Toothwear Flashcards
What are the causes of Non-carious tooth surface loss? (3)
Trauma, Developmental Problems or Tooth Wear
What measurements are regarded as normal physiological tooth wear?
20 – 38um per annum
What makes toothwear pathological? (3)
Occurs if the remaining tooth structure or pulpal health is compromised
or the rate of tooth wear is more than what would be expected for that age.
if the patient experiences a masticatory or aesthetic deficit.
What are the 4 causes of toothwear?
Attrition
Abrasion
Erosion
Abfraction
Define attrition
The physiological wearing away of tooth structure as a result of tooth to tooth contact.
Where are attritive lesions commonly found
found on the occlusal and incisal contacting surfaces (parts of teeth that touch
Describe the early appearance of attractive lesions (2)
polished facet on a cusp
slight flattening of an incisal edge/cusps.
Describe the progression of attrition lesions (3)
reduction in cusp height
flattening of occlusal inclined planes
shortening of the clinical crown of the incisor and canine teeth
What is the cause of attrition
Almost always related to a parafunctional habit (bruxism) – is it historic or current?
Describe the characteristics of teeth with attrition (2)
Flat facets are present and related to functional and often parafunctional movements (where teeth meet)
and Restorations show the same wear as tooth structure (different from erosion)
Define abrasion
The physical wear of tooth substance through an abnormal mechanical process independent of occlusion.
It involves a foreign object or substance repeatedly contacting the tooth.
Where are abrasive lesions commonly found?
Commonest area is labial/buccal, cervical on canine and premolar teeth.
Describe the characteristics of teeth with abrasion (3)
V shaped or rounded lesions
Sharp margin at enamel edge where dentine is worn away first (easier)
Can manifest as notching of the incisal edges
What is the cause of abrasion?
Commonest cause is tooth brushing
Can be related to habits/lifestyle/occupation – holding Pins, nails, electrical wire stripping, fishing line, thread, pipe smoking
Define erosion
The loss of tooth surface by a chemical process that does not involve bacterial action
What is the cause of erosion?
chronic exposure of dental hard tissues to acidic substances which can be extrinsic or intrinsic.
Describe the characteristics of erosion (6)
Typically bilateral
Concave lesions without chalky appearance of bacterial acid decalcification
Increased translucency of incisal edges (patient complain of dark/black edges)
Base of lesion (deepest part of cupping) not in contact with opposing tooth (difference between erosion and abrasion)
Amalgam and composite restorations stand proud of the tooth and are not affected by the acids (difference between erosion and abrasion)
There is no tooth staining present
Describe the early stages of erosion
enamel surface detail (roughness) is affected, surfaces become flat and smooth
Describe the progression of erosive lesions
Dentine becomes exposed.
Preferential wear of dentine leads to ‘cupping’ of the occlusal surfaces of the molars (most commonly) and incisal edges of the anteriors without the chalky appearance
Where are erosive lesions commonly found?
Exact position and severity of erosive wear is dependent on the source, type and frequency of exposure to the acid.
Define abfraction
The loss of hard tissue from eccentric occlusal forces leading to compressive and tensile stresses at the cervical fulcrum areas of the tooth
What is the cause of abfraction (2)
- Abfraction if the basic cause of all non-carious cervical lesions (debatable)
- Multifactorial aetiology. A combination of occlusal stress, abrasion and erosion
Describe the characteristics of abfraction (4)
Pathological loss of tooth substance at the cervical margin
V shaped tooth loss where the tooth is under tension.
sharp rim at the amelo-cemental junction.
Restorations in this area wear at the same rate as the tooth structure
(Seen in px with Good OH)
Where are abfraction lesions commonly found?
Lesions mainly in canine, premolar and molars on the buccal surface almost never lingually.
More commonly in maxilla.
What medical history factors are commonly linked to toothwear (commonly erosion) (9)
- Medications with low pH
- Medications which dry the mouth
- Eating Disorders
- Alcoholism
- Heartburn (Patients are not always aware of reflux – can also occur at night)
- GORD
- Hiatus Hernia
- Rumination (regurgitate food and chew)
- Pregnancy: transient erosive problems (morning sickness, reflux etc)
What is the most common type of pathological toothwear?
