toothwear - paterson Flashcards
aetiology of toothwear types
- Attrition – opposing dentition
- Erosion – acid attack
- Abrasion – toothbrush most common
- Combination
- Unknown
Time – more in older person, need to relate aetiology to chronological age
why is working out aetiology of toothwear important
7
- Attempt to reduce further wear
- Plan for problems, contingencies & failure
- Allow you to be realistic with yourself & patient
- Identifies wider medical & wellbeing issues & allows signposting
- Prognostic indicator
- Enhances consent process
- Aids clinical diagnosis & treatment planning
modifying factors for attrition
5
- Lack of posterior teeth – wear on other teeth is higher
- Occlusion – deeper overbite, edge to edge occlusion
- Restorations
- Erosion & Abrasion
- Stress & Anxiety
spectrum; physiologucal wear-> bruxist
bruxist common features
- Significant wear throughout dentition
- Repeated restoration failure
- Root fractures
- Often onset in early adulthood
- Progressive
physiological toothwear
common features
Wear that you would expect to see given the age of pt
* Caine more rounded, incisal edges
* Not worrying – expect
* Pt may want cupping filled
lack of posterior support
common features
- Wear is more extensive as no posterior support (inc severeity and rate of progression)
- Modifying factor of tooth wear
- Ultimately can lead to occlusal collapse
- Functional & aesthetic problems
Dentist role – advise denture to protect remaining natural teeth
occlusion impact on toothwear
A lot of the wear is caused by the nature of the occlusion often compounded by parafunction
* Deep overbite – lower incisors
* Edge to edge occlusion – localised wear
restorations impact on toothwear
Wear worse than you would expect as natural teeth opposed by restorations
* Porcelain mainly
key signs of evidence of parafunction
but lack toothwear
4
- soft tissue abrasion - lip/cheek/tongue chewing
- multiple cusp fracture
- multiple cracks around restorations
- root fractures in unrestored teeth
extrinsic erosion causes
8
- Carbonated drinks
- Sports drinks
- Alcoholic acidic drinks
- Citrus drinks
- Acidic fruits
- Acidic sweets
- Pickles
- Drugs (amphetamines)
intrinsic erosion causes
4
- Eating disorders
- GORD
- rumination syndrome
- Other medical conditions (causing nausea etc)
modifying factors in erosion
- Lifestyle
- Multiple factors
- Amount & frequency
- Level of control
- Psychosocial
common features in erosion caused by carbonated drinks
5
- Incisal erosion on upper centrals
- Cupping on lower molars
- Palatal erosion on upper incisors
- Sensitivity
- Interproximal caries and buccal white spot/brown spot caries
eating disorder erosion
common features
8
- Palatal erosion on upper teeth
- Polished restorations (esp amalgams)
- Erosion around restorations
- Sensitivity
- Caries
- Altered taste – sometimes
- Halitosis – sometimes
- Soft tissue changes (bulimia) – rarely –* abrading on incisal edges of tongue when vomiting *
Can also commonly have abrasion/attrition too
abrasion behaviours
5
- Toothbrush abrasion
- Oral self-harm
- Tongue studs
- Occupational
- Unusual habits
able to modify if pt takes on behaviour change you suggest
good hx key
toothbrush abrasion
7 factors to consider
- Localised or Generalized
- Frequency & duration
- Bristle & toothpaste abrasiveness
- Brushing technique instruction
- Electric Vs manual
- Part of a combination wear problem eg Eating disorder?
- Part of a stress/anxiety related problem?
combination aetiology of some toothwear
important to remember that….
common combos
Erosion (Intrinsic & Extrinsic); Attrition; Abrasion
* Alcoholism & Drug abuse
* Eating disorder
Erosion (Extrinsic) & Attrition
* Bruxist with poor diet
Erosion (Intrinsic & Extrinsic) & Attrition
* Bruxist with poor diet & GORD
**Synergistic rate of wear progression when multiple wear factors **
multiple wear factors present (combination aetiology)
then…
**Synergistic rate of wear progression when multiple wear factors
how to manage unknown toothwear aetiology
Often unusual wear pattern
* Patient may know aetiology but will not tell you
Plan warily
Communicate a guarded prognosis
* If place restoration and wear not resolved than likely fail of restoration as same process will occur again
history taking for toothwear pts
History taking can be challenging:
* Comprehensive
* Compassionate
* Unconditional positive regard
* Show patience
What you may uncover
* Eating disorder
* Undiagnosed diabetes
* Mental health issues
* GI issues
* Abuse/harm/addiction
* Vulnerable adult/child
examination for toothwear
Comprehensive
Use of indices
* BEWE (erosion), Smith and White Index - more useful for research
* Generalized/localized
* Mild/moderate/severe
Try relate findings to aetiology
* What you would expect? Worse? Better? Relation to chronological age?
