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DR.

APPLU ATREY PG PART I DEPT OF CONSERVATIVE DENTISTRY AND ENDODONTICS

INTRODUCTION DIFFERENT TYPES OF NON CARIOUS LESIONS CONSEQUENCES OF TOOTH WEAR TREATMENT MODALITIES OF TOOTH SURFACE LOSS CONCLUSION REFERENCES

Normal physiologic process that occurs throughout life.

Problems arise when the rate of loss becomes


excessive causing functional or esthetic problems or sensitivity for the patient.

Enamel is one of the few tissues in the body that


does not regenerate or replace itself in the way that skin, blood cells, and fractured bones do. Fortunately, the dentine does show some reparative mechanisms as reactionary or reparative dentine which is laid down in the pulp chamber as a response to tooth wear

Traditionally, the terms erosion, abrasion and attrition were used to describe non carious pathologic loss of tooth structure.

Smith and Knight advocated the use of term

tooth

wear .

Tooth wear is defined as the surface loss of dental hard tissues other them by caries or trauma .

Tooth wear is a cumulative lifetime process which is irreversible . Clinically tooth wear appears to progress very slowly over years

Tooth wear has the multi-factorial aetiology, but certain clinical features may suggest a major contributory factor.
Traditionally, cervical lesions caused purely by abrasion have sharply defined margins and a smooth, hard surface. The lesion may become more rounded and shallow if there is an element of erosion present

Flattening of cusps or incisal edges and localized facets on occlusal or palatal surfaces would indicate a primarily attritional aetiology. Once dentine is exposed, the clinical appearance is determined by the relative contribution of the etiological factors. If wear is primarily attritional, then dentine tends to wear at the same rate as the surrounding enamel. Erosive lesions cause cupping to form in the dentin.

Change in appearance of teeth


Exposure of dentin normally covered by enamel Dentin Hypersensitivity Loss in occlusal vertical dimension Loss in posterior occlusal stability resulting in

Mechanical failure of teeth or restorations


Hypermobility and drifting

Exposure of pulp
Pulpitis and loss of vitality

In-vitro measurement
Macroscopic changes Polarized light microscopy Surface profilometry Microhardness tests Scanning electron microscopy In-vivo Microradiography measurement Digital image analysis Iodine permeability Macroscopic Synthetic hydroxyapattite changes powders/discs Replica Calcium and phosphorus technique dissolution Intra-oral carcinogenicity test

Newer methods
Scanning tunneling microscope Atomic force microscope Finite element analysis

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9. 10. 11. 12. 13.

Attrition Erosion Abrasion Abfraction Localized non hereditory Enamel hypoplasia Localized non hereditory enamel hypocalcification Localized non hereditory dentin hypoplasia Localized non hereditory dentin hypocalcification Discolourations Malformations Amelogenesis imperfecta Dentinogenesis imperfecta Trauma

ATTRITION
Derived from Latin word ATTRITIM meaning action of rubbing against something

The physiologic wearing of the teeth resulting from tooth to tooth contact as in mastication.

Shafer

Wear caused by endogenous material such as microfine particles of enamel prisms caught between two opposing tooth surfaces.

Every (1972)

Loss by wear of surface of tooth or restoration caused by tooth to tooth contact during mastication or parafunction

Milosevic, 1998

Attrition occurs at an ultra structural level It can be caused by direct contact between surfaces or the action of an intervening slurry

Attrition can be hastened by coarse diet and abrasive dust

Some para-functional habits like Bruxism may also contribute to attrition

Distribution of attrition is influenced by the type of occlusion, the geometry of stomatognathic system and grinding pattern of the individual.

If occlusal wear occurs at a rate faster than compensatory physiologic mechanisms, it is considered pathologic.
Vertical loss of enamel of 50-68 m/year is considered physiologic

ATTRITION

PROXIMAL SURFACE ATTRITION (PROXIMAL SURFACE FACETING) OCCLUDING SURFACE ATTRITION (OCCLUSAL WEAR)

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3. 4. 5.

Shiny wear facets with well defined borders The surface of wear facet is flat and flush with the opposing tooth on contact Enamel and dentin wear at the same rate Possible fracture of cusps or restorations Pure attrition shows equal wear on both arches. (unlike erosion)

SCORE
0 1 2

CLINICAL FEATURE
NO WEAR MINIMAL WEAR NOTICIBLE FLATTENING PARALLEL TO OCCLUDING PLANES

3
4

FLATTENING OF CUSPS AND GROOVES


TOTAL LOSS OF CONTOUR AND/OR DENTIN EXPOSURE

Richard and brown, 1981

EROSION
Derived from Latin verb EROSUM meaning to corrode

Erosion is defined as superficial loss of hard tissue due to chemical process not involving bacteria.

Every (1972)

Erosion is process of gradual destruction of tooth surface, usually by a chemical or electrolytic process.

Imfeld T (1996)

Erosion is defined as the chemical dissolution of teeth by acids

Martin

Dental erosion is defined as the progressive, irreversible loss of hard dental tissues due to a chemical process not involving bacteria

Gandara BK, Truelove EL. Diagnosis and management of dental erosion. J. of Contemporary Dental Practice 1999; 1(1): 1-17

Clinically, erosion is primarily a surface phenomenon The solubility of enamel is pH dependent The rate at which apatite precipitates depends on factors such as calcium binding in saliva. The critical pH of enamel is 5.5, any solution with a lower pH may cause erosion if the attack is lengthy and intermittent over time.

