NON CARIOUS LESIONS

By Varun Menon P Final year BDS

OVERVIEW

INTRODUCTION DEFINITION ETIOLOGY CLINICAL FEATURE DIAGNOSIS CLINICAL MANAGEMENT TRATMENT OPTIONS PREVENTION SUMMARY CONCLUSION

INTRODUCTION

Gradual loss of tooth structure is a physiologic process that occurs through out life, most often is slow it rarely poses any problem to the patient Loss of tooth structure from the cervical regions of teeth occurs due to pathological processes like abrasion erosion and abfraction Failure to correctly diagnose and manage these lesions can result in continued loss tooth structure, weakening the tooth, need for endodontic therapy, tooth loss and the possibility of involvement with such lesions

Non-carious cervical lesions is defined as tooth loss or surface loss due to process other than dental caries

NON CARIOUS LESIONS

ATTRITION

ABRASION

EROSION

ABFRACTION

EROSION
DEFINITIONS This is the loss of tooth substance by a non-bacterial chemical process or progressive loss of hard dental tissue by an acidic chemical process without bacterial action.
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ETIOLOGY

This may be due to acids from extrinsic or intrinsic sources

Extrinsic sources of erosion are acids from

external sources such as diet or environment 1, dieterary acids are the most common cause of extrinsic erosion, frequent consumption of foods and drinks with a low Ph can lead to erosion these include citrus fruits ,carbonated drinks like colas, pickles containing vinegar etc 2, environmental erosion is related to occupational hazards in professions :wine tasting, metal plating, battery manufactures etc
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Intrinsic sources erosion are due to

regurgitation of gastric acid into the mouth .this may occur in gastric disorders or eating disorders -Gastric disorders include gastrointestinal ulcers, hiatus hernia, chronic alcoholism etc -Eating disorders include anorexia nervosa and bulimia nervosa -Chronic vomiting and pregnancy morning sickness
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CLINICAL FEATURES
generally present as broad, shallow, saucer shaped defects involving enamel and dentin. There are no sharp line angles and the margins of the defects are not well defined. The surface of erosion lesions appears smooth and polished, usually cervical area is affected

ABRASION
DEFINITION Dental abrasion is the pathological wearing away of teeth due to abnormal process, habits or abrasive substances

ETIOLOGY

Commonly associated with :Over vigorous tooth brushing. Use of hard tooth brush, an abrasive dentifrice improper brushing techniques Abnormal habits like biting a pipe stem, biting finger nails, opening bobby pins are also responsible for abrasion defects
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present as notched or v shaped defects involving cervical enamel as in dentin, typical toothbrush abrasions are unilateral, canine and premolars are most affected. exhibit sharp margins, sharp internal line angles, most often surface appear smooth and polished Different types of abrasion are:-cervical, habitual, iatrogenic, industrial abrasion

CLINICAL FEATURES

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ABFRACTION
DEFINITION This is a pathologic loss of tooth substance due to biomechanical loading forces that result in flexure and ultimate fatigue of enamel and dentin at a location away from loading The term abfractionwas coined from the Latin words ab, or away, and fractio, or breaking.
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ETIOLOGY
Occlusal effects have an important role in the development of non-carious cervical lesions Teeth tend to flex or bend when subjected to excessive occlusal forces and the point of stress concentration is in the cervical area. Tensile forces produced weaken the bonds between the cervical enamel hydroxyapatite leading to cracks in the cervical enamel eventually there is loss of tooth tissue in this area producing non-carious tooth loss

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 Evidences

1, only a single tooth may be affected leaving the neighboring teeth uninvolved 2, more number of teeth is affected in bruxists and in older patients 3, these lesions can progress around existing cervical restorations and extend subgingivally 4, the lingual surface of mandibular teeth are rarely affected

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theory

to support abfraction

CLINICAL FEATURES

appear as wedge-shaped defects with sharp margins sharp internal line angels only single tooth is affected neighboring teeth uninvolved more number of teeth is affected in bruxists and in older patients, lingual surface of mandibular teeth are rarely affected, common in premolar region Hypothesis is that the tensile or compressive stress gradually produces microfracture in the thinnest region of the enamel at CEJ

