1. Wasting disease

2. INTRODUCTION
“ Wasting disease is defined as any gradual loss of tooth substance characterised by formation of polished surface ,without regard to the possible mechansim of this loss”

4. ATTRITION
Definition
Defined as the physiologic wearing away of a tooth as a result of tooth –to -tooth contact , as in mastication . this occurs only on occlusal, incisal and proximal surface of teeth ,not on other surfaces unless a very occlusal relation or malocclusion exists.
TYPES
PHYSIOLOGIC ATTRITION
PATHOLOGIC ATTRITION i

8. . PHYSIOLOGIC ATTRITON It is an age related process.
older individual exhibit more attrition as than young individuals
The rate and severity depends up on : Diet quality, dentition , force of the masticatory muscles and chewing habits etc…. .

9. PATHOLOGICAL ATTRITION
can occur due to certain abnormalities in occlusion, chewing pattern or due to some structural defects in the teeth
The tooth wear in this type does not maintain a constant pattern and the amount of tooth loss is not proportional to the age of individual.
SITE...
mainly on the incisal, occlusal and proximal surfaces of teeth.
Proximal attrition due to vertical movement of teeth during friction.

10. CAUSES ABNORMAL OCCLUSION
May be developmental, e .g: crowding of teeth or malpossed teeth.
abnormal occlusal positioning of teeth may lead to traumatic contact during chewing which may lead to more tooth wear.
May be acquired eg; extraction of teeth, extraction of some teeth from the dental arch will increases the occlusal load on remaining teeth as the chewing force for the individual remains constant.

11. ABNORMAL CHEWING HABITS:
Paraf unctionl chewing habits e.g.Bruxism (habitual grinding of teeth)& chronic persist ant chewing of coarse &abrasive foods

13. STRUCTURAL DEFECTS IN TEETH…
AMELOGENESIS IMPERFECTA…..
DENTINOGENESIS IMPERFECTA….
here hardness of enamel or dentin is much more inferior as compared to the normal teeth and there for , the rate of tooth wear is high even in normal chewing pressure .

14. FACTORS….. Age: As age increases, attrition increases
Type of dentition: More seen in permanent dentition than in primary dentition
Sex: Seen more in man than in women
Diet: Persons with coarse diet, increase chance of attrition
Habits: Chewing tobacco, bruxism increase attrition
Occupation: sand blasters or person who exposed to abrasive dust , increased chance of attrition,

16. How attrition occurs……..
Starts at time when there is contact or occlusion occurs between adjacent or opposing teeth
first clinical manifestation
Appearance of small polished facet on a cusp tip or Slight flattening of incisal ridge
Gradual reduction in cusp height and consequent flattening of the occlusal inclined plane

17. Loss of enamel, and dentin exposure
attrition advances
Exposure of dentinal tubules&subsiquent irritation of odentoblastic process
Formation of secondary cementum pulpal to primary cementum

18. CLINICAL FEATURES
manifested by the formation of well – polished facets on the tip of the cusps, incisal edges and proximal contact areas of tooth
In advanced cases ,attrition may lead to severe reduction in cuspal height with complete wearing of enamel and flattening of the occlusal surface
When dentin becomes exposed it generally becomes discolored brown
When the enamel is lost on the occlusal surface the dentin becomes attrided faster and the lesion may become cap shaped, surrounded by a rim of enamel at the periphery.

19. in the proximal surface of teeth it causes transformation of proximal “contact points” to relatively broader” contact areas” and it may even lead to mesial migration of teeth in the dental arch.
Normally men show more severe attrition than women.
Exposure of dentinal tubule in severe cases of attrition may lead to hypersensitivity.
On some occasions attrition may even result in pulp exposure.
Attrition may also occur in the restoration of teeth .a common example in this regard, is the development of shiny facets on the amalgam filled surfaces
Attrition may even possibly lead to fracture of the cusp of teeth or restorations.

21. TREATMENT
Treatment of attrition is difficult, However certain things can be done to reduce further tooth wear.
Correction of developmental abnormalities causing traumatic occlusion.
Correction of parafunctional chewing habits.
Protection of tooth by metal or metal ceramic crowns where structural defects( amelogenesis or dentinogenesis imperfecta) exit.
Construction of occlusal guard if bruxism habit is persisting.

22. ABRASION
Abrasion is the pathological wearing of dental tissues by friction with the foreign substances independent of occlusion.
ETIOLOGY & PATHOGENESIS
Different foreign substances produce different patterns of tooth abrasion . However, the process of tooth wear in similar in every cases.

