1. Prevention of tooth wear - 2
Dr Ahmad Aljafari
BDS, MFDS RCSEd, MSc, PhD

2. Lecture outline History, examination and diagnosis of tooth wear.
Prevention of tooth wear:
Attrition
Abrasion
Erosion
Monitoring tooth wear progression

3. Prevention of tooth wear
Prevention of tooth wear requires that you:
Recognise that the problem is present.
Grade its severity.
Diagnose the likely cause or causes.
Monitor progress of the disease in order to assess the success, if any, of any preventative measures.

4. History, examination and diagnosis of tooth wear.

5. Chief complaint Common complaints associated with tooth wear include:
Aesthetic impairment (fractured, unattractive teeth or tooth discoloration).
Difficulties with function (mastication or lip/cheek or tongue biting).
pain and sensitivity (Less common).

6. Medical history
Reveals any underlying conditions which preclude the provision of complex treatment.
Provides insight into the aetiology of the wear pattern observed.

7. Medical history Gastro-oesophageal reflux disease (GORD):
Signs and symptoms:
Heartburn.
Indigestion.
Epigastric pain.
Underlying risk factors:
Obesity.
Pregnancy.
Neurological disorders.
Osephageal conditions.
Drugs (e.g. Diazepam).

8. Medical history Chronic vomiting Eating disorders.
Cyclical vomiting syndrome.
Pregnancy.

9. Medical history Eating disorders (Anorexia, Bulimia):
Signs and symptoms:
Low BMI
Chronic fatigue
Amenorrhea
Hypotension
Underlying risk factors:
Young female patients
Preoccupation with diet, exercise, weight.

10. History
Medications:
Does the patient take any medications that are acidic?
Acidic medications:
Vitamin C.
Iron supplements.
Aspirin.
Steroidal asthma inhalers
Does the patient take any medications that can cause xerostomia? E.g.: diuretic agents and antidepressant drugs.

11. Dental history Oral hygiene habits:
Type of toothbrush used (hard, soft).
Intensity and frequency of toothbrushing.
Timing of toothbrushing (immediately following acidic meals or not).
Dentifrice being used (abrasivity).
Vigorous or frequent brushing, hard brushes, strong abrasives, and brushing following acidic meals, increase risk of abrasion

12. Dental history Dietary habits (consumption of acidic foods or drinks)
Bruxism, clenching.
Nail, pen or other foreign object biting.

13. Social history Lifestyle Stress. Alcohol consumption.
Recreational drug use.
Playing wind instruments.
Occupation
factory workers.
Miners.
Professional swimmers.

14. Extra-oral examination
General appearance.
TMJ function (pain, clicking, crepitus, deviations, limited mouth opening)
Muscles of mastication.
Facial height (reduced in those with severe tooth wear).
Parotid glands (enlarged in those with chronic vomiting).

15. Intra-oral examination
Soft tissues:
Signs of clenching (buccal keratoses, scalloping of the tongue).
Signs of recurrent vomiting, regurgitation (ulcers, burning mouth, sore throat, halitosis).
Signs of xerostomia (fissured tongue, atrophic mucosa, fungal infections, burning mouth)
Occlusal assessment:
Crowding, rotations , tilting, drifting, spacing, over-eruption, mobility., cross-bites.
Interferences during lateral excursive and protrusive movements.

16. Intra-oral examination
Location of tooth wear:
Localised vs. generalised.
Anterior vs. posterior.
Tooth surfaces involved.

17. Intra-oral examination
Attrition:

18. Intra-oral examination
Abrasion

19. Intra-oral examination
Erosion:

20. Intra-oral examination
Severity of the tooth surface loss (restricted to enamel only, into dentine or severely affecting the teeth or series of teeth).

21. Further investigations
Radiographs.
Sensibility tests (Ethyl chloride, electric pulp test).
Intra-oral photographs.

22. Further investigations
Articulated study casts:
Assessment of the occlusion in the absence of soft tissue/muscular interferences.

