Assignment #2

Dentition failures and principle of their management

ID NUMBER: 1063533

DATE: 10/10/2011

WORD COUNT: 4230

Introduction: People around the world are at risk of losing their dentition through the life for several reasons. Specific diseases and risk factors are contributing for failure of dentition. However, Understanding and identifying of these diseases and risk factors play an important role in minimizing the risk dentition failure and increase the success rate of any suggested treatment. These papers will discuss why dentitions may fail and the principles of their management. Whether, what are the different causes of dentition failure? Additionally, what are the risk factors that involved in initiation and progression of disease? Furthermore, how can we prevent these diseases? What are the applicable treatments for the conditions? Or even after extraction of the tooth or teeth. Hence the reasons of dentition failure and their management will be discussed in these papers.

Dental caries: Dental caries, otherwise known as tooth decay, is one of the most common chronic diseases of people worldwide (fig. 1). Through all stages of their life, people are susceptible to this disease. Moreover, it is the major cause of oral pain and tooth loss. Dental caries can be defined as a destructive process causing decalcification of one or both of tooth enamel and cementum leading to continued destruction of dentin, and cavitation of the tooth until the tooth is destroyed. Destruction of dental hard tissues occurs by acid production resulting from interaction over time between acid-producing bacteria and fermentable carbohydrate. Kagihara, L., Niederhauser, V. and Stark, M. (2009) indicated that the basic mechanism for all type of dental caries is demineralization, or tooth mineral loss through attack by acid generated by cariogenic bacteria. Root surface caries is similar to enamel caries in mechanism of action but usually associated with gingival margin recession resulting from poor oral hygiene leading to exposure of root surface. Untreated dental caries results in pain, bacteremia, reduced growth and development premature loss of teeth with its sequelae speech disorder, loss of self-esteem, compromised chewing and high treatment cost.

Figure 1: dental caries

Risk assessment of dental caries is essential tool to identify the people who at greatest risk for dental caries and then initiating a preventive dental treatment as early as possible. The new policy of American Academy of Pediatrics (2008) suggested that the American Academy of Pediatric Dentistry, the American Dental Association, and the American Association of Public Health Dentistry recommend that infants be scheduled for an initial oral examination within 6 months of the eruption of the first primary tooth but by no later than 12 months of age. Tinanoff, N. (1995) demonstrated that because caries has multiple causes, multiple risk factors may be required to properly assess the risk for disease. He demonstrated a model of risk assessment that was carried in preschool children and was including a combination of social, biologic and psychological variables. They found the strongest correlation for the dental caries risks were the mutans streptococci levels and the prior history of caries.

Caries risk is changeable as many factors are involved in initiation of caries development. Selwitz, R., Ismail, A. and Pitts, N. (2007) divided the risk factors into three groups: Physical and biological: Inadequate salivary flow and composition, high number f cariogenic bacteria, insufficient fluoride exposure, gingival recession, immunological components, need for special health care and genetic factors. Behavioral: Poor oral hygiene, poor dietary habits including (frequent consumption of refined carbohydrates, frequent use of oral medications that contain sugars and inappropriate methods of feeding infants). social: Numbers of years in education, dental insurance coverage, use of dental sealant, use of orthodontist appliances and poorly designed or ill-fitting partial dentures.

The socioeconomic of parents greatly affects the risk of dental caries in young children, despite the fact that they are covered by comprehensive public oral health program (Peterson, P. 2005). Improving methods of caries detection, assessment and prevention will lead us to an international trend in clinical practice towards prevention of caries instead of operative intervention. Elderton, R. (1993) provides a decision trees to the management of carious lesion or restored tooth indicating when to intervene as opposed to when to do nothing and he indicating that the greater implementation of a restorative philosophy, with all its shortcomings and inherent costs, especially in parts of the world where caries levels are rising, would be to unreasonably ignore research findings and use precious resources to achieve an unwanted and irrational outcome. Several methods have been

