1. DENTAL EROSION—TOOTH WEAR Physiology, Etiology, Epidemiology, Diagnosis, and Treatment

2. Dental Erosion: Tooth Wear After viewing this lecture, attendees should be able to: understand the oral anatomy and physiology as they relate to dental erosion/tooth wear identify the etiology of and risk factors associated with dental erosion/tooth wear describe the epidemiology and prevalence of dental erosion/tooth wear make the correct differential diagnosis and understand the management of dental erosion/tooth wear

3. Oral Anatomy and Physiology Primary (deciduous) Secondary (permanent) Definition (teeth): There are two definitions

4. Primary (deciduous) Consist of 20 teeth Begin to form during the first trimester of pregnancy Typically begin erupting around 6 months Most children have a complete primary dentition by 3 years of age Oral Anatomy and Physiology Dentition (teeth): There are two dentitions 1. Oral Health for Children: Patient Education Insert. Compend Cont Educ Dent.

5. Oral Anatomy and Physiology Secondary (permanent) Consist of 32 teeth in most cases Begin to erupt around 6 years of age Most permanent teeth have erupted by age 12 Third molars (wisdom teeth) are the exception; often do not appear until late teens or early 20s Dentition (teeth): There are two dentitions Mandible Maxilla Incisors Canine (Cuspid) Premolars Molars

6. Classification of Teeth: Incisors (central and lateral) Canines (cuspids) Premolars (bicuspids) Molars Oral Anatomy and Physiology Identifying Teeth Incisor Canine Premolar Molar

7. Oral Anatomy and Physiology Apical Labial Lingual Distal Mesial Incisal Teeth: Identification Tooth Surfaces Labial Apical Lingual Incisal Distal Apical Mesial

8. Anatomic Crown Anatomic Root Pulp Chamber The 3 parts of a tooth: Anatomic Crown Anatomic Root Pulp Chamber Oral Anatomy and Physiology

9. Enamel Dentin Cementum Dental Pulp The 4 main dental tissues: Enamel Dentin Cementum Dental Pulp

10. Structure –Highly calcified and hardest tissue in the body –Crystalline in nature –Enamel rods Insensitive—no nerves Acid-soluble—will demineralize at a pH of 5.5 and lower Cannot be renewed Darkens with age as enamel is lost Fluoride and saliva can help with remineralization Dental Tissues—Enamel 2 Oral Anatomy and Physiology

11. Softer than enamel Susceptible to tooth wear (physical or chemical) Does not have a nerve supply but can be sensitive Is produced throughout life Three classifications –Primary –Secondary –Tertiary Will demineralize at a pH of 6.5 and lower Dental Tissues—Dentin 2 Oral Anatomy and Physiology

12. Dentin Pulp Tubule Fluid Nerve Fibers Odontoblast Cell Oral Anatomy and Physiology Presence of tubules renders dentin permeable to fluoride Number of tubules per unit area varies depending on the location because of the decreasing area of the dentin surfaces in the pulpal direction Dental Tissues—Dentin (Tubules) 2

13. Association between erosion and dentin hypersensitivity 3 Open/patent tubules – Greater in number – Larger in diameter Removal of smear layer Erosion/tooth wear Enamel Exposed Dentin Receding Gingiva Tubules Odontoblast Oral Anatomy and Physiology Dental Tissues—Dentin (Tubules) 2

14. Oral Anatomy and Physiology Thin layer of mineralized tissue covering the dentin Softer than enamel and dentin Anchors the tooth to the alveolar bone along with the periodontal ligament Not sensitive Dental Tissue—Cementum 2

15. Innermost part of the tooth A soft tissue rich with blood vessels and nerves Responsible for nourishing the tooth The pulp in the crown of the tooth is known as the pulp chamber Pulp canals traverse the root of the tooth Typically sensitive to extreme thermal stimulation (hot or cold) Dental Tissue—Dental Pulp 2 Oral Anatomy and Physiology

16. Plaque Saliva pH Values Demineralization Remineralization Oral Cavity/Environment 4,5 Oral Anatomy and Physiology

17. Plaque: 4,5 is a biofilm contains more than 600 different identified species of bacteria there is harmless and harmful plaque salivary pellicle allows the bacteria to adhere to the tooth surface, which begins the formation of plaque Oral Cavity

18. Oral Anatomy and Physiology Saliva: 4,5 complex mixture of fluids performs protective functions: –lubrication—aids swallowing –mastication –key role in remineralization of enamel and dentin –buffering Oral Cavity

19. Oral Anatomy and Physiology pH values: 4,5 measure of acidity or alkalinity of a solution measured on a scale of 1-14 pH of 7 indicated that the solution is neutral pH of the mouth is close to neutral until other factors are introduced pH is a factor in demineralization and remineralization Oral Cavity 3. Strassler HE, Drisko CL, Alexander DC.

