Toothwear part 1 Flashcards
3 causes of NCTSL?
- Trauma
- Developmental problems
- Toothwear
What are the 2 types of tooth wear?
- Physiological increases with age (normal rate)
- Pathological - fast rate
What are the 4 causes of tooth wear?
- Attrition
- Abrasion
- Erosion
- Abfraction
Define attrition?
The physiological wearing away of tooth structure as a result of tooth to tooth contact
Where is attrition found?
Occlusal and incisal contacting surfaces
5 intraoral signs of attrition?
- Flattening of incisal edges
- Facets on a cusp
- Reduction of cuspal height
- flattening of occlusal inclined planes
- Wear of restorations at the same level of toothwear
To what is attrition mostly related?
Parafunctional habits (bruxism)
What is abrasion?
The physical wear of tooth substance through an abnormal mechanical process independent of the occlusion such as abrasive toothbrushing
What is most common site of abrasion?
- Labial/buccal , cervical on canine and premolar teeth
What is the most common cause of abrasion?
tooth brushing , also related to habits and lifestyle
What 4 intraoral signs of abrasion?
- V shaped or rounded lesions
- Sharp margin at enamel edge where dentine is worn away preferentially
- notching of the incisal edges
- Gingival recession
What is erosion?
The loss of tooth surface by a chemical process that does not involve bacterial action due to exposure of dental hard tissue to acidic substance
What is the most common cause of pathological toothwear?
Erosion
6 intraoral signs of erosion?
- Loss of surface detail and flattening of surfaces (early)
- Bilateral concave lesions that are not chalky
- Cupping of occlusal and incisal surfaces due to dentine wear
- Increased translucency of incisal edges
- Direct restorations stand proud of the tooth
- No tooth staining
What is abfraction?
The loss of hard tissue from eccentric occlusal forces leading to compressive and tensile stresses at the cervical fulcrum areas of the tooth
Explain how abfraction occurs?
- Biomechanical loading forces result in flexure of enamel and dentine at areas away from the loading
- leads to disruption enamel and dentine crystallite structure by cyclic fatigue
- Resulting in cracks in tooth substance which causes it to chip out
What are the 2 theories related to abfraction?
- it is the basic cause of all non carious cervical lesions
- A combination of occlusal stress, abrasion and erosion
3 intraoral signs of abfraction?
- V shaped tooth loss where the tooth is under tension
- Sharp rim at the amelocemental junction
- Mainly in buccal of premolar and molar area
How many of adults have some wear on their anterior teeth involving dentine?
77%
Who is affected the most from tooth wear , males or females?
Males
What information should you gather from a toothwear patient regardung their toothbrushung?
- Frequency
- Intensity
- Duration
- Type of toothpaste
What is important to gather from toothwear patient social history?
- Stress - bruxism
- Occupation
- Alcohol
- Diet analysis
- Habits
- Sports
What occlusal records should you gather from a toothwear patient during examination? 6
- Freeway space
- Dento-alveolar compensation
- Overbite
- Overjet
- OVD
- Resting face height
- Contacts in centric relation
What 3 things you should note about soft tissues when examining a toothwear patient?
- Xerostomia
- Buccal keratosis
- Lingual scalloping
What are 2 indices that can be used for toothwear?
- Smith and Knight
- BEWE
What 6 special tests would you carry out for a toothwear patient?
- Radiographs
- Articulated study models
- Intra-oral radiographs
- Diagnostic wax ups
- Dietary analysis
- Sensibility testing
What are three types of generalised toothwear?
- Wear with loss of OVD
- Wear without loss of OVD but with space available
- Wear without loss OVD but with limited space
What 2 things should you take into consideration when diagnosing toothwear?
- Pattern of tooth wear
- Dento-alveolar compensation
What 3 basline recordings would you do for a toothwear patient for monitoring?
- Study models
- Clinical photos
- Wear indices : Smith and Knight and BEWE
How can you prevent abrasion? 3
- Change toothpaste if abrasive
- Alter tooth brushing habits
- advice on changing habits such as nail biting , wire stripping, piercing biting etc..
- Simple cervical RMGIC, GIC or composite restoration
What material have the best survival rate for filling abrasion cavities?
RMGIC
Why would a composite restoration not be as good as an RMGIC restoration for an abrasion cavity?
- Its higher modulus may compromise its retention
- because composite is sensitive to moisture
2 methods for prevention of attrition?
- Manage parafunctional habit by CBT or hypnosis
- Splints
what is the difference between a hard splint and a soft splint?
- Hard splint more robust and can used long term
- Soft splint can be used as a diagnostic device as will show signs of wear
Why is Michigan splint a good choice for preventing attrition? 3
- It is a hard splint
- provides Ideal occlusion with even centric stops
- Has a canine rise which provide disclusion in eccentric mandibular movements (canine guidance)
What are the two sources of acids that may cause erosion?
Intrinsic and extrinsic
4 methods to prevent erosion?
- Fluoride use (toothpaste, varnish, mouthwash)
- Dietary management
- Habit changes : rumination, swilling drinks etc..
- Control gastric acid
Give 3 advice you would give to a patient who drinks carbonated drinks to prevent erosion?
- Avoid swilling drinks around mouth
- Use a straw instead of drinking from cans
- Try to avoid drinking as can cause erosion or at least keep it to meal times only
4 medical causes of erosion?
- GORD
- Reflux
- Hiatus hernia
- Anorexia and bulimia
What would you do if erosion is caused by a medical problem?
- consult patient general medical practitioner
- May require to refer to specialist after that
- you must gain consent
Who would you refer a GORD patient to prevent erosion?
