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BDS4 Restorative > Wear > Flashcards

Wear Flashcards

1
Q

what are kinds of NCTSL?

A
  • trauma
  • development problems
  • tooth wear
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2
Q

when is tooth wear considered pathological?

A

when wear is in excess of expected for that age and when patient experiences a masticatory or aesthetic deficit

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3
Q

what are causes of tooth wear?

A
  • attrition
  • abrasion
  • erosion
  • abfraction
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4
Q

what is definition of attrition?

A

The physiological wearing away of tooth structure as a result of tooth to tooth contact

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5
Q

attrition
Where found?
early appearance?
Progression leads to what?

A

found - occlusal and incisal contacting surfaces

early appearance - polished facet on a cusp or slight flattening of an incisal edge

progression - reduction in cusp height and flattening of occlusal inclined planes and There can be shortening of the clinical crown of the incisor and canine teeth

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6
Q

slide 11 get pic attrition

A
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7
Q

what is definition of abrasion?

A

The physical wear of tooth substance through an abnormal mechanical process independent of occlusion. It involves a foreign object or substance repeatedly contacting the tooth.

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8
Q

abrasion
- where common areas?
- appearance?
- commonest cause?
- how can it manifest?

A
  • Common areas - labial/buccal, cervical on canine and premolar teeth.
  • appearance - V shaped or rounded lesions . Sharp margin at enamel edge where dentine is worn away preferentially
  • common cause - tooth brushing
  • manifest - manifest as notching of the incisal edges and can be related to habits/lifestyle/occupation
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9
Q

slide 15 abrasion picture

A
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10
Q

what is definition of erosion?

A

The loss of tooth surface by a chemical process that does not involve bacterial action. Most common tooth wear

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11
Q

erosion
- cause?
- how does it develop early stages?
- appearance?
-preferential wear?
- determinants of effect?

A
  • cause - chronic exposure of dental hard tissues to acidic substances which can be extrinsic or intrinsic
  • early stages - Early stages enamel surface is affected, there is loss of surface detail, surfaces become flat and smooth
  • appearance - bilateral, concave lesions without chalky appearance of bacterial acid decalcification
  • preferential wear - Later dentine becomes exposed the preferential wear of dentine leads to ‘cupping’ of the occlusal surfaces of the molars and incisal edges of the anteriors
  • determinants - Exact position and severity of erosive wear is dependent on the source, type and frequency of exposure to the acid
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12
Q

what are signs of erosion?

A
  • Increased translucency of incisal edges (can appear dark)
  • Base of lesion not in contact with opposing tooth
  • Amalgam and composite restorations stand proud of the tooth
  • There is no tooth staining present
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13
Q

slide 24 erosion picture

A
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14
Q

what is definition of abfraction?

A

The loss of hard tissue from eccentric occlusal forces leading to compressive and tensile stresses at the cervical fulcrum areas of the tooth

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15
Q

what are the 2 theories about abfraction?

A
  • basic cause of all non-carious cervical lesions
  • A combination of occlusal stress, abrasion and erosion
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16
Q

abfraction
- loss of where?
- caused by?
- what does it result in?
- appearance

A
  • where - loss of tooth substance at the cervical margin
  • cause - biomechanical loading forces
  • result - Forces result in flexure and failure of the enamel and dentine at a location away from the loading
    Disruption of the ordered crystalline structure of the enamel and dentine by cyclic fatigue.
  • appearance - V shaped tooth loss where the tooth is under tension. CLASSICALLY SHARP RIM AT THE AMELO-CEMENTAL JUNCTION
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17
Q

abrfraction picture slide 29

A
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18
Q

cervical wear
- cause?
- where?
- who gets it?
- most important factor in this area?

A
  • cause - Overzealous Tooth brushing
  • where - Lesions mainly in premolar and molars on the buccal surface almost never lingually
  • who - Good OH and this wear pattern go together. (Restorations in this area wear at the same rate as the tooth structure)
  • factor - Likely to be a combination of erosion, abrasion +/- abfraction
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19
Q

during assessment what must you do to prevent or reduce tooth loss due to wear?

A
  • Recognise the problem is present
  • Grade its’ severity
  • Diagnose the likely cause or causes
  • Monitor the progression of the disease
    – Is it active or historic
    – Are preventative measures working or is active restorative treatment required
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20
Q

what is rare in wear patients?

