Erosion, Abrasion, Attrition and Abfrcation. We wonder why our teeth are sensetive

Tooth Tissue Loss - Erosion, Abrasion, Attrition and Abfraction; we wonder why our teeth are sensitive!

Sonia Jones RDH CFET

South West Post Graduate Dental Deanery DCP Advisor Devon/Cornwall

sonijones@hotmail.co.uk

www.bristol.ac.uk/dentalpg

Aims and Objectives

Aim: to ensure delegates understand how tooth tissue loss can be detrimental to dentine hypersensitivity

Objectives:

By the end of the session you should be able to:

Distinguish between erosion, abrasion, attrition and abfraction

Determine the causative factors of tooth tissue loss

Describe how to prevent further tooth tissue loss

Discuss sensitivity theories and explain the way they work

List topical medicaments available to relieve sensitivity

Tooth tissue loss

Tooth surface loss can arise as the result of:

Erosion

Abrasion

Attrition

Abfraction

Erosion

Abrasion

Attrition

Abfraction

Tooth tissue loss

Patients often seek treatment for pain

Function can be altered

Compromised aesthetics

All ages

Tooth tissue loss

The 4 types of tooth tissue loss all have their own characteristic appearance

However, the wear of a persons teeth is usually from a mixture of all 4, with one type of TTL predominating.

Sometimes difficulty in determining the dominant aetiology

The thickness of the pellicle and the pressure of the tongue contribute to the extent of the condition

Tooth Tissue Loss

Relatively slow progression

Study models

Indices

Photographs

Can all be helpful

Restorative treatment

Difficult to control

Very different to dental caries in appearance and causation

Erosion

Described as early as 1892 among Sicilian lemon pickers

Definition: The loss of tooth tissue by a chemical process that does not involve bacteria, acids are most commonly involved in the dissolution process

Non carious pathological loss of tooth tissue

Plaque not involved in the process

Clinical Presentation

Occurs most frequently on the palatal and labial surfaces of the incisor teeth

The effected surfaces appear smooth and highly polished with a scooped out depression

The lesion primarily occurs in the enamel

In more severe cases the dentine becomes exposed

As enamel loss progresses sensitivity to thermal changes are noticed

More persistent pain occurs in severe cases

Erosion

Erosion

Causes of erosion

Extrinsic factors

Intrinsic factors

Idiopathic factors

Extrinsic causes of erosion

Habitual consumption of highly acidic, low pH carbonated drinks, sports drinks or concentrated fruit juices

Alco pops, fruit flavoured alcoholic beverages and strong ciders

Causing a wide shallow lesion effecting the labial and palatal surfaces of the upper teeth

Extrinsic causes of erosion

Swishing or holding drinks in the mouth

Modern packaging has also been blamed, tetra pack, plastic bottles and cans directional flow onto teeth

Can extend from the labial and palatal lesions of the upper teeth to all surfaces of all teeth

Chemicl pH

Acids involved

The principal ingredient linked with erosion is citric acid, found in most fruit juices and soft drinks

Other fruit acids have an effect

The erosive effect is due to its low chemical pH

Also by chelation, the acids demineralise the enamel by binding to the calcium and removing it from the enamel

Cola type drinks may also contain phosphoric acids

While the pH of a drink is an indicator of its erosive potential, a measure called total titratable acidity is a better guide of how a liquid can dissolve a mineral

Total Titratable Acidity

Titratable acidity

How long it takes for the saliva to compensate

How much saliva (flow)

Buffering capabilities of the saliva

Citric acid the biggest culprit

Thickness of the pellicle can protect to a degree

Higher temperatures increase titratable acidity

Extrinsic causes of erosion

Habitual sucking of citrus fruits

The lesion may occur in either the upper or lower anterior teeth

Depending on the way the fruit is eaten

(Remember fruit eaten as a whole unit does not generally cause a problem)

Acidic foods

Pickles, sauces, vinegars, yoghurts, roasted vegetables

Extrinsic causes of erosion

Industrial atmospheric pollution

Chemical workers, battery manufacturers, crystal glass workers

Less common now due to stricter working conditions and regulations (H&S at work act 1978)

Acidic fumes effect the labial surfaces of the upper and lower anterior teeth

When talking or the mouth is at rest

Extrinsic causes of erosion

Chlorine, from gas chlorinated swimming pools

Professional swimmers

If the chemicals are not properly regulated

Less common now due to regulations

Intrinsic causes of erosion

From within the body

Usually hydrochloric acid from the stomach (pH 2)

Reflux

Regurgitation

Vomiting

Rumination

Rumination

The term rumination is derived from the Latin word ruminare, which means to chew the cud. Rumination is characterized by the voluntary or involuntary regurgitation and rechewing of partially digested food that is either reswallowed or expelled. This regurgitation appears effortless, may be preceded by a belching sensation, and typically does not involve retching or nausea.

