TOOTHWEAR PART 2

Question 1

What is the aetiology of toothwear?

Answer 1

• attrition
• erosion
• abrasion
• combination of above
• unknown

Question 2

Why is knowing the aetiology of a patients toothwear important?

Answer 2

• attempt to reduced further wear
• plan for problems, contingencies & failure
• allow you to be realistic with yourself & pt
• identifies wider medical & wellbeing issues
• prognostic indicator

Question 3

What can attrition be split into?

Answer 3

• physiological wear
• bruxism

Question 4

What are modifying factors of attrition?

Answer 4

• lack of posterior teeth
• occlusion
• restorations
• erosion & abrasion
• stress & anxiety

Question 5

what are common clinical features seen in bruxism patients?

Answer 5

• significant wear throughout dentition
• repeated restoration failure
• root fractures
• often onset in early adulthood
• progressive

Question 6

How can you decide if toothwear is physiological or pathological?

Answer 6

Is the toothwear what you would expect of a patient at that age??
- if NOT… suspect pathology (eg bruxism)

Question 7

A patient has lack of posterior support in their mouth, what common toothwear features are seen?

Answer 7

• extensive anterior wear
• progresses rapidly

Question 8

What restorations/material can make toothwear WORSE?

Answer 8

Porcelain restorations!
- you will see significantly worse wear than you would expect if dentition was opposed by natural teeth

Question 9

What are signs that a patient may have a parafunctional habit, even if there is no obvious toothwear present?

Answer 9

• multiple cusp fracture
• multiple cracks around restorations
• root fractures in unrestored teeth

Question 10

What modifying factors affect the rate of erosion in patients’ mouths?

Answer 10

• lifestyle
• amount & frequency of acid intake
• level of control

Question 11

Give examples of extrinsic factors that can increase rate of progression of erosion?

Answer 11

• carbonated drinks
• acidic drinks (eg sports drinks)
• acidic foods (eg pickles)
• drugs

Question 12

Give examples of intrinsic factors that can increase rate of progression of erosion?

Answer 12

• eating disorders
• GORD
• other medical conditions

Question 13

What are common erosion features seen in patients with a high carbonated drink intake?

Answer 13

• incisal erosion of upper centrals
• cupping on lower molars
• palatal erosion of upper incisors
• sensitivity
• interproximal caries & buccal white spots/brown caries

Question 14

What are common erosion features seen in patients with an eating disorder?

Answer 14

• palatal erosion of upper anteriors
• polished restorations
• erosion around restorations
• sensitivity
• caries
• halitosis

Question 15

What are examples of factors that can cause abrasion?

Answer 15

• toothbrush abrasion
• oral self harm
• tongue studs
• unusual habits

Question 16

If a patient presents with toothwear abrasion what should you do?

Answer 16

• brushing technique instruction
• find out if its as a result of stress/anxiety?

Question 17

What are common combinations of NCTSL that you may see in pts with alcoholism & drugs abuse?

Answer 17

Erosion + Attrition + Abrasion

Question 18

What are common combinations of NCTSL that you may see in pts with an eating disorder?

Answer 18

Erosion + Attrition + Abrasion

Question 19

What combination of NCTSL may you see in pts with a bruxism habit & poor diet?

Answer 19

erosion (extrinsic) & attrition

Question 20

Why can uncovering toothwear aetiology when history taking be challenging?

Answer 20

You may uncover:
- eating disorders
- undiagnosed diabetes
- mental health issues
- GI issues
- abuse/harm/addiction
- vulnerable adult/child

Question 21

What preventative advice can you give to patients with toothwear?

Answer 21

1. Fluoride: high dose tp & alcohol free mouthwas
2. Dietary modification
3. Remineralisation: tooth mousse
4. Sugar free gum?

Question 22

Where can we signpost patients with severe toothwear related to habits/stress/suspected medical disorders?

Answer 22

• CBT
• hypnotherapy
• GMP
• psychiatrist
• social services

Question 23

Why might patients have a lack of posterior support?

Answer 23

• denture intolerance
• denture refusal
• supervised neglect

Question 24

Why should you try to avoid complete dentures in bruxist toothwear patients?

Answer 24

Bruxism does not stop!
- fractured dentures
- ridge resorption
- pain & ulceration under denture

Question 25

what is an overdenture?

