Toothwear 1 Flashcards
Types of toothwear?
Physiological - normal wear associated with age
Pathological - wear exceeds what
would be seen as normal for the age.
Define attrition
Physiological wearing away of tooth structure, due to tooth to tooth contact.
Where may attrition be found? What are typical presentations?
Occlusal and incisal contacting surfaces
Reduction in cusp heigh and flattening of inclined planes
Shortening of crown length.
Almost always related to parafunctional habit
What is abrasion?
Physical wear through abnormal mechanical processes, irrespective of occlusion. Involves foreign object or substance repeatedly contacting tooth.
Common presentations for abrasion?
Site / pattern related to abrasive element
Often buccal or incisal or cervical on canine or premolars
Most common cause is aggressive tooth brushing
Define erosion
Loss of tooth surface due to chemical process that does not involve bacterial action
Typical presentations of erosion?
Chronic exposure to acidic substances
Early stages, enamel is affected and loss of surface detail
Eventually surfaces become concave, smooth and eroded
Typically bilateral, concave lesions
Increased translucency of incisal edges
No staining
Restorations sit proud of teeth
What is abfraction?
Loss of hard tissue from eccentric occlusal forces, leading to compressive and tensile stresses at the cervical fulcrum areas of tooth
What occurs during abfraction? Typical presentation?
Tooth loss at cervical margin
Loading forces on occlusal surface cause flexural stress and failure of enamel and dentine at a location away from the loading
What are the main things an assessment of toothwear needs to do?
Recognise problem
Grade it’s severity
Diagnose likely cause or causes
Monitor progression
- active or historic
- preventative measures working?
What MH may mean erosion is involved?
Bulimia
Alcoholism
Eating disorders
Low pH medication
Heartburn and GORD
Pregnancy
What things about a patients history should we know for toothwear
Chief complaint
Medical history and meds
Regular attender who will comply with treatment?
- OH habits
- brushing regime
Social
- smoking, drinking
- bruxism
- habits such as fingernail biting
- sports
What should be checked in an EO exam for toothwear?
TMJ for restriction of movement
Musculature, for hypertrophy
Mouth opening, for restriction or deviation on movement
Overclosure
Lip line and smile line
FWS, OVD and RFH
What IO examinations should be checked for tooth wear?
Occlusion
Overbite and overjet
Assess contacts, are they stable
Assess tooth movements when jaw moves
Soft tissues, keratosis from parafunction?
When examining tooth wear specifically, what should be recorded?
Location of wear
- anterior / posterior
- localised / generalised
Severity
- enamel only
- into dentine
- severe
What is the BEWE?
immediate treatment for toothwear?
Deal with pain
Sensitivity - de sensitising agents
Pulp extirpation if pulp health compromised
Smooth sharp edges - if causing trauma
Extraction - pain in unrestoreable teeth
TMJ pain - needs to be controlled, especially in attrition
Initial treatment, after immediate, for toothwear
Stabilise dentition
Deal with caries
Deal with perio
Deal with Oro-mucosal
Wear is important but whole mouth essential
Then finally develop a preventative programme of treatment, as no point treating an ongoing problem
What preventative treatment might be done?
Monitoring of wear
Baseline wear recording required
- bewe
- photographs
- will identify if it is historic or active
How might one prevent abrasion?
Remove ‘foreign object’
Change toothpaste
Alter brushing habits
Change habits such as nail biting, wire stripping, pen chewing etc
Place RMGIC or GIC in cervical abrasion due to tooth brushing etc
Why is RMGIC first line cervical restoration material?
Best survival rate
Fluoride release
Composite had higher modulus compromising retention
Balance aesthetics with retention of restoration
How is attrition prevented?
Parafunction is usually the cause
often a centrally mediated response to life stressors
- CBT
- hypnosis
Can help prevent parafunction
Splints can be used, wear is done to these rather than teeth
- soft splint is a good diagnostic device as it shows where wear facets mainly are. Hard splint is more robust.
How might erosion be prevented?
Target source of the acid
Use fluorides, such as tooth mousse GC, dural hat varnish, fluoride mouthwash, high fluoride toothpaste etc.