A

pain unless there is pulpal involvement

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21
Q

what part of patient history gives an indication of erosion?

A
  • Medications with low pH
  • Medications which dry the mouth
  • Eating Disorders
  • Alcoholism
  • Heartburn
  • GORD
  • Hiatus Hernia
  • Rumination (regurgitation food)
  • Pregnancy - morning sickness
  • Patients are not always aware of reflux

need consent to refer them to GMP

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22
Q

if toothbrishing causes abrasive wear what is important to ask?

A
  • frequency
  • intensity
  • duration
  • type of toothpaste
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23
Q

during exam of patient what do you examine?

A
  • Extra Oral
  • Must examine TMJ for restriction of movement, clicking, crepitus
  • Examine musculature for -
    hypertrophy
  • Examine mouth opening for restriction (<4cm) and deviation during movement
  • ? Parotid hypertrophy
  • Overclosure ?
  • Lip Line
  • Smile line
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24
Q

what do you examine when checking the occlusion?

A
  • Freeway space should be assessed
  • Record the OVD and resting face height
  • Has their been dento-alveolar compensation?
  • Record overbite and overjet
  • Are there stable contacts in centric relation
  • What are tooth contacts like in excursive movements
  • Non functional wear facets are looked for in excursive movements shows a parafunctional wear habit
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25
Q

during intra oral exam what on soft tissues can be bruxist habits?

A
  • buccal keratosis
  • lingual scalloping
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26
Q

what is most common place for wear?

A

localised anteriors

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27
Q

what is the severity levels of wear?

A
  • enamel only
  • into dentine
  • severe
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28
Q

what are the type of wear indices?

A
  • smith and knight
  • BEWE (basic erosive wear exam) (more common than other)
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29
Q

what is score and criteria for BEWE? what is risk level criteria?

A

like BPE for erosive wear
0 - no erosive wear
1 - initial loss of surface texture
2 - distinct defect; hard tissue loss <50% of surface
3- hard tissue loss >50% of surface area

risk level
none - less than or equal to 2
low - between 3 and 8
medium - between 9 and 13
high - 14 and over

30
Q

what are special tests that can be taken for wear?

A
  • Sensibility testing
  • Radiographs - for severe wear
  • Articulated study models
  • Intra-oral photographs
  • ? Salivary analysis
  • Diagnostic Wax-up
  • Dietary analysis
31
Q

what are the different types of generalised toothwear?

A
  • Wear with loss of OVD
  • Wear without loss of OVD but with space available
  • Wear without loss of OVD but with limited space
32
Q

what would you do from sensitivity from toothwear?

A

Desensitising agents. Fluorides, bonding agents GIC coverage of exposed dentine

33
Q

what must you do after having a diagnosis of toothwear?

A

identified primary causative factor
- institute a preventative regime
- tx will fail otherwise

34
Q
  • how to record baseline wear?
  • why important to monitor wear?
A
  • Wear indices: Smith and Knight, BEWE
  • Models
  • Photos
  • to identify if wear is progressing or historic. If historic and unproblematic, tx may not be required. if Active and progressive tx will be required.
    tx includes prevention and that comes first. Biggest element of prevention is removal of cause
35
Q

how could you prevent abrasion?

A
  • Remove the ‘foreign object or substance’ involved in causing the abrasive wear
    such as:
  • Change toothpaste
  • Alter tooth brushing habits
  • Change habits e.g Nail biting
36
Q

how to fix cervical toothbrush abrasion?

A
  • use Simple RMGIC(he would use this one), GIC or composite restorations
  • placed with no tooth prep
  • patient wears through restoration rather than damaging tooth
37
Q

for abrasion why use rmgic over composite?

A
  • rmgic has a better survival rate due to lower modulus so more likely to bend so less likely to stress bond. composite more rigid
38
Q

what is prevention for attrition?
what are some benefits to splints?
why is a soft splint used?

