non carious lesions and their management
TRANSCRIPT
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NON CARIOUS LESIONS AND THEIR
MANAGEMENT
DR. APPLU ATREYPG PART IDEPT OF CONSERVATIVE DENTISTRY AND ENDODONTICS
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INDEX
INTRODUCTION DIFFERENT TYPES OF NON CARIOUS
LESIONS CONSEQUENCES OF TOOTH WEAR TREATMENT MODALITIES OF TOOTH
SURFACE LOSS CONCLUSION REFERENCES
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INTRODUCTION
Normal physiologic process that occurs
throughout life.
Problems arise when the rate of loss
becomes excessive causing functional or
esthetic problems or sensitivity for the
patient.
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Enamel is one of the few tissues in the body
that does not regenerate or replace itself in the
way that skin, blood cells, and fractured bones do.
Fortunately, the dentine does show some
reparative mechanisms as reactionary or
reparative dentine which is laid down in the pulp
chamber as a response to tooth wear
Traditionally, the terms erosion, abrasion and attrition were used to describe non carious pathologic loss of tooth structure.
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Tooth wear Smith and Knight advocated the use of term
tooth wear . Tooth wear is defined as the surface loss
of dental hard tissues other them by
caries or trauma .
Tooth wear is a cumulative lifetime process which is irreversible .
Clinically tooth wear appears to progress very slowly over years
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The features of different types of tooth
Tooth wear has the multi-factorial aetiology, but certain clinical features may suggest a major contributory factor.
Traditionally, cervical lesions caused purely by abrasion have sharply defined margins and a smooth, hard surface.
The lesion may become more rounded and shallow if there is an element of erosion present
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Flattening of cusps or incisal edges and localized facets on occlusal or palatal surfaces would indicate a primarily attritional aetiology.
Once dentine is exposed, the clinical appearance is determined by the relative contribution of the etiological factors.
If wear is primarily attritional, then dentine tends to wear at the same rate as the surrounding enamel. Erosive lesions cause ‘cupping’ to form in the dentin.
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Consequences
Change in appearance of teeth
Exposure of dentin normally covered by enamel
Dentin Hypersensitivity
Loss in occlusal vertical dimension
Loss in posterior occlusal stability resulting in
Mechanical failure of teeth or restorations
Hypermobility and drifting
Exposure of pulp
Pulpitis and loss of vitality
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Methods and instruments to measure tooth wear
In-vitro measurement
• Macroscopic changes• Polarized light microscopy• Surface profilometry• Microhardness tests• Scanning electron
microscopy• Microradiography• Digital image analysis• Iodine permeability• Synthetic hydroxyapattite
powders/discs• Calcium and phosphorus
dissolution
Newer methods• Scanning tunneling microscope
• Atomic force microscope
• Finite element analysis
In-vivo measurem
ent• Macroscopic
changes• Replica
technique• Intra-oral
carcinogenicity test
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TYPES OF NON CARIOUS LESIONS1. Attrition2. Erosion3. Abrasion 4. Abfraction5. Localized non hereditory Enamel hypoplasia6. Localized non hereditory enamel hypocalcification7. Localized non hereditory dentin hypoplasia8. Localized non hereditory dentin hypocalcification9. Discolourations10. Malformations11. Amelogenesis imperfecta12. Dentinogenesis imperfecta13. Trauma
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ATTRITION
Derived from Latin word - ATTRITIM meaning “action of rubbing against something”
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DEFINITIONS The physiologic wearing of the teeth resulting from
tooth to tooth contact as in mastication.
Shafer
Wear caused by endogenous material such as microfine particles of enamel prisms caught between two opposing tooth surfaces.
Every (1972)
Loss by wear of surface of tooth or restoration caused by tooth to tooth contact during mastication or parafunction
Milosevic, 1998
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Attrition occurs at an ultra structural level
It can be caused by direct contact between
surfaces or the action of an intervening slurry
Attrition can be hastened by coarse diet and
abrasive dust
Some para-functional habits like Bruxism may
also contribute to attrition
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Distribution of attrition is influenced by the type of occlusion, the geometry of stomatognathic system and grinding pattern of the individual.
