Transcript Tooth wear: aetiology, prevention, clinical implication

Libyan International Medical University
2nd Year 2nd Semester
D Caroline Piske de A. Mohamed
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Objectives:
• Definitions of tooth wear
• Epidemiology of tooth wear
• Aetiological factors
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1.Definitions of tooth wear
Non carious destruction of teeth tissues.
Tooth wear is usually due to a combination of processes,
abrasion, attrition, and erosion.
It is unusual for wear to be solely attributed to one of
these. Rather, tooth wear is due to all three processes
with perhaps one of these predominating.
 Tooth wear:
a. Attrition
b. Abrasion
c. Erosion-Corrosion
d. Demastication
e. Abfraction
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a) Attrition-definition
 Loss by wear of surface tooth or restoration caused
by tooth to tootth contact during oclusion,
mastigation or parafunction.
 Microwear detail: parallel striations within the facet
border.
 Shiny facets
 Bruxism
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Attrition

Destruction accelerated
by:
I. Poor quality or absent
enamel
II. Premature contacts, edge
to edge oclusion
III. Intraoral abrasives,
erosion or grinding /
clenching habits
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Grinding, clenching habits
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Attrition / clinical appearence
 Matching wear on occluding surfaces
 Shiny facets on amalgam contacts
 Enamel and dentine wear at the same time
 Possible fracture of cusps or restorations
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b) Abrasion-definition
 Loss of tooth structure secondary to the action of an
external
agent.
Most
toothbrushing.
 Method of brushing
 Toothpaste abrasives
 Habits
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 Most abrasion is located in the cervical area of
teeth and associated with tooth brushing.
Incorrect or over-vigorous brushing with an
abrasive toothpaste is usually the prime
aetiological factor.
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 The orientation of the toothbrush influenced the wear
of the teeth. Horizontal brushing was suggested as
causing 2 to 3 times as much wear compared with vertical
brushing.
 Some studies suggest that toothpaste has more
relevance to abrasion than does the toothbrush itself.
 Abrasion can occur as a result of overzealous
toothbrushing, improper use of dental floss and
toothpick, or detrimental oral habits such as chewing
tabacco, biting on hard objects such as pens, pencils/
opening hair pins with teeth, and biting finger nails.
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 It is not just the abrasive content of the toothpaste that is
important; the abrasive type, particle size and surface,
and the chemical effects of the other constituents will
also affect the amount of abrasion. For example, most of the
hydrated silica-based toothpastes have good cleaning
values with a low to moderate dentine abrasivity.
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Occupational abrasion.
 Tailors, seamstresses ( server thread with their teeth)
 Shoemakers and upholsters ( hold nails between their
teeth)
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Occupational abrasion.
 Glassblowers and musicians (play wind instruments)
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c) Erosion—Corrosion
definition
 Progressive lost of hard dental tissue by chemical or
electrochemical process not involving bacteria
action.
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Erosion
Erosion has a mutifactorial etiology.
 A susceptible tooth
 The mineralisation of the dental hard tissues
(presence
of
fluorapatite
rather
than
hydroxyapatite
affects the acid solubility).
 Time
 Salivary flow rates and buffering capacity at
different sites also influence erosion.
Where there is abundant saliva such as in the lower
incisor region, there tends to be little erosion.
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Multi-factorial aetiology of dental erosion: the overlapping
factors may all be required to some extent to produce severe
erosion shown as the red area in the centre.
L. Shaw,and A. J. Smith,2 Dental erosion — the problem and some practical
solutions BRITISH DENTAL JOURNAL, VOLUME 186, NO. 3, FEBRUARY 13
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Clinical appearence
 Lost of detailed surface microanatomy ( glazed and
rounded)
 Cupping or Cratering: It is one of the most obvious
characteristics of erosive and abrasive attrition.
 Cupping happens on the cusp tips of molars and
premolars
and incisal edges of incisors and
canines.
 Cupping on molars has less to do with bruxing than with
erosion caused by acids, while cupping on anterior teeth
is more likely due to bruxing in older patients.
