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tooth wear, abrasion cavity, sandwich techque
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TOOTH WEAR & RESTORATION OF ABRASION LESIONS DR HSU ZENN YEW
DDS (UKMal), DCLINDENT (Adel)
TERMINOLOGY
‘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.
Caries
Caries
Tooth wear
Subsurface mineral loss
www.doctorspiller.com
Ungar et.al (2008)
Bailey S & Liu W (2010)
“…the human dentition is basically “designed” on the premise that extensive wear will occur…” Kaifu et al
BDJ 2006
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
Defined as loss of dental hard tissue as a result of chemical process NOT involving bacteria
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 shallow concavities coronal from the cemento-enamel junction
rounding of the cusps and grooves No occlusal morphology present
Lussi et 2006
CAUSES OF EROSION
ACID ATTACK PROTECTIVE MECHANISM
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 Chemical factors
• pH and buffering capacity of the product
• Type of acid (pKa values)
•Citric acid caused more erosion than phosphoric acid
Occupation:
•Workers chemical industry
•Wine tasters
•Swimmers exercising in water with low pH
•Athletes consuming frequently erosive sport drinks.
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
EXTRINSIC 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
ABRASION 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)
Pickards’ Manual, Lussi 2006 http://www.teethforbetterhealth.com Badel et. Al 2007
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
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
Pickards’ Manual, Lussi 2006 http://www.teethforbetterhealth.com Badel et. Al 2007
ATTRITION
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
Pickards’ Manual, Lussi 2006, Badel et al 2007
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
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
Pickards’ Manual, Lussi 2006, Badel et al 2007
ATTRITION
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.
Pickards’ Manual, Lussi 2006, Badel et al 2007
CLASSIFICATION
TOOTH WEAR
EROSION/ COROSSION
Chemical wear
ATTRITION
Physical wear: tooth-tooth
surfaces
ABRASION
Physical wear
? ABFRACTIONS
Flexion of tooth
Lussi 2006, D.W. Bartlett and P. Shah (2006)
“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.”
MANAGEMENT
DIAGNOSIS
PREVENTION
STABILIZATION
RESTORATION/ REHABILITATION
REVIEW / MONITORING
PREVENTION
TOOTH WEAR PROTECTIVE MECHANISM
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
MEDICAL REFERRAL
Refer patients or advise them to seek appropriate medical attention gastroenterologist and/or a psychologist) when intrinsic causes of erosion are involved.
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
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.
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 semi-permanently over exposed dentine.
Composites may be placed temporarily or semi-permanently 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
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
Esthetic Sensitivity to moisture
Amalgam Poor Requires removal of tooth structure for retention
Poor Requires removal of tooth structure for retention
Poor Good
Gold foil (not widely used)
Poor
Good
Gold inlay
Poor
Good
Flowable resin composite
Good Poor Excellent Poor Blood, gingival crevicular fluid, saliva affect success
Allow easier sculpting
Resin composite with dentine bonding systems
Good Poor High C-factor Esp in deep, subgingival cavity
Excellent
Glass ionomer Good Good Satisfactory Satisfactory F- release
Resin Modified Glass Ionomer
Good Good Good Satisfactory
Compomer Good Poor Good Poor Inferior to CR
Porcelain Inlay (not widely used)
Poor Poor Excellent Good Requires laboratory
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.
Composite resin is used to replace enamel and seal the enamel margins surrounding the cavity
Enamel remaining in gingival margin
This modification of the closed sandwich untilized in cavities lacking enamel at the cervical margin.
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
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
Further reading
Bailey S & Liu W. A comparative dental metrical and morphological analysis of a Middle Pleistocene hominin maxilla from Chaoxian (Chaohu), China. Hominin Morphological and Behavioral Variation in Eastern Asia and Australasia: Current Perspectives. 2010;211(1),p14–23
Ungar et.al (2008). Dental Microwear and Diet of the Plio-Pleistocene Hominin Paranthropus boisei. PLoS ONE, 3(4), e2044.
Laser dentistry and prehistoric teeth. British Dental Journal 201, 693 (2006)
Yousuke Kaifu, Kazutaka Kasai, Grant C. Townsend, Lindsay C. Richards. Tooth wear and the “design” of the human dentition: A perspective from evolutionary medicine. 2003; 122(37) p47–61
http://www.ucl.ac.uk/archaeology/research/directory/disease_hillson
Addy M, Hunter ML: Can toothbrushing damage your health? Effects on oral and dental tissues. Int Dent J 2003;53:177–186.
Badel et al. Clinical and Tribological View on Tooth Wear. Acta Stomatol Croat. 2007;41(4):355-365.
Hewlett et al . Glass Ionomers in Contemporary Restorative Dentistry -- A Clinical Update.JUNE 2003 JOURNAL OF THE CALIFORNIA DENTAL ASSOCIATION