Tooth Wear Aetiology and Risk Assessment (2012) PDF

Oral diagnosis and treatment IN BRIEF Highlights that...

Oral diagnosis and treatment IN BRIEF Highlights that non-carious tooth planning: part 4. Non-carious surface loss or tooth wear is becoming an PRACTICE increasingly significant factor affecting the long-term health of the dentition. tooth surface loss and Defines attrition as the wear that occurs from tooth-to-tooth contact without the presence of food. assessment of risk Describes abrasion as wear occurring due to the friction of exogenous material (anything foreign to the tooth) forced over the surfaces of the tooth. J. A. Kaidonis1 Non-carious tooth surface loss or tooth wear is becoming an increasingly significant factor affecting the long-term health of the dentition. The adverse effects of tooth wear are becoming increasingly apparent both in young persons and, as more people retain their teeth, into old age. This situation challenges the preventive and restorative skills of dental practitioners. INTRODUCTION this problem and then devise a preventive a common clinical condition that can be Non-carious tooth surface loss can be and monitoring programme that is specific difficult to manage, but interproximal diagnosed and managed following the for the patient. Finally, where an operative wear is of little consequence to the gen- principles of minimum intervention den- approach is required, minimum interven- eral practitioner. tistry, where the clinician must firstly tion requiring the preservation of tooth The philosophy of minimum interven- identify the clinical presence of the wear structure is essential. tion dentistry has been applied success- mechanism(s) in question (either attri- It has been well-documented that the fully regarding dental caries, and the tion, abrasion, erosion or combinations main mechanisms of clinical tooth surface principles of minimal intervention can thereof) and determine if the presenting loss (TSL) or tooth wear are erosion (cor- also be applied to the diagnosis and man- mechanism(s) is active. Secondly, the cli- rosion), attrition, and abrasion. Co-factors agement of non-carious TSL. The practi- nician must identify why the patient has such as hyposalivation and hypominer- tioner must have sufficient background alisation of the teeth may exacerbate the knowledge of this dental condition for its effects of the primary cause. As people are effective management. The basic clinical ORAL DIAGNOSIS now retaining their teeth for longer into approach should be as follows: AND TREATMENT PLANNING* old age, the extent of TSL can be expected Identify the mechanism(s) causing the Part 1. Introduction to oral diagnosis to increase further. The greatest increase in wear (attrition, abrasion, erosion or and treatment planning TSL has occurred from erosive wear, espe- combinations thereof) Part 2. Dental caries and assessment of risk cially in younger persons in both denti- Determine if the evident mechanism(s) Part 3. Periodontal disease and assessment of risk tions. In the primary dentition, the dental is active Part 4. Non-carious tooth surface loss pulps may be exposed. Unless it is con- Identify why the patient has this and assessment of risk trolled early, TSL may result subsequently problem(s) and then tailor-make a Part 5. Preventive and treatment in widespread exposure of dentine with preventive and monitoring programme planning for dental caries hypersensitivity, an unsightly appearance that is specific for the patient Part 6. Preventive and treatment planning for periodontal disease of the teeth and reduced masticatory func- Where an operative approach is Part 7. Treatment planning for tion. The costs of treatment and rehabilita- required, minimum intervention missing teeth tion may then be considerable. requiring the preservation of tooth Part 8. Reviews and maintenance Although each individual mechanism structure is essential. of restorations produces TSL with clinically distinguish- *This series represents chapters 1, 7, 8, 9, 14, 15, 16 and 19 from the BDJ book A Clinical Guide to Oral Diagnosis and Treatment able characteristics, in reality the mecha- It is important that the patient assumes Planning, edited by Roger Smales and Kevin Yip. All other chapters are published in the complete clinical guide available nisms often coexist, acting with different responsibility for the success of the pre- from the BDJ Books online shop. intensities and durations to produce clini- ventive treatment. The patient should be cal patterns of wear that at times are not made aware of the consequences if nothing easily identifiable. In addition to the is done, both in terms of dental damage 1 Associate Professor, School of Dentistry, Faculty of Health Sciences, The University of Adelaide, Adelaide, clinical appearances that result from the and eventual cost, versus the advantage South Australia 5005, Australia above-mentioned mechanisms, character- of preventive action and its benefits. The Correspondence to: John Kaidonis Email: [email