24. Cervical abrasion

25. TOOTH BRUSH ABRASION
It is the most common type of abrasion &is mostly associated with faulty tooth brushing technique.
Abrasion occurs when the tooth brushing is done in a horizontal rather than a vertical direction and excessive force is applied during brushing.
The condition is made even worse when an abrasive dentifrice is used.

26. Tooth brush abrasion

27. Chewing tobacco cause abrasion.
HABITATUAL ABRASION
Bobby pin opening- notching on incisal edge of maxillary central incisor.
Pipe smokers- notching on teeth that conforms to the shape of pipe stem.
Chewing tobacco cause abrasion.
ABRASION BY PROSTHETIC APPLIANCES
IMPROPER USE OF DENTAL FLOSS AND TOOTH PICKS.
RITUAL ABRASION.

29. Abrasive potential of material varies among individual.
ABRASION BY DENTIFRICES
The role of dentifrices in abrading enamel and dentin has been established.
A number of studies have confirmed the adverse effect of highly abrasive tooth paste and powder.
Modern dentifrice have greatly reduced on their degree of abrasiveness and now seen to be insignificant in the progression of lesion.
Abrasive potential of material varies among individual.
The amount of dentifrice applied, the degree of salivary dilution ,technique and force applied during tooth brushing all influences abrasion.

31. SITES Usually occurs on exposed root surface of teeth.
Under circumstances ,it may be seen in elsewhere ,such as on incisal or proximal surface.
Degree of loss is more on prominent tooth (cuspids ,tricuspids and teeth adjacent to edentulous areas)

32. CLINICAL FEATURES
Abrasion has a variety of pattern depending on the cause.Tooth brush abrasion typically appear as horizontal cervical notches on the buccal surface of exposed ridiculars cementum and dentin. The defects usually have sharply defined margins and a hard smooth surface.
If acid is also present lesion will be more rounded or shallower.

33. The degree of loss is greatest on prominent teeth(i
The degree of loss is greatest on prominent teeth(i.e cuspids ,bicuspids and teeth adjacent to edentulous areas)and on side of arch opposite to the dominant hand.
Thread biting or use of pipes or bobby pins usually produces rounded or ‘V’ shaped notches in the incisal edge of anterior teeth.
The inappropriate use of dental floss or tooth picks result in the loss of interproximal radicular cementum and dentin.
Pulpal exposure and dentin sensitivity are rare.

34. MORPHOLOGY AND LOCATION
Abrasion lesions are of varying morphology and may be classified as :
Notch(N)/V- shaped defects: Where oblique occlusal and cervical walls intersect at certain depth with no definite axial walls in between them.
C- shaped defects: Where cross- section of the defect is C-shaped with rounded floors.
Under cut concave(UC) :Where occlusal and cervical wall intersect with a definite axial wall in between them.
Divergent box(DB): Where a definite axial wall is present with the occlusal &cervical walls diverging towards the surface.

35. Cervical lesion thought to because of abrasive forces generally have sharply defined margins, & hard smooth surface with burnished appearance.
Occasionally surface may exhibit scratches.
Hypersensitivity is intermittent character, appearing or disappearing with intervals.
In slowly progressive defects , reparative dentin formation occur over a period of time making them asymptomatic.
Abrasion may show varying grades of depths like

36. Shallow(s): .01-0.5mm in depth
Deep(D):more than 0.5mm but no pulp exposure&
Exposure(E): pulp is exposed.
* Abrasion lesion are usually generalised & most commonly seen to damage facial surface of maxillary teeth , Whereas lingual surface are rarely affected.
*Lesions are generally located on canine through molars, with the premolars exhibiting the highest frequency
*Occasionally localised lesion may be present on teeth placed facial to remaining dental arch.

37. TREATEMENT
Correct abnormal oral habits- Abnormal oral habits like nail biting ,holding objects like pins, pipes etc. in the mouth should be corrected.
Correct brushing techniques & recommended the use of soft brushes & less abrasive tooth

38. ETIOLOGICAL FACTORS OF EROSION
Irreversible loss of dental hard tissue by a chemical process that does not involve bacteria.
*The dissolution of mineralized tooth structures occurs upon contact with acid that are introduced into oral cavity from intrinsic and extrinsic sources.
ETIOLOGICAL FACTORS OF EROSION
Extrinsic sources of erosion are acids from external sources such as diet and environment.
Dietary acids are most common cause of extrinsic erosion.
Frequent conception of foods &drinks with a low PH can lead to erosion. 8

40. Dietary acids

41. Cond…
These include citrus fruits and fruit juices(citric acids),carbonated drink like colas (carbonic acids),pickles containing vinegar (acetic acids)etc.
Environmental erosion is related to occupational hazards in professions such as wine tasting , metal plating, battery manifacture,etc…

42. MEDICATIONS
Drugs acidic in nature when chewed or held in mouth prior to swallowing- erosion
Vitamin C preprations or hydrochloric acid supplements'- extensive erosion
b) Intrinsic sources of erosion are due to regurgitation of gastric acids in to the mouth . This may occur in gastric disorders or eating dissorders.
Gastric disorders includes gastrointestinal ulcers , hiatus hernia , chronic alcholism,etc…
Eating disorders include anorexia nervosa & bulimia nervosa.

