2 Management of Non Carious Lesions Dr Omar.pdf

Chapter 3 Management of Non-Carious Lesion Dr. Omar Abdelaziz Ismail Lecturer of Operative Dentistry Hours University in Egypt Chapter 3 Management of Non-Carious Lesion A. Identification: Chronic destru...

Chapter 3 Management of Non-Carious Lesion Dr. Omar Abdelaziz Ismail Lecturer of Operative Dentistry Hours University in Egypt Chapter 3 Management of Non-Carious Lesion A. Identification: Chronic destructive processes other than caries (no bacteria). Affecting teeth faces leading to loss of tooth structures Responsible for 25 % loss of hard tooth structures While dental caries which is the main tooth pathologic disease of hard tooth structure → 75% loss. Tooth wear can be defined as the surface loss of dental hard tissues other than by caries or trauma, and is natural consequence of ageing. It is commonly divided into three components (erosion, attrition, and abrasion) but these conditions often coexist. B. Acceptable and pathological levels of tooth wear: It is normal for teeth to wear but the process is regarded as pathological if they become so worn that they function ineffectively or seriously bad appearance. The distinction between acceptable and pathological tooth wear at a given age is based on a prediction as to whether the tooth will survive that rate of wear in a functional and reasonably aesthetic state until the end of the patient's normal lifespan. - 71 - Chapter 3 Management of Non-Carious Lesion C. Consequences of pathological tooth wear: There are several important clinical features that can result from pathological tooth wear. These include the following: Exposure of dentine on buccal or lingual surfaces normally covered by enamel. Notched cervical surface. Exposure of dentine on incisal or occlusal surfaces - further erosion often results in preferential loss of dentine to produce a Cupped surface. Restorations (which do not erode) are left projecting above the tooth Surface. Exposure of reparative dentine or pulp. wear producing sensitivity Pulpits and loss of vitality attributable to tooth wear. Wear in one arch more than in the other. Inability to make contact between worn incisal or occlusal surfaces in any excursion of the mandible. Reduction in length of the incisor teeth so that length is out of proportion to width. Some of these features require operative intervention to protect the pull, reduce sensitivity, and improve appearance or function however; restorations will not prevent further wear. Just as with dental caries, restoration can temporarily replace the lost tooth surface but wear will continue on any tooth surface exposed around the restoration if the cause is not identified and prevented - 72 - Chapter 3 Management of Non-Carious Lesion D. Diagnosing and monitoring tooth wear: It is relatively easy to diagnose that teeth are worn, provided that they are viewed clean and dry. Differentiating between acceptable and pathological levels of wear can be more difficult because the decision depends on the age of the patient. Also, a single examination will not show whether the wear is static or progressing, nor the speed of any progression. Where a pathological rate of tooth wear is suspected, study models taken at six months or yearly intervals will determine the rate of progress and the effectiveness of preventive measures. If these measures are not entirely successful, the series of' models will help to decide if and when to intervene operatively. Classification of non-carious tooth defects I. Attrition. II. Abrasions. III. Demastication. IV. Erosion. V. Abfraction. VI. Trauma & fracture. VII. Acquired developmental conditions. i. Enamel hypoplasia. ii. Enamel hypomineralization. VIII. Hereditary condition. i. Hypodontia microdontia. ii. Amelogenesis imperfecta iii. Dentinogenesis imperfecta. - 73 - Chapter 3 Management of Non-Carious Lesion Types of non carious tooth defect I. Attrition: 1) Definition: It is a physico-mechanical loss of the tooth structures (enamel and dentin). The surface tooth structures loss resulting from normal direct functional forces between contacting teeth. Considered as a continuous age-dependent process. Beginning from the time the tooth being erupted and come in contact with the opposing and the adjacent tooth or teeth during eating, swallowing and speaking. 