protected] istically different variations of TSL also patient then should be asked to select or exist including the wedge-shaped non- choose from these alternatives, thereby Accepted 7 June 2012 DOI: 10.1038/sj.bdj.2012.722 carious cervical lesion and interproximal making him or her take responsibility © British Dental Journal 2012; 213: 155-161 wear. The non-carious cervical lesion is for treatment. BRITISH DENTAL JOURNAL VOLUME 213 NO. 4 AUG 25 2012 155 © 2012 Macmillan Publishers Limited. All rights reserved. PRACTICE EROSION Rumination, where the refluxate enters Table 1 The pH, titratable acid, and erosion the mouth and is chewed, has been potential of selected beverages and foods Background knowledge noted among bulimics and infants. mmol OH−/l Erosion Item pH Erosion (corrosion) has been defined as Here the erosive pattern is more to pH 7.0 potential the chemical dissolution of tooth sub- generalised and, in particular, includes Coca Cola 2.6 34.0 Medium stance without the presence of dental the occlusal tooth surfaces Pepsi light 3.1 34.6 Medium plaque. In comparison to the weak plaque Eructation (burping) where moist acids that act over relatively long periods ‘acidic air’ enters the oral cavity also Sprite light 2.9 62.0 High (15‑20 minutes), the acids causing erosion will have an effect. Though the palatal Fanta 2.9 83.6 Medium are moderate (approximately pH = 5) to surfaces of the maxillary teeth are orange strong (pH = 1.2) acids that act on tooth generally involved, other surfaces Red Bull 3.4 91.6 High surfaces over short periods (15‑60 sec- certainly can be affected depending Carlsberg 4.4 40.0 Low onds). The slow percolation of plaque whether the mouth is opened or closed beer acids within the laminar pores of enamel during the burping action White wine 3.7 70.0 Medium rods produces subsurface demineralisation Dietary: as a general rule, if the Red wine 3.4 76.6 Medium with the characteristic carious ‘white spot’ clinician observes that the occlusal lesion, while those acids producing erosive surfaces of the mandibular teeth are Carrot juice 4.2 42.0 Low demineralisation act much faster and by affected more than the maxillary Apple juice 3.4 82.0 High comparison affect only the tooth surface teeth, then the agent is usually a Orange with very little subsurface damage. liquid that floods the mandibular 3.7 109.4 Medium juice The sources of acids that cause tooth ero- teeth. If the occlusal surfaces of both Grapefruit 3.2 218.0 High sion originate either from inside the body as arches are equally affected, then the juice gastric acid (intrinsic or endogenous erosion) agent is usually solid acidic food that Milk 7.0 4.0 Low or from outside the body as dietary, envi- is masticated Yoghurt ronmental or occupational acids (extrinsic More importantly, liquids of low pH 4.2 105.6 Low natural or exogenous erosion). In addition to the and high titratable acid also affect Salad 3.6 210.0 High source of the acid and its pH/buffering titra- the palatal surfaces of the maxillary dressing tion, the frequency of acid exposure is one anterior and premolar teeth (Table 1). Vinegar 3.2 740.8 High of the main factors that will determine the The action of swallowing causes a (Adapted from Lussi, 2006: with permission) severity or extent of the problem. Depending seal by the lips, the tightening of the on the source of the acid, different erosive cheeks up against the buccal and patterns often are observed orally, which labial tooth surfaces, and the tongue sour chewable and powdered sweets can guide the clinician towards the correct rising hard up against the palate, may have pH values as low as 2.0, history taking to determine the cause of the thus distributing the liquid against which is well below the critical pH for condition. This is essential if appropriate the palatal surfaces of the maxillary enamel and dentine demineralisation. preventive measures are to be instituted. The teeth. Practitioners often erroneously general erosive patterns observed clinically conclude that the affected palatal It must be stressed that long-term expo- are as follows: surfaces of the maxillary anterior teeth sure to acids, no matter what the sources, Vomiting: generally, the palatal are caused only by intrinsic acid will eventually produce a pattern where surfaces of all the maxillary teeth Different actions of drinking directly many tooth surfaces are affected, making are affected most because the tongue from a bottle or from a glass also will the original source unidentifiable. In addi- usually covers the mandibular teeth produce erosion variations. Here, the tion, missing tooth spaces, the wearing of during vomiting. Immediately after labial surfaces of the anterior teeth are prostheses, and individual variations of the episode, gravity and the actions of affected. The use of a straw usually mastication and swallowing, often produce the cheeks and lips during swallowing prevents the labial surfaces of the unusual characteristic patterns specific for will distribute the vomitus