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restorative > toothwear > Flashcards

toothwear Flashcards

1
Q

causes of TSL

A

caries
trauma
developmental problems
toothwear

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2
Q

causes of NCTSL

A

trauma
developmental problems
toothwear

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3
Q

what is physiological toothwear?

A

normal wear associated with normal function

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4
Q

what does physiological toothwear increase with?

A

age

elderly often have TW - not necessary to tx

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5
Q

what is a normal amount of physiological toothwear per year?

A

20-38 um

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6
Q

pathological toothwear

A

remaining tooth/pulpal health compromised
OR
rate in excess of what is expected for that age
OR
pt experiences masticatory/aesthetic deficit

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7
Q

attrition

A

physiological wearing away of tooth structure as a result of tooth to tooth contact

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8
Q

where are attritive lesions located and why?

A

occlusal and incisal

contacting surfaces

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9
Q

what does attrition do to the length of incisor and canine crowns?

A

shortens them

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10
Q

cause of attrition

A

bruxism - parfct habit

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11
Q

restoration wear in attrition

A

equal to tooth

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12
Q

progression of attrition

A

polished facet on cusp/slight flattening of incisal edge

decrease in cusp height and flattening of occlusal inclined planes

flat facets

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13
Q

abrasion

A

physical wear of tooth substance through an abnormal mechanical process, independent of occlusion
- foreign object/substance repeatedly contacting tooth

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14
Q

site and pattern of abrasion

A

related to abrasive element

often labial/buccal/cervical on 3,4,5

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15
Q

abrasive lesions

A

V or O lesions
sharp margin at E edge - D worn preferentially
- notching of incisal edges

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16
Q

main causative factor in abrasion

A

toothbrush

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17
Q

other causative factors in abrasion

A

habits/lifestyle/occupation

pins, nails, electrical wire, stripping, fishing line, thread, pipe smoking, E-cigs

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18
Q

erosion

A

loss of tooth substance by a chemical process that does not involve bacterial action

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19
Q

what is the main cause of pathological toothwear?

A

erosion

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20
Q

erosion is caused by a chronic exposure of hard tissues to what?

A

acids (intrinsic or extrinsic)

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21
Q

what is the position and severity of erosion determined by?

A

source, type and freq of acid exposure

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22
Q

progression of erosion

A

E loss of surface detail, flat, smooth, shiny. bilateral concave lesions
(not chalky like bacterial acid decalcification)

D exposure
- cupping of occ surfaces (preferential wear)

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23
Q

erosion and restorations

A

sit proud of tooth

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24
Q

erosion and staining

A

no tooth staining as gets washed away by acid

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25
Q

in erosion is the base of the lesion in contact with the opposing tooth?

A

no

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26
Q

what happens to the incisal edges in erosion?

A

increased translucency - dark

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27
Q

abfraction

A

the loss of hard tissues from eccentric occlusal forces leading to compressive and tensile stresses at the cervical fulcrum areas of the tooth

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28
Q

2 theories for abfraction

A

basic cause of all non-carious cervical lesions

multifactorial aetiology - occlusal stress, abrasion, erosion

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29
Q

what is the consequence of abfraction?

A

pathological loss at the cervical margin where stress concentration
V shaped loss where tooth under tension - sharp rim at ACJ

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30
Q

what is abfraction caused by?

A

biomechanical loading forces

  • flexure and failure of E and D at a location away from loading
  • disruption of ordered crystalline structure of E and D by cyclic fatigue
  • cracks - chips out
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31
Q

cervical wear causes

A

multifactorial? abrasion?
likely erosion + abrasion +/- abfraction
no definitive conclusive studies

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32
Q

location of cervical wear

A

buccal of 4,5,6,7,8
almost never lingually
usually more U

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33
Q

features of cervical wear

A

goes with good OH

restorations and tooth wear at same rate

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34
Q

what is the cause of almost all toothwear?

A

multifactorial

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35
Q

what is the most common type of wear in older patients?

A

physiological

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36
Q

gender pattern of wear

A

M>F

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37
Q

assessment of toothwear overall

A 
recognise problem
grade severity
diagnose likely cause(s)
monitor progression
 - active/historic?
 - preventive measures working/need active Rx tx?
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38
Q

what is a contraindication for complex tx in PDH?

