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Discuss why dentitions may fail and

the principles of their management

Student ID: 1150831

Word Count: 3689

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The Keyes diagram (above) shows that cavities are the result of the interaction between asusceptible tooth, a dietary substrate (sugar), a chronic bacterial infection, and time. Apersons risk factor for caries varies over time so they are subject to change. The risk factorsare listed below:

Risk Factors

PhysicalVariations in tooth enamel; deep pits andfissures; anatomically susceptible areas.Gastric refluxHigh mutans streptococci countSpecial health care needsPrevious caries experience

History of baby bottle tooth decay (earlychildhood caries)

BehavioralBottle used at night for sleep or at will whileawakeFrequent snackingInadequate oral hygieneEating disorders, including self-inducedvomiting (bulimia)

Socio environmental

Inadequate floridePoor family oral healthPovertyHigh parental levels of bacteria (mutansstreptococci)

Disease or treatment relatedSpecial carbohydrate dietFrequent intake of sugared medicationsReduced saliva flow from medication orirradiationOrthodontic appliances

Protective factors

Sealants (if possible) or observation

Management of conditionReduction of mutans streptococciPreventive intervention to minimize effectIncreased frequency of supervision visits

Increased frequency of supervision visits

Prevention of bottle habit and weaning frombottle by age 12Reduction in snacking frequencyImprove oral hygieneReferral for counseling

Optimal systemic and /or topical fluorideAccess to care and good oral hygieneAccess to careGood parental oral health and hygiene

Preventive intervention to minimize effectsAlternate medications or preventiveintervention to minimizeeffectsSaliva substitutesGood oral hygiene for appliances

DM Krol, Dental caries, oral health, and pediatricians. Curr Probl Pediatr Adolesc HealthCare, 33 (2003), pp. 253270

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Clinical Photographs Showing Dental Caries

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Although the risk factors listed in Table 1 are for children, in most cases these risk factorsremain the same for adults as well. The principle method used for management of dentalcaries is usually by a restoration. However in recent times more emphasis is being put onpreventive measure to control dental caries. This is a better option for most dentalpractitioners as it allows for control of the disease in its infancy and reduces excessivetrauma to the tooth caused by cavity preparation (Pitts 2004). This approach relies heavilyon accurate diagnosis of the disease and preventive measures taken to reduce risk to thetooth.

PERIODONTAL DISEASE:

Chronic plaque-associated gingivitis and periodontitis are destructive inflammatory diseasessometimes referred to together simply as chronic periodontal disease, although there isevidence that, at least clinically, several distinct types of chronic destructive periodontaldiseases may exist. The term gingivitis is used to designate inflammatory lesions that areconfined to the marginal gingiva. Once the lesions extend to include destruction of theconnective tissue attachment of the tooth and loss of alveolar bone the disease isdesignated periodontitis (Soames 2005). A risk factor for periodontal disease is anenvironmental, behavioral, or biological factor which increases the chances of occurrence ofthe disease in a patient (Timmerman 2006).Abundant evidence exists to emphasize that riskfactors are closely related to the occurrence of periodontal disease (Borrell 2005). Use ofvarious tools can aid the dental practitioner in identifying the increased chances of a patientdeveloping periodontal disease.

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Flow chart for Risk factors involved in periodontal disease

Clinical Photo Showing Periodontal Disease

http://moabdental.files.wordpress.com/2010/09/gum20disease2.jpg

The risk calculator for periodontal disease is a good example of such a tool (Page et al2002). This basically utilizes a grading system of examining patients on a scale of 1-5 (1

being the lowest risk and 5 the highest). This plays an important role in identifying riskfactors specific to a patient and hence improves the management of the disease (Douglass2006). The Management of periodontal disease is three fold, starting with regular visits to thedental hygienist for removal of plaque and calculus deposits, followed by instructions inproper oral hygiene maintenance with emphasis on brushing techniques and flossingregularly. Counseling the patient on any habits they might have that may be detrimental tothe treatment plan. Regular follow up visits after the treatment has been completed tomaintain the patients periodontal status are a must for good long term prognosis.

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TRAUMA:

Trauma to the tooth is also an important cause of failure of teeth, which results in either lossof functionality or complete removal of the tooth all together. The most common causes oftrauma to the tooth are as a result of accidental falls, sports injuries and violence. Newtechnology has led to a better understanding of the process of inflammation that occurs inthe tooth after it experiences a trauma and led to a more conservative approach (Florres etal 2009). Separate guidelines have been developed for children and adults as the treatmentprotocols for both vary (Florres et al 2009).

