Tooth Wear Flashcards
Tooth wear also referred to as
Non carious tooth tissue loss (NCTTL)
Or
Non carious tooth surface loss (NCTSL)
Describe tooth wear
- 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
Tooth wear due to a non carious process
Erosion, abrasion, attrition
Defined by;
- aetiology
- severity (mild, moderate, severe)
- distribution (localised, generalised)
Dental health in the uk
- 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
Prevalence
2009 dental health survey
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
UK child dental health survey 2013
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
Pathological loss of tooth tissue
Attrition
Abrasion
Erosion
Define attrition
The loss of tooth substance or a restoration caused by tooth-to-tooth contact
Define abrasion
The abnormal wearing away of tooth substance or a restoration by a mechanical process other than tooth contact
Eg, toothbrushing, restorations
Define erosion
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
Clinical presentation - attrition
- 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)
Bruxism
Common para functional activity on response to stress
Associated tongue scalloping and/or cheek ridging in active cases
Masseteric hypertrophy in severe cases
Abrasion causes
- 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
Clinical presentation - abrasion
- mainly cervical
- sharply defined margins
- smooth, hard surface
- more rounded and shallow if associated with erosion
Theory of abfraction
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
Abfraction
- deep V shaped notch
- may be a single tooth affected
- toothbrush unable to contact base of defect
- defects may be subgingival
How is erosion classified
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)
Sources of acid involved in erosion
Intrinsic
- acid coming up (from stomach)
Extrinsic
- acid going in (from food / drink)
Clinical presentation - erosion
Anterior teeth
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
Clinical presentation - erosion
Posterior teeth
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
Clinical presentation - erosion
General
Worn surface not in contact in closed eccentric movements
How does erosion differ from caries
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
Intrinsic acid: regurgitation erosion
Gastro oesophageal reflux (GOR)
Vomiting (voluntary / involuntary)
- eating disorders
- pregnancy
- metabolic / endocrine
- GI disorders
- drug induced (eg, chemotherapy)
- alcoholism (reflux / vomiting)
Gastro oesophageal reflux (GOR) symptoms
- heartburn
- retro sternal discomfort
- epigastric pain
- dysphagia
- chronic cough
- sore throat
- hoarseness
- sour taste at back of throat
However may be silent
Eating disorders
- 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
Eating disorders - anorexia nervosa
- 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
Eating disorders - bulimia nervosa
- 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
Dietary acid sources
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
Dietary erosion - important factors
- amount
- frequency
- method of consumption
- timing of consumption
Other potential contributors to erosion
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
Dry mouth - xerostomia cause
Results from reduced saliva secretion
Caused by…
- drugs
- dehydration
- anxiety
- Sjögren’s syndrome - affects salivary glands
- head / neck radiotherapy
Initial management
- identify presence and severity of tooth wear
- identify aetiology
- monitoring
- prevention
Severity of toothwear
- symptoms
- affecting enamel/dentine/pulp
- loss of crown height
- structural integrity compromised?
- aesthetic concern?
Clinical consequences of NCTTL (non carious tooth tissue loss)
One or more of the following
- change in appearance
- pain and/or sensitivity
- loss of OVD and/or lack of occlusal stability
- functional difficulties
Aetiology - what to ask / look for
Patient history
- food / drink
- medication
- medical history
- habits
Diet sheet may be helpful
Clinical appearance
The severely worn dentition
What are the main difficulties / issues with these patients?
- 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
Habitual / aetiological factors
Aetiological factors ongoing may cause
- damage to restorations
- further wear of teeth
Is the toothwear progressing (and at what rate?)
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
Is the toothwear progressing (and at what rate?)
Monitoring tooth surface loss
Initial review 4-6 months then annually
- study models
- silicone index
- clinical photographs
- description indices
- measurement - (crown height / gingival margin)
Prevention: erosion
- 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
Desensitisation and protection
- fluoride mouth rinse / fluoride varnish
- fluoride paste - GelKam
- low abrasivity toothpaste
- sugar free chewing gum
- dentine bonding agents
- ‘anti-erosion’ toothpastes
- tooth mousse
Prevention: attrition
- patient awareness / education
- splints
- composite
Soft splint
- 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
