Tooth Tissue Loss - Erosion, Abrasion, Attrition and Abfraction; we wonder why our teeth are sensitive! Sonia Jones RDH CFET South West Post Graduate Dental Deanery DCP Advisor Devon/Cornwall [email protected]
www.bristol.ac.uk/dentalpg Aims and Objectives Aim: to ensure delegates understand how tooth tissue loss can be detrimental to dentine hypersensitivity Objectives: By the end of the session you should be able to: Distinguish between erosion, abrasion, attrition and
abfraction Determine the causative factors of tooth tissue loss Describe how to prevent further tooth tissue loss Discuss sensitivity theories and explain the way they work List topical medicaments available to relieve sensitivity Tooth tissue loss Tooth surface loss can arise as the result of:
Erosion Abrasion Attrition Abfraction Erosion Abrasion
Attrition Abfraction Tooth tissue loss
Patients often seek treatment for pain Function can be altered Compromised aesthetics All ages
Tooth tissue loss
The 4 types of tooth tissue loss all have their own characteristic appearance However, the wear of a persons teeth is usually from a mixture of all 4, with one type of TTL predominating. Sometimes difficulty in determining the dominant aetiology
The thickness of the pellicle and the pressure of the tongue contribute to the extent of the condition Tooth Tissue Loss Relatively slow progression
Study models Indices Photographs Can all be helpful
Restorative treatment Difficult to control Very different to dental caries in appearance and causation Erosion
Described as early as 1892 among Sicilian lemon pickers Definition: The loss of tooth tissue by a chemical process that does not involve bacteria, acids are most commonly involved in the dissolution
process Non carious pathological loss of tooth tissue Plaque not involved in the process Clinical Presentation
Occurs most frequently on the palatal and labial surfaces of the incisor teeth The effected surfaces appear smooth and highly polished with a scooped out depression The lesion primarily occurs in the enamel
In more severe cases the dentine becomes exposed As enamel loss progresses sensitivity to thermal changes are noticed More persistent pain occurs in severe cases Erosion
Erosion Causes of erosion Extrinsic factors
Intrinsic factors Idiopathic factors Extrinsic causes of erosion
Habitual consumption of highly acidic, low pH carbonated drinks, sports drinks or concentrated fruit juices Alco pops, fruit flavoured alcoholic beverages and strong ciders Causing a wide shallow lesion effecting the
labial and palatal surfaces of the upper teeth Extrinsic causes of erosion
Swishing or holding drinks in the mouth Modern packaging has also been blamed, tetra pack, plastic bottles and cans directional flow onto teeth Can extend from the labial and palatal lesions of the upper teeth to all surfaces of all teeth Chemicl pH
Acids involved
The principal ingredient linked with erosion is citric acid, found in most fruit juices and soft drinks Other fruit acids have an effect The erosive effect is due to its low chemical pH Also by chelation, the acids demineralise the
enamel by binding to the calcium and removing it from the enamel Cola type drinks may also contain phosphoric acids While the pH of a drink is an indicator of its erosive potential, a measure called total titratable acidity is a better guide of how a liquid can dissolve a mineral Total Titratable Acidity
Titratable acidity
How long it takes for the saliva to compensate How much saliva (flow) Buffering capabilities of the saliva Citric acid the biggest culprit Thickness of the pellicle can protect to a
degree Higher temperatures increase titratable acidity Extrinsic causes of erosion Habitual sucking of citrus fruits The lesion may occur in either the upper or lower anterior teeth Depending on the way the fruit is eaten
(Remember fruit eaten as a whole unit does not generally cause a problem) Acidic foods
Pickles, sauces, vinegars, yoghurts, roasted vegetables Extrinsic causes of erosion
Industrial atmospheric pollution Chemical workers, battery manufacturers, crystal glass workers
Less common now due to stricter working conditions and regulations (H&S at work act 1978) Acidic fumes effect the labial surfaces of the upper and lower anterior teeth When talking or the mouth is at rest Extrinsic causes of erosion
Chlorine, from gas chlorinated swimming pools Professional swimmers If the chemicals are not properly regulated
Less common now due to regulations Intrinsic causes of erosion From within the body Usually hydrochloric acid from the stomach (pH 2) Reflux Regurgitation
Vomiting Rumination Rumination The term rumination is derived from the Latin word ruminare, which means to chew the cud. Rumination is characterized by the voluntary or involuntary regurgitation and rechewing of
partially digested food that is either reswallowed or expelled. This regurgitation appears effortless, may be preceded by a belching sensation, and typically does not involve retching or nausea. Reflux, Regurgitation and Vomiting of gastric contents
Anorexia Bulimia Hiatus Hernia Pregnancy/Hormones Motion sickness Obesity
Eating too much Drinking too much Alcoholism Anorexia Bulimia
Saturday Night? Habitual regurgitation of gastric contents
Heavily acidic diet increases gastric erosion The palatal surfaces of the upper anteriors and premolars are eroded Produces wide shallow lesions Enamel may be completely lost
Tackle the problem with care! Patient might not admit to unattractive aspect of psychological illness Idiopathic causes of erosion
Unknown cause Patient will not admit to or be aware of intrinsic or extrinsic causes Vigorous tooth brushing can contribute to an over polished appearance - shiny