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 Increased incisal translucency
 Wear on non occluding surfaces
 “Raised amalgam or composite restorations”
 Clean, non tarnished appearance of amalgam
restorations
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 Loss of surface characteristics of enamel in young
children
 Hypersensitivity
 Pulp exposure in deciduous teeth.
 Preservation of enamel “cuff” in gengival crevice is
common
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Sources
 Intrinsic sources
 Extrinsinc sources
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Erosion-corrosion








Intrinsic sources: gastroesophageal acid
reflux, regurgitation or vomiting.
Associated with:
Nervous system disorders.
Eating disorders such as: Anorexia and
Bulimia nervosa
Gastrointestinal disorders such as peptic
ulcers or gastritis
Alcohol abuse –gastrites associated
Pregnancy
Diabetes or others medical conditions
Drug side effects
Acid mouthwashes may be implicated
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Intrinsic sources of acid
 Intrinsic sources of acid are essentially gastric contents,
which enter the mouth as a result of reflux and vomiting. There
are also some occasional case reports of rumination—
deliberately bringing food back into the mouth to re-chew—which
has led to extensive erosion.
 Gastric reflux is much commoner than was once thought.
Relatively, recent research has shown that, in the developed
world, 7% of the adult population have gastrooesophageal reflux
on a daily basis and more than 30% every few days.
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Principal causes of gastrooesophageal reflux
Increased gastric pressure
Obesity
Ascites
Increased gastric volume
after heavy meals
Obstruction
Spasm
Sphincter incompetence
Hiatus hernia
Diet
Drugs, e.g. diazepam
Neuromuscular, e.g. cerebral palsy
Oesophagitis
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General associated symptoms are heartburn, retrosternal discomfort and dysphagia.
People with neurological impairments such as
cerebral palsy also have significantly higher levels of
reflux.
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 Vomiting, either spontaneous or self induced, may be
associated with a variety of medical problems.
 This phenomenon must continue over a long period to
cause significant erosion, and again, there is a range in
susceptibility.
 Current research shows an increasing prevalence of such
conditions as bulimia and anorexia nervosa, both of which
may be associated with self-induced vomiting.
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 Recognizing Bulimia Wear patterns on the teeth
 Loss of tooth structure is progressively worse toward the anterior teeth.
 This is because of the way the tongue is held in the mouth when the
patient vomits. The vomitus is projected especially toward the palatal
surfaces of the maxillary incisors with progressively less damage as
you proceed posteriorly.
 As the palatal surfaces of the maxillary incisors erode, the incisal edges
become more and more thin and translucent, eventually producing a knifeedge which is easily crazed and chipped.
 Note the image above. Nearly all of the palatal enamel has been dissolved
by the acidic stomach contents which have been projected against the
incisors.
 Note especially in the image above that the loss of tooth structure is fairly
even beginning at the free gingival margin.
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Principal causes of vomiting
Psychosomatic Stress-induced psychogenic vomiting
Eating disorders
Bulimia nervosa
Anorexia nervosa
Metabolic and endocrine
Uraemia
Diabetes
Gastro-intestinal disorders
Peptic ulcer
gastritis
Obstruction
Nervous system disorders
Cerebral palsy
Drug induced
Primary, eg. cytotoxics
Secondary to gastric irritation e.g. aspirin, non steroidal anti-inflammatory drugs
Drug-induced xerostomia over a period of time may also influence erosion
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Extrinsic sources of acid
• There are many sources of acid from outside the body,
•
•
•
•
which may affect the dental tissues.
Dietary practices ,‘nibbling’ and ‘snacking’.
Increase in soft drink consumption (children and
adults)
Soft drink consumption and dental erosion are
corelated, particularly, the bed-time consumption of
fruit-based drinks.
Acidic foods, high consumption of fruit, pickles, and
sauces and the use of acid mouthwashes.
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Lifestyle influences
 Sports drinks are not only acidic,
but also contain a considerable
amount of simple sugars.
 Both competitive swimmers and
cyclists have been reported as
having higher levels of dental
erosion.
 The dry mouth combined with
dehydration from vigorous exercise
and excessive consumption of low
pH drinks has also been linked to
dental erosion.
