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NON-CARIOUS CLASS V LESIONS: ASSESSING THE CAUSE Nichole Dicke, LDH, BGS
OBJECTIVES Identify the clinical characteristics of non-carious class V lesions Discuss the traditional suspected causes of these lesions Describe the theory of abfraction Compare the various types/sources of abfractive forces Identify potential co-contributers to class V lesionsDescribe patient evaluation procedures for diagnosing the cause of the lesions Describe the management and treatment of these lesions and their causes
A FAMILIAR SIGHTThese lesions are typically diagnosed as abrasion or erosion .
ABRASION: THOUGHTS TO CONSIDER * Home self-care….what if they’re doing it right?* Are we giving toothbrushes and toothpastes too much credit? Researchers think so. 1,2,3,4,5,6
ABRASION: THOUGHTS TO CONSIDER How can oral hygienetechnique, which all too often results in this…. ….also result in this?
EROSION: THOUGHTS TO CONSIDER* Location, location, location. * Where’s the acid source?
ABRASION AND EROSION: A FINAL THOUGHTHow could abrasion and/or erosion cause this?
SO WHAT’S REALLY GOING ON?Imagine Grandpa at the dining table.
ABFRACTION = PHYSICS Misallignment may cause teeth to: * “Hit early”* Occlude with the opposing tooth on a cuspal incline * Have heavy contact with opposing teeth
ABFRACTION = PHYSICS* Tongue thrust applies lateral pressure to the crown. * Remember: it’s the cumulative effect of repeated forces, not necessarily the amount of force applied.* And remember grandpa! He may not be very strong or heavy, but he can still cause damage over time.
ABFRACTION: THE RESEARCH * Controversial* Burden of Proof* Does it matter? Innocent until proven guilty!
ABFRACTION: THE RESEARCH Research tells us that:* Occlusal forces are concentrated at the cervical region.7,8,9 * Cervical enamel is inherently weak. 10,11,12
ABFRACTION: THE RESEARCH *Occlusal forces cause teeth to flex. *Cycles of occlusal loads on extracted teeth have causedcervical fractures after 2.5 months worth of “chewing”. 8,9 *Forces applied to cuspal inclines = more stress. 13*Heavy occlusal contact areas are directly associated with cervical lesions.14
ABFRACTION: THE RESEARCHResearch that DOES suggest toothbrush abrasion (suchas the 1960’s study pictured below) resulted in distinctive lesions. Abrasion from toothbrushing machine abfraction
ABFRACTION: OBSERVATIONAL EVIDENCE* Cervical lesions are frequently found on teeth with heavy wear facets.15 * Cervical lesions not commonly found on mobile teeth.12,16 Why? * Patient profiling15
ASSESSING FOR ABFRACTION: CONTACT POINTS*Occlusal indicator wax*Articulating paper*Pressure detecting sheets*Computerized assessment T-Scan II by Tekscan
ASSESSING FOR ABFRACTION: CONTACT POINTSHeavy contact markings Heavy markings on cuspal inclines
ASSESSING FOR ABFRACTION: CANINE GUIDANCE Canine Guidance Illustration
ASSESSING FOR ABFRACTION: CANINE GUIDANCE
ASSESSING FOR ABFRACTION: TONGUE THRUST*A healthy swallow involves the tongue and the palate.17*A tongue thrust swallow involves the tongue, palate, and the teeth.17*Some patients are at risk of developing a tongue thrust swallow. 17
ASSESSING FOR ABFRACTION: TONGUE THRUST *With the patient in centricocclusion, ask him to swallow, watch the tongue. *Watch for bubbles and saliva. *Tongue thrust may easily be corrected through therapy. Tongue thrust with abfraction
ASSESSING FOR ABFRACTION: MULTIFACTORIAL CONSIDERATIONS ? * The questionremains…..erosion, abrasion, or abfraction? * Why Does it have to beeither-or? Why not both, or even all?
