Tooth wear: aetiology, prevention, clinical implication

Tooth wear: prevention, clinical implicationII

Libyan International Medical University 2nd Year 2nd Semester D Caroline Piske de A. Mohamed

Objectives: Preventing tooth wear Clinical implications

How can tooth wear be prevented?

It is vital that the existence of tooth wear is identified early and appropriate preventive measures put into place.

Abrasion/Erosion Prevention

Changing toothbrush technique and type of toothpaste.Other aetiological factors need to be identified and then appropriate advice given. Also, factors such as frequency and method of intake of acidic beverages as well as proximity of toothbrushing after intake may influence susceptibility to erosion.In-depth history to include dietary history, medical history, dental hygiene habits, and lifestyle factors.

A three-day diet history.The periodicity of eating and toothbrushing Habits as continuous sipping or frothing of drinks should be noted.(Frothing is the habit of holding carbonated drinks in the mouth and sucking them in and out of the teeth to make froth. This tends to add the ultrasonic effect of the bursting bubbles to the erosive effects of the acid. It also extends contact time.)

Give appropriate dietary counselingThis can only be given after a thorough analysis of the diet and influencing factors. It must be tailored to the individual, bearing in mind the constraints that are operating on them. It needs to be given in a positive, individualized way to maximize compliance.

Drink and Diet modificationFinish meals with something alkaline such as a small piece of cheese or milk.Drinks with low erosive potential (or that had addition of calcium citrate-malate.)Reduce and limit acid foods and drinks to mealtimes.Reduce frequency. Avoid acidic substances last thing at night.

Advise the patients to modify their diet.Considering the increasing prevalence of tooth erosion, specially in children and teenagers and the strong association between consumption of acidic drinks and tooth erosion, it still seems logical to develop drinks with low erosive potential.Drink modification has been developing by addition of calcium citrate-malate but the researches are not absolutely in concordance with the results.Drinking cola by straw has been shown to reduce the potential for tooth erosion from acidic drinks, specially on the palatal surfaces of the maxillary incisors that are most commonly affected in patients with erosion.7Avoid toothbrushing for at least an hour after acidic substances.Drinking through a straw lessens the contact time of the beverage with the teeth compared to drinking from a cup.Check the formulations or constituents of any medication, mouthwashes, etc.Chewing gum has been shown to stimulate salivary flow and increase buffering capacity, but may also secretion cause increased gastric acidity . It should not be recommended for children, probably below the age of 7 years, and is not suggested for those with a history of gastric reflux..

SalivaErosion is usually found in areas of the dental arches that are lacking in pellicle. Saliva and pellicle are important factors in protection of toothsubstance against acid attach. Increasing salivary flow and hence accumulation of pellicle will, therfore, probably offer protection against erosion. Increasing salivary flow and, consequentely, buffer capacity should increase protection against erosion and promote remineralization.

Salivary flow Buffer capacityAccumulation of pellicle Remineralization

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AbrasionAbrasive foods are uncommon in developed countries, but may be significant factors in certain areas of the developing world.

AttritionIf attrition related to parafunctional activity is found to be progressing to unacceptable levels, then prevention of further tooth surface loss must be considered.

Although males consistently show more attrition than females, they experience far fewer symptoms of temporo-mandibular dysfunction or myofascial pain than females.

AttritionBruxism76 year old farmer who has been "grinding his teeth".

The severity of attrition has not been shown to be strongly associated with the development of signs and symptoms.

It has proved to be impossible to totally stop nocturnal bruxing activity.

The most realistic method of controlling attrition is not in the prevention of the parafunctional activity itself, but rather in the prevention of the damage it causes. An occlusal splint (mouthguard) can be constructed, which will prevent the tooth to tooth contact which results in attrition.

The NTI-tss Plus does the job of a bite guard but covers only the front teeth. Attached on the incisal edge of the shell is an anterior-posterior discluding element (DE) that provides for a point stop on the mesial-incisal edges of the two opposing central incisors.

Preventing Erosion

Making a diagnosis.It is essential to record accurately the severity and extent. This will establish the clinical baseline so that any progression can be assessed, and the effects of preventive measures monitored. It may also be necessary to undertake these procedures in patients with marked abrasion and attrition.

Typical examples of localised anterior tooth wear predominantly due to acid erosion

Record the clinical situation Stone study casts. Clinical photographs .Tooth Wear Index.A silicone index can be prepared.Try to determine the etiological factors.

Intrinsic acid sources If there is any evidence or suspicion of gastric reflux, then referral to the general medical practitioner and onward to a gastro-enterologist or psychiatrist may be required. Medication may be helpful, but this obviously needs medical supervision.If reflux or vomiting are occurring, then rinsing the mouth with water and sodium bicarbonate helps to neutralize the oral environment.

People who have vomited should not rush off to clean their teeth. It has been shown that if teeth have been subjected to an acidic attack and are then brushed, up to five times as much enamel is removed. If reflux is occurring during sleep then an occlusal guard containing sodium bicarbonate can be used in adults or teenagers.

Follow upWhen the patient returns for a review, their compliance with all the advice given should be checked and the state of the dentition must be examined very carefully.A localized silicone index should be taken of the original study casts in the area of most concern.