Clinical Situation

The tooth has already been replanted.o Clean affected areas with water spray, saline or chlorhexidine do not extract

the tooth.o Suture gingival laceration, especially in the cervical areao Verify normal position of the replanted tooth radiographically.o Apply a flexible splint for 1 week. Administer systemic antibiotics: Doxycycline

2 per day for 7 days at appropriate dose for patient age and weight.o Refer to physician to evaluate need for a tetanus booster if avulsed tooth has

come into contact with soil or tetanus coverage is uncertaino Initiate endodontic treatment after 710 days. Place calcium hydroxide as an

intra-canal medicament.

The tooth has been kept in special Extra-oral dry time 60 min storage media, milk,saline or saliva.

o If contaminated clean the root surface with saline. Examine the alveolarsocket. If there is a fracture of the socket wall, reposition it with a suitableinstrument. Replant slowly with slight digital pressure.

o Suture gingival laceration, especially in the cervical areao Verify normal position of the replanted tooth radiographically.o Apply a flexible splint for 1 week. Administer systemic antibiotics:

Doxycycline 2 per day for 7 days at appropriate dose for patient age andweight.

o Refer to physician to evaluate need for a tetanus booster if avulsed tooth hascome into contact with soil or tetanus coverage is uncertain

o Initiate endodontic treatment after 710 days. Place calcium hydroxide as anintra-canal medicament.

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time is less than60 mino Remove debris and necrotic periodontal ligament.o Remove the coagulum from the socket with a stream of saline. Examine the

alveolar socket. If there is a fracture of the socket wall, reposition it with asuitable instrument.

o Immerse the tooth in a 2.4% sodium fluoride solution acidulated to a pH5.5for a minimum of 5 min.

o Replant slowly with slight digital pressure.o Suture gingival laceration, especially in the cervical areao Verify normal position of the replanted tooth radiographically.o Apply a flexible splint for 1 week. Administer systemic antibiotics:

Doxycycline 2 per day for 7 days at appropriate dose for patient age andweight.

o Refer to physician to evaluate need for a tetanus booster if avulsed tooth hascome into contact with soil or tetanus coverage is uncertain

o Initiate endodontic treatment after 710 days. Place calcium hydroxide as anintra-canal medicament.

PATIENT INSTRUCTIONS:o Soft diet for 2 weekso Brush teeth with a soft toothbrush after each mealo Use a chlorhexidine mouth rinse (0.1%) twice a day for 1 week

(Flores, M. T., Andreasen, J. O. and Bakland, L. K. (2001), Guidelines for the evaluation andManagement of traumatic dental injuries. Dental Traumatology, 17: 193196)

The other kind of trauma occurring to teeth is usually involved with the fracture of the crownor root or both of them depending on the extent of the injury. The examination of thefractured tooth should be done as indicated in most books. The radiographs recommendedfor use in this situation are peri apical from 3 different angles. i 90 degree horizontal iiocclusal view iii lateral view from mesial or distal aspect. The International Association ofdental traumatology revised its guidelines for management of crown and root fractures, and

the same are presented here as follows (Florres et al 2007).

Uncomplicated crown fracture

Clinical finding

Fracture involves enamel or dentin and enamel; the pulp is not exposed. Sensibility testingmay be negative initially indicating transient pulpal damage; monitor pulpal response until a

definitive pulpal diagnosis can be made.

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Clinical Photograph of a Simple Non-complicated Crown Fracture

http://www.estetskastomatologija.rs/theme/images/ispuni_plombe/galerija/velike/15.-prelom-krunice-zuba-crown-fracture.jpg

Radiographic Finding

The 3 angulations described in radiographic examination to rule out displacement or fractureof the root. Radiograph of lip or cheek lacerations is recommended to search for toothfragments or foreign material.

Treatment

If tooth fragment is available, it can be bonded to the tooth. Urgent care option is to cover theexposed dentin with a material such as glass ionomer or a permanent restoration using abonding agent and composite resin. Definitive treatment for the fractured crown may berestoration with accepted dental restorative materials.

Complicated Crown Fracture

Clinical Finding

Fracture involves enamel and dentin and the pulp is exposed. Sensibility testing is usuallynot indicated initially since vitality of the pulp can be visualized. Follow-up control visits afterinitial treatment includes sensibility testing to monitor pulpal status.

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Clinical Picture and Radiograph of a complicated Crown Fracture

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Radiographic Finding

The 3 angulations described in radiographic examination to rule out displacement or fractureof the root. Radiograph of lip or cheek lacerations is recommended to search for toothfragments or foreign material. The stage of root development can be determined from theradiographs.