introduced to prevent early carious lesions. Fluoride is the most powerful intervention for caries inhibition by altering bacterial metabolism and promoting mineralization. Moreover, the reviewers recommended sealing of pit and fissures in permanent molars to prevent dental caries. Furthermore, elimination of sucrose as can as possible and improving of oral hygiene status play an important role in reducing dental caries. Education of people about dental caries and the different ways for prevention may help in reducing the prevalence of caries. If the caries lesion at stage beyond the early carious lesion, the prevention methods will not be applicable and restorative intervention may needed to stop dental caries extension and preserving tooth structure. A tooth extraction might be indicated especially when the tooth have extensive decay (dental caries)

Periodontal diseases: Several adults around the world currently have some forms of periodontal diseases (fig. 2). Periodontal diseases are inflammatory diseases associated with bacterial infection that affect the gingiva and other tissues supporting the tooth structure (periodontal ligaments, alveolar bone and cementum). In their advanced forms, left untreated periodontal diseases can lead to tooth mobility or even tooth loss. Nyman, S. and Lindhe, J (1979) reported that frequently in cases of advanced periodontitis, the destruction of attachment apparatus has reached a level which calls for extraction of several teeth. Periodontal diseases always start as a mild form of gum disease characterized by swollen, red gum and can easily bleed which called gingivitis. If gingivitis is not treated, periodontitis can be developed leading to pocket formation, loss of attachment and destruction of the bone and connective tissue that hold teeth (fig. 3). Johnson, N. et al (1988) suggested that the inflammatory periodontal diseases encompass anything from the mildest gingival gingivitis to the most advanced destructive periodontitis with loss of bone, loss of attachment and considerable tooth mobility.

Figure 2: periodontal disease

figure 3: stages of development of periodontal disease

The role of risk assessment becomes increasingly crucial on clinical decision making and in identifying patients and population at increased risk of periodontal diseases. Use of formal risk assessment tool can aid dental professionals in the identification of patients at elevated risk of periodontal disease and may help in the selections of patients who require additional education or targeted interventions to prevent or minimize the impact of periodontal disease (Douglass, CH. 2006). In 2002, Page and colleagues introduced the periodontal risk calculator (PCR) which has been shown accurate assessment for patients risk of developing periodontal disease. Information were gathered and entered from the base line of dental research into (PCR) including (patient age, smoking history, diabetes diagnosis, history of periodontal surgery, pocket depth, bleeding on probing, restorations below the gingival margin, root calculus, radiographic bone height, furcation involvement and vertical bone lesions). Then the patients level of risk was determined on a scale from 1 (lowest risk) to 5 (highest risk) for each subject. They found a strong association between scale score of risk and the actual periodontal deterioration observed during a 15-year period.

It has clear that there are several risk factors associated with development of periodontal disease. Page, R. et al (2002) showed that the risk of periodontal disease varies greatly from one person to another and many characteristics and factors have been identified that placed people at enhanced risk. Johnson, N. et al (1988) demonstrated that there are many different forms of periodontal disease with different clinical presentations, and rates of progression, reflecting important differences in etiological factors and host susceptibility and it is no longer to talk of periodontal disease as a single entity. Understanding the risk factors and the proper use of risk assessment tools will maximally reduce the risk of periodontal diseases. These factors can be summarized as the following: Genetic: One of the dominant determinants of periodontal disease onset and progression is host factors and that the risk and susceptibility vary from one person to another. Genetic susceptibility has a dominant effect on the clinical expression of periodontitis among younger patients (Stabholz, A., Soskolne, W. and Shapira, L. 2010). Smoking: Has a major effect on the periodontal ligaments in which the heat from smoke increase calculus deposition and enhance attachment loss. Tanner, A. et al (2005) show that early periodontitis was associated with gingivitis, subject age and cigarette smoking.

