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

2. 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

3. 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

4. Factors precipitating wear

5. 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

7. 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

8. 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)

9. Extrinsic Acid Erosion Intrinsic Acid Erosion

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

12. Para-function
Stress induced parafunction
Bruxism
Object biting

13. 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

14. 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

15. Defective enamel formation

16. 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

17. 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

18. 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

19. 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

20. 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)

21. Attrition

22. Abrasion Overzelous brushing Horizontal Strokes
Abrasive Dentifrices and Brushes

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

24. 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

26. 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

27. Soft bite guards/ Michigan splints

28. 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

29. Management of Localized tooth wear

30. 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

31. Re-organization of occlusion Case 1

32. Re-organization of occlusion Case 2

33. Re-organization Case 3

34. Re-organization Case 4

35. Thanks