TOOTH WEAR DR HSU ZENN YEW
DDS (UKMal), DCLINDENT (Adel)
Tooth wear
TERMINOLOGY
Caries Subsurface mineral loss
Caries
‘Tooth surface loss/ TSL’ or ‘tooth wear’: refers to the loss of tooth tissue by a disease process other than dental caries/ trauma. (Eccles, 1982) VS
‘Early Enamel Caries’: Subsurface mineral loss beneath relatively intact surface zone.
www.doctorspiller.com
BDJ 2006
“…the human dentition is basically “designed” on the premise that extensive wear will occur…” Kaifu et al
Ungar et.al (2008)
Bailey S & Liu W (2010)
CAVEMAN DIET.. BEST WAY TO SLIM DOWN?..
Is Tooth Wear Physiological or Pathological? Physiological TSL: Wear & tear process
Increased wear in older patient
Pathological TSL: Teeth are so worn that they affect Function: difficulty in mastication, speech
Aesthetics : seriously affect the appearance Longevity / survival of teeth : whether tooth will survive until end of life span Comfort: Exposed dentine -> dentinal sensitivity or pulpal symptoms
CLASSIFICATION
TOOTH WEAR
EROSION
ABRASION
ATTRITION
? ABFRACTIONS
D.W. Bartlett and P. Shah (2006)
EROSION ď‚š Defined as loss of dental hard tissue as a result of chemical process NOT involving bacteria ď‚š Clinical features:
melted appearance (dull appearance)
cupping or grooving on occlusal/incisal surfaces
edges of restorations appear to rise above the level of the adjacent tooth Lussi 2006
EROSION
silky-glazed appearance of the tooth
rounding of the cusps and grooves
shallow concavities coronal from the cementoenamel junction
No occlusal morphology present Lussi et 2006
Ana Carolina Magalh達es et al J Appl Oral Sci. 2009;17(2):75-86
Ana Carolina Magalh達es et al J Appl Oral Sci. 2009;17(2):75-86
EROSION VS CARIES
EXTRINSIC Behavioural: •Healthier diet style: diet high in acidic citrus fruits, fruit juices, vegetables •Unhealthy life style: consumption of designer drugs •Alcoholic •Excessive consumption of acidic foods and drinks: soft drinks, wine, vinegar
Occupation: •Workers chemical industry •Wine tasters •Swimmers exercising in water with low pH •Athletes consuming frequently erosive sport drinks.
Chemical factors • pH and buffering capacity of the product • Type of acid (pKa values) •Citric acid caused more erosion than phosphoric acid
ACID ATTACK
INTRINSIC Medical:
Common causes for the migration of gastric juice through the lower and upper oesophageal sphincters are • Gastroesophageal reflux disease, hiatus hernia, chronic indigestion •Eating disorders: Anorexia and Bulimia, ruminification •Chronic alcoholism •Pregnancy
Pickards’ Manual, Lussi 2006
CAUSES OF EROSION Biological: •Saliva: flow rate, composition, buffering capacity and stimulation capacity •Acquired pellicle: composition, maturation and thickness •Type of dental substrate (permanent and primary enamel, dentin) and composition (e.g. fluoride content as FHAP or CaF2-like particles) •Dental anatomy and occlusion
PROTECTIVE MECHANISM
ABRASION
Pickards’ Manual, Lussi 2006 http://www.teethforbe tterhealth.com Badel et. Al 2007
Defined as ‘the pathological wearing away of dental hard tissue through abnormal mechanical processes involving foreign objects or substances other than by opposing teeth’.
‘Three- body wear’
Clinical characteristics: Commonly present buccally Cervical region Disc shaped ??V-shaped notch (a/w abfractions)
ABRASION Causes: Abnormal habits: Chewing pencils, cigar pipe, thread biting
www.mymuseum.org.uk
ABRASION Causes: Toothbrushing/ Oral hygiene habits Depends on relative dentine abrasivity (RDA) of the toothpaste. International Standards Organisation (ISO) laboratory test. ISO stipulates that the RDA of toothpastes should not exceed 250
Whitening toothpaste containing alumina may have high abrasivity.