A

non-regular
poorly motivated
phobic

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39
Q

SH aspects of toothwear

A 
lifestyle stresses - bruxism
occupation (drivers grind)
alcohol consumption (reflux)
diet
habits
sports (weightlifting, sports gels v acidic)
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40
Q

history - main complaint?

A

aesthetics
fct difficulties - masticatory efficiency, biting tongue/lips
pain

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41
Q

why is it uncommon to feel pain in toothwear?

A

unless rapidly progressing/pulpal involvement

as wear usually slow - get secondary dentine and pulp recedes

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42
Q

MH aspects

A 
esp in erosion
meds with low pH
meds which dry mouth
eating disorders
alcoholism
heartburn - pts not always aware of reflux - may be benign nocturnal
GORD
hiatus hernia
rumination
pregnancy - transient - morn sickness, reflux and heartburn
GP referral?  - get consent
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43
Q

EO exam

A 
TMJ
muscles
mouth opening
? parotid hypertrophy - if bulimic
? overclosure - if nose and chin approaching each other
lip line
smile line
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44
Q

EO exam - TMJ

A

restriction of movement
clicking
crepitus

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45
Q

EO exam - muscles

A

hypertrophy of masseter

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46
Q

EO exam - mouth opening

A

restriction (<4cm) - tense muscles?

deviation during movement

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47
Q

assessing occlusion

A

assess FWS, OVD and RFH - often normal if slow wear
dento-alveolar compensation?
record OB and OJ
stable contacts in centric relation?
what are tooth contacts like in excursive movements?

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48
Q

STs

A

dry?

buccal keratosis or lingual scalloping? - sign they are likely bruxist

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49
Q

IO exam

A 
occlusion
STs
OJ
perio
charting
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50
Q

location

A

anterior
posterior
generalised

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51
Q

where does toothwear caused by bulimia typically affect?

A

anterior and palatal

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52
Q

basic severity grading

A

E only
into D
severe

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53
Q

Smith and Knight tooth wear index grades

A

0-4

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54
Q

Smith and Knight tooth wear index grade 0

A

no loss of E surface characteristics

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55
Q

Smith and Knight tooth wear index grade 1

A

loss of surface E characteristics

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56
Q

Smith and Knight tooth wear index grade 2

A

B, L and O loss of E, exposing D for <1/3 of the surface
incisal loss of E
minimal D exposure

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57
Q

Smith and Knight tooth wear index grade 3

A

B, L and O loss of E, exposing D for >1/3 of the surface
incisal loss of E
substantial D exposure

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58
Q

Smith and Knight tooth wear index grade 4

A

B, L and O complete loss of E, pulpal exposure or exposure of secondary dentine
incisal pulp exposure or exposure of secondary dentine

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59
Q

what can be used as a basic wear examination?

A

BEWE - Basic Erosive Wear Examination

60
Q

BEWE score 0

A

no erosive wear

61
Q

BEWE score 1

A

initial loss of surface texture

62
Q

BEWE score 2

A

distinct defect, hard tissue loss <50% of surface

63
Q

BEWE score 3

A

hard tissue loss >50% of surface area

64
Q

BEWE scores

A

0-3

65
Q

BEWE risk level cumulative sextants score

A

none 2 or less
low 3-8
medium 9-13
high 14 or more

66
Q

special tests

A

sensibility testing
radiographs
articulated study models - see jaw movement relations
IO photos
(? salivary analysis) - quantity and buffering capacity
dietary analysis
diagnostic wax up
- useful for tx and let pt see what is possible

67
Q

what does most toothwear start as?

A

localised

68
Q

categories of generalised toothwear

A

1 - wear with loss of OVD
2 - wear without loss of OVD but with space available (often class 2 div 1)
3 - wear without loss of OVD but limited space

69
Q

dentoalveolar compensation

A

teeth wear slowly, bone and gingival tissues come down

70
Q

immediate tx planning

A

same as any pt - deal with pain

sensitivity - desensitising agents: F, DBAs, GIC
pulp extirpation
smooth sharp edges - prevent trauma
extraction - pain from unrestorable/non-fct tooth
TMJ pain - attrition - tx before wear

71
Q

initial tx

A

stabilise dentition - state of dental health

then preventative regime - tx without prevention will fail

72
Q

what is the aim of preventative tx?