20. Oral Anatomy and Physiology Demineralization: 4,5 mineral salts dissolve into the surrounding salivary fluid: –enamel at approximate pH of 5.5 or lower –dentin at approximate pH of 6.5 or lower erosion or caries can occur Oral Cavity

21. Oral Anatomy and Physiology Remineralization: 4,5 pH comes back to neutral (7) saliva-rich calcium and phosphates minerals penetrate the damaged enamel surface and repair it: –enamel pH is above 5.5 –dentin pH is above 6.5 Oral Cavity

22. Dental Erosion: Etiology Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of physical loss, chemical dissolution, and/or multifactorial etiology. 3,6 Tooth Wear

23. Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of: 3,6 Physical Loss – Abrasion—mechanical – Attrition—tooth-to-tooth contact – Abfraction—lesions Chemical dissolution Multifactorial etiology Dental Erosion: Etiology Tooth Wear

24. Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of: 3,6 Physical Loss Chemical dissolution – Erosion -- Extrinsic acids -- Intrinsic acids Multifactorial etiology Dental Erosion: Etiology Tooth Wear

25. Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of: 3,6 Physical Loss Chemical dissolution Multifactorial etiology – Erosion – Abrasion – Attrition – Abfraction Dental Erosion: Etiology Tooth Wear

26. The pathological wearing away of hard dental tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth. 6 Oral hygiene habits –Excessive brushing/flossing –Abrasives in dentifrices/toothpastes Personal habits –Putting foreign objects in the mouth Demastication –Wear from chewing food Abrasion Dental Erosion: Etiology

27. The pathological wearing away of hard dental tissue as a result of tooth-to-tooth contact, with no foreign substance intervening. 6 Enamel wearing enamel –Occlusal wear –Malocclusion (buccal, lingual, and interproximal surfaces) Attrition Dental Erosion: Etiology

28. Wedge-shaped defects at the cementoenamel junction of a tooth caused by eccentrically applied occlusal forces leading to tooth flexure that results in microfracture of enamel and dentin. 6 Loss of tooth in the cervical area –Tooth flexure – Chewing – Grinding (bruxism) Abfraction Dental Erosion: Etiology

29. The physical results of a pathologic, chronic, localized loss of hard dental tissue that is chemically etched away from the tooth surface by acid and/or chelation without bacterial involvement. 7 Extrinsic acids—ingested –Food, beverages, medicine Intrinsic acids—internal –Originate in the stomach Erosion Dental Erosion: Etiology

30. Tooth wear is multifactorial One process typically impacts the other – Erosion and abrasion Multifactorial Dental Erosion: Etiology

31. Tooth erosion was described as a condition distinct from caries as early as the 18 th century. 8 Dental Erosion: Epidemiology

32. In 1995, the European Journal of Oral Science stated that “dental erosion is an area of research and clinical practice that will undoubtedly experience expansion in the next decade.” 9 Change in Perception Dental Erosion: Epidemiology

33. Global Prevalence Global data on the prevalence of dental erosion is building. “Erosive tooth wear is a common condition in the developed countries.” 10 United States Canada Iceland Ireland Sweden Germany Turkey Saudi Arabia India Brazil Japan Malaysia Switzerland The Netherlands UK China

34. European studies suggest prevalence of: 11-13 –Up to 50% if all preschool children –Between 24% to 60% of school-aged children –As high as 82% in 18 to 88 years of age 10 Emerging prevalence studies providing data on gender, socio-economic status, ethnic, and culture difference in addition to the age factor will prove to be invaluable Global Prevalence Dental Erosion: Epidemiology

35. “Diagnosis is the intellectual course that integrates information obtained by clinical examination of the teeth, use of diagnostic aids, conversation with the patient, and biological knowledge. A proper diagnosis cannot be performed without inspection of the teeth and their immediate surroundings.” 14 Dental Erosion: Diagnosis

36. Dental Erosion— Diagnosis Check list to unveil etiological factors for erosion 15

37. Dental Erosion: Diagnosis Interaction of the different factors for the development of erosive tooth wear 16,18 From: Lussi A. Dental Erosion: From Diagnosis to Therapy. Karger; 2006.

