Occlusion. Factors of occlusion Occlusion. Factors of occlusion. The clinical significance of restoring individual occlusion, tools and steps to achieve it.

Dental Erosion: Etiology Tooth Wear Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of physical loss, chemical dissolution, and/or multifactorial etiology.3,6 Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of physical loss, chemical dissolution, and/or multifactorial etiology.3,6

Dental Erosion: Etiology Tooth Wear Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6 Physical Loss – Abrasion—mechanical – Attrition—tooth-to-tooth contact – Abfraction—lesions Chemical dissolution Multifactorial etiology Abrasion is usually caused be excessive tooth brushing with highly abrasive toothpastes and/or aggressive oral hygiene habits (hard bristles with much manual force, reloading the brush with paste, etc).3   Attrition is wear resulting from tooth- to-tooth contact such as occlusal parafunctional habits, or in the regular function of mastication of abrasive foods. 3 Abfraction is a non-carious cervical lesion hypothetically caused by occlusal parafunctional forces. Loss of enamel resulting from trauma can lead to exposed dentin. Abfraction also puts the tooth at risk of dentin/root surface chemical erosion. 3 3

Dental Erosion: Etiology Tooth Wear Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6 Physical Loss Chemical dissolution – Erosion -- Extrinsic acids -- Intrinsic acids Multifactorial etiology Chemical erosion of the enamel and dentin is most commonly produced by excessive and frequent intake of an acidic diet and less commonly by the reflux of hydrochloric acid from the stomach. Acids demineralize and soften the enamel and dentin surfaces, making them more susceptible to abrasion, particularly by toothbrushing with or without toothpaste.3 4

Dental Erosion: Etiology Tooth Wear Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6 Physical Loss Chemical dissolution Multifactorial etiology – Erosion – Abrasion – Attrition – Abfraction Multifactorial causes include the combination of erosion and abrasion, with erosion initiating wear and abrasion localizing it to a particular part of the tooth.3  5

Dental Erosion: Etiology Abrasion The pathological wearing away of hard dental tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth.6 Oral hygiene habits Excessive brushing/flossing Abrasives in dentifrices/toothpastes Personal habits Putting foreign objects in the mouth Demastication Wear from chewing food Abrasion is: The pathological wearing away of hard dental tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth.6 Oral hygiene habits Excessive brushing/flossing Abrasives in dentifrices/toothpastes Personal habits Putting foreign objects in the mouth Demastication Wear from chewing food

Dental Erosion: Etiology Attrition The pathological wearing away of hard dental tissue as a result of tooth-to-tooth contact, with no foreign substance intervening.6 Enamel wearing enamel Occlusal wear Malocclusion (buccal, lingual, and interproximal surfaces) Attrition is the pathological wearing away of hard dental tissue as a result of tooth-to-tooth contact, with no foreign substance intervening.6 Enamel wearing enamel Occlusal wear Malocclusion (buccal, lingual, and interproximal surfaces)

Dental Erosion: Etiology Abfraction Wedge-shaped defects at the cementoenamel junction of a tooth caused by eccentrically applied occlusal forces leading to tooth flexure that results in microfracture of enamel and dentin.6 Loss of tooth in the cervical area Tooth flexure – Chewing – Grinding (bruxism) Abfraction is wedge-shaped defects at the cementoenamel junction of a tooth caused by eccentrically applied occlusal forces leading to tooth flexure that results in microfracture of enamel and dentin.6 Loss of tooth in the cervical area Tooth flexure Chewing Grinding (bruxism)

Dental Erosion: Etiology The physical results of a pathologic, chronic, localized loss of hard dental tissue that is chemically etched away from the tooth surface by acid and/or chelation without bacterial involvement.7 Extrinsic acids—ingested Food, beverages, medicine Intrinsic acids—internal Originate in the stomach Erosion is the physical results of a pathologic, chronic, localized loss of hard dental tissue that is chemically etched away from the tooth surface by acid and/or chelation without bacterial involvement.7 Extrinsic acids—ingested Food, beverages, medicine Intrinsic acids—internal Originate in the stomach

Dental Erosion: Etiology Multifactorial Tooth wear is multifactorial One process typically impacts the other Erosion and abrasion Tooth wear is multifactorial One process typically impacts the other Erosion and abrasion

Dental Erosion: Epidemiology Tooth erosion was described as a condition distinct from caries as early as the 18th century.8

Dental Erosion: Epidemiology Change in Perception In 1995, the European Journal of Oral Science stated that “dental erosion is an area of research and clinical practice that will undoubtedly experience expansion in the next decade.”9 In 1995, the European Journal of Oral Science stated that “dental erosion is an area of research and clinical practice that will undoubtedly experience expansion in the next decade.” This quote has proven correct as the number of published studies increase substantially: In the 1970s less than 5 studies per year were published about erosion, less than 10 in the 1980s, but has now increased to about 50 studies per year.17

