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Case Pres > Toothwear > Flashcards

Toothwear Flashcards

1
Q

Which teeth have erosion?

A

Palatal aspect of 13-23
Incisal edge of 11 and 21
Occlusal surface of 46- cupping

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2
Q

Which teeth have attrition?

A

12, 11, 21, 22
Posterior teeth as well

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3
Q

What are the options for different splints?

A

Soft splint
Bilaminar splint (hydrid)
Hard splint- i.e. Michigan splint

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4
Q

What is the BEWE?

A

Basic erosive wear examination

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5
Q

What do the different BEWE scores represent?

A

0- no erosive wear
1- Initial loss of surface texture
2- Distinct defect, hard tissue loss less than 50& of the surface area
3- Hard tissue loss greater than or equal to 50% of the surface area

Use the most severely affected surface in a sextant and the cumulative score guides the management of the condition for the practitioner.

Based on the cumulative score, it determines a risk level and the appropriate management for this.

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6
Q

Give an analysis of the diet diary.

A

On quick glance there is quite a lot of sugar but not a lot of acid.

Sugar in coffee first thing in the morning.
Sugar in the latte at breakfast time.
Chocolate milk, Maltesers, chocolate biscuits.
Dr Pepper- this would be an extrinsic acid source.
More sugar in the latte.
Chocolate biscuits as a snack.
Heinz tomato soup- 4g of sugar in it.

Acidic aspects to the diet
- Dr Pepper
- Coffee and tea

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7
Q

Based off the diet diary, what advice did you give the patient?

A

Try to change the sugar in the coffee to sweeteners, same with the latte.

Cut down on the chocolate biscuits- try have them at meal times.

Try to only drink water in between meals- he said he doesn’t like water so I suggested drinking sugar free flavoured water and drink it through a straw.

Also suggested an air up bottle- plain water but flavoured pods with no added sugar.
- He said that sounded good and he would try that.

He said he wasn’t willing to give up his Dr Pepper, so I suggested drinking the sugar free Dr Pepper and drink through a straw, make sure to only have it at meal times.

It has also been suggested that eating a day product after eating an acidic drink/food may neutralise the acid.

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8
Q

Is the patient’s toothwear likely to be from an extrinsic or intrinsic source?

A

Intrinsic.
- potential gastric reflux and inhaler contributing as well.

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9
Q

What does the BEWE score tell you in terms of treatment plan?

A

This patient’s cumulative score is 10- this puts them in the medium risk category.

Oral hygiene and dietary assessment and advice
Identify the main etiological factor for tissue loss and develop strategies to eliminate respective impacts

Consider fluoridation measures or strategies to increase the resistance of tooth surfaces

Monitor erosive wear with study casts, photographs and silicone impressions

Monitor at 6-12 month intervals

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10
Q

Why did you choose to use study casts?

A

As a method for monitoring the toothwear and to allow fabrication of a stent.

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11
Q

What splint did you choose to use and why?

A

Soft splint-
- Can be used as a diagnostic device, get the patient back in 6 weeks and see where the wear is on the splint.
- Preferentially wears the splint rather than the teeth.
- May function as a habit breaker.
- Cause no damage to opposing teeth.
- Generally tolerated well.

Bilaminar splint- hydrid.
- Soft inner layer and hard outer layer.
- Inside is ethylene vinyl acetate.
- Cheaper than hard splints.
- Tolerated better.

Michigan splint-
- Hard splint.
- Provides a balanced and even centric occlusion.
- Has canine rise, provides disclusion in eccentric mandibular movements.
- Technically demanding to make and not tolerated well by patient.
- More expensive.

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12
Q

How does erosion typically present?

A

Early stages- enamel is affected, loss of surface detail, surfaces become flat and smooth.

Bilateral concave lesions without chalky appearance of bacterial acid calcification.

Dentine involvement later on- dentine becomes exposed.
- leads to cupping of the occlusal surface and incisal edge.
- Increased translucency of incisal edge.

Restorations aren’t affected- they tend to stand proud of the occlusal surface.

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13
Q

How does attrition typically present?

A

Flattened cusps
Wearing down of incisal edge
Reduction in cusp height
Restorations are worn down as well as the tooth surface.

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14
Q

What clinical features of the teeth that have erosion, make you think it is erosion?

A

Loss of palatal enamel on 13-23- exposing dentine.
Incisal edge cupping on upper anteriors.
Cupping seen on the occlusal surface of lower posteriors.

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15
Q

What is attrition?

A

Pathological toothwear that is caused by tooth to tooth contact.

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16
Q

What is erosion?

A

Pathological toothwear that is caused by acid but not from acid that comes from bacterial action.

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17
Q

What are the extrinsic and intrinsic sources of erosion?

A

Intrinsic is within the body
- Acid reflux
- Heartburn
- GORD
- Vomiting
- Hiatus Hernia

Extrinsic is outwith the body
- Diet
- Alcoholism
- Sports drinks
- Medications which dry the mouth

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18
Q

Describe the patient’s occlusion.

A

Class II Div 2
Deep overbite
Retroclined upper incisors
Retroclined lower incisors
Overjet slightly reduced

19
Q

What measurements did you take prior to providing the incisal restorations on 11 and 21?

A

Check for canine guidance- get the patient to move the mandible during lateral excursion and see of there is guidance.

OVD, RVD and freeway space.

Stable contacts in centric occlusion- yes.

Inter-occlusal space for the restorations anteriorly- yes.

20
Q

How would you classify this toothwear?

