Wasting diseases of teeth final

The wasting diseases of teeth, namely attrition, abrasion and dental erosion have taken their toll in the population around the world due to the changing lifestyles, increase in the stress levels and many others factors that were persistent earlier but have suddenly increased drastically. This presentation brings to light the new factors that have attributed to this condition as well as discusses the previous ones.

1. Wasting Diseases Of Teeth Presented by; Guided by; Dr. Prachee Hendre Dr. Suresh Lele 2 nd MDS Prof, HOD & Guide

2. Contents Introduction-tooth structure Definition Tooth wear Classification of tooth wear Prevalence and distribution of tooth wear Etiology Chemistry of demineralization Method to measure tooth wear

3. Attrition Abrasion Abfraction Erosion Approaches to prevention of tooth wear Restorative management of worn dentition Conclusion References

4. Introduction- Tooth structure The enamel and dentine have a distinct capacity to recognize and respond to stimuli. Dentition is unique in terms of mineralized tissue biology, because Ca (PO 4 ) is exposed to the outer environment. Prism is the fundamental structural unit of enamel. The dentine is porous biological composite composed of apatite crystal fillers in collagen matrix.( Pashley 1996) Dentine is much softer and so exhibits much faster wear.(Craig 1993)

5. Enamel structure Enamel is the most calcified and hardest tissue of the body. It is produced by cells of ectodermal origin- ameloblasts The prisms are composed of millions of hydroxyapetite crystals.The boundaries of human enamel crystals are incomplete cervically. The configuration of enamel crystals is related to the organization of the ameloblasts .

6. Chemically enamel consists of 96%inorganic material and 4%-organic material and water. The inorganic material is formed of the hydroxyapetite crystals which form the enamel prisms. The organic material mainly consists of the specific enamel proteins- amelogenins (90%) and nonamelogenins and lipids. The inorganic core of the prisms are mainly made up of Mg and CO 3 hence making the core more soluble in acids than the periphery.

7. Mineralization of enamel matrix It takes place in two stages primary and secondary stages. In the first stage immediate partial mineralization occurs in the matrix segments and interprismatic substance is laid down. The 2 nd stage or maturation stage is characterized by gradual completion of mineralization unlike bone and dentin. This stage starts from the height of the crown and progresses cervically.

8. Dentin structure Unlike enamel dentin is viscoelastic and suspetible to slight deformation. It consists of 35% organic and 65%inorganic material. Organic substance is collagenous fibrils embedded in ground substance mucopolysaccarides (proteoglycans and GAGs) Inorganic structure consists of hydroxyapetite crystals with a formula of 3Ca 3 (PO4) 2 .Ca(OH) 2

9. Dentin mineralization The mineralization sequence is, Hydroxyapetite crystal deposition on surface of collagen fibrils and ground substance. Crystals are arranged in orderly fashion with the long axes parallel to the fibril long axes. In the islands of mineralization the crystals deposit radially- spherulite form- which act as centre of mineralization, these are the first sites of mineralization. General calcification process is gradual, but the peripheral region becomes highly mineralized at a very early stage.

10. Tooth wear

11. Definition Wasting is defined as any gradual loss of tooth substance, characterized by the formation of smooth polished surfaces without regard to the possible mechanism of this loss. Carranza's Clinical Periodontology 10 th ed ; Clinical Diagnosis;540-60 Tooth wear is a common problem with a prevalence of 97%, out of which 7% exhibit pathological degrees of wear that require treatment.(Smith and Robb 1996) The forms of wasting are, erosion abrasion, attrition and abfraction.

12. Classification Wasting diseases of teeth Chemical causes Physical causes Attrition Abrasion Abfraction Erosion

13. Prevalence Sognnaes et al 1972, published first study on prevalence. They examined 10,000 extracted teeth, 1700 teeth (18%) showed erosive lesions with incisors most frequently affected. Another study showed 30 out of 151 skulls (19.9%) with tooth wearing. Robb et al 1991

14. Another study in asthamatics in India showed a prevalence of 76.5% and 66.7% nonasthmatic adults. Jain M et al, Rev Clín Pesq Odontol . 2009 set/dez;5(3 ): 247-254 Recent study on Indian population in 2013 showed a prevalence of 8.9% for dental erosions in school children. Kumar S et al, Journal of Oral Science, Vol. 55, No. 4, 329-336, 2013

15. Etiology It is a result of a pathologic, chronic or localized loss of dental hard tissue surface by forces, acids and/or chelation without bacterial involvement. Ten Cate and Imfeld 1996 The causes are intrinsic and extrinsic