43. Contd…………. iii)Chronic vomiting & pregnancy morning sickness.
MEDICATIONS
Antidepressants or other psychotic medications which cause salivary hypo function.
CLINICAL APPEARANCE
Broad concavities with smooth surface enamel
Capping of occlusal surfaces( incisal grooving) with dentin exposure.
Increased incisal translucency.
Wear on non occluding surfaces

44. Contd…… ‘Raised’ amalgam restoration.
Clean or non tarnished of appearance of amalgam.
Preservation of enamel ‘cuff’ in gingival crevice is common.
Hypersensitivity
Pulp exposure in deciduous teeth.

45. PROTOCOL FOR PREVENTION &PROGRESSION OF EROSION
1.Diminish the frequency &severity of the acid challenge
Decrease amount & frequency of acidic food& drinks
Acidic drinks should be drunk quickly rather than sipped. The use of straw could reduces the erosive potential of soft drinks.

46. In these case of bulimia, a physician or psychologist referral is appropriate.
Patient with alcoholism should be assisted in seeking treatment in rehabilitation programs.

47. 2.Enhance defense mechanism of the body (Increase salivary flow & pellicle formation ).
Saliva provides buffering capacity that resist acid attacks. this buffering capacity increases with salivary flow rate.
Saliva is also super sutured with calcium& phosphorus which inhibit demineralization of tooth structure.
Stimulation of salivary flow by use of a sugarless lozenge, candy/gum is recommended.

48. 4.Impove chemical protection
3.enhances acid resistances, remineralization & rehardening of tooth surface.
Have the patient use daily topical fluoride at home
Apply fluoride in the office 2-4 times a year a fluoride varnish is recommended.
4.Impove chemical protection
Neutralize acid in mouth by dissolving sugar free antacid tablets 5 times a day , particularly after an intrinsic or extrinsic acid challenge.

49. Cont…
Dietary components such as hard cheese (provide calcium &phosphate) can be held in the mouth after acidic challenge (e.g. hold cheese in mouth for a few minutes after eating a fruit salad).
5.Decrease abrasive forces.
Use of soft tooth brushes &dentifrices low in abrasiveness in a gentle manner.
Do not brush teeth immediately after an acidic challenge to the mouth, as the teeth will abrade easily.
Rinsing with water is better than brushing immediately after a acidic challenge.

50. 6.Provide mechanical protection.
Consider application of composite and direct bonding where appropriate to protect exposed dentin.
Construction of an occlusal guard is recommended if a bruxism habit is present.
7.Monitor stability.
Use cats or photos to document tooth wear status .
Regular recall examination should be due to review diet , oral hygiene methods ,compliance with medication ,topical fluoride & splint usage.

51. ABFRACTION
Loss of tooth structure that results from result from repeated tooth flexure caused by occlusal stress .Dentin is able to withstand greater tensile stresses than enamel. When occlusal force is applied electrically to a tooth, the tensile stress is concentrated at the cervical fulcrum, leading to flexure that may produces disruption in the chemical bonds of el enamel crystal. Once damaged, the cracked enamel can bee lost or more easily removed by erosion or abrasion.

53. Cont….
Current reserches suggested that abfraction may not be a distinct clinical entity or a primary factor in the development of non carious cervical lesions.
However there are several evidences to support the abfraction theory they are..
Only single tooth may be affected leaving the neighbouring teeth un involved.
More number of teeth are affected in bruxists & in older patients.

54. 3. These lesion can progress around existing cervical restoration &extend sublingually. 4. The lingual surface of mandibular teeth are rarely affected. CAUSES a. Excessive occlusal stresses. b. Para functional habits - Bruxism -Clenching

55. CLINICAL FEATURES
Abfraction lesion appear as wedge shaped defects with sharp margins & sharp internal angles.
Closely resemble the cervical erosion or abrasion.
Chief to the diagnosis include defects that are deep narrow &v – shaped (Which do not allow the toothbrush to contact the base of defect)& often affect a single tooth with adjacent un effected teeth .
Lesions are seen almost exclusively in the facial surface & exhibit a much greater prevalence in those with bruxism.