Erosion
What factors relating to social history are commonly associated with pathological toothwear? (7)
• Lifestyle stresses – high stress can cause grinding
• Bruxism – can be transient or long term (must treat this before toothwear tx)
• Occupational details – some more prone
• Alcohol consumption – types and volume (everything except gin is acidic)
• Dietary analysis
• Habit
• Sports – use of gels, weightlifters grind etc
What do we record whilst examining wear? (2)
- Location (determines cause)
- Anterior or posterior
- Generalised or localised - Severity
- Enamel only
- Into dentine
- Severe
What wear index is the most useful?
BEWE (basic erosive wear exam however can be used for all pathological wear)
how do we diagnose a toothwear patient?
- Determine the primary causative factor – although most are multifactorial
- Identify patterns:
• Localised
• Generalised
- Wear with loss of OVD
- Wear without loss of OVD but with space available
- Wear without loss of OVD but with limited space
assess if dente-alveolar compensation has occurred
What is involved in the immediate stages of a preventative plan? (5)
Deal with pain;
• Sensitivity
- Provide Desensitising agents, fluorides, bonding agents GIC coverage of exposed dentine
• Pulp extirpation - If wear has compromised pulpal health
• Smooth sharp edges = Prevent trauma to cheeks and tongue
• Extraction- Pain from unrestorable/non-functional tooth
• TMJ pain - Important in attrition, acute symptoms need to be controlled
What is involved in the initial stages of prevention plan?
Stabilise the existing dentition – get them to a state of dental health (treat caries and perio)
• Remove caries and restore
• Treat perio condition
• Oro-mucosal
When is it acceptable to create a prevention regime?
Once you have a dentally fit patient, have a diagnosis and have identified the primary causative factor
What is the key element in prevention regimes?
remove the cause
How do we prevent abrasion? (4)
• Remove the ‘foreign object or substance’ involved in causing the abrasive wear
• Change toothpaste to a less abrasive one
• Alter tooth brushing habits
• Change general habits
- Nail biting
- Wire stripping
- Piercing biting
- Pen chewing etc.
How do we treat abrasion?
For toothbrush abrasion, if habits cannot be changed;
Simple RMGIC = best survival rate, GIC or composite restorations can almost be considered as a preventative measure
placed with no tooth preparation
The patient then wears through the restoration rather than damaging their tooth.
Simple and effective measure for this type of cavity
How do we prevent attrition?
• Difficult to prevent as it is generally related to a parafunctional habit - see tx
How do we treat attrition? (3)
• Cognitive Behavioral Therapy
• Hypnosis (dental hypnosis is only private now)
• Splints can be used
In what type of pathological wear do we not use a splint?
Do not use splints with erosive wear (can get trapped beneath and worsen condition)
What are the advantages of using splints?
Cause no damage to the opposing teeth
May be a habit breaker
Soft splint = can be used as a diagnostic device (wear for 2 weeks): The splint will wear rapidly and show wear facets as scrapes and gouges in the surface of the splint
Hard splints = more robust and can be used over longer term
What are the advantages of a Michigan splint? (3)
- Provides an ‘ideal occlusion’ in centric with even centric stops
- Has canine rise which provide disclusion in eccentric mandibular movements
- Provides Canine guidance in lateral movements
How do we prevent erosion? (5)
• Fluorides to strengthen the tooth tissue (harden)
• Desensitising agents – not prevention more relief of symptoms
• Dietary management esp if extrinsic acid
• Habit changes:
- Swilling drinks around in mouth
- Drinking from cans
- Promote Use of a straw
- Rumination
- Overly Healthy eating
- Too much fruit = very acidic
- Vegan diet
- Sports drinks/gels
• Medical conditions:
Control;
- gastric acid
- GORD
- Reflux
- Haitus Hernia
- Xerostomia
- Anorexia and Bulimia
How do we prevent abfraction? (2)
Consider occlusal equilibration
Fill cavities with low modulus restorative materials = RMGIC or Flowable composite.
How long is passive management of wear patient carried out for in practice?
minimum 6 months
When is active management of toothwear used?
