Toothwear; An emerging trend in Sri Lanka Dr. Manil Fonseka BDS, LDSRCS (Eng) MS (Restorative Dentistry) Department of Restorative Dentistry 11th September 2014

Historical Perspective Normal physiologic process Some tooth-wear essential for efficient function of teeth which is seen in many herbivores Important to establish unhindered guidance during mastication However the level of tooth wear minimal

Rates of tooth-wear 2500 years for 1mm of enamel wear with normal function Estimated the level of tooth wear to be 29µm for molars and 15µm for premolars (Lambrechts et al, 1989) Physiological wear poses minimal problems If the rate of wear challenges the viability of teeth TSL considered pathologic

Factors precipitating wear

Factors precipitating tooth-wear Multi-factorial aetiology Increase in life expectancy Increased functional demand Longer exposure to erosive foods Recession and exposure of relatively weaker cementum Increased use of medication Quantitative and qualitative reduction in salivary flow Loss of teeth increases demand on the remaining teeth

Diet Dietary changes have resulted in the diets being less abrasive Should theoretically reduce the levels of tooth-wear Excessive consumption of erosive beverages and foods has had a potentiating effect on the increased prevalence of NCTSL

Implicated foods Fizzy drinks (pH 2.2 – 3.8) Fruit juices (pH 3.0 – 4.0) Wines (pH 3.2 – 4.8) Cider and Beer (pH 3.5 – 4.0) Citrus fruits Increased prevalence among children and adolescents in the UK (35%) Condition of affluent in Sri Lanka (Ratnayake N & Ekanayake L. 2010)

Extrinsic Acid Erosion Intrinsic Acid Erosion

Intrinsic Acid pH of Gastric acid is 1-2 Gastric Regurgitation Bulaemia and anorexia Vomitting Classically presents as palatal/lingual erosive defects

Para-function Stress induced parafunction Bruxism Object biting

Problems of para-function 700 times the normal masticatory load Force used is considerably greater than during normal mastication Seen as wear in non functional cusps Molars may be severely affected Prominant masseters Marked antigonial notching Tenderness of muscles of mastication

Other factors contributing to tooth surface loss Defective enamel and dentine deposition and maturation ( E.g AI, DI, Hypoplasias) Abrasive restorative material (Unglazed porcelain) Abrasive dentifrices and hard brushing in horizontal strokes Habits – Instrument biting, Needles etc

Defective enamel formation

Scale of the Problem 98% of individuals in the UK have some amount of tooth wear Increased prevalence among children, deciduous teeth 30% of individuals in the UK have severe tooth wear (Tooth Wear Index scores of 3 & 4) Problem of affluent in Sri Lanka

Types of tooth-wear Erosion - Intrinsic or Extrinsic acid Attrition - Tooth to tooth contact Abrasion - Due to foreign objects Abfraction - Repeated cyclic flexion of teeth Mostly multi-factorial thus cannot home-in on one cause

Erosion Due to intrinsic or extrinsic acid Intrinsic acid regurgitation due to gastric reflux disease (Bullaemia, Anorexia, Gastritis, GORD) Extrinsic acid consumption (Coke, Fizzy drinks, Fruit juices, tamarind) Increasingly seen in young due to change in lifestyles

Extrinsic Acid Erosion Intrinsic Acid Erosion Buccal and Labial surfaces Lingual and palatal spared Intrinsic Acid Erosion Palatal and lingual surfaces Lower incisors spared Etched like appearance Cupping Discoloured if historical “Proud” restorations

Attrition Tooth to tooth contact Accelerated due to para-function Wear on non-functional cusps Seen in anterior teeth when posteriors are lost No loss of OVD due to dento-alveolar compensation Erosion potentiates attrition (De-mastication)

Attrition

Abrasion Overzelous brushing Horizontal Strokes Abrasive Dentifrices and Brushes

Effects of NCTSL Sensitivity of teeth Pulpal and Periodontal complications Poor aesthetics Impeded function Prone to fracture Low self esteem (OHRQoL)

Aides to Diagnosis Detailed history Examination Investigations Occupation, Social, Dietary analysis, Medical history Examination Masticatory apparatus, Wear facets and their location, “proud” restorations Investigations Radiographs, Photographs, Dated study casts

Strategies in the management of NCTSL Psycho-social support Medical referrals (GERD) Habit intervention Reduction in consumption of erosive beverages Using a straw Soft mouth guards to protect teeth during gastric regurgitation (Addition of Fluoride gel) Michigan splints to reduce effects of bruxism

Soft bite guards/ Michigan splints

Challenges in management Lack of vertical space due to dento-alveolar compensation mechanisms Excessive loading of restorations If the cause continues tooth-wear would continue Frequent recall and maintenance Primary aim in treatment prevent/reduce the causes and replace what is lost and maintain available tooth tissue for adequate function and aesthetics

Management of Localized tooth wear

Re-organisation Should be well planned not haphazard Based on sound prosthodontic principles In dentate patients a raise of 11mm of OVD could be tolarated Anterior and canine guidance maintained without posterior interference Try with a splint first and go for definitive restorations if patient tolarates

Re-organization of occlusion Case 1

Re-organization of occlusion Case 2

Re-organization Case 3

Re-organization Case 4

Thanks