Toothwear II

Question 1

How is erosion defined?

Answer 1

Chemical dissolution of dental hard tissues by acids of non-bacterial origin.

Question 2

What is the difference between intrinsic and extrinsic erosion?

Answer 2

Intrinsic erosion: caused by gastric contents in the mouth

Extrinsic erosion: caused by either diet or environmental factors

Question 2

What are some examples of environmental factors that can cause extrinsic erosion?

Answer 2

Acid fumes in factories (very rare for erosion to be caused in this way)

Inadequately maintained gas-chlorinated swimming pools (also very rare)

Dietary acid consumption is more common in causing extrinsic erosion

Question 3

What diet information do you need from your patients?

Answer 3

The specific dietary acids

How often they are having them (frequency)

When they are having it, with meals, between meals etc. (timing)

How much of the acid they’re having (quantity)

How long they are having it for (duration)

Habits associated with intake (habits)

Question 4

What can stop acidic food/drink from damaging the enamel?

Answer 4

Calcium and phosphate

Question 5

How can the timing of dietary acid intake cause tooth wear?

Answer 5

Fruit with meals= no increased risk

Fruit outside of meals: 1 per day= 1.95x more likely to get tooth wear; 2 per day= 5.35x more likely to get tooth wear

Acidic drinks with and outside of meals showed increased risk of tooth wear

Acidic drinks with meals: 1 per day= 1.81x more likely; 2 per day= 6.42x more likely

Acidic drinks outside of meals: 1 per day= 2.49x more likely; 2 per day= 11.84x more likely

Question 5

What frequency of dietary acid intake can cause tooth wear?

Answer 5

If you have 2 acids per day, your risk of having tooth wear is 2.33x greater than someone who doesn’t

If you have 3 acids per day, your risk of having tooth wear is 13.5x greater than someone who doesn’t

Question 6

How can the quantity of dietary acid intake cause tooth wear?

Answer 6

There is limited data on whether quantity vs frequency is the important thing but generally, increased quantity is associated with erosive tooth wear.

Question 7

How does the duration of the dietary acid in your mouth influence tooth wear?

Answer 7

look at the slide

Question 8

In terms of intrinsic erosion, what are the 2 types?

Answer 8

Voluntary: Vomiting eating disorders

Involuntary:
-Reflux
-Rumination
-Chronic alcoholism
-Vomiting due to pregnancy/ pregnancy reflux
-Heavy abdominal exercise

Question 9

Describe the anatomy of the oesophageal tract.

Answer 9

-muscular 25cm muscle with sphincter at each end.

-Upper sphincter composed of strained muscle

-As you descend there is a change from squamous cells to columnar cells = important because it’s a common site for malignant transformations

look at the slide

Question 10

How can movement of gastric contents occur?

Answer 10

Either because the lower oesophageal sphincter isn’t tight, or because of motility disorders:

-Transient relaxations of the lower oesophageal sphincter
-Incompetent sphincter
-Abnormalities of peristalsis
-Hiatus hernia

Question 11

When does the gastric-oesophageal reflux occur?

Answer 11

When the oesophageal pressure is lower than the intragastic pressure

Question 12

What is the definition of reflux?

Answer 12

Mild heartburn and/or regurgitation occurring at least 2 days per week or moderate/severe heartburn and/or regurgitation occurring at least 1 day per week should lead to a symptom based diagnosis of GERD (gastro-oesophageal reflux disease).

Question 13

What should you do if you suspect an eating disorder?

Answer 13

• Refer to GP - only with their permission

Question 13

What are the symptoms of reflux?

Answer 13

-Heartburn
-Regurgitation
-Difficulty swallowing
-Tooth wear
-Chest pain
-Chronic cough
-Sore throat/alteration of voice/hoarseness
-Globus (feeling of lump in throat)

Question 14

How common are eating disorders in the UK?

Answer 14

1 in every 88 adults in UK have an eating disorder, 11% are male

6.4% of adults show signs of a eating disorder & 25% of those are male

More likely to drink diet soft drinks which can mask vomiting erosive wear

Question 15

What are the NICE guidelines for helping someone with a vomiting eating disorder?

