Toothwear Flashcards by Caitlin MacDonald

What are the causes of non various tooth surface loss?

Trauma
Developmental problems
Tooth wear

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What is the difference between normal and pathological tooth wear?

Normal- wear associated with normal function (20-38 um per annum)
Pathological- when remaining tooth structure or pulpal health is compromised/ excessive rate/ masticatory or aesthetic deficit

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What are the 4 causes of toothwear?

Attrition - result of tooth to tooth contact
Abrasion - through an abnormal mechanical process independent of occlusion (foreign object)
Erosion - by a chemical process that does not involve bacterial action
Abfraction - loss of hard tissue from eccentric occlusal forces leading to stresses at cervical fulcrum areas

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What is the most common cause of attrition?

Parafunctional habit

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What is the clinical presentation of attrition?

Polished facet on cusps/ flattening incisal edges
Progression to reduction in cusp height/ shortening of clinical crown

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Where is abrasion most common?

Labial/ buccal, cervical on canine and premolar teeth (V shaped lesions)

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What is the most common cause of abrasion?

Toothbrushing

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How does erosion present clinically?

Loss of surface detail
Bilateral, concave lesions (without chalky appearance of bacterial decalcification)
Progression - dentine becomes affected, preferential wear of dentine leads to cupping of occlusal surfaces and incisal edges. Increased translucency of incisal edges, restorations sit proud, no tooth staining present

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What causes abfraction?

combination of occlusal stress (loading forces), abrasion and erosion leading to loss of substance at the cervical margin.

Loading forces result in flexure and failing of enamel and dentine at a location away from the loading- causing cracks in the tooth which chip out

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How prevelant is toothwear in adults?

77% have wear in their anteriors involving dentine

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How prevelant is toothwear in children?

> 50% of 5 year olds exhibit tooth wear on their primary incisors

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Why is masticatory deficiency uncommon in toothwear?

Toothwear generally happens slowly- time for passive eruption to maintain occlusion

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What would be relevant MH to tooth wear?

Medication with low pH/ which cause dry mouth
Eating disorder
Alcoholism
Heartburn/GORD
Hiatus hernia
Rumination
Pregnancy

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When examining the patient, what should you look for - extra oral

TMJ (restriction, clicking, crepitus?)
Musculature (hypertrophy)
Mouth opening restriction? (<4cm) and deviation on movement
Parotid hypertrophy
Overclosure
Lip line, smile line

IO:
FWS and OVDS
Stable contacts in centric relation? Tooth contacts in excursion movements?

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Describe BEWE classification

0- no erosive wear
1- initial loss of surface
2- distinct defect, <50% hard tissue loss
3- hard tissue loss>50%

Count up scores for each sextant

<2 - no risk
3-8 - low risk
9-13 - med risk
>14 - high risk

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Which special tests are appropriate for tooth wear treatment planning?

Sensibility (pulpal damage rare due to deposition of 3ry dentine over a period of time)
Radiographs- AP related to toothwear if lost 1/3 -1/2 tooth
Articulated study models
Intra oral photographs
Diagnostic wax up
Dietary analysis

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How is toothwear diagnosed?

Pattern:
- localised
- generalised: wear with loss OVD, wear without loss OVD but space, wear without loss OVD with no space

Dento-alveolar compensation- important for tx planning

Immediate treatment of toothwear?

Address pain:
- sensitivity (desens, fluoride, GIC over exposed dentine)
- pulp extripation (if required)
- smooth sharp edges (prevent trauma)
- extraction (unrestorable/ non-functional teeth)
- TMJ pain (needs to be controlled before restorations)

Initial treatment of toothwear

Stabilise existing dentition
Deal with caries, perio etc (treat other problems as well as toothwear as wear is a slow progress)
Diagnosis and identify causative factor - institute preventative regime (prevention)

Preventative treatment of tooth wear

Baseline wear recording (BEWE/ pictures/ models)
Monitor (restoration required if active)
Remove cause

Prevention for abrasion

Remove foreign object/ habit
RMGIC restoration at cervical margin- pt will wear through this rather than tooth (better bond to dentine than composite, YM similar to tooth)

Prevention for attrition

Address parafunctional habit- CBT, hypnosis
Splints- wear away in preference to tooth, can be used as a habit breaker (can also be sued as diagnostic device), Michigan splint has canine rise to provide disclusion in eccentric mandibular movements.

