months then annually - study models - silicone index - clinical photographs - description indices - measurement - (crown height / gingival margin)

Question 40

Prevention: erosion

Answer 40

- diet advice - avoid brushing immediately after acidic foods - allow 30min for acid neutralisation - control of GORD/eating disorders (may need to liaise with the GMP) - water and sodium bicarbonate m/w

Question 41

Desensitisation and protection

Answer 41

- fluoride mouth rinse / fluoride varnish - fluoride paste - GelKam - low abrasivity toothpaste - sugar free chewing gum - dentine bonding agents - ‘anti-erosion’ toothpastes - tooth mousse

Question 42

Prevention: attrition

Answer 42

- patient awareness / education - splints - composite

Question 43

Soft splint

Answer 43

- vacuum formed on model of one arch - usually lower in bruxism cases — prevention of wear — protection of new restorations - can be used as an upper fluoride / sodium bicarbonate tray - full coverage - quick and easy