Abrasion Definition: The abnormal wearing away of tooth tissue by a mechanical process The location and pattern of abrasion is directly dependent upon its course It usually occurs on the exposed root surfaces when gingival recession has exposed the cementum
It may be seen on the incisal or inteproximal surfaces of the teeth Causes of Abrasion Incorrect or destructive use of a toothbrush Use of an abrasive detrifice
The enamel and dentine is worn away to produce a V shaped notch at the neck of the tooth Areas most affected are the labial and buccal surfaces of the canines and premolars Powerful back hand, RHS of right handed person LHS of Left handed person Para
functions, habits, occupations Mainly affects the incisal edges of the anterior teeth Clinical appearance of Abrasion
Worn, shiny often yellow/brown areas at the cervical margin Worn notches on the incisal surfaces of the anterior teeth Abrasion
Abrasion Causes of Abrasion
Seamstresses pins, Carpenters nails, Hairdressers hairgrips Pipe smokers, nail biters, causing notching Attrition Definition: The physiological wearing away of the tooth surface as a result of tooth to tooth contact as in mastication
Occlusal and incisal surfaces of the teeth most commonly affected May also affect the proximal surfaces of the teeth due to slight movement of the teeth in their sockets during mastication Age related process Varies from person to person
Attrition Causes: Bruxism Abrasive (gritty) diet Constant chewing tobacco/ betel nut Marked malalignment or malocclusion Loss of posterior teeth Occupational, dust/grit mixed with saliva
Clinical appearance of Attrition Polished facets on enamel surfaces Cupping dentine is exposed
Occasional full loss of enamel, dentine is exposed and stains heavily Attrition Attrition
Ranges from part of the enamel being worn away in the early stages to the full thickness of the enamel wearing away in advanced attrition The dentine may be exposed and stained In extreme cases the teeth may be worn down
to the gingivae Attrition Attrition
Process of attrition is slow
Secondary dentine is laid down to protect the pulp chamber and the pulp chamber narrows Pain is rarely associated with attrition Men usually show a greater degree of attrition than women Severe attrition is seldom seen in deciduous teeth, (not retained for long) However if a child suffers from dentinogenesis
imperfecta (an hereditary disorder of the dentine) pronounced attrition may result from mastication Abfraction Definition: The pathological loss of enamel and dentine due to occlusal stresses Recently interest has grown in the development of cervical abrasive lesions
The term abfraction has been used to describe these cervical lesions Some Clinicians do not believe that this is the reason and that erosion and abrasion cause the wear facets, research continues
Abfraction Causes of Abfraction
Occlusal forces which cause the tooth to flex, cause small enamel flecks to break off, inducing the abrasive lesions
Usually wedge shaped lesions with sharp angles found at the cervical margins However can be found on the occlusal surfaces, presenting as circular areas These lesions can occur with occlusion alone or as with most TTL cases which are multi factorial, can be associated with toothbrush abrasion These lesions are often diagnosed as toothbrush
abrasion, but they differ as their angles are sharper Abfraction Common in patients with poor tooth alignment Can be associated with: Anterior open bite Occlusal restorations that change the cuspal
movements Abnormal tongue movement Treatment of Tooth Tissue Loss 1. 2.
3. 4. 5. 6. Relieve sensitivity and pain fluoride, desensitising agents/toothpastes
Identify aetiological factors modify diet/habits, eliminate acidic foods/drinks, stop habitual practices, gentle tooth brushing techniques Protect the remaining tooth tissue reconstruct the effected teeth, restorations, inlays/onlays, crowns, check occlusion Bite raising devices/splints Referral to TTL Expert
Prevention of further episodes Treatment Plan
Take a detailed history from the patient Examination Radiographs Vitality testing
Patients wishes/needs Study models Photographs Indices Indices BEWE
Basic Erosive Wear Examination 0 No Erosive Wear 1 Initial loss of Surface texture 2 Distinct defect, hard tissue <50% of the surface area 3 Hard tissue loss >50% of the surface area * (2,3) dentine involved
Tooth wear index according to Smith and Knight Score Surface Criteria 0 C 1 C 2
C 3 C 4 C
B/L/O/I No loss of enamel surface characteristics No loss of contour B/L/O/I Loss of enamel surface characteristics Minimal loss of contour B/L/O Loss of enamel exposing dentine for less than one-third of the surface I Loss of enamel just exposing dentine
Defect less than 1mm deep B/L/O Loss of enamel exposing dentine for more than one-third of the surface I Loss of enamel and substantial loss of dentine Defect less than 1-2mm deep B/L/O Complete loss of enamel, or pulp exposure, or exposure of secondary dentine I Pulp exposure or exposure of secondary dentine
Defect more than 2mm deep, or pulp exposure, or exposure of secondary dentine Sensitivity Dentine Hypersensitivity Dentine is the highly sensitive part of the tooth Patients suffering from dentine hypersensitivity often think that they have developed a cavity or lost a filling
On examination there is often no obvious reason for their pain, gingival recession is sometimes evident The amount of recession does not seem to correlate with the amount of pain they are experiencing c/o short sharp episodes of pain caused by temperature, touch by metal, sweet foods/drinks Patients can be very distressed by the pain of dentine hy