If occlusal wear occurs at a rate faster than compensatory physiologic mechanisms, it is considered pathologic.
Vertical loss of enamel of 50-68 µm/year is considered physiologic
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ATTRITION
PROXIMAL SURFACE ATTRITION (PROXIMAL SURFACE FACETING)
OCCLUDING SURFACE ATTRITION (OCCLUSAL WEAR)
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CLINICAL FEATURES
1. Shiny wear facets with well defined borders2. The surface of wear facet is flat and flush
with the opposing tooth on contact 3. Enamel and dentin wear at the same rate 4. Possible fracture of cusps or restorations5. Pure attrition shows equal wear on both
arches. (unlike erosion)
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ATTRITION INDEX
SCORE CLINICAL FEATURE
0 NO WEAR
1 MINIMAL WEAR
2 NOTICIBLE FLATTENING PARALLEL TO OCCLUDING PLANES
3 FLATTENING OF CUSPS AND GROOVES
4 TOTAL LOSS OF CONTOUR AND/OR DENTIN EXPOSURE
Richard and brown, 1981
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MANAGEMENT
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EROSION
Derived from Latin verb EROSUM meaning “to corrode”
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DEFINITIONS Erosion is defined as superficial loss of hard tissue due to
chemical process not involving bacteria.
Every (1972)
Erosion is process of gradual destruction of tooth surface,
usually by a chemical or electrolytic process.
Imfeld T (1996)
Erosion is defined as the chemical dissolution of teeth by
acids
Martin
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Dental erosion is defined as the progressive, irreversible loss of hard dental tissues due to a chemical process not involving bacteria
Gandara BK, Truelove EL. Diagnosis and management of dental erosion. J. ofContemporary Dental Practice 1999; 1(1): 1-17
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SALIENT FEATURES Clinically, erosion is primarily a surface
phenomenon
The solubility of enamel is pH dependent
The rate at which apatite precipitates depends on
factors such as calcium binding in saliva.
The critical pH of enamel is 5.5, any solution with
a lower pH may cause erosion if the attack is
lengthy and intermittent over time.
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In early stages, erosion effects enamel resulting in smooth, glazed surfaces
In advanced cases, restorations may project above the occlusal surfaces and exhibiting concavities known as cupping; increased incisal translucency
Rapid process may lead to sensitive teeth due to dentin exposure while slower progressive lesions may be asymptomatic
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CLASSIFICATION I Class I – superficial lesion involving enamel
only
Class II – localized lesions that involve dentin or less than 1/3rd of the surface
Class III – generalized lesions involving dentin and more than 1/3rd of the surfaces
Eccles et al, 1979
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CLASSIFICATION II Extrinsic (exogenous)
Environmental – by acid fumes and aerosols in occupational, swimmers
Diet – citrus fruits, carbonated drinks, vinegar Medication – aspirin, vit-C, calcium chelators Life style – fruits and diet drinks, bleaching agents
Intrinsic – conditions that lead to chronic vomiting
or persistent gastroesophageal reflux Anorexia and bulimia nervosa Chronic alcoholism Morning sickness associated with pregnancy
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Clinical severity Superficial Localized Generalized
Activity of progression Active or manifest Inactive or latent
SUPERFICIAL EROSION
GENERALISED SEVERE EROSION
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Mannerberg described 2 types of erosive lesions as viewed under SEM Active lesions – shows distinctive etched
enamel prisms resembling honeycomb Inactive or latent lesions – faint with
unrecognizable characteristics
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CLINICAL FEATURES
Enamel erosion appears smooth and rounded and the surface contour is lost
Broad concavities within smooth surface enamel Cupping of occlusal surfaces,
(incisal grooving) with dentin exposure Increased incisal translucency Wear on non-occluding surfaces There is a difference in wear in opposing
arches
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Biological Modifying Factors
Saliva – flow, composition, buffering capacity,
pH
Acquired pellicle – diffusion limiting
properties and thickness
Tooth composition and structure
Dental anatomy and occlusion
Physiologic soft tissue movements
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Erosive potential of foods and beverages influenced by
pH Total acid level Type of acid (pKa) Calcium chelating properties Calcium phosphorus and fluoride content Physical and chemical properties affecting
adherence to the enamel surface and stimulation of saliva flow.