2) Clinical signs and symptoms: Differ from one person to other, from one tooth to other and from one area in the same tooth to other. Site Occur at the occluding surfaces (incisal or occlusal surface). It also includes the proximal surface wear at the contact area because of the physiologic tooth movement. May occur at labial or lingual surfaces as in cross bite. - 74 - Chapter 3 Management of Non-Carious Lesion Appearance Attrition is seen as loss, flattening, faceting (facets), saucering at the occluding surfaces or, at reverse cusping of the occluding surfaces or elements (palatal cusps of upper premolars and molars and facial cusps of lower posterior teeth). Shiny facets on amalgam contacts Facets: flat surface with a circumscribed and well-defined border. Reverse cusp: in severe cases and it is in the place of the cusp tip and the inclined planes, leading to loss of the vertical dimension of the teeth. palatal cusps of upper premolars and molars and facial cusps of lower posterior teeth. Sometimes there may be presence of peripheral, ragged, sharp enamel edges. The degree of wear in both arches is normally equal. The presence of hypertrophic masseter is indication of impact of Para functional habits such as bruxism and clenching which accelerate the attrition. Attrition can predispose to the following: - A) Proximal surface attrition (proximal surface facets) Results from surface tooth structure loss and flattening, resulting in widening of the proximal contact areas. Surface area proximally increases in dimension, which is susceptible to decay. Mesiodistal dimension of the teeth is decreased, leading to drifting, with the possibility of overall reduction in the dental arch. B) Occluding surface attrition (OCCLUSAL WEAR) ▪ It is the loss, flattening of the occluding elements. ▪ It leads to loss of vertical dimension of the tooth. - 75 - Chapter 3 Management of Non-Carious Lesion 3) Complications associated with attrition process: Tooth sensitivity will occur due to dentin exposure to the oral environments. Pulpal & periapical affection due to the presence of abnormal physiological forces and stresses. Tearing of the periodontal ligaments. Micro-cracks (crazing) and liability for stagnation of irritating substrates on the created flat or concave areas of exposed dentin with discomfort and pain If the loss is severe & accomplished in a relatively short time: - ▪ There would be no chance for the alveolar bone to erupt occlusally to compensate for the occlusal tooth loss & therefore the vertical loss might be imparted to the face. ▪ Leading to overclosure during mandibular functional movements & strain areas on stomato-gnathic system. ▪ In sever attrition conditions, tempro-mandibular disorders and musculature problems. If the loss occurs over a long period: - ▪ The alveolar bone can grow occlusally, bringing the teeth to their original occlusal termination i.e. vertical dimension loss will be confined to teeth but not imparted to face. ▪ Deficient masticatory capabilities. ▪ Cheek biting: vertical overlap between the working inclined planes will be lost, which will cause surrounding cheek, lip, tongue to be fed between the teeth. ▪ Decay: because the underlying dentin will be exposed & there by becomes more susceptible to decay. - 76 - Chapter 3 Management of Non-Carious Lesion ▪ Severe occluding surface attrition → predominantly horizontal masticatory movement of the mandible→ extreme strain on the muscles of stomatognathic system. ▪ TMJ problems by the over closure situation (will overstretch the joint ligaments). ▪ When surface attrition is slower & compensated by, intrapulpal deposition of secondary & tertiary dentin, then there will be no pulpal exposure. ▪ At other times, the attrition is faster than the intrapulpal dentine deposition, leading to direct pulpal exposure. 4) Treatment modalities: Line of treatment according to the complications may be: - ▪ Treatment of hypersensitivity ▪ Direct occlusal correction through a mounted diagnostic casts and correction can be made with selective grinding. ▪ Soft vinyl night mouth guards. - 77 - Chapter 3 Management of Non-Carious Lesion 5) Bruxism and attrition: Bruxism can be defined as non functional approach and Para function activity of mandibular movements and grinding of upper and lower jaws. Lead to sever wearing and loss of enamel and dentin structures hyper mobility of teeth and TMJ disorders. Bruxism is associated with muscle spasm, split teeth and fractured fillings. It is the screeching, grating sound in the night Attrition process is usually accelerated by Bruxism. Its considered pathological attrition. II. Abrasion: 1. Definition: The pathological wearing away of dental hard tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth contacting the teeth. The pattern of wear can be diffuse or localized. Clinically there is frequent coincidence of smooth surface cervical lesion with excessive tooth brushing. 