Toothwear 2

Question 1

pattern of tooth wear

Answer 1

localised
generalised:
- wear with loss of OVD
- wear without loss of OVD but with space available
- wear without loss of OVD but limited space
dentoalveolar compensation

Question 2

immediate tx of tooth wear case

Answer 2

deal with pain
- sensitivity; desensitising agents, fluorides, bonding agents, GIC, coverage of exposed dentine
- pulp extirpation; if wear has compromised pulpal health
- smooth sharp edges; prevent trauma to cheeks & tongue
- XLA; pain from unrestorable / non functional teeth
- TMJ pain; important in attrition, acute symptoms need to be controlled

Question 3

initial tx

Answer 3

stabilise existing dentition
deal with caries / perio
oromucosal
treat whole mouth & whole pt
once you have a diagnosis & have identified a primary causative factor initiate preventative regime
tx without prevention will fail

Question 4

prevention of abrasion

Answer 4

remove object / substance
change toothpaste
alter tooth brushing habits
change habits i.e. nail biting, wire stripping, piercing biting, pen chewing

Question 5

materials for abrasion prevention

Answer 5

simple RMGIC, GIC or composite restorations are considered preventative
can be placed with no tooth prep
pt wears through the restoration rather than damaging tooth
simple & effective
RMGIC has best survival rate, higher YM of composite can compromise its retention & more likely to stain
flowable is another option
have to balance aesthetics v retention

Question 6

prevention of attrition

Answer 6

generally related to parafunctional habit
CBT / hypnosis can be useful
splints

Question 7

pros and cons of splints

Answer 7

work by being softer than teeth, wear away in preference to tooth & cause no damage to opposing teeth; may be a habit breaker
soft splint can be used as diagnostic device as it will wear rapidly & show wear facets in surface
hard splints are more robust & can be used over longer term
Michigan splint - popular type of hard splint. provides ideal occlusion even with centric stops, has canine rise which provide disclusion in eccentric mandibular movements; canine guidance

Question 8

what kind of wear can a splint not be used with

Answer 8

erosion as it will make the erosion worse

Question 9

prevention of erosion

Answer 9

most prevalent
tx via fluoride, desensitising agents, dietary management
habit changes = swilling drinks around mouth, use straw, rumination, healthy eating, vegan diet causative perhaps, sports drinks & gels
medical = control gastric acid i.e. GORD, reflux, hiatus hernia, xerostomia, anorexia & bulimia
may require discussion with GP & subsequent referral to specialist
must gain consent to contact GMP
change in drugs may not be possible & beware proton pump rebound

Question 10

prevention of abfraction

Answer 10

assess occlusion on teeth with abfraction lesions
consider occlusal equilibration
fill cavities with low modulus restorative materials i.e. RMGIC, flowable

Question 11

passive management

Answer 11

prevention & monitoring
should be first part of any tx of dental wear
most pt in practice will be in this phase for 6 months
for many pt this is all that is required

Question 12

goal of active management of tooth wear

Answer 12

preservation of remaining tooth structure
pragmatic improvement in aesthetics
functioning occlusion
stability

Question 13

5 factors of active management of maxillary anterior tooth wear

Answer 13

1. pattern of anterior maxillary tooth wear
2. inter occlusal space
3. space required for restorations being planned
4. quality & quantity of remaining tooth tissue, particularly enamel
5. aesthetic demands of pt

Question 14

pattern of maxillary anterior tooth wear

Answer 14

1. tooth wear limited to palatal surfaces only
2. tooth wear involving palatal & incisal edges with reduced clinical crown height
3. tooth wear limited to labial surfaces

Question 15

impact of maxillary anterior tooth wear

Answer 15

if teeth wear rapidly there is no time for alveolar compensation leading to AOB & increased OJ (huge class II div 2)
in majority of cases there is no increase in FWS as there is compensation for loss of tooth substance be dento-alveolar bone growth
this maintains masticatory efficiency which is good but then leaves no space for restorations to be placed

Question 16

how to create space for active management of maxillary anterior tooth wear

Answer 16

1. increase OVD; multiple posterior extra coronal restorations, reorganised approach (complex, destructive, expensive)
2. occlusal reorganisation from ICP to RCP; complicated, can be destructive, specialist tx
3. surgical crown lengthening; doesn’t really create more space
4. elective RCT & post crowns; very destructive
5. conventional ortho; length tx

Question 17

surgical crown lengthening

Answer 17

exposes more of crown for retention of final restoration
repositioning of gingiva apically generally with removal of bone
sensitivity
still need occlusal reduction

Question 18

dahl technique

Answer 18

method of gaining space in cases of localised tooth wear
covering of palatal surfaces & allowing occlusion on raised cingulum of anteriors
results in posterior disclusion and increase in OVD of 2-3mm
occlusal contacts only on incisor / canine teeth
over a period of 3-6mths gain space between anteriors and posteriors overerupt
this allows for restoration & no need for occlusal reduction

Question 19

+ / - of the dahl technique

Answer 19

+ carried out in composite nowadays
+ better aesthetics
+ better compliance
+ easier to adjust
+ can be immediate, definitive tx
+ 90+% success rate
- faster in younger pt
- if no improvement in 6mths it is not going to work
- can be variable

Question 20

who is the dahl technique not suitable for

Answer 20

active perio disease
TMJ problems
post ortho
bisphosphonates
if dental implants present
if existing conventional bridges

Question 20

when is the dahl technique used

Answer 20

for localised anterior tooth wear