toothwear Flashcards
1
Q
causes of TSL
A
caries
trauma
developmental problems
toothwear
2
Q
causes of NCTSL
A
trauma
developmental problems
toothwear
3
Q
what is physiological toothwear?
A
normal wear associated with normal function
4
Q
what does physiological toothwear increase with?
A
age
elderly often have TW - not necessary to tx
5
Q
what is a normal amount of physiological toothwear per year?
A
20-38 um
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
7
Q
attrition
A
physiological wearing away of tooth structure as a result of tooth to tooth contact
8
Q
where are attritive lesions located and why?
A
occlusal and incisal
contacting surfaces
9
Q
what does attrition do to the length of incisor and canine crowns?
A
shortens them
10
Q
cause of attrition
A
bruxism - parfct habit
11
Q
restoration wear in attrition
A
equal to tooth
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
13
Q
abrasion
A
physical wear of tooth substance through an abnormal mechanical process, independent of occlusion
- foreign object/substance repeatedly contacting tooth
14
Q
site and pattern of abrasion
A
related to abrasive element
often labial/buccal/cervical on 3,4,5
15
Q
abrasive lesions
A
V or O lesions
sharp margin at E edge - D worn preferentially
- notching of incisal edges
16
Q
main causative factor in abrasion
A
toothbrush
17
Q
other causative factors in abrasion
A
habits/lifestyle/occupation
pins, nails, electrical wire, stripping, fishing line, thread, pipe smoking, E-cigs
18
Q
erosion
A
loss of tooth substance by a chemical process that does not involve bacterial action
19
Q
what is the main cause of pathological toothwear?
A
erosion
20
Q
erosion is caused by a chronic exposure of hard tissues to what?
A
acids (intrinsic or extrinsic)
21
Q
what is the position and severity of erosion determined by?
A
source, type and freq of acid exposure
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)
23
Q
erosion and restorations
A
sit proud of tooth
24
Q
erosion and staining
A
no tooth staining as gets washed away by acid
25
in erosion is the base of the lesion in contact with the opposing tooth?
no
26
what happens to the incisal edges in erosion?
increased translucency - dark
27
abfraction
the loss of hard tissues from eccentric occlusal forces leading to compressive and tensile stresses at the cervical fulcrum areas of the tooth
28
2 theories for abfraction
basic cause of all non-carious cervical lesions
multifactorial aetiology - occlusal stress, abrasion, erosion
29
what is the consequence of abfraction?
pathological loss at the cervical margin where stress concentration
V shaped loss where tooth under tension - sharp rim at ACJ
30
what is abfraction caused by?
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
31
cervical wear causes
multifactorial? abrasion?
likely erosion + abrasion +/- abfraction
no definitive conclusive studies
32
location of cervical wear
buccal of 4,5,6,7,8
almost never lingually
usually more U
33
features of cervical wear
goes with good OH
| restorations and tooth wear at same rate
34
what is the cause of almost all toothwear?
multifactorial
35
what is the most common type of wear in older patients?
physiological
36
gender pattern of wear
M>F
37
assessment of toothwear overall
```
recognise problem
grade severity
diagnose likely cause(s)
monitor progression
- active/historic?
- preventive measures working/need active Rx tx?
```
38
what is a contraindication for complex tx in PDH?
non-regular
poorly motivated
phobic
39
SH aspects of toothwear
```
lifestyle stresses - bruxism
occupation (drivers grind)
alcohol consumption (reflux)
diet
habits
sports (weightlifting, sports gels v acidic)
```
40
history - main complaint?
aesthetics
fct difficulties - masticatory efficiency, biting tongue/lips
pain
41
why is it uncommon to feel pain in toothwear?
unless rapidly progressing/pulpal involvement
| as wear usually slow - get secondary dentine and pulp recedes
42
MH aspects
```
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
```
43
EO exam
```
TMJ
muscles
mouth opening
? parotid hypertrophy - if bulimic
? overclosure - if nose and chin approaching each other
lip line
smile line
```
44
EO exam - TMJ
restriction of movement
clicking
crepitus
45
EO exam - muscles
hypertrophy of masseter
46
EO exam - mouth opening
restriction (<4cm) - tense muscles?
| deviation during movement
47
assessing occlusion
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?