ScoreSurfaceCriteria0B/L/O/INo loss of enamel surface characteristicsCNo loss of contour1B/L/O/ILoss of enamel surface characteristicsCMinimal loss of contour2B/L/OLoss of enamel exposing dentine for less than one third of surfaceILoss of enamel just exposing dentineCDefect less than 1mm deep3B/L/OLoss of enamel exposing dentine for more than one third of surfaceILoss of enamel and substantial loss of dentineCDefect less than 12mm deep4B/L/OComplete enamel losspulp exposuresecondary dentine exposureIPulp exposure or exposure of secondary dentineCDefect more than 2mm deeppulp exposuresecondary dentine exposureSmith and Knight tooth wear index ScoreCriteria0No wear into dentine1Dentine just visible (including cupping) or dentine exposed for less than 1/3 of surface2Dentine exposure greater than 1/3 of surface3Exposure of pulp or secondary dentineSimplified scoring criteria for TWISurfaceScoreCriteriaFacial0No erosion. Surface with a smooth, silky glazed appearance, possible absence of developmental ridges1Loss of surface enamel. Intact enamel cervical to the erosive lesion; concavity on enamel where breadth clearly exceeds depth, thus distinguishing it from toothbrush abrasion. Undulating borders of the lesion are possible and dentine is not involved2Involvement of dentine for less than half of tooth surface3Involvement of dentine for more than half of tooth surfaceOcclusal/lingual0No erosion. Surface with a smooth, silky glazed appearance, possible absence of developmental ridges1Slight erosion, rounded cusps, edges of restorations rising above the level of adjacent tooth surface, grooves on occlusal aspects. Loss of surface enamel. Dentine is not involved2Severe erosions, more pronounced signs than in grade 1. Dentine is involvedErosion index according to Lussi

The effects of tooth wear that may require treatment are esthetics, tooth sensitivity, prevention of pulp exposure, fractured teeth and restorations and, occasionally, the improvement of masticatory function.

Treatment of tooth sensitivity can be a challenging problem if tooth wear is progressing. Some dental materials are themselves more susceptible to wear than others. For example, each composite material has its own wear resistance, which is improved by increasing the inorganic filler fraction and decreased by reducing the average filler particle size.

Although a composite might appear to have an optimal wear rate, its filler particles may increase the wear on opposing enamel and dentine surfaces, and lead to an increasing loss of vertical dimension. Adhesive materials based on (bis-glycidyl-methacrylate) bis-GMA-resins are also susceptible to chemical dissolution and may not have good long term survival in situations of high acidic challenge. However, restoration with composite or compomer materials may be useful as an interim treatment with progression to adhesive metal castings and porcelain veneers if necessary.

Suggested preventive measures for progression of erosionPREVENTIVE MEASURESDiminish the frequency and severety of the acid challenge Enhance the defense mechanisms of the body (increase salivary flow and pellicle formation)Enhance acid resistant, remineralization and rehardening of the tooth surfaces (use of Topical fluorides)Improve chemical protection (use of antacids and cheese)Decrease abrasive forces ( Use of soft tooh brushes and avoid brushing immediately after acid challenge)Provide mechanical protection (use of bonding agents on exposed dentine and Occlusal guards)Monitor stabilityTables source: CM Marya. A Textbook of Public Health Dentistry. Jaypee Brothers Medical Publishers2011.

Advice on brushing can be contentious, particularly when dentin is exposed. Gentle softbrushing only before bed time, using a soft multitufed brush and fluoride dentifrice may be advisable.Patients should be monitored intensively during the first few weeks for treatment compliance, and again after 2 or 3 months. Any soft dentin present should have hardened after 3 months. Continued dentin hypersensitivity indicates continued erosive activity31

Thats how men brush teeth!32D.caroline MohamedClinical implicationsPatients that are not compliant with preventive measures or that cant control the aetiological factors may need complex restorative techniques, with all the implications for expensive maintenance that these incur.

Vomiting bulimia patients restorations are required in order to retain any remnants of the dentition.

Treatment for sensitive dentineFluoride mouthrinses varnish toothpastes, with or without iontophoresis* (with low abrasivity)Copal varnishesPotassium oxalateStrontium chlorideDentine-bonding agentsSealantsRestorative techniques Glass ionomers Compomers Composites*Iontophoresisuse of a small electric current to introduce sodium fluoride and/or corticosteriods into the dentinal tubules.

The Fluorinex operating principle differs from previously proposed iontophoretic fluoride delivery systems, where current clearly passes through the patients tissues. In the Fluorinex method, positive and negative electrodes are within the gel whenenergized, and are a part of the tray itself. There is no passage of the current through the patients body.35Recommending the use of a potassium ion-containing gel or dentifrice in combination with watchful waiting with stimulus avoidance has long been the favored initial approach for DH management. Fluoride varnish is easy to apply and can also provide prompt relief.

There are faster-acting professional approaches aimed at narrowing or occluding dentinal tubules. Iontophoresis-based acceleration of tubular narrowing or occlusionfollowed by resin impregnation (or longer lasting) glass ionomer coverage will usually provide both immediate and lasting relief.

It needs to be emphasized that treatment of tooth wear will be ineffective in the long term, unless the aetiological factors are controlled or eliminated.

Night Guard

Dental sealants

Restorations Before After

Prostheses

Surgery

Root coverage

Take a good look!

46Questions..

ReferencesCM Maya. A textbook of Public Health Dentistry, first edition. Jaypee Brothers Medical Publishers. Highly recommendedErosiondiagnosis and risk factorshttp://scolaris.beta.semantico.com/articles/clinical-oral-investigations/2238777#_diagnosisManagment of dental erosion.http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=1427&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=121&isPDF=NOThank you!!!