Reflux, Regurgitation and Vomiting of gastric contents

Anorexia

Bulimia

Hiatus Hernia

Pregnancy/Hormones

Motion sickness

Obesity

Eating too much

Drinking too much

Alcoholism

Anorexia

Bulimia

Saturday Night?

Habitual regurgitation of gastric contents

Heavily acidic diet increases gastric erosion

The palatal surfaces of the upper anteriors and premolars are eroded

Produces wide shallow lesions

Enamel may be completely lost

Tackle the problem with care!

Patient might not admit to unattractive aspect of psychological illness

Idiopathic causes of erosion

Unknown cause

Patient will not admit to or be aware of intrinsic or extrinsic causes

Vigorous tooth brushing can contribute to an over polished appearance - shiny

Abrasion

Definition: The abnormal wearing away of tooth tissue by a mechanical process

The location and pattern of abrasion is directly dependent upon its course

It usually occurs on the exposed root surfaces when gingival recession has exposed the cementum

It may be seen on the incisal or inteproximal surfaces of the teeth

Causes of Abrasion

Incorrect or destructive use of a toothbrush

Use of an abrasive detrifice

The enamel and dentine is worn away to produce a V shaped notch at the neck of the tooth

Areas most affected are the labial and buccal surfaces of the canines and premolars

Powerful back hand, RHS of right handed person

LHS of Left handed person

Para functions, habits, occupations

Mainly affects the incisal edges of the anterior teeth

Clinical appearance of Abrasion

Worn, shiny often yellow/brown areas at the cervical margin

Worn notches on the incisal surfaces of the anterior teeth

Abrasion

Abrasion

Causes of Abrasion

Seamstresses pins, Carpenters nails, Hairdressers hairgrips

Pipe smokers, nail biters, causing notching

Attrition

Definition: The physiological wearing away of the tooth surface as a result of tooth to tooth contact as in mastication

Occlusal and incisal surfaces of the teeth most commonly affected

May also affect the proximal surfaces of the teeth due to slight movement of the teeth in their sockets during mastication

Age related process

Varies from person to person

Attrition

Causes:

Bruxism

Abrasive (gritty) diet

Constant chewing tobacco/ betel nut

Marked malalignment or malocclusion

Loss of posterior teeth

Occupational, dust/grit mixed with saliva

Clinical appearance of Attrition

Polished facets on enamel surfaces

Cupping dentine is exposed

Occasional full loss of enamel, dentine is exposed and stains heavily

Attrition

Attrition

Ranges from part of the enamel being worn away in the early stages to the full thickness of the enamel wearing away in advanced attrition

The dentine may be exposed and stained

In extreme cases the teeth may be worn down to the gingivae

Attrition

Attrition

Process of attrition is slow

Secondary dentine is laid down to protect the pulp chamber and the pulp chamber narrows

Pain is rarely associated with attrition

Men usually show a greater degree of attrition than women

Severe attrition is seldom seen in deciduous teeth, (not retained for long)

However if a child suffers from dentinogenesis imperfecta (an hereditary disorder of the dentine) pronounced attrition may result from mastication

Abfraction

Definition: The pathological loss of enamel and dentine due to occlusal stresses

Recently interest has grown in the development of cervical abrasive lesions

The term abfraction has been used to describe these cervical lesions

Some Clinicians do not believe that this is the reason and that erosion and abrasion cause the wear facets, research continues

Abfraction

Causes of Abfraction

Occlusal forces which cause the tooth to flex, cause small enamel flecks to break off, inducing the abrasive lesions

Usually wedge shaped lesions with sharp angles found at the cervical margins

However can be found on the occlusal surfaces, presenting as circular areas

These lesions can occur with occlusion alone or as with most TTL cases which are multi factorial, can be associated with toothbrush abrasion

These lesions are often diagnosed as toothbrush abrasion, but they differ as their angles are sharper

Abfraction

Common in patients with poor tooth alignment

Can be associated with:

Anterior open bite

Occlusal restorations that change the cuspal movements

Abnormal tongue movement

Treatment of Tooth Tissue Loss

Relieve sensitivity and pain fluoride, desensitising agents/toothpastes

Identify aetiological factors modify diet/habits, eliminate acidic foods/drinks, stop habitual practices, gentle tooth brushing techniques

Protect the remaining tooth tissue reconstruct the effected teeth, restorations, inlays/onlays, crowns, check occlusion

Bite raising devices/splints

Referral to TTL Expert

Prevention of further episodes

Treatment Plan

Take a detailed history from the patient

Examination

Radiographs

Vitality testing

Patients wishes/needs

Study models

Photographs

Indices

Indices BEWE

Basic Erosive Wear Examination

0 No Erosive Wear

1 Initial loss of Surface texture

2 Distinct defect, hard tissue 50% of the surface area

* (2,3) dentine involved

Tooth wear index according to Smith and Knight

Score Surface Criteria

0 B/L/O/I No loss of enamel surface characteristics

C No loss of contour

1 B/L/O/I Loss of enamel surface characteristics

C Minimal loss of contour

2 B/L/O Loss of enamel exposing dentine for less than one-third of

the surface

I Loss of enamel just exposing dentine

C Defect less than 1mm deep

3 B/L/O Loss of enamel exposing dentine for more than one-third

of the surface

I Loss of enamel and substantial loss of dentine

C Defect less than 1-2mm deep

4 B/L/O Complete loss of enamel, or pulp exposure, or exposure of

secondary dentine

I Pulp exposure or exposure of secondary dentine

C Defect more than 2mm deep, or pulp exposure, or exposure

of secondary dentine

Sensitivity

Dentine Hypersensitivity Dentine is the highly sensitive part of the tooth

Patients suffering from dentine hypersensitivity often think that they have developed a cavity or lost a filling

On examination there is often no obvious reason for their pain, gingival recession is sometimes evident

The amount of recession does not seem to correlate with the amount of pain they are experiencing

c/o short sharp episodes of pain caused by temperature, touch by metal, sweet foods/drinks

Patients can be very distressed by the pain of dentine hypersensitivity and often avoid the causative stimuli as much as possible

Sensitivity

Women more pre disposed than men

Age 20-40

Ranges from 15-70

Dentine

Made up of dentinal tubules

Looks like honeycomb under the microscope

Similar in composition to bone

Can remodel itself and lay down reparative and secondary dentine

When exposed to the oral environment can be sensitive

Dentine

Larger tubules = more pain

More open tubules = more sesitivity

Dentinal tubules

Dentine Hypersensitivity Theories

3 theories as to how we feel the pain of dentine hypersensitivity

Dentine Innervation Theory

Odontoblast receptor theory

Hydrodynamic theory

Dentine Innervation Theory

Nerve fibres from the Nerve Plexus of Raschkow (next to the dentine /pulp boundary, along side the Odontoblast activity) penetrate the dentinal tubules and cause impulses

Not the most likely theory: whilst the nerve fibres do penetrate the tubules, there are not enough of them and they do not penetrate deeply enough into the tubules to pass on impulses

Odontoblast Receptor Theory

Proposes that Odontoblasts receive and pass on impulses and that when they are touched cause the sensation of pain

Not the most likely theory: as there are no synapses between the Odontoblasts and the Nerve Plexus of Raschkow

(Synapses junctions between neurones where chemicals transmit the impulse)

Hydrodynamic Theory

Most likely theory: Answers more questions

Lymph like fluid inside the dentinal tubules is stimulated by temperature, touch and sweet sensations, causing it to flow backwards and forwards within the tubules, this gives the sensation of pain

Hot/cold causes expansion/contraction causing the fluid to flow

Salt/sweet causes osmotic pressure, flows towards the concentrate

Tactile/Electrical (Touch) ?! contraction of the fluid?

