1. Tooth wear: prevention, clinical implicationII
Libyan International Medical University
2nd Year nd Semester
D Caroline Piske de A. Mohamed

2. Objectives:
• Preventing tooth wear
• Clinical implications

3. How can tooth wear be prevented?
It is vital that the existence of tooth wear is identified early and appropriate preventive measures put into place.

4. Abrasion/Erosion Prevention
Changing toothbrush technique and type of toothpaste.
Other aetiological factors need to be identified and then appropriate advice given.
Also, factors such as frequency and method of intake of acidic beverages as well as proximity of toothbrushing after intake may influence susceptibility to erosion.
In-depth history to include dietary history, medical history, dental hygiene habits, and lifestyle factors.

5. A three-day diet history.
The periodicity of eating and toothbrushing
Habits as continuous sipping or ‘frothing’ of drinks should be noted.
(Frothing is the habit of holding carbonated drinks in the mouth and sucking them in and out of the teeth to make froth. This tends to add the ‘ultrasonic’ effect of the bursting bubbles to the erosive effects of the acid. It also extends contact time.)

6. Give appropriate dietary counseling
This can only be given after a thorough analysis of the diet and influencing factors.
It must be tailored to the individual, bearing in mind the constraints that are operating on them.
It needs to be given in a positive, individualized way to maximize compliance.

7. Drink and Diet modification
Finish meals with something alkaline
such as a small piece of cheese or milk.
Drinks with low erosive potential
(or that had addition of calcium
citrate-malate.)
Reduce and limit acid foods and drinks to mealtimes.
Reduce frequency.
Avoid acidic substances last thing at night.
Advise the patients to modify their diet.
Considering the increasing prevalence of tooth erosion, specially in children and teenagers and the strong association between consumption of acidic drinks and tooth erosion, it still seems logical to develop drinks with low erosive potential.
Drink modification has been developing by addition of calcium citrate-malate but the researches are not absolutely in concordance with the results.
Drinking cola by straw has been shown to reduce the potential for tooth erosion from acidic drinks, specially on the palatal surfaces of the maxillary incisors that are most commonly affected in patients with erosion.

8. Avoid toothbrushing for at least an hour after acidic substances.
Drinking through a straw lessens the contact time of the beverage with the teeth compared to drinking from a cup.
Check the formulations or constituents of any medication, mouthwashes, etc.
Chewing gum has been shown to stimulate salivary flow and increase buffering capacity, but may also secretion cause increased gastric acidity .
It should not be recommended for children, probably below the age of 7 years, and is not suggested for those with a history of gastric reflux. .

9. Accumulation of pellicle
Saliva
Erosion is usually found in areas of the dental arches that are lacking in pellicle. Saliva and pellicle are important factors in protection of toothsubstance against acid attach.
Increasing salivary flow and hence accumulation of
pellicle will, therfore, probably offer protection against
erosion. Increasing salivary flow and, consequentely,
buffer capacity should increase protection against
erosion and promote remineralization.
Remineralization
Accumulation of pellicle
Buffer capacity
Salivary flow

10. Abrasion

11. Abrasive foods are uncommon in developed countries, but may be significant factors in certain areas of the developing world.

12. Attrition
If attrition related to parafunctional activity is found to be progressing to unacceptable levels, then prevention of further tooth surface loss must be considered.
Although males consistently show more attrition than females, they experience far fewer symptoms of temporo-mandibular dysfunction or myofascial pain than females.

13. Attrition

14. Bruxism
76 year old farmer who has been "grinding his teeth". 

15. The severity of attrition has not been shown to be strongly associated with the development of signs and symptoms.
It has proved to be impossible to totally stop nocturnal bruxing activity.

16. The most realistic method of controlling attrition is not in the prevention of the parafunctional activity itself, but rather in the prevention of the damage it causes.
An occlusal splint (mouthguard) can be constructed, which will prevent the tooth to tooth contact which results in attrition.

17. The NTI-tss Plus™ does the job of a bite guard but covers only the front teeth. Attached on the incisal edge of the shell is an anterior-posterior discluding element (DE) that provides for a point stop on the mesial-incisal edges of the two opposing central incisors.

18. Preventing Erosion Making a diagnosis.
It is essential to record accurately the severity and extent.
This will establish the clinical baseline so that any progression can be assessed, and the effects of preventive measures monitored.
It may also be necessary to undertake these procedures in patients with marked abrasion and attrition.

19. Typical examples of localised anterior tooth wear predominantly due to acid erosion

21. Record the clinical situation
Stone study casts.
Clinical photographs .
Tooth Wear Index.
A silicone index can be prepared.
Try to determine the etiological factors.

22. Intrinsic acid sources
If there is any evidence or suspicion of gastric reflux, then referral to the general medical practitioner and onward to a gastro-enterologist or psychiatrist may be required. Medication may be helpful, but this obviously needs medical supervision.
If reflux or vomiting are occurring, then rinsing the mouth with water and sodium bicarbonate helps to neutralize the oral environment.

23. People who have vomited should not rush off to clean their teeth.
It has been shown that if teeth have been subjected to an acidic attack and are then brushed, up to five times as much enamel is removed.
If reflux is occurring during sleep then an occlusal guard containing sodium bicarbonate can be used in adults or teenagers.

24. Follow up
When the patient returns for a review, their compliance with all the advice given should be checked and the state of the dentition must be examined very carefully.
A localized silicone index should be taken of the original study casts in the area of most concern.

