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TEERTHANKER MAHAVEER DENTAL COLLEGE

AND RESEARCH CENTRE

DEPARTMENT OF ORALPATHOLOGY

:-Seminar Topic:-

REGRESSIVE ALTERATIONSOF THE TEETH

Guided by:-Guided by:-Presented byPresented by

Dr. Kunal shahDr. Kunal shahSharib ali khanSharib ali khan

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MDS

BDS 3rd year

INTRODUCTION:-

Regressive changes in the dental tissues include

a variety of alterations that are not necessarily

related either etiologically or pathologically.

Some of the changes to be considered here are

associated with the general aging process of the

individual.

Others arise as a result of injury to the tissues.

Still other regressive changes of teeth occur with

such frequency that there is some doubt whether

they should actually be considered pathologic.

ATTRITION, ABRASION AND EROSION

Mechanical wear and tear of tooth substance is a

consequence of both physiological and

pathological means and therefore different

adaptive strategies have evolved to tackle this

situation.

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A disease state arises when this delicate balance

goes away resulting in early dissolution and loss

of tooth substance with subsequent involvement

of pulpal and periapical tissues.

It is currently acknowledged that there are

several mechanisms that contribute to there are

several mechanisms that contribute to tooth

wear.

These include abrasion resulting from the friction

of exogenous material forced over tooth surfaces

(e.g. masticating food) or the use of teeth as

tools; erosion resulting from the chemical

dissolution of tooth surfaces (e.g. effects of acid

from various sources or from a highly acidic diet),

and attrition from tooth-to-tooth contact (e.g.

night grinding ).

These mechanisms most often occur together,

each acting at different intensity and duration in

a continuously hanging salivary medium,

producing immensely variable patterns and

degrees of wear.

ATTRITION

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Definition:-

Attrition may be defined as, the physiologic

wearing away of a tooth as a result of tooth-to-

tooth contact, as in mastication.

This occurs only on the occlusal, incisal, and

proximal surfaces of teeth, not other surfaces

unless a very unusual occlusal relation or

malocclusion exist.

This phenomenon is physiologic rather thanpathologic, and it is associated with the aging

process.

The order a person becomes, the more attrition is

exhibited.

Attrition commences at the time contact or

occlusion occurs between adjacent or opposing

teeth.

It may be seen in the deciduous dention as well

as in the permanent, but severe attrition is

seldom seen in primary teeth because they are

not retained normally for any great period of

time Occasionally, however, children may suffer

from either dentinogenesis imperfecta or

amelogenesis imperfecta, and in both diseases

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pronounced attrition may result from ordinary

masticatory stresses.

Clinical features

o The first clinical manifestation of attrition

may be the appearance of a small polished

facet on a cusp tip or ridge or a slight

flattening of an incisal edge.

o Because of the slight mobility of the teeth in

their sockets, a manifestation of the

resiliency of the periodontal ligament,

similar facets occur at the contact points on

the proximal surfaces of the teeth.

o As the person becomes older and the wear

continues, there is gradual reduction in cusp

height and consequent flattening of the

occlusal inclined planes.

o According to Robinson and his associates,

there is also shortening of the length of the

dental arch due to reduction in the

mesiodistal diameters of the teeth through

proximal attrition.

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o Only minor variation in the hardness of tooth

enamel exists between individuals;

nevertheless considerable variation in the

degree of attrition is observed clinically.

o Men usually exhibit more severe attrition

than women of comparable age, probably as

a result of the greater masticatory force of

men.

o Variation also may be a result of differences

in the coarseness of the diet or of habits

such as chewing tobacco or bruxism either of

which would predispose to more rapid

attrition.

o Certain occupations, in which the person is

exposed to an atmosphere of abrasive dustand cannot avoid getting the material into

his mouth, also are important in the etiology

of severe attrition.

o Advanced attrition, in which the enamel has

been completely worn away in one or more

areas, sometimes results in an extrinsic

yellow or brown staining of the exposed

dentin from food or tobacco.

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o Provided there is no premature loss of the

teeth, attrition may progress to the point of

complete loss of cuspal interdigitation. In

some cases the teeth may be worn down

nearly to the gingiva, but this extreme

degree is unusual even in elderly persons.

o The exposure of dentinal tubules and the

subsequent irritation of odontoblastic

processes result in formation of secondary

dentin , pulpal to the primary dentin, and

this serves as an aid to protect the pulp from

further injury.

o The rate of secondary dentin deposition is

usually sufficient to preclude the possibility

of pulp exposure through attrition alone.

ABRASION

Definition:-

Abrasion is the pathologic wearing away of tooth

substance through some abnormal mechanical

process.

