TOOTHWEAR Flashcards
What is tooth surface loss?
EVERYTHING = caries, trauma, developmental problems, tooth wear
What are the types of tooth wear?
PHYSIOLOGICAL = normal process and increases with age, associated with normal function
PATHOLOGICAL = occurs if the remaining tooth structure or pulpal health is compromised or the rate of tooth wear is in excess for what is expected
What are some causes of tooth wear?
- attrition
- abrasion
- erosion
- abfraction
What is attrition?
The physiological wearing away of tooth structure as a result of tooth to tooth contact
Where are attritive lesions found?
The occlusal and incisal contacting surfaces (early appearance is of a polished facet on a cusp or flattening of incisal edge)
What is attrition typically related/caused by?
Parafunctional habit
How does attrition present?
- polished facet of cusps
- flattened incisal edge
- reduction in cusp heights
- shortened clinical crown
What is abrasion?
The physical wear of tooth substance through an abnormal mechanical process independent of occlusion
- involves foreign object or substance repeatedly contacting the tooth
Where is the commonest area to find abrasion?
Labial/buccal, cervical on canine and premolar teeth (aggressive toothbrushing)
How can abrasion manifest on incisors?
Notching of incisal edges
What is erosion?
The loss of tooth surface by a chemical process that does not involve bacterial action.
What is the most common type of pathological tooth wear?
Erosion
What causes erosion?
Chronic exposure of dental hard tissues to acidic substances which can be extrinsic or intrinsic
How does erosion present in the mouth?
EARLY STAGES = enamel surface is affected with loss of surface detail, surfaces become flat and smooth
LATER = dentine becomes exposed
How do erosion lesions clinically present?
Typically bilateral
- concave lesions without chalky appearance of bacterial acid décalcification
What can transparent incisal edges suggest?
Erosion
What is abfraction?
The loss of hard tissue from eccentric occlusal forces leading to compressive and tensile stresses at the cervical fulcrum areas of tooth
You suspect a patient with heavily restored anterior teeth is suffering from erosion, what would be a sign?
Teeth are affected BUT restorations are not
How does abfraction present?
Loss of tooth substance at the cervical margin
(cracks in tooth substance which causes tooth substance to chip out)
What causes abfraction?
Caused by biomechanical loading forces
- results in flexure and failure of the enamel and dentine at a location away from the loading
What clinical signs would suggest a patient is suffering from abfraction?
V shaped tooth loss where the tooth is under tension
- classically sharp rim at the ACJ
In order to prevent or reduce tooth loss due to wear you must…:
- recognise the problem
- grade its severity
- diagnose the likely cause or causes
- monitor the progression of disease
What are some medical history causes fo tooth wear?
- medications with low pH
- medications which dry the mouth
- eating disorders
- alcoholism
- heart burn
- GORD
- hiatus hernia rumination
When examining a patient with toothwear, what must you asses when looking at occlusion?
- FWS checked
- resting face height and OVD
- any dento-alveolar compensation?
- record overbite & overjet
- are there stable contacts in centric relation
- check tooth contacts in excursive movements
What might toothwear patients come to you complaining of?
- aesthetic impairment
- functional difficulties
How might the musculature of a toothwear patient present during your extra oral exam?
hypertrophy !
How might the TMJ of a toothwear patient present during your extra oral exam?
- restricted movement
- clicking
- crepitus
Give an example of a tooth wear index that you may refer to on clinic?
BEWE (basic erosive wear examination)
Where is the most common area for toothwear?
Localised anterior teeth
What special tests might you do on a patient with toothwear?
- sensibility testing
- radiographs
- articulated study models
- intra-oral photographs
- salivary analysis
- diagnostic wax up
- dietary analysis
What is the first stage of treatment planning for a patient with tooth wear?
DEAL WITH PAIN
- sensitivity
- pulp extripation
- smooth sharp edges
- extraction
- TMJ pain
How can you deal with sensitivity caused by tooth wear?
Desensitising agents
- fluorides
- bonding agents GIC coverage of exposed dentine
What is dento-alveolar compensation?