Prevention for erosion

Establish if intrinsic or extrinsic?

Fluoride- sensory energy, tooth mousse, duraphat
Desensitising agents- more symptomatic relief
Dietary management- fruit juice, fizzy juice, acidic foods
Gastric acid control- GORD, reflux, hiatus hernia (refer to GP)

Prevention of abfraction

Fill cavities with RMGIC/ flowable composite

What is passive management of tooth wear

Prevention and monitoring (6 months)

What is active management?

Simple restorative intervention- cover exposed dentine Composite restorations (aesthetic)- should be >2mm to prevent de bond

What are the 5 considerations when treatment planning for active management of maxillary anterior toothwear

Pattern of tooth wear Inter occlusal space Space required Quality and quantities of remaining enamel Aesthetic demands of patient

What are the 3 main patterns of anterior maxillary tooth wear

Limited to palatal surfaces (vomiting etc) Involving palatial and incisal edges with reduced crown height Limited to labial surfaces (holding juice in mouth, uncommon)

What are the tx options for anterior maxillary wear?

Increase OVD- reorganised approach (complex) Reorganisation from ICP to RCP Surgical crown lengthening Elective RCT and post crowns Conventional ortho Dahl technique

What is the Dahl technique

Method of gaining space in localised tooth wear Composite covering palatal surfaces and allowing occlusion on a raised cingulum - resulting in posterior disclusion and increase in OVD (2-3mm) Over 3-6 months gain space between incisors (passive eruption) Definitive treatment 90% success rate (if no movement in 6 months, not going to work)

Contraindications for Dahl technique

Active perio TMD Post ortho Bisphosphonates (poor bone turnover) Implants- ankylosis to bone so wont continue to erupt Existing conventional bridges- not likely to continue to erupt

Contraindications for composite build ups

Short roots (will be increasing tooth length with already decreased support) Reduced periodontal support due to perio disease Lack of enamel - not contraindication but reduces success rate

What is the ring of confidence?

Thickness of remaining enamel- has a positive relationship on retention

Reasons why mandibular anterior builds are less successful than maxillary?

Less enamel, smaller bonding area Harder to achieve moisture control

Management of localised posterior tooth wear?

Unusual on its own Fill directly with composite with no change in OVD Composite added to palatal of canines to disclude posteriors- often canine wear resulted in the posterior wear (saves from further damage)

Methods of composite build ups?

Direct build up- alginate imps, wax up, putty matrix Clear vacuum formed matrix- alginate imps, wax up, impression of wax up poured in stone, clear plastic matrix formed and cut to size

What is the first treatment option for toothwear?

Composite resin restoration (minimally invasive)

Information for patients getting composite build ups

- tooth coloured fillings on front teeth to prevent wearing more (no LA, minimal drilling- no tooth substance is removed) - bite will feel strange for a couple of days, will resolve (only front teeth will come together, back teeth will come together within 3-6 months) - may cause lisp for a few days - front teeth may feel tender for a few days - may accidentally bit tongue/ lips over next few days - crowns/ bridges/ dentures at back of mouth will need replaced - longevity should be good although small chance de bonds- will require maintenance (including cost)

3 categories of generalised tooth wear

Excessive wear with loss of OVD Excessive wear without loss OVD but with space Excessive wear without loss OVD and no space

Management of generalised toothwear - excessive loss with loss of OVD

Easiest to treat but least common Splint to assess pt tolerance to new face height Half OVD increase maxillary and half mandibular Alveolar compensation

Management of generalised toothwear - without loss of OVD with limited space

Re-organisation of occlusion Splint Then restoration of anterior and posterior teeth at new face height (minimal prep adhesive restorations)

Management of generalised toothwear - loss of OVD and no space

Refer to specialist Attempt to increase OVD by use of splints/ dentures if lack of posterior support (as there is often in these cases) Crown lengthening- increases amount of coronal tooth substance (black triangles where ID papilla is further down) - unfavourable crown to root ratio Over-dentures (although can be bulky for pt to wear)