“Normal toothbrushing habits with toothpastes that conform with the ISO standard will, in a lifetime’s use, cause virtually no wear of enamel and clinically insignificant abrasion of dentine (a figure of 1 mm in around 100 years is often cited)” Addy et al 2003
ABRASION Causes: Toothbrushing/ Oral hygiene techniques Modified bass and roll technique vs horizontal/scrub technique The effect of acid on enamel and dentine makes the tooth more susceptible to abrasion. Recommendation : delay at least 1 hour after acidic meals Addy et al 2003
ABFRACTION
Pickards’ Manual, Lussi 2006 http://www.teethforbe tterhealth.com Badel et. Al 2007
Controversial Defined as fracture of dental tooth structure caused by occlusal loads of functional and parafunctional force producing stress concentrations around the cervical margin of the crown. Occlusal forces produce the flexion of the teeth both axially and paraaxially. The destructive effect on teeth will be intensified by effects of erosion and abrasion ?V-notched at cervical area
ATTRITION
Pickards’ Manual, Lussi 2006, Badel et al 2007
Attrition is defined as the loss of enamel, dentin, or restoration by tooth-to-tooth contact (Pindborg, 1970). Physical wear as a result of the action of antagonistic teeth with no foreign substances intervening (two body wear) It occurs primarily on occlusal surfaces of teeth or interproximal areas. Clinical features: Flat surfaces Glossy areas with distinct margins
Correspond to antagonistic teeth
ATTRITION Mechanical loss or in combination with erosion Affects non-contacting occlusal
Causes: 1. ? Diet: Abrasive diet (e.g vegetarian) ? contemporary diet
Pickards’ Manual, Lussi 2006, Badel et al 2007
ATTRITION
Pickards’ Manual, Lussi 2006, Badel et al 2007
Causes: 2. Bruxism: diurnal and nocturnal parafunctional activity that includes clenching, bracing, gnashing, and grinding of teeth But.. “Tooth wear is a poor indicator of bruxism..” -> Patients with tooth wear may not have bruxism “Even if a patient is suspected of having bruxism, dental erosion is more likely the cause of tooth-tissue loss than attrition.”
Khan et al 1998
ATTRITION
Pickards’ Manual, Lussi 2006, Badel et al 2007
ď‚š Causes: 3. Iatrogenic: If the restorative material has a greater abrasiveness than enamel (for example, ceramic bridges and crowns and ceramic pontics in dentures), only the antagonist teeth surfaces will undergo tooth wear Materials which are softer than tooth enamel (composite fillings, acrylic pontics in dentures, acrylic facets and occlusal planes in crowns and bridges, etc.) will wear out to a greater extent whereas enamel of antagonist teeth will remain intact.
CLASSIFICATION TOOTH WEAR
EROSION/ COROSSION
Chemical wear
ATTRITION
Physical wear: tooth-tooth surfaces
? ABFRACTIONS
ABRASION
Physical wear
Flexion of tooth
“It is challenging to distinguish between the influences of erosion, attrition or abrasion during a clinical examination.” “..They may occur simultaneously with sometimes similar shape.” Lussi 2006, D.W. Bartlett and P. Shah (2006)
ď‚š Although there are known situations where only one single process causes tooth wear (e.g. nocturnal teeth grinding produces wear by attrition alone), the clinical presentation often results from a combination of tooth wear processes.
Combination of erosion, abrasion and attrition
Abrasion, abfraction and erosion
MANAGEMENT
DIAGNOSIS
PREVENTION STABILIZATION
Phase 2
RESTORATION/ REHABILITATION – Phase 3 REVIEW / MONITORING
DIAGNOSIS ď‚š Although a combination of factors is usually involved, it is feasible in most cases to identify a perceived major factor ď‚š Assessment of possible causative factors should include a systematic history and a methodical approach to the clinical examination. Johansson et al 2008
CLINICAL EXAMINATION Quantify the severity and progression of wear Location of wear: enamel, dentine or pulpal
Alteration in morphology Changes in the height of tooth
Johansson et al 2008
MEDICAL REFERRAL
Refer patients or advise them to seek appropriate medical attention gastroenterologist and/or a psychologist) when intrinsic causes of erosion are involved. OHE • Reduce acid exposure by reducing the frequency, and contact time of acids (main meals only). Do not hold or swish acidic drinks in your mouth. Avoid sipping these drinks.
PROFESSIONAL INTERVENTION •Night guard for bruxism •Stimulate saliva flow with chewing gum or lozenges. •Remineralization:•Topical fluoride (NaF, APF, SnF)
•ToothMousse® (CPP-ACP/ Casein Phosphopeptide -amorphous calcium phosphate
OHI •Avoid tooth brushing immediately after an erosive challenge (vomiting, acidic diet). •Use a fluoride containing mouth rinse, a sodium bicarbonate (baking soda) solution, milk or food such as cheese or sugar-free yoghurt. If none of the above are possible, rinse with water.
•Use a soft toothbrush and low abrasion fluoride containing toothpaste. & proper technique
OHI •Avoid tooth brushing immediately after an erosive challenge (vomiting, acidic diet).
