DENTAL EROSION—TOOTH WEAR Physiology, Etiology, Epidemiology, Diagnosis, and Treatment

DENTAL EROSION—TOOTH WEAR

Physiology, Etiology, Epidemiology, Diagnosis, and Treatment

Dental Erosion: Tooth Wear

After viewing this lecture, attendees should be able to:

• understand the oral anatomy and physiology as they relate to dental erosion/tooth wear

• identify the etiology of and risk factors associated with dental erosion/tooth wear

• describe the epidemiology and prevalence of dental erosion/tooth wear

• make the correct differential diagnosis and understand the management of dental erosion/tooth wear

Oral Anatomy and Physiology

• Primary (deciduous)

• Secondary (permanent)

Definition (teeth): There are two definitions

Primary (deciduous)• Consist of 20 teeth• Begin to form during the

first trimester of pregnancy• Typically begin erupting

around 6 months• Most children have a

complete primary dentition by 3 years of age

Oral Anatomy and PhysiologyDentition (teeth): There are two dentitions

1. Oral Health for Children: Patient Education Insert. Compend Cont Educ Dent.


Secondary (permanent)• Consist of 32 teeth in most

cases• Begin to erupt around 6

years of age

• Most permanent teeth have erupted by age 12

• Third molars (wisdom teeth) are the exception; often do not appear until late teens or early 20s

Dentition (teeth): There are two dentitions

Mandible

Maxilla Incisors

Canine (Cuspid)

Premolars

Molars

Classification of Teeth:

• Incisors (central and lateral)

• Canines (cuspids)

• Premolars (bicuspids)

• Molars

Oral Anatomy and PhysiologyIdentifying Teeth

Incisor Canine Premolar Molar


• Apical

• Labial

• Lingual

• Distal

• Mesial

• Incisal

Teeth: IdentificationTooth Surfaces

Labial

Apical

Lingual

Incisal Incisal

Distal

Apical

Mesial

• Anatomic Crown

• Anatomic Root

• Pulp Chamber

The 3 parts of a tooth:Anatomic Crown

Anatomic Root

PulpChamber



• Enamel

• Dentin

• Cementum

• Dental Pulp

The 4 main dental tissues:

Enamel

Dentin

Cementum

Dental Pulp

• Structure– Highly calcified and hardest

tissue in the body– Crystalline in nature– Enamel rods

• Insensitive—no nerves• Acid-soluble—will

demineralize at a pH of 5.5 and lower

• Cannot be renewed• Darkens with age as enamel is

lost• Fluoride and saliva can help

with remineralization

Dental Tissues—Enamel2


• Softer than enamel• Susceptible to tooth wear

(physical or chemical)• Does not have a nerve

supply but can be sensitive• Is produced throughout

life• Three classifications

– Primary– Secondary– Tertiary

• Will demineralize at a pH of 6.5 and lower

Dental Tissues—Dentin2


Dentin

Pulp

Tubule

Fluid Nerve Fibers

Odontoblast Cell


• Presence of tubules renders dentin permeable to fluoride

• Number of tubules per unit area varies depending on the location because of the decreasing area of the dentin surfaces in the pulpal direction

Dental Tissues—Dentin (Tubules)2

Association between erosion and dentin hypersensitivity3

• Open/patent tubules– Greater in number– Larger in diameter

• Removal of smear layer• Erosion/tooth wear

Enamel

ExposedDentin

RecedingGingiva

Tubules

Odontoblast


Dental Tissues—Dentin (Tubules)2


• Thin layer of mineralized tissue covering the dentin

• Softer than enamel and dentin

• Anchors the tooth to the alveolar bone along with the periodontal ligament

• Not sensitive

Dental Tissue—Cementum2

• Innermost part of the tooth• A soft tissue rich with blood

vessels and nerves• Responsible for nourishing the

tooth• The pulp in the crown of the

tooth is known as the pulp chamber

• Pulp canals traverse the root of the tooth

• Typically sensitive to extreme thermal stimulation (hot or cold)