A
  • generally related to a parafunction habit which is generally centrally mediated response to life stressors so CBT and hypnosis

Splints can also be used they benefit by:
- All work by being softer than teeth.
- Wear away in preference to tooth
- Cause no damage to the opposing teeth
- May be habit breaker

softs splints can be used as a diagnostic device and the splint will wear rapidly and show wear facets and gouges in surface of splint. give them it for 6 weeks to see if they grind

39
Q

what is a michigan splints?
what do you not use splints for and why>

A

hard splint. Provides ideal occlusion with even centric stops. has a canine rise which provide disclusion in eccentric mandibular movement - canine guidance

dont use splints for erosion as can make wear worse as will give a place for acid to sit

40
Q

in terms of erosion what is prevention dependent on?
what are some methods of prevention?
what are some of the challenges of preventing erosion in terms of medical problems?

A
  • source of acid
  • desensitising agents which are more for symptomatic relief than prevention
  • fluroides
  • habit changes in terms of swilling drinks in mouth, drinking cans, rumination, sports drink etc
  • medical ways - control gastric acid (gord, reflux, hiatus hernia), xerostomia, anorexia and bullimia
  • You may require to have discussions with the patients doctor. Subsequent referral to specialist such Gastroenterologist; GORD or Psychiatrist/psychologist: Anorexia/Bulemia
  • You must gain consent to contact GMP
  • Change in drugs may not be possible
  • Beware Proton Pump rebound
41
Q

how to prevent abfraction?

A
  • Assess occlusion on teeth with abfraction lesions and Consider occlusal equilibration
  • Fill cavities with low modulus restorative materials
    RMGIC
    Flowable composite.
42
Q

when do you progress to active treatment on wear? and what are goals of active treatment?

A
  • Intervention threshold
  • Simple restorative intervention
  • Covering exposed dentine, filling cupped defects in molars or incisors
  • The requirements for more extensive definitive restoration are not always clear
  • Wear leading to further complications
  • Aesthetics have gone beyond patient acceptability
  • Leaving intervention may cause more complex treatments to be required.
  • preservation of remaining tooth structure
  • pragmatic improvement in aesthetics
  • a functioning occlusion
  • stability
43
Q

what are the factors that decision on treatment depend on?

A
  • The pattern of anterior maxillary tooth wear
  • Inter-occlusal space
  • Space required for the restorations being planned
  • Quality and quantity of remaining tooth tissue, particularly enamel
  • The aesthetic demands of the patient
44
Q

how is maxillary anterior tooth wear categorised?

what kind of cases do they tend to show up in?

A

Tooth wear limited to the palatal surfaces only
Tooth wear involving the palatal and incisal edges with reduced clinical crown height
Tooth wear limited to labial surfaces

palatal - vomitting
labial - diet

45
Q

what are the kinds of cases where there is adequate inter incisal space?

A
  • If teeth wear rapidly and there is no time for alveolar compensation
  • Where there is an anterior open bite
  • Where there is an increased overjet
  • In these cases there can be available space for restorations with no change in OVD
46
Q

what tends to happen in terms of occlusion for most cases of wear and why can it be a good thing but also a bad thing?

A
  • most cases when teeth wear there is no increase in freeway space
  • There is compensation for the loss of tooth substance by dento-alveolar bone growth
  • maintains masticatory efficiency - good
  • leaves potentially no space for restorations to be placed - bad
47
Q

why might creating space when there is no space for restorations be a bad thing?

A
  • Little tooth tissue to begin with
  • Poor retention due to short axial walls
  • Good chance of pulpal damage due to short clinical crowns
48
Q

how else can you make space for restorations?

A
  • Increase OVD: multiple posterior extra-coronal restorations. Reorganised approach
  • Complex, Destructive, Expensive
  • Occlusal reorganisation from ICP to RCP
  • Complicated, can be destructive, specialist treatment
  • Surgical Crown lengthening
  • Doesn’t really create more space
  • Elective RCT and post crowns
  • Very destructive
  • Conventional Orthodontics
  • Lengthy treatment
49
Q

what is surgical crown lengthening?