No complete rules - since simple restorative intervention can occur at early stages
e.g. - Covering exposed dentine, filling cupped defects in molars or incisors
What are the requirements for more extensive definitive restorations (active management) of toothwear? (3)
again, No complete rules;
if Wear leading to further complications = intervention
if Aesthetics have gone beyond patient acceptability = intervention
if Leaving intervention may cause more complex treatments to be required. = intervention since localised leads to generalised.
What are the goals of active management? (4)
Preservation of:
- remaining tooth structure
- or a pragmatic improvement in aesthetics
- a functioning occlusion
- Stability
What 5 factors must be considered when deciding tx options in active management of maxillary anterior toothwear?
- The pattern of anterior maxillary tooth wear
- Inter-occlusal space
- Space required for the restorations being planned
- Quality and quantity of remaining tooth tissue, particularly enamel
- The aesthetic demands of the patient
List the 3 patterns of maxillary incisor wear
Tooth wear limited to the palatal surfaces only
Tooth wear involving the palatal and incisal edges with reduced clinical crown height
Tooth wear limited to labial surfaces
What are the tx options for toothwear limited to the palatal surfaces only on maxillary anterior teeth?
= use tooth coloured materials i.e. composite bonded to the palatal surfaces.
What are the tx options for toothwear involving the palatal and incisal edges with reduced clinical crown height & Tooth wear limited to labial surfaces only on maxillary anterior teeth?
• Tooth wear involving the palatal and incisal edges with reduced clinical crown height & Tooth wear limited to labial surfaces
= build up use composite resin materials
In what cases is there adequate inter-incisal space in maxillary anterior teeth? (3)
(This is quite unusual but these cases are the easiest to treat)
- If teeth wear rapidly and there is no time for alveolar compensation
- Where there is an anterior open bite
- Where there is an increased overjet (Class II Div I) : In these cases there can be available space for restorations with no change in OVD
Describe why In the majority of cases when teeth wear there is no increase in freeway space?
There is compensation for the loss of tooth substance by dento-alveolar bone growth
= This maintains masticatory efficiency and is a good thing however Leaves no space for restorations to be placed
List the 5 ways we regain space to allow us to build up toothwear on maxillary anterior teeth?
- Increase OVD: multiple posterior extra-coronal restorations
- reorganized approach = Complex, Destructive, Expensive (historic) - Occlusal reorganisation from ICP to RCP
- Complicated, can be destructive, specialist treatment and minimal space created - Surgical Crown lengthening = Doesn’t really create more space
- Elective RCT and post crowns = Very destructive
- Conventional Orthodontics = Lengthy treatment
What technique is often used now to create space and to allow us to build up localised toothwear on maxillary anterior teeth?
The DAHL technique
When using the DAHL technique, What are the advantages of using composite instead of using Co-Cr anterior bite planes? (4)
- Better aesthetics
- Better compliance as its not removable
- Easier to adjust
- Can be immediate or definitive treatment
How does the DAHL technique work?
- Anteriors intrude
- Posteriors erupt
= Results in space between upper and lower anteriors allowing restoration with no need for occlusal reduction
(posteriors will close and adapt over time)
What are the disadvantages of the DAHL technique? (2)
posterior disclusion with an increase in OVD of 2-3mm
Occlusal contacts only on incisor/canine teeth (initially)
What are the advantages of the DAHL technique? (2)
- Good success rate 90+%
- Occlusion is disorganised at first but re-establishes with time
In which patients does the DAHL technique work faster?
younger
Why do we have to monitor patients when using the DAHL technique?
as If there is no movement in 6 months it is not going to work
When is the DAHL method contra-indicated? (6)
- Active periodontal disease
- TMJ problems
- Post Orthodontics
- Biphosphonates = slow turn over of bone
- If dental implants (ankylosed and wont move)
- If existing conventional bridges
When is active toothwear treatment contraindicated in anterior wear cases? (3)
- Short roots
- Reduced periodontal support due to periodontal disease.
- Not a contra indication but lack of remaining enamel reduces the success rate significantly
In what patients is erosive localised posterior tooth wear common?