Gastroenterologist
Who you would refer an anorexic/bulimic patient to prevent erosion?
- Psychiatrist or Psychologist
How would you prevent further abfraction
- Assess occlusion on teeth with abfraction cavities and consider occlusal equilibration
- Fill cavities with RMGIC, Flowable composite
How long would most patients be in the passive management phase for managing their tooth wear?
6 months
When do you progress to active management of toothwear? 3
- Wear leading to further complications
- unacceptable aesthetics
- complicated future treatment without intervention
What are 4 goals of active management of toothwear?
- Preservation of remaining tooth structure
- Improve aesthetics
- occlusal function
- Stability
What 5 factors contributes to the decision on managing maxillary anterior toothwear?
- The pattern of tooth-wear
- Inter-occlusal space
- Space required for restorations
- Quality and quantity of remaining tooth tissue (enamel)
- The aesthetic demand of the patient
What are 3 categories of anterior maxillary tooth wear pattern?
- limited to the palatal surface
- involving palatal and incisal edges with reduced crown height
- limited to labial surfaces
In what cases there is available space for restoration of maxillary anterior toothwear? and easiest to treat?
- Increased overjet
- anterior open bite
Why is there no increase in freeway space in most cases although tooth wear has occured ? and what is the disadvantage of this in managing toothwear?
- Dentoalveolar compensation, because it leaves no space for restorations to be placed
Give 4 different ways to create space for upper anterior toothwear cases ? other than the DAHL technique
- Increase OVD through posterio indirect restorations (unorganised approach)
- Occlusal reorganisation from ICP to RCP
- Elective RCT and post crowns
- Orthodontics
What is involved in surgical crown lengthening?
- exposes more crown to aid retention of restorations
- Reposition the gingivae apically
What are 2 disadvantages of crown lengthening?
- Sensitivity
- Still need occlusal reduction
What is the DAHL technique
- Method of gaining space in cases of localised anterior toothwear
- Using a removable CoCr anterior bite plane (carried out with composite now)
*Covering palatal surfaces and allowing occlusion on raised cingulum - Resulting in posterior disclusion and increase of 2-3mm in OVD
- Posteriors erupt into occlusion and anteriors intrude over a period of 3-6 months
- This results in space between incisor teeth to place restorations
4 reasons why composite is a better choice than Cocr for DAHL technique?
- Easier to adjust
- Better aesthetics
- Better compliance
Success rate of DAHL technique?
90% and above
6 contraindications of DAHL technique?
- Active periodontal disease
- TMJ problems
- Post orthodontics
- Bisphosphonates patients
- Conventional bridgework
- If dental implants exist
What 2 things reduce the success rate of managing anterior wear?
- Short roots
- Periodontal disease leading to poor periodontal support
What is the ring of confidence?
- when there is remaining enamel in managing anterior wear which has a positive effect on retention
give a reasons why is managing lower anterior tooth wear more difficult than upper?
- Less enamel
- Small bonding area
Which teeth will you build up first , the uppers or the lowers?
Lowers
PS . do not increase OVD with lowers
2 restorative management of occlusal posterior wear?
- Fill posterior lesions with composite
- Restore canine guidance by adding composite to the palatal of the upper canines to provide posterior disclusion in lateral movements
2 methods of composite build ups?
- Alginate impressions -> wax up -> putty matrix
- Alginate impression > diagnostic wax > poured in stone> vacuum formed clear plastic matrix > cut to size and use as mould
Why do maxillary anterior restorations last better than mandibular ?
- Increased bonding area
Why is maxillary anterior tooth wear more common than lower?
Tongue and saliva protects the lowers
What 3 information would you give to a patient recieving composite build ups for anterior teeth to gain consent before treatment?
- Your front teeth will receive tooth coloured fillings to cover worn teeth this will prevent them from wearing more
- This Procedure will be carried out without LA as there will be no to minimal drilling to your teeth
- your bite will feel strange for a few days and you may have difficulty chewing this will get better over the next week
- Your front teeth may feel a little tender to bite on for few days
- you may have lisping due to this for few days
- if you have crowns or bridges or partial dentures they will have to be replaced
Additional information you would give to the patient?
- Initially you will have to cut your food into small pieces to help swallowing and digestion
- Your back teeth will come back together in 3-6 months as only your front teeth will be touching
- The restorations will require regular maintenance
What is the least common catagory of generalised toothwear and the easiest to treat?
Excessive tooth wear with loss of OVD
Treatment of generalised toothwear with loss of OVD?
- increase face height with permanent direct or indirect restorations
- Half mandible / half maxillary for OVD increase
What you may provide the patient with for posterior support after increasing the ovd for generalised tooth wear?
Dentures
How can you assess the patient tolerance to the new OVD before going ahead with restorations
Provide a splint
What approach would you take to manage excessive generalised tooth-wear without loss of OVD but with limited space available?
Reorganised approach
with minimal preparation adhesive restorations
What is the most severe type of toothwear and the most difficult to treat?
Excessive tooth wear without loss of OVD with no space available
Treatment options for excessive toothwear without loss ovd with no space available?
- Attempt to increase OVD by splints ± dentures
- Crown lengthening surgery
- Elective endodontics
- Orthodontics
- Overdentures
3 Disadvantages of crown lengthening?
- Unfavourable crown to root ratio (more chance of mobility)
- Post op sensitivity
- Black triangles between the teeth due to ID papilla is further down
Give 1 advantage of over-dentures for treatment of tooth wear?
Preserve tooth substance and bone
Give 2 disadvantages of over-dentures for treatment of tooth wear?
- can be bulky for patient
- difficulty cleaning underneath
RCS guidance for toothwear treatment
Risk management in toothwear
