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

2. Lecture outline Definition of tooth wear Classification of tooth wear
Prevalence of tooth wear
Aetiology of tooth wear
Aetiology of attrition
Aetiology of abrasion
Aetiology of erosion
Overview of the next lecture

3. Definition of tooth wear

4. Definition of tooth wear
“A general term that can be used to describe the surface loss of dental hard tissues from causes other than dental caries, trauma or as a result of developmental disorders.”
Non-carious tooth surface loss (NCTSL)

5. Definition of tooth wear
Physiological:
- An irreversible process.
A natural consequence of ageing.
*No intervention is usually required*
Normal vertical loss of enamel from physiological wear = μm per annum.

6. Definition of tooth wear
Pathological:
Associated with functional or aesthetic concerns.
Associated with symptoms of discomfort
Disproportionate for the age of the patient.
Deemed to be so severe that it may be of concern to the operator.
*Intervention is required*

7. Classification of tooth wear

8. Types of tooth wear Attrition Abrasion Erosion Abfraction
Demastication

9. Attrition
- Loss of tooth substance due to tooth to tooth contact

10. Abrasion
Loss of tooth substance due to mechanical friction from a foreign body. (E.g. toothbrush)

11. Erosion
Loss of tooth substance by chemical means associated with extrinsic and/or intrinsic acid that is not produced by bacteria.

12. Abfraction
Wedge-shaped defects observed at the cemento-enamel junction.
Axial forces on the tooth stress in cervical region microfractures.
Presents similarly to cervical abrasion.

13. Demastication Loss of tooth substance during mastication
Combination of attrition and abrasion

14. However, in many cases, one of the processes predominates.
Tooth wear is usually due to a combination of the afromentioned processes (erosion, attrition, abrasion).
However, in many cases, one of the processes predominates.

15. Prevalence of tooth wear

16. Prevalence of tooth wear
Up to 97% of adults affected by physiological tooth wear.
Up to 7% exhibit pathological tooth wear.
Variations in the threshold for considering tooth wear pathological have complicated the findings.

17. Prevalence of tooth wear
Recent studies indicate erosion is now considered the major cause of pathological tooth wear.
Up to 32% of adults might exhibit dental erosion.

18. Prevalence of tooth wear
5-6 year-old children (primary teeth)
50% showed signs of tooth wear.
25% had dentine involvement.
11 year-old children (permanent teeth)
25% displayed signs of erosion affecting the palatal surfaces of their maxillary incisors.
14 year-old children (permanent teeth)
- 32% displayed signs of erosion affecting the palatal surfaces of their maxillary incisors.

19. Prevalence of tooth wear
There has been a steady increase in reports of erosion especially in young adults, adolescents.
This has been largely linked to the high consumption of fruit juice and carbonated drinks.

20. Tooth wear index

21. Aetiology of tooth wear

22. Aetiology of attrition
Normal occlusal forces through life can cause physiological attrition, which is common and increases with age.
Several factors can accelerate the process and cause pathological attrition:
Parafunctional habits: Bruxism, clenching.
Coarse or abrasive diet.
Traumatic occlusion.

23. Aetiology of attrition
Bruxism: “the habitual grinding, clenching, and gnashing of teeth during the day or night for non functional purposes”.
Aetiology of bruxism not well understood:
mostly related to stress and occlusal interferences.
Uncertain whether it leads to attrition, or the other way around (attrition leads to bruxism).

24. Clinical presentation of attrition
Wear facets on the occlusal surfaces of posterior teeth.

25. Clinical presentation of attrition
Wear facets on the incisal edges of anterior teeth.

26. Clinical presentation of attrition
Reduced vertical dimension in more severe cases.
Increased dental sensitivity is rare, due to secondary dentin formation.

27. Aetiology of abrasion
Associated with incorrect or over-vigorous tooth brushing with abrasive toothpastes or hard tooth brushes.
The abrasivity of the toothpaste can be affected by:
Amount of abrasive content.
Type of abrasive used.
Size of abrasive particle.
Surface of abrasive particle.
The chemical effects of the other toothpaste components.

28. Aetiology of abrasion
Toothbrushing shortly after acid ingestion greatly increases the risk of abrasion.
Oral habits related to objects, such as pipe-smoking, pen chewing, Miswak, playing wind musical instruments can also lead to abrasion.

29. Clinical presentation of abrasion
Related to the foreign object causing the abrasion.
Toothbrushing:
V-shaped ditch on the labial- cervical region of teeth.
Canines and premolars most commonly affected.

