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Tooth Surface Loss (TSL)

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Tooth Surface Loss (TSL) Tooth Surface Loss (TSL) Sumamry This lesson is intended to give an overview of what to consider when treating patients with TSL, including the causes and management. Tooth surface loss can be physiological or pathological. These are distinguished by taking into account the patient’s age and the severity of tooth wear e.g. in a young person with severe TSL would be pathological, whereas in an older person with moderate TSL this may be physiological from normal use over the years. Buzz words: Erosion Abrasion Attrition Abfraction Tooth Wear Index (TWI) Basic Erosive Wear Examination (BEWE) Occlusal Vertical Dimension (OVD) Centric Occlusion (CO) Retruded contact position (RCP) Intercuspal position (ICP) Dahl Effect Diagnostic wax up Mock upsReviseDental.com Conformative Reorganised Splints (Michigan and Tanner, soft and bilaminar) Epidemiology (1) 77% of the adult population have tooth wear of some degree. (2) 15% of dentate adults exhibited moderate tooth wear (exposing substantial dentine) 2% of adults suffered from severe tooth wear (exposing secondary dentine or pulp) More prevalent in men (70%) than women (61%) Causes: There are 4 causes of tooth surface loss: 1. Erosion 2. Abrasion (Think abrasion= brushing aka an object other than an opposing tooth) 3. Attrition (Think attrition = teeth) 4. Abfraction Tooth surface loss is often a multifactorial problem. The different causes often appear simultaneously which potentiate their effects. It is important to identify the etiological factors of tooth wear so that the patient can be advised of ways to manage it. ReviseDental.com Erosion (3) Erosion is the loss of tooth substance by chemical action, not involving bacteria. (4) Erosion can potentiate the effects of other sources of tooth wear. Erosion can have different aetiologies: Intrinsic and/ or extrinsic Intrinsic: (3) Gastro-oesophageal reflux disease (GORD )-Please refer to Gastrointestinal diseases for more information about GORD. Vomiting - spontaneous or self-induced. This includes morning sickness. Note: Hyperemesis gravidarum. Eating disorders such as bulimia nervosa and anorexia nervosa. (5) A study found that frequency and duration of episodes were not linearly associated with the severity or number of eroded teeth.(6). Rumination - relaxation of lower oesophageal sphincter allows gastric contents to move into the mouth which is then re-swallowed (effortless regurgitation). This is uncommon. Extrinsic: (3) ReviseDental.com Drinks - Carbonated drinks, soft drinks (smoothies, juices, fruit flavoured water) and some alcoholic drinks, including dry wine, cider and alcopops are erosive. (7) Alcohol is also the most common cause of heart burn and chronic gastritis. (11) Food - Including citrus fruits and foods pickled in vinegar. Less well known foods that are acidic in nature include, brown sauce, crisps, ketchup and vinaigrette. Flavoured gum can also be erosive. Medications - Vitamin C, aspirin and some iron preparations. Medications that cause dry mouth (e.g. antihypertensives) potentiate the effects of erosion and other medications can cause nausea and vomiting. Beta-adrenergic bronchodilators that may be used for asthma therapy are associated with reduced saliva flow. This may lead to an increased risk of erosion. (8) Lifestyle - grazing habits, diet trends e.g. having lemon in water. Drugs - e.g. ecstasy can increase the risk of erosion. (9) Environmental - work related exposure e.g. battery workers, laboratory technicians and competitive swimmers. Predisposing factors - individual saliva flow and buffering capacity as well as clearance rates. (10) Other factors to look out for: (8) Some mouth washes can have a very low pH Orthophorphoric acid and guarana extract may be used in diet or normal colas. These can cause erosion. Slimming pills and laxatives cause dehydration and this may be a risk factor for erosion. Acetic acidsReviseDental.com are used to preserve fruits and vegetables so can cause erosion. Signs: (3) Restorations that stand proud. (8) Cupping of cusp tips. Extrinsic sources often manifest in TSL of the labial surfaces of maxillary teeth . Intrinsic sources normally manifest on the palatal aspect of maxillary anterior teeth. (11) Chamfered ridges or ledges that may be visible or felt with a probe. Grooves in incisal edges with dentine show. Incisal chipping. Shortened teeth. Mainly affects maxillary teeth (although can occur on any surface). Dentine exposure can cause the tooth to look darker and patients may complain about the aesthetics. Preventative management (3) Pt education Counselling on erosive habits Can be facilitated with information leaflets. Advise on acid attacks and importance of limiting acidic food and drink consumption