Dental Tissue—Dental Pulp2


• Plaque

• Saliva

• pH Values

• Demineralization

• Remineralization

Oral Cavity/Environment4,5



Plaque:4,5

• is a biofilm • contains more than 600

different identified species of bacteria

• there is harmless and harmful plaque

• salivary pellicle allows the bacteria to adhere to the tooth surface, which begins the formation of plaque

Oral Cavity


Saliva:4,5

• complex mixture of fluids

• performs protective functions:

– lubrication—aids swallowing

– mastication

– key role in remineralization of enamel and dentin

– buffering

Oral Cavity


pH values:4,5

• measure of acidity or alkalinity of a solution

• measured on a scale of 1-14 • pH of 7 indicated that the

solution is neutral• pH of the mouth is close to

neutral until other factors are introduced

• pH is a factor in demineralization and remineralization

Oral Cavity

3. Strassler HE, Drisko CL, Alexander DC.


Demineralization:4,5

• mineral salts dissolve into the surrounding salivary fluid: – enamel at approximate

pH of 5.5 or lower– dentin at approximate pH

of 6.5 or lower • erosion or caries can occur

Oral Cavity


Remineralization:4,5

• pH comes back to neutral (7)• saliva-rich calcium and

phosphates• minerals penetrate the

damaged enamel surface and repair it:– enamel pH is above 5.5– dentin pH is above 6.5

Oral Cavity

Dental Erosion: Etiology

Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of physical loss,

chemical dissolution, and/or multifactorial etiology.3,6

Tooth Wear

Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6

• Physical Loss

– Abrasion—mechanical

– Attrition—tooth-to-tooth contact

– Abfraction—lesions

• Chemical dissolution

• Multifactorial etiology


Tooth Wear


• Physical Loss


– Erosion

-- Extrinsic acids

-- Intrinsic acids



Tooth Wear


• Physical Loss



– Erosion

– Abrasion

– Attrition

– Abfraction


Tooth Wear

The pathological wearing away of hard dental tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth.6

• Oral hygiene habits– Excessive brushing/flossing– Abrasives in dentifrices/toothpastes

• Personal habits– Putting foreign objects in the mouth

• Demastication – Wear from chewing food

Abrasion


The pathological wearing away of hard dental tissue as a result of tooth-to-tooth contact, with no foreign substance intervening.6

• Enamel wearing enamel– Occlusal wear– Malocclusion (buccal, lingual, and interproximal surfaces)

Attrition


Wedge-shaped defects at the cementoenamel junction of a tooth caused by eccentrically applied occlusal forces leading to tooth flexure that results in microfracture of enamel and dentin.6

• Loss of tooth in the cervical area– Tooth flexure

– Chewing – Grinding (bruxism)

Abfraction


The physical results of a pathologic, chronic, localized loss of hard dental tissue that is chemically etched away from the tooth surface by acid and/or chelation without bacterial involvement.7

• Extrinsic acids—ingested– Food, beverages, medicine

• Intrinsic acids—internal– Originate in the stomach

Erosion


Tooth wear is multifactorial

• One process typically impacts the other

– Erosion and abrasion

Multifactorial


Tooth erosion was described as a condition distinct from caries as early as the 18th century.8

Dental Erosion: Epidemiology

In 1995, the European Journal of Oral Science stated that “dental erosion is an area of research and clinical practice that will undoubtedly experience expansion in the next decade.”9

Change in Perception



Global Prevalence

Global data on the prevalence of dental erosion is building. “Erosive tooth wear is a common condition in the developed

countries.”10

United States

CanadaIceland

Ireland

Sweden

Germany

Turkey

Saudi ArabiaIndia

Brazil

Japan

Malaysia

Switzerland

The NetherlandsUK

China

• European studies suggest prevalence of:11-13

– Up to 50% if all preschool children– Between 24% to 60% of school-aged children– As high as 82% in 18 to 88 years of age10

• Emerging prevalence studies providing data on gender, socio-economic status, ethnic, and culture difference in addition to the age factor will prove to be invaluable

Global Prevalence


“Diagnosis is the intellectual course that integrates information obtained by clinical examination of the teeth, use of diagnostic aids, conversation with the patient, and biological knowledge. A proper diagnosis cannot be performed without inspection of the teeth and

their immediate surroundings.”14

Dental Erosion: Diagnosis

Dental Erosion—Diagnosis

Check list to unveil etiological factors for

erosion15


Interaction of the different factors for the

development of erosive tooth wear16,18

From: Lussi A. Dental Erosion: From Diagnosis to Therapy. Karger; 2006.