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 DEFINITION Loss of tooth structure or of a restoration as a result of mastication or of occlusal or proximal contact between the teeth or physiologic wearing away of teeth due to teeth to teeth contact

ATTRITION

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ETIOLOGY
Common

cause :-

Bruxism

TMJ dysfunction Tobacco chewing Malocclusion age

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CLINICAL FEATURES

seen on occlusal surface shortening of crown, exposure of dentin or secondary dentin formation occlusal facet in sever form cause reverse cusp Loss of vertical dimension. The vertical dimension loss confined to the teeth is known as Dentoalveolar compensation:-resulting in cheek biting, susceptibility to caries especially in reverse cusp situation, tooth sensitivity & TMJ dysfunction. Proximal surface attrition cause flattening and widening of proximal contact

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DIAGNOSIS OF NON-CARIOUS CERVICAL LESIONS

Careful history taking and proper clinical examination are important in correct diagnosis of Non-carious cervical lesions

I. HISTORY

Any history of intrinsic or extrinsic erosion, digestive problems like anorexia, gastric regurgitation etc Diet diary in detecting excessive consumption of citrus fruits, carbonated drinks, vitamin C tablets, vinegar, natural yoghurt etc Which are common causes of dietary erosion The patient brushing technique, brush type should be noted Abnormal habits like clenching grinding etc which 19 may be factors responsible for abfraction

Excessive vomiting, rumination Eating disorder Gastroesophageal reflux disease Symptoms of reflux Frequent use of antacids Alcoholism Autoimmune disease (Sjogren's) Radiation tx of head and neck Oral dryness, eye dryness Medications that cause salivary hypofunction Medications that are acidic

Medical History

Dental History History of Bruxism (grinding or clenching) -Grinding Bruxism sounds during sleep noted by bed partner? -Morning masticatory muscle fatigue or pain? Use of occlusal guard

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Dietary History

Acidic food and beverage frequency Method of ingestion (swish, swallow?)

Oral Hygiene Methods

Toothbrushing method and frequency Type of dentifrice (abrasive?) Use of mouth rinses Use of topical fluorides

Occupational/Recreational History
Regular swimmer? Wine-tasting? Environmental work hazards?

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II Perform physical assessment. Observe for following features:

Head and Neck Examination

Tender muscles (Bruxism?) Masseteric muscle hypertrophy (bruxism?) Enlarged parotid glands (autoimmune disease, anorexia, alcoholism) Facial signs of alcoholism: -Flushing, puffiness on face -Spider angiomas on skin

Intra-oral Examination

Signs of salivary hypofunction: -Mucosal inflammation -Mucosal dryness -Unable to express saliva from gland ducts Shiny facets or wear on restorations (bruxism?) Location and degree of tooth wear (document with photos, models, radiographs
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CLINICAL EXAMINATION

Look for signs of erosion, abrasion and abfraction Careful occlusal examination to detect signs of occlusal problems like Tooth mobility, open contacts, tilted or drifted teeth, atypical occlusal wear, over erupted teeth, crossbites, deepbites and openbites, fewer number of occluding teeth

General Survey

Underweight (anorexia)

Salivary function assessment

Flow rate pH, buffer capacity ( in research)

RADIOGRAPH

Useful in identifying the following changes -altered laminadura and periodontal space -evidence of hypercementosis, resorptions 23 -pulpal calcifications

CLINICAL MANAGEMENT OF NONCARIOUS CERVICAL LESIONS

These require clinical attention if any of the following factor exist: 1, tooth sensitivity 2, Compromised esthetics 3, Risk of tooth fracture 4, pulpal damage 5, Caries 6, poor periodontal

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TREATMENT OPTIONS
Treatment options for non-carious cervical lesions: 1, Dentin desensitization 2, Restorations 3, Endodontic therapy 4, periodontal therapy

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1, DENTIN DESENSITIZATION

its a viable option for those situations where minimal amount of dentin is exposed (<1 mm) the patient experience hypersensitivity This may be managed by -fluoride varnishes or fluoride iontophoresis, -dentin bonding agents, - use of desensitizing tooth pastes
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2, RESTORATIVE TREATMENT