30. Clinical presentation of abrasion
Pipes, wind instruments, seeds, nail biting or pen chewing:
Notches on the incisal edges of anterior teeth

31. Clinical presentation of abrasion
Toothpicks:
Proximal surfaces of exposed roots
Miswak use:
Labial abrasion

32. Aetiology of erosion
Demineralisation of enamel occurs once the oral environment pH goes below 5.5.
Acids in the mouth originate from three main sources:
Acidogenic bacteria Caries
Ingested extrinsic acids Erosion
Dislocated intrinsic acids Erosion

33. Aetiology of erosion
The development of erosion is impacted by two properties of the ingested acid: pH
Titratable acidity: the amount of alkali that needs to be added to an acid to bring it up to a neutral pH.

34. Intrinsic acids
Gastric acids that enter the mouth as a result of reflux, vomiting or rumination.
Gastric juice consists mainly of hydrochloric acid, making the juice highly acidic (pH ).

35. Gastro-oesophageal reflux disease (GORD)
“The passive or effortless movement of regurgitated gastric acid into the mouth.”
Can be caused by a variety of underlying medical conditions/medications/behaviours.

36. Gastro-oesophageal reflux disease (GORD)

37. Gastro-oesophageal reflux disease (GORD)
Affects up to 7% of adults daily, up to 33% every few days.
Associated with heartburn, indigestion, and epigastric pain.
However, 25% of adult patients with extensive palatal erosion may have GORD but not have any symptoms of reflux.

38. Gastro-oesophageal reflux disease (GORD)
Especially common in those with neurological impairment (e.g. cerebral palsy).
Not a common cause of erosion in children.

39. Vomiting
The forceful propulsion of stomach and upper intestinal contents toward the mouth.
Mediated by a host of physiological events, co-ordinated in the medulla.
Spontaneous or self-induced.

41. Vomiting
In children, chronic cyclic vomiting associated with medical conditions, such as:
Irritable bowel syndrome.
Motion sickness.
Migraine.
Epilepsy.
Usually self-limiting and stop when the child reaches adulthood.

42. Vomiting
Self-induced vomiting common in people with eating disorders (anorexia nervosa, bulimia nervosa).
Bulimia affects 1-2% of the general population, Anorexia affects %/
Teeange females, from higher socio-economic classes, are the highest risk group.

43. Persistent vomiting in those patients can cause various oral complications, in addition to tooth erosion:
Cervical caries
Tooth sensitivity
Periodontal disease
Glossodynia
Xerostomia
Enlargement of the parotid glands
Mouth ulcers
Sore throat

44. Rumination
The deliberate bringing back of food into the mouth to re-chew.
Some have the ability to relax the lower oesophageal sphincter and reflux gastric contents into the mouth.
Rare in occurrence.
Should be considered in patients with unknown cause of erosive tooth wear.

45. Extrinsic acids
The dentition can be exposed to extrinsic acids from a variety of sources:
Drinks
Foods
Medications
Recreational drugs
Enviromental

46. Drinks
There is a significant association between the consumption of soft drinks and dental erosion.
Consumption close to bed time especially increases risk of erosion.
Toothbrushing after ingestion of acids increases risk.
Frequency of, rather than total intake, may be critical in the erosive process.

47. Foods
The erosive potential of acidic foods is not as well understood as drinks.
Research has shown frequent ingestion of citric fruits or berries may be associated with dental erosion.

49. Medication Some medicines are acidic:
Vitamin C.
Aspirin.
Iron preparations.
Other medications can cause vomiting or dry mouth, increasing the risk of erosion.

50. Recreational drugs
The use of mood enhancing drugs such as ecstasy increases the risk of dental erosion (due to causing dry mouth).

51. Environmental factors
Work related exposure to acids can result in dental erosion.
Examples:
Battery and sheet metal workers.
Laboratory technicians.
Competitive swimmers.
Probably not common risks for dental erosion.

52. Aetiology of erosion
Erosion, in a similar manner to dental caries, has a multifactorial aetiology.
Examples of factors impacting the severity of erosion:
Salivary flow rate.
Salivary buffering capacity.
Fluoride availability.
Tooth structure and anatomy.

55. Clinical presentation of erosion
Bilateral concave defects without the associated chalkiness normally seen in bacterial acid decalcification (surface looks glazed).

56. Clinical presentation of erosion

57. Clinical presentation of erosion
Restorations projecting above the occlusal surface (proud restorations).

58. Clinical presentation of erosion
Cupping of tooth cusps and incisal edges in more severe cases.

59. Clinical presentation of erosion
Extrinsic erosion is evident of the labial surface of maxillary teeth.
Intrinsic erosion is evident on the palatal surface of maxillary teeth.
Perimolysis: erosive lesions on the palatal aspect of maxillary teeth as a result of chronic vomiting.
The tongue protects the lower teeth while projecting the acids towards the palatal surface of the maxillary teeth.

60. Next lecture
History, examination, and diagnosis of patients with tooth wear.
Prevention of tooth wear
Overview of management of patients with tooth wear
Discussion

61. Thank You