Clinical Appearance

There is no device available for the specific detection of dental erosion in routine practice. Therefore, the clinical appearance is the most

important feature for dental professionals to diagnosis dental erosion.16

Dental Erosion—Diagnosis

Tooth Wear—Clinical Appearance17

• Chemical factors—erosive potential of intrinsic and extrinsic acids

• Biological factors—involve properties and characteristics of the oral cavity

• Behavioral factors—personal and oral habits

Erosion is multifactorial


• pH and buffering capacity of the product

• Type of acid (pKa values) – Intrinsic (gastric origin)– Extrinsic (environmental, dietary, medicinal)

• Adhesion of the products to the dental surface• Chelating properties of the products• Calcium concentration• Phosphate concentration• Fluoride concentration

Chemical Factors18


• Saliva: flow rate, composition, buffering, capacity, and stimulation capacity

• Acquired pellicle: diffusion-limiting properties, composition, maturation, and thickness

• Type of dental substrate (permanent and primary enamel, dentin) and composition (eg, fluoride content as FHAp or CaF2-like particles)

• Dental anatomy and occlusion• Anatomy of oral soft tissues in relationship to the teeth• Physiologic soft tissue movements

Biological Factors19


• Unusual eating and drinking habits

• Healthy lifestyle: diets high in acidic fruits and vegetables

• Unhealthy lifestyle: frequent consumption of “alcopops” and designer drugs

• Alcoholic disease

• Excessive consumption of acidic foods and drinks

• Nighttime baby bottle feeding with acidic beverages, including milk

• Oral hygiene practices: frequent toothbrushing, abrasive oral care products

Behavioral Factors20


Loss of tooth surface is a multifactorial process and education

is the first step in the line of defense.4

Prevention


Dynamics of Dental Erosion21

Before During After

Time (Frequency)

Interactions between Behavioral and Biological Factors

Dental Erosion: Diagnosis/Management

21. Lussi A, Kohler N, Zero D, et al.

Dental Erosion:Management/Etiological Factors

Dietary factors15

• Avoid radical changes in dietary habits

• Reduce acid exposure by reducing frequency and contact time of acid

• Avoid acidic foods and drinks late at night

• Avoid high-acidity liquids via baby bottle for infants

• Avoid low pH values in food and beverages

Awareness/Association/Education

Dental ErosionManagement/Etiological

Factors

Dietary factors: generally, a pH value of 5.5 or lower is capable

of softening the surface of enamel

in only a few minutes.3


3. Strassler HE, Drisko CL, Alexander DC.


Behavioral/habits15

• Do not hold or swish acidic drinks in your mouth

• Avoid sipping acidic drinks—use a straw

• Avoid toothbrushing immediately after an erosive challenge (vomiting, acidic diet)

• Avoid toothbrushing immediately before an erosive challenge, as the acquired pellicle provides protection against erosion

• Use a soft toothbrush



Behavioral/Habits15

• Use a low-abrasion fluoride-containing toothpaste; high-abrasive toothpaste may destroy pellicle

• Avoid toothpastes or mouthwashes with too-low pH

• After acid intake, stimulate saliva flow with chewing gum or lozenges

• Use chewing gum to reduce postprandial reflux

• Refer patients or advise them to seek appropriate medical attention when intrinsic causes are involved


Gastroesophageal Origin22

• Heartburn and other symptoms of reflux

• Regurgitation

• Dysphagia

• Asthma

• Rumination

• Eating disorders (anorexic or bulimia)



Medicinal factors associated with dental erosion23

• Some medicines can potentially induce GERD– theophyline– progesterone– anti-asthmatics– calcium channel blockers

• Aspirin (especially in chewable format)

• Medicines that decrease salivary flow– antihistamines– anticholinergics– antidepressants– antipsychotics



Dental Erosion/Toothwear

Prevention is better than a cure… Education is the key!

Documents

DENTAL EROSION—TOOTH WEAR Physiology, Etiology, Epidemiology, Diagnosis, and Treatment