Question 53

Question 1

causes and types of toothwer

Answer 1

o Attrition – tooth to tooth contact
 Bruxism often due to stress/anxiety
* Root fractures, cuspal fracture, restoration fracture
 Lack of posterior teeth – increases anterior wear
 Occlusion – deep OB or edge to edge
 Restorations – porcelain very abrasive
o Abrasion – physical wear of tooth through an abnormal mechanical process (tooth brushing)
o Erosion – loss of tooth substance by a chemical process not involving bacterial action
 Intrinsic – GORD, bulimia, regurgitation
 Extrinsic – acidic drinks
o Abfraction – loss of hard tissues from eccentric occlusal forces leading to compressive and tensile stresses in cervical fulcrum areas

Question 2

what is history and exam for toothwear

Answer 2

• History:
  o PC – aesthetic, function, pain?
  o MH – medications (low pH, xerostomia), eating disorders, alcoholism, GORD
  o DH – attendance (long plan), prev treatment, OH
  o SH – stress (bruxism), alcohol, diet, habits
• Examination
  o E/O – TMJ (crepitus, restriction of movement), MoM (masseteric hypertrophy), OVD, tooth show, lip line
  o I/O – occlusion, FWS, dry mouth, linea alba, tongue scalloping, OH, perio
  o Wear – location, severity (enamel, dentine, severe), indices (BEWE)

Question 3

what is special investigations and diagnosis for toothwear

Answer 3

• SI’s – sensibility testing, radiographs, articulated study models, photos, diagnostic wax-up, dietary analysis
• Diagnosis
  o Pattern of wear
   Localised
   Generalised – with loss of OVD, without loss of OVD and space available, or without loss of OVD with limited space
  o Dento-alveolar compensation

Question 4

what is treatment planning for toothwear

Answer 4

o Immediate (relief of symptoms – pain)
 Sensitivity – desensitising agents, fluorides (Duraphat), bonding agents, GIC coverage of exposed dentine
 Pulp extirpation
 Smooth sharp edges
 Extraction
o Initial
 Stabilise existing dentition – caries, perio, endo
 Prevention (passive management)
* Treatment without prevention of cause will fail
* Need for baseline wear recording using indices, models or photos for monitoring
* Abrasion
o Remove foreign object causing, change TP, alter TB, change habits (nail biting, wire striping…)
o Simple RMGIC/GIC/Comp restoration for cervical TB abrasion
* Attrition
o Stress – CBT, hypnosis
o Splint – Michigan (upper hard bite raising appliance)
* Erosion
o Identify source and control
 Dietary modification
 Control GORD, xerostomia, bulimia, anorexia
o Habit changes – avoid swilling drinks, rumination, sports drinks/gels, use a straw
o Fluorides (harden tooth surface - MW, TP, varnish, tooth mousse) and desensitising agents
* Abfraction
o Occlusal equilibration
o Restore cervical cavities with RMGIC or flowable comp (low modulus)
o Review – compare with baseline to see if progression has slowed
o Reconstructive (active management)
 Decide whether conforming to or changing the OVD
 Simple restorative intervention – coverage of exposed dentine, filling cupped defects

 Maxillary anterior tooth wear - Dahl technique
o Composite build ups 3-3 increase OVD slightly and canine guidance causes posterior disclusion on excursive movement. Occlusion re-establishes with time
o CI – short roots, active perio disease/reduced periodontal support, TMJ problems, post ortho, bisphosphonates, implants
o Lack of remaining enamel ring reduces success rate due to poorer retention/bond
o Inform patient of procedure, no LA/prep, improved appearance, changes to occlusion, lisping, tenderness of front teeth, difficulty eating initially, bite lips/tongue, chance of debonding/chipping
 Lower anterior tooth wear
* Similar technique to uppers however more difficult due to less surface area
 Localised posterior tooth wear
* Rare, usually due to erosive component – prevention
* Occlusal cupping can be filled with composite
* Aim for canine guidance to ensure post disclusion on excursion
 Generalised tooth wear
* Splint should be considered to assess patients tolerance of new face height
* With loss of OVD
o Increase OVD with mixture of adhesive/conventional restorations and dentures
* Without loss of OVD but with limited space
o Restoration of ant/post teeth at new OVD with minimal prep and adhesive restorations
* Without loss of OVD but with no space
o Increase OVD with use of splints and dentures if lack of posterior support
o Crown lengthening surgery
o Elective endodontics – destructive and post/cores and attrition don’t go well
o Orthodontics
o Overdentures
o Monitor