DENTAL EROSION—TOOTH WEAR Physiology, Etiology, Epidemiology, Diagnosis, and Treatment.
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Transcript of DENTAL EROSION—TOOTH WEAR Physiology, Etiology, Epidemiology, Diagnosis, and Treatment.
DENTAL EROSION—TOOTH WEAR
Physiology, Etiology, Epidemiology, Diagnosis, and Treatment
Dental Erosion: Tooth Wear
After viewing this lecture, attendees should be able to:
• understand the oral anatomy and physiology as they relate to dental erosion/tooth wear
• identify the etiology of and risk factors associated with dental erosion/tooth wear
• describe the epidemiology and prevalence of dental erosion/tooth wear
• make the correct differential diagnosis and understand the management of dental erosion/tooth wear
Oral Anatomy and Physiology
• Primary (deciduous)
• Secondary (permanent)
Definition (teeth): There are two definitions
Primary (deciduous)• Consist of 20 teeth• Begin to form during the
first trimester of pregnancy• Typically begin erupting
around 6 months• Most children have a
complete primary dentition by 3 years of age
Oral Anatomy and PhysiologyDentition (teeth): There are two dentitions
1. Oral Health for Children: Patient Education Insert. Compend Cont Educ Dent.
Oral Anatomy and Physiology
Secondary (permanent)• Consist of 32 teeth in most
cases• Begin to erupt around 6
years of age
• Most permanent teeth have erupted by age 12
• Third molars (wisdom teeth) are the exception; often do not appear until late teens or early 20s
Dentition (teeth): There are two dentitions
Mandible
Maxilla Incisors
Canine (Cuspid)
Premolars
Molars
Classification of Teeth:
• Incisors (central and lateral)
• Canines (cuspids)
• Premolars (bicuspids)
• Molars
Oral Anatomy and PhysiologyIdentifying Teeth
Incisor Canine Premolar Molar
Oral Anatomy and Physiology
• Apical
• Labial
• Lingual
• Distal
• Mesial
• Incisal
Teeth: IdentificationTooth Surfaces
Labial
Apical
Lingual
Incisal Incisal
Distal
Apical
Mesial
• Anatomic Crown
• Anatomic Root
• Pulp Chamber
The 3 parts of a tooth:Anatomic Crown
Anatomic Root
PulpChamber
Oral Anatomy and Physiology
Oral Anatomy and Physiology
• Enamel
• Dentin
• Cementum
• Dental Pulp
The 4 main dental tissues:
Enamel
Dentin
Cementum
Dental Pulp
• Structure– Highly calcified and hardest
tissue in the body– Crystalline in nature– Enamel rods
• Insensitive—no nerves• Acid-soluble—will
demineralize at a pH of 5.5 and lower
• Cannot be renewed• Darkens with age as enamel is
lost• Fluoride and saliva can help
with remineralization
Dental Tissues—Enamel2
Oral Anatomy and Physiology
• Softer than enamel• Susceptible to tooth wear
(physical or chemical)• Does not have a nerve
supply but can be sensitive• Is produced throughout
life• Three classifications
– Primary– Secondary– Tertiary
• Will demineralize at a pH of 6.5 and lower
Dental Tissues—Dentin2
Oral Anatomy and Physiology
Dentin
Pulp
Tubule
Fluid Nerve Fibers
Odontoblast Cell
Oral Anatomy and Physiology
• Presence of tubules renders dentin permeable to fluoride
• Number of tubules per unit area varies depending on the location because of the decreasing area of the dentin surfaces in the pulpal direction
Dental Tissues—Dentin (Tubules)2
Association between erosion and dentin hypersensitivity3
• Open/patent tubules– Greater in number– Larger in diameter
• Removal of smear layer• Erosion/tooth wear
Enamel
ExposedDentin
RecedingGingiva
Tubules
Odontoblast
Oral Anatomy and Physiology
Dental Tissues—Dentin (Tubules)2
Oral Anatomy and Physiology
• Thin layer of mineralized tissue covering the dentin
• Softer than enamel and dentin
• Anchors the tooth to the alveolar bone along with the periodontal ligament
• Not sensitive
Dental Tissue—Cementum2
• Innermost part of the tooth• A soft tissue rich with blood
vessels and nerves• Responsible for nourishing the
tooth• The pulp in the crown of the
tooth is known as the pulp chamber
• Pulp canals traverse the root of the tooth
• Typically sensitive to extreme thermal stimulation (hot or cold)
Dental Tissue—Dental Pulp2
Oral Anatomy and Physiology
• Plaque
• Saliva
• pH Values
• Demineralization
• Remineralization
Oral Cavity/Environment4,5
Oral Anatomy and Physiology
Oral Anatomy and Physiology
Plaque:4,5
• is a biofilm • contains more than 600
different identified species of bacteria
• there is harmless and harmful plaque
• salivary pellicle allows the bacteria to adhere to the tooth surface, which begins the formation of plaque
Oral Cavity
Oral Anatomy and Physiology
Saliva:4,5
• complex mixture of fluids
• performs protective functions:
– lubrication—aids swallowing
– mastication
– key role in remineralization of enamel and dentin
– buffering
Oral Cavity
Oral Anatomy and Physiology
pH values:4,5
• measure of acidity or alkalinity of a solution
• measured on a scale of 1-14 • pH of 7 indicated that the
solution is neutral• pH of the mouth is close to
neutral until other factors are introduced
• pH is a factor in demineralization and remineralization
Oral Cavity
3. Strassler HE, Drisko CL, Alexander DC.
Oral Anatomy and Physiology
Demineralization:4,5
• mineral salts dissolve into the surrounding salivary fluid: – enamel at approximate
pH of 5.5 or lower– dentin at approximate pH
of 6.5 or lower • erosion or caries can occur
Oral Cavity
Oral Anatomy and Physiology
Remineralization:4,5
• pH comes back to neutral (7)• saliva-rich calcium and
phosphates• minerals penetrate the
damaged enamel surface and repair it:– enamel pH is above 5.5– dentin pH is above 6.5
Oral Cavity
Dental Erosion: Etiology
Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of physical loss,
chemical dissolution, and/or multifactorial etiology.3,6
Tooth Wear
Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6
• Physical Loss
– Abrasion—mechanical
– Attrition—tooth-to-tooth contact
– Abfraction—lesions
• Chemical dissolution
• Multifactorial etiology
Dental Erosion: Etiology
Tooth Wear
Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6
• Physical Loss
• Chemical dissolution
– Erosion
-- Extrinsic acids
-- Intrinsic acids
• Multifactorial etiology
Dental Erosion: Etiology
Tooth Wear
Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6
• Physical Loss
• Chemical dissolution
• Multifactorial etiology
– Erosion
– Abrasion
– Attrition
– Abfraction
Dental Erosion: Etiology
Tooth Wear
The pathological wearing away of hard dental tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth.6
• Oral hygiene habits– Excessive brushing/flossing– Abrasives in dentifrices/toothpastes
• Personal habits– Putting foreign objects in the mouth
• Demastication – Wear from chewing food
Abrasion
Dental Erosion: Etiology
The pathological wearing away of hard dental tissue as a result of tooth-to-tooth contact, with no foreign substance intervening.6
• Enamel wearing enamel– Occlusal wear– Malocclusion (buccal, lingual, and interproximal surfaces)
Attrition
Dental Erosion: Etiology
Wedge-shaped defects at the cementoenamel junction of a tooth caused by eccentrically applied occlusal forces leading to tooth flexure that results in microfracture of enamel and dentin.6
• Loss of tooth in the cervical area– Tooth flexure
– Chewing – Grinding (bruxism)
Abfraction
Dental Erosion: Etiology
The physical results of a pathologic, chronic, localized loss of hard dental tissue that is chemically etched away from the tooth surface by acid and/or chelation without bacterial involvement.7
• Extrinsic acids—ingested– Food, beverages, medicine
• Intrinsic acids—internal– Originate in the stomach
Erosion
Dental Erosion: Etiology
Tooth wear is multifactorial
• One process typically impacts the other
– Erosion and abrasion
Multifactorial
Dental Erosion: Etiology
Tooth erosion was described as a condition distinct from caries as early as the 18th century.8
Dental Erosion: Epidemiology
In 1995, the European Journal of Oral Science stated that “dental erosion is an area of research and clinical practice that will undoubtedly experience expansion in the next decade.”9
Change in Perception
Dental Erosion: Epidemiology
Dental Erosion: Epidemiology
Global Prevalence
Global data on the prevalence of dental erosion is building. “Erosive tooth wear is a common condition in the developed
countries.”10
United States
CanadaIceland
Ireland
Sweden
Germany
Turkey
Saudi ArabiaIndia
Brazil
Japan
Malaysia
Switzerland
The NetherlandsUK
China
• European studies suggest prevalence of:11-13
– Up to 50% if all preschool children– Between 24% to 60% of school-aged children– As high as 82% in 18 to 88 years of age10
• Emerging prevalence studies providing data on gender, socio-economic status, ethnic, and culture difference in addition to the age factor will prove to be invaluable
Global Prevalence
Dental Erosion: Epidemiology
“Diagnosis is the intellectual course that integrates information obtained by clinical examination of the teeth, use of diagnostic aids, conversation with the patient, and biological knowledge. A proper diagnosis cannot be performed without inspection of the teeth and
their immediate surroundings.”14
Dental Erosion: Diagnosis
Dental Erosion—Diagnosis
Check list to unveil etiological factors for
erosion15
Dental Erosion: Diagnosis
Interaction of the different factors for the
development of erosive tooth wear16,18
From: Lussi A. Dental Erosion: From Diagnosis to Therapy. Karger; 2006.