Restorations are indicated for non-carious cervical lesions in the following conditions -considerable loss of enamel and dentin -esthetics is compromised -deep lesions affecting strength of the tooth and pulpal integrity -caries beginning in the cervical lesions -significant sensitivity of the exposed dentin
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Choice of restorative material

Class V lesions may be restored with any of the permanent restorative materials of these amalgam, direct gold and ceramic inlays are no longer preferred Composite restorations are selected when esthetics is of prime concern It has excellent polishability, high bond strength, good abrasion resistance, Disadvantage is technique sensitivity; polymerization shrinkage may open marginal gaps Compomers combine the durability of composite resin and fluoride releasing ability of glass ionomer cements
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Chemically cured glass ionomer cements are also used now a days resin modified glass ionomer cements are preferred due to improved properties it has better adhesion to tooth structure, fluoride release,biocompatability,coefficient of thermal expansion similar to tooth structure, Disadvantage is less esthetic than composite restorations, brittleness, and sensitive to moisture contaminations

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3, ENDODONTIC THERAPY

When cervical lesion is extensive resulting in pulp involvement endodontic therapy is indicated followed by post placement and full coverage restoration in form of crown

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4, PERIODONTAL THERAPY
Is required when non-carious cervical lesions are associated with gingival recession and mucogingival defects This consist of root coverage procedures using free gingival grafts or connective tissue grafts Root coverage procedures using non grafting procedures like rotational and coronally advanced flaps or guided tissue regeneration

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PREVENTION
Prevention lies in identifying and eliminating the causes such as dietary sources of acids, improper brushing and abnormal occlusal stresses these include : 1, Diet counseling:- Advice the patient to reduce the intake of erosive products such as acidic foods and beverages 2, Use of sodium bicarbonate mouth rinse:patients with gastric regurgitation, a sodium bicarbonate mouth rinse is prescribed to neutralize the effect of acid

Exposure to fluoride will reduce the softening effects of acids; xylitol gum reduces the effects of tooth erosion from acidic drinks 4, psychiatric consultation:-For anorectic and bulimics psychiatric consultation is required 32

3, use of fluoride mouth rinse and xylitol gum:-

5, Correct brushing technique

Advice the patient to modify their brushing technique and recommend the use of soft brushes and less abrasive tooth pastes

6, Correct occlusal stresses

In patients with traumatic occlusion or abnormal occlusal stresses, correction of these occlusal problems should be done by occlusal adjustments

7, Provide Mouth guards

In patients with bruxism, provide mouth guards to prevent tooth flexure

8, correct abnormal oral habits

Abnormal habits like nail biting, holding objects like pins, pipes etc in the mouth should be corrected
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SUMMARY
Term Erosion Progressive loss of hard dental tissue by chemical processes not involving bacterial action

* Adapted from: Milosevic, 1998

Definition Clinical Appearance

Broad concavities within smooth surface enamel Cupping of occlusal surfaces, (incisal grooving) with dentin exposure Increased incisal translucency Wear on non-occluding surfaces "Raised" amalgam restorations Clean, non-tarnished appearance of amalgams Loss of surface characteristics of enamel in young children Preservation of enamel "cuff" in gingival crevice is common Hypersensitivity 34 Pulp exposure in deciduous teeth

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

Clinical Appearance Matching wear on occluding surfaces Shiny facets on amalgam contacts Enamel and dentin wear at the same rate Possible fracture of cusps or restorations
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Term Definition Abrasion Loss by wear of dental tissue caused by abrasion by foreign substance (e.g., toothbrush, dentifrice)

Clinical Appearance Usually located at cervical areas of teeth Lesions are more wide than deep Premolars and cuspids are commonly affected

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Term

Definition

Clinical Appearance Affects buccal/labial cervical areas of teeth Deep, narrow V-shaped notch Commonly affects single teeth with excursive interferences or eccentric occlusal loads
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Abfraction Loss of tooth surface at the cervical areas of teeth caused by tensile and compressive forces during tooth flexure

CONCLUSION
With increasing dental awareness and improved dental care, more and more people are retaining their teeth for a longer period of Time. Dentists therefore have to treat the ravages of tooth wear. When loss of enamel and dentin at the CEJ becomes significant resulting in loss of function and esthetics, restoration of these defects become necessary

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