A

Localised
Anterior-posterior
Into dentine on most teeth

21
Q

What is the primary causative factor here?

A

I think erosion from an intrinsic source.

22
Q

What is the first stage of treating a wear case?

A

Prevention.

23
Q

What aspects of prevention have you implemented into this patient’s treatment plan?

A

Need to monitor the toothwear
- Clinical photographs
- BEWE
- Study casts

Must remove the cause of the toothwear
- Attrition- splint
- Erosion- referral to GDP, suspicion of intrinsic cause, diet analysis, fluoride supplementation.

24
Q

What fluoride supplementation could you provide the patient with?

A

Duraphat toothpaste- 2800ppm toothpaste
Fluoride varnish- but patient is asthmatic so would need to check this.
Tooth mousse- CPP-ACP

25
Q

How would you describe this patient’s pattern of anterior toothwear?

A

Toothwear involving the palatal and incisal edges with reduced crown height.

26
Q

Decision on treatment and restoration of maxillary anterior toothwear depends on 5 factors, what are these?

A

Pattern of anterior maxillary toothwear

Inter-occlusal space- this is fine in this case

Space required for restorations

Quality and quantity of remaining tooth tissue

Aesthetic demands of the patient.

27
Q

If there wasn’t enough inter-occlusal space, what technique could you use?

A

Dahl technique

28
Q

What features of remaining enamel would you look for to determine bonding ability of composite?

A

You need enamel to bond to composite- look for the ring of confidence of the remaining enamel.

29
Q

What options are there for composite build up of anteriors?

A

Direct build up with a putty matrix based off a wax up
- Take impressions of the teeth, cast them and have them articulated, diagnostic wax up and then take a putty matrix of this and use this as a template to build up the teeth.

Clear vacuum formed splint
- alginate impression, diagnostic wax up, impression of this poured in stone, make a vacuum formed splint from this and use as a mould.

30
Q

What information must you give to patients before providing a restoration for the incisal edge?

A

You are going to receive tooth coloured fillings to cover the exposed and worn tooth surface.
- This will help with preventing the tooth from wearing down more.

Improvement in appearance will also occur.

Change in appearance of the front teeth may cause lisping for a few days.

Front teeth may feel tender to bite on.

Potential for restoration to debone and fall off.

Composite is prone to staining over time and they will need replaced, may also chip or debone as well.
- This will all come at a cost to the patient.

No tooth destruction during replacement.

31
Q

Why did you provide a splint in a patient that is known to have erosion?

A

On balance, I felt that the benefits outweighed the risks for this.

The erosion, we don’t know if this was a historic issue or whether it is still active but we are taking the steps to try improve this by getting the patient referred to GDP for potential systemic help with this and we are closely monitoring the erosive toothwear to determine if it is being maintained or getting progressively worse.

I felt it was important to prevent the attrition from getting worse because this works synergistically with the erosion and that if I didn’t provide a splint then this might make the toothwear worse.

So on balance, I felt it was justified.

32
Q

What might the GDP provide the patient with, if it is determined to be an intrinsic cause of erosion?

A

Proto pump inhibitor- omeprazole, lansoprazole.
Antacid- gaviscon.
- Alakali- so they neutralise the stomach acid.

33
Q

What is a PPI and an antacid?

A

PPI is a proton pump inhibitor.
- They inhibit acid secretion from the stomach, specifically from the parietal cells within the stomach.

Antacid- alkali that neutralises the acid that is already released.
- Aluminium hydroxide and magnesium carbonate.

34
Q

What materials are soft and hard splints made from?

A

Soft- rubber
Hard- acrylic

35
Q

Which teeth are showing signs of gingival recession?

A

16, 13, 23, 26, 37, 36, 46 and 47.

36
Q

What factors would make you think the gingiva have receded?

A

The gingivae is now below the CEJ.

37
Q

Where can you see calculus deposits on the radiograph?

A

Mostly seen on the bitewings but can also be seen on the OPT in some areas.

38
Q

If the patient is placed on omeprazole, what do you need to bear in mind?

A

May interact with methotrexate, clopidogrel or dipyridamole.

39
Q

What are the potential side effects of omeprazole?

A

Abdominal pain, constipation, nausea, DRY MOUTH, headache.

May cause leucopenia (deficiency of leukocytes) or thrombocytopenia (deficiency of platelets).

Be wary of using NSAID’s- particularly because of his asthma and also because of the potential peptic ulceration.

40
Q

What instructions would you give the patient after fitting a splint?

A

Ensure you brush your teeth thoroughly.
Place the splint in place and make sure it is fully seated.
Wear it every night while you sleep.
Remove it in the morning- rinse in cold water.
Place in solution to clean for 10-15 minutes and rinse throughly- sterodent.
Can also use a toothbrush with soap to remove bacteria as well.

41
Q

What would you look for when monitoring the toothwear?

A

BEWE- any change in the BEWE classification
Cupping of cusps and incisal edges
More teeth involved than before
Loss of more enamel/dentine
Patient becomes symptomatic

Use BEWE, study casts, clinical photographs.

42
Q

What is GORD?

A

Gastro-oesophageal reflux disease- stomach contents are regurgitated back ip the oesophagus and into the oral cavity.
- Can be due to too much acid being secreted, defect in the upper oesophageal sphincter.

43
Q

What other wear indices could you have used?

A

The toothwear index- Smith and Knight.
The anterior clinical erosive classification- this tool was aimed to be easier to use than the BEWE.

Case Pres (7 decks)

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