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DENTAL EROSION—TOOTH WEAR . Physiology, Etiology, Epidemiology, Diagnosis, and Treatment. Reviewed by:. Dental Erosion: Tooth Wear. After viewing this lecture, attendees should be able to: understand the oral anatomy and physiology as they relate to dental erosion/tooth wear 

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dental erosion tooth wear

DENTAL EROSION—TOOTH WEAR

Physiology, Etiology, Epidemiology, Diagnosis, and Treatment

Reviewed by:

dental erosion tooth wear2
Dental Erosion: Tooth Wear

After viewing this lecture, attendees should be able to:

  • understand the oral anatomy and physiology as they relate to dental erosion/tooth wear 
  • identify the etiology of and risk factors associated with dental erosion/tooth wear
  • describe the epidemiology and prevalence of dental erosion/tooth wear
  • make the correct differential diagnosis and understand the management of dental erosion/tooth wear
oral anatomy and physiology
Oral Anatomy and Physiology

Definition (teeth): There are two definitions

  • Primary (deciduous)
  • Secondary (permanent)
slide4

Oral Anatomy and Physiology

Dentition (teeth): There are two dentitions

Primary (deciduous)

  • Consist of 20 teeth
  • Begin to form during the first trimester of pregnancy
  • Typically begin erupting around 6 months
  • Most children have a complete primary dentition by 3 years of age

1. Oral Health for Children: Patient Education Insert. Compend Cont Educ Dent.

oral anatomy and physiology5
Oral Anatomy and Physiology

Dentition (teeth): There are two dentitions

Incisors

Canine (Cuspid)

Secondary (permanent)

  • Consist of 32 teeth in most cases
  • Begin to erupt around 6 years of age
  • Most permanent teeth have erupted by age 12
  • Third molars (wisdom teeth) are the exception; often do not appear until late teens or early 20s

Premolars

Molars

Maxilla

Mandible

slide6

Oral Anatomy and Physiology

Identifying Teeth

Classification of Teeth:

  • Incisors (central and lateral)
  • Canines (cuspids)
  • Premolars (bicuspids)
  • Molars

Incisor Canine Premolar Molar

oral anatomy and physiology7
Oral Anatomy and Physiology

Teeth: Identification

Tooth Surfaces

  • Apical
  • Labial
  • Lingual
  • Distal
  • Mesial
  • Incisal

Apical

Apical

Labial

Lingual

Distal

Mesial

Incisal

Incisal

slide8

Oral Anatomy and Physiology

Anatomic Crown

The 3 parts of a tooth:

  • Anatomic Crown
  • Anatomic Root
  • Pulp Chamber

PulpChamber

Anatomic Root

oral anatomy and physiology9
Oral Anatomy and Physiology

Enamel

Dentin

Cementum

The 4 main dental tissues:

Dental Pulp

  • Enamel
  • Dentin
  • Cementum
  • Dental Pulp
slide10

Oral Anatomy and Physiology

Dental Tissues—Enamel2

  • Structure
    • Highly calcified and hardest tissue in the body
    • Crystalline in nature
    • Enamel rods
  • Insensitive—no nerves
  • Acid-soluble—will demineralize at a pH of 5.5 and lower
  • Cannot be renewed
  • Darkens with age as enamel is lost
  • Fluoride and saliva can help with remineralization
slide11

Oral Anatomy and Physiology

Dental Tissues—Dentin2

  • Softer than enamel
  • Susceptible to tooth wear (physical or chemical)
  • Does not have a nerve supply but can be sensitive
  • Is produced throughout life
  • Three classifications
    • Primary
    • Secondary
    • Tertiary
  • Will demineralize at a pH of 6.5 and lower
oral anatomy and physiology12
Oral Anatomy and Physiology

Dentin

Nerve Fibers

Odontoblast Cell

Fluid

Tubule

Dental Tissues—Dentin (Tubules)2

Pulp

  • Presence of tubules renders dentin permeable to fluoride
  • Number of tubules per unit area varies depending on the location because of the decreasing area of the dentin surfaces in the pulpal direction
slide13