Answer 25

Any removable prosthesis that rests on one or more remaining natural teeth, the roots of natural teeth and/or dental implants

Question 26

What are some advantages of using overdentures?

Answer 26

- correction of occlusion & aesthetics - support - toothwear management - preservation of ridge form - increased proprioception - denture retention - avoids extractions - psychological benefits - eases transition to edentulism

Question 27

What are some disadvantages of overdentures?

Answer 27

- NEED good oral hygiene - increased caries/perio risk - denture fracture - discomfort/infection

Question 28

How should overdenture patients be cared for?

Answer 28

- ensure good OH - fluoride toothpaste application to remaining teeth/roots - regular exams/radiographs - ensure good denture hygiene

Question 29

What is the function of transitional dentures in toothwear pts?

Answer 29

Transitional dentures can increased OVD in cases where poor posterior support to create space for restorations

Question 30

What change is there between conforming to a pts occlusions vs rehabilitating a pts occlusion?

Answer 30

Conforming = OVD stays the same Rehabilitation = OVD is changed

Question 31

What planning/clinical steps are required in tooth wear rehabilitation patients?

Answer 31

- impressions & facebow - mounted articulated casts on semi-adjustable articulator - high quality interocclusal record - diagnostic wax-ups - stents for build-ups - clinical photographs

Question 32

Why is tooth preparation in tooth wear cases difficult?

Answer 32

- lack of occluso-gingival height - lack of occlusal space - severly compromised tooth

Question 33

Why do we need to modify preparations in tooth wear patients when aiming to restore?

Answer 33

creating retention & resistance in small teeth

Question 34

What are some examples of modified preparations performed in restorative work of tooth wear pts?

Answer 34

- grooves - inlays - ferrule - parallel preps - cores - electrosurgery - surgical crown lengthening

Question 35

What material do we tend to use in tooth wear pt biting surfaces?

Answer 35

metals! - to prevent fracture

Question 36

How can electrosurgery be used in toothwear patients restorative treatment?

Answer 36

Electrosurgery used to remove gingiva and lengthen appearance of tooth crown (creates ferrule of sorts) to allow restorative work

Question 37

If you are using a metal crown, what margin preparation should you have?

Answer 37

metal margin = chamfer

Question 38

If you are using a porcelain crown, what margin preparation should you have?

Answer 38

porcelain margin = shoulder

Question 39

Why should porcelain preps be curved and smooth in toothwear pt?

Answer 39

To prevent crack propagation of porcelain, especially in pt with increased occlusal load/parafunction

Question 40

How long does it roughly take for gingiva to stabilise after crown lengthening surgery?

Answer 40

About 3 months

Question 41

What problems are sometimes associated with silver points used for root filling?

Answer 41

They can become corroded - very difficult to remove once this happens

Question 42

What bur should be used for cutting porcelain when removing restorations?

Answer 42

Coarse diamond bur

Question 43

What bur should be used for cutting metal when removing restorations?

Answer 43

Gold cutting bur (these cause loads of vibration)

Question 44

Describe the steps of removing an indirect restoration such as a crown/bridge:

Answer 44

- cut whole way up buccal surface with bur - use chisel to split things apart - ensure high volume suction

Question 45

What problem may arise when removing an indirect restoration with instruments such as enamel chisel or sliding hammers?

Answer 45

High risk of core fracture

Question 46

Before removal of an indirect restoration that to plan to replace long term, what clinical procedure should you carry out?

Answer 46

Take a pre-op impression so you can make a temporary restoration for in between appts.

Question 47

What can be used to soften gutta-percha during re-RCT?

Answer 47

Eucalyptus/Turpentine oil

Question 48

What must we determine before removing a post from a pt tooth?

Answer 48

- is there a fracture risk? - how easy will the removal be - have plan in place in case of fracture - is there other pathology within tooth?

Question 49

Effective communication is important in managing patients with failing dentitions. Give examples of aspects of effective communication:

Answer 49

- effective listening - honesty & transparency - seeking advice - listen to pt wishes - documenting discussions - time & patience

Question 50

Outline the SPIKES protocol for giving bad news:

Answer 50

Set up the interview: mental & physical preparation Perception: asses what the pt knows about the medical situation Invitation: ask how much they want to know Knowledge: give the facts Emotion: response to pt emotions Strategy and summary