toothwear - paterson Flashcards
aetiology of toothwear types
- Attrition – opposing dentition
- Erosion – acid attack
- Abrasion – toothbrush most common
- Combination
- Unknown
Time – more in older person, need to relate aetiology to chronological age
why is working out aetiology of toothwear important
7
- Attempt to reduce further wear
- Plan for problems, contingencies & failure
- Allow you to be realistic with yourself & patient
- Identifies wider medical & wellbeing issues & allows signposting
- Prognostic indicator
- Enhances consent process
- Aids clinical diagnosis & treatment planning
modifying factors for attrition
5
- Lack of posterior teeth – wear on other teeth is higher
- Occlusion – deeper overbite, edge to edge occlusion
- Restorations
- Erosion & Abrasion
- Stress & Anxiety
spectrum; physiologucal wear-> bruxist
bruxist common features
- Significant wear throughout dentition
- Repeated restoration failure
- Root fractures
- Often onset in early adulthood
- Progressive
physiological toothwear
common features
Wear that you would expect to see given the age of pt
* Caine more rounded, incisal edges
* Not worrying – expect
* Pt may want cupping filled
lack of posterior support
common features
- Wear is more extensive as no posterior support (inc severeity and rate of progression)
- Modifying factor of tooth wear
- Ultimately can lead to occlusal collapse
- Functional & aesthetic problems
Dentist role – advise denture to protect remaining natural teeth
occlusion impact on toothwear
A lot of the wear is caused by the nature of the occlusion often compounded by parafunction
* Deep overbite – lower incisors
* Edge to edge occlusion – localised wear
restorations impact on toothwear
Wear worse than you would expect as natural teeth opposed by restorations
* Porcelain mainly
key signs of evidence of parafunction
but lack toothwear
4
- soft tissue abrasion - lip/cheek/tongue chewing
- multiple cusp fracture
- multiple cracks around restorations
- root fractures in unrestored teeth
extrinsic erosion causes
8
- Carbonated drinks
- Sports drinks
- Alcoholic acidic drinks
- Citrus drinks
- Acidic fruits
- Acidic sweets
- Pickles
- Drugs (amphetamines)
intrinsic erosion causes
4
- Eating disorders
- GORD
- rumination syndrome
- Other medical conditions (causing nausea etc)
modifying factors in erosion
- Lifestyle
- Multiple factors
- Amount & frequency
- Level of control
- Psychosocial
common features in erosion caused by carbonated drinks
5
- Incisal erosion on upper centrals
- Cupping on lower molars
- Palatal erosion on upper incisors
- Sensitivity
- Interproximal caries and buccal white spot/brown spot caries
eating disorder erosion
common features
8
- Palatal erosion on upper teeth
- Polished restorations (esp amalgams)
- Erosion around restorations
- Sensitivity
- Caries
- Altered taste – sometimes
- Halitosis – sometimes
- Soft tissue changes (bulimia) – rarely –* abrading on incisal edges of tongue when vomiting *
Can also commonly have abrasion/attrition too
abrasion behaviours
5
- Toothbrush abrasion
- Oral self-harm
- Tongue studs
- Occupational
- Unusual habits
able to modify if pt takes on behaviour change you suggest
good hx key
toothbrush abrasion
7 factors to consider
- Localised or Generalized
- Frequency & duration
- Bristle & toothpaste abrasiveness
- Brushing technique instruction
- Electric Vs manual
- Part of a combination wear problem eg Eating disorder?
- Part of a stress/anxiety related problem?
combination aetiology of some toothwear
important to remember that….