ASSESSING FOR ABFRACTION: MULTIFACTORIAL CONSIDERATIONS * Erosion-Abfraction: Erosive agents seep into microfractures, undermining and the enamel. Even GCF may be errosive. 12,15,18 * Abrasion-Abfraction occurs when occlusal forces cause stress concentration in areas with external friction sources. 12 * Erosion-Abrasion, likewise, combines corrosive chemical exposures with external friction sources.12* Caries can also combine with erosion, abrasion, and abfraction. 12
TREATING ABFRACTIONS * Many practitioners do not restore cervical lesions unless necessary. * If the occlusal forces are not corrected, a cervical lesion will likely fail.* It is recommended that dentists consider making fine adjustments to the occlusion prior to placing composite restorations. 17* It has been speculated that isolated areas of recession, or clefting, is a precursor to abfraction and warrants an occlusal assessment. 17,19
TREATING ABFRACTIONS Occlusal adjustment exampleClassic abfraction affecting Canines and premolars. Heavy contacts on cuspal Contact points reduced.Patient experiences severe inclines. sensitivity tooth #12.
TREATMENT OF ABFRACTION Example continuedHeavy markings on opposing Contact point reduced. Canine guidance restored. tooth #21 Sensitivity on tooth End of case. #12 eliminated!
REMEMBER…The treatment isonly as good as the diagnosis.
REFERENCES1. Radentz WH, Barnes GP, Cutright DE. A survey of factors possibly associated with cervical abrasion of tooth surfaces. J Periodontol. 1976; 47: 148-542. Sangnes G, Gjermo P. Prevalence of oral soft and hard tissue lesions related to mechanical toothcleansing proceedures. Community Dent Oral Epidemiol. 1976;4:77-833. Saxton CA, Cowell CR. Clinical investigation of the effects of dentifrices on dentin wear at the cementoenamel junction. J Am Dent Assoc. 1981; 10:, 38-43.4. Sognnaes R, Wolcott R, Xhonga F. Dental erosion: erosion-like patterns occurring in association with other dental conditions. J Am Dent Assoc. 1972; 84: 571-82.5. Volpe A, Mooney R, Zumbrunnen C, et al. A longterm clinical study evaluating the effect of two dentifrices on oral tissue. J Periodont. 1975; 46: 113-8.6. Joiner A, Pickles MJ, Tanner C, et al. An in situ model to study the toothpaste abrasion of enamel. J Clin Periodontol. 2004; 31: 434-8.7. Nohl FS, McCabe JF, Walls AWG. The Effect of Load Angle on Strains Induced in Maxillary Premolars in vitro. British Society of Dental Research Meeting. University of Leeds. April 12-15 1999; Abstract no. 200.
8. Palamara D, Palamara JE, Tyas MJ, et al. Effect of stress on acid dissolution of enamel. Dent Mater. 2001; 17(2):109-15.9. Hanaoka K, Magao D, Mitusi K, et al. A biomechanical approach to the etiology and treatment of non-carious dental cervical lesions. Bull Kanagawa Dent Coll. 1998; 26(2) 103-11.10. Scott JH, Symons NBB. Introduction to Dental Anatomy, 9 th ed. 1982. Churchill Livingstone, Edinburgh, UK.11. Stanford JW, Paffenbarger GC, Kampula JW. Determination of some compressive properties of human enamel and dentine. J Am Dent Assoc. 1958; 57: 487-95.12. Grippo JO, Simring M, Schreiner S. Attrition, abrasion, corrosion, and abfraction revisited. J Am Dent Assoc 2004; 135: 1109-18.13. Rees J. The effect of variation in occlusal loading on the development of abfraction lesions: a finite element study. J Oral Rehabil. 2002; 29: 188-93.14. Takehara J, Tomotsugu T, Akhter R, et al. Correlations of noncarious cervical lesions and occlusal factors determined by using pressure-detecting sheet. J Dent. 2008; 36: 774-9.
15. Rees J, Hammadeh M. Undermining of enamel as a mechanism of abfraction lesion formation: a finite element study. Eur J Oral Sci. 2004; 112: 347-52.16. Kuroe T, Itoh H, Caputo AA, et al. Potential for load-induced cervical stress concentration as a function of periodontal support. J Esthet Dent. 1999; 11: 215- 22.17. Palmer B. The significance of lateral forces to the development of dental abfractions. Available at http://www.brianpalmerdds.com/lateralforce_abfract.htm. Accessed Jan 27, 2011.18. Bodecker CF. Local acidity: a cause of dental erosion-abrasion. Ann Dent. 1945; 4(1): 50-55.19. Solnit A, Stambaugh R. Treatment of gingival clefts by occlusal therapy. Int J Periodont Rest. March 1983:38-55. Intra-oral images used with explicit permission from Dr. Brian Palmer, DDS.