- Ruminating patients
- Bulimic and alcoholic patients
How do we treat localised and asymptomatic Localised anterior mandibular wear?
prevention and monitoring are appropriate
- Occlusal erosive wear can be filled directly with composite with no change in occlusion
What is a common cause of posterior wear?
loss of canine guidance
In posterior wear cases, how do we correct the loss of canine guidance?
rebuild up the canine using composite resin to the palatal of the upper canines to increase the canine rise and disclude the posteriors during lateral and protrusive excursions
- can carry out freehand or using diagnostic waxups and templates
(Often there is canine wear which has removed guidance and led to posterior wear = Correct the canine wear and the posterior will be saved from further damage)
In what arch is pathological wear most common?
Maxillary wear more common (Tongue and saliva protect lowers)
What general information do we give to patients? (11)
Your front teeth will receive tooth coloured fillings to cover the exposed and worn tooth surface- This will prevent them from wearing more and this is the main reason for your treatment
This procedure will be carried out without local anesthetic as there will be no/or minimal drilling to your teeth (except polishing)
We add on to your teeth, not remove any tooth
An improvement in the appearance of your teeth should be possible
Your ‘bite’ will feel strange for a few days and you may have difficulty chewing
Initally only your front teeth will touch together and your back teeth will gradually come back together but this will take 3 – 6 months
Over a week or so, you will become accustomed to your new ‘bite’ and will be able to eat more normally. You may have to cut your food into small pieces to help with swallowing and digestion initially.
The change in the shape of your front teeth may cause lisping for a few days
Your front teeth may feel a little tender to bite on for a few days
You may bite your lips and tongue initially
If you have crowns/bridges or partial dentures at the back of your mouth it is likely that these will need to be replaced as they will not move as your natural teeth will.
What information do we give to patients regarding the longevity of toothwear tx? (5)
The longevity of these restorations should be good, but there is a small potential for restorations to debond and fall off = this is normal as the materials are not as strong as your natural teeth
They can be replaced with no damage to your remaining tooth
These restorations will require maintenance
The margins of these restorations will require occasional polishing
Occasional chipping of restorations may occur
List the 3 categories of general toothwear
- Excessive wear with loss of OVD = occurs quickly with no DA compensation
- Excessive wear without loss of OVD but with available space = AOB or class II
- Excessive wear without loss of OVD and with no space available
What are the advantages of using an adhesive approach initially when treating generalised toothwear? (2)
Adhesives can be used to assess the patients tolerance of a new occlusal scheme as a medium term restoration
If conventional preparations are required at a later date these adhesive additions may form the bulk of the removed material. Preserving tooth structure.
How do we treat excessive toothwear with loss of OVD? (4)
- A splint can be used to assess the patients’ tolerance of the new face height or use an adhesive approach is being used.
- You can go straight to increase in face height with ‘permanent’ bonded restorations (Ideally half the OVD increase should be maxillary and half mandibular)
- Often a mixture of adhesive and conventional restorations are required
- Dentures may be required to provide posterior support at the new OVD and maintain it.
How do we treat excessive tooth wear without loss of OVD but with limited space? (3)
- Can involve re-organisation of the occlusion
- A splint should be considered as an increase in occlusal face height is required
- Restoration of anterior and posterior teeth is then carried out at the new occlusal face height.
If possible this should involve minimal preparation adhesive restorations if possible
How do we treat excessive generalised tooth wear without loss of OVD but with NO space? (5)
Probably require specialist opinion prior to commencing treatment
Attempt to increase OVD by use of splints+/- dentures if there is lack of posterior support (often the case) or if enough teeth use adhesive restorations
- Crown lengthening surgery
- Elective endodontics
- Orthodontics
- Overdenture
What are the disadvantages of crown lengthening surgery? (4)
- May result in ‘black triangles’ between the teeth where the ID papilla is further down
- Can lead to unfavorable crown to root ratio = mobile/Increased chance of loosening or tooth movement if tooth is loaded subsequently
- Often post op sensitivity
- Any subsequent conventional crown preparation will be further down the root, this is problematic if the tooth has a significant coronal-cervical taper and has a greater chance of pulpal damage
What is the purpose of an over denture?
Preserves tooth substance and bone for support of denture when teeth as so worn down that restoration is impossible
What are the disadvantages of an overdenture? (2)
- Can be bulky for patient to wear
- Difficulties with keeping teeth and gingivae healthy beneath the prosthesis