common combos
Erosion (Intrinsic & Extrinsic); Attrition; Abrasion
* Alcoholism & Drug abuse
* Eating disorder
Erosion (Extrinsic) & Attrition
* Bruxist with poor diet
Erosion (Intrinsic & Extrinsic) & Attrition
* Bruxist with poor diet & GORD
**Synergistic rate of wear progression when multiple wear factors **
multiple wear factors present (combination aetiology)
then…
**Synergistic rate of wear progression when multiple wear factors
how to manage unknown toothwear aetiology
Often unusual wear pattern
* Patient may know aetiology but will not tell you
Plan warily
Communicate a guarded prognosis
* If place restoration and wear not resolved than likely fail of restoration as same process will occur again
history taking for toothwear pts
History taking can be challenging:
* Comprehensive
* Compassionate
* Unconditional positive regard
* Show patience
What you may uncover
* Eating disorder
* Undiagnosed diabetes
* Mental health issues
* GI issues
* Abuse/harm/addiction
* Vulnerable adult/child
examination for toothwear
Comprehensive
Use of indices
* BEWE (erosion), Smith and White Index - more useful for research
* Generalized/localized
* Mild/moderate/severe
Try relate findings to aetiology
* What you would expect? Worse? Better? Relation to chronological age?
Remember tooth wear patients have caries & perio disease
* Radiographs and other tx needs
BEWE is
basic erosive wear exam
scores look at buccal/occlusal/lingual surfaces of teeth and most affected tooth surface per sextant is recorded
sum of scores is added to aid tx plan
BEWE sum score is used to
aid tx plan
when work out aetiology of toothwear can
plan
* Individualized preventive plan
* Reinforcement – diet advice, non abrasive toothbrushing
* Signposting/referral to other health & social care professionals
* Review before definitive plan
common preventative advice
Fluoride:
* High dose toothpaste
* Alcohol free mouthwash
Dietary modification:
* Frequency & quantity
* Method of delivery (glass, straw, can, bottle)
* Elimination & addition
Remineralization:
* Tooth Mousse
Sugar free gum – awake bruxist, but depend on their job if socially acceptable
possible interventions to control aetiology of toothwear
4
Toothbrushing instruction
Splint therapy
Signposting:
* CBT
* Hypnotherapy
Referral:
* GMP
* Psychiatrist
* Social services
failure to control aetiology of toothwear risk
failure
Reality check: Can you control aetiology?
Reality is: We rehabilitate people with uncontrolled or partially controlled aetiology
Result: Higher failure rates
* Be realistic with pt – due to aetiological control of their tooth wear = high failure rate, restorations wont last as long, face greater tooth loss
examination findings for this case
due to erosive diet (drinks)
* translucent incisal edges on central
* Cupping defects in cervical third of centrals (erosion more than abrasion)
* Caries of UL2 mesially
due to erosion and attrition
* Large cracked amalgam on UR6
* Wear in dentine into lower arch on lower posteriors
* Tongue stud
* Attrition on lower incisors
questions to ask this case to work out aetiology
- Symptoms – sensitivity, when they begin, worse or better/any change
- Any acid regurgitation
- Any eating disorders
- Detail of diet and intake
- are they arware of clenching/grinding teeth
any previous tx attempts/mentioning of toothwear by previous dentists
special tests neeeded for this case
bitewings
Lower L 6 – caries, angular bone loss, loss of all enamel (same as lower 5).
Greater than thought
dx for this case
Extrinsic acid problem primarily, with combination of attrition (poss intrinsic acid too depend on MHx)
intial plan for this
PREVENTION
Modify diet,
* advice of alternatives
Fluoride use
* try to remineralise
* caries can spread more rapidly through dentine so higher risk
Study models to monitor wear
INTERVENTION
Some restorative treatment is essential for 6; what is the prognosis with & without aetiology controlled?
would you consider referral for this pt
MHx may uncover eating disorder – possible referral to psychologist/therapist
why try to avoid complete dentures in toothwear pts
Bruxism does not stop. So, fractured dentures; ridge resorption; pain & ulceration under complete denture
overdenture
Any removable prosthesis that rests on one or more remaining natural teeth, the roots of natural teeth and/or dental implants.
