Tooth Wear

8th sem. dental students, Spring 2008

Department of Cariology and Gerodontology, Faculty of Dentistry, UiO

Alix Young Vik

Tooth Wear
Unrefined diets severely worn dentition Modern refined diet - low degree of wear
Excessive toothbrushing Bruxism Erosion
- considered pathological

Tooth wear denotes the gradual loss of hard dental tissues through several processes..

Tooth wear
Attrition Abrasion (Abfraction) Erosion

Each wear process can under some circumstances operate alone Tooth wear observed in an individual will have resulted from a combination of the these main processes, even though one process may predominate

Attrition
Gradual and natural loss of tooth substance under toothtooth contact Functional and parafunctional movements Pathologic attrition
biting habits or abnormal occlusion

Clinical features

(approximal surfaces)

occlusal and incisal facets

Attrition: Influencing factors

Age Salivation (quantity/quality) State of the dentition, occlusion Diet Parafunction
(bruxism, clenching of teeth)

Attrition: Consequences
Loss of vertical dimension (without compensatory eruption) Pulpal trauma Hypercementosis/ periodontal bone trabeculation Exposure of dentine
Sensitivity Faster mineral loss in dentine than in enamel pitting:
Food retention, enamel fracture, chin-/tongue biting, irritation

Attrition: Treatment
Inform the patient Restore deep pits in dentine Consider use of an occlusal splint Consider prosthetic rehabilitation

Abrasion
Gradual loss of tooth substance caused by friction between teeth and other materials

e.g. toothbrush, hard toothpicks, chewing of pens, pipe

Clinical features

smooth buccal surfaces that have lost their developmental patterns wedge-shaped defects in cervical region atypical defects on the incisal edge in special cases

Abrasion
- well-defined margins - hard smooth surfaces (scratches) - normally free of plaque

Abrasion
Abrasion lesions are worsened in an acidic oral environment
the abrasive object can more readily remove tooth mineral that is softened by acid

Abrasion: Consequences
Sensitivity Weakening of the tooth

Abrasion: Treatment
Identify the cause Modify habits (oral hygiene, diet) Fluoride, especially if the oral cavity is acidic (active) Consider restoration of lesions

(Abfraction)
Cervical lesions caused by abnormal occlusal loading leading to mechanical and chemical wear
Under large occlusal forces or offaxis loading of tooth cusps, the teeth experience microscopic levels of bending at the CEJ, leading to concentration of stress and microcrack formation These areas are more susceptible to mineral loss in connection with abrasion and erosion

Clinical features

Wedge-shaped non-carious defects that look like abrasion lesions

Limited evidence and support for this hypothesis: a hypothetical component of tooth wear

Abfraction: Consequences
Sensitivity Weakening of the tooth Reduced lifetime of restorations (GIC, ceramics) plus Possible TMD (temporomandibular dysfunction) Tooth fracture and wear Residual endo/perio lesions

Abfraction: Treatment
Modify diet Fluoride daily extra tilfrsel Occlusal splint Consider restoring lesions

Erosion
Gradual loss of tooth substance caused by acid other than that produced by bacteria
abscence of perikymatia, even, smooth surfaces concavities, mainly cervically on labial surfaces, but also on lingual surfaces: much greater width than depth prone' restorations and clean' amalgam surfaces pits/gropes on cusps and incisal edges

Clinical features

Erosion: Classification
Acid source

Extrinsic (external)

Food and drinks Medicine Swimming pool water Industrial (acidic- vapour, dust)

Intrinsic (internal)

Eating disorders Gastrointestinal disorders Gravidity Alcoholism

Erosion: Classification
Localization
General involves many teeth Local involves only a few teeth

Clinical severity Pathogenic activity

Manifest active and progressive Latent- inactive or stopped

(based often on either a micromorfological examination done in a microscope using a replica or a model of the tooth surface, or on symptoms such as sensitivity)

Erosion: Evaluation
Grading (clinical index)
- different grading systems for erosion

Eccles 1979, Smith & Knight 1984, Lussi 1996, Larsen et al. 2000

Erosion: Classification
From Lussi (Eur J Oral Sci 1996; 104: 191-198) Labial/palatinal surfaces
0 = original developmental structures present 1 = signs of erosion - smooth, glazed enamel without loss of original morphology 2 = signs of erosion, loss of enamel with flattening of surfaces or concavities, width greater than depth, no dentine loss 3 = loss of enamel with exposed dentine less than 1/3 of surface area 4 = loss of enamel with exposed dentine > 1/3 of surface area 5 = original morphology changed labially or palatinally in addition to one or both approximal surfaces