Use desensitising agents for symptomatic relief
Manage diet if consuming high volumes of sugar / high frequency
- use a straw for drinks etc
Medical control of gastric acid - possible consult doctor
- Rennie or omeprazole
How might abfraction be prevented?
Low modulus restorations in cervical cavities
Assess occlusion, any heavy occlusal contacts
Classifications of maxillary anterior toothwear?
Limited to palatal surfaces only
Palatal and incisal edges, with reduced crown height
Limited to labial surfaces
How actively treat maxillary anterior toothwear limited to palatal surfaces?
Tooth coloured restoration material placed palatally
Why might OVD be unchanged but teeth be worn?
Rapid toothwear with no time for alveolar compensation
Easiest to treat as no change in OVD
How might space be created for restoration of tooth wear?
DAHL TECHNIQUE
- removable COCR or composite anterior bite plane
Allows occlusion on raised Cingulum, and disclusion of posterior teeth, leading to increase in OVD
3-6 months, variable length but faster in younger patients. If no movement in 6 months it wont work.
When wont DAHL technique work?
Active periodontal disease
TMJ issues
Post ortho
Bisphosphonate medication
Dental implants
Existing conventional bridges
What clinical feature gives confidence worn anterior teeth can be restored?
Remaining enamel ‘ring of confidence’
What should not be done when treating lower anteriors for tooth wear? What should be done if building them up?
No not increase OVD in lowers
If have to build up, do them first before uppers
How can localised posterior tooth wear be treated restoratively?
Composite resin to the palatal of the maxillary canines
Puts posterior teeth in disclusion during lateral movements a
Posterior saved from further damage and can be restored
What information would i give to a patient before completing diagnostic wax ups?
Your front teeth will receive tooth coloured fillings to cover the exposed and worn tooth surface
This will prevent them from wearing more, this is the reason it needs treating
Procedure carried out without local anaesthetic, minimal to no drilling to teeth
We add to teeth, not remove
Improved aesthetics
Your bite may feel strange at first as only front teeth with contact, may have trouble chewing
This will change as your back teeth gradually come back together in 3-6 months
May lisp at first and may bite lips and tongue initially but this will all resolve
If you have crowns or bridges or RPDs at the back, they will likely need replacing
What information can i give regarding longevity of tooth wear restorations?
Should be good, small potential for deboning though
But these can be replaced easily with no damage to tooth
Will require maintenance with some polishing, occasional chipping may occur
What 3 categories of generalised wear are there?
Excessive wear with loss of OVD
Excessive wear without loss of OVD but available space
Excessive wear without loss of OVD and with no space
What is crown lengthening surgery? Pros cons?
Crown lengthening by lowering gingiva and adjusting crowns
Can improve aesthetics and make space in OVD
Often post op sensitivity
Black triangles due to papilla change
Greater chance of pulpal damage
How must i cover myself when treating a patient with toothwear?
NOTES
- wear recognised
- patient informed of wear
- monitoring
- advice given
- patient compliant / non complaint our unwilling to follow course of action
- surface treatments e.g. topical fluoride noted at each occasion
- consent gained for treatment
- pt must understand their role in this
- all discussions recorded properly
- record rationale behind preventative treatment or temporary treatment, and pt must understand this
- minimally invasive treatments done first
- second opinion from specialist in tough cases
- referral documentation kept
How treat toothwear with space present?
Direct or indirect composite
Porcelain veneers
Onlays
Adhesive dentistry
How treat localised maxillary anterior tooth wear with little / no space?
Gain space with DAHL appliance
Restore with composites, veneers, crowns etc
Over-dentures
How treat localised mandibular anterior toothwear with little to no space?
Monitor of only lower anteriors
If both, gain space with DAHL then restore lowers before uppers
How treat localised posterior tooth wear with little to no space available?
Accept and monitor
Provide canine rise if posterior disclusion absent on lateral / Protrusive movement
How treat generalised toothwear with increased FWS
Overclosed because wear uncompensated
Work to existing RFH
How treat generalised toothwear with normal FWS?
Compensation occured
Increase OVD and check tolerance to new OVD
If tolerated then treatment plan for full mouth, if not
Consider crown lengthening