Other terms: Overlay denture or Overlay prothesis
adv of overdentures
11
- Correction of occlusion and aesthetics
- Support
- Tooth wear management - can inc OVD to gain space for restorations
- Preservation of ridge form – allows bone to be persevered for possible future implants
- Proprioception – as PDL around roots still there, better chewing efficiency and sensation
- Denture retention – undercuts used around roots
- Can be used with precision attachments - retention
- MRONJ & radiotherapy patients – avoids extractions
- Psychological benefits
- Useful in elderly patients
- Eases transition to edentulism
disadv of overdentures
5
Need for good oral health
* Increased caries/periodontal problems
* Care homes – can be harder for OH
Denture fracture – can be more prone
Discomfort/infection –* around roots*
Medical history – can worsen if avoid extraction with overdenture but need one at a later date could be greater risk
Potentially more traumatic extractions
care of overdentures
- Good oral hygiene
- Fluoride toothpaste application to roots
- Regular examinations & radiographs
- Denture hygiene
transitional denture role
inc OVD when occlusal collapse has occured to due toothwear (lack posteiror support)
this creates space for restorations
place acrylic dentures which have OVD that teeth would be if not worn
can place tooth coloured acrylic over lower denture to get balanced occlusion
wear for 3-6months - if pt copes with denture and inc OVD then place restorations at inc OVD and make definitive dentures
bruxist denture design
fracture denture in palate or midline (lower)
so go for metal based denture
Co/Cr Backing
* Technically difficult - Need to have a wax trial of teeth before making Co/Cr – so technician can put the CoCr backing correct place
Metal palate with acrylic post-dam
* An attempt to make a complete denture both retentive & indestructible
simplify denture design with free end saddles and smaller saddles
Bridgework can simplify small saddles –
careful with occlusion – no lateral or protrusive forces on pontic -> debonding of adhesive bridge
overlay denture
Overlays teeth to protect remaining teeth
* E.g odd occlusion – posterior open bite
Technically demanding but often well-tolerated
Wax trial before decide where to place CoCr
conforming
Works best in a stable occlusion with sufficient index teeth
* Ensure your prosthesis/restoration does not alter the occlusion
planning in both conforming and rehabilitation cases
requires
7
- Impressions & facebow
- Mounted articulated casts on semi-adjustable articulator +/– surveying (dentures)
- High quality Interocclusal record – with & without increasing the OVD (e.g. in alminwax - exclude anterior teeth so technician can see how much inc by when mounth)
- Diagnostic wax up(s)
- Stents – mock-up – temporaries (if indirect); for build-ups; aids consent (pt can see what it will look like)
- Temporary (transitional) dentures
- Clinical photographs
- (Radiographs)
indirect toothrestoration when
unable to minimally invasive adhesive
usually possible if 50% tooth structure remaining above gingival margin - unless can crown lengthen
difficulties in tooth prep for toothwear cases
3
Lack of occluso-gingival height
* Top of gingival margin to occlusal surface
* prep (right picture) - little retention and resistance form
Lack of occlusal space
Severely compromised tooth
reasons for modified prep in tooth wear cases
creates retention and resistance in smaller teeth
modified prep options
9
- Materials
- Grooves
- Inlays
- Ferrule
- Parallel preps
- Margins & occluding surfaces
- Cores
- Electrosurgery
- Surgical Crown lengthening
metal on occluding surfaces of restorations
more ductile than porcelain (brittle)
but balance between health & appearance
* MB cusp in porcelain (in smile line), rest metal
* also metal is stronger in thin section than porcelain
grooves in toothwear
help maximise retention and resistance
- need to parallel groves with POI and removal
- need to inform technician that you want the metal in the fitting surface of crown to fit into the groove
Enhance resistance form by reduction in radius of rotation, place inlays & grooves in long axis of tooth
* Long axis of tooth, in line with POI
* Assess first by radiograph so know where pulp is – how deep can place inlays/grooves
inlays in toothwear
if existing restoration in place – take them out and make inlay prep within the crown prep, the walls will help add retention
Enhance resistance form by reduction in radius of rotation, place inlays & grooves in long axis of tooth
* Long axis of tooth, in line with POI
* Assess first by radiograph so know where pulp is – how deep can place inlays/grooves
resistance in indirect tooth restoration
essential
ferrule
Circumferential coronal dentine
Essential – no ferrule = unlikely to be restored by crowns
* 22, 23 – none