Treatment

In young patients with immature, still developing teeth, it is advantageous to preserve pulpvitality by pulp capping or partial pulpotomy. This treatment is also the choice in youngpatients with completely formed teeth. Calcium hydroxide and MTA (white) are suitablematerials for such procedures. In older patients, root canal treatment can be the treatment ofchoice, although pulp capping or partial pulpotomy may also be selected. If too much timeelapses between accident and treatment and the pulp becomes necrotic, root canaltreatment is indicated to preserve the tooth. In extensive crown fractures a decision must bemade whether treatment other than extraction is feasible

Crown Root Fracture

Clinical Finding

Fracture involves enamel, dentin and root structure; the pulp may or may not be exposed.Additional findings may include loose, but still attached, segments of the tooth. Sensibilitytesting is usually positive.

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Radiograph of Crown Root Fracture

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Radiographic Finding

As in root fractures, more than one radiographic angle may be necessary to detect fracture

lines in the root.

Treatment

Treatment recommendations are the same as for complicated crown fractures (see above).In addition, attempts at stabilizing loose segments of the tooth by bonding may beadvantageous, at least as a temporary measure, until a definitive treatment plan can beformulated.

Root Fracture

Clinical Finding

The coronal segment may be mobile and may be displaced. The tooth may be tender topercussion. Sensibility testing may give negative results initially, indicating transient or

permanent pulpal damage; monitoring the status of the pulp is recommended. Transientcrown discoloration (red or grey) may occur.

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Radiograph Showing Root Fracture in a tooth

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Radiographic Finding

The fracture involves the root of the tooth and is in a horizontal or diagonal plane. Fracturesthat are in the horizontal plane can usually be detected in the 90 angle film with the centralbeam through the tooth. This is usually the case with fractures in the cervical third of theroot. If the plane of fracture is more diagonal, which is common with apical third factures, anocclusal view is more likely to demonstrate the fracture including those located in the middlethird.

Treatment

Reposition, if displaced, the coronal segment of the tooth as soon as possible. Checkposition radiographically. Stabilize the tooth with a flexible splint for 4 weeks. If the rootfracture is near the cervical area of the tooth, stabilization is beneficial for a longer period oftime (up to 4 months). It is advisable to monitor healing for at least 1 year to determinepulpal status. If pulp necrosis develops, root canal treatment of the coronal tooth segment tothe fracture line is indicated to preserve the tooth.

( Flores, M. T., Andersson, L., Andreasen, J. O., Bakland, L. K., Malmgren, B., Barnett, F.,Bourguignon, C., DiAngelis, A., Hicks, L., Sigurdsson, A., Trope, M., Tsukiboshi, M. and VonArx, T. (2007), Guidelines for the management of traumatic dental injuries. I. Fractures andluxations of permanent teeth. Dental Traumatology, 23: 6671)

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TOOTH WEAR:

Tooth wear is the loss of tooth surface i.e. enamel with or without dentine loss due to anumber of reasons which include Abrasion, attrition, erosion and abfraction. It is not alwayspossible to differentiate between these terms hence they are usually used in combination todescribe tooth wear in patients. An alternative term, tooth surface loss (TSL), has beenproposed (Bernard et al 1997). However, this term has two significant disadvantages. First, itunderstates the severity of the condition by implying that only the surface of the tooth is lost,whereas in some situations, the wear can be very extensive (Bernard et al 1997). Thesecond disadvantage of the term is its subtlety that escapes most patients and somedentists (Bernard et al 1997).

Abrasion:

This is the pathological wearing away of tooth substance by the friction of a foreign bodyindependent of occlusion (Soames 2005). Different foreign bodies produce different patternsof abrasion.

1. Toothbrush abrasion is common and is seen most frequently on exposed rootsurfaces of teeth. It is commonly associated with tooth brushing in a horizontal ratherthan a vertical direction and is made worse by an abrasive dentifrice.

2. Habitual abrasion may be seen in pipe-smokers.3. Occupational abrasion develops when objects are held between or against the teeth

during work, for example hair-grips.4. Ritual abrasion of the teeth is uncommon today and is confined mainly to Africa.

Clinical Photograph Showing Abrasion

http://2.bp.blogspot.com/-HSHrKqkbpZU/TjQu4G-ecDI/AAAAAAAACm0/66UDykvIq8o/s1600/abrasion.jpg

Attrition:

This is loss of tooth substance as a result of tooth-to-tooth contact (Soames 2005) .It may bephysiological or pathological in origin, although clinically the distinction is often unclear(Soames 2005). The pattern of tooth loss in physiological attrition is fairly constant: theincisal edges of the incisors are worn first, followed by the occlusal surfaces of the molars,the palatal cusps of the maxillary teeth, and the buccal cusps of the mandibular teeth.