to meal times. Acid attacks should be limited to 4 times a day. Better to drink a fizzy drink quickly than constantly sipping for a longer period of time. Role of milk or cheese in neutralising intra-oral acids and chewing sugar-free gum to increase saliva flow. The bufferingReviseDental.com effect of saliva Diet diaries to identify erosive food and drink. This should be recorded 3 days in a week including a day at the weekend. Advise against the frequent consumption of sports drinks if this is applicable, especially after exercise when saliva flow is lower. Behaviour education- holding drinks in the mouth or swishing the drink around the mouth increases the risk of erosion because it affects the tooth surface pH (13). Better to drink through a straw directed straight to the back of the mouth Oral hygiene advice Fluoride is important in remineralisation. Consider fluoride varnish application and prescription of a high fluoride toothpaste If the patient has just had an episode of vomiting, recommending to not brush their teeth for at least 20 minutes (ideally up to 60 mins) after the episode will help, as this will increase the risk of abrasive wear on the softened tooth surface.(14) Rinse with water or milk after an episode. Not to eat or drink anything after brushing their teeth before bed. Not to brush their teeth after consuming erosive food/ drink Referrals If suspected GORD then refer to a GP or gastroenterologist. Ensure the patient has given consent for this. If patients have an eating disorder, a referral to receive medical and psychological advice and counselling will help them, but ensure the patient has given consent and that confidentiality is maintained, e.g. the patient may not want a family member to know. ReviseDental.com Abrasion Abrasion is tooth wear caused by an object other than an opposing tooth. Sources of abrasion: Brushing (too hard) Biting pen lids Hobbies e.g. using teeth to hold onto fishing hooks or sewing needles. This can cause defects where the object would usually be placed. Musical instruments involving reeds can also cause abrasion. Industrial abrasives include dusts of silica, carborundum and diamond. Preventative management: Patient education on abrasive habits- holding objects between their teeth. Warning of brushing their teeth too aggressively. Recommendation of a softer toothbrush. The use of a non-abrasive toothpaste. (note: tooth paste abrasion count) ReviseDental.com Note: remember TSL can be multifactorial. This, alongside brushing aggressively may also have a high acidic diet. Attrition (8) Attrition is tooth wear caused by tooth to tooth contact. Risk factors: Parafunctional habits e.g. bruxism Conditions with abnormal neuromuscular activity and bruxism e.g. cerebral palsy Drug use e.g. MDMA, cocaine ("gurning") ReviseDental.com Signs: Scalloped tongue/ tooth indentations Masseter hypertrophy (tenderness in the muscle on palpation) Pronounced linea alba Reports of clenching and grinding (at night or during the day) Note: association with headaches Preventative treatment: Splint therapy (discussed later) ReviseDental.com Abfraction Occlusal loading leads to compression and flexion of the tooth. This can cause microfractures in the enamel rods in the cervical region leading to TSL. Signs Sharp cervical cavities ("Class V") Note: Degradation refers to the fusion of tooth wear on occlusal/ incisal surfaces with tooth wear on a cervical area. This occurs in a late stage of wear. (8) Tooth wear can expose the pulp but in adults this is very rare since the rate of wear is normally slow enough to allow sclerotic and reparative dentine to be formed. In these cases indirect pulp capping should be attempted and elective endodontics should be avoided because there is no bacterial invasion, unlike with caries.(8) ReviseDental.com Summary of clinical presentations: (8) Type Presentation Primarily affects the cusps of posterior teeth and palatal of anterior teeth. Chipping of the thin enamel margins of incisors.Molar and premolar teeth show cupping of the cusps. Erosion Anterior teeth can show cupping of the incisal edges. These can merge across the oblique and marginal ridges to form a bowl shape. Mandibular molar teeth often most severely affected in this instance. Margins of restoration may stand proud of the natural tooth. Flat, well defined and demarcated.Shiny if active progression. Complementary facets often present on the opposing teeth. Primarily affects the cusps of posterior teeth and the incisal edges and palatal of Attrition anterior teeth. Tooth indentations on the tongue (scalloped tongue). Pronounced linea alba. Masseter hypertrophy.Reports of clenching and grinding (at night or during the day). Cervical lesions. Abrasion Specific shaped lesions on incisal edges from holding objects in between teeth. Wedge-shaped
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