Incisal/occlusal surfaces

0 = original developmental structures present 1 = loss of enamel glazed appearance either locally or over the whole surface, facets or rounded cusps 2 = loss of enamel with exposed dentine i small areas 3 = loss of enamel with exposed dentine over the whole surface or on large parts of one or more cusps 4 = extensive loss of enamel and dentine corresponding to 1/32/3 of crown height 5 = extensive loss of enamel and dentine corresponding to > 2/3 of crown height

Lussi: Simplified grading system

Facial surfaces
Grade 0: No erosion. Surface with a smooth, silky-shining appearance, absence of developmental ridges possible Grade 1: Loss of surface enamel. Intact enamel found cervical to the lesion. Concavity in enamel, the width of which clearly exceeds its depth, thus distinguishibg it from toothbrush abrasion. Undulating borders of the lesion are possible Grade 2: Involvment of dentine for less than one half of the tooth surface Grade 3: Involvement of dentine for more than one half of the tooth surface

Oral and occlusal surfaces

Grade 0: No erosion. Surface with a smooth silky-shining appearance. Absence of developmental ridges possible Grade 1: Slight 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 involved. Grade 2: Severe erosion, more pronounced signs than in grade 1. Dentine is involved.

NTF-Tidende 2005;115: 160-164

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Clinical routines in cariology

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Erosion: Classification
Grade 1: Early erosion
Early stage Loss of enamel structures Dull surface appearance (active)
(Can be smooth/shiny -chronic)

Minimal loss of enamel (only just measurable)

Erosion: Classification
Grade 2: Erosion in enamel
Obvious loss of enamel Dentine not exposed

Lemon sucking

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Erosion: Classification
Grade 3: Erosion in dentine
Dentine involved:
Less than del of the tooth surface with exposed dentine

Erosion: Classification
Grade 4:
1/3 - 2/3 of tooth surface has exposed dentine
Grade 4 Grade 3

Grade 4

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Erosion: Classification
Grade 5:
More than 2/3 of the tooth surface has exposed dentine and/or the pulp is exposed

Grade 5

Grade 5 erosion

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Erosion: Etiology
High consumption of acidic food/drinks (soft drinks, juice and fruit)

Norway: ca. 120 L soft drink per person/year and 30 L juice

NB! sports drinks, herb teas, acidic candies, alcohol, effervescent vitamin C tablets

Frequent vomiting and digestive problems

Vomiting, acid taste in the mouth and gastric pain (especially when awakening), stomach ache, any sign of anorexia Drugs: alcohol, tranquillizers, antimimetics, antihistamines, lemonade tablets (replacement of acidic drugs or salivareducing drugs is possible)

Erosion
Factors that influence the erosive potential of food and drink*
Chemical factors Habit-related factors Biological factors
(*from Lussi et al. Caries Res 2004; 38: 34-44)

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Erosion: Chemical factors*

pH and buffer capacity

Adhesion of the product to the tooth surface Modification of amount/type of acid Calcium chelation properties:
e.g. use of maleic acid instead of citric acid

High buffer capacity in a drink means that it will take longer for saliva to neutralize it

Calcium-, phosphate- and fluoride concentration: in vitro studies: e.g. orange juice (pH 4) with added calcium and
phosphate has low erosive potential yoghurt contains both calcium and phosphate less erosive

strong chelators will bind the calcium that is solubilized from the tooth surface (not available for remineralization)

(*from Lussi et al. Caries Res 2004; 38: 34-44)

Erosion: Habit-related factors*

Eating and drinking habits
Healthier lifestyle (+++ fruit and vegetables) Increasing consumption of acidic food and drink (e.g. wine, salad dressings)

Baby bottle with cordial/juice Oral hygiene

(*from Lussi et al. Caries Res 2004; 38: 34-44)

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Erosion: Biological factors*

Saliva: flow rate, composition, buffer capacity, stimulation properties Pellicle: thickness, composition, diffusion properties Dental anatomy and occlusion Soft tissue anatomy and relation to the teeth Physiological soft tissue movements

(*from Lussi et al. Caries Res 2004; 38: 34-44)

Erosion: Consequences
Sensitivity Weakening of the teeth Reduced lifetime for some restorations (GIC and ceramic)

Erosion: Treatment
Dietary analysis change in unfavourable dietary habits Psychological/medical factors Fluoride - daily Consider restoring the most serious erosion lesions

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Erosion/abrasion can lead to tertiary dentine formation in the pulp

Tooth Wear: Prophylaxis/therapy

Good diagnosis Causal therapy Prophylactic changes in possible causal factors Fluoride Documentation and follow-up Restorative treatment

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Tooth Wear: Diagnosis

Good diagnosis is a prerequisite for causal therapy

Clinical examination

Documentation

surface changes loss of substance (facets, concavities, filling relationship) gingival/periodontal conditions saliva (stimulated/resting, volume, buffer capacity) muscular activity clinical photographs (NB! date important) impressions models drawing/description

Fluoride (NaF)
Toothpaste Painting (brush application) Tablets (dissolving) Mouthrinses

Fluor protector

In vitro: Results look promising if F-treatment is intensive enough In situ: Intensive F-treatment is effective In vivo: ?

