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Toothwear Flashcards

1
Q

What is toothwear?

A

The pathological non carious loss of tooth tissue

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2
Q

What is the normal amount of toothwear per annum?

A

20-30um
30y+ =1mm wear
60+ = 2mm wear

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3
Q

What are the usual toothwear concerns?

A

Aesthetics
Function
Sensitivity
Rate

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4
Q

What is attrition?

A

The loss of tooth substance or a restoration as a result of contact between occluding surfaces

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5
Q

What is abrasion?

A

The physical wear caused by materials other than tooth contact

  • nail biting
  • pen chewing
  • overzealous tooth brushing
  • oral piercings
  • restorations
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6
Q

What is erosion?

A

Loss of tooth tissue due to chemical processes not involving bacterial action

key sign - enamel cupping

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7
Q

What are extrinsic acids?

A

Acidic drinks/food
Buccal/cervical surfaces of the maxillary teeth and the occlusal surfaces of mandibular posterior dentition

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8
Q

What is intrinsic acid and where does it act?

A

Mandibular dentition tend to be protected by tongue

stomach acid

acts on the palatal surfaces of the maxillary dentition

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9
Q

What do erosive enamel lesions look like?

A

Rounded and smooth with surface enamel loss

Increased translucency, e.g. at incisal edge

Chipped enamel

Proud restoration margins

Gloss of enamel and surface anatomy losss

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10
Q

What do erosive dentine lesions look like?

A

Dentine more susceptible to erosion then enamel - more rapid loss of dentine

Cupping/dished out lesions

Teeth appear darker due to exposed dentine

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11
Q

What does an active erosive lesion appear to look like?

A

No staining on teeth
Enamel = loss of lustre
Hypersensitivity

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12
Q

What does an inactive enamel lesion look like?

A

May be stained if dentine is exposed

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13
Q

What is abrfraction?

A

Tooth wear located in the cervical area caused nu flexural forces during function and parafunction

angular wedged lesions at CEJ
Result to flexure and fracture of enamel/cementum
Tend to be more angular and undercut than erosive/abrasive lesions
Evidence regarding correlation with occlusion but evidence not conclusive
Likely to have multifactorial aetiology

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14
Q

What are the risk factors for toothwear?

A

Parafunctional habits e.g. bruxism
Enamel/dentine anomalies - amelogenesis imperfecta
Saliva
MH
Intrinsic/extrinsic acid

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15
Q

What are parafunctional habits

A

Bruxism, clenching, lip biting, thumb sucking and any other oral habit not associated with mastication, deglutition and speech

Significant increase in duration and frequency of occlusal forces

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16
Q

What is the normal occlusal force?

A

200N

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17
Q

Why does saliva play an important role in erosion?

A
  • eliminates acids
  • presents buffering capacity causing neutralisation
  • flow of saliva allows dilution of acids
  • super saturated with ca and po4 for remineralisation
  • proteins present in saliva and acquired pellicle play an important role in erosion
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18
Q

What factors increase xerostomia?

A

Head and neck RT
Salivary gland disorder e.g. sjogrens
Medications
Diabetes

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19
Q

What is the histopathology of erosion?

A

Chemical dissolution of tooth tissue caused by H+ ions and anions capable of binding to calcium

  1. Early demineralisation and softening of the tooth tissue without surface loss
  2. Microscopic material loss
  3. Clinically visible erosive lesions
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20
Q

Histopathology of enamel

A

Loss of surface minerals causes an increase in roughness

Bulk mineral loss

Surface structure of eroded enamel corresponds more or less to a typical etching pattern

Partial loss of mineral at the surface results in softening of enamel and vulnerability to physical impacts

Enamel remains soft and vulnerable to abrasive injury after hours

IO saliva - limited remineralisation of softened surface

Solutions or preps of active agents applied, can gain minerals due to precipitation of various salts

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21
Q

Histopathology of dentine during erosion

A

Mineral component readily dissolves whilst organic portion is retained

Thin zone of dense fibrous collagen network present, increases depth with increasing erosion time

Depending on time of exposure, fully demineralised zone develops beneath where partially demineralised dentine is found

Peritubular dentine dissolves at a quicker rate than inter-tubular dentine

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22
Q

What are the acids that cause erosion?