A
  • Exposes more of the crown for retention of final restoration
  • Repositioning of gingivae apically generally with removal of bone
  • Sensitivity
  • Still need occlusal reduction
50
Q
  • what is the DAHL technique?
  • how long does it take and what does it result in?
  • what does it tend to be done in and why is this good?
    who does it tend to work in best?
    what patients is it not suitable for?
A

commonest way for localised anterior toothwear

  • Covering palatal surfaces and allowing occlusion on raised cingulum
  • Resulted in posterior disclusion and increase in OVD of 2-3mm
  • Occlusal contacts only on incisor/canine teeth
  • Over a period of 3-6 months you gain space between incisor teeth
  • Interiors intrude
  • Posteriors erupt
  • Results in space between upper and lower anteriors allowing restoration with no need for occlusal reduction
  • Generally carried out in composite now (as opposed to CoCr like before)
  • Better aesthetics
  • Better compliance
  • Easier to adjust
  • Can be immediate, definitive treatment
  • faster in younger patients if no movement after 6 months won’t work. monitor progress. really good success rate
  • Occlusion is disorganised at first but re-establishes with time
  • Active periodontal disease
  • TMJ problems
  • Post Orthodontics
  • Biphosphonates
  • If dental implants present
  • If existing conventional bridges
51
Q

what are contra indications to treating anterior wear with build ups?

A
  • short roots
  • Reduced periodontal support due to periodontal disease.
52
Q

in terms of lower anterior toothwear how would you treat it and what does it tend be in conjunction with?
how would you treat them on their own?

A
  • Generally in conjunction with maxillary wear
  • More difficult to fix
  • Less enamel, smaller bonding area.
  • If possible improve aesthetics but do not increase OVD with lowers
  • If you have to build them up do this first before the uppers
  • Same techniques as uppers
  • rare for this to be on it’s own
  • if it was both you would just do uppers
  • on its own lower you would build up labial and come over incisal onto lingual so composite is grabbing on tooth and have more enamel to bond on to
53
Q
  • how would you treat localised posterior tooth wear?
  • ## who does it tend to show in?
A
  • Unusual on its’ own
  • Sometimes erosive in ruminating patients
  • Erosive in bulimic and alcoholic patients
  • If localised and asymptomatic, prevention and monitoring are appropriate
  • Occlusal erosive wear can be filled directly with composite with no change in occlusion
  • Restorative care can be aimed at providing sufficient canine guidance to ensure posterior disclusion
  • Composite resin can be added to the palatal of the upper canines to increase the canine rise and disclude the posteriors during lateral and protrusive excursions
  • Often there is canine wear which has removed guidance and led to posterior wear.
  • Correct the canine wear and the posterior will be saved from further damage
54
Q

slide 9 wear 3 get pictures what is this treamtent being shown and what does it do and why is it effective and how would you do it?

A

Canine is restored to original length. This results in disclusion of the posterior teeth in lateral excursions
Simple, effective, reversible technique
Can be freehand or with use of diagnostic wax and template

55
Q

how would you do comp build up?

A
  • take alginate impression
  • create study casts
  • do diag wax up
  • then use putty matrix to take impression of wax up
  • then direct build up with putty matrix
56
Q

how would you do a clear vacuum formed matrix?

A
  • Alginate impression
  • Diagnostic wax
  • Impression of this poured in stone.
  • Vacuum formed clear plastic matrix formed on this
  • Cut to size and used as mould for build up
57
Q

what is the success rate for comp build ups?
what is their longevity like?
what do they tend to be better in and why?

A
  • Generally good patient satisfaction
  • Posterior occlusion is normally re-achieved
  • Seldom TMJ problems
  • No detrimental effect on Pulpal health
  • No worsening of Periodontal condition
  • viable medium term option
  • will require repair and maintenance
  • Maxillary restorations last better than mandibular
  • Probably due to increased bonding area
  • Maxillary wear more common
    ** Tongue and saliva protect lowers
58
Q

what is daughter test?

A

would you do that treatment to a family member? If you’re not then why are you doing it at all?

59
Q

in terms of comp build ups how does it affect the patient eating and speaking?
what will need to be replaced?

A
  • Your ‘bite’ will feel strange for a few days and you may have difficulty chewing (most people get hang of eating in 2-3 days)
  • Only your front teeth will touch together
  • Your back teeth will gradually come back together but this will take 3 – 6 months
  • Over a week or so you will become accustomed to your new ‘bite’ and will be able to eat more normally
  • Initially though you may have to cut your food into small pieces to help with swallowing and digestion
  • The change in the shape of your front teeth may cause lisping for a few days
  • Your front teeth may feel a little tender to bite on for a few days
  • You may bite your lips and tongue initially
  • crowns bridges or partial dentures at back of mouth
60
Q

what kind of maintenance will comp build ups require?