2. Etiological factors: Patient factors include: brushing technique, frequency of brushing, time spent on brushing and force applied Material factors refer to: type of material stiffness and end rounding of tooth brush bristles, tuft design of the brush, flexibility and length of tooth brush grip, abrasiveness, pH and amount of dentifrice used. Abrasion on proximal tooth surfaces by extensive use of interdental devices such as tooth picks or interdental brushes and floss - 78 - Chapter 3 Management of Non-Carious Lesion Occupational abrasion, tooth wear due to any professional causes such as abrasive dust at work place, holding nails, biting thread. Iatrogenic causes such as dentures with porcelain teeth opposing natural teeth or using cast alloys with higher abrasive resistance than enamel. Depression abrasion (pipe smoker): (Habits like pipe smoking) 3. Clinical signs and symptoms: Site It occurs most frequently on the cervical neck of the teeth. The labial or buccal surfaces and lingual surfaces (in case of poorly fitted clasps and artificial dentures). Incisal Surface as in pipe smokers Proximal surface as in tooth pick or interdental brushes and floss. Appearance May be linear in outline. The peripheries of the lesion are angularly demarcated from the adjacent tooth surface. Surface of the lesion is extremely smooth and polished. Walls of the abrasive lesion tend to make a v-shape meeting at an acute angle axially. Probing or stimulating (hot, cold, sweet) can elicit pain. - 79 - Chapter 3 Management of Non-Carious Lesion 4. Microscopic appearance: The abraded surface shows-oriented scratch marks and numerous pits. The length, and depth of these scratches are depending on the abrasive material and the pressure applied during mastication. 5. Treatment modalities: ▪ Diagnose the cause of the present abrasion. ▪ Try to prevent the patient from practicing the causative habits (removal of the cause). ▪ It is preferable to desensitize the exposed dentin before restorative treatment (Desensitization can be accomplished by topical application of 10% stannous fluoride for 4 to 8 min and the patient is recommended not to rinse his mouth or eat for 15 min after application. Ionophoresis using an electrolyte containing fluoride ions can also be used) Restorative treatment: a) If the lesions are multiple, shallow (less than 0.5 mm in dentin) wide and involve enamel or cementum only there is no need to restore only the edges are eradicated to a smooth surface for esthetic and plaque control. Surface should be treated with fluoride solution to improve caries resistance. b) If the lesion is at an occluding surface, no need for cavity preparation, restoration can be done with bonded direct tooth colored materials. c) If the abrasive lesions are deep and at an occluding tooth surface, metallic restoration should be used. - 80 -  Chapter 3 Management of Non-Carious Lesion III. Demastication: ▪ Wearing a way of tooth substance during the mastication of certain type of food. ▪ wear is influenced by the abrasiveness of the-individual food ▪ A physiological process affecting primarily the occlusal and incisal surfaces. ▪ May be termed pathological when occurring due to abnormal food consumption such as betel nut Demastication. ▪ Can also be looked at as a combination of abrasion and attrition. IV. Erosion: Definition: Irreversible pathological, chronic, localized, painless loss of dental hard tissue by a chemical process that does not involve bacteria Acids responsible for erosion are not products of the intraoral flora. Such tissue loss is not apparent until the patient reports symptoms of sensitivity. Unlike-dental caries, erosion occurs on plaque free sites. - 81 - Chapter 3 Management of Non-Carious Lesion 1. Etiological factors: A. Acidic material: Acids play great role in the production of the erosion lesions. Citric acid was found to be the most damaging agent. 1. Dietary foods: Habitual drinking of acid beverages (citrate ions). Excessive consumption of citrus fruits (lemon juice & grape fruit). Habitual lemon sucker patients. Prolonged contact between the candy and lozenges of low PH values. 