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Restorative Dentistry > Toothwear > Flashcards

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
Q

Sources of intrinsic acids

A

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
Q

Vomiting disorders?

A

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
Q

Basic erosion wear examination

A

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
Q

BEWE score of 9-13 (medium)

A

OH, dietary assessment
Routine maintenance
Fluoride measures
Avoid restorations
Repeat at 3-6m intervals

29
Q

BEWE score of 14+

A

As in medium
Consider restorations

30
Q

What are the benefits of a BEWE?

A

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
Q

What are the disadvantages of BEWE?

A

Erosion only
Larger discrepancies measuring enamel lesions

32
Q

What 5 factors are measured in the anterior clinical erosive index?

A

Dentine exposure in contact areas
Preservation of incisal edges
Length of remaining clinical crown
Presence of enamel on vestibular surfaces
Pulp

33
Q

Benefits of anterior clinical erosive index

A

Detailed classification staging
Recommended treatment options
Idea od prognosis of restorations given
Useful to review a patient over time

34
Q

What are the disadvantages of clinical erosive index?

A

Anterior teeth only
Does not cover diagnosis/tx options for posterior teeth

35
Q

What advice can be given after extrinsic acid consumption

A

Consuming dairy products
Chewing gum following acid exposure
- re hardening of enamel
- stimulation of saliva flow
- increase in saliva pH

36
Q

Which topical agents can be used in the rehardening of enamel?

A

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
Q

Topical agents for hypersensitivity

A

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
Q

Advice to avoid abrasion

A

Tooth brushing advice
Use of less abrasive toothpastes
Avoid tooth brushing after acid exposure
Stop prevent
Remove oral piercings
Appropriately plan restorations

39
Q

Advice to prevent attrition

A

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
Q

How can space be created for restorations?

A

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
Q

Assessing restorability of worn teeth

A

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
Q

How to perform a diagnostic wax up

A

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
Q

What are the benefits of using a hard acrylic full coverage splint?

A

Protect teeth from further wear
Management of TMJD
Testing pt tolerance of an increased OVD
Disrupts habitual path of closure in ICP

44
Q

How is a hard acrylic full coverage splint designed?

A

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
Q

Indications of managing toothwear

A

Pain/discomfort
Aesthetics
Function disrupted
Compromised structural integrity of tooth/teeth
Alveolar compensation with reduced interocclusal space for restoration

46
Q

What are the contraindications of managing toothwear?

A

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
Q

What is the Dahl concept?

A

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
Q

Basic principles of Dahl

A
  • 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
Q

How much space can be created?

A

1.8 - 4.7mm av = 2.84

50
Q

What is the ratio of intrusion v eruption

A

Intrusion - 40%
Eruption = 60%

51
Q

How long can it take for re-establishment of occlusal contacts?

A

6m but can be up to 18-24m

52
Q

What are the adverse effects/symptoms?

A

4% reversible pulpal
3-10% reversible perio tenderness
2-4% reversible TMJ
No root resorption reports
Partial occlusal re-establishment often involving premolars

53
Q

Posterior toothwear management

A

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
Q

How much more wear does composite have than an indirect?

A

3-4x but composite restoration involve more minimal prep to tooth

55
Q

Occlusal reduction for different indirects:

A

PFM - 2mm
Metal onlay - 1mm
Metal veneers - 0.7mm
Zirconia - 1mm
Composite -1-2mm

56
Q

What is an overdenture?

A

Completely covers on one or more natural teeth and a flange
- When teeth worn down to gingival level or unrestorable

57
Q

What is an overlay denture?

A

Cover teeth with full labial veneer facing as well as occlusal coverage
Used when flange not indicated - undercuts/aesthetics)

58
Q

What is an onlay denture?

A

Cover entire occlusal/incisal surface
Indicated when 1/3 to 1/2 of coronal tooth present, healthy remaining tooth tissue and acceptable aesthetics

59
Q

What are the benefits of overdentures?

A

Psychological benefit of tooth retention
Continued proprioceptive feedback from PDL
Decreased ridge resorption
Additional retention from abutments
Replace soft tissue

60
Q

Disadvantages of overdentures

A

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
Q

What features must an overdenture abutment have?

A

1.5-2mm supragingival tooth tissue
Dome shaped
Min 5mm alveolar bone support
Band of attached gingivae

62
Q

Maintenance of overdenture abutment

A

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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