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  1. Tooth wear: aetiology, prevention, clinical implication Libyan International Medical University 2nd Year 2nd Semester D Caroline Piske de A. Mohamed D.caroline Mohamed

  2. Objectives: • Definitions of tooth wear • Epidemiology of tooth wear • Aetiological factors D.caroline Mohamed

  3. 1.Definitions of tooth wear Non carious destruction of teeth tissues. Tooth wear is usually due to a combination of processes, abrasion, attrition, and erosion. It is unusual for wear to be solely attributed to one of these. Rather, tooth wear is due to all three processes with perhaps one of these predominating. • Tooth wear: • Attrition • Abrasion • Erosion-Corrosion • Demastication • Abfraction D.caroline Mohamed

  4. a) Attrition-definition • Loss by wear of surface tooth or restoration caused by tooth to tootth contact during oclusion, mastigation or parafunction. • Microwear detail: parallel striations within the facet border. • Shiny facets • Bruxism D.caroline Mohamed

  5. Attrition • Destruction accelerated by: • Poor quality or absent enamel • Premature contacts, edge to edge oclusion • Intraoral abrasives, erosion or grinding / clenching habits D.caroline Mohamed

  6. Grinding, clenching habits D.caroline Mohamed

  7. Attrition / clinical appearence • Matching wear on occluding surfaces • Shiny facets on amalgam contacts • Enamel and dentine wear at the same time • Possible fracture of cusps or restorations D.caroline Mohamed

  8. b) Abrasion-definition • Loss of tooth structure secondary to the action of an external agent. Most commom source is toothbrushing. • Method of brushing • Toothpaste abrasives • Habits D.caroline Mohamed

  9. Most abrasion is located in the cervical area of teeth and associated with tooth brushing. Incorrect or over-vigorous brushing with an abrasive toothpaste is usually the prime aetiological factor. D.caroline Mohamed

  10. The orientation of the toothbrush influenced the wear of the teeth. Horizontal brushing was suggested as causing 2 to 3 times as much wear compared with vertical brushing. • Some studies suggest that toothpaste has more relevance to abrasion than does the toothbrush itself. • Abrasion can occur as a result of overzealous toothbrushing, improper use of dental floss and toothpick, or detrimental oral habits such as chewing tabacco, biting on hard objects such as pens, pencils/ opening hair pins with teeth, and biting finger nails. D.caroline Mohamed

  11. It is not just the abrasive content of the toothpaste that is important; the abrasive type, particle size and surface, and the chemical effects of the other constituents will also affect the amount of abrasion. For example, most of the hydrated silica-based toothpastes have good cleaning values with a low to moderate dentine abrasivity. D.caroline Mohamed

  12. Occupational abrasion. • Tailors, seamstresses ( server thread with their teeth) • Shoemakers and upholsters ( hold nails between their teeth) D.caroline Mohamed

  13. Occupational abrasion. • Glassblowers and musicians (play wind instruments) D.caroline Mohamed

  14. c) Erosion—Corrosion definition • Progressive lost of hard dental tissue by chemical or electrochemical process not involving bacteria action. D.caroline Mohamed

  15. Erosion Erosion has a mutifactorial etiology. • A susceptible tooth • The mineralisationof the dental hard tissues (presence of fluorapatiterather than hydroxyapatite affects the acid solubility). • Time • Salivary flow rates and buffering capacity at different sites also influence erosion. Where there is abundant saliva such as in the lower incisor region, there tends to be little erosion. D.caroline Mohamed

  16. Multi-factorial aetiology of dental erosion: the overlapping factors may all be required to some extent to produce severe erosion shown as the red area in the centre. L. Shaw,and A. J. Smith,2 Dental erosion — the problem and some practical solutions BRITISH DENTAL JOURNAL, VOLUME 186, NO. 3, FEBRUARY 13 1998 D.caroline Mohamed

  17. Clinical appearence • Lost of detailed surface microanatomy ( glazed and rounded) • Cupping or Cratering: It is one of the most obvious characteristics of erosive and abrasive attrition. • Cupping happens on the cusp tips of molars and premolars  and incisal edges of incisors and canines.  • Cupping on molars has less to do with bruxing than with erosion caused by acids, while cupping on anterior teeth is more likely due to bruxing in older patients. D.caroline Mohamed

  18. Increased incisal translucency • Wear on non occluding surfaces • “Raised amalgam or composite restorations” • Clean, non tarnished appearance of amalgam restorations D.caroline Mohamed

  19. Loss of surface characteristics of enamel in young children • Hypersensitivity • Pulp exposure in deciduous teeth. • Preservation of enamel “cuff” in gengival crevice is common D.caroline Mohamed

  20. Sources • Intrinsic sources • Extrinsinc sources D.caroline Mohamed

  21. Erosion-corrosion Intrinsic sources: gastroesophageal acid reflux, regurgitation or vomiting. Associated with: • Nervous system disorders. • Eating disorders such as: Anorexia and Bulimia nervosa • Gastrointestinal disorders such as peptic ulcers or gastritis • Alcohol abuse –gastrites associated • Pregnancy • Diabetes or others medical conditions • Drug side effects • Acid mouthwashes may be implicated D.caroline Mohamed

