• Non carious tooth tissue loss is defined as surface
loss due to a disease process other than dental
caries. (Pual A Brunton ,Decision making in Operative
• Although decay is the usual cause of tooth
destruction necessitating operative procedures , it
has been estimated that 25% of tooth destruction
does not originate from a carious process .
The etiology of the non carious tooth surface lesions
( John O Grippo,Marvin Simmering,JADA 2004
Osborne-Smith KL, Burke FJ, Wilson NH.
Int Dent J. 1999 Jun;49(3):139-43. Review)
• Defined as the mechanical wear of the incisal or occlusal
surface as a result of functional or parafunctional
movements of mandible (tooth to tooth contacts)
• It is an age dependent ,continuous process usually
• It also includes the proximal surface wear at the contact
area because of the physiologic tooth movement
Attrition can predispose to or
precipitate any of the following :
A) Proximal surface attrition (proximal surface
• Results from surface tooth structure loss and flattening ,
widening of the proximal contact areas.
• Surface area proximally increases in dimension , which is
susceptible to decay.
• Mesiodistal dimension of the teeth is decreased, leading to
drifting , with the possibility of overall reduction in the dental
B) Occluding surface attrition
( OCCLUSAL WEAR)
It is the loss ,flattening , faceting or reverse cusping of
the occluding elements.
It leads to loss of vertical dimension of the tooth .
a. If the LOSS IS SEVERE & accomplished in a relatively
there would be no chance for the alveolar bone to erupt
occlusally to compensate for the occlusal tooth loss, &
therefore the vertical loss might be imparted to the face
overclosure during mandibular functional movements & strain
areas on stomato-gnathic system.
a. if the loss occurs over a long period-
the alveolar bone can grow occlusally, bringing the teeth to
their original occlusal termination.
i.e vertical dimension loss will be confined to teeth but not
imparted to face.
Deficient masticatory capabilities
Cheek bitingvertical overlap between the working inclined planes will be
lost, which will cause surrounding cheek, lip, tongue to be
fed between the teeth.
Decay- because the underlying dentin will be exposed &
thereby becomes more susceptible to decay.
Clinical presentation :
• Attrition in its purest form is seen as flattened
• The degree of wear in both arches is normally equal.
• Sometimes there may be presence of peripheral, ragged,
sharp enamel edges .
• The presence of hypertrophic masseter is a warning
sign of the impact of bruxism .
• TMJ problems can be elicited especially by the over
closure situation ( will overstretch the joint ligaments ).
• Severe occluding surface attrition → predominantly
horizontal masticatory movement of the mandible →
extreme strain on the muscles of stomatognathic system .
• When surface attrition is SLOWER & compensated by,
intrapulpal deposition of secondary & tertiary dentin, then
there will be no pulpal exposure.
• At other times, the attrition is faster than the intrapulpal
dentine deposition, leading to direct pulpal exposure.
The treatment must involve several modalities ,which
should be chosen and initiated in the following sequence:
• Pulpally involved teeth →endodontic therapy /extraction
depending upon their restorability .
• Para functional activities ,( bruxism)-- be controlled with
protecting occlusal splints.
• Myofunctional , TMJ/ any other symptoms in the stomatognathic system -----diagnosed and resolved (modifying the
• Occlusal equilibration : should be performed by :
Selective grinding of tooth surfaces that includes
rounding and smoothening the peripheries of the occlusal
And by creating adequate overlap between the working
inclines to prevent further cheek biting.
• Any exposed sensitive dentin should be protected and
actual carious lesion be obliterated .
• Periodontium be examined and any pathology be
• Restorative modalities can than be initiated.
Restorations are only needed in the following situations:
Noticeable loss of vertical dimension
Or a progressive loss of tooth structure is observed
compromising the tooth strength .
Caries ,if present
Defect contributes to a periodontal problem.
Worn tooth contour, (usually proximal ) which is not
conducive to the maintenance of periodontium .
A tooth is cracked or endodontically treated.
• The most involved treatment modality is regaining the
lost vertical dimension .
• Verify and reverify its necessity i.e. one should make
sure that alveolar bone did not grow occlusally at the
same pace at which attrition occurred .
• Amount of V.D. lost is estimated .
• It gives an estimate up to what should be the height of
the worn clinical crowns be increased .