Tubules

Enamel

Oral Anatomy and Physiology

Odontoblast

RecedingGingiva

ExposedDentin

Dental Tissues—Dentin (Tubules)2

Association between erosion and dentin hypersensitivity3

  • Open/patent tubules

– Greater in number

– Larger in diameter

  • Removal of smear layer
  • Erosion/tooth wear
oral anatomy and physiology14
Oral Anatomy and Physiology

Dental Tissue—Cementum2

  • Thin layer of mineralized tissue covering the dentin
  • Softer than enamel and dentin
  • Anchors the tooth to the alveolar bone along with the periodontal ligament
  • Not sensitive
slide15

Oral Anatomy and Physiology

Dental Tissue—Dental Pulp2

  • Innermost part of the tooth
  • A soft tissue rich with blood vessels and nerves
  • Responsible for nourishing the tooth
  • The pulp in the crown of the tooth is known as the pulp chamber
  • Pulp canals traverse the root of the tooth
  • Typically sensitive to extreme thermal stimulation (hot or cold)
slide16

Oral Anatomy and Physiology

Oral Cavity/Environment4,5

  • Plaque
  • Saliva
  • pH Values
  • Demineralization
  • Remineralization
oral anatomy and physiology17
Oral Anatomy and Physiology

Oral Cavity

Plaque:4,5

  • is a biofilm
  • contains more than 600 different identified species of bacteria
  • there is harmless and harmful plaque
  • salivary pellicle allows the bacteria to adhere to the tooth surface, which begins the formation of plaque
oral anatomy and physiology18
Oral Anatomy and Physiology

Oral Cavity

Saliva:4,5

  • complex mixture of fluids
  • performs protective functions:
    • lubrication—aids swallowing
    • mastication
    • key role in remineralization of enamel and dentin
    • buffering
oral anatomy and physiology19
Oral Anatomy and Physiology

Oral Cavity

pH values:4,5

  • measure of acidity or alkalinity of a solution
  • measured on a scale of 1-14
  • pH of 7 indicated that the solution is neutral
  • pH of the mouth is close to neutral until other factors are introduced
  • pH is a factor in demineralization and remineralization

3. Strassler HE, Drisko CL, Alexander DC.

oral anatomy and physiology20
Oral Anatomy and Physiology

Oral Cavity

Demineralization:4,5

  • mineral salts dissolve into the surrounding salivary fluid:
    • enamel at approximate pH of 5.5 or lower
    • dentin at approximate pH of 6.5 or lower
  • erosion or caries can occur
oral anatomy and physiology21
Oral Anatomy and Physiology

Oral Cavity

Remineralization:4,5

  • pH comes back to neutral (7)
  • saliva-rich calcium and phosphates
  • minerals penetrate the damaged enamel surface and repair it:
    • enamel pH is above 5.5
    • dentin pH is above 6.5
dental erosion etiology
Dental Erosion: Etiology

Tooth Wear

Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of physical loss, chemical dissolution, and/or multifactorial etiology.3,6

slide23

Dental Erosion: Etiology

Tooth Wear

  • Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6
  • Physical Loss
  • – Abrasion—mechanical
  • – Attrition—tooth-to-tooth contact
  • – Abfraction—lesions
  • Chemical dissolution
  • Multifactorial etiology
slide24

Dental Erosion: Etiology

Tooth Wear

  • Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6
  • Physical Loss
  • Chemical dissolution
  • – Erosion
  • -- Extrinsic acids
  • -- Intrinsic acids
  • Multifactorial etiology
slide25

Dental Erosion: Etiology

Tooth Wear

  • Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6
  • Physical Loss
  • Chemical dissolution
  • Multifactorial etiology
  • – Erosion
  • – Abrasion
  • – Attrition
  • – Abfraction
slide26

Dental Erosion: Etiology

Abrasion

The pathological wearing away of hard dental tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth.6