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Abrasion usually occurs on the exposed root

surfaces of teeth, but under certain

circumstances it may be seen elsewhere, such as

on incisal or proximal surfaces.

Robinson stated that the most common cause of

abrasion of root surfaces is the use of an

abrasive dentifrice.

Although modern dentifrices are not sufficiently

abrasive to damage intact enamel severely, they

can cause remarkable wear of cemented and

dentin if the toothbrush carrying the dentifrice is

injudiciously used, particularly in a horizontal

rather than vertical direction.

Clinical features:-

o Abrasion caused by a dentifrice manifests

itself usually as a V-shaped or wedge-shaped

ditch on the root side of the cementoenamel

junction in teeth with some gingival

recession.

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o The angle formed in the depth of the lesion,

as well as that at the enamel edge, is a

rather sharp one, and the exposed dention

appears highly polished.

o It has been shown by Kitchin and by Ervin

and Bucher that some degree of tooth root

exposure is a common clinical finding, and a

66 per cent incidence of abrasion among

1252 patients examined was reported by

Ervin and Bucher.

o Abrasion was more common on the left side

of the mouth in right-handed people, and

vice versa, suggested that improper tooth

brushing caused abrasion.

o

The habitual opening of bobby pins with theteeth may result in a notching of the incisal

edge of one maxillary central incisor

o Similar notching may be noted in carpenters,

shoemakers, their teeth. Habitual pipe

smokers may develop the pipe stem

o The improper use of dental floss and

toothpicks may produce lesions on the

proximal exposed root surface, which also

should be considered a form of abrasion.

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o It is apparent that pathogenesis under these

different conditions is essentially identical.

o The loss of tooth substance that occurs by

one means or another is certainly pathologic

but should present no problem in diagnosis

o The exposure of dentinal tubules and the

consequent irritation of the odontoblastic

processes stimulate the formation of

secondary dentin similar to that seen in

cases of attrition.

o Unless the form of abrasion is an extremely

severe and rapidly progressive one, the rate

of secondary dentin formation is usually

sufficient to protect the tooth against pulp

exposure.

EROSION

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Definition:-

Dental erosion is defined as,

irreversible loss of dental hard tissue by a

chemical process that does not involve bacteria.

Dissolution of mineralized tooth structure occurs

upon contact with acids that are introduced into

the oral cavity from intrinsic (e.g. gastro-

esophageal reflux, vomiting) or extrinsic sources

(e.g. acidic beverages, citrus fruits).

This form of tooth surface loss is part of a large

picture of tooth wear, which also consists of

attrition, abrasion and possibly abfraction.

CAUSES

Extrinsic causes. :

Erosion of tooth substance is mainly due to

contact with acidic media either by way of food

stuff or by iatrogenic exposure.

There could be either extrinsic or intrinsic

sources of acid that could cause this mode of

tooth substance loss.

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Examples of extrinsic acids. (Source outside the

body ) are acidic beverages, foods, medications

or environmental acids.

The most common of these are dietary acids. It

can be seen that most fruits and fruit juices have

a very low pH (high acidity).acidic.

Several studies have found that the frequency of

consumption of acidic drinks was significantly

higher is patients with erosion than without.

This finding is of concern, particularly since

children and adolescents are the primary

consumers of these drinks.

With consumption of acidic drinks identified as a

risk factor in erosion, this amount of soft drink

consumption will likely lead to an increase in

prevalence of erosion.

The erosive potential of beverages does not

depend on pH alone. Other components of

beverages, such as calcium, phosphates, and

fluoride, may lessen erosive potential .

Also, factors such as frequency and method of

intake of acidic beverages as well as the tooth

brushing frequency after intake may influence

susceptibility to erosion.

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Therefore, the role of confounders like oral

hygiene status, complicate the role of acids per

se which necessitates further investigation to

clarify the relationship between acidic beverage

intake and dental erosion.

Medications that the acidic in nature can also

cause erosion via direct contact with the teeth

when the medication is chewed or held in the

mouth prior to swallowing.

Numerous case reports exist describing extensive

erosion secondary to chewing vitamin C

preparations or hydrochloric acid supplements.

Less common sources of extrinsic erosive acids

are related to occupational and recreational

exposure.

Chromic, hydrochloric, sulfuric and nitric acids

have been identified as erosion-causing acid

vapors.

They are released into the work environment

during industrial electrolytic processes.

However current work safety standards make

this type of erosion very rare. Dental erosion has

been reported in swimmers who work out

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regularly in pools with excessive acidity as well

as individuals who are occupational wine-tasters.