48
STs
dry?
| buccal keratosis or lingual scalloping? - sign they are likely bruxist
49
IO exam
```
occlusion
STs
OJ
perio
charting
```
50
location
anterior
posterior
generalised
51
where does toothwear caused by bulimia typically affect?
anterior and palatal
52
basic severity grading
E only
into D
severe
53
Smith and Knight tooth wear index grades
0-4
54
Smith and Knight tooth wear index grade 0
no loss of E surface characteristics
55
Smith and Knight tooth wear index grade 1
loss of surface E characteristics
56
Smith and Knight tooth wear index grade 2
B, L and O loss of E, exposing D for <1/3 of the surface
incisal loss of E
minimal D exposure
57
Smith and Knight tooth wear index grade 3
B, L and O loss of E, exposing D for >1/3 of the surface
incisal loss of E
substantial D exposure
58
Smith and Knight tooth wear index grade 4
B, L and O complete loss of E, pulpal exposure or exposure of secondary dentine
incisal pulp exposure or exposure of secondary dentine
59
what can be used as a basic wear examination?
BEWE - Basic Erosive Wear Examination
60
BEWE score 0
no erosive wear
61
BEWE score 1
initial loss of surface texture
62
BEWE score 2
distinct defect, hard tissue loss <50% of surface
63
BEWE score 3
hard tissue loss >50% of surface area
64
BEWE scores
0-3
65
BEWE risk level cumulative sextants score
none 2 or less
low 3-8
medium 9-13
high 14 or more
66
special tests
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
what does most toothwear start as?
localised
68
categories of generalised toothwear
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
dentoalveolar compensation
teeth wear slowly, bone and gingival tissues come down
70
immediate tx planning
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
initial tx
stabilise dentition - state of dental health
| then preventative regime - tx without prevention will fail
72
what is the aim of preventative tx?
for toothwear to progress more slowly or not at all
| monitor
73
what is needed to start preventative tx?
baseline recording
- wear indices
- models (alginate)
- photos
to decide if active and progressive or historic
74
historic tw
if not problematic don't tx
75
first stage of treating active and progressive toothwear
prevention first
| removal of cause
76
which type of toothwear is easiest to provide preventive treatment for?
abrasion
77
preventive tx for abrasion
remove foreign object/substance
- use less abrasive toothpaste
- change toothbrushing habits
- change habits - nail biting etc
78
treating cervical toothbrush abrasion
RMGIC best
almost prevention
no tooth prep
wear through Rx not tooth
79
prevention of attrition
hard - parafct habit
life stressors - CBT, hypnosis (works well)
splints
80
hard splints
more robust
long-term
acrylic
81
how do splints work for attrition?
softer than teeth
wear away in preference
don't damage opposing teeth
may be habit breaker
82
soft splints
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
Michigan splint
provides 'ideal occlusion' with even centric stops
has canine rise - provides discussion in eccentric mandibular movements
- canine guidance
84
when should splints not be used and why?
if erosion present
| acid stuck under splint - makes erosion worse (esp intrinsic)
85
prevention of abfraction
```
assess occlusion on teeth with lesions
- consider occlusal equilibration
fill cavities with low modulus restorative materials
- RMGIC
- flowable composite
```
86
passive management
```
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
which type of wear should you consider to tx in all cases?
erosion
88
management of erosion broad categories
F
desensitising agents
dietary management
medical
89
F to reharden in erosion
Duraphat
tooth mousse
MWs
90
desensitising agents in erosion
more symptomatic relief than prevention
| try several - work different ways
91
dietary management in erosion
habit changes: swilling, use straw, rumination, health eating, vegan diet (more acidic?), sports drinks/gels
92
medical management in erosion
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
simple Rx intervention
covering exposed D
| filling cupped defects in molars/incisors
94
intervention threshold for active management - not always clear
wear leading to further complications
pt unable to accept aesthetics
leaving intervention may cause more complex txs to be required
95
aims of active management
preserve remaining tooth structure
pragmatic improvement in aesthetics
fct occlusion
stability
96
what does most generalised tooth wear start as?