Dental Erosion: Epidemiology Global Prevalence Global data on the prevalence of dental erosion is building. “Erosive tooth wear is a common condition in the developed countries.”10 United States Canada Iceland Ireland Sweden Germany Turkey Saudi Arabia India Brazil Japan Malaysia Switzerland The Netherlands UK China It is difficult to compare the results of epidemiological studies because of different examination standards. However, it is important to remember that while detection and prevalence of erosion may vary, it is something that affects all sectors of society and is independent of age. The emerging clinical studies tend to focus on schoolchildren and adolescents because they are much easier to recruit than adults. In the years to come, incidences will be apparent as these current study patients age.

Dental Erosion: Epidemiology Global Prevalence European studies suggest prevalence of:11-13 Up to 50% if all preschool children Between 24% to 60% of school-aged children As high as 82% in 18 to 88 years of age10 Emerging prevalence studies providing data on gender, socio-economic status, ethnic, and culture difference in addition to the age factor will prove to be invaluable European studies suggest prevalence of:11-13 Up to 50% of all preschool children Between 24% to 60% of school- aged children As high as 82% in 18 to 88 years of age10 Emerging prevalence studies providing data on gender, socio- economic status, ethnic, and culture difference in addition to the age factor will prove to be invaluable

Dental Erosion: Diagnosis “Diagnosis is the intellectual course that integrates information obtained by clinical examination of the teeth, use of diagnostic aids, conversation with the patient, and biological knowledge. A proper diagnosis cannot be performed without inspection of the teeth and their immediate surroundings.”14 As Kidd et al noted in their contribution to Dental Caries: The Disease and its Clinical Management: “Diagnosis is the intellectual course that integrates information obtained by clinical examination of the teeth, use of diagnostic aids, conversation with the patient, and biological knowledge. A proper diagnosis cannot be performed without inspection the teeth and their immediate surroundings.”14

Dental Erosion—Diagnosis Check list to unveil etiological factors for erosion15 Check list to unveil etiological factors for erosion15 Case history (medical and dental) Detection of the main noncarious hard tissue lesions (site-specific distribution) Record dietary intake over 4 days (estimation of the erosive potential) Specific factors that the patient may not be aware of: Diet Herbal teas, acidic candies, alcohol, sports drinks, effervescent vitamin C tablets, etc Gastric Symptoms Vomiting, acid taste in mouth, gastric pain (especially when awake), stomach ache, any sign of anorexia nervosa Drugs Alcohol, tranquillizers, antiemetics, antihistamines, lemonade tablets (change of acidic or saliva-reducing drugs is possible) Determination of flow rate and buffering capacity of saliva Oral hygiene habits (technique, abrasivity of toothpaste) Occupational exposure to acidic environments X-ray therapy of the head area Silicone impressions, study models, and/or photographs to assess further progression

Dental Erosion: Diagnosis Interaction of the different factors for the development of erosive tooth wear16,18 Different factors interact in the development of erosive tooth wear. These include: Biological factors such as saliva, soft tissue, tooth anatomy/structure, and the pellicle. Chemical factors such as pH, buffering capacity, acid types, adhesion, chelators, calcium phosphate, and fuoride. Behavioral factors such as eating and drinking habits, toothbrushing, acidic bottle feeding, regurgitation, vomiting, drugs, and occupation. From: Lussi A. Dental Erosion: From Diagnosis to Therapy. Karger; 2006.

Dental Erosion: Diagnosis Clinical Appearance There is no device available for the specific detection of dental erosion in routine practice. Therefore, the clinical appearance is the most important feature for dental professionals to diagnosis dental erosion.16 There is no device available for the specific detection of dental erosion in routine practice. Therefore, the clinical appearance is the most important feature for dental professionals to diagnosis dental erosion.16

Dental Erosion—Diagnosis Tooth Wear—Clinical Appearance17 Abrasion is Usually located at cervical areas of teeth Lesions are more wide than deep Premolars and cuspids are more commonly affected Attrition is Matching wear on occluding surfaces Shiny facets on amalgam contacts Enamel and dentin wear at the same rate Possible fracture of cusps or restorations Abfraction Affects buccal/labial cervical areas of teeth Deep, narrow V-shaped notch Commonly affects single teeth with excursive interferences or eccentric occlusal loads Erosion is Broad concavities within smooth surface enamel Cupping of occlusal surfaces (incisal grooving) with dentin exposure Increased incisal translucency Wear on non-occluding surfaces "Raised" amalgam restorations Clean, non-tarnished appearance of amalgams Loss of surface characteristics of enamel in young children Preservation of enamel "cuff" in gingival crevice is common Dentin hypersensitivity Pulp exposure in deciduous teeth

