Toothwear (ALL LECTURES) Flashcards
What are the steps in tx of toothwear?
Diagnosis (type of toothwear and identify cause)
Construct tx plan
Preventative Management
Active management
What is tooth surface loss?
Loss of tooth substance due to caries, trauma, toothwear, developmental diseases
What is non carious tooth surface loss?
Loss of tooth substance NOT due to caries - ie toothwear, developmental issues, trauma
What are the two main classifications of toothwear?
Physiological
Pathological
What is physiological tooth wear?
This is normal tooth wear that we expect as a person ages and is associated with normal function - normal tooth wear per year is 20-40 microns (normal wear expected at pts age)
What is pathological tooth wear?
This is tooth wear that exceeds the expected wear for the pts age or if pt is symptomatic (ie doesn’t like aesthetics or functional problems)
What are the types of pathological toothwear?
Attrition
Abrasion
Erosion
Abfraction
Combination
Aetiology Unknown
Why must we determine aetiology of wear?
If we dont known the aetiology then toothwear will continue to progress as we cant remove causative factor
we must know cause to reduce further wear and tx plan
can also be sign the pt requires further medical signposting (ED, acid reflux)
What is attrition?
Type of tooth substance loss due to tooth to tooth contact resulting in physiological wear
common in pts with parafunctional habits such as bruxism, clenching and grinding
Where is attritional commonly seen? 2
Incisal surfaces
Occlusal surfaces
What is early appearance of attrition? 2
Polished appearance, smooth facets on cusps
slightly flattened incisal egde
What is late appearance of attrition?
Flat incisal edges/occlusal surface
reduction in cusp height
loss of canine cusp resulting in teeth joining
What increases rate of attrition?
Lack of posterior support
Stress/anxiety
Deep OB or Edge to edge occlusion
What are common features in burixms?
Significant toothwear
root fracture in virgin teeth
Eraly onset and quick progression
cracks around restorations - fillings failing
Why can deep overbite cause attrition?
Deep OB results in attrition to palatal surface of upper incisors and labial wear of lowers
What is a sign of parafunction with no obvious wear?
Root fracture in unrestored teeth
soft tissue features - cheek, lips tongue chewing
cracks around restorations
What is erosion?
Loss of tooth substance due to chemical process (not bacterial) - teeth are chronically exposed to either intrinsic or extrinsic acid resulting in loss of tooth substance
What are the different intrinsic and extrinsic acids?
Intrinsic: GORD, Acid reflux, ED (bulimia), uncontrolled diabetes
Extrinsic: fruit juice, fizzy juice, sports drinks, citric fruits, sweets, drugs such as methanphetamines
What are the early stages of erosion?
Transpartent incisal edges - inc shine through of mouth
flat shiny smooth enamel, loss of surface detail
What are late stages of erosion?
exposed dentine
cupping - enamel is more mineralised than dentine so dentine preferentially dissolves leaving enamel ring and dentine cupping
How can we tel diff between erosion and attrition?
In attrition the deepest areas of wear touch
in erosion deepest aspect of wear is into dentine and this wont occlude
Do we get staining in erosion?
No as acid washes staining away
What are some signs of eating disorders?
Palatal erosion
Polished/shiny restorations
may have tongue lesion in centre of tongue due to tongue thrusting when throwing up
halitosis
altered taste
high caries rate (high calorie intake –> sick)
Signs of excess carbonated drinks?
Incisial erosion on upper teeth from bottle or can
Cupping on lower molars
Palatal erosion uppers
What is abfraction?
Theoretical concept
Force on tooth results in tooth flexing at area away from the point of load (cervical margin) and the tooth flexes which results in micro mechanical stresses on the enamel and can eventually lead to cyclic fatigue and enamel fracture
What is abrasion?
This is loss of dental tooth substance as a result of a foreign object in contact with the teeth (often a toothbrush but can be oral self harm such as toothpick, tongue stud or vape)
What is the pattern of abrasion like?
Depends on abrasive element - usually tends to be labially at cervical aspect and U or rounded lesuions on canines and pre molars
What is important in abrasion lesions?
Can modify behaviour and prevent wear progressing easily if pt is receptive
ask pt about Oh routing - brushing duration, frequency, type of toothbrush, type of toothpaste
What can abrasion be connected with?
Stress/axiety
MH conditions
ED - inc tendency to be sick so wanting to brush teeth for taste/cleaness
Where does abrasion form quicker?