25. Smith and Knight tooth wear index
Score
Surface
Criteria
B/L/O/I
No loss of enamel surface characteristics C
No loss of contour 1
Loss of enamel surface characteristics
Minimal loss of contour 2
B/L/O
Loss of enamel exposing dentine for less than one third of surface I
Loss of enamel just exposing dentine
Defect less than 1 mm deep 3
Loss of enamel exposing dentine for more than one third of surface
Loss of enamel and substantial loss of dentine
Defect less than 1–2 mm deep 4
Complete enamel loss–pulp exposure–secondary dentine exposure
Pulp exposure or exposure of secondary dentine
Defect more than 2 mm deep–pulp exposure–secondary dentine exposure

26. Simplified scoring criteria for TWI
Score
Criteria
No wear into dentine 1
Dentine just visible (including cupping) or dentine exposed for less than 1/3 of surface 2
Dentine exposure greater than 1/3 of surface 3
Exposure of pulp or secondary dentine

27. Erosion index according to Lussi
Surface
Score
Criteria
Facial
No erosion. Surface with a smooth, silky glazed appearance, possible absence of developmental ridges 1
Loss of surface enamel. Intact enamel cervical to the erosive lesion; concavity on enamel where breadth clearly exceeds depth, thus distinguishing it from toothbrush abrasion. Undulating borders of the lesion are possible and dentine is not involved 2
Involvement of dentine for less than half of tooth surface 3
Involvement of dentine for more than half of tooth surface
Occlusal/
lingual
Slight erosion, rounded cusps, edges of restorations rising above the level of adjacent tooth surface, grooves on occlusal aspects. Loss of surface enamel. Dentine is not involved
Severe erosions, more pronounced signs than in grade 1. Dentine is involved

28. prevention of pulp exposure, fractured teeth and restorations
The effects of tooth wear that may require treatment are
esthetics,
tooth sensitivity,
prevention of pulp exposure,
fractured teeth and restorations
and, occasionally,
the improvement of masticatory
function.

29. Treatment of tooth sensitivity can be a challenging problem if tooth wear is progressing.
Some dental materials are themselves more susceptible to wear than others.
For example, each composite material has its own wear resistance, which is improved by increasing the inorganic filler fraction and decreased by reducing the average filler particle size.

30. Although a composite might appear to have an optimal wear rate, its filler particles may increase the wear on opposing enamel and dentine surfaces, and lead to an increasing loss of vertical dimension.
Adhesive materials based on (bis-glycidyl-methacrylate) bis-GMA-resins are also susceptible to chemical dissolution and may not have good long term survival in situations of high acidic challenge.
However, restoration with composite or compomer materials may be useful as an interim treatment with progression to adhesive metal castings and porcelain veneers if necessary.

31. Suggested preventive measures for progression of erosion
Diminish the frequency and severety of the acid challenge
Enhance the defense mechanisms of the body (increase salivary flow and pellicle formation)
Enhance acid resistant, remineralization and rehardening of the tooth surfaces (use of Topical fluorides)
Improve chemical protection (use of antacids and cheese)
Decrease abrasive forces ( Use of soft tooh brushes and avoid brushing immediately after acid challenge)
Provide mechanical protection (use of bonding agents on exposed dentine and Occlusal guards)
Monitor stability
Advice on brushing can be contentious, particularly when dentin is exposed. Gentle softbrushing only before bed time, using a soft multitufed brush and fluoride dentifrice may be advisable.Patients should be monitored intensively during the first few weeks for treatment compliance, and again after 2 or 3 months. Any soft dentin present should have hardened after 3 months. Continued dentin hypersensitivity indicates continued erosive activity
Tables source: CM Marya. A Textbook of Public Health Dentistry. Jaypee Brothers Medical Publishers2011.

32. That´s how men brush teeth!
D.caroline Mohamed

33. Clinical implications
Patients that are not compliant with preventive measures or that can´t control the aetiological factors may need complex restorative techniques, with all the implications for expensive maintenance that these incur.

34. Vomiting bulimia patients restorations are required in order to retain any remnants of the dentition.

35. Treatment for sensitive dentine
Fluoride
• mouthrinses
• varnish
• toothpastes, with or without iontophoresis*
(with low abrasivity)
Copal varnishes
Potassium oxalate
Strontium chloride
Dentine-bonding agents
Sealants
Restorative techniques
• Glass ionomers
• Compomers
• Composites
*Iontophoresis—use of a small electric current to introduce sodium fluoride and/or corticosteriods into the dentinal tubules.
The Fluorinex operating principle differs from previously proposed “iontophoretic” fluoride delivery systems, where current clearly passes through the patient’s tissues. In the Fluorinex method, positive and negative electrodes are within the gel  when energized, and are a part of the tray itself. There is no passage of the current through the patient’s body.

36. Recommending the use of a potassium ion-containing gel or dentifrice in combination with watchful waiting with stimulus avoidance has long been the favored initial approach for DH management.
Fluoride varnish is easy to apply and can also provide prompt relief.

37. There are faster-acting professional approaches aimed at narrowing or occluding dentinal tubules.
Iontophoresis-based acceleration of tubular narrowing or occlusion followed by resin impregnation (or longer lasting) glass ionomer coverage will usually provide both immediate and lasting relief.

38. It needs to be emphasized that treatment of tooth wear will be ineffective in the long term, unless the aetiological factors are controlled or eliminated.

39. Night Guard

40. Dental sealants

41. Restorations Before After

42. Prostheses

43. Surgery

44. Root coverage

45. Take a good look!

47. Questions……………..

48. References
CM Maya. A textbook of Public Health Dentistry, first edition. Jaypee Brothers Medical Publishers.

49. Highly recommended Erosion—diagnosis and risk factors
Managment of dental erosion.

50. Thank you!!!