Dental Erosion: Diagnosis Erosion is multifactorial Chemical factors—erosive potential of intrinsic and extrinsic acids Biological factors—involve properties and characteristics of the oral cavity Behavioral factors—personal and oral habits Erosion is multifactorial Chemical factors—erosive potential of intrinsic and extrinsic acids Biological factors—involve properties and characteristics of the oral cavity Behavioral factors—personal and oral habits

Dental Erosion: Diagnosis Chemical Factors18 pH and buffering capacity of the product Type of acid (pKa values) Intrinsic (gastric origin) Extrinsic (environmental, dietary, medicinal) Adhesion of the products to the dental surface Chelating properties of the products Calcium concentration Phosphate concentration Fluoride concentration Chemical Factors18 pH and buffering capacity of the product Type of acid (pKa values) Intrinsic (gastric origin) Extrinsic (environmental, dietary, medicinal) Adhesion of the products to the dental surface Chelating properties of the products Calcium concentration Phosphate concentration Fluoride concentration

Dental Erosion: Diagnosis Biological Factors19 Saliva: flow rate, composition, buffering, capacity, and stimulation capacity Acquired pellicle: diffusion-limiting properties, composition, maturation, and thickness Type of dental substrate (permanent and primary enamel, dentin) and composition (eg, fluoride content as FHAp or CaF2-like particles) Dental anatomy and occlusion Anatomy of oral soft tissues in relationship to the teeth Physiologic soft tissue movements Biological Factors19 Saliva: flow rate, composition, buffering capacity, and stimulation capacity Acquired pellicle: diffusion-limiting properties, composition, maturation, and thickness Type of dental substrate (permanent and primary enamel, dentin) and composition (eg, fluoride content as FHAp or CaF2-like particles) Dental anatomy and occlusion Anatomy of oral soft tissues in relationship to the teeth Physiological soft tissue movements

Dental Erosion: Diagnosis Behavioral Factors20 Unusual eating and drinking habits Healthy lifestyle: diets high in acidic fruits and vegetables Unhealthy lifestyle: frequent consumption of “alcopops” and designer drugs Alcoholic disease Excessive consumption of acidic foods and drinks Nighttime baby bottle feeding with acidic beverages, including milk Oral hygiene practices: frequent toothbrushing, abrasive oral care products Behavioral Factors20 Unusual eating and drinking habits Healthy lifestyle: diets high in acid fruits and vegetables Unhealthy lifestyle: frequent consumption of “alcopops” and designer drugs Alcoholic disease Excessive consumption of acidic foods and drinks Nighttime baby bottle feeding with acidic beverages Oral hygiene practices: frequent toothbrushing, abrasive oral care products

Dental Erosion: Diagnosis Prevention Loss of tooth surface is a multifactorial process and education is the first step in the line of defense.4 Loss of tooth surface is a multifactorial process and education is the first step in the line of defense.5

Interactions between Behavioral and Biological Factors Dental Erosion: Diagnosis/Management Dynamics of Dental Erosion21 Before During After Time (Frequency) Interactions between Behavioral and Biological Factors The dynamics of dental erosion involve the interactions between behavioral and biological factors across the time continuum. As demonstrated by Dom Zero et al 21. Lussi A, Kohler N, Zero D, et al.

Dental Erosion: Management/Etiological Factors Awareness/Association/Education Dietary factors15 Avoid radical changes in dietary habits Reduce acid exposure by reducing frequency and contact time of acid Avoid acidic foods and drinks late at night Avoid high-acidity liquids via baby bottle for infants Avoid low pH values in food and beverages Dietary factors15 Radical changes in dietary habits should be avoided Reduce acid exposure by reducing frequency and contact time of acid Avoid acidic foods and drinks late at night For infants, avoid high-acidity liquids via baby bottle pH values in food and beverages

Dental Erosion Management/Etiological Factors Awareness/Association/Education Dietary factors: generally, a pH value of 5.5 or lower is capable of softening the surface of enamel in only a few minutes.3 Dietary factors: generally, a pH value of 5.5 or lower is capable of softening the surface of enamel in only a few minutes.3 3. Strassler HE, Drisko CL, Alexander DC.