Oral hygiene: Long-term studies showing greater tooth loss (assuming periodontitis being the major cause) in patient with poorer oral hygiene (Stabholz, A., Soskolne, W. and Shapira, L. 2010). Stress: Clinical observations and epidemiologic studies suggest that periodontal disease may be affected by depression and stress and anxiety. Stress and related body distress, as well as inadequate coping mechanisms, are important risk indicators. Age: Periodontal disease prevalence and severity increases with increasing age in all populations. Tanner, A. et al (2005) suggested that attachment loss was associated with subject age, gingival index, and bleeding on probing. Diabetes: People with diabetes are at higher risk for developing oral infections, including periodontitis. Campus, G. et al (2005) indicated that poorly controlled diabetic patients have a worse periodontal status than control subject. Medications: Ciancio, s. (2005) has divided the medication and their impact on periodontal disease into four main categories: I. Those which affect oral hygiene. II. Those which affect diagnosis of periodontal disease. III. Those which affect gingival and oral mucosal tissues. IV. Agents affecting alveolar bone. Illnesses: Diseases like quantitative and qualitative neutrophil deficiencies, Down syndrome, AIDS, functional leukocyte disorders, chronic granulomatous disease, papllon-lefevre syndrome, trisomy 21 and cancer and their treatments can also negatively affect the health of gums. Obesity: Studies have indicated that the fat distributions pattern plays a crucial role in the association with periodontitis hygiene (Stabholz, A., Soskolne, W. and Shapira, L. 2010). Socioeconomics level: Socioeconomic status historically has been found to be related to gingival and poor oral hygiene (Douglass, CH. 2006). Hormonal changes: Hormonal changes during pregnancy or puberty in girls/women can make gums more sensitive and make it easier for developing of periodontal disease.

Periodontal diseases treatment requires patient motivation and self-care to ensure the treatment will succeed. In addition, identifying the risk factors and attempting to stop or modify it play an important role in management of periodontal diseases. Control of infection by doing deep scaling, root planning and elimination of pockets and other retention factors for plaque is first choice of treatment. Some cases may require prescription of antibiotic such as low-dose doxycycline to inhibit periodontal bone loss. In advanced cases or if the disease is not responding to the deep cleaning, surgical option (flap or bone and tissue graft) may take place in the treatment. When the level of supporting bone is largely reduced and the tooth become excessively mobile tooth extraction may be the only options.

Tooth wear: Loss of minimal amount of tooth tissue on the occlusal, incisal and proximal is a normal physiological process and occurs throughout the life. When the degree of tooth wear exceeds what would be considered normal for particular age, then it may be considered pathological and that may lead to loss of the dentition. Hemmings, K. et al (1995) indicated that tooth wear is believed to be multifactorial in nature and in approximately 30% of cases the precise etiology is unknown. Tooth wear is often localized to anterior teeth but some time may be generalized through dentition. Many of these patients are teenagers or young adults and not the middle aged or elderly who are classically associated with loss of tooth tissues (Bishop, K., Briggs, P. and Kelleher, M. 1994). Tooth wear can be classified according to its etiology into erosion and Para functional habits (abrasion and attrition). Erosion: Kelleher, M. and Bishop, k. (1999) defined erosion as the progressive loss of hard dental tissues by chemical process not involving bacterial action (fig. 4). In general dental practice, erosion is becoming an increasingly important problem. Erosion make affected teeth surfaces round and destroy their surface characteristics. The widely held believe that intrinsic (gastric) acid result in palatally eroded site and extrinsic (dietary) acids lead to labial erosion remain controversial (Milosevic, A. 1999).

Figure 4: dental erosion

There are several etiological factors which are associated with tooth erosion such as: 1. Diet: The soft drinks have acidic natures which increase the susceptibility to erosion. In addition alcohol consumption is major risk factors. Ph. of commonly consumed drinks Manufacturer brand pH Pepsi-cola diet 2.95 Coca Cola regular 3.15 Caffeine free-diet 3.30 Tab clear- diet 3.20 lucozada Sport orange 3.78 tango Diet orange 2.80 Orange juice 3.50 2. Acid regurgitation: Hydrochloric acid regurgitated into the mouth will cause dental erosion (Bartlett, D. and Smith, B. 1996). Gastric contents are directed by the tongue forward during voluntary and prepared vomiting while the lateral spread of the tongue protects the lower teeth. 3. Salivary flow: If reduced, may increase the potential of erosive damage.