INTRINSIC CAUSES

Intrinsic causes (acid source inside the body), for

erosion are gastric acids regurgitated into the

esophagus and mouth.

Gastric acids, with pH levels that can be less than

1, reach the oral cavity and come in contact with

the teeth in conditions such as gastroesophageal

reflux and exessive vomiting related to eating

disorders.

The association of gastroesophageal reflux

disease (GERD) with dental erosion has been

established in a number of studies in adults is a

common condition estimated to affect 7 %of the

adult population on a daily basis and 36 % at

least one time a month.

In this condition gastric contents pass

involuntarily into the esophagus and can escapeup into the mouth.

This is caused by increased abdominal pressure,

inappropriate relaxation of the lower esophageal

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sphincter or increased acid production by the

stomach.

However, GERD can also be silent with the

patient unaware of his or her condition until

dental changes elicit assessment for the

condition.

Chronic, excessive vomiting has long been

recognized as causing erosion of the teeth.

The patient with an eating disorder such as

anorexia nervosa or bulimia is the classic

example.

The addition, treatment for bulimia may include

use of antidepressants or other psychoactive

medications that may cause salivary

hypofunction.

Therefore, the cause of erosion cannot be

reliably determined from its location.

Erosion associated with alcoholism is caused by

frequent vomiting. Other causes of vomiting that

may cause erosion include gastrointestinal

disorders such as peptic ulcers or gastritis,

pregnancy, drug side effects, diabetes or nervous

system disorders.

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SALIVA AS A MODIFYING FACTOR.

The fluctuations in pH of saliva are mainly kept inbalance by the buffering capacity of saliva.

This property is largely due to the bicarbonate

content of the saliva which is in turn dependent

on the salivary flow rate.

Bicarbonate concentration also regulates salivary

pH. Therefore, there is a relationship between

salivary pH, buffering capacity and flow rate

increases.

Normally, when an acid enters the mouth,

whether from an intrinsic or extrinsic source,

salivary flow rate increases, along with pH and

buffer capacity.

Within minutes, the acid is neutralized and

cleared from the oral cavity and the pH returns to

normal.

Patients with erosion were found to have lower

salivary buffer capacity when compared with

controls in several studies.

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In other studies, low whole salivary flow rates in

patients with erosion were determined to be the

major difference.

Therefore, salivary function is an important

factor in the etiology of erosion.

Since many common medications and diseases

can lower salivary flow rate (xerostomia), both

whole and stimulated, it is important to assess

salivary characteristics when evaluating a patientwith erosion.

RISK FACTORS FOR DENTAL EROSION

Soft drinks consumed (4-6 or more per week)

Eating disorder (weekly or more often)

Bruxism habit

Whole saliva unstimulated flow rate (0.1ml/min)

Sports drinks intake (weekly or more often)

Excessive attrition Vomiting

Symptoms or history of gastroesophageal reflux

disease

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PREVENTION OF PROGRESSION OF EROSION

Diminish the frequency and severity of the acid

challange

Enhance the defense mechanisms of the body

(increase salivary flow and pellicle formation

Enhance acid resistence,remineralization and

rehardening of the tooth surfaces

Improve chemical protection

Decrease abrasive forces

Provide mechanical protection

Moniter stability

MANAGEMENT OF EROSION

Treatment of the etiology.

Identification of the etiology is important as a

first step in management of erosion .

If excessive dietary intake of acidic foods or

beverages is discovered, patient education and

counseling are important.

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If the patient has symptoms of GERD, then he/she

should be referred to a medical doctor for

complete evaluation and institution of therapy if

indicated.

A patient with salivary hypofunction may benefit

with the use of sugarless chewing gum of mints

to increase residual salivary flow.

The use of oral pilocarpine (Salagen) may be

beneficial in patients with dry mouth caused bySjogrens syndrome or post-therapeutic head and

neck radiation.

A patient suspected of an eating disorder should

be referred to a medical doctor for evaluation.

In some cases, an etiologic agent is not

identifiable.

In other cases, the etiologic agent may be

difficult to control, such as the problem of

alcoholism. However, regardless of the cause, it

is important to follow preventive measures to

prevent the progress of erosion. There are

several preventive measures that can be taken to

control tooth erosion.

Much of erosion prevention depends on the

compliance of the patient with dietary

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modification, use of topical fluorides, use of

occlusal splints, etc.

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BIBILOGRAPHY:-

Robinson HBG. Abrasion, Attrition and erosion of the

tteth. Health Center j Ohio State Univ. 3:21, 1949.

Rudolph CE A Comparative study in root resumption

in permanent teeth J am Dent Assoc. 23:822,1936.