A

Citric acid
Phosphoric acid
Malic acid

Damage depends on buffering capacity

Amount of undissociated acid present in food/drinks

Greater the buffering capacity of the drink, longer for saliva to neutralise

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23
Q

Why is citric acid so erosive?

A

1 acid molecule creates 3x hydrogen atoms

Citric acid has the increased capability to bind calcium ions - this can occur at higher pHs

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24
Q

What can be done to reduce erosivity of soft drinks?

A

Addition of calcium
Avoid swishing of drinks around mouth
Rinse acids out of mouth with neutral solution e.g. water after ingesting
Avoid abrasive activities, toothbrushing for up to 2hrs

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25
Sources of intrinsic acids
Vomitting Rumination GORD Sphincter incompetence - oesophagitis, hiatus hernia, diet, pregnancy, drugs, neuromuscular Increased gastric pressure, obesity, pregnancy, ascites Increased gastric volume - meals, obstructions, spasms
26
Vomiting disorders?
Psychosomatic - stress, eating disorders, anorexia etc Metabolic and endocrine - diabetes, pregnancy and uraemia Gi - peptic ulcers, obstructions, cerebral palsy and nervous system disorders Drug induced - primary - cytotoxic, secondary - NSAIDS, alcohol, aspirin
27
Basic erosion wear examination
0 - no erosive wear 1 - initial loss of enamel surface texture 2 - distinct defect, hard tissue loss extending to loss than 50% 3 - Hard tissue over 50% loss
28
BEWE score of 9-13 (medium)
OH, dietary assessment Routine maintenance Fluoride measures Avoid restorations Repeat at 3-6m intervals
29
BEWE score of 14+
As in medium Consider restorations
30
What are the benefits of a BEWE?
More easily applied to practice settings Includes management of tooth wear as well as diagnosis and staging Recall recommendations included Ability to assess if toothwear is localised/generalised Can be used to monitor tooth wear over time
31
What are the disadvantages of BEWE?
Erosion only Larger discrepancies measuring enamel lesions
32
What 5 factors are measured in the anterior clinical erosive index?
Dentine exposure in contact areas Preservation of incisal edges Length of remaining clinical crown Presence of enamel on vestibular surfaces Pulp
33
Benefits of anterior clinical erosive index
Detailed classification staging Recommended treatment options Idea od prognosis of restorations given Useful to review a patient over time
34
What are the disadvantages of clinical erosive index?
Anterior teeth only Does not cover diagnosis/tx options for posterior teeth
35
What advice can be given after extrinsic acid consumption
Consuming dairy products Chewing gum following acid exposure - re hardening of enamel - stimulation of saliva flow - increase in saliva pH
36
Which topical agents can be used in the rehardening of enamel?
Remineralising toothpastes - NaF and ACP Fluoride Neutral NaF mouthrinse/gel can be recommended Avoid toothbrushing after acid exposure Custom made trays for topical appl
37
Topical agents for hypersensitivity
Potassium - sensodyne daily care CPP-ACP - calcium phosphopeptide amorphous calcium phosphate - increased precipitation of phosphate - hardening of dentine, closure of tubules Bioglass - sensodyne complete protection - obstructs tubules Arginine - colgate sensitive pro-relief
38
Advice to avoid abrasion
Tooth brushing advice Use of less abrasive toothpastes Avoid tooth brushing after acid exposure Stop prevent Remove oral piercings Appropriately plan restorations
39
Advice to prevent attrition
Splint therapy - full coverage hard acrylic splint - michigan/tanner Thermoform Bilaminar - hard and soft layer. must provide balanced occlusion with all teeth in contact with splint (soft splints can increase parafunctional habits and lead to orthodontic movement of teeth)
40
How can space be created for restorations?
Crown lengthening surgery - increase height of teeth to aid retention and can improve gingival aesthetics which does not create space in itself - increased SA of tooth for cement/bond to Elective RCT - destructive which worsens prognosis of tooth - posts and cores to maintain restorations Occlusal reduction of teeth to be restored - destructive Occlusal reduction of opposing teeth - only in select cases