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DIAGNOSTIC PROTOCOL FOR DENTAL EROSION
Medical History Excessive vomiting, rumination Gastroesophageal reflux disease (Symptoms of reflux) Frequent use of antacids Alcoholism
Dental History History of bruxism (grinding or clenching) Morning masticatory muscle fatigue or pain? Use of occlusal guard
Dietary History Acidic food and beverage frequency Method of ingestion (swish, swallow?)
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Occupational/Recreational History Regular swimmer? Wine-tasting? Environmental work hazards? Sports energy drinks
Oral Hygiene Methods Tooth brushing method and frequency Type of dentifrice (abrasive?) Use of mouthrinses Use of topical fluorides
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MANAGEMENT OF EROSION
Identification of the etiology
Preventive measures
Patients compliance.
Early recognition of erosion is important to successfully manage and prevent disease progression.
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PROTOCOL FOR PREVENTION OF PROGRESSION OF
EROSION
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Diminish the frequency and severity of the acid challenge.
Decrease amount and frequency of acidic foods or drinks. If undiagnosed Gastroesophageal reflux is suspected, refer
to a physician. A patient with alcoholism should be assisted in seeking
treatment in rehabilitation programs.
Enhance the defense mechanisms of the body (increase salivary flow and pellicle formation). Saliva buffering capacity resists acid attacks. Saliva is also supersaturated with calcium and
phosphorus, which inhibits demineralization of tooth structure
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Enhance acid resistance, remineralization and
rehardening of the tooth surfaces.
Daily topical fluoride at home.
Apply fluoride in the office 2-4 times a year.
A fluoride varnish is recommended.
Improve chemical protection.
Neutralize acids in the mouth by dissolving sugar-
free antacid tablets.
Dietary components such as hard cheese (provides
calcium and phosphate) can be held in the mouth
after acidic challenge
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Decrease abrasive forces.
Use soft toothbrushes and 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 an acidic challenge.
Provide mechanical protection.
Consider application of composites and direct
bonding where appropriate to protect exposed
dentin.
Construction of an occlusal guard is recommended if
a Bruxism habit is present.
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ABRASSIONDerived from Latin verbABRASUM meaning “ Scrape off ”
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DEFINITIONS Abrasion is wearing away of tooth substance or
structure through mechanical process.
Imfeld T (1996)
Abrasion is the wearing of tooth substance that results
from friction of exogenous material forced over the
surface by incisive, masticatory and grasping functions
Every (1972)
Loss by wear of dental tissue caused by abrasion by
foreign substance
Milosevic, 1998
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The location and pattern of abrasion may be
dependent on the cause
Most common area is cervical area, related to
improper tooth brushing technique, zealous and
vigorous methods, and use of abrasive dentrifice.
Notching of incisal edges in pipe smokers, nail
biters, hair pin biting
Notching of incisors in Tailors, carpenters,
musicians
Proximal tooth abrasion due to improper
flossing and use of tooth picks
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CLINICAL FEATURES An abrasion area is generally not well
defined unlike in attrition. Abrasion tends to round off or blunt tooth
cusps or cutting edges. Where dentin is exposed, it may be scooped
out because it is softer than enamel.
PIPE SMOKERS
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Tooth surface will have a pitted
appearance.
Microscopically an abraded
surface shows haphazardly oriented
scratch marks and numerous pits .
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