Clinical Photograph Showing Attrition

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http://findmeacure.com/wp-content/uploads/2010/08/worn-teeth-attrition-bruxism.jpg

Erosion:

This is the loss of tooth substance by a chemical process that does not involve knownbacterial action (Soames 2005). It may render the teeth more susceptible to attrition andabrasion.

1. Dietary erosion may follow the excessive intake of acidic beverages, such as fruit juices orcarbonated soft drinks, or the habit of sucking citrus fruits.

2. Occupational (environmental) erosion is now relatively uncommon. It is seen in workers

exposed to acids in their workplace and is usually due to atmospheric pollution.

3. Regurgitation of stomach contents or persistent vomiting causes erosion in which thepalatal surfaces of the maxillary teeth are primarily affected.

Clinical Photograph showing Erosion

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Tooth wear is a condition that causes permanent damage to the dentition of the patienttherefore a long term strategy for management of the problem is needed. For this however

the exact cause of the tooth wear has to be first established by the dental professional so asto prevent further damage from occurring. This coupled with continuous monitoring of the

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situation helps in measuring the effectiveness of the treatment. Restorative treatment is onlyindicated when the patient is concerned with the appearance of his or her dentition (Kehllerand Bishop 1999). Consultation with a medical physician for treatment of medical problemsrelated to the tooth wear (Kehller and Bishop 1999).

DEVELOPMENTAL DEFECTS:

Another reason for failure of dentition is defects in the tooth structure during stages ofdevelopment of the tooth. These defects can either be in the enamel, dentine or cementum.These changes although being permanent can be managed with proper

Amelogenisis Imperfecta:

Amelogenesis imperfecta presents with abnormal formation of the enamel or external layerof teeth (Soames 2005). Enamel is composed mostly of mineral, which is formed andregulated by the proteins in it (Soames 2005). Amelogenesis imperfecta is due to themalfunction of the proteins in the enamel: ameloblastin, enamelin, tuftelin and amelogenin(Soames 2005). People afflicted with amelogenesis imperfecta have teeth with abnormalcolor: yellow, brown or grey (Soames 2005). The teeth have a higher risk for dental cavitiesand are hypersensitive to temperature changes. This disorder can afflict any number ofteeth. The disorder may create unaesthetic appearance, dental sensitivity and attrition.Management of this condition usually involves ceramic crowns for compensation of theaesthetic drawbacks, as well as the maintenance of oral hygiene (Mobin and Tugsel 2002).

Clinical Photograph showing Amelogenisis Imperfecta

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Dentinogensis Imperfecta:

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Dentinogenesis imperfecta (hereditary Opalescent Dentin) is a genetic disorder of toothdevelopment. This condition causes teeth to be discolored (most often a blue-gray or yellow-brown color) and translucent (Soames 2005). Teeth are also weaker than normal, makingthem prone to rapid wear, breakage, and loss. The main objectives of treatment include i)maintenance of dental health, form, size and vitality ii) improve aesthetics iii) improve

function of the dentition iv) prevent loss of vertical dimension (Sapir and Shapira 2001).

Clinical Photograph Showing Dentinogenesis Imperfecta

http://www.mchoralhealth.org/PediatricOH/images/dentio_imp.jpg

ENDODONTIC PROBLEMS:

Although Endodontic problems are discussed here separately they result either fromprolonged dental caries exposure or from periodontal problems occurring around a localizedpart of the oral cavity. The indication for the appropriate endodontic treatment depends onthe causes, effects, and dynamics of pulpal pathosis (Baume 1970). This requires followinga classification to correctly understand the cause of the pulpal injury.

(Etiological Classification of Pulp Injury)

(Local factors :) Mechanicalirritation

Causative Thermicirritation

Chemical irritationInflammation Bacterialirritation

Systemic factors: Severe general conditions

Predisposing Nutritional deficiencies

Endocrine disturbances

Periodontal conditionsDegeneration

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Diagnosing the exact cause requires taking a proper history Details of the patient's complaintshould be considered together with the medical history. Questions like where is the pain?When was the pain first noticed? Description of the pain. Under what circumstances doesthe pain occur? Does anything relieve it? Any associated tenderness or swelling ? are goodquestions to start with (Carrote 2004).

Particular note should be made of any disorders which may affect the differential diagnosisof dental pain, such as myofascial pain dysfunction syndrome (MPD), neurological disorderssuch as trigeminal neuralgia, vascular pain syndromes and maxillary sinus disorders(Carrote 2004).