41
Assessing restorability of worn teeth
Look for ring of enamel to bond to Remaining clinical crown height for resistance and retention form Pulp status of tooth Perio status of tooth
42
How to perform a diagnostic wax up
EO assessment of dentition Occlusal relationships, contacts and interferences Restorative space available Plan occlusal changes Clin stages - maxillary and mandibular impressions Capture desired OVD with a jaw reg Wax up at desired OVD
43
What are the benefits of using a hard acrylic full coverage splint?
Protect teeth from further wear Management of TMJD Testing pt tolerance of an increased OVD Disrupts habitual path of closure in ICP
44
How is a hard acrylic full coverage splint designed?
Bilateral occlusal contact along the retruded arc of closure Anterior guidance on anterior teeth and canine guidance in lateral excursion Posterior discussion in excursions AVOID partial and soft splints
45
Indications of managing toothwear
Pain/discomfort Aesthetics Function disrupted Compromised structural integrity of tooth/teeth Alveolar compensation with reduced interocclusal space for restoration
46
What are the contraindications of managing toothwear?
Perio and caries Unrestorable teeth - vertical height Root fractures Horizontal/oblique fractures to bone crest, caries to bone crest and failed endo Extensive edentulous spans, insufficient posterior support and dental implants are not considered
47
What is the Dahl concept?
Localised appliances/restorations placed in supra-occlusion Occlusion re-establishes and arch contacts over a period of time Originally removable CoCr bite raising appliances used After 8m, sufficient space created to provide palatal gold onlays
48
Basic principles of Dahl
- Thickness of material = amount of inter occlusal space required Increase OVD Ideally ensure that occlusal forces are directed against the long axis of the tooth Stable interocclusal contacts Appliance/restoration should not impede movement of discluded teeth
49
How much space can be created?
1.8 - 4.7mm av = 2.84
50
What is the ratio of intrusion v eruption
Intrusion - 40% Eruption = 60%
51
How long can it take for re-establishment of occlusal contacts?
6m but can be up to 18-24m
52
What are the adverse effects/symptoms?
4% reversible pulpal 3-10% reversible perio tenderness 2-4% reversible TMJ No root resorption reports Partial occlusal re-establishment often involving premolars
53
Posterior toothwear management
monitor and review composite added superior to centric stops palatally (+/- wax up) Indirect restorations Provides separation of posterior teeth on mandibular excursions to prevent further wear
54
How much more wear does composite have than an indirect?
3-4x but composite restoration involve more minimal prep to tooth
55
Occlusal reduction for different indirects:
PFM - 2mm Metal onlay - 1mm Metal veneers - 0.7mm Zirconia - 1mm Composite -1-2mm
56
What is an overdenture?
Completely covers on one or more natural teeth and a flange - When teeth worn down to gingival level or unrestorable
57
What is an overlay denture?
Cover teeth with full labial veneer facing as well as occlusal coverage Used when flange not indicated - undercuts/aesthetics)
58
What is an onlay denture?
Cover entire occlusal/incisal surface Indicated when 1/3 to 1/2 of coronal tooth present, healthy remaining tooth tissue and acceptable aesthetics
59
What are the benefits of overdentures?
Psychological benefit of tooth retention Continued proprioceptive feedback from PDL Decreased ridge resorption Additional retention from abutments Replace soft tissue
60
Disadvantages of overdentures
Reduction in prosthetic space Increased incidence of caries and perio Risk of pulp inflammation/exposure when replacing abutment teeth Complex to provide High maintenance regime
61
What features must an overdenture abutment have?
1.5-2mm supragingival tooth tissue Dome shaped Min 5mm alveolar bone support Band of attached gingivae
62
Maintenance of overdenture abutment
High risk of caries and perio Regular review and OH reinforcement - brush abutment with high F toothpaste - daily F mw - apply high F gel to fit surface in AM and do not eat for 30m afterwards - Dentures out at night - Clean dentures after meals

Restorative Dentistry (11 decks)

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