localused
97
what is the most common type of site of tooth wear?
maxillary anterior
98
active management of maxillary anterior tooth wear: factors that determine tx and Rx
```
pattern
inter-occlusal space
space required for planned Rxs
quantity and quality of remaining tooth tissue, particularly E
pt aesthetic demands
```
99
what did palatal surface only wear used to be treated with?
metal Rx
100
getting space for Rxs
```
traditional
increase OVD
occlusal reorganisation from ICP to RCP
surgical crown lengthening
elective RCT and postcrowns
conventional ortho
```
101
getting space for Rxs - traditional
```
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
getting space for Rxs - increase OVD
multiple posterior EC Rxs
reorganised approach
complex, destructive, £££
103
getting space for Rxs - occlusal reorganisation from ICP to RCP
push mandible back slightly - get some space anteriorly, but doesn't work for everyone
complicated, can be destructive, specialist tx
104
getting space for Rxs - surgical crown lengthening
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
getting space for Rxs - elective RCT and psotcrowns
v destructive
106
getting space for Rxs - conventional ortho
long tx
107
disadvantages of surgical crown lengthening
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
cases where there is adequate inter-incisal space
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
consequences of dentoalveolar bone growth compensation
most cases no increase in freeway space
maintains masticatory efficiency
no space for Rx
110
what is the aim of the Dahl technique?
gain space in localised wear cases
111
what is used in the Dahl technique compared to previously and why?
composite anterior bite plane
prev removable CoCr
aesthetics
compliance (non-removable)
easier to adjust
112
what does the composite anterior bite plane in the Dahl technique achieve?
```
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
advantages of Dahl technique
immediate definitive tx - anteriors look better after 1st visit
non-invasive, usually 1st choice
114
variableness of Dahl technique success
variable effect rate - faster in younger pts
variable degree - if no movement in 6m it won't work
monitor progress
115
success rate of Dahl technique
90+%
116
describe how the occlusion changes through the Dahl technique
occ disorganised at first but re-establishes
| - initially no posterior occlusion
117
what increases the success rate if the Dahl technique?
remaining E 'ring of confidence'
| aids retention
118
contraindications for the Dahl technique
```
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
lower anterior toothwear - what is it generally found with?
maxillary
120
why is lower anterior toothwear harder to tx?
less E
| smaller bonding area
121
treating lower anterior toothwear
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
methods of composite build up
```
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
localised posterior toothwear prevalence and causes
```
rare on own
causes
- rumination
- bulimia
- alcoholism
```
124
localised posterior toothwear - asymptomatic
prevention and monitoring
125
what can you do for localised posterior erosive toothwear?
fill directly with composite - no change in occlusion
126
aim of treating localised posterior toothwear
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
success of composite build up for anteriors
normally reachieve posterior occlusion
pt satisfaction
rarely TMJ problems
safe for pulp and PD condition
128
longevity of composite build up for anteriors
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
composite build up for anteriors - pragmatic aesthetics
good but not best
| doesn't damage teeth
130
what can composite build up be known as?
biologically based management
131
info for pts having Dahl technique
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
info for pt re longevity of Dahl/composite anterior build ups
```
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
what does most generalised toothwear start as?
localised anterior
134
why is it important to identify localised toothwear early?
```
avoid it progressing to generalised
more complicated (demanding, lengthy, £££)
```
135
categories of generalised toothwear
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
general principles of tx of generalised toothwear
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
which is the easiest to tx but least common form of generalised toothwear?
excessive wear with loss of OVD
138
tx of generalised toothwear - excessive wear with loss of OVD
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
tx of generalised toothwear - excessive wear without loss of OVD but with limited space available
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
tx of generalised toothwear - excessive wear without loss of OVD, no space available
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
risk management
record, point out to pt and monitor if wear has been there for long time and not progressing
142
overdentures
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
preventive advice/counselling - recording in notes
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
consent
```
must understand
- proposed tx, inc passive preventative
- their part and cooperation in tx
- consequences of not following advice
record
```
145
how to explain provisional tx (often passive preventative) to pt
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
what should you try before definitive tx?
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
