Tooth Wear Yr 2 by HSU ZENN YEW

TOOTH WEAR & RESTORATION OF ABRASION LESIONS 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: diificulty 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&#x201A;&#x161; Defined as loss of dental hard tissue as a result of chemical process NOT involving bacteria ď&#x201A;&#x161; 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

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

Pickardsâ&#x20AC;&#x2122; Manual, Lussi 2006, Badel et al 2007

ď&#x201A;&#x161; 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)

MANAGEMENT

 DIAGNOSIS

 PREVENTION  STABILIZATION

 RESTORATION/ REHABILITATION  REVIEW / MONITORING

Pickards’ Manual, Lussi 2006 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. 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.

PREVENTION 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

PROTECTIVE MECHANISM

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.

 Composites may be placed temporarily or semipermanently over exposed areas  Endodontic treatment: irreversible pulpitis necrotic pulp or periapical pathology

RESTORATION  ONLY NECESSARY IF TOOTH WEAR IS PATHOLOGICAL  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

ABRASION LESIONS  a.k.a. non carious cervical lesions (NCCL), non carious Class 5 lesions

 NOT ALL ABRASION LESIONS REQUIRE RESTORATIONS:  When do we restore?

RESTORATION OF ABRASION LESIONS  ACCESS & ISOLATION  Difficult access in buccal surface of upper posterior, lingual of lower molar  Difficult access in subgingival lesion :  Non surgical retraction: retraction cords, rubber dam is sometimes useful to retract tissue  Surgical retraction: conventional, electrocautery, laser surgery  Simultaneus: combined surgical-restorative or  Two-step: surgery-> 4-6 weeks for gingival healing and maturation > restoration

Pickard’s Manual www.cdeworld.com

RESTORATION OF ABRASION LESIONS ď&#x201A;&#x161; SELECTION OF DENTAL MATERIALS RESTORATIVE MATERIALS Non esthetic materials Amalgam Gold foil (not widely used) Gold inlay

Esthetic Materials Resin composite Flowable resin composite Resin composite with dentine bonding systems Resin composite with glass ionomer liner Glass ionomer Resin Modified Glass Ionomer Compomer Porcelain Inlay (not widely used)

RESTORATIVE MATERIALS

Adhesion to enamel

Adhesion to dentine

Poor Requires removal of tooth structure for retention

Poor

Good

Poor

Good

Poor

Good

Flowable resin composite

Good

Poor

Excellent

Poor

Resin composite with dentine bonding systems

Good

Poor High Cfactor Esp in deep, subgingival cavity

Excellent

Glass ionomer

Good

Satisfactory

Resin Modified Glass Ionomer

Good

Satisfactory

Compomer

Good

Poor

Good

Poor

Inferior to CR

Porcelain Inlay (not widely used)

Poor

Excellent

Good

Requires laboratory

Amalgam

Gold foil (not widely used) Gold inlay

Esthetic

Sensitivity to moisture

Blood, gingival crevicular fluid, saliva affect success

Allow easier sculpting

F- release

Factors: Depth of cavity, remaining tooth structure (enamel/dentine) on margin, esthetic requirement, ability for moisture control,cost, operator preference

SANDWICH TECHNIQUE  Defined as resin composite with glass ionomer liner  ‘Closed’(enamel margin)/ ‘Open’ (bonded margin) sandwich techniques

 Combined benefits of GIC and composite  GIC is used to replace missing dentine  fluoride release ->Protect gingival margin against demineralization  Better adhesion to dentine through chemical bonding/ ion exchange mechanism ->reduce microleakage and increase retention

 Composite is used to replace missing enamel  Esthetics (compare to opaque GIC)  Increased abrasion resistance  Good bonding to enamel

 Missing dentin is replaced with either a resin-modified or high-viscosity glass ionomer.

 This modification of the closed sandwich untilized in cavities lacking enamel at the cervical margin.

 Composite resin is used to replace enamel and seal the enamel margins surrounding the cavity

 A glass ionomer is used in lieu of composite resin to restore the cervical aspect of the proximal box, imparting optimal resistance to microleakage and secondary caries along dentin margins

 Enamel remaining in gingival margin

 Bonded base

 Clinical trial: 96% survival after 5 years  Open sandwich: indicated for patients with good oral hygiene  GIC susceptible to surface degradation esp in acidic environment/ high caries risk

Fundamental Operative Dentistry Hewlett et al 2003