As teeth wear your bone remodels to ensure biting surfaces of teeth remain in contact
What is involved in the initial treatment of toothwear patients?
Stabilise the existing dentition (wear is important but treat the whole mouth and whole patient)
- deal with caries
- deal with perio
What is the key element in prevention?
Removal of the cause
How might abrasion be prevented?
- remove foreign object/substance involved in causing the wear
- change toothpaste
- alter tooth brushing habits
- change habits (nail biting, wire stripping, piercing biting, pen chewing)
How can cervical toothbrush abrasion be prevented (treated)?
Simple RMGIC, GIC or composite restorations can be placed with no tooth prep
- patient then wears through the restoration rather than damaging teeth
- simple & effective measure
What dental material would be the first choice of filling for abrasion cavities?
RMGIC (best survival rate)
Why is composite compromised when consideration of use in abrasion cavity treatment?
Higher modulus may compromise its retention
How can attrition be prevented?
- lower patients stress levels (CBT, hypnosis)
- splints
Why are splints used in the prevention of attrition?
Splint softer than teeth
- soft splint can be used as a diagnostic device as it will wear rapidly and show wear facets
Give an example of a type of splint used in attrition prevention?
Michigan splint
- hard splint
- provides ideal occlusion
- has canine rise which provide disclusion in eccentric mandibular movements
How can erosion be prevented?
- desensitising agents (this is rly more symptomatic relief)
- dietary management
- using straws when drinking acidic drinks
- avoid sports drinks/gels
- control gastric acid
- control xerostomia
- control anorexia and bulimia
What GI conditions may speed up tooth erosion?
- GORD
- reflux
- hiatus hernia
Which tooth wear patients are splints not suitable for?
Erosion patients (especially relating to acid reflux)
In cases of maxillary anterior tooth wear, what factors affect decision on treatment and restorations of these teeth?
- the pattern of anterior maxillary tooth wear
- inter-occlusal space
- space required for the restorations being planned
- quality and quantity of remaining tooth tissue (especially enamel)
- aesthetic demands of patient
What are the different categories 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 is the Dahl Technique in reference to toothwear cases?
- method of gaining space in cases of localised tooth wear
- add composite to anterior teeth, which causes posteirors to over erupt
- anteriors then have space to be restored with no need for occlusal reduction
Who is the Dahl Technique not suitable for?
- active periodontal disease
- TMJ problems
- post orthodontics
- bisphosphonates
- if dental implants present
- if existing conventional bridges
What might be a contraindication of repairing anterior toothwear?
- short roots
- reduced periodontal support due to perio disease
Is upper or lower anterior tooth wear harder to fix? Why?
LOWER
- less enamel, smaller bonding area
What increases the likelihood of longevity of toothwear repair?
Sufficient remaining enamel
In which patient cases might you see localised posterior erosive toothwear?
Bullimic and alcoholic patients
What is a way to help localised posterior toothwear?
Adding composite resin to palatal of upper canines to increase the canine rise & disclude the posteriors during later & protrusive excusions
Loss of what typically leads to posterior toothwear?
Loss of canine guidance
What is a common method of anterior composite buildup?
- alginate impressions
- wax up
- putty matrix
When you decide to build up anterior teeth with composite to help toothwear, what information do you give to patients?
- front teeth will receive tooth coloured fillings to cover worn surface
- no local anaesthetic needed
- bite will feel strange for a few days but this will sort itself out (back teeth will touch again in 3-6 months)
- over a week or so you will be used to new bite
- may experience lisping for a few days
When you perform anterior composite build ups, and the patient has posterior crowns/bridges, what will need to occur?
Replacement of posterior crowns/bridges
What is generalised tooth wear divided into?
- excessive wear with loss of OVD
- excessive wear without loss of OVD but with available space
- excessive wear without loss of OVD and with no space available
What are some negatives to crown lengthening surgery?
- may results in black triangles
- can lead to unfavourable crown to root ratio
- post op sensitivity
When examining a patient with toothwear, what must you asses when looking at them extra-orally?
- is there any overclosure?
- lip line
- smile line