56. Cont…..
Initial stage of enamel surface is rough &show striations & grooves .In the cases later stages as the defect progress deeper in dentin two or more grooves may be visible on the surface.
Teeth affected – May even be seen in a single tooth.
Subgingival location is possible.

57. TREATEMENT
Correct occlusal stresses:- Traumatic occlusion or abnormal occlusal stresses, correction of these occlusal problem should be done by occlusal adjustments.
Providing mouth guards:- In patient with clenching & bruxism , provide mouth guard to prevent tooth flexure.

58. DIAGNOSIS:
Careful history taking and proper clinical examination are important in correct diagnosis of wasting disease.
HISTORY:
Note down any history of intrinsic or extrinsic erosion. The dentist must be trying to identify digestive problems like anorexia , gastric regurgitation etc. By careful questioning of the patient .
A diet diary is useful in detecting excessive consumption of citrus fruits, carbonated drinks, vitamin c tablets, vinegar, natural yoghurt etc. which are the common cause of dietary erosion

59. 3) The patients brushing technique, brush type and dentifrice used should be noted ,as improper brushing with a hard brush and abrasive dentifrice can be a contributing factor for abrasion. The dentist must also question about abnormal habit like clenching, grinding etc which may be a factor responsible for abfraction.

60. CLINICAL EXAMINATION
During clinical examination the dentist must concentrate on looking for signs of erosion, abrasion, attrition and abfraction. A careful occlusal examination is important to detect signs of occlusal problems which may be responsible for abfraction defects.

61. Clinical signs of occlusal problems:
Tooth mobility.
Open contacts.
Tilted or drifted teeth.
Atypical occlusal wear.
Over erupted teeth.
Cross bites , deep bites and open bites.
Fewer number of occluding teeth.
RADIOGRAHS:
They may be useful in identifying the following changes.
Altered lamina Dura and periodontal space.
Evidence of hyper cementosis, resorptions.
Pulpal calcification.

62. CLINICAL MANAGEMENT:
Wasting disease require clinical attention if any of following factors exist- 1)TOOTH SENSITIVITY: exposure of dentin in the cervical area may result in dentin hypersensitivity. 2)COMPROMISED ESTHETICS: Loss of tooth structure in the cervical region of tooth may produce an unaesthetic appearance , especially in anterior region. 3)RISK OF TOOTH FRACTURE: deep wedge shaped lesions in cervical area of teeth can increase the risk of tooth fracture due to lowered strength at this critical region.

63. 4. PULPAL DAMAGE :-Result in Irriverssible pulpitis & pulpal death. 5
4.PULPAL DAMAGE :-Result in Irriverssible pulpitis & pulpal death. 5. CARIES:- Also favour plaque accumulation which could eventually leads to the development of caries. 6.POOR PERIODONTAL HEALTH:- The gingiva may be irritated & inflamed.

64. PREVENTION
Prevention of wasting disease is a very important aspect in the clinical management of these defects. Failure to eliminate the cause may compromise the long term survival of restoration and result in further deterioration of the dentition
Prevention lies in identifying and eliminating the cause such as dietary source of acid ,improper brushing and abnormal occlusal stress .

65. STEPS…………
DIET COUNSELLING: advice patient to reduce the intake of erosive products such as acidic foods and beverages
USE OF SODIUM BICARBONATE MOUTH RINSE: in patients with gastric regurgitation ,a sodium bicarbonate mouth rinse should be prescribed to neutralize the effect of the acid
USE OF FLUORIDE MOUTH RINSE AND XYLITOL GUM:exposure to fluoride will reduce the softening effect of acids. xylitol gum also reduce the effect of tooth erosion from acidic drinks

66. PSYCHIATRIC CONSULTATION :for suspected anorectics and bulimics
CORRECT BRUSHING TECHNIQUES: advice patient to modify their brushing techniques & recommended the use of soft brushes and less abrasive tooth paste
CORRECT OCCLUSAL STRESSES :In patient with traumatic occlusion or abnormal occlusal stresses ,correction of these occlusal problems should be done by occlusal adjustment

67. PROVIDE MOUTH GUARDS: in patients with clenching and bruxism ,provide mouth guard to prevent tooth flexure.
CORRECT ABNORMAL ORAL HABITS :abnormal oral habits like nail biting ,holding objects like pin ,pipes etc should be corrected.
Effectiveness of these measures should be periodically monitored

68. CONCLUSION
With increasing dental awareness an improved dental care, more and more people are retaining their teeth fore longer period of time .Dentist there for have to treat the tooth wear . When loss of enamel & dentin at the cementoenamel junction become significant ,resulting in loss of function &esthetics.
Accurately correcting & treating this condition.