Wear 2 Flashcards
How is a wear diagnosis determined?
As almost all wear is multifactorial- decide on the primary causative factor (best fit)
What are the different patterns of tooth wear?
Localised
Generalised
-> Wear with loss of OVD
-> Wear without loss of OVD but with space available (C2div1)
-> Wear without loss of OVD but with limited space
What is done in the immediate phase of treatment when treating patients with wear?
Deal with pain:
Sensitivity- Desensitising agents, Fluorides, bonding agents GIC coverage of exposed dentine
Pulp extripation- if wear has compromised pulpal health
Smooth sharp edges- prevent trauma to cheeks and tongue
Extraction- pain from unrestorable/non-functional tooth
TMJ pain- important in attrition, acute symptoms need to be controlled
What can be done to treat TMJ pain?
Splint, ultrasound, jaw exercises, relaxation techniques
-> treated before wear
What is done in the initial phase of plan when treating patients with wear?
Stabilise the existing dentition
Deal with caries
Deal with perio condition
What is done when you identify a primary causative factor for tooth wear?
Institute a preventive regime (cannot treat an ongoing problem or it will fail)
How can wear be monitored?
Wear indices
Models
Photos
Why is it important to monitor wear?
Helps decide if it is active (requiring treatment/prevention) or historic (may not require treatment if not problems)
What is the key element in prevention?
Removal of the cause
How is abrasion prevention achieved?
Remove the ‘foreign object or substance’ involved in causing the abrasive wear
Change toothpaste (less abrasive)
Alter tooth brushing habits
Change parafunctional/functional habits
What can be done to treat abrasion?
Put in simple restorations (may not require preparation)- so patient wears them out rather than their own tooth tissue
->replace as required
Why may flowable composite be less useful in restoring abrasive wear?
Flowable composite may not be the best as it is more translucent- dentine underneath shines through
Why is RMGIC preferred to composite to restore abrasive lesions?
RMGIC- lower modulus, more flexible than composite in this situation
-> Higher modulus of composite compromises retention
How is attrition prevented?
Treat parafunction- CBT, hypnosis, relaxation, splinting
What are the ADV of using splints to treat attritive wear?
Softer than teeth- Wear away in preference to tooth
Cause no damage to the opposing teeth
May work as habit breaker
What types of splints can be used?
Soft- good as diagnostic device to determine whether patient is grinding
Hard- better long term (more robust)
What are the features of a Michigan splint (hard)?
Made of acrylic
Provides an ‘ideal occlusion’ with even centric stops
Has canine rise which provide disclusion in eccentric mandibular movements (canine guidance)
What is it important to establish or fix before prescribing a patient a splint?
That the patient does not suffer from erosion (esp intrinsic)
-> would accelerate tooth wear
What patient habits contributing to erosive wear may need to be changed when treating patients?
Swilling drinks around in mouth
Drinking from cans/bottles- Use a straw
Rumination
Educating patient about hidden sugars and acids
Vegan diet
Use of sports drinks/gels in athletes
Which medical conditions can cause erosion from intrinsic acid production?
GORD
Reflux
Hiatus Hernia
Xerostomia
Anorexia and Bulimia
What can be used to prevent erosion?
Fluoride supplements (help remineralisation)
Desensitising agents (trial and error)
Dietary modifications (extrinsic acids)
Habit changes
Medicines- PPI, h2 blockers (ranitidine), antacids
What is the issue with PPI?
Patient can suffer rebound when they stop using them
Which specialists may you refer patients on to if you notice a problem with intrinsic acid?
Gastroenterologist- GORD
Psychiatrist/psychologist- Anorexia/Bulemia
What is done to treat abfraction?
(if it exists)
Restore cavities with low modulus materials
-> RMGIC
-> Flowable Composite
What should the first form of treatment for dental wear be?
Passive management- prevention and monitoring
-> most patients will be in this stage for around 6 months (this may be all that is required)
What is the issue when choosing the right time to begin active management approach to treat tooth wear?
There is no intervention threshold (lack of evidence)
-> manage with simple interventions for as long as possible (covering exposed dentine etc)
What situations would prompt you to consider starting active management of wear?
Wear leading to further complications
Aesthetics have gone beyond patient acceptability
Leaving intervention may cause more complex treatments to be required
What are the goals in active management of tooth wear?
Preserve remaining tissue
Pragmatic aesthetics
Functioning occlusion
Stability
What is the decision on whether to treat maxillary anterior tooth wear based on?
The pattern of anterior maxillary tooth wear
Inter-occlusal space
Space required for the restorations being planned
Quality and quantity of remaining tooth tissue, particularly enamel (important for bonding)
Aesthetic demands of the patient
What are the categories of maxillary anterior tooth wear?
Tooth wear limited to the palatal surfaces only (assoc. with reflux and vomiting)
Tooth wear involving the palatal and incisal edges with reduced clinical crown height
Tooth wear limited to labial surfaces (assoc. with drink holding/over-brushing)
What material is used to treat maxillary anterior tooth wear?
Composites
What are examples of instances when inter-incisal space is adequate in maxillary anterior tooth wear? (easiest to treat)
If teeth wear rapidly and there is no time for alveolar compensation
Anterior open bite
Increased overjet
-> Space available with no need for change in OVD
What is the issue with dental-alveolar compensation?
FWS remains the same and OVD will need to change when placing restorations (complex)
- is good for maintaining masticatory efficiency
What makes it difficult to create space in maxillary anterior tooth wear?
Little tooth tissue to begin with
Poor retention due to short axial walls
Good chance of pulpal damage due to short clinical crowns
What can be done to make space when teeth are already shortened?
Increase OVD via multiple posterior extra-coronal restorations (reorganised approach)- Complex, Destructive, Expensive
Occlusal reorganisation from ICP to RCP-complicated, can be destructive
Surgical Crown lengthening- doesn’t really create more space
Elective RCT and post crowns- very destructive
Conventional Orthodontics- lengthy treatment
What is surgical crown lengthening?
Repositioning of gingivae apically generally with removal of bone to expose more crown for retention of restoration
-> can result in sensitivity (exposes root)
-> occlusal reduction still required
-> better if high smile line
What is the Dahl technique?
Propping occlusions open anteriorly with a bite plane/composite build up creating posterior disocclusion to allow over-eruption
*Anteriors should intrude slightly
-> can increase OVD by 2-3mm
When is the Dahl Technique used?
To create space in localised areas of tooth wear
Why is composite now used instead of CoCr bite plane?
Better aesthetic
Better compliance
Easier to adjust
Quicker- teeth look better automatically
Why is the Dahl technique more successful in younger patients?
More eruptive potential
What is the success rate with the Dahl technique?
90+%
What is a sign the Dahl technique is not working?
If there is no movement after 6 months
What are the contraindications for the Dahl technique?
Active periodontal disease- don’t want to overload anteriors
TMJ problems
Post Orthodontics
Biphosphonates- slows turnover of bone
If dental implants present
If existing conventional bridges