A

for toothwear to progress more slowly or not at all

monitor

73
Q

what is needed to start preventative tx?

A

baseline recording

  • wear indices
  • models (alginate)
  • photos

to decide if active and progressive or historic

74
Q

historic tw

A

if not problematic don’t tx

75
Q

first stage of treating active and progressive toothwear

A

prevention first

removal of cause

76
Q

which type of toothwear is easiest to provide preventive treatment for?

A

abrasion

77
Q

preventive tx for abrasion

A

remove foreign object/substance

  • use less abrasive toothpaste
  • change toothbrushing habits
  • change habits - nail biting etc
78
Q

treating cervical toothbrush abrasion

A

RMGIC best
almost prevention
no tooth prep
wear through Rx not tooth

79
Q

prevention of attrition

A

hard - parafct habit
life stressors - CBT, hypnosis (works well)
splints

80
Q

hard splints

A

more robust
long-term
acrylic

81
Q

how do splints work for attrition?

A

softer than teeth
wear away in preference
don’t damage opposing teeth
may be habit breaker

82
Q

soft splints

A

can use as diagnostic device to see if pt grinding

wear rapidly - shows wear factors as scrapes and gouges in the surface of the splint

83
Q

Michigan splint

A

provides ‘ideal occlusion’ with even centric stops
has canine rise - provides discussion in eccentric mandibular movements
- canine guidance

84
Q

when should splints not be used and why?

A

if erosion present

acid stuck under splint - makes erosion worse (esp intrinsic)

85
Q

prevention of abfraction

A 
assess occlusion on teeth with lesions
 - consider occlusal equilibration
fill cavities with low modulus restorative materials
- RMGIC
 - flowable composite
86
Q

passive management

A 
prevention and monitoring
1st part of any wear tx
most pts in this phase for at least 6m
for many it is all that is required
this is tx
87
Q

which type of wear should you consider to tx in all cases?

A

erosion

88
Q

management of erosion broad categories

A

F
desensitising agents
dietary management
medical

89
Q

F to reharden in erosion

A

Duraphat
tooth mousse
MWs

90
Q

desensitising agents in erosion

A

more symptomatic relief than prevention

try several - work different ways

91
Q

dietary management in erosion

A

habit changes: swilling, use straw, rumination, health eating, vegan diet (more acidic?), sports drinks/gels

92
Q

medical management in erosion

A

control gastric acid - GORD, reflux, hiatus hernia
xerostomia
anorexia and bulimia

GP contact/specialist? - need consent

beware PP rebound - when you come off them you get more reflux for a while until stomach readjusts

93
Q

simple Rx intervention

A

covering exposed D

filling cupped defects in molars/incisors

94
Q

intervention threshold for active management - not always clear

A

wear leading to further complications
pt unable to accept aesthetics
leaving intervention may cause more complex txs to be required

95
Q

aims of active management

A

preserve remaining tooth structure
pragmatic improvement in aesthetics
fct occlusion
stability

96
Q

what does most generalised tooth wear start as?

A

localused

97
Q

what is the most common type of site of tooth wear?

A

maxillary anterior

98
Q

active management of maxillary anterior tooth wear: factors that determine tx and Rx

A 
pattern
inter-occlusal space
space required for planned Rxs
quantity and quality of remaining tooth tissue, particularly E
pt aesthetic demands
99
Q

what did palatal surface only wear used to be treated with?

A

metal Rx

100
Q

getting space for Rxs

A 
traditional
increase OVD
occlusal reorganisation from ICP to RCP
surgical crown lengthening
elective RCT and postcrowns
conventional ortho
101
Q

getting space for Rxs - traditional

A 
cut teeth down
but little tooth to begin with
poor retention - short axial walls
chance of pulpal damage - short clinical crowns
new materials (composites) more conservative
102
Q

getting space for Rxs - increase OVD

A

multiple posterior EC Rxs
reorganised approach
complex, destructive, £££

103
Q

getting space for Rxs - occlusal reorganisation from ICP to RCP

A

push mandible back slightly - get some space anteriorly, but doesn’t work for everyone
complicated, can be destructive, specialist tx