  • Oral hygiene habits
    • Excessive brushing/flossing
    • Abrasives in dentifrices/toothpastes
  • Personal habits
    • Putting foreign objects in the mouth
  • Demastication
    • Wear from chewing food
slide27

Dental Erosion: Etiology

Attrition

The pathological wearing away of hard dental tissue as a result of tooth-to-tooth contact, with no foreign substance intervening.6

  • Enamel wearing enamel
    • Occlusal wear
    • Malocclusion (buccal, lingual, and interproximal surfaces)
slide28

Dental Erosion: Etiology

Abfraction

Wedge-shaped defects at the cementoenamel junction of a tooth caused by eccentrically applied occlusal forces leading to tooth flexure that results in microfracture of enamel and dentin.6

  • Loss of tooth in the cervical area
    • Tooth flexure

– Chewing

– Grinding (bruxism)

slide29

Dental Erosion: Etiology

Erosion

The physical results of a pathologic, chronic, localized loss of hard dental tissue that is chemically etched away from the tooth surface by acid and/or chelation without bacterial involvement.7

  • Extrinsic acids—ingested
    • Food, beverages, medicine
  • Intrinsic acids—internal
    • Originate in the stomach
slide30

Dental Erosion: Etiology

Multifactorial

Tooth wear is multifactorial

  • One process typically impacts the other
    • Erosion and abrasion
slide31

Dental Erosion: Epidemiology

Tooth erosion was described as a condition distinct from caries as early as the 18th century.8

slide32

Dental Erosion: Epidemiology

Change in Perception

In 1995, the European Journal of Oral Science stated that “dental erosion is an area of research and clinical practice that will undoubtedly experience expansion in the next decade.”9

slide33

Dental Erosion: Epidemiology

Global Prevalence

Global data on the prevalence of dental erosion is building. “Erosive tooth wear is a common condition in the developed countries.”10

UK

The Netherlands

Iceland

Sweden

Turkey

Germany

Ireland

Japan

Malaysia

Switzerland

China

Brazil

Canada

United States

India

Saudi Arabia

slide34

Dental Erosion: Epidemiology

Global Prevalence

  • European studies suggest prevalence of:11-13
    • Up to 50% if all preschool children
    • Between 24% to 60% of school-aged children
    • As high as 82% in 18 to 88 years of age10
  • Emerging prevalence studies providing data on gender, socio-economic status, ethnic, and culture difference in addition to the age factor will prove to be invaluable
slide35

Dental Erosion: Diagnosis

“Diagnosis is the intellectual course that integrates information obtained by clinical examination of the teeth, use of diagnostic aids, conversation with the patient, and biological knowledge. A proper diagnosis cannot be performed without inspection of the teeth and their immediate surroundings.”14

dental erosion diagnosis
Dental Erosion—Diagnosis

Check list to unveil etiological factors for erosion15

dental erosion diagnosis37
Dental Erosion: Diagnosis

Interaction of the different factors for the development of erosive tooth wear16,18

From: Lussi A. Dental Erosion: From Diagnosis to Therapy. Karger; 2006.

slide38

Dental Erosion: Diagnosis

Clinical Appearance

There is no device available for the specific detection of dental erosion in routine practice. Therefore, the clinical appearance is the most important feature for dental professionals to diagnosis dental erosion.16

dental erosion diagnosis39
Dental Erosion—Diagnosis

Tooth Wear—Clinical Appearance17

slide40

Dental Erosion: Diagnosis

Erosion is multifactorial

  • Chemical factors—erosive potential of intrinsic and extrinsic acids
  • Biological factors—involve properties and characteristics of the oral cavity
  • Behavioral factors—personal and oral habits
slide41

Dental Erosion: Diagnosis

Chemical Factors18

  • pH and buffering capacity of the product
  • Type of acid (pKa values)
    • Intrinsic (gastric origin)
    • Extrinsic (environmental, dietary, medicinal)
  • Adhesion of the products to the dental surface
  • Chelating properties of the products
  • Calcium concentration
  • Phosphate concentration
  • Fluoride concentration
slide42