23. Further investigations
Salivary analysis
Flow and consistency of saliva assessed clinically.
Salivary flow rate testing (stimulated, unstimulated).
Salivary buffering capacity:
Bicarbonate buffer (most efficient)
Phosphate buffer.
Protein buffer.

24. Diagnosis
Diagnosis should include a description of the type(s) of lesions observed (attrition, abrasion, erosion, abfraction).
Remember that in most cases tooth wear is due to a combination of processes with one of them predominating.
Account of lesions extent/location and severity.
Differential diagnosis:
Inherited developmental defects of enamel and dentin.

25. Prevention of tooth wear

26. Prevention of Attrition
Occlusal splints:
full coverage hard acrylic splints (Michigan splint or Tanner appliance)
The splint should be fabricated to provide an ‘ideal occlusion’:
Even centric stops.
Canine guidance during lateral extrusion.
Anterior guidance on protrusion.

27. Prevention of Attrition

28. Prevention of Attrition
Correction of occlusal interferences:
Elimination of those interferences will not necessarily eliminate bruxism, but will reduce rate of attrition.

29. Prevention of Abrasion
If the main aetiology is incorrect tooth brushing:
Give advice to alter tooth brushing methods:
Avoid highly abrasive toothpastes.
Avoid hard tooth brushes.
Avoid brushing immediately following acid intake.
Use proper force during tooth brushing.
If condition is caused by other factors, give advice accordingly.

30. Prevention of Erosion
If aetiology determined to be related to extrinsic acid ingestion:
Dietary counselling.
Topical agents application.

31. Prevention of Erosion Dietary counselling:
In depth dietary history (three-day dietary sheet):
Frequency and amount of acidic drink/food intake.
Frequency of tooth brushing.
Habits such as sipping or frothing of carbonated drinks (adds ‘ultrasonic’ effect of bubble bursting to chemical acidity)

32. Prevention of Erosion Dietary counselling:
Limit acid food or drink intake to meal time.
Avoid acidic substances last thing at night.
Finish meals with alkaline foods such as cheese or milk.
Avoid toothbrushing for at least one hour following acidic food or drinks ingestion.
Use a wide bore straw placed toward the back of the mouth for acidic drinks.

33. Prevention of Erosion Dietary counselling:
Avoid acidic mouthwashes, medications.
Use non-sugar chewing gums to stimulate salivary flow and buffering (contraindicated in children below the age of 7 and those with a history of gastric reflux).
Advice on using alternative drinks reinforced with Calcium lactate, fluoride, or xylitol.

34. Prevention of Erosion Topical agents application:
Neutral sodium fluoride mouth rinse or gel.
High fluoride toothpastes.
Tooth Mousse ACP (GC): ‘Recaldent’ derived from casein, a protein found in bovine milk, promotes remineralisation.
Dentin bonding agents/ sealants in cases of hypersensitivity
(CPP-ACP): Casein Phosphopeptide - Amorphous Calcium
Phosphate (tooth mousse)

35. Prevention of Erosion
If aetiology determined to be related to intrinsic acid exposure (GORD, eating disorders, vomiting):
Referral to a general medical practitioner.
Advice to delay tooth brushing after vomiting.
Advice on rinsing with water and sodium bicarbonate.
Use topical agents as in erosion caused by extrinsic acids
Construct protective occlusal splints (see next slide).

36. Prevention of Erosion
Protective occlusal splint need to have a reservoir for neutral fluoride gels, or alkali in the form of milk of magnesia or sodium bicarbonate.

37. Monitoring tooth wear progression

38. Monitoring tooth wear progression
Regular review of the patient to assess compliance with advice.
Use of the tooth wear index to monitor progress clinically (inter- and intra-examiner reliability can vary).
Comparison of clinical photographs and study casts (Every 6-12 months, provides only gross estimation).

39. Monitoring tooth wear progression
Use of a sectional silicone index (Correct re-seating can be challenging)
Use of computerised software to map changes in tooth surface profiles (Not practical, expensive).

40. Thank you