38. Dental Erosion: Diagnosis Clinical Appearance There is no device available for the specific detection of dental erosion in routine practice. Therefore, the clinical appearance is the most important feature for dental professionals to diagnosis dental erosion. 16

39. Dental Erosion— Diagnosis Tooth Wear—Clinical Appearance 17

40. Chemical factors—erosive potential of intrinsic and extrinsic acids Biological factors—involve properties and characteristics of the oral cavity Behavioral factors—personal and oral habits Erosion is multifactorial Dental Erosion: Diagnosis

41. pH and buffering capacity of the product Type of acid (pK a values) –Intrinsic (gastric origin) –Extrinsic (environmental, dietary, medicinal) Adhesion of the products to the dental surface Chelating properties of the products Calcium concentration Phosphate concentration Fluoride concentration Chemical Factors 18 Dental Erosion: Diagnosis

42. Saliva: flow rate, composition, buffering, capacity, and stimulation capacity Acquired pellicle: diffusion-limiting properties, composition, maturation, and thickness Type of dental substrate (permanent and primary enamel, dentin) and composition (eg, fluoride content as FHAp or CaF 2 -like particles) Dental anatomy and occlusion Anatomy of oral soft tissues in relationship to the teeth Physiologic soft tissue movements Biological Factors 19 Dental Erosion: Diagnosis

43. Unusual eating and drinking habits Healthy lifestyle: diets high in acidic fruits and vegetables Unhealthy lifestyle: frequent consumption of “alcopops” and designer drugs Alcoholic disease Excessive consumption of acidic foods and drinks Nighttime baby bottle feeding with acidic beverages, including milk Oral hygiene practices: frequent toothbrushing, abrasive oral care products Behavioral Factors 20 Dental Erosion: Diagnosis

44. Loss of tooth surface is a multifactorial process and education is the first step in the line of defense. 4 Prevention Dental Erosion: Diagnosis

45. Dynamics of Dental Erosion 21 BeforeDuringAfter Time (Frequency) Interactions between Behavioral and Biological Factors Dental Erosion: Diagnosis/Management 21. Lussi A, Kohler N, Zero D, et al.

46. Dental Erosion: Management/Etiological Factors Dietary factors 15 Avoid radical changes in dietary habits Reduce acid exposure by reducing frequency and contact time of acid Avoid acidic foods and drinks late at night Avoid high-acidity liquids via baby bottle for infants Avoid low pH values in food and beverages Awareness/Association/Education

47. Dental Erosion Management/Etiological Factors Dietary factors: generally, a pH value of 5.5 or lower is capable of softening the surface of enamel in only a few minutes. 3 Awareness/Association/Education 3. Strassler HE, Drisko CL, Alexander DC.

48. Dental Erosion: Management/Etiological Factors Behavioral/habits 15 Do not hold or swish acidic drinks in your mouth Avoid sipping acidic drinks—use a straw Avoid toothbrushing immediately after an erosive challenge (vomiting, acidic diet) Avoid toothbrushing immediately before an erosive challenge, as the acquired pellicle provides protection against erosion Use a soft toothbrush Awareness/Association/Education

49. Dental Erosion: Management/Etiological Factors Behavioral/Habits 15 Use a low-abrasion fluoride-containing toothpaste; high-abrasive toothpaste may destroy pellicle Avoid toothpastes or mouthwashes with too-low pH After acid intake, stimulate saliva flow with chewing gum or lozenges Use chewing gum to reduce postprandial reflux Refer patients or advise them to seek appropriate medical attention when intrinsic causes are involved Awareness/Association/Education

50. Gastroesophageal Origin 22 Heartburn and other symptoms of reflux Regurgitation Dysphagia Asthma Rumination Eating disorders (anorexic or bulimia) Dental Erosion: Management/Etiological Factors Awareness/Association/Education

51. Medicinal factors associated with dental erosion 23 Some medicines can potentially induce GERD –theophyline –progesterone –anti-asthmatics –calcium channel blockers Aspirin (especially in chewable format) Medicines that decrease salivary flow –antihistamines –anticholinergics –antidepressants –antipsychotics Awareness/Association/Education Dental Erosion: Management/Etiological Factors

52. Dental Erosion/Toothwear Prevention is better than a cure… Education is the key!