Dr./ Basant Hamdy PhD, MSc, BDS Oral Pathology Lecturer  Email [email protected] References & suggested reading Regressive

• Becoming or making something less advanced (Oxford dictionary)

• Return to former or earlier state (Medical dictionary)

DR_Basant Hamdy DR_Basant Hamdy Enamel Dentin Wear (, Dead tracts Abrasion, Erosion) Sclerotic dentin Permeability Secondary dentin Discoloration Tertiary dentin

Cementum Pulp Pulp calcification Fibrous change Permeability Cementum in pulp Resorption & repair

DR_Basant Hamdy DR_Basant Hamdy

• Non-specific term refers to the process of non-carious tooth damage/ tooth surface loss. • Attrition, abrasion & erosion causes tooth wear. • A combination of these processes may be active in the same patient.

DR_Basant Hamdy DR_Basant Hamdy Attrition • Definition

Progressive loss of tooth structure due to tooth-to-tooth contact during occlusion & mastication.

DR_Basant Hamdy Attrition • According to severity

1. Physiologic → advances with age

2. Pathologic → excessive tooth loss – interferes with esthetics or function

DR_Basant Hamdy Sites: incisal, cusp tips, inter-proximal. Males < females DR_Basant Hamdy Factors affecting rate of tooth attrition

1. Poor quality or absent enamel (e.g. fluorosis, hypocalcification, amelogenesis imperfecta, dentinogenesis imperfecta).

2. Premature contacts (edge-to- edge occlusion).

DR_Basant Hamdy Factors affecting rate of tooth attrition

3. Intraoral abrasives, erosion & grinding habits ().

4. Habits such as tobacco & betel chewing.

DR_Basant Hamdy Wear facets

✓ Large, flat, smooth & shiny facets.

✓ Affects deciduous & permanent teeth.

✓ Proximally, arch length & mesial drifting.

DR_Basant Hamdy Radiographic features

• Change in normal outline. • Loss of mammelons. • Flat occlusal plane. • Decreased Pulp chamber/ canal size. • Hypercementosis.

DR_Basant Hamdy Microscopic features

• Formation of reactionary dentin (C) protects pulp.

• Formation of dead tracts (A) & sclerotic dentin (B).

DR_Basant Hamdy DR_Basant Hamdy Abrasion • Definition

Pathologic loss of tooth structure due to the action of an external agent “non- masticatory physical friction”.

DR_Basant Hamdy Etiological factors

1. Abrasive with heavy pressure.

2. trauma (horizontal strokes).

3. Improper use of

DR_Basant Hamdy Etiological factors

4. Other items: pencils, toothpicks, pipe stems & bobby pins (hair grips).

5. Chewing tobacco or betel

DR_Basant Hamdy Toothbrush abrasion • Horizontal cervical notches on buccal surface of exposed cementum & dentin. • Degree of loss is greatest on prominent teeth (i.e.: cuspids, bicuspids). DR_Basant Hamdy Pipe stem Bobby pin Rounded or V-shaped incisal notches conform to outline of the object DR_Basant Hamdy Toothpick abrasion

• Radiolucent defects at cervical region.

• Well-defined semilunar defects (loss of proximal dentin/ cementum).

• Pulp chambers sclerosed.

DR_Basant Hamdy DR_Basant Hamdy Erosion • Definition o Loss of tooth structure caused by a non- bacterial chemical process.

Etiology

1. Extrinsic 2. Intrinsic 3. Idiopathic DR_Basant Hamdy 1. Extrinsic a. Dietary

• Food/ beverages with acidic pH: ✓ Citrus fruits & carbonated soft drinks (ex. Cola).

pH 3.5 pH 2.5

DR_Basant Hamdy 1. Extrinsic b. Occupational (environmental) - Exposure to industrial gases + saliva → pH. - Acidic swimming pool water

c. Medication (ex. Some products has acidic pH, xerostomia potentiates effect)

DR_Basant Hamdy 2. Intrinsic o Acid reflux or chronic vomiting (GERD, patients on chemotherapy, bulimics)

3. Idiopathic o Increased levels of citric acid in saliva

DR_Basant Hamdy Extrinsic • Smooth, saucer-shaped concavities on labial surfaces. • Loss of translucency (opaque). DR_Basant Hamdy Intrinsic ‘Perimolysis’ • Flattened, concave palatal surfaces. • Loss of occlusal enamel with relative elevation of occlusal amalgam above remaining DR_Basanttooth Hamdy surface. DR_Basant Hamdy • Dead tracts.