A
  • may debond and fall off can be placed back on
  • maintenance - margins of these restorations will require occasional polishing and Occasional chipping of restorations may occur
    composite so it will stain
61
Q

what patient is this picture slide 22 wear 3

A
62
Q

what are categorise for generalised toothwear?

A
  • Excessive wear with loss of OVD
  • Excessive wear without loss of OVD but with available space
  • Excessive wear without loss of OVD and with no space available
63
Q

in generalised toothwear what should be done to these case as a medium term restoration and why is it done and what can it help with?

A
  • adhesive approach
  • They can be used to assess the patients tolerance of a new occlusal scheme as a medium term restoration
  • If conventional preparations are required at a later date these adhesive additions may form the bulk of the removed material. Preserving tooth structure
64
Q

how would you treat generlaised toothwear with loss of OVD?

A
  • least common
  • A splint can be used to assess the patients’ tolerance of the new face height.
  • May not be necessary if an adhesive approach is being used.
  • You can go straight to increase in face height with ‘permanent’ bonded restorations
  • Ideally half the OVD increase should be maxillary and half mandibular
  • Often a mixture of adhesive and conventional restorations are required
  • Dentures may be required to provide posterior support at the new OVD
65
Q

how would you treat excessive toothwear without loss of OVD but with limited space available?

A
  • Much more complicated to treat
  • Can involve re-organisation of the occlusion
  • A splint should be considered as an increase in occlusal face height is required
  • Most patients accommodate to this increase
  • Restoration of anterior and posterior teeth is then carried out at the new occlusal face height.
  • If possible this should involve minimal preparation adhesive restorations
66
Q

how would you treat Excessive tooth wear without loss of OVD with no Space available?

A

The most severe type
The most difficult to treat
Probably require specialist opinion prior to commencing treatment

67
Q

if you do treat Excessive tooth wear without loss of OVD with no Space available how would you do it?

A
  • Attempt to increase OVD by use of splints+/- dentures if there is lack of posterior support
  • As there often is in these cases
  • Crown lengthening surgery
  • Elective endodontics
  • Destructive and posts and cores and attrition do not go together
  • Orthodontics
  • overdenture
68
Q

what may crown lengthening result in?
what can it lead to?

A
  • May result in ‘black triangles’ between the teeth where the ID papilla is further down
  • Can lead to unfavourable crown to root ratio
  • Increased chance of loosening or tooth movement if tooth is loaded subsequently
  • Often post op sensitivity
  • Any subsequent conventional crown preparation will be further down the root
  • Problem if the tooth has a significant coronal-cervical taper.
  • Greater chance of pulpal damage
69
Q

what is overdenture good for and what can it’s difficulties be?

A
  • Preserves tooth substance and bone for support of denture when teeth as so worn down that restoration is impossible
  • Can be bulky for patient to wear
  • Difficulties with keeping teeth and gingivae healthy beneath the prosthesis
70
Q

what is important in risk management in tooth wear?

A
  • Preventative Advice/Counselling
  • Advice must be recorded and detailed in the patients notes.
  • If the patient is not compliant, reluctant or unwilling to follow a recommended course of action this must be recorded
  • Any surface treatments, eg topical fluoride, must be recorded on each occasion.
  • It is important to record if the patient complied with repeat applications.
  • consent
  • The patient must understand the proposed treatment, Including passive preventative
  • The patient must understand their part in the treatment and how their cooperation is integral to a favourable outcome
  • The patient must understand the consequences of not following the advice given
  • These discussions must be recorded clearly in the patients’ notes
  • Provisional Treatment (often passive preventative)
  • The importance of this treatment in establishing a definitive diagnosis must be explained to and understood by the patient
  • If this is temporary this must be explained to the patient as must the reason for not providing definitive treatment at that time
  • These discussions must be recorded clearly in the patients’ notes
  • Definitive Treatment
  • Minimum intervention treatments should be tried before considering a more radical interventive approach
  • If in doubt a second opinion from a restorative specialist is sensible
  • Any referral documentation must be copied and retained in the patients’
71
Q
A

BDS4 Restorative (7 decks)

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