Remember tooth wear patients have caries & perio disease
* Radiographs and other tx needs
BEWE is
basic erosive wear exam
scores look at buccal/occlusal/lingual surfaces of teeth and most affected tooth surface per sextant is recorded
sum of scores is added to aid tx plan
BEWE sum score is used to
aid tx plan
when work out aetiology of toothwear can
plan
* Individualized preventive plan
* Reinforcement – diet advice, non abrasive toothbrushing
* Signposting/referral to other health & social care professionals
* Review before definitive plan
common preventative advice
Fluoride:
* High dose toothpaste
* Alcohol free mouthwash
Dietary modification:
* Frequency & quantity
* Method of delivery (glass, straw, can, bottle)
* Elimination & addition
Remineralization:
* Tooth Mousse
Sugar free gum – awake bruxist, but depend on their job if socially acceptable
possible interventions to control aetiology of toothwear
4
Toothbrushing instruction
Splint therapy
Signposting:
* CBT
* Hypnotherapy
Referral:
* GMP
* Psychiatrist
* Social services
failure to control aetiology of toothwear risk
failure
Reality check: Can you control aetiology?
Reality is: We rehabilitate people with uncontrolled or partially controlled aetiology
Result: Higher failure rates
* Be realistic with pt – due to aetiological control of their tooth wear = high failure rate, restorations wont last as long, face greater tooth loss
examination findings for this case
due to erosive diet (drinks)
* translucent incisal edges on central
* Cupping defects in cervical third of centrals (erosion more than abrasion)
* Caries of UL2 mesially
due to erosion and attrition
* Large cracked amalgam on UR6
* Wear in dentine into lower arch on lower posteriors
* Tongue stud
* Attrition on lower incisors
questions to ask this case to work out aetiology
- Symptoms – sensitivity, when they begin, worse or better/any change
- Any acid regurgitation
- Any eating disorders
- Detail of diet and intake
- are they arware of clenching/grinding teeth
any previous tx attempts/mentioning of toothwear by previous dentists
special tests neeeded for this case
bitewings
Lower L 6 – caries, angular bone loss, loss of all enamel (same as lower 5).
Greater than thought
dx for this case
Extrinsic acid problem primarily, with combination of attrition (poss intrinsic acid too depend on MHx)
intial plan for this
PREVENTION
Modify diet,
* advice of alternatives
Fluoride use
* try to remineralise
* caries can spread more rapidly through dentine so higher risk
Study models to monitor wear
INTERVENTION
Some restorative treatment is essential for 6; what is the prognosis with & without aetiology controlled?
would you consider referral for this pt
MHx may uncover eating disorder – possible referral to psychologist/therapist
transitional denture role
inc OVD when occlusal collapse has occured to due toothwear (lack posteiror support)
this creates space for restorations
place acrylic dentures which have OVD that teeth would be if not worn
can place tooth coloured acrylic over lower denture to get balanced occlusion
wear for 3-6months - if pt copes with denture and inc OVD then place restorations at inc OVD and make definitive dentures
bruxist denture design
fracture denture in palate or midline (lower)
so go for metal based denture
Co/Cr Backing
* Technically difficult - Need to have a wax trial of teeth before making Co/Cr – so technician can put the CoCr backing correct place
Metal palate with acrylic post-dam
* An attempt to make a complete denture both retentive & indestructible
simplify denture design with free end saddles and smaller saddles
Bridgework can simplify small saddles –
careful with occlusion – no lateral or protrusive forces on pontic -> debonding of adhesive bridge
overlay denture
Overlays teeth to protect remaining teeth
* E.g odd occlusion – posterior open bite
Technically demanding but often well-tolerated
Wax trial before decide where to place CoCr
difficulties in tooth prep for toothwear cases
3
Lack of occluso-gingival height
* Top of gingival margin to occlusal surface
* prep (right picture) - little retention and resistance form
Lack of occlusal space
Severely compromised tooth
resistance in indirect tooth restoration
essential
ferrule
Circumferential coronal dentine
Essential – no ferrule = unlikely to be restored by crowns
* 22, 23 – none
* 11, 21* – possible
Posts allow you to persevere as much coronal dentine as possible (can add a grove too)
SPIKES
breaking bad news
set up
preception
invitation
knowledge
emotion
strategy
rehabilitation of occlusion
Often occlusion is unstable and lack of sufficient index teeth
Usually more challenging to record occlusion
Decision on how much to increase OVD
common in toothwear
special tests neeeded for this case
bitewings
Lower L 6 – caries, angular bone loss, loss of all enamel (same as lower 5).
Greater than thought