2. The acids of salivary secretions: Salivary secretion has citrate ions, responsible for the acidic medium of the saliva and its low PH which increase the severity of the erosion of tooth structure. - 82 - Chapter 3 Management of Non-Carious Lesion 3. Acids secreted by the gingival glands: In cases of traumatic occlusion more acids are secreted around the eroded tooth 4. Low PH medications and oral hygiene products: Oral hygiene products containing EDTA Saliva substitute with low PH Increase use of vitamin C Chewable aspirin. Iron tonic products for athletics 5. The industrial atmospheric pollution in work places: Battery factors Galvanizing factory Researches in laboratories Etching with sulfuric acid in some industries 6. The individuals with habitual regurgitation: Reflux, Regurgitation and Vomiting of gastric contents Anorexia Bulimia Pregnancy/Hormones Obesity Eating and Drinking too much Alcoholism Chronic vomiting. Persistent esophageal reflux Peptic ulcer. - 83 - Chapter 3 Management of Non-Carious Lesion Chronic gastritis. B. Alkaline material: Alkaline PH materials act as an effective chelating agent with decalcification of the tooth surfaces producing an erosive area. Alkaline material is responsible for decalcification of the tooth surface. Calcium removed from the tooth surface in alkaline media, decalcification accelerating the erosion. 2. Types of erosive lesions: a. Dish or saucer shaped: Shallow concavities most commonly occurring on incisors Deepest part is the center of concavity and the walls radiate upwards to sound tooth structure It appears glossy when the tooth is dried b. Wedge, notch or V-shaped: Occur on the buccal surface of premolar and molar Start at the level of the gingival borders as thin, straight and sharp depression May cause pulp exposure and has a marked sensitivity c. Irregularly shaped: Occur in the proximal and lingual surfaces of teeth Due to systemic or environmental disorders Chemical fumes and chronic regurgitation can cause this type - 84 - Chapter 3 Management of Non-Carious Lesion Classification of erosion A) Extrinsic Environmental factors Exposure to acid fumes Battery factory workers (sulfuric acid) Galvanizing factory workers (hydrofluoric acid) Acidic water in swimming pools Dietary factors Citrus fruits juice Acidic carbonate beverage and Acidic fruit flavored candies wines Medication Low Ph medications taken frequently and in contact to the dentition. Increased use of Vitamin C (ascorbic acid) Chewable tablets of aspirin Iron tonic products of low pH of 1.5 Mouth washes containing EDTA B) Intrinsic As a result of endogenous acids. Gastric acids reach the oral cavity and the teeth during recurrent vomiting disorder of alimentary tract (peptic ulcer) Specific metabolic and endocrine disorder (hyperthyroidism, adrenal insufficiency, and pregnancy) As a side effect of drugs Estrogens, chemotherapeutic agents, and tetracycline - 85 - Chapter 3 Management of Non-Carious Lesion Certain psychosomatic disorders, stresses inducing vomiting. 4. Treatment modalities: a) Conservative approach: i. Surface hardening: ▪ application of 10% stannous fluoride for 30 seconds ▪ Sodium fluoride paste will aid also in surface hardening and reduce tooth sensitivity. ii. Remineralization: ▪ to prevent destruction of enamel and dentin ▪ Dentifrices and solutions containing calcium fluoride traces phosphates are capable of causing surface changes. iii. Prevention and care of periodontal tissues ▪ Relief of traumatic occlusion. ▪ Proper selection and use of tooth brush iv. Desensitization to decrease hypersensitivity by: ▪ Paste which contains equal parts of sodium fluoride and kaoline in glycerin base ▪ Siloxane ester which contain 10% strontium chloride and 1.5% formaline - 86 - Chapter 3 Management of Non-Carious Lesion b) Restorative approach: Indicated in large lesions Metallic and non metallic restorations depending on the location and the extent of eroded area. No need for protective base because of the limited depth. Dentin should be painted with varnish to decrease postoperative hypersensitivity. V. Abfraction: ▪ A special form of wedge-shaped defect at the cementoenamel junction of a tooth. ▪ Observed on a single tooth. ▪ Hypothesized to be the result of eccentrically applied occlusal forces leading to tooth flexure. ▪ According to the tooth flexure theory, masticatory or parafunctional forces in areas of hyber-or malocclusion may lead to strong tensile, compressive or shear stress. ▪ The forces are focused on the