• Sclerotic dentin.

• Secondary dentin.

• Reparative & Reactive dentin.

DR_Basant Hamdy ➢ Write an assignment on Pulp stones indicating:

- Types - Mechanism of formation - Signs (clinical/ radiographic) - Microscopic features - Clinical significance

DR_Basant Hamdy DR_Basant Hamdy • Hypercementosis (cemental hyperplasia)

✓ Non-neoplastic deposition of excessive cementum, continuous with the normal radicular cementum.

• Cementoblast precursors lie in PDL & are recruited in normal turnover + repair root fractures or resorption defects. • New cementum is added without significant resorption → cementum increases slightly with age.

DR_Basant Hamdy Etiological factors

1. Local factors 2. Systemic factors - Abnormal - Acromegaly & gigantism - Unopposed teeth - Thyroid gioter - Adjacent inflammation - Paget disease of bone (pulpal, periapical & - Rheumatic fever periodontal) - Arthritis Localized Generalized (single tooth/ multiple teeth) (entire dentition) DR_Basant Hamdy Radiographic features

• Blunting of apex. • Rounded outline of the root. DR_Basant Hamdy Radiographic features

• Normal lamina dura. • Normal periodontal ligament space. • D.D.: Cementoblastoma

DR_Basant Hamdy Microscopic features

• Dense bone-like cementum (osteocementum) formed over regular acellular cementum.

DR_Basant Hamdy Complications / clinical significance

• May delay eruption. • May cause root curvature. • May cause fusion of adjacent roots. • Difficult extraction. • If generalized, it can point to a more serious condition.

DR_Basant Hamdy DR_Basant Hamdy • Resorption of roots of deciduous teeth prior to shedding.

DR_Basant Hamdy • Mediated by cells:

Located in dental pulp (i.e., In periodontal ligament (PDL) internal resorption) (i.e., external resorption).

DR_Basant Hamdy • Occurs at any site that contact vital pulp tissue, may be: 1. Secondary to . 2. Idiopathic (most cases). • Usually asymptomatic. • Pain if significant pulpitis present. • Two main patterns: a. Inflammatory b. Replacement (metaplastic)

DR_Basant Hamdy Inflammatory resorption

• Dentin replaced by inflamed granulation tissue. • Cervical zone is affected most frequently. • Inflammation usually due to bacterial invasion. • Resorption continues as long as vital pulp remains.

An Insight into Internal Resorption DR_BasantPriya Thomas, Hamdy Rekha Krishna Pillai, Bindhu Pushparajan Ramakrishnan, and Jayanthi Palani Inflammatory resorption

• In crown: Pink tooth of Mummery (Pink spot).

• Radiographically: - Balloon-like/ fusiform enlargement of the canal.

DR_Basant Hamdy Microscopic features

• Loose CT with increased vascularity & few inflammatory cells.

• Cases associated with pulpitis, “granulation tissue”.

• Odontoclasts-giant cells.

DR_Basant Hamdy • Affects external surface of the root. • Radiographically: moth-eaten radiolucent defects.

• Dental trauma • Periodontal treatment • Excessive mechanical forces • Peri-radicular inflammation (e.g. orthodontic therapy) • Pressure from impacted teeth • Excessive occlusal forces • Reimplantation of teeth • Grafting of alveolar clefts • Cysts • Hormonal imbalances • Tumors DR_Basant Hamdy Several forms of external resorption: 1. Idiopathic lesions (in the cervical areas) 2. Traumatic incidents (midroot area) 3. Inflammatory or neoplastic lesions (usually at the apex)

DR_Basant Hamdy Several forms of external resorption: 4. Impacted teeth (mottled radiolucent areas in the crown) 5. Aggressive orthodontic movement (localized or generalized pattern)

DR_Basant Hamdy DR_Basant Hamdy • Internal resorption • Removal of all soft tissue from site of resorption. • Endodontic treatment before perforation. • Placement of calcium hydroxide paste. • Extraction if untreatable. • External resorption • Identification and elimination the accelerating factor. DR_Basant Hamdy سُبحانَكَ اللهُمّ وبِحمدِك نَشهَدُ أن ال إله إال أنت نَستَغفِرُكَ ونتوبُ إليك

DR_Basant Hamdy