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Soda Swishing
 Soda swishing is the habit of retaining each mouthful of soda in the
mouth for a few seconds and swishing it around between the teeth
before swallowing.
 All sodas, including diet soda contain three acids: Phosphoric acid,
Citric acid and Carbonic acid.
 Mandibular molars are much more heavily affected than maxillary
molars because gravity keeps the soda in contact with them.
 Over the years, the posterior teeth become more worn than
anterior teeth due to tongue position while swishing.
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Fruit mulling
is the habit of "chewing" fruit pulp for prolonged
periods before swallowing it. This habit causes loss of tooth
structure due to a combination of erosion from the acidity of the fruit
itself, as well as a modified form of abrasion from the constant
rubbing together of the teeth over the fruit pulp during the mulling
process.
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Erosion clinical differences
 Erosion due to acidic
drinks:
 -Facial surface of maxillary
anteriors mostly affected.
Appears as shallow spoon
shaped depressions in cervical
portion of the crown and
occlusal of posterior teeth.
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 Erosion due to gastric
regurgitation:
 Palatal surface of maxillary
anteriors mostly affected and
occlusal of posterior teeth
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Occupational tooth erosion
 Competitive swimming, (exposes the dentition to repeated
contact with acids)
 Can occur during exposure to industrial gases that contain
hydrochloric or sulfuric acid, as well as acids used in plating
and galvanizing and in the manufacture of batteries,
ammunitions and soft drinks.
 Professional wine tasters.
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Drugs recreational exposure.
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d) Demastication is a term used for wearing
away of tooth substance during mastication. This
could be specifically applied to the type of wear
shown by the ancient Egyptians, and would depend
on the abrasivity of the food consumed.
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Tooth wear in noncivilized
communities
 ‘The total absence of cervical abrasion
in the Yanomamis leads us to believe that
this phenomenon, so common in men of
our civilization, is caused by tooth
brushing. The Yanomamis had no brushing
habits.’
 ‘… it was evident that caries incidence was
significantly lower than in present day
civilized men. Neither water nor enamel
mineralization were analyzed. Apart from
those two factors we believe that
physiological
occlusal
abrasion
(eliminating sulci and fissures) produced by
the intense masticatory activity, with its self
cleaning and anti-plaque effects, has
appreciably influenced caries incidence.”
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PEREIRA
et
all.
DISEASE,
OCCLUSION,
DENTAL
CHARACTERISTICS
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Teeth
IN
of
yanomamy
ATTRITION
PRIMITIVE
peoplePERIODONTAL
AND
OTHER
BRAZILIAN
MEN
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e) Abfraction Definition
 Loss of tooth surface at the cervical areas of
teeth caused by tensile and compressive forces
during tooth flexure.
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The theory of abfraction suggests that the cervical
buccal lesions were caused by the biomechanical
"bending" of the teeth due to severe bruxing forces.
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 Note the pattern of cervical tooth wear seen in the images
below.
 Was this caused by the process of abfraction, or is this
toothbrush abrasion?
Toothbrush abrasion
Abfraction
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Aetiology of tooth wear
• Abrasion: usually due to incorrect or over-vigorous brushing,
but there are many unusual habits that are occasionally implicated.
•Attrition: parafunctional activities, such as bruxism, are
probably the most significant factors in the development of
pathological tooth wear in contact areas.
•Erosion: always multifactorial but one specific aetiological
factor usually predominates:
Intrinsic acid sources
• Gastro-oesophageal reflux
• Vomiting; spontaneous or self-induced
Extrinsic acid sources
• Dietary, drinks etc.
• Lifestyle influences
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Indices
 The many published clinical indices suggest that it has
been difficult to devise an ideal index for use in all clinical
circumstances.
 The Tooth Wear Index of Smith and Knight (1984) is a
qualitative clinical index and has probably achieved the
greatest general acceptance. It is intended for both
epidemiological studies and individual patients for longterm monitoring of tooth wear.
 Poor reproducibility of diagnosis of tooth wear in large
surveys with many examiners indicate that the results of
studies should be interpreted with caution.