Diagnostic aids

Periapical radiographs should be taken using paralleling technique. Electric pulp testershould be used for testing pulpal responses in the tooth. Ice sticks, hot gutta-percha, coldspray and hot water can be used for testing thermal responses.

Periapical Radiolucency as seen in a Radiograph

http://www.suttondentist.com/content/images/endodonticabscess_img_1.jpg

Management of the problem can vary in different a case, as the treatment plan cannot bedeveloped on the diagnosis alone, indications and contraindications for root canal treatmentexist which is the treatment of choice in such cases (Carrote 2004). Factors like adequateaccess, poor oral hygiene of the patient, any medical conditions the patient might have, non-cooperative nature of the patient, poor condition of the tooth, root fractures, resorption can

be a cause for concern for the prognosis if the treatment is carried out (Carrote 2004).

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CONCLUSION:

The knowledge of various causes of failure of dentition is an important tool in the correctdiagnosis and treatment of patients. It helps in planning a successful treatment for thepatient and predicting a good prognosis. Although the management of any of the problemsmentioned above seems simple enough on paper, there is a large variety of other factorsthat have to be taken account as well, which include the expectations of the patient mostimportantly, what does he expect from you as his doctor, the socio-economic status of thepatient which could in the end rule out some of your treatment options from the start. Thehabits of the patient e.g. smoking , alcohol use etc. can also effect the prognosis, anymedical conditions the patient might have could also change the treatment modalities.Hence a large a number of factors exist which the dental professional must consider besides

his diagnosis for proper management of the failed dentition and a good prognosis.

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REFRENCES:

Baume, L.J.(1970). Diagnosis of diseases of the Pulp. Journal of Oral Surgery. 29 (1), p102-116.

Bernard G.N. Smith, David W. Bartlett, Nigel D. Robb, The prevalence, etiology andmanagement of tooth wear in the United Kingdom, The Journal of Prosthetic Dentistry, Volume78, Issue 4, October 1997, Pages 367-372

Borrell, L. N. and Papapanou, P. N. (2005), Analytical epidemiology of periodontitis. Journal ofClinical Periodontology, 32: 132158

Carrote, P.. (2004). Endodontics: Diagnosis and Treatment planing. British Dental Journal. 197(5), p231-238.

Carrote, P.. (2004). Treatment of Endodontic Emergencies. British Dental Journal. 197 (1), p299-304.

DM Krol, Dental caries, oral health, and pediatricians. Curr Probl Pediatr Adolesc HealthCare, 33 (2003), pp. 253270

Douglass, C.W.. (2006). Risk Assesment and Management of Periodontal Disease. JADA. 137(1), p27-32.

Flores, M. T., Andreasen, J. O. and Bakland, L. K. (2001), Guidelines for the evaluation andManagement of traumatic dental injuries. Dental Traumatology, 17: 193196

Flores, M. T., Andersson, L., Andreasen, J. O., Bakland, L. K., Malmgren, B., Barnett, F.,Bourguignon, C., DiAngelis, A., Hicks, L., Sigurdsson, A., Trope, M., Tsukiboshi, M. and Von Arx,

T. (2007), Guidelines for the management of traumatic dental injuries. I. Fractures and luxationsof permanent teeth. Dental Traumatology, 23: 6671

Kellher, M. and Bishop, K.. (1999). Tooth Surface Loss: an overview. British Dental Journal. 186(2), 61-66

Mobin, U. and Tugsel, Z.. (2002). Management of Amelogensis Imperfecta. Journal of theFaculty of Dentistry. 5 (1), p31-32.

NB Pitts, Are we ready to move from operative to non-operative/preventive treatment of dentalcaries in clinical practice?. Caries Res, 38 (2004), pp. 294304.

Page RC, Krall EA, Martin J, Mancl L, Garcia RI. Validity and accuracy of a risk calculator inpredicting periodontal disease. JADA 2002;133(5):56976

Robert H Selwitz, Amid I Ismail, Nigel B Pitts, Dental caries, The Lancet, Volume 369, Issue9555, 6-12 January 2007, Pages 51-59

Timmerman, M. and van der Weijden, G. (2006), Risk factors for periodontitis. InternationalJournal of Dental Hygiene, 4: 27

Sapir, S. and Shapira, J.. (2001). Dentinogenisis Imperfecta: An Early Treatment Strategy.American Academy of Pediatric Dentistry. 23 (3), p232-237

Soames,J.V. and Southam, J.C. (2005). Oral Pathology: Oxford University Press.