CEJ, where they provoke microfractures in enamel and dentin. ▪ Resulting wedge-shaped defects have sharp rims. - 87 -  Chapter 3 Management of Non-Carious Lesion Restoration when clinical consequences (e.g. dentin hypersensitivity) have developed or likely to be developed. Aesthetics demands are a concern. Tyas recommended the RMGIC should be the first preference( Tyas MJ,the class V lesion –aetiology ,restoration,Aust. Dental Journal.1995)In esthetically demanding cases,RMGIC/GIC liner laminated with resin composite. Vandelwalle and Vigil (Gen Dent 1997) Recommended the use of microfilled resin composite (low modulus of elasticity) as it will flex with tooth and not compromise retention. VI. Trauma & fracture : 1. Definition: Loss of tooth structure due to trauma. 2. Etiology of trauma: Trauma is commonly caused be the following: Falls Sports or athletics. Blows from foreign bodies Fights. Car or bicycle accidents Injuries during convulsive seizures (e.g. epilepsy) Battered child syndrome (the most difficult and yet the most important to diagnose) - 88 - Chapter 3 Management of Non-Carious Lesion 3. Trauma can produce these local injuries: Lacerations to lips, tongue and gingival tissue. Alveolar fractures so that a number of teeth become mobile within a block of bone. Complete or partial subluxation of a tooth. Root fracture. Damage to apical blood vessels without fracture. Fracture of the crown of the tooth involving enamel alone, enamel and dentine or exposure of pulp. Only the last one listed will be discussed in detail here. 4. Examination and diagnosis of trauma: The crowns of the teeth are examined for fractures, pulp exposure, and color changes. Displacement or looseness of teeth should be noted, together with abnormalities of the occlusion. The vitality of the injured and adjacent (and usually the opposing) teeth must be tested and preapical radiographs must always be taken to look for tooth fracture. At subsequent recall visit the color of the tooth and further vitality test and periapical radiographs will show whether the pulp has remained vital or not. - 89 - Chapter 3 Management of Non-Carious Lesion 5. Types of fracture can be: a) Enamel fracture: the best solution would be enamel recontouring, smoothing the edges and peripheries of the defect, may be sufficient treatment in most cases. b) Enamel and dentin fracture without pulpal involvement treated by either tooth fracture reattachment or composite restorations: Tooth fracture reattachment offer several advantages over restorations with composite resins: Better esthetics. Long lasting esthetics. Better emotional and social response from the patient. A simple and faster technique in many cases. Tooth fracture reattachment techniques: Dentist must dip the dental fragment in a vessel with water immedialy. - 90 - Chapter 3 Management of Non-Carious Lesion Instruct the patient about the advantages and disadvantages offered by the procedure. Analyze clinically and radiographically the remaining tooth structure (root fracture, pulp exposure, amount of exposed dentin, pulp condition) Analyze the fragment regarding degree of dehydration and degree of adaptation. Isolation of the operative field. Fragment attached using gutta percha rod or sticky wax just to hold it. Cleaning of the dental fragment and coronal remnant with pumice-water slurry. Cleaning of the exposed dentin with 3% H2O2 for 10 seconds. Protection of the exposed dentin with a CAOH liner. Acid etching for 1 min for both fragment and the coronal remnant. Washing for 40 seconds by air/water spray. Application for adhesive resin to etched enamel on both fragment and coronal remnant. Proper seating of the fragment before polymerization of the resin. Union line evaluated few days after reattachment. If clearly seeen with deterioration in esthetics. Line can be masked by a small chamfer then will be veneered with a microfilled resin. - 91 - Chapter 3 Management of Non-Carious Lesion Restoration with composite resin: Diagnostic data collected just as for dental fragment reattachment. Proper cleansing of the tooth with a pumice/water slurry Field isolation Beveling along the whole cavosurface angle. Matrix selection and adaptation should offer adequate reproductiono of the original anatomy with minimal excesses (crown former or angle shaped transparent matrices) Etching of enamel surface by acid Bonding agent application Composite resin insertion will be incrementally made Proper finishing and polishing. - 92 -