Toothwear; An emerging trend in Sri Lanka

Dr. Manil Fonseka BDS, LDSRCS (Eng) MS (Restorative Dentistry)

Department of Restorative Dentistry11th September 2014

Historical Perspective

• Normal physiologic process• Some tooth-wear essential for efficient

function of teeth which is seen in many herbivores

• Important to establish unhindered guidance during mastication

• However the level of tooth wear minimal

Rates of tooth-wear

• 2500 years for 1mm of enamel wear with normal function

• Estimated the level of tooth wear to be 29µm for molars and 15µm for premolars (Lambrechts et al, 1989)

• Physiological wear poses minimal problems• If the rate of wear challenges the viability of

teeth TSL considered pathologic

Factors precipitating wear

Factors precipitating tooth-wear

• Multi-factorial aetiology• Increase in life expectancy

Increased functional demandLonger exposure to erosive foodsRecession and exposure of relatively weaker

cementumIncreased use of medicationQuantitative and qualitative reduction in salivary flowLoss of teeth increases demand on the

remaining teeth

Diet

• Dietary changes have resulted in the diets being less abrasive

• Should theoretically reduce the levels of tooth-wear

• Excessive consumption of erosive beverages and foods has had a potentiating effect on the increased prevalence of NCTSL

Implicated foods• Fizzy drinks (pH 2.2 – 3.8)• Fruit juices (pH 3.0 – 4.0)• Wines (pH 3.2 – 4.8)• Cider and Beer (pH 3.5 – 4.0)• Citrus fruits

• Increased prevalence among children and adolescents in the UK (35%)

• Condition of affluent in Sri Lanka (Ratnayake N & Ekanayake L. 2010)

Extrinsic Acid Erosion

Intrinsic Acid Erosion

Intrinsic Acid

• pH of Gastric acid is 1-2Gastric RegurgitationBulaemia and anorexiaVomitting

Classically presents as palatal/lingual erosive defects

Para-function

• Stress induced parafunction• Bruxism• Object biting

Problems of para-function

• 700 times the normal masticatory load• Force used is considerably greater than during

normal mastication• Seen as wear in non functional cusps

Molars may be severely affectedProminant massetersMarked antigonial notchingTenderness of muscles of

mastication

Other factors contributing to tooth surface loss

• Defective enamel and dentine deposition and maturation ( E.g AI, DI, Hypoplasias)

• Abrasive restorative material (Unglazed porcelain)

• Abrasive dentifrices and hard brushing in horizontal strokes

• Habits – Instrument biting, Needles etc

Defective enamel formation

Scale of the Problem

• 98% of individuals in the UK have some amount of tooth wear

• Increased prevalence among children, deciduous teeth

• 30% of individuals in the UK have severe tooth wear (Tooth Wear Index scores of 3 & 4)

• Problem of affluent in Sri Lanka

Types of tooth-wear

• Erosion - Intrinsic or Extrinsic acid• Attrition - Tooth to tooth contact • Abrasion - Due to foreign objects• Abfraction - Repeated cyclic flexion of

teeth

• Mostly multi-factorial thus cannot home-in on one cause

Erosion

• Due to intrinsic or extrinsic acid• Intrinsic acid regurgitation due to gastric reflux

disease (Bullaemia, Anorexia, Gastritis, GORD)• Extrinsic acid consumption (Coke, Fizzy drinks,

Fruit juices, tamarind)• Increasingly seen in young due to change in

lifestyles

Extrinsic Acid Erosion•Buccal and Labial surfaces•Lingual and palatal spared

Intrinsic Acid Erosion•Palatal and lingual surfaces•Lower incisors spared•Etched like appearance•Cupping•Discoloured if historical•“Proud” restorations

Attrition

• Tooth to tooth contact• Accelerated due to para-function• Wear on non-functional cusps• Seen in anterior teeth when posteriors are lost• No loss of OVD due to dento-alveolar

compensation• Erosion potentiates attrition (De-mastication)

Attrition

Abrasion

Overzelous brushingHorizontal StrokesAbrasive Dentifrices and Brushes

Effects of NCTSL

• Sensitivity of teeth• Pulpal and Periodontal complications• Poor aesthetics• Impeded function• Prone to fracture• Low self esteem (OHRQoL)

Aides to Diagnosis

• Detailed history – Occupation, Social, Dietary analysis, Medical history

• Examination– Masticatory apparatus, Wear facets and their

location, “proud” restorations

• Investigations– Radiographs, Photographs, Dated study casts

Strategies in the management of NCTSL

• Psycho-social support• Medical referrals (GERD)• Habit intervention• Reduction in consumption of erosive

beverages• Using a straw• Soft mouth guards to protect teeth during

gastric regurgitation (Addition of Fluoride gel)• Michigan splints to reduce effects of bruxism

Soft bite guards/ Michigan splints

Challenges in management

• Lack of vertical space due to dento-alveolar compensation mechanisms

• Excessive loading of restorations• If the cause continues tooth-wear would continue• Frequent recall and maintenance

Primary aim in treatment prevent/reduce the causes and replace what is lost and maintain available

tooth tissue for adequate function and aesthetics

Management of Localized tooth wear

Re-organisation

• Should be well planned not haphazard• Based on sound prosthodontic principles• In dentate patients a raise of 11mm of OVD

could be tolarated• Anterior and canine guidance maintained

without posterior interference• Try with a splint first and go for definitive

restorations if patient tolarates

Re-organization of occlusion Case 1

Re-organization of occlusion Case 2

Re-organization Case 3

Re-organization Case 4

Thanks