  22. Intrinsic sources of acid • Intrinsic sources of acid are essentially gastric contents, which enter the mouth as a result of reflux and vomiting. There are also some occasional case reports of rumination—deliberately bringing food back into the mouth to re-chew—which has led to extensive erosion. • Gastric reflux is much commoner than was once thought. Relatively, recent research has shown that, in the developed world, 7% of the adult population have gastrooesophageal reflux on a daily basis and more than 30% every few days. D.caroline Mohamed

  23. Principal causes of gastro-oesophageal reflux Increased gastric pressure Obesity Ascites Increased gastric volume after heavy meals Obstruction Spasm Sphincter incompetence Hiatus hernia Diet Drugs, e.g. diazepam Neuromuscular, e.g. cerebral palsy Oesophagitis D.caroline Mohamed

  24. General associated symptoms are heartburn, retro-sternal discomfort and dysphagia. • People with neurological impairments such as cerebral palsy also have significantly higher levels of reflux. D.caroline Mohamed

  25. Vomiting, either spontaneous or self induced, may be associated with a variety of medical problems. • This phenomenon must continue over a long period to cause significant erosion, and again, there is a range in susceptibility. • Current research shows an increasing prevalence of such conditions as bulimia and anorexia nervosa, both of which may be associated with self-induced vomiting. D.caroline Mohamed

  26. Recognizing Bulimia Wear patterns on the teeth • Loss of tooth structure is progressively worse toward the anterior teeth.  • This is because of the way the tongue is held in the mouth when the patient vomits. The vomitus is projected especially toward the palatal surfaces of the maxillary incisors with progressively less damage as you proceed posteriorly. • As the palatal surfaces of the maxillary incisors erode, the incisal edges become more and more thin and translucent, eventually producing a knife-edge which is easily crazed and chipped.  • Note the image above.  Nearly all of the palatal enamel has been dissolved by the acidic stomach contents which have been projected against the incisors.  • Note especially in the image above that the loss of tooth structure is fairly even beginning at the free gingival margin.  D.caroline Mohamed

  27. Principal causes of vomiting Psychosomatic Stress-induced psychogenic vomiting Eating disorders Bulimia nervosa Anorexia nervosa Metabolic and endocrine Uraemia Diabetes Gastro-intestinal disorders Peptic ulcer gastritis Obstruction Nervous system disorders Cerebral palsy Drug induced Primary, eg. cytotoxics Secondary to gastric irritation e.g. aspirin, non steroidal anti-inflammatory drugs Drug-induced xerostomia over a period of time may also influence erosion D.caroline Mohamed

  28. Extrinsic sources of acid • There are many sources of acid from outside the body, which may affect the dental tissues. • Dietary practices,‘nibbling’ and ‘snacking’. • Increase in soft drink consumption (children and adults) • Soft drink consumption and dental erosion are corelated, particularly, the bed-time consumption of fruit-based drinks. • Acidic foods, high consumption of fruit, pickles, and sauces and the use of acid mouthwashes. D.caroline Mohamed

  29. D.caroline Mohamed

  30. Lifestyle influences • Sports drinks are not only acidic, but also contain a considerable amount of simple sugars. • Both competitive swimmers and cyclists have been reported as having higher levels of dental erosion. • The dry mouth combined with dehydration from vigorous exercise and excessive consumption of low pH drinks has also been linked to dental erosion. D.caroline Mohamed

  31. Soda Swishing • Soda swishing is the habit of retaining each mouthful of soda in the mouth for a few seconds and swishing it around between the teeth before swallowing.  • All sodas, including diet soda contain three acids:  Phosphoric acid, Citric acid and Carbonic acid. • Mandibularmolars are much more heavily affected than maxillary molars because gravity keeps the soda in contact with them. • Over the years, the posterior teeth become more worn than anterior teeth due to tongue position while swishing.  D.caroline Mohamed

  32. Fruit mulling is the habit of "chewing" fruit pulp for prolonged periods before swallowing it. This habit causes loss of tooth structure due to a combination of erosion from the acidity of the fruit itself, as well as a modified form of abrasion from the constant rubbing together of the teeth over the fruit pulp during the mulling process.  D.caroline Mohamed

  33. Erosion clinical differences • Erosion due to acidic drinks: • -Facial surface of maxillary anteriors mostly affected. Appears as shallow spoon shaped depressions in cervical portion of the crown and occlusal of posterior teeth. • Erosion due to gastric regurgitation: • Palatal surface of maxillary anteriors mostly affected and occlusal of posterior teeth D.caroline Mohamed