16. Etiology Extrinsic Intrinsic Recurrent vomiting Medical conditions Side-effects of drugs Psychogenic vomiting syndrome Eating disorders Chronic alcoholism Pregnancy induced vomiting Regurgitation Occupational factors Diet Medicaments Behavioral factors Habits

17. Chemistry of demineralization

18. Measurements of tooth wear Measurements in vitro Polarized light microscopy Surface profilometry Microhardness Scanning electron microscopy Microradiography Digital image analysis Iodide permeability Synthetic hydroxyapetite crystals Calcium Phosphorous dissolution

19. Measurements in vivo Replica technique Macroscopic changes Measurements in situ Newer developments Scanning tunneling microscopes Scanning probe microscopes

20. Attrition

21. It is defined as the physiologic wearing of the tooth as a result of tooth-to-tooth contact, as in mastication. It occurs in incisal, occlusal and proximal surfaces of teeth. It is physiologic rather than a pathologic phenomenon. It is associated with ageing process.

22. 2 TYPES a) Proximal surface attrition b) Occluding surface attrition Proximal surface attrition : Widening of proximal contact areas. Decreased mesio -distal width of teeth. Interproximal space will be decreased in dimension. Occluding surface attrition : Loss, flattening, faceting and /or reverse cusping of occluding elements. Loss of vertical dimension of tooth. Cheek biting and gingival irritation occurs.

23. Predisposing factors ; coarseness of diet ,chewing tobacco or bruxism, occupation –person exposed to an atmosphere of abrasive dust . Clinical manifestation It begins as a small polished facet on a cusp tip or ridge or a slight flattening of incisal edge. Gradual reduction of cusp height & flattening of occlusal inclined plane with aging. Tooth sensitivity TMJ problem elicited especially due to overclosure .

24. In some older patients, the enamel of the cusp tips or incisal edges is worn off, resulting in cupped-out areas because the exposed, softer dentin wears faster than surrounding enamel. Sometimes these areas are an annoyance because of food retention or the presence of peripheral, ragged, sharp enamel edges. Advanced attrition – enamel may worn away results in an extrinsic yellow or brown staining of exposed dentin from food or tobacco. May progress to complete loss of cuspal interdigitation .

25. The exposure of dentinal tubules and subsequent irritation of the odontoblastic processes result in the formation of secondary dentine. This aids in the protection of the pulp from further injury.

26. Primary and secondary dentin Primary dentin Secondary dentin Formed before completion of teeth Formed after completion of teeth Uniform distribution of dentinal tubules Ununiform distribution, fewer dentinal tubules More mineralized Less mineralized (less ca,p )

27. Abrasion

28. It is the pathologic wearing away of the tooth substance through some abnormal mechanical process. Usually occurs in the exposed root surfaces of teeth. Sometimes can be seen on incisal or proximal surfaces. Robinson et al stated abrasive dentifrices as the most common cause of abrasion. It manifests as a V-shaped notch or a wedge shaped ditch on the root side of the CEJ in teeth with gingival recession.

29. Sturdevant’s Art and Science of Operative Dentistry-A South Asian Edition. SIGNS & SYMPTOMS OF TOOTHBRUSH ABRASION : The lesion may be linear in outline, following the path of brush bristles. The surface of the lesion is extremely smooth and polished, and it seldom has any plaque accumulation or carious activity in it. The surrounding walls of abrasive lesion tend to make a v-shape . Probing or stimulating (hot, cold or sweets) the lesion can elicit pain .

30. Clinical features It can be seen involving cervical enamel and dentin . Many teeth are affected . Usually on the facial surfaces of maxillary left canine to molar region in right handed person and vice versa Canines and premolars are most affected . Exhibit sharp margins and sharp internal angles . Exposed surface appears smooth and polished . Sometimes the surface may show scratches.

31. Modern dentifrices are not sufficiently abrasive to damage intact enamel severely, can cause wear cementum & dentin , particularly in horizontal direction rather than vertical direction . Pipe smoking “depression abrasion” which is an abraded depression on the occluding surfaces of teeth at a latero -anterior of arch coinciding with intraoral location of pipe stem. Chewing tobacco cause generalized occlusal surface abrasion. Pica-syndrome, which is due to the habit chewing clay(mud) has a specific occlusal abrasion. Iatrogenic tooth abrasion .

32. Erosion

33. It is defined as the irreversible loss of dental hard tissue by chemical process that does not involve the bacteria. Dissolution may occur on exposure to acids that can be introduced into the oral cavity.

34. Clinical features: Erosion lesion generally present as broad, shallow, saucer- shaped defects involving enamel and dentin. No sharp line angles and the margins of the defects are not well defined. Surface appears smooth and polished Occurs on facial or lingual surfaces.But usually on the lingual surfaces of maxillary anteriors . Exogeneous agents such as lemon juice (by lemon sucking) , cause crescent or dished defects ( rounded as opposed to angular) on the surfaces of exposed teeth. Endogenous agents cause generalized erosion on the lingual, incisal and occlusal surfaces .