Dental Erosion: Diagnosis

Biological Factors19

  • Saliva: flow rate, composition, buffering, capacity, and stimulation capacity
  • Acquired pellicle: diffusion-limiting properties, composition, maturation, and thickness
  • Type of dental substrate (permanent and primary enamel, dentin) and composition (eg, fluoride content as FHAp or CaF2-like particles)
  • Dental anatomy and occlusion
  • Anatomy of oral soft tissues in relationship to the teeth
  • Physiologic soft tissue movements
slide43
Behavioral Factors20

Dental Erosion: Diagnosis

Unusual eating and drinking habits

Healthy lifestyle: diets high in acidic fruits and vegetables

Unhealthy lifestyle: frequent consumption of “alcopops” and designer drugs

Alcoholic disease

Excessive consumption of acidic foods and drinks

Nighttime baby bottle feeding with acidic beverages, including milk

Oral hygiene practices: frequent toothbrushing, abrasive oral care products

slide44
Prevention

Dental Erosion: Diagnosis

Loss of tooth surface is a multifactorial process and education

is the first step in the line of defense.4

slide45

Dental Erosion: Diagnosis/Management

Dynamics of Dental Erosion21

Before

During

After

Time (Frequency)

Interactions between Behavioral and Biological Factors

21. Lussi A, Kohler N, Zero D, et al.

dental erosion management etiological factors
Dental Erosion:Management/Etiological Factors

Awareness/Association/Education

Dietary factors15

  • Avoid radical changes in dietary habits
  • Reduce acid exposure by reducing frequency and contact time of acid
  • Avoid acidic foods and drinks late at night
  • Avoid high-acidity liquids via baby bottle for infants
  • Avoid low pH values in food and beverages
dental erosion management etiological factors47
Dental ErosionManagement/Etiological Factors

Awareness/Association/Education

Dietary factors: generally, a pH value of 5.5 or lower is capable of softening the surface of enamel in only a few minutes.3

3. Strassler HE, Drisko CL, Alexander DC.

dental erosion management etiological factors48
Dental Erosion:Management/Etiological Factors

Awareness/Association/Education

Behavioral/habits15

Do not hold or swish acidic drinks in your mouth

Avoid sipping acidic drinks—use a straw

Avoid toothbrushing immediately after an erosive challenge (vomiting, acidic diet)

Avoid toothbrushing immediately before an erosive challenge, as the acquired pellicle provides protection against erosion

Use a soft toothbrush

dental erosion management etiological factors49
Dental Erosion:Management/Etiological Factors

Awareness/Association/Education

Behavioral/Habits15

Use a low-abrasion fluoride-containing toothpaste; high-abrasive toothpaste may destroy pellicle

Avoid toothpastes or mouthwashes with too-low pH

After acid intake, stimulate saliva flow with chewing gum or lozenges

Use chewing gum to reduce postprandial reflux

Refer patients or advise them to seek appropriate medical attention when intrinsic causes are involved

slide50

Dental Erosion:Management/Etiological Factors

Awareness/Association/Education

Gastroesophageal Origin22

  • Heartburn and other symptoms of reflux
  • Regurgitation
  • Dysphagia
  • Asthma
  • Rumination
  • Eating disorders (anorexic or bulimia)
slide51

Dental Erosion:Management/Etiological Factors

Awareness/Association/Education

Medicinal factors associated with dental erosion23

  • Some medicines can potentially induce GERD
    • theophyline
    • progesterone
    • anti-asthmatics
    • calcium channel blockers
  • Aspirin (especially in chewable format)
  • Medicines that decrease salivary flow
    • antihistamines
    • anticholinergics
    • antidepressants
    • antipsychotics
dental erosion toothwear
Dental Erosion/Toothwear

Prevention is better than a cure… Education is the key!

slide53

Dental Erosion/Tooth Wear—References

References

1. Oral Health for Children: Patient Education Insert. Compend Contin Educ Dent. 2005;26(5 Suppl 1):Insert.

2. Sturdevant JR, Lundeen TF, Sluder TB Jr. Clinical significance of dental anatomy, histology, physiology, and occlusion. In: Robertson TM, Heymann HO, Swift EJ Jr, eds. Sturdevant’s Art and Science of Operative Dentistry. 4th ed. Mosby: St. Louis, MO; 2002:13-61.