  34. Occupational tooth erosion • Competitive swimming, (exposes the dentition to repeated contact with acids) • Can occur during exposure to industrial gases that contain hydrochloric or sulfuric acid, as well as acids used in plating and galvanizing and in the manufacture of batteries, ammunitions and soft drinks. • Professional wine tasters. D.caroline Mohamed

  35. Drugs recreational exposure. D.caroline Mohamed

  36. D.caroline Mohamed

  37. d) Demasticationisa term used for wearing away of tooth substance during mastication. This could be specifically applied to the type of wear shown by the ancient Egyptians, and would depend on the abrasivity of the food consumed. D.caroline Mohamed

  38. Tooth wear in noncivilized communities • ‘The total absence of cervical abrasion in the Yanomamis leads us to believe that this phenomenon, so common in men of our civilization, is caused by tooth brushing. The Yanomamis had no brushing habits.’ • ‘… it was evident that caries incidence was significantly lower than in present day civilized men. Neither water nor enamel mineralization were analyzed. Apart from those two factors we believe that physiological occlusal abrasion (eliminating sulci and fissures) produced by the intense masticatory activity, with its self cleaning and anti-plaque effects, has appreciably influenced caries incidence.” D.caroline Mohamed


  40. e) Abfraction Definition • Loss of tooth surface at the cervical areas of teeth caused by tensile and compressive forces during tooth flexure. D.caroline Mohamed

  41. The theory of abfractionsuggests that the cervical buccal lesions were caused by the biomechanical "bending" of the teeth due to severe bruxing forces.  D.caroline Mohamed

  42. Note the pattern of cervical tooth wear seen in the images below.  • Was this caused by the process of abfraction, or is this toothbrush abrasion?  Toothbrush abrasion Abfraction D.caroline Mohamed

  43. Aetiology of tooth wear • Abrasion:usually due to incorrect or over-vigorous brushing, but there are many unusual habits that are occasionally implicated. •Attrition:parafunctional activities, such as bruxism, are probably the most significant factors in the development of pathological tooth wear in contact areas. •Erosion: always multifactorial but one specific aetiologicalfactor usually predominates: Intrinsic acid sources • Gastro-oesophageal reflux • Vomiting; spontaneous or self-induced Extrinsic acid sources • Dietary, drinks etc. • Lifestyle influences D.caroline Mohamed

  44. Indices • The many published clinical indices suggest that it has been difficult to devise an ideal index for use in all clinical circumstances. • The Tooth Wear Index of Smith and Knight (1984) is a qualitative clinical index and has probably achieved the greatest general acceptance. It is intended for both epidemiological studies and individual patients for long-term monitoring of tooth wear. • Poor reproducibility of diagnosis of tooth wear in large surveys with many examiners indicate that the results of studies should be interpreted with caution. D.caroline Mohamed

  45. 2 Epidemiology of tooth wear • Tooth wear has long been a recognized phenomenon in adults and ascribed to the triumvirate of attrition, abrasion and erosion. • Pathological tooth wear has been seen in antiquity but the problems are becoming even more evident in society now, with an ageing population who are retaining their natural teeth for significantly longer. • There has been a gradual realization in recent years that our younger population may also be increasingly affected. • This is with increasing dental erosion, rather than attrition and abrasion, although these factors also contribute. D.caroline Mohamed

  46. Epidemiology of tooth wear • Very different types of tooth tissue loss are observed in the older adult population than in children. It is, therefore, essential to consider them separately but to regard tooth wear as a continuum throughout life with very different etiological factors at the ends of the age spectrum. D.caroline Mohamed

  47. Prevalence of tooth wear and erosion in the deciduous teeth • Researches indicate high variety in tooth wear prevalence between pre-scholars in different countries. • The primary dentition is more susceptible than the permanent because of higher acid solubility and reduced thickness of the enamel. D.caroline Mohamed

  48. Prevalence in children • The United Kingdom Child Dental Health Survey of 1993 randomly selected a sample of 17,061 children aged from 5 to 15 years which had their oral health condition examined. • It was found that 50 per cent of children aged 5 and 6 years had evidence of tooth wear, largely attributed to erosion, with almost 25 per cent having dentine involvement. • Over half of palatal surfaces of primary upper incisors showed erosion in this age group. • At eleven years of age, 2 per cent of children were found to have erosion in their permanent teeth. D.caroline Mohamed

  49. Prevalence of tooth wear and erosion in Adolescents • The 15-year-olds sampled in the National Children’s Dental Health Survey [Chadwick et al., 2006] showed an increase in Tooth Surface Loss into dentine or pulp on palatal surfaces from 2% in 1993 to 5 % in 2003 (3% in this study). D.caroline Mohamed

  50. The Erosion in 13-14-year-olds on Isle of Man , Milosevic et all, 1987 concluded that drinking fizzy drinks more than once a day was associated with erosion. • Mean DMFT scores were not statistically different for children with smooth surface/occlusally exposed dentine. • Multiple regression analysis showed age, gender and toothbrushingto be significant predictors of erosion. D.caroline Mohamed