35. Abfraction

36. Abfraction is the pathological loss of tooth substance due to biomechanical loading forces that result in flexure and ultimate fatigue of enamel and dentin at a location away from loading. It has been proposed that the predominant causative factor of some cervical, wedge- shaped is a strong(heavy) eccentric occlusal force resulting in microfractures or abfractures . Such microfractures occurs as the cervical areas of the tooth flexes under such loads. This defect is termed idiopathic erosion or abfraction. Mainly confined to gingival third of clinical crown was thought to the result of tooth brush abrasion.

37. With each bite , occlusal forces causes teeth to flex. Constant flexing ; enamel to break from the crown usually on the buccal surface. Parafunctional habits such as bruxism and clenching is also a cause of abfraction. Forces could be static ,such as produced by swallowing & clenching or cyclic as those generated during chewing action. Abrasive lesions were caused by flexure & ultimate material fatigue of susceptible teeth at locations away from the point of loading. The breakdown was dependent on the magnitude , duration ,direction , frequency & location of the forces .

38. Clinical features : Appears as wedge-shaped defects on the facial aspects. With sharp margins and internal line angles. In the initial stages the enamel surface is rough and shows striations or grooves. Later stages the defects progresses deeper in dentin two or more grooves may be visible on the surface.

39. REGRESSIVE ALTERATIONS OF TEETH MANAGEMENT ATTRITION Desensitizing agents such as topical fluoride varnishes Direct composite restorations, Orthodontic treatment, Crown lengthening procedures and Protective splints ABRASION AND EROSION Soft bristled tooth brush Avoid acidic food Composites (plastic fillings) Glass ionomers Fluoride varnish ABFRACTION Occlusal adjustment Clinical management of non-carious lesions

40. Non-carious lesions require clinical attention if any of the following factors exist : Tooth sensitivity Compromised esthetic Risk of tooth fracture Pulpal damage Caries Poor periodontal health

41. Treatment options Dentin desensitization Restorations Endodontic therapy Periodontal therapy

42. Dentin desensitization Used in situations where minimal amount of dentin is exposed (less than 1mm) & patient experiences hypersesitivity . This managed by any of the method suggested for dentin desensitization such as : Fluoride varnishes Dentin bonding agents Use of desensitization tooth pastes

43. Restortions Indicated in following situations Considerable loss enamel and dentin Esthetic is compromised Deep lesion affecting the strength of the tooth and pulpal integrity Caries beginning in the cervical lesion Significant sensitivity of the exposed dentin .

44. ENDONTIC THERAPY When cervical tooth loss is extensive resulting in pulpal involvement, endodontic therapy is necessary followed by post placement & full coverage in the form of crown

45. PERIODONTAL THERAPY Required when non-carious cervical defects are associated with gingival recession and mucogingival problems .

46. PREVENTION Diet counselling Use of sodium bicarbonate mouth rinse Use of fluoride mouth rinse & xylitol gum Psychiatric consultation Correct brushing technique Correct occlusal stresses Provide mouth guards Correct abnormal oral habits

47. Preventive approaches

48. Management of Attrition Pulpally involved tooth should be extracted or undergo endontic therapy. Para-functional activities, notably bruxism, controlled with proper disoccluding or protecting occlusal splints. Occlusal equilibration – by selective grinding of tooth surfaces (include rounding and smoothening the peripheries of occlusal tables. Restorative modalities- Metallic restoration in high stress concentrating areas

49. Management of Abrasion Remove the cause. Treated with fluoride solution to improve its caries resistance. Lesion exceeding 0.5mm into dentin, should be restored. Tooth is sensitive then desensitize the exposed dentin before starting restorative treatment. (Desensitization by 8-30% Na or Stannous fluoride for 4 to 8 min ) Restoration by Direct tooth coloured materials(in anterior) & metallic restoration in posteriors.

50. Management of Erosion Remove the cause. If restoration is the choice of treatment, metallic restoration is indicated because it is resistant to erosion.

51. Conclusion With increasing dental awareness and improved dental care, more and more people are retaining their teeth for a longer period of time. When loss of enamel and dentin at the CEJ becomes significant, resulting in loss of function and esthetic , restoration of these defects becomes necessary. Composite resins and GIC are used extensively for restoration of non-carious cervical defects.

52. References Shafer’s Textbook of Oral Pathology, 6 th ed Bruxism Theory & Practice, Daniel A Paesani , Quintessence Publishing Tooth wear and Sensitivity, Martin Addy . Orban’s Oral Histology and Embryology, 12 th ed