• The additional V.D. that the stomognathic system can
accommodate without untoward effects is estimated.
• Hence , if a substantial increase in the dimension is to be
considered (>2mm), it is wise to build a temporary restoration
or removable occlusal splint that can be easily adjusted
through subsequent addition or removal of material .
• Composite temporary restorations are most frequently used.
• Permanent restoration should be done in a cast alloy material
to preserve the remaining the tooth structure and to assure
the integrity of the supporting tissues. .
• A fully adjustable articulator ,hinge axis determination ,use of
pantographic tracings and face bow records are essential for
such cases .
• These restorations should be cemented only temporarily
for an extended period of time ,until it is established
that no untoward symptoms would occur.
• An acrylic splint ( as a stabilization splint) may be
necessary to protect the dentition from further damage
due to attrition and this is frequently the only treatment
required to prevent further tooth tissue loss .
• Can also be used as a diagnostic aid ( esp. if an increase in
the vertical dimension is planned subsequently )
The splint would need to be relined with cold cure acrylic resin to
improve the retention of the appliance and occlusal adjustments
will typically be required
• tooth wear can be followed and re-evaluated during recall
• When the wear requires restorative intervention, less
severe anterior wear can be treated with adhesive
(Strassler HE, Kihn PW, Yoon R. Conservative treatment of the worn
dentition with adhesive composite resin. Contemp Esthet Restor Pract.
• When the wear is more severe, a number of treatment
modalities are available.
Bonded porcelain veneers have been used to treat incisal
(Ibsen RL, Ouellet DF. Restoring the worn dentition. J Esthet Dent.
• In some cases, the incisal edges can be restored to the
original vertical dimension with direct composite resin.
(Strassler HE, Kihn PW, Yoon R. Conservative treatment of the worn dentition
with adhesive composite resin. Contemp Esthet Restor Pract. 1999)
• Hemmings and coworkers reported on the restoration of
severe anterior wear with composite restoration
including re-establishment of the occlusal vertical
dimension. They reported a 89.4% success at 30
( Hemmings KW, Darbar UR, Vaughan S. Tooth wear treated with direct
composite restorations at an increased vertical )dimension: results at 30
months. J Prosthet Dent. 2000;83:287-293.
• Adhesive cast metal restorations have also been
used to replace missing tooth structure.
( Nohl FS, King PA, Harley KE, et al. Retrospective survey of resinretained cast-metal palatal veneers for the treatment of anterior
palatal tooth wear. Quintessence Int. 1997)
• In cases where the occlusion is severely altered by
attrition, the only treatment choice may be a
reconstruction with crowns and bridges.
(Stewart B. Restoration of the severely worn dentition using a
systematized approach for a predictable prognosis. Int J
Periodontics Restorative Dent. 1998;18:46-57.)
The Dahl concept
• In this approach, space is created by placing restorations
intentionally ‗high‘ – i.e. in supra-occlusion – allowing axial tooth
movement that, over time, re-establishes complete occlusion.
• This principle was known prior to the publication of Dahl‘s work
in 1975. For example, the anterior bite platforms of removable
orthodontic appliances have long made use of this effect
(Cousins AJ, Brown WA, Harkness EM, 1969).
• Dahl and his coworkers (1975) were, however, the first to
describe how it may be used in the management of the worn
dentition. They described the use of a ‗partial bite raising
appliance‘ to create inter-occlusal space in an 18-year-old patient
with severe localised attrition.
• The removable appliance was cast in cobalt-chromium, placed on
the palatal aspects of the upper anterior teeth, and worn 24
hours a day.
• After a period of eight months sufficient
space was created
to restore the worn upper anterior teeth.
• once sufficient inter-occlusal space had been
created. However, the creation of interocclusal space significantly reduced the
amount of tooth preparation required,
especially on the already compromised palatal
• teeth were restored with full coverage
porcelain bonded crowns
2 schools of thought to increase the V.D.
• Addition of increments : gradual increments by
progressively adding to the hard splint at 1mm /week,
until the patient reaches the increased V.D. for
restorative purposes----time consuming
• The second approach ----taking the patient immediately
to a needed increase in V.D.----considerably lesser
adjustments are made ,lesser time consuming
•To ensure that the patient is able to tolerate the increase in
the vertical dimension , it is necessary to wear the appliance
for at least 6- 8 weeks
(12 hours /day ,generally evenings and nights)
• At this time if the muscles of mastication are flaccid and
show no tenderness to palpation and the TMJ‘s are free
from pain , palpation and opening clicks , then it is usually
safe to proceed , to the restorative care .