104
Q

getting space for Rxs - surgical crown lengthening

A

expose more of the crown for retention of the final Rx - increase amount of coronal tooth substance available

repositioning of gingivae apically generally with removal of bone - need to remove bone or gingivae will generally grow back to where they were before

105
Q

getting space for Rxs - elective RCT and psotcrowns

A

v destructive

106
Q

getting space for Rxs - conventional ortho

A

long tx

107
Q

disadvantages of surgical crown lengthening

A

doesn’t really create more space
sensitivity
still need occ reduction
unpleasant surgery
may get ‘black triangles’ between the teeth where ID papilla further down - a bit like PDD
can lead to unfavourable C:R - increase chance of loosening or tooth movement if tooth loaded subsequently
any subsequent conventional crown prep further down the root
- problem if tooth has significant coronal-cervical taper
- increased chance of pulpal damage

108
Q

cases where there is adequate inter-incisal space

A

if teeth wear rapidly, no time for alveolar compensation
if AOB
if increased OJ

available space for restoration with no change in OVD
quite unusual but easiest to treat

109
Q

consequences of dentoalveolar bone growth compensation

A

most cases no increase in freeway space

maintains masticatory efficiency
no space for Rx

110
Q

what is the aim of the Dahl technique?

A

gain space in localised wear cases

111
Q

what is used in the Dahl technique compared to previously and why?

A

composite anterior bite plane
prev removable CoCr

aesthetics
compliance (non-removable)
easier to adjust

112
Q

what does the composite anterior bite plane in the Dahl technique achieve?

A 
covers palatal surfaces, occlusion on raised cingulum
= posterior discussion, increased OVD of 2-3mm
occ contacts only on anteriors
3-6m get space between incisors
 - anteriors intrude
 - posteriors erupt
= space between anteriors
Rx without occ reduction
113
Q

advantages of Dahl technique

A

immediate definitive tx - anteriors look better after 1st visit
non-invasive, usually 1st choice

114
Q

variableness of Dahl technique success

A

variable effect rate - faster in younger pts
variable degree - if no movement in 6m it won’t work
monitor progress

115
Q

success rate of Dahl technique

A

90+%

116
Q

describe how the occlusion changes through the Dahl technique

A

occ disorganised at first but re-establishes

- initially no posterior occlusion

117
Q

what increases the success rate if the Dahl technique?

A

remaining E ‘ring of confidence’

aids retention

118
Q

contraindications for the Dahl technique

A 
active PDD (reduced PD support)
TMJ problems
post-ortho
bisphosphonates - slow bone turnover
implants (don't move)
existing conventional bridges (won't move like natural teeth)
short roots
119
Q

lower anterior toothwear - what is it generally found with?

A

maxillary

120
Q

why is lower anterior toothwear harder to tx?

A

less E

smaller bonding area

121
Q

treating lower anterior toothwear

A

if possible improve aesthetics but don’t increase OVD

if have to build up do lowers first

  • more likely to break off
  • also bond over and onto lingual to increase E bonding area
122
Q

methods of composite build up

A 
1 - direct build up with putty matrix
 - imps and wax up
2 - clear vacuum formed matrix
 - imps, wax up, pour stone
 - form matrix
 - cut to size and use as mould for build up
123
Q

localised posterior toothwear prevalence and causes

A 
rare on own
causes
 - rumination
 - bulimia
 - alcoholism
124
Q

localised posterior toothwear - asymptomatic

A

prevention and monitoring

125
Q

what can you do for localised posterior erosive toothwear?

A

fill directly with composite - no change in occlusion

126
Q

aim of treating localised posterior toothwear

A

provide sufficient canine guidance to ensure posterior disclusion
- composite on palatal of U3s
increase canine rise
posteriors disocclude during lateral and protrusive excursions
often canine wear has removed guidance and lead to posterior wear
- correct canine wear
- avoid further damage to posteriors

simple, effective, reversible

127
Q

success of composite build up for anteriors

A

normally reachieve posterior occlusion
pt satisfaction
rarely TMJ problems
safe for pulp and PD condition

128
Q

longevity of composite build up for anteriors

A

medium term
repair and maintenance
U last better - increased bonding area
U wear more common - tongue and saliva protect lowers and erosive potential
can be replaced/repaired, no tooth destruction

129
Q

composite build up for anteriors - pragmatic aesthetics

A

good but not best

doesn’t damage teeth

130
Q

what can composite build up be known as?