Dental Erosion: Management/Etiological Factors Awareness/Association/Education Behavioral/habits15 Do not hold or swish acidic drinks in your mouth Avoid sipping acidic drinks—use a straw Avoid toothbrushing immediately after an erosive challenge (vomiting, acidic diet) Avoid toothbrushing immediately before an erosive challenge, as the acquired pellicle provides protection against erosion Use a soft toothbrush Behavioral/habits15 Do not hold or swish acidic drinks in your mouth Avoid sipping acidic drinks—use a straw Avoid toothbrushing immediately after an erosive challenge (vomiting, acidic diet) Avoid toothbrushing immediately before an erosive challenge, as the acquired pellicle provides protection against erosion Use a soft toothbrush

Dental Erosion: Management/Etiological Factors Awareness/Association/Education Behavioral/Habits15 Use a low-abrasion fluoride-containing toothpaste; high- abrasive toothpaste may destroy pellicle Avoid toothpastes or mouthwashes with too-low pH After acid intake, stimulate saliva flow with chewing gum or lozenges Use chewing gum to reduce postprandial reflux Refer patients or advise them to seek appropriate medical attention when intrinsic causes are involved Behavioral/habits15 Use a low-abrasion fluoride- containing toothpaste; high-abrasive toothpaste may destroy pellicle Avoid toothpastes or mouthwashes with a too-low pH After acid intake, stimulate saliva flow with chewing gum or lozenges Use chewing gum to reduce postprandial reflux Refer patients or advise them to seek appropriate medical attention when intrinsic causes are involved Postprandial: after a meal (source: Dorland’s Medical Dictionary)

Dental Erosion: Management/Etiological Factors Awareness/Association/Education Gastroesophageal Origin22 Heartburn and other symptoms of reflux Regurgitation Dysphagia Asthma Rumination Eating disorders (anorexic or bulimia) Gastroesophageal Origin22 Heartburn and other symptoms of reflux Regurgitation Dysphagia Asthma Rumination Eating disorders (anorexic or bulimia) Definitions (source: Dorland’s Medical Dictionary) Heartburn: an esophageal symptom consisting of a retrosternal [behind the sternum] sensation of warmth or burning occurring in waves and tending to rise towards the neck; it may be accompanied by a reflux of fluid into the mouth (water brash). It is often associated with gastroesophageal reflux. Regurgitation: to flow in the opposite direction from normal Dysphagia: difficulty in swallowing Asthma: recurrent attacks of paroxysmal dyspnea [shortness of breath], with airway inflammation and wheezing due to spasmodic contraction of the bronchi. Some cases are allergic manifestations in sensitized persons; others are provoked by factors such as vigorous exercise, irritant particles, psychological stresses, and others. Rumination: in ruminants [eg, cows], the casting up of food (called "cud") out of the rumen and chewing of it a second time. In humans, the regurgitation of food after almost every meal, part of it being vomited and the rest being swallowed. Eating disorders: 1. Anorexia: more properly, anorexia nervosa. An eating disorder primarily affecting females, usually with onset in adolescence, characterized by refusal to maintain a normal minimal body weight, intense fear of gaining weight or becoming obese, and a disturbance of body image resulting in a feeling of being fat or having fat in certain areas even when extremely emaciated, undue reliance on body weight or shape for self-evaluation, and amenorrhea. Associated features often include denial of illness and resistance to psychotherapy, depressive symptoms, markedly decreased libido, and obsessions or peculiar behavior regarding food, such as hoarding. The disorder is divided into two subtypes, a "restricting" type, in which weight loss is achieved primarily through diet or exercise, and a "binge- eating/purging" type, in which binge eating or purging behavior also occur regularly. 2. Bulimia: episodic binge eating usually followed by behavior designed to negate the excessive caloric intake, most commonly purging behaviors such as self- induced vomiting or laxative abuse but sometimes other methods such as excessive exercise or fasting.

Dental Erosion: Management/Etiological Factors Awareness/Association/Education Medicinal factors associated with dental erosion23 Some medicines can potentially induce GERD theophyline progesterone anti-asthmatics calcium channel blockers Aspirin (especially in chewable format) Medicines that decrease salivary flow antihistamines anticholinergics antidepressants antipsychotics Medicinal factors associated with dental erosion23 Some medicines can potentially induce GERD theophyline progesterone anti-asthmatics calcium channel blockers Aspirin (especially in chewable format) Medicines that decrease salivary flow antihistamines anticholinergics antidepressants antipsychotics Definition (source: Dorland’s Medical Dictionary) GERD: gastroesophageal reflux disease. Reflux of the stomach and duodenal contents into the esophagus, particularly in the distended stomach postprandially, as a chronic pathological condition.

Prosthodontic Treatment of Tooth Wear

Dental Erosion/Toothwear Prevention is better than a cure… Education is the key!