Anterior Bite plane
• Used in the reduction of overbite.
• Occurs by altering the rate of eruption of posterior teeth relative to the eruption
of lower incisors that are in contact with the bite plane.
• Overbite reduction by this method ---most successful in actively growing patients
• Overbite reduction should be evident within first two
months of fitting the appliance .
• It is important to increase the thickness of bite plane
slowly with progressive additions of cold cure acrylic
as the overbite reduces .
• In certain cases intentional endodontic therapy has to be
performed in hyper erupted teeth or drifted teeth, worn
that have to reduced drastically, that pulp is certain to be
• Careful examination of the color changes in pulp chamber
floor ,along with aids like magnification and
transillumination can help safely locate the canals .
Additional aids like:
staining the pulp chamber floor with 1%methylene blue dye .
searching for canal bleeding points .
Performing the sodium hypochlorite ―champagne bubble test
―are helpful in locating calcified.
Long ,thin Ultrasonic tips can also be used
Treatment strategies for Dentinal
( DCNA 53 ,2009; 47-60)
There are a number of treatment options for managing
dentinal hypersensitivity .
Can be broadly be categorized into :
1. Nerve desensitization
2 .Anti-inflammatory agents
3. Covering or plugging dentinal tubules
• calcium hydroxide
• sodium fluoride
• A number of studies have reported the efficacy of
potassium nitrate for managing dentinal hypersensitivity
• Tarbet et al demonstrated that potassium nitrate at a
concentration of 5%in a low abrasive tooth paste was able
to desensitize dentin for up to 4 weeks compared to a
control paste .
• In bio adhesive gels at a concentration of 5% and 10% has
also been shown to be effective in reducing dentinal
hypersensitivity .(Freschoso SC,Menendez M,2003)
Anti inflammatory agents
• It has been suggested that application of anti-inflammatory
drugs such as glucocorticoids to the cavity preparation may
reduce dentinal hypersensitivity by their effect on pain
Lawson and Huff found that paramethasone had a significant
• Furseth and Mjor reported complete obturation of dentinal
tubules after corticosteroid application to exposed dentin ,thus
reducing dentin permeability.
However there is a little experimental evidence to support or
refute the use of such agents .
Covering or plugging dentinal tubules .
• It has little or no effect on the dentine sensory nerve
activity (Trowbrdge H ,Edwall L ,1982)
• However it is thought that it induces peritubular dentin
remineralization and less hypersensitive dentin .(Mjor IA
• Levin and colleagues found that application of Ca(OH)2
paste to hypersensitive exposed dentine resulted in an
immediate decrease of dentinal hypersensitivity in over
90%of treated teeth .
• Many clinical studies have shown that the treatment of
exposed root surface with fluoride toothpaste (1.1%)
and conc. fluoride solutions(0.2%) is very efficient in
managing dentinal hypersensitivity. (Minkow
B,1975;Kerns D G 1991)
Tal et al suggested that the probable desensitizing
effects of fluorides are related to precipitated
fluoride compound mechanically blocking the exposed
• Tooth pastes containing sodium monoflourophospshates have
been shown to be effective in managing dentinal
(Hernandez F,Mohammed C,1972)
• It does not appear to act by occluding dentinal tubules since
scanning electron microscopic studies have failed to
demonstrate any visual changes to the dentinal surface
treated with it .(Addy M ,1983)
• Any tubule occlusion which might occur does not appear to be
permanent .(Tarbet WJ et al ,1983)
• Its mechanism of action is unclear (,Scherman A et al 1992)
• Stannous fluoride in aqueous solution or in glycerin gelled
with carboxymethylcellulose is effective in controlling
(Miller JT et al 1969)
Mode of action appears to be through induction of high
mineral content which creates a calcific barrier blocking
the tubular openings on the dentine surface .