SnF2, TiF4 can be effective against erosion Acidic, increase F-retention time, promote CaF2formation a protective glaze forms
Effect of stannous fluoride toothpaste on erosion-like lesions: an in vivo study. Young A, Thrane PS, Saxegaard E, Jonski G, Rlla G. Eur J Oral Sci 2006; 114: 180-183.

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Treatment General guidelines

Erosion and abrasion lesions should be considered for restoration when the lesions are:
carious deep enough that tooth integrity or pulp are in danger sensitive (conservative desensititizing methods do not help) esthetically unacceptable involved in a partial prothesis design

Choice of restorative material

Dependent on:
Size Esthetics Moisture control Occluso-gingival placement

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Occlusal and palatinal erosion with dentine involvement

History: Bullimia

Photos: Dental erosion. From diagnosis to therapy. Lussi (ed)

Severe facial erosion defects with dentine involvement

History: Lemon slices under the lip

Photos: Dental erosion. From diagnosis to therapy. Lussi (ed)

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Advanced erosive tooth wear indirect ceramic veneers and overlays

Raised vertical dimension ca. 1.5 mm

History: Bullimia as teenager

Photos: Dental erosion. From diagnosis to therapy. Lussi (ed)

Advanced erosive tooth wear indirect ceramic restorations

Raised vertical dimension ca. 4 mm History: anorexia nervosa, acidic diet

Photos: Dental erosion. From diagnosis to therapy. Lussi (ed)

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Norwegian Labour and Welfare Organisation (NAV)

Rundskriv 5-6, Tannbehandling. 9 Patologisk tap av tannsubstans ved attrisjon/erosjon The condition must be serious in order to be financed. This means that the condition must have an essential role in function/esthetics. In order to be able to determine whether the condition is serious it must have been followed up over at least one year. The seriousness of the condition must be documented prior to commencement of treatment. Treatment must be planned based on the activity of the condition, the long-term prognosis and on minimal intervention treatment, whereby semi-permanent treatment can be considered in the first phase. Utgiftene dekkes etter refusjonstakstene

Erosion: Simple advice for patients

Drink water (or milk) ! Avoid/limit intake of very acidic drinks and food Finish meals with neutral food, e.g. cheese Use a straw, do not rinse mouth with acidic drinks

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Advice cont.
Do not brush teeth right after acidic drinks/food, rinse with water before brushing Use a soft toothbrush and toothpaste with low abrasive effect Regular local F-treatment ( F-conc. if active, sensitive lesions)

Referances
Dental erosion. From diagnosis to therapy. Lussi A (ed.), Monographs in Oral Science, vol 20 Whitford G.M. (ed.) Karger 2006. Dental erosion. Bakgrund og kliniska aspekter. Johansson A-K., Carlsson GE (eds.). Gothia, Stockholm 2006. Occlusal wear of teeth and restorative materials. Dahl B, Carlsson GE, Ekfeldt A. Acta Odont Scand 1993, 52: 299-311. Progression of and risk factors for dental erosion and wedge-shaped defects over a 6-year period. Lussi A, Schaffner M. Caries Res 2000; 34: 182-187. The role of diet in the etiology of dental erosion. Review. Lussi A, Jaeggi T, Zero D. Caries Res 2004; 38 Suppl 1: 34-44. Dental erosion. Clinical diagnosis, prevention and minimally invasive treatment. Lussi A, Schaffner M, Jaeggi T. NTF-Tidende 2005; 115: 160-4. A critical review of non-carious cervical (wear) lesions and the role of abfraction, erosion, and abrasion. Bartlett D, Shah P. J Dent Res 2006; 85(4): 306-312. Extra-esophageal manifestations of gastroesophageal reflux. Farrokhi F, Vaezi MF. Oral Diseases 2007; 13: 349-359.

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 http://www.odont.uio.no/om/iko/fagavdeli nger/kariologi/undervisning/foreles.html

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