In early stages, erosion effects enamel resulting in smooth, glazed surfaces In advanced cases, restorations may project above the occlusal surfaces and exhibiting concavities known as cupping; increased incisal translucency Rapid process may lead to sensitive teeth due to dentin exposure while slower progressive lesions may be asymptomatic

Class I superficial lesion involving enamel only


Class II localized lesions that involve dentin or less than 1/3rd of the surface Class III generalized lesions involving dentin and more than 1/3rd of the surfaces Eccles et al, 1979

Extrinsic (exogenous)

Environmental by acid fumes and aerosols in occupational, swimmers


Diet citrus fruits, carbonated drinks, vinegar Medication aspirin, vit-C, calcium chelators Life style fruits and diet drinks, bleaching agents

Intrinsic conditions that lead to chronic vomiting or


persistent gastroesophageal reflux

Anorexia and bulimia nervosa Chronic alcoholism Morning sickness associated with pregnancy

Clinical severity

SUPERFICIAL EROSION

Superficial Localized Generalized

Activity of progression

Active or manifest Inactive or latent

GENERALISED SEVERE EROSION

Mannerberg described 2 types of erosive lesions as viewed under SEM Active lesions shows distinctive etched enamel prisms resembling honeycomb Inactive or latent lesions faint with unrecognizable characteristics

Enamel erosion appears smooth and rounded and the surface contour is lost Broad concavities within smooth surface enamel Cupping of occlusal surfaces,

(incisal grooving) with dentin exposure


Increased incisal translucency Wear on non-occluding surfaces

There is a difference in wear in opposing


arches

Saliva flow, composition, buffering capacity, pH


Acquired pellicle diffusion limiting properties and thickness Tooth composition and structure Dental anatomy and occlusion Physiologic soft tissue movements

pH Total acid level Type of acid (pKa)

Calcium chelating properties


Calcium phosphorus and fluoride content Physical and chemical properties affecting adherence to the enamel surface and stimulation of saliva flow.

Medical History

Excessive vomiting, rumination Gastroesophageal reflux disease (Symptoms of reflux) Frequent use of antacids Alcoholism History of bruxism (grinding or clenching) Morning masticatory muscle fatigue or pain? Use of occlusal guard Acidic food and beverage frequency Method of ingestion (swish, swallow?)

Dental History

Dietary History

Occupational/Recreational History

Regular swimmer? Wine-tasting? Environmental work hazards? Sports energy drinks Tooth brushing method and frequency Type of dentifrice (abrasive?) Use of mouthrinses Use of topical fluorides

Oral Hygiene Methods


Identification of the etiology Preventive measures Patients compliance. Early recognition of erosion is important to successfully manage and prevent disease progression.

Diminish the frequency and severity of the acid challenge.


Decrease amount and frequency of acidic foods or drinks.


If undiagnosed Gastroesophageal reflux is suspected, refer to a physician. A patient with alcoholism should be assisted in seeking treatment in rehabilitation programs.

Enhance the defense mechanisms of the body (increase salivary flow and pellicle formation).

Saliva buffering capacity resists acid attacks. Saliva is also supersaturated with calcium and phosphorus, which inhibits demineralization of tooth structure

Enhance acid resistance, remineralization and rehardening

of the tooth surfaces.


Daily topical fluoride at home. Apply fluoride in the office 2-4 times a year.

A fluoride varnish is recommended.


Neutralize acids in the mouth by dissolving sugar-free antacid tablets. Dietary components such as hard cheese (provides calcium

Improve chemical protection.

and phosphate) can be held in the mouth after acidic


challenge

Decrease abrasive forces.

Use soft toothbrushes and dentifrices low in abrasiveness in


a gentle manner. Do not brush teeth immediately after an acidic challenge to

the mouth, as the teeth will abrade easily. Rinsing with


water is better than brushing immediately after an acidic challenge.

Provide mechanical protection.

Consider application of composites and direct bonding where appropriate to protect exposed dentin. Construction of an occlusal guard is recommended if a Bruxism habit is present.

ABRASSION
Derived from Latin verb ABRASUM meaning Scrape off

Abrasion is wearing away of tooth substance or structure

through mechanical process.


Imfeld T (1996)

Abrasion is the wearing of tooth substance that results from


friction of exogenous material forced over the surface by incisive, masticatory and grasping functions

Every (1972)

Loss by wear of dental tissue caused by abrasion by foreign

substance
Milosevic, 1998

The location and pattern of abrasion may be dependent on

the cause

Most common area is cervical area, related to improper tooth brushing technique, zealous and vigorous methods, and use of abrasive dentrifice.

Notching of incisal edges in pipe smokers, nail biters, hair

pin biting

Notching of incisors in Tailors, carpenters, musicians

Proximal tooth abrasion due to improper flossing and use of tooth picks

An abrasion area is generally not well defined unlike in attrition. Abrasion tends to round off or blunt tooth cusps or cutting edges. Where dentin is exposed, it may be scooped out because it is softer than enamel.

PIPE SMOKERS

Tooth surface will have a pitted appearance.

Microscopically an abraded

surface shows haphazardly oriented scratch

marks and numerous pits .