Para functional habits: Para functional activity may cause anterior teeth wear especially if protrusive grinding activities exist. Continued wear may cause shortening of teeth, fracture of enamel and may loss of teeth. It divided into two types of diseases: Attrition Defined as the loss by wear of tooth substance or a restoration caused by mastication or contact between occluding or a proximal surfaces (fig. 5). Associated with flattening of incisal edges, cusp tips and localized facets on the palatal or occlusal surfaces. Abrasion Defined as the loss by wear of tooth substance or a restoration caused by factors other than tooth contact (fig. 6). Caused by abnormal rubbing of tooth structure by hair-grips, pipe-smoking and over vigorous tooth brushing. Tooth wear can be accelerated by abrasive nature of many component of diet.

Figure 5: dental attrition

figure 6: dental abrasion

Several factors may influencing the choice of treatment worn dentition such as amount of remaining tooth structure, occlusal vertical dimension, patient compliance and expectations, vitality of the affected teeth and occlusal guidance. Early diagnosis of the problem and understanding of the properties of dental materials and different treatment strategies and technique will help to achieve successful management of different degree of tooth wear. Treatment plan should be as following: Monitoring: Monitoring of the rate of tooth wear is the first sensible step in planning of treatment. Prevention: Should be including the following: I. Correction of etiological factors. II. Occlusal splint therapy to reduce the effect of para-functional habits. III. Topical application of fluoride. IV. Alkaline solutions used after vomiting. Restorative treatment: It is advisable to use a reversible device such as a hard maxillary occlusal splint or removable overlay denture to evaluate a patients adaptive ability to the new occlusal scheme and protect the remaining tooth structure (Chu, F. et al. 2002). Treatment choices are include: I. Reduction of clinical crowns and position of complete or partial overdenture. II. Restoration of occlusal surfaces using complete or partial onlay or overlay dentures. III. Restorations of anterior teeth using crowns or veneers, a removable partial denture providing posterior support. IV. Restoration with conventional crown. V. Restoration with adhesive techniques:

Direct composite restorations placed at an increased occlusal vertical dimension can provide a simple, short-term restorative solution to patient with localized anterior tooth wear and loss of interocclusal space (Hemmings, K., Darbar, U. and Vaughan, S. 2000). An effective maintenance regime and recall system should be instituted. When teeth are beyond restoration or patient does not wish to receive more complex treatment extraction of teeth is the last solution.

Occlusion: Occlusal factors may be important in the etiology of increased tooth mobility and loss of dentition. Chu, F. et al. (2002) demonstrated that increase of OVD may lead to tooth mobility, repeated failure of restorations, clenching and even myofacial pain. Traumatic occlusion defined as repeated excessive force in closure of the teeth that injures the teeth, the periodontal tissues, the residual ridge, or other oral structures. The closure extends beyond the reparative ability of the attachment apparatus (cementum, periodontal ligaments, and alveolar bone). Traumatic occlusion can affect an individual tooth or group of teeth (fig. 7). Increase in mobility might happen when a new restoration produces a premature occlusal contact or interference (direct occlusal trauma), or as a result of an occlusal interference somewhere else in the mouth causing a damaging deflection (indirect occlusal trauma) Wassell, R. et al (2008).

Figure 7: traumatic occlusion Treatment of Traumatic occlusion: Should be treated as early as possible. Mostly treated by grinding the chewing and biting surfaces of teeth to achieve balance and proper alignment and this procedure called occlusal equilibration. occlusal restoration is also sometimes is needed to: I. Correct the alignment of teeth. II. Increase distribution of occlusal force over a large number of teeth surfaces. III. Prevent over eruption of any opposing teeth.