(Furseth R ,1970)
• Alternatively ,it may precipitate on the dentine surface
leading to occlusion of the exposed dentinal tubules
• It is the process of influencing ionic motion by an
electric current and has been used as a desensitizing
procedure in conjunction with sodium fluoride .(Mc Fall
Studies report that there is a immediate reduction in
sensitivity after treatment with iontophoresis, but the
symptoms gradually return over the next six months
(Kern DA et al 1989 )
This method has gained popularity but more controlled
studies are required .(Gillian DG et al 1990)
• It has been shown that potassium oxalates have both tubule
obturation properties and inhibitory effects caused by
potassium ions on nerve activity (Pashly DH ,1986)
• Oxalate ion reacts with calcium to form insoluble calcium
oxalate crystals that bind tightly to dentin and obturate
dentinal tubules (TrowbridgeHO,1990)
Three types of oxalates are available :
6% ferric oxalate (Sensodyne Sealant )
30% dipotassium oxalate( Butler Protect )
3% monohydrogen monopotassium oxalate
• It has been proposed that the ions occlude dentinal tubules by
binding to the tooth substance and stimulating reparative
• It has also been suggested that strontium ions have the
capacity to reduce sensory nerve activity, but less effectively
than potassium ions.
(MarkowitzK , kim S 1990).
• Dentifrices containing 10% strontium chloride (Sensodyne) -widely used as desensitizing agents and were one of the first
agents to be marketed for that purpose.
• Cohen found that 67% of the subjects using a strontium
chloride containing toothpaste reported complete relief of
dentinal hypersensitivity within a 2 month period.
• Protein precipitants
• Claims have been made that Formaldehyde and
glutaraldehyde through their ability to precipitate salivary
proteins in the dentinal tubules, can be used to manage
dentinal hypersensitivity .
• However this effect has been questioned since various
formulations have been found to have little or no effect on
dentinal hypersensitivity (Addy M,Mostafa P,1988)
• Given that these agents are very strong fixatives ,they should
be used with extreme caution too ensure they do not come in
contact with vital gingival tissues.
Resins and Adhesives
The rationale for the use of resins and adhesives is to
seal the dentinal tubules and hence to preclude the
transmission of pain causing stimuli to the pulpal nerve
• This mode of treatment is performed on localized
• Resin-based materials have been reported to
successfully reduce dentinal hypersensitivity.(Kakaboura
• Copeland reported successful treatment of dentinal
hypersensitivity for up to 18 months in 89% of
hypersensitive teeth treated by Scotchbond.
• A combination product consisting of an aqueous solution
of 5% glutaraldehyde and 35% hydroxyethyl
methacrylate (Gluma Desensitizer) has been reported to
be an effective desensitizing agent for up to 9 months.
.( Kakaboura A ,2005)
The glutaraldehyde intrinsically blocks dentinal tubules
counteracting the hydrodynamic mechanism that leads to
• In summary, resin restorations have been used to cover
of denuded dentin. This would seem to be a rational
• NovaMin is the brand name of a particulate bioactive
glass that is used in dental care products
for remineralisation of teeth, treating
The active ingredient is called Calcium Sodium
• NovaMin is an ionic form of calcium, phosphorus, silica,
and sodium which are necessary for bone and tooth
There are a number of reports that suggest that laser
treatment may be useful in the treatment of, dentinal
hypersensitivity although definitive trials are
lacking(Cooper LF et al ,1988).
• A recent review of the literature by Kimura and colleagues
reported that effectiveness of laser treatment of dentinal
hypersensitivity ranged from 5% to 100%.
• In a clinical and SEM study, Kumar and Mehtas (2005) found
that Nd:YAG laser irradiation in combination with 5%
sodium fluoride varnish has higher efficacy in the
management of DH
than either treatment alone.
• Slutzky-Goldberg (2008)and colleagues have demonstrated
that CO2 laser treatment resulted in decreased permeability
of dentinal tubules as shown by a dye penetration test.
• The use of restorative materials is generally an invasive
solution to the problem of hypersensitivity.
• Commonly used materials include composite resins and
glass ionomer restorations.
Generally this approach is reserved for situations where
there has been significant prior loss of cervical tooth
structure or as a last resort for a tooth which does not
respond to other less invasive desensitizing protocols.
• Abnormal tooth surface loss resulting from direct
frictional forces between the teeth and external objects
or from frictional forces between contacting teeth
components in the presence of abrasive medium.
(Sturdevant 5 th edition)
• It occurs most frequently on the cervical neck of the teeth.
• The labial or buccal surfaces. (tooth brush abrasion )
• Labial or buccal and lingual surfaces( in case of poