Toothwear Flashcards
What is the difference between physiological and pathological toothwear?
Physiological toothwear is normal wear associated with function.
- roughly 20-38 microns per annum.
Pathological toothwear occurs if the remaining tooth structure or pulpal health is compormosed or the rate of toothwear is in excess of what would be expected for that age.
What is attrition?
Physiological wearing away of tooth structure as a result of tooth to tooth contact.
What intra-oral signs would suggest attritional wear?
Polished facet on a crisp of slight flattening of an incisal edge
Reduction in cusp height and flattening of occlusal inclined planes
Shortening of clinical crown and canine teeth
Restorations show the same wear as the tooth- both become flat.
Almost always related to a parafunctional habit.
What is abrasion?
Physical wear of a tooth substance through an abnormal mechanical process that is not related to the occlusion.
It involves a foreign object or substance repeatedly contacting the tooth.
- Toothbrush
- Tongue stud
- Interdental brushes
- oral self harm
- chewing pens
How does abrasion present intra-orally?
V-shaped or rounded indents at the cervical margin of teeth.
Usually labial/buccal area, cervical on canines and premolar teeth.
Sharp margin at enamel edge where dentine is worn away preferentially.
Can manifest as notching on the incisal edge.
Usually caused by a toothbrush.
What is erosion?
Physiological loss of tooth substance by a chemical process that doe snot involve bacterial action
- most commonly from acid in the diet or systemic acid reflux.
Can be extrinsic or intrinsic.
How does erosion present intra-orally?
Early stages- enamel surface is affected, loss of surface detail and surfaces become flat and smooth.
- typically bilateral, concave lesions without chalky appearance of bacterial acid calcification.
Later lesions- dentine becomes exposed, cupping of occlusal surfaces of the molars and incisal edges of anteriors.
- restorations aren’t affected- they will usually stand high of the occlusal surface.
Increased translucency of incisal edges.
Loss of staining- acid is stripping it away.
Base of lesion not in contact with opposing tooth.
Altered taste
Halitosis
Caries
Sensitivity
If someone presented with palatal erosion on their upper incisors, what would you think?
Probably more of a systemic cause- alcoholics, bullimics, GORD, acid reflux.
What is abfraction?
Loss of hard tissue from eccentric occlusal forces leading to compressive and tensile stresses at the cervical fulcrum area of the tooth.
Likely to be multifactorial.
How does abfraction present?
V-shaped tooth loss where the tooth is under tension- classically sharp rim at the ACJ.
What aspects of patient history will tell you about the possible aetiology of their toothwear?
Find out the chief complaint- is it aesthetics, functional difficulties, pain?
Detailed medical history
- GORD
- Hiatus Hernia
- Medication that has a low pH
- Eating disorders
- Alcoholism
- Heartburn
- Rumination
- Pregnancy
Past dental history
- Previous attendance
- Previous treatment history
- Oral hygiene habits- important to determine this if abrasive lesions are present.
- Frequency, intensity, duration and the of toothpaste.
Social history
- Lifestyle stresses- bruxism
- Occupational details
- Alcohol consumption
- Dietary analysis
- Habits
What aspects should be examined?
Full E/O examination- muscular hypertrophy, TMJ tenderness, limited mouth opening, clicking/crepitus noises, parotid hypertrophy, lip Line, smile line, overclosure.
Occlusion- OVD, RVD, freeway space, overbite, overjet, stable contacts in centric occlusion, guidance.
Examine the soft tissues- linea alba, tongue scalloping, wear signs on the teeth.
Location and severity of the toothwear.
What wear indices might you use to monitor toothwear?
Smith and Knight
- 0- no loss of enamel characteristics
- 1- Loss of surface enamel characteristics
- 2- buccal, lingual and occlusal loss of enamel, exposing dentine for less than 1/3 of the surface. Incisal loss of enamel and minimal dentine exposure.
- 3- Buccal, lingual and occlusal surface loss for more than 1/3 of dentine. Incisal loss of enamel, substantial dentine exposure.
- 4- Buccal, lingual and occlusal complete loss of enamel, pulpal exposure or exposure of secondary dentine.
BEWE-
- 0- no erosive wear
- 1- Initial loss of surface texture
- 2- Distinct defect hard tissue loss less than 50% of surface
3- hard tissue loss greater than 50% of surface area.
Cumulative BEWE score determines risk level and treatment need.
What special investigations might you want to do?
Diet diary
Sensibility tests
6PPC
Articulated study models
Diagnostic wax up
Clinical photographs
Radiographs
In terms of treatment planning for wear cases, what is the first thing you should do?
Determine a diagnosis and causative factor.
Then plan a preventative regime.
- Important to have a scheme to be able to monitor the wear as well.
What prevention can be done or abrasion?
Change habits- stop biting nails, alter tooth brushing habits, change toothpaste.
GIC, RMGIC or composite restorations cervically so the patient wears through the material and not the tooth structure.
- RMGIC recommended.
What prevention can be done for attrition?
Generally related to a parafunctional habit.
Hypnosis
CBT
Splint- Upper Michigan splint provides an ideal occlusion with even centric stops- has canine rise which provides discussion in eccentric mandibular movements.
Soft splints can be used as a diagnostic device.
What prevention can be done for erosion?
Fluorides
Dietary management
Referral to GP for further investigation
Use a straw when drinking something acidic
Sports drinks/gels
Eating lots of acidic fruit
Gaviscon, Omeprazole
What prevention can be done for abfraction?
Fill cavities with RMGIC or flowable composite.
Consider occlusal equilibration.
What are the goals of active management of toothwear?
Preservation of remaining tooth tissue
Improvement to aesthetics
A functioning occlusion
Stability
What factors determine decisions on treatment for maxillary anterior tooth wear?
Pattern of anterior maxillary tooth wear
Inter-occlusal space
Space required for the restorations being planned
Quality and quantity of tooth structure left
Aesthetic demands of the patient
What categories are there that describe patterns of maxillary incisal wear?
Toothwear limited to palatal surfaces only
Toothwear involving the palatal and incisal edges with reduced clinical crown height
Toothwear limited to labial surfaces
Under what circumstances might there be enough inter-incisal space to provide restorations?
AOB
Overjet
Teeth wear rapidly and there has been no time for alveolar compensation
In most toothwear cases, what happens to maintain masticatory efficiency?
Dentoalveolar compensation
- to combat the fact that tooth structure is being lost, there will be dento-alveolar bone growth to maintain masticatory efficiency.
This is a good thing but it leaves no space for restorations to be placed.
How could you make space for restorations?
Increase the OVD- multiple posterior extra-coronal restorations.
Occlusal reorganisation from ICP to RCP
Surgical crown lengthening
Elective RCT and post crowns
Conventional orthodontics.
Dahl technique
What is the Dahl technique?
Method for gaining space in cases of localised toothwear.
originally a removable CoCr anterior bite plane but can also use composite on the palatal aspects of the anterior teeth.
Results in posterior disclusion and increase in OVD by 2-3mm.
- Anteriors intrude
- Posteriors erupt
Results in space between upper and lower anteriors allowing restoration with no need for occlusal reduction.
What are the advantages of the Dahl technique?
Conservative of tooth substance
Reversible
Repairable
Performed in a single visit
Relatively simple
What cohorts of patients are not suitable for the Dahl technique?
Active periodontal disease
TMJ problems
Previous ortho treatment
Bisphosphonates
Dental implants present
Existing conventional bridges