Prosthetic failure: Prosthetic failure may lead to the need for extraction of the abutments teeth or inability to further restore of the teeth. Downer, M. et al (1999) suggested that 50%of all restorations last 10 to 20 years. Dental prosthesis fails for great variety of reasons such as: Fracture of the artificial or natural crown and the tooth considered unrestorable due to location of fracture or carious destruction of the remaining tooth. Reuter, J. and Brose, M. (1984) indicated those abutments that were root-treated after bridge cementation were more prone to retainer or abutment fracture than vital abutments or those root-treated beforehand. Fracture of the root (fig. 8). Severe bone destruction due to improper prosthetic margin.

Figure 8: root fracture

Endodontic failures: The success rate of endodontic treatment is directly related to reducing the number of microbial population within the root canal system and to prevent reinfection by a tight seal of root canal space. Some endodontic failure make the endodontic retreatment is impossible and the only choice of treatment is extraction. Vire, d. (1991) showed that failure of endodontic origin is less frequent but appears to occur faster than that of periodontal and prosthetic failures. Several reasons are contributing to endodontic failure such as: Vertical root fractures. Instrumentations failure such as: strips, zips, and incomplete instrumentations. Severe resorption. Loss of periradicular bone support, due to periradicular inflammation or after apical surgery (fig. 9).

Figure 9: periradicular inflammation

Trauma: Trauma is one of the most common causes of failing of dentition and extraction of teeth especially in the children and adolescents (fig. 10). In addition, traumatic injuries to the dentofacial part of body have a substantial impact on people daily life. Loss of one or more teeth may have psychological effect on patient life. The most common causes of dentofacial injuries are: falls, collision with an object, assault, bicycle accidents and vehicle accident. Trauma may lead to one or several of the following probabilities root fracture, crown root fracture, avulsion, alveolar fracture and jaw fracture. Adekoyasofowora, c. (2008) indicated that dental injuries could have improved outcomes if public were aware of first aids measures and the need to seek immediate treatment. Dental trauma also may cause root resorption and failing of dentition so that teeth should be under observation after the trauma.

Figure 10: traumatic injury

Developmental failures: Several dental abnormalities may occur during the development stages of dentition. Disorders of development of teeth may be inherited or acquired causing anomalies in the number, size, and form of teeth. Hypodontia and anodontia: Congenital absence of one or several permanent teeth referred as hypodontia (fig. 11), while absence of all teeth referred as anodontia. These developmental abnormalities are usually associated with: I. Genetic disorders: Down syndrome. II. Environmental factors: radiation. III. Hormonal factors: Hypoparathyroidism. IV. Infectious factors: rubella.

Figure 11: hypodontia

Amelogenesis imperfecta: Hereditary condition affecting enamel formation causing thin, discolored and with high risk of dental cavities. The enamel has a similar density to dentine on radiographs Because of the deficient mineralization. Crowns are sometimes being indicated to protect the soft enamel. Usually stainless steel crowns are used in children that replaced by porcelain once they reach adulthood. Sometime, the teeth may have to be extracted. Dentinogenesis imperfecta: Defect of the dentin that causes discoloration and translucency and weakness of dentin.

Pathological failures: External root resorption can be caused by pressure adjacent to the area near the stimulation source. Larson, TH. (2007) explained that Tumor pressure caused mostly by slow growing tumors such as cysts, ameloblastoma, giant cell tumors, and fiberosseous lesions, does not affect the pulpal health unless the tumors are located at the apical foramen and disturb blood flow (fig. 12). Relieve the tumor pressure stop the root resorption. In some cases, extraction of involved teeth is part of tumor management.