A

biologically based management

131
Q

info for pts having Dahl technique

A

front teeth get tooth coloured fillings - cover exposed and worn tooth

  • prevent them from wearing more
  • main reason for tx
  • your fillings will wear so your teeth don’t

no LA - no/min drilling (mostly polishing) - adding to teeth

should improve appearance

your ‘bite’ will feel strange for a few days, may have difficulty chewing

  • only front teeth will touch together
  • back teeth will gradually come back together, will take 3-6m
  • you will get used to it
  • initially may need to cut your food into small pieces

change in shape of your front teeth may cause lisping for a few days

front teeth may feel a little tender to bite on for a few days
- like when you get a new brace

may bite your lips and tongue initially

if you have crowns/bridges/RPDs at the back of your mouth they will likely need replaced
- won’t move

132
Q

info for pt re longevity of Dahl/composite anterior build ups

A 
not as good as tooth
should be good, may debond and fall off
 - can be replaced with no damage to your remaining tooth
will require maintenance
 - margins occasional polishing
 - may get occasional chipping

this is all part of the process - pt will need to pay for the maintenance

133
Q

what does most generalised toothwear start as?

A

localised anterior

134
Q

why is it important to identify localised toothwear early?

A 
avoid it progressing to generalised
more complicated (demanding, lengthy, £££)
135
Q

categories of generalised toothwear

A

excessive toothwear with loss of OVD (happened quickly)
excessive wear without loss of OVD but with available space (often class 2 div 1)
excessive wear without loss of OVD and with no space available
- most common and hardest to tx

136
Q

general principles of tx of generalised toothwear

A

if possible use adhesive approach
use to assess pt tolerance of a new occlusal scheme as a medium term Rx
if need conventional preps later these additions may form bulk of the removed material - preserve tooth

137
Q

which is the easiest to tx but least common form of generalised toothwear?

A

excessive wear with loss of OVD

138
Q

tx of generalised toothwear - excessive wear with loss of OVD

A

splint - assess pt tolerance of new face height

may not be necessary if adhesive approach - straight to increase in face height with ‘permanent’ bonded Rxs

ideally OVD increases 50% maxillary and 50% mandibular

often need mix of adhesive and conventional Rxs

may require dentures to provide posterior support at the new OVD

139
Q

tx of generalised toothwear - excessive wear without loss of OVD but with limited space available

A

complicated

can involve occlusion reorganisation

consider splint as increase in occlusal face height required - most patients accommodate increase

Rx anterior and posterior teeth at new occlusal face height - if possible min prep adhesive Rxs

140
Q

tx of generalised toothwear - excessive wear without loss of OVD, no space available

A

most severe and difficult to tx - get specialist opinion

1 - attempt to increase OVD using splints +/- dentures if there is a lack of posterior support (often is)
2 - crown lengthening
3 - elective endo - destructive, posts and cores and attrition - DON’T DO
4 - ortho

141
Q

risk management

A

record, point out to pt and monitor if wear has been there for long time and not progressing

142
Q

overdentures

A

preserves tooth substance (for proprioception) and bone for support of denture when teeth so worn down that Rx is impossible
bulky - pts don’t like it
hard to keep teeth and gingivae healthy beneath prosthesis

specialist opinion
pt needs realistic expectations

143
Q

preventive advice/counselling - recording in notes

A

this is tx
record in notes
- also record if pt not compliant/unwilling to follow recommendations
diet advice
any surface txs eg fluoride - record on each occasion - record if pt complied with repeat applications

144
Q

consent

A 
must understand
 - proposed tx, inc passive preventative
 - their part and cooperation in tx
 - consequences of not following advice
record
145
Q

how to explain provisional tx (often passive preventative) to pt

A

explain importance - definitive diagnosis
- work out why your teeth are wearing away

if temp - explain and reason for no definitive tx at that time

record

146
Q

what should you try before definitive tx?

A

try min intervention txs before considering a more radical interventive approach

if in doubt get a specialist opinion

copy and retain any referral docs in pts notes

restorative (12 decks)

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