Research continues, what they do know is how to treat it

Dentine Hypersensitivity Treatments

Most commonly treated by:

Mechanical Barriers

Stimulation of Peritubular or Reactive Dentine

Increasing potassium concentrations

Mechanical Barriers

Applied over the open ends of the Dentine Tubules

Restorations Glass ionomers, Composites, Inlays/Onlays, Dentine bonding agents that form a chemical bond with the dentine locking into the tubules, Resins/Adhesives

Tubule occluding toothpastes need to be replaced daily

Stimulation of Peritubular or Reactive Dentine

The dentine lays down a protective layer

High concentration fluoride Duraphat Varnish, Gel Kam (Fluorigard gel)

Siloxane Esters Tresiolan, Sensitrol etc

Both will wear off so need to be reapplied

Fluoride

Fluoride irritates the dentine

It irritates the dentine sufficiently for it to lay down a secondary layer and therefore protect the tooth from further stimuli

It does this by occluding the tubules

Mouthwashes daily 0.05% and weekly 0.2% solutions

High fluoride toothpastes - Duraphat 2800, 5000

Varnishes Duraphat 2.26% 22,000ppm

Gels 0.4% stannous fluoride

Increase Potassium Concentrations

Nerve Depolarising

Potassium chloride, Potassium Nitrate, Potassium Citrate found in desensitising toothpastes increase the potassium concentrations around the nerve plexus

This prevents action potentials being transmitted (nerve impulses)

By keeping the sodium outside the cell wall

Nerve Impulses

Sodium is attracted to Potassium

By increasing the Potassium levels outside the nerve cell walls, the Sodium stays outside and doesnt diffuse in

This stops the nerve impulse

Depolarisation

Action Potentials Nerve Impulses

Sodium Potassium Exchange

Toothpaste Claims

Nerve Depolarising Toothpastes

Tubule Occluding Toothpastes

Each manufacturer claims that their toothpaste has the best technology

Do they work?

Sensodyne

Traditionally Nerve depolarising toothpastes

Active ingredients :

- Potassium Nitrate + Sodium Fluoride

- Potassium Chloride + Sodium fluoride

Potassium keeps the sodium outside the cell wall

By adding the fluoride to the newer types of Sensodyne you get the tubule occlusion phenomenon caused by dentine irritation and laying down of a secondary layer

Sensodyne Pronamel

Claims to reharden softened enamel

- be low in abrasives to prevent further tooth tissue loss

Active ingredient Potassium Nitrate + Sodium Fluoride

?

Sensodyne new Occluding toothpaste

Sensodyne Rapid Relief

Active Ingredient Strontium Acetate + Sodium Mono-fluorophosphate

Published studies support the mode of action and tubular occlusion occurs

but:

Strontium Chloride Sensodyne Original, occludes tubules! However as it reacts with fluoride became less popular

Colgate Sensitive Pro Relief

Pro Argin Technology

Active Ingredients: Arginine, Calcium Carbonate, Hydroxyapatite, Sodium Mono-fluorophosphate

The Arginine complex binds to the tooth surface, it is positively charged this is attracted to the negatively charged dentine

It encourages a calcium rich mineral layer into the open (exposed) dentine tubules

This acts as an effective plug (tubular occlude)

Resistant to acid attacks

Needs to be reapplied twice daily

Other Brands

Enamel Care toothpaste - Amorphous Calcium Phosphate ACP (soluble salts of Calcium and Phosphate): highly soluble and there is limited data in the treatment of Dentine Hypersensitivity

Recaldent (Toothmoose) CCP-ACP Casein Phosphates, derived from milk proteins mixed with the calcium and phosphate salts: no apparent published clinical data on its effects of reducing Dentine Hypersensitivity

Blanx, Biorepair- Hydroxyapatite + Sodium Mono-fluorophosphate: tubular occlusion but limited published data

Monitoring

Treatment of active tooth tissue loss

Fluoride toothpastes/ mouthwashes/gels

De sensitising toothpastes

Study models

Photographs

Indices

Identify causative factors

Prevention

Limit acidic food and drink to meal times

Eliminate from diet

Cut down on carbonated beverages

Eat citrus fruits whole not sucked in 1/4s

Do not hold/swish drinks

Use a straw

Refer to specialist

Refer to councillor for eating disorders/alcohol addiction

Refer to GP gastric problems

Milk or cheese after meals to neutralise acids

Avoid toothbrushing after an acid attack

Aims and Objectives

Aim: to ensure delegates understand how tooth tissue loss can be detrimental to dentine hypersensitivity

Objectives:

By the end of the session you should be able to:

Distinguish between erosion, abrasion, attrition and abfraction

Determine the causative factors of tooth tissue loss

Describe how to prevent further tooth tissue loss

Discuss sensitivity theories and explain the way they work

List topical medicaments available to relieve sensitivity

Thank you