* 11, 21* – possible
Posts allow you to persevere as much coronal dentine as possible (can add a grove too)
retention can be aided by
parallel preps
but less ability for technician to develop more aesthetic result
retention groves
metal prep
good for short of space as minimal prep
chamfer margin
porcelain prep
need more space
shoulder margin
better aesthetics
needs curves to try and minimise crack propagation (high load)
surgical crown lengthening
last resort - adhesive failed, not enough tissue for indirect prep
Remove bone around tooth and excess gum, suture apically so increase amount of tooth in mouth (gingival margin heals more apically)
* Inc clinical crown heigh so occlusal-gingival height of prep
3 months for gingival margins to stabilise
* Can place temporary crowns in this time – esp if pt has sensitivity as root cementum above gum
then use additional retention factors for prep - grooves, inlayers, parallel preps
electrosurgery
remove some gum to ensure accurate impression and go beyond restoration to make ferrule
how to modify old denture that have been worn (so lost OVD)
inverted cone bur and drill into the acrylic teeth and fill in composite (retained by holes)
This inc OVD 1.5mm approx. to establish posterior support on existing denture - prevent inc wear of anterior teeth due to overbite
what to expect in toothwear cases
failure, complications and cycles of replacement and consent patients accordingly
compromise between function and aesthetics - discuss with pt
Case selection is crucial and individual … Understand your limitations…Seek advice by referral if in doubt
important to consider when planning
occlusion
both static and dynamic - protrusive and lateral movements
what to ensure in dental demolation cases
in you expertise - may need to refer
operator and pt safety - PPE and high volume suction to prevent aspiration, caution re sharps
inform pt of risk tooth is unrestorable on removal of old restoration
removal of indirects
consent pt to contingencies/extractions
pre-op impression for temporary - same design (possible to utilise part) or need for temp denture
removal - porcelain and metal cutting burs, sliding hammers, masseran kits, moskito forceps
key to success when managing failure
- Comprehensive history and examination (Information gathering)
- Thorough planning
- Seek advice if needed
- Prevention
- Avoid overambitious treatment
- Effective communication
- Decision-making and treatment planning around basic principles
- Keep plans simple
- Have an effective maintenance strategy and regularly reassess the situation
failing dentition definition
dentition where deteriorating teeth, restorations or oral health or a combination of issues means a loss of adequate basic oral functions such as mastication and acceptable aesthetics is inevitable if untreated.
A failing dentition is sometimes a terminal dentition
prevention in failing dentition
- Basic Oral health messages
- Individualised oral hygiene instruction
- Individualised dietary advice
- Individualised fluoride regime
- Individualised habit advice & management/referral to other health & social care professionals advice/safeguarding issues
- Information provision & documentation in the records
- Assess response to preventive and oral health measures before embarking on advanced treatment
Keep things simple
* Get rid of the impossible – you can deal with difficult teeth later
* Oral Health
* Caries management
* Simple endodontics
* Dentures/additive composite
* Be prepared to change plan/ amend diagnosis due to problems encountered
effective communication in restorative dentistry cases
managing failure
Effective listening
Honesty & transparency
Taking into account patient’s wishes
Addressing difficult issues – oral hygiene, habits, failing restorations, previous treatment, fixed solution > removable solution
Seeking advice
Giving patient’s a reality check
Documenting discussions
Being assertive & compassionate
Time & patience
Avoiding patient led treatment
Have a holistic approach to treatment
SPIKES
breaking bad news
set up
preception
invitation
knowledge
emotion
strategy
rehabilitation of occlusion
Often occlusion is unstable and lack of sufficient index teeth
Usually more challenging to record occlusion
Decision on how much to increase OVD
common in toothwear
special tests neeeded for this case
bitewings
Lower L 6 – caries, angular bone loss, loss of all enamel (same as lower 5).
Greater than thought
combination aetiology of some toothwear
important to remember that….
common combos
Erosion (Intrinsic & Extrinsic); Attrition; Abrasion
* Alcoholism & Drug abuse
* Eating disorder
Erosion (Extrinsic) & Attrition
* Bruxist with poor diet
Erosion (Intrinsic & Extrinsic) & Attrition
* Bruxist with poor diet & GORD
**Synergistic rate of wear progression when multiple wear factors **