Root surface
What is combination wear?
This is where we have combo of all 3 types of wear:
common in alcoholics, ED pts, mental health pts, poor diet pts, bruxist pts
Why may aetiology be unknown? Implications of this?
Pt may be embarrassed or unwilling to tell us cause and we cant identify It
proceed with tx with caution –> if causative factor not addressed then tooth wear willl continue to progress
What is important to note about the toothwear?
Is it
ACTIVE
HISTORIC
Difference between active and historic wear?
Active = ongoing tooth substance loss
Historic = prev tooth substance loss which has now arrested due to removal of causative factor (for example pt prev went through stressful period and now that has passed along with tooth wear) - easier to tx as it wont progress
In tooth wear what may pt C/O?
Aesthetics - short looking teeth, not visible when smiling
very rarely about function but may be
pain - sensitivity due to exposed dentine or if rapid then may have pulp exposure
Why do toothwear pts tend not get pain?
Slowly progressing and as protective mechanism tooth lays down tertiary dentine for pulpal protection
What medical reasons can lead to toothwear?
EDs - bullemia
Alcoholism
Medications with low pH
Medications causing xerostomia
GORD
Pregnancy (morning sicking and acid reflux)
What is important in relation to PDH of toothwear pt?
Attendance
Motivation
Prev tx experience
Toothbrushing routine
Why do we need to determine SH of toothwear pt?
Stress
Occupation
Diet
Habits
Sports - energy drinks, running gel, weightlifter
What do we assess in E/O exam of toothwear pt?
TMJ (may be sign of parafunctional habit)
LN (lympadenopathy)
MOM (hypertrophy?)
Asymmetry
Overclosure - are lips and nose getting closer
Smile line
What do we assess in terms of pts occlusion?
OVD = when pt is in maximum intercuspation
RVD = when pt at rest (say letter m)
FWS= RVD - OVD
Describe what would happen to OVD RVD and FWS in rapidly progressing toothwear
OVD would decrease
RVD increase
FWS increase
What happens to OVD RVD and FWS in slow progression toothwear?
In slow progression toothwear there is dentoalveolar compensation which is where posterior teeth over erupt to compensate for loss of OVD and as a result there is no change to OVD RDV or FWS
teeth get smaller but incisal edges stay in contact
What is the BEWE?
Basic erosive wear exam: sextant approach
0 = no erosive wear
1 = initial loss of surface texture
2 = erosive wear <50% of tooth hard tissue
3 = erosive wear >50% of tooth hard tissue
then add up and figure:
RISK:
NONE = < OR EQUAL TO 2
LOW = 3-8
MED = 8-13
HIGH - > OR EQUAL TO 14
What is the location of tooth wear?
Localised (anterior only)
Generalised - A and P
What SIs can we carry out in tooth wear?
Clinical photographs
Sensibility testing
radiographs
articulated study casts
diet analysis
What is the first line of tx in toothwear?
PREVENTATIVE MANAGEMENT
When may we have no loss of OVD but space available?
AOB
Class II Div I
What are the stages of a tx plan?
Immediate
Initial
Re-evaluation
Recon
Maintenance
What does preventative management do?
Prevents wear progressing
if we dont do it then it will progress and tx will fail
What are some generalised preventative measures?
Fluoride toothpaste - 2800 or 5000ppmF
Fluoride mouthwash - 225ppmF
Diet advice
OHI
Splinting (to prevent progression)
Referral to GP
How do we tx abrasion?
BEHAVIOUR MODIFICATION = due to foreign object (toothbrush etc)
need to establish pts current routine and modify this to prevent wear progressing
if pt cant modify behaviour or if behaviour is being modified we can do RMGIC restorations to replace loss of tooth substance - IT IS PREVENTION AS NO TOOTH PREP REQUIRED
Why do we use RMGIC for abrasion lesions?
Increased flexibility - when tooth flexes, GI will flex also with the tooth rather than fracture - it has low Youngs modulus
composite is brittle so not good option
How do we tx attrition?
Tooth to tooth often due to bruxism so need to look at management of bruxism
STRESS MANAGEMENT
SPLINT
What is the purpose of a splint?
Used in attrition cases
prevents further tooth surface loss as splint is worn rather than tooth
Relaxes muscles and take the load of the TMJ
What is the tx for erosion?
Modification of factors
If extrisinic - dietary changes
if intrinsic - refer to doctor
remember PPI rebound when pt comes off this drug!
How long does passive management last?
6 months before going to active tx
What is active tx?
This is where we
preserve remaining tooth structure
improve aestehtics
preserve function and stability
What is a simple restorative tx we can do in toothwear?
Covering of exposed dentine
DBA
Filling cupped defects
What is an extensive definitive restoration?
if there is tooth wear and further complications we can consider extensive restorative tx
What does the decision of tx depends on in anterior tooth wear?
Pattern of maxillary anterior wear
Inter-occlusal space
Space required for restorations
Quality and quantity of remaining tooth (enamel bonding)
Pts aesthetic demands
What are the patterns of anterior wear?
Palatal
Palatal and incisal
Labial
What is the tx of palatal wear?
Comp resin palatally - aesthetics not really issue
When may there be toothwear with adequate incisal space? 3
class II Div I
AOB
rapidly progressing wear
When may there be no increase in FWS
Slow progressing toothwear and dentoalveaolr compensation to maintain masticatory efficiency
What is the issue with tooth wear and dente-alveolar comp?
Leaves no room for restorative tx
What is the issues when we have no FWS and toothwear
Small amount of tooth tissue
poor retention due to short dial walls
inc risk of pulp damage as clinical crown short
Ways to create space?
DAHL
A AND P INDIRECT RESTORATIONS TO INC OVD
SURGICAL CROWN LENGTEHNING
ICP TO RCP
What is the Dahl technique?
this is where we gain space in localised toothwear cases by adding composite resin anteriorly at the incisal and palatal surfaces in order to create posterior disclusion (POB) which increases the OVD and then over course of several months dente-alveolar comp occurs and the posterior teeth erupt into the new occlusion resulting in occlusal harmony and space anteriorly
benefit is that the DAHL technique and definitive rest can be done at same time
6 months –> if not success then wont work
Contraindication of DAHL
Bisphpsphonates
Implants as ankyloses to bone
Active PD
TMJD
post ortho tx
What is the purpose of a face bow?
Records terminal hinge axis and intercondyalr distance
relates the maxillary base to condylar head and measures IC distance to accurately translate onto articulator in lab
What is issue with reduced posterior support?
Increased severity and progression of tooth-wear
Why do pts lack posterior support?
Denture intolerant
Denture Refusal
Supervised Neglect
What is an overdenture?
This is where we have a removable prosthesis that rests on one or more remaining natural tooth or roots
Advantages of overdenture?
Correction of occlusal and aesthetics (Bette than mix of natural and acrylic teeth)
Tooth support
Preserves ridge
Proprioception - force transmitted down long axis of tooth to PDL
MRONJ/ONJ prevention
psychological - hard to have all teeth gone
Eases transition to dentures
Disadvantages of overdenture
Needs excellent OH or teeth will get worse
Inc caries/PD problems
more pront to denture fracture as acrylic thinner
discomfort/infection
MH - can get moree difficult if teeth then need to come out and are very carious
May be more traumatic XLAs in end due to caries progression
When are over dentures good?
severe tooth wear where building up is impossible
prevents XLa of teeth in medically compromised pts
Prevents moving straight to denture
Increases OVD
What are transitional dentures?
This is where we provide pt with denture at an inc OVD and we add acrylic to anterior aspect to ensure stable occlusion and then see if pt tolerates this over 2-3 months –> if so then we can alter occlusion to new OVD but if not then remove and tx as is
What can we do for bruxism pts?
cobalt chrome backing on denture teeth onto incisal edge and palatally so teeth occlude on metal rather than acrylic which would fracture
How can we simplify small saddles?
Utilise bridgework for single tooth replacement - less likely to fracture than single tooth on denture anteriorly
What is the conformist approach?
This is where we provide restorative work to the existing occlusion so teeth occlude unaltered
it works when we have stable occlusion with index teeth and we conform to this
What is reorganised approach?
This is when we provide restorative work to. new, different pre planned occlusion when there is a lack of stable occlusion and index teeth
we must decide on OVD prior to tx and can use transition denture first to see if pt copes
used when tooth wear
lack of posterior teeth
How do we plan full mouth rehab cases?
U and L impressions
Facebow recording with Denar articulator
articulate casts on semi adjustable aritculator
take high quality inter occlusal record
diagnostic wax up
stent to show pt and provide temps
clinical photos
radiographs
How can we increase retention and resistance in small teeth?
Choice of material
grooves
ferrule
parallel preps
MCC
Electrosurgery