Dental Erosion: Diagnosis
Clinical Appearance
There is no device available for the specific detection of dental erosion in routine practice. Therefore, the clinical appearance is the most
important feature for dental professionals to diagnosis dental erosion.16
Dental Erosion—Diagnosis
Tooth Wear—Clinical Appearance17
• Chemical factors—erosive potential of intrinsic and extrinsic acids
• Biological factors—involve properties and characteristics of the oral cavity
• Behavioral factors—personal and oral habits
Erosion is multifactorial
Dental Erosion: Diagnosis
• pH and buffering capacity of the product
• Type of acid (pKa values) – Intrinsic (gastric origin)– Extrinsic (environmental, dietary, medicinal)
• Adhesion of the products to the dental surface• Chelating properties of the products• Calcium concentration• Phosphate concentration• Fluoride concentration
Chemical Factors18
Dental Erosion: Diagnosis
• Saliva: flow rate, composition, buffering, capacity, and stimulation capacity
• Acquired pellicle: diffusion-limiting properties, composition, maturation, and thickness
• Type of dental substrate (permanent and primary enamel, dentin) and composition (eg, fluoride content as FHAp or CaF2-like particles)
• Dental anatomy and occlusion• Anatomy of oral soft tissues in relationship to the teeth• Physiologic soft tissue movements
Biological Factors19
Dental Erosion: Diagnosis
• Unusual eating and drinking habits
• Healthy lifestyle: diets high in acidic fruits and vegetables
• Unhealthy lifestyle: frequent consumption of “alcopops” and designer drugs
• Alcoholic disease
• Excessive consumption of acidic foods and drinks
• Nighttime baby bottle feeding with acidic beverages, including milk
• Oral hygiene practices: frequent toothbrushing, abrasive oral care products
Behavioral Factors20
Dental Erosion: Diagnosis
Loss of tooth surface is a multifactorial process and education
is the first step in the line of defense.4
Prevention
Dental Erosion: Diagnosis
Dynamics of Dental Erosion21
Before During After
Time (Frequency)
Interactions between Behavioral and Biological Factors
Dental Erosion: Diagnosis/Management
21. Lussi A, Kohler N, Zero D, et al.
Dental Erosion:Management/Etiological Factors
Dietary factors15
• Avoid radical changes in dietary habits
• Reduce acid exposure by reducing frequency and contact time of acid
• Avoid acidic foods and drinks late at night
• Avoid high-acidity liquids via baby bottle for infants
• Avoid low pH values in food and beverages
Awareness/Association/Education
Dental ErosionManagement/Etiological
Factors
Dietary factors: generally, a pH value of 5.5 or lower is capable
of softening the surface of enamel
in only a few minutes.3
Awareness/Association/Education
3. Strassler HE, Drisko CL, Alexander DC.
Dental Erosion:Management/Etiological Factors
Behavioral/habits15
• Do not hold or swish acidic drinks in your mouth
• Avoid sipping acidic drinks—use a straw
• Avoid toothbrushing immediately after an erosive challenge (vomiting, acidic diet)
• Avoid toothbrushing immediately before an erosive challenge, as the acquired pellicle provides protection against erosion
• Use a soft toothbrush
Awareness/Association/Education
Dental Erosion:Management/Etiological Factors
Behavioral/Habits15
• Use a low-abrasion fluoride-containing toothpaste; high-abrasive toothpaste may destroy pellicle
• Avoid toothpastes or mouthwashes with too-low pH
• After acid intake, stimulate saliva flow with chewing gum or lozenges
• Use chewing gum to reduce postprandial reflux
• Refer patients or advise them to seek appropriate medical attention when intrinsic causes are involved
Awareness/Association/Education
Gastroesophageal Origin22
• Heartburn and other symptoms of reflux
• Regurgitation
• Dysphagia
• Asthma
• Rumination
• Eating disorders (anorexic or bulimia)
Dental Erosion:Management/Etiological Factors
Awareness/Association/Education
Medicinal factors associated with dental erosion23
• Some medicines can potentially induce GERD– theophyline– progesterone– anti-asthmatics– calcium channel blockers
• Aspirin (especially in chewable format)
• Medicines that decrease salivary flow– antihistamines– anticholinergics– antidepressants– antipsychotics
Awareness/Association/Education
Dental Erosion:Management/Etiological Factors
Dental Erosion/Toothwear
Prevention is better than a cure… Education is the key!