residue to anterior teeth being eroded. Swishing the patient. other parts of the mouth including the acidic drinks before swallowing mandibular arch until, over time, most may cause widespread tooth erosion Identifying erosion of the tooth surfaces are affected involving multiple posterior tooth The teeth lose their micro-anatomical Gastro-oesophageal reflux disease surfaces, while sucking citrus fruits enamel features and develop a ‘glazed’ (GORD): the degree of gastric reflux also may affect the labial surfaces or ‘silky’ appearance (Fig. 1) into the mouth varies between of the anterior teeth. More recently, As the erosion progresses, teeth lose individuals. However, as a general there has been an increase in the their normal contours causing curved rule, the refluxate rises to the back consumption by young children of enamel areas to flatten and to become of the throat and soft palate. Usually, acidic sour-sweets or candies following ‘dished-out’ eventually. In particular, the palatal surfaces of the maxillary increased targeted marketing of these this occurs on the buccal and labial posterior teeth are affected products. These ‘extreme’ or ‘intense’ surfaces of the tooth crowns 156 BRITISH DENTAL JOURNAL VOLUME 213 NO. 4 AUG 25 2012 © 2012 Macmillan Publishers Limited. All rights reserved.  PRACTICE Fig. 3 A wedge-shaped non-carious cervical lesion has developed on the upper first premolar Fig. 1 Active erosion, where the teeth have Fig. 2 Active erosion has scooped out the tooth. Similarly, an erosion lesion has continued lost their micro-anatomical features and exposed dentine. Here, the dentinal tubules to develop on the upper second premolar even appear to have a ‘glazed’ or ‘silky’ surface are open causing hypersensitivity after the primary lesion was restored As the dentine becomes exposed, Active erosion will remove the surface a small amount of a low-viscosity particularly on the occlusal surfaces smear layer from exposed dentine, resin composite or an addition-cured (Fig. 2), the severity of the ‘scooping’ opening the dentinal tubules and silicone to take an impression with a or ‘cupping’ increases significantly, causing dentine hypersensitivity wooden tongue blade, which can be often leaving high enamel ridges If the dentition shows no evidence labelled with the patient’s name and surrounding the dentine. A similar of plaque (especially when the mouth date. Repeat the impression 1‑4 weeks ‘grooving’ of the dentine occurs on the is in pristine condition) then this later and observe, using magnification, incisal edges of the anterior teeth also is evidence of high erosive the rate of disappearance of the The presence of non-carious cervical activity, as continuous exposure ‘groove’ in the impression lesions (including wedge-shaped to acids will remove any evidence Recently, a new basic erosive wear lesions) should also indicate to of biofilms in the oral cavity. examination (BEWE) scoring system has practitioners the activity of erosion Alternatively, it must be noted that been proposed for use in general dental (Fig. 3). Though abfraction (the flexing in some cases erosion can be very practice where the worst-affected tooth of teeth under load leading to non- mildly active over many years, and in each quadrant is scored according to carious cervical lesions) has been pristine oral conditions and dentine defined criteria (Table 2). referred to in the literature as the hypersensitivity may not be present cause of such wedge-shaped lesions, Activity can also be determined using The summed score from the sextants recent studies have found a multifactor either a ‘scratch test’ over a short time may be used as a provisional guide to explanation where toothbrush/ period, or serial colour photographs clinical management (Table 3). dentifrice abrasion and, in particular, (to compare changes in enamel erosion are significant aetiological translucency and shade from thinning Identify contributing factors co-factors. of the enamel) and high-quality dental specific to the patient casts (to compare subtle changes in The identification of the source of Identify activity tooth morphology) over a much longer acid such as from dietary habits or Enamel surfaces that appear ‘glazed’ or time period. The scratch test uses a no. the presence of GORD directs the ‘silky’ demonstrate evidence of current 12 scalpel blade to score a line across clinician towards eliminating the erosive activity an affected tooth surface, before using aetiological agent(s) Table 2 Basic erosive wear examination Table 3 Risk levels as a guide to clinical management of tooth erosion (BEWE) Score Description Risk level Summed score Management No erosive tooth wear on any Routine maintenance and observation. Review at Score 0 None £2 surfaces (excludes third molars) 3 year intervals Score 1 Initial loss of surface texture As above plus oral hygiene, dietary assessment, advice. Low 3‑8 Review at 2 year intervals Distinct defect, hard tissue loss Score 2* As above plus identify main aetiological factors and