Figure 12: Ameloblastoma

Treatment of failed dentition: There are number of reasons why your tooth or teeth might be unrestorable and the dentist indicates that you have tooth or several teeth must be extracted. In most of cases replacement of extracted tooth or teeth are mandatory to restore the normal function and esthetic of dentition. Careful evaluation of the existing dental and functional situation, benefits, risks and costs of any prosthetic management must be preceding the decision of tooth replacement. Kayser, A. (1981) suggested that there is sufficient

adaptive capacity in shortened dental arches when at least 4 occlusal units are left, preferably in a symmetrical position. Multiple ways of prosthetic treatment are available for replacing of any extracted teeth. Several factors determined the best way of treatment such as: the patients degree of cooperation, biological and technical quality of prosthetic materials general and oral health status of the patient, economic resources and the prosthodontists knowledge. The most common replacement procedures for teeth are as follows: Do nothing: Accept the space and leave it empty. Budtz-jorgensen, E. (1993) indicated that in patients with poor oral hygiene, the best solution with regard to the prognosis of the remaining teeth is to abstain from any prosthetic treatment. In addition, studies indicate that oral function can be achieved by premolars and anterior teeth. Implants: Usually made of titanium and is placed within bone of the jaw leading to a process which called osteointegration (fusion between implant surface and surrounding bone) (fig. 13). Can be used to replace tooth or several teeth by supporting dental prosthesis including: crowns, implant- supported dentures and bridges. The jaw should have sufficient and strong amount of bone to hold and support the implants. The main advantages of dental implant low marginal bone loss around the implant, limited adjustment of the prosthesis, last longer, perfectly safe for the teeth adjacent to the missing tooth and high success rate. The main disadvantage is the high initial cost.

Figure 13: implants Removable dentures: Removable dentures are divided into two main categories: partial denture replacing one or more teeth which are missing (fig. 14). While, full dentures replacing all teeth in the upper or lower jaw. Patient has the ability to remove and reinsert them without professional assistance. There are several drawbacks of removable dentures such as impaired esthetic and oral comfort, accumulation of plaque, root caries, mechanical failure (fracture of major or minor connectors,

occlusal rests, and retentive clasps) and frequent readjustment due to bone resorption. The positive things in the removable dentures are a non-invasive and low cost solution.

Figure 14: removable partial denture Fixed partial denture: Also known as dental bridge and mostly used to fill a gap between two teeth or tooth and implant by grinding down and creation of two crowns for the teeth on each side of the gap and permanently joining them by a false tooth/teeth (fig. 15). Multiple materials can used to fabricate of dental bridge such as: porcelain, gold or porcelain fused to gold. The main weaknesses of the fixed partial denture are the invasive and irreversible nature of the treatment, tooth fracture, caries, technical, periodontal and endodontic complication. On the other hand, success rate of fixed partial denture is high with better patient comfort and occlusal stability than treatment with removable denture or a partial denture.

Figure 15: fixed partial denture Overdenture: Overdenture is a complete or partial denture supported by tooth abutments or implant (fig. 16). Retention of the overdenture can be improved by using magnets or precision attachments. Gillings, B. (1983) described that the magnetic retention can be used on roots that would have a poor prognosis with conventional precision attachments without transmitting significant tipping forces to the tooth root. The main advantages of overdenture are decreased resorption of residual ridges, easily modified if one or several abutments are lost and psychological benefits. The main disadvantages are associated with caries and

progression of periodontal disease. Overdenture treatment should not be considered if treatment with fixed or removable partial denture is possible (Budtzjorgensen, E. 1993).

Figure 16: overdenture

Conclusion: In conclusion, it seem that dentition failure have numerous reasons. Dental health practitioners should be able to identifying and determining the causative diseases and the involved risk factors. Using and improving risk assessment tools may help in reducing the incidence of dentition failure. Applying of preventive measures plays crucial roles in preserving and maintaining the natural teeth and their function. Frequent recall examination keep the dentist updated with the oral status of patient and minimize the need for invasive treatment. In some cases extraction of tooth or teeth is the only choice. Dentist should be having adequate knowledge about multiple ways of teeth replacement and the advantages and disadvantages of each way to achieve best results.

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