3. Strassler HE, Drisko CL, Alexander DC. Dentin hypersensitivity: its inter-relationship to gingival recession and acid erosion. Inside Dentistry. 2008;29(5 Special Issue):3-4.

4. Robertson TM, Lundeen TF. Cariology: the lesion, etiology, prevention, and control. In: Robertson TM, Heymann HO, Swift EJ Jr, eds. Sturdevant’s Art and Science of Operative Dentistry. 4th ed. Mosby: St. Louis, MO; 2002:63-132.

5. Tooth Erosion in Children—US Perspective. Inside Dentistry. 2009;5(3 Suppl):8.

6. Imfeld T. Dental erosion. Definition, classification and links. Eur J Oral Sci. 1996;104(2 (Pt 2)):151-155.

7. ten Cate JM, Imfeld T. Dental erosion. Summary. Eur J Oral Sci. 1996;104(2 (Pt 2)):241-244.

8. The dental cosmos: a monthly record of dental science. Perioscope. 1875;17(2):93-109.

9. ten Cate JM, Imfeld T. Dental erosion. Preface. Eur J Oral Sci. 1996;104(2 (Pt 2)):149.

10. Jaeggi T, Lussi A. Prevalence, incidence, and distribution of erosion. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:44-65. Whitford GM. Monographs in Oral Science; vol. 20.

11. Ganss C, Klimek J, Giese K. Dental erosion in children and adolescents: a cross-sectional and longitudinal investigation using study models. Community Dent Oral Epidemiol. 2001;29(4):264-271.

12. Truin GJ, van Rijkom HM, Mulder J, van’t Hof MA. Caries trends 1996-2002 among 6- and 12-year-old children and erosive wear prevalence among 12-year-old children in The Hague. Caries Res. 2005;39(1):2-8.

slide54

Dental Erosion/Tooth Wear—References

References

13. Dugmore CR, Rock WP. The prevalence of tooth erosion in 12-year-old children. Br Dent J. 2004;196(5):279-282.

14. Kidd EAM, Mejare L, Nyvad B. Clinical and radiographic diagnosis. In: Fejerskov O, Kidd EAM, eds. Dental Caries: The Disease and its Clinical Management. Copenhagen: Blackwell Munksgaard; 2003:111-128.

15. Lussi A, Hellwig E. Risk assessment and preventative measures. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:190-199. Whitford GM. Monographs in Oral Science; vol 20.

16. Lussi A. Erosive toothwear: a multifactorial condition of growing concern and increasing knowledge. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:1-8. Whitford GM. Monographs in Oral Science; vol. 20.

17. Gandara BK, Truelove EL. Diagnosis and management of dental erosion. J Contemp Dent Pract. 1999;1(1):16-23.

18. Lussi A, Jaeggi T. Chemical factors. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:77-87. Whitford GM. Monographs in Oral Science; vol. 20.

19. Hara AT, Lussi A, Zero DT. Biological factors. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:88-91. Whitford GM. Monographs in Oral Science;vol 20.

20. Zero DT, Lussi A. Behavioral factors. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:100-105. Whitford GM. Monographs in Oral Science;vol 20.

21. Lussi A, Kohler N, Zero D, et al. A comparison of the erosive potential of different beverages in primary and permanent teeth using an in vitro model. Eur J Oral Sci. 2000;108(2):110-114.

22. Bartlett D. Intrinsic causes of erosion. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:119-139. Whitford GM. Monographs in Oral Science;vol 20.

23. Hellwig E, Lussi A. Oral hygiene products and acid medicines. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:112-118. Whitford GM. Monographs in Oral Science;vol 20.

dental erosion tooth wear55
Dental Erosion—Tooth Wear

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