•Use a fluoride containing mouth rinse, a sodium bicarbonate (baking soda) solution, milk or food such as cheese or sugar-free yoghurt. If none of the above are possible, rinse with water. •Use a soft toothbrush and low abrasion fluoride containing toothpaste. & proper technique
TOOTH WEAR
MEDICAL REFERRAL
Refer patients or advise them to seek appropriate medical attention gastroenterologist and/or a psychologist) when intrinsic causes of erosion are involved.
Pickards’ Manual, Lussi 2006
PREVENTION PROFESSIONAL INTERVENTION
OHE • Reduce acid exposure by reducing the frequency, and contact time of acids (main meals only). Do not hold or swish acidic drinks in your mouth. Avoid sippingt hese drinks.
•Night guard for bruxism •Stimulate saliva flow with chewing gum or lozenges.
•Remineralization:•Topical fluoride (NaF, APF, SnF) •ToothMousse® (CPP-ACP/ Casein Phosphopeptide amorphous calcium phosphate
Avoid parafunctional/ abnormal habits
PROTECTIVE MECHANISM
Prescription of night guard
Prescription of Michigan splint
Prescription of Tanner appliance
J L Wickens. British Dental Journal 186, 371 - 376 (1999)
STABILIZATION Observation, monitoring and palliative strategies Study cast Intraoral photographs computerised software
It is recommended that serial observations be performed at approximately 6–12 monthly intervals (depending on the perceived rate of progression) and comparing the recordings
Johansson et al 2008
ď‚š
Serial casts recorded over a period of 7 years showing the value of using models to judge the extent of tooth wear. J L Wickens. British Dental Journal 186, 371 - 376 (1999)
What is a pathological wear rate? Exceeds physiological wear rates: 10–30 µm on occlusal and 7.5 µm on palatal surfaces annually
A sectional silicone index formed from the initial cast can be used as a reference guide
STABILIZATION Monitor preventions strategies: monitor progression of tooth wear OHE reinforcement. Address symptoms and prevent further damage Eg: dentine hypersensitivity: bonding agent / topical desensitizing agent may be placed temporarily or semipermanently over exposed dentine.
RESTORATION/ REHABILTATION ONLY NECESSARY IF TOOTH WEAR IS PATHOLOGICAL Degree of wear relative to the age of the patient, the aetiology, the symptoms and the patient’s wishes
Patient complaint/ presented with: Function deficit: diificulty in mastication, speech
Aesthetics problems: seriously affect the appearance Longevity: threat to the strength of tooth Cause discomfort/ pain/ sensitivity
Function Aesthetic Longevity Comfort
RESTORATIVE CHALENGES Adhesion of the restorative material. resin bond strengths to noncarious sclerotic cervical dentine are lower than bonding to normal dentine. This is thought to be a result of tubule occlusion by mineral salts, preventing resin tag formation.
RESTORATIVE CHALENGES Loss of vertical dimension – increased in free way space
S. B. Mehta, S. Banerji, B. J. Millar & J.-M. Suarez-Feito. BDJ 212, 17 - 27 (2012)
RESTORATIVE CHALENGES ď‚š Compensatory eruption: lack of restorative space
RESTORATIVE CHALENGES ď‚š Compensatory eruption: lack of restorative space
RESTORATIVE CHALENGES Restorability of tooth
DoctorSpiller.com
Localized tooth wear Adequate restorative space ď‚š Direct restoration
Direct composite resin
Localized tooth wear Adequate restorative space ď‚š Indirect restoration
Crowns /Veneers
Onlays
Generalized tooth wear Proper planning: diagnostic mock-up Interdisciplinary management: periodontal ( surgical crown lengthening), endodontics ( RCT/ elective endodontics), surgery ( extractions, alveolaplasty) Need to consider referral to restorative specialist or prosthodontist
Combination of various restorative methods Direct and indirect
Fixed and removable (+ implants)
PBM crowns made on 34, 35, 44,45
Upper full clearance and moditication of existing RPD
Lower wax up at increase OVD
Composite build ups and FGC on 47,36
MAINTENANCE PHASE
Cases should be reviewed at least annually when new study casts, and photographs should be taken A careful clinical and radiographical examination of abutments should be performed: caries, failed retention, wear facets, porcelain integrity, etc., must be checked, recorded, and treated as necessary. Assess progression of tooth wear. Reinforcement of preventive measures
Tooth wear is a multifactorial process, which makes it difficult to identify a single cause. Definitive restorative procedures should not be performed without identification of aetiological factors, in conjunction with adequate preventive measures and advice.
‘Tooth wear is a natural process that normally does not require specific treatment. Even patients with more extensive tooth wear do not necessarily require oral rehabilitation if the adaptation is good’ Carlsson GE, Magnusson T. 1999