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2 Epidemiology of tooth wear
 Tooth wear has long been a recognized
phenomenon in adults and ascribed to the
triumvirate of attrition, abrasion and
erosion.
 Pathological tooth wear has been seen in
antiquity but the problems are becoming even
more evident in society now, with an ageing
population who are retaining their natural
teeth for significantly longer.
 There has been a gradual realization in
recent years that our younger population may
also be increasingly affected.
 This is with increasing dental erosion, rather
than attrition and abrasion, although these
factors also contribute.
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Epidemiology of tooth wear
 Very different types of tooth tissue loss are observed in the
older adult population than in children. It is, therefore,
essential to consider them separately but to regard tooth wear
as a continuum throughout life with very different
etiological factors at the ends of the age spectrum.
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Prevalence of tooth wear and erosion in the
deciduous teeth
 Researches indicate high variety in tooth wear prevalence
between pre-scholars in different countries.
 The primary dentition is more susceptible than the
permanent because of higher acid solubility and
reduced thickness of the enamel.
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Prevalence in children

The United Kingdom Child Dental Health Survey of 1993
randomly selected a sample of 17,061 children aged from 5 to
15 years which had their oral health condition examined.
 It was found that 50 per cent of children aged 5 and 6 years
had evidence of tooth wear, largely attributed to erosion,
with almost 25 per cent having dentine involvement.
 Over half of palatal surfaces of primary upper incisors
showed erosion in this age group.
 At eleven years of age, 2 per cent of children were found
to have erosion in their permanent teeth.
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Prevalence of tooth wear and
erosion in Adolescents
 The 15-year-olds sampled in the National Children’s
Dental Health Survey [Chadwick et al., 2006] showed an
increase in Tooth Surface Loss into dentine or pulp
on palatal surfaces from 2% in 1993 to 5 % in 2003
(3% in this study).
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 The
Erosion in 13-14-year-olds on Isle of Man ,
Milosevic et all, 1987 concluded that drinking fizzy
drinks more than once a day was associated with
erosion.
 Mean DMFT scores were not statistically different for
children with smooth surface/occlusally exposed
dentine.
 Multiple regression analysis showed age, gender and
toothbrushing to be significant predictors of
erosion.
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Prevalence of tooth wear and erosion
in Adults
 Subjects aged between 26-30 years - 7.7 % had facial
erosive lesions into dentine and 29.9 % had
occlusal teethwear into dentin.
 In the 46-50 year group, 13.2 % had facial erosive
lesions into dentine and 42.6 % had occlusal involving
dentine. Lussiet al. 1991.
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 The consistent finding from very different published
studies is that tooth wear increases with age, and a
certain amount is considered to be a normal
‘physiologic’ ageing process.
 An attempt has been made to determine ‘threshold’
levels, which are regarded as acceptable levels of wear
for a given age.
 More recent studies using the Tooth Wear Index
(TWI) of Smith and Knight have indicated that
young adults are showing accelerated wear,
which may pose a problem for the future.
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Risk factors for erosion-corrosion
RISK FACTORS
FREQUENCY
Citrus fruit intake
> Than twice daily
Sports drink intake
Weekly or more often
Soft drinks consumed
4-6 or more per weeek
Bruxism habit
Whole saliva unstimulated flow rate (
0.1 ml/min
Excessive attrition
Apple vinegar intake
Weekly or more often
Eating disorder
Vomiting
Symmtoms or history of
gastroesophageal reflux
disease
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Weekly or more often
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Questions……………..
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6.References
 CM Maya. A textbook of Public Health Dentistry, first
edition. Jaypee Brothers Medical Publishers.
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Activity
Bring next class an 1 page research about recreative
Drugs and oral helth
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Highly recommended
 Erosion—diagnosis and risk factors
 http://scolaris.beta.semantico.com/articles/clinical-
oral-investigations/2238777#_diagnosis
 Managment of dental erosion.
 http://www.jaypeejournals.com/eJournals/ShowText.a
spx?ID=1427&Type=FREE&TYP=TOP&IN=_eJournals/i
mages/JPLOGO.gif&IID=121&isPDF=NO
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Thank you!!!
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