Answer 15

Have regular dental and medical reviews

Avoid brushing teeth immediately after vomiting

Rinse gently with non-acid fluoride mouthwash

Avoid highly acidic food and drinks

Question 16

How does fluoride affect erosive tooth wear?

Answer 16

Residual fluoride from brushing teeth did not reduce erosive tooth wear

High dose fluoride reduced erosive tooth wear in enamel but not dentine

Stannous fluorides more effective at preventing erosion

Question 17

How can toothbrush abrasion lead to tooth wear?

Answer 17

look at the slide

Question 17

How could you encourage remineralisation?

Answer 17

-Stannous fluorides are more effective

-High dose fluoride varnish

-Regular use of fluoride

Question 18

How does abrasivity of toothpastes affect tooth wear?

Answer 18

The more abrasive the toothpaste, the greater the wear

The lower the RDA value, the less abrasive it is

Avoid whitening toothpastes since they’re more abrasive, especially around dentine

Question 18

How does the type of toothbrush affect tooth wear?

Answer 18

It was previously thought that hard toothbrushes cause more wear but recent studies suggest that softer toothbrushes retain more toothpaste and as a result, increase tooth wear.

Question 19

What has been observed about toothbrushing after eating?

Answer 19

Delayed toothbrushing after eating was associated with increased tooth wear

However, brushing within 10 minutes of eating/drinking a dietary acid was associated with erosive wear but not when the frequency of dietary acids were fully controlled for.

Question 20

What are the actions of saliva?

Answer 20

-Dilutes the acid
-Assists with oral clearance
-Buffers the acid with minerals
-Salivary pellicle acts as physical barrier against erosion
-Remineralising effect of saliva unclear

Question 20

What advice should you give to a patient with xerostomia?

Answer 20

-Diet advice regarding acids and sugars
-Sugar free chewing gum to stimulate the saliva
-Prescribe high fluoride toothpaste and supplemental fluoride mouth rinse
-Advise to keep sufficiently hydrated and drink fluids throughout day

Question 21

What does attrition look like in teeth?

Answer 21

Very flat surfaces (due to heavy bruxism)

Attrition is usually associated with an acidic cause

look at the slide

Question 21

What is normal occlusal force in the mouth?

Answer 21

27kg is normal force for last occlusal contact before swallowing

42kg at higher end of the scale

Question 22

At what forces does attrition occur?

Answer 22

-Lower loads are strongly influenced by the amount of lubricant in the mouth

-Dry teeth will start to wear at <10 kg

-Saliva-lubricated teeth will start to wear at >14kg

-Dentine wears greater than enamel at smaller loads; at greater loads they are the same

Question 23

How is attrition affected when acid is also present?

Answer 23

It will greatly increase the amount of attrition that will occur:

A short exposure to a dietary acid increases rates of enamel attrition

On dentine, citric acid exposure prior to abrasion resulted in 60% more wear

There is a smoothening effect on enamel as acid can dissolve any abrasive tooth remnants

Question 24

What preventative advice would you give to someone with attrition (bruxism)?

Answer 24

-Avoid frequent intake of acid food or drinks

-keep acidic drinks to mealtimes and limit number of fruit drinks.

-Do not brush immediately after vomiting

-Advise patients to seek medical assistance for GORD and eating disorders.

-Ensure regular medication is acid free and be aware of medications that reduce saliva flow and thus impact on clearance

Question 25

How do you identify active erosive tooth wear as opposed to inactive tooth wear?

Answer 25

It’s considered that if the tooth looks shiny, and there’s a lack of staining, that is active tooth wear

look at the slide

Question 25

Tips for minimising risk:

Answer 25

-ETW should be part of every routine oral health assessment to avoid a missed diagnosis.

-Routinely record ETW using BEWE alongside BPE and document preventative advice given.

-Patients should be fully informed about condition to be able to provide valid consent.

-Patients need to understand importance of looking after their own oral health