TOOTHWEAR PART 2 Flashcards
What is the aetiology of toothwear?
- attrition
- erosion
- abrasion
- combination of above
- unknown
Why is knowing the aetiology of a patients toothwear important?
- attempt to reduced further wear
- plan for problems, contingencies & failure
- allow you to be realistic with yourself & pt
- identifies wider medical & wellbeing issues
- prognostic indicator
What can attrition be split into?
- physiological wear
- bruxism
What are modifying factors of attrition?
- lack of posterior teeth
- occlusion
- restorations
- erosion & abrasion
- stress & anxiety
what are common clinical features seen in bruxism patients?
- significant wear throughout dentition
- repeated restoration failure
- root fractures
- often onset in early adulthood
- progressive
How can you decide if toothwear is physiological or pathological?
Is the toothwear what you would expect of a patient at that age??
- if NOT… suspect pathology (eg bruxism)
A patient has lack of posterior support in their mouth, what common toothwear features are seen?
- extensive anterior wear
- progresses rapidly
What restorations/material can make toothwear WORSE?
Porcelain restorations!
- you will see significantly worse wear than you would expect if dentition was opposed by natural teeth
What are signs that a patient may have a parafunctional habit, even if there is no obvious toothwear present?
- multiple cusp fracture
- multiple cracks around restorations
- root fractures in unrestored teeth
What modifying factors affect the rate of erosion in patients’ mouths?
- lifestyle
- amount & frequency of acid intake
- level of control
Give examples of extrinsic factors that can increase rate of progression of erosion?
- carbonated drinks
- acidic drinks (eg sports drinks)
- acidic foods (eg pickles)
- drugs
Give examples of intrinsic factors that can increase rate of progression of erosion?
- eating disorders
- GORD
- other medical conditions
What are common erosion features seen in patients with a high carbonated drink intake?
- incisal erosion of upper centrals
- cupping on lower molars
- palatal erosion of upper incisors
- sensitivity
- interproximal caries & buccal white spots/brown caries
What are common erosion features seen in patients with an eating disorder?
- palatal erosion of upper anteriors
- polished restorations
- erosion around restorations
- sensitivity
- caries
- halitosis
What are examples of factors that can cause abrasion?
- toothbrush abrasion
- oral self harm
- tongue studs
- unusual habits
If a patient presents with toothwear abrasion what should you do?
- brushing technique instruction
- find out if its as a result of stress/anxiety?
What are common combinations of NCTSL that you may see in pts with alcoholism & drugs abuse?
Erosion + Attrition + Abrasion
What are common combinations of NCTSL that you may see in pts with an eating disorder?
Erosion + Attrition + Abrasion
What combination of NCTSL may you see in pts with a bruxism habit & poor diet?
erosion (extrinsic) & attrition
Why can uncovering toothwear aetiology when history taking be challenging?
You may uncover:
- eating disorders
- undiagnosed diabetes
- mental health issues
- GI issues
- abuse/harm/addiction
- vulnerable adult/child
What preventative advice can you give to patients with toothwear?
- Fluoride: high dose tp & alcohol free mouthwas
- Dietary modification
- Remineralisation: tooth mousse
- Sugar free gum?
Where can we signpost patients with severe toothwear related to habits/stress/suspected medical disorders?
- CBT
- hypnotherapy
- GMP
- psychiatrist
- social services
Why might patients have a lack of posterior support?
- denture intolerance
- denture refusal
- supervised neglect
Why should you try to avoid complete dentures in bruxist toothwear patients?
Bruxism does not stop!
- fractured dentures
- ridge resorption
- pain & ulceration under denture
what is an overdenture?
Any removable prosthesis that rests on one or more remaining natural teeth, the roots of natural teeth and/or dental implants
What are some advantages of using overdentures?
- correction of occlusion & aesthetics
- support
- toothwear management
- preservation of ridge form
- increased proprioception
- denture retention
- avoids extractions
- psychological benefits
- eases transition to edentulism
What are some disadvantages of overdentures?
- NEED good oral hygiene
- increased caries/perio risk
- denture fracture
- discomfort/infection
How should overdenture patients be cared for?
- ensure good OH
- fluoride toothpaste application to remaining teeth/roots
- regular exams/radiographs
- ensure good denture hygiene
What is the function of transitional dentures in toothwear pts?
Transitional dentures can increased OVD in cases where poor posterior support to create space for restorations
What change is there between conforming to a pts occlusions vs rehabilitating a pts occlusion?
Conforming = OVD stays the same
Rehabilitation = OVD is changed
What planning/clinical steps are required in tooth wear rehabilitation patients?
- impressions & facebow
- mounted articulated casts on semi-adjustable articulator
- high quality interocclusal record
- diagnostic wax-ups
- stents for build-ups
- clinical photographs
Why is tooth preparation in tooth wear cases difficult?
- lack of occluso-gingival height
- lack of occlusal space
- severly compromised tooth
Why do we need to modify preparations in tooth wear patients when aiming to restore?
creating retention & resistance in small teeth
What are some examples of modified preparations performed in restorative work of tooth wear pts?
- grooves
- inlays
- ferrule
- parallel preps
- cores
- electrosurgery
- surgical crown lengthening
What material do we tend to use in tooth wear pt biting surfaces?
metals!
- to prevent fracture
How can electrosurgery be used in toothwear patients restorative treatment?
Electrosurgery used to remove gingiva and lengthen appearance of tooth crown (creates ferrule of sorts) to allow restorative work
If you are using a metal crown, what margin preparation should you have?
metal margin = chamfer
If you are using a porcelain crown, what margin preparation should you have?
porcelain margin = shoulder
Why should porcelain preps be curved and smooth in toothwear pt?
To prevent crack propagation of porcelain, especially in pt with increased occlusal load/parafunction
How long does it roughly take for gingiva to stabilise after crown lengthening surgery?
About 3 months
What problems are sometimes associated with silver points used for root filling?
They can become corroded
- very difficult to remove once this happens
What bur should be used for cutting porcelain when removing restorations?
Coarse diamond bur
What bur should be used for cutting metal when removing restorations?
Gold cutting bur (these cause loads of vibration)
Describe the steps of removing an indirect restoration such as a crown/bridge:
- cut whole way up buccal surface with bur
- use chisel to split things apart
- ensure high volume suction
What problem may arise when removing an indirect restoration with instruments such as enamel chisel or sliding hammers?
High risk of core fracture
Before removal of an indirect restoration that to plan to replace long term, what clinical procedure should you carry out?
Take a pre-op impression so you can make a temporary restoration for in between appts.
What can be used to soften gutta-percha during re-RCT?
Eucalyptus/Turpentine oil
What must we determine before removing a post from a pt tooth?
- is there a fracture risk?
- how easy will the removal be
- have plan in place in case of fracture
- is there other pathology within tooth?
Effective communication is important in managing patients with failing dentitions. Give examples of aspects of effective communication:
- effective listening
- honesty & transparency
- seeking advice
- listen to pt wishes
- documenting discussions
- time & patience
Outline the SPIKES protocol for giving bad news:
Set up the interview: mental & physical preparation
Perception: asses what the pt knows about the medical situation
Invitation: ask how much they want to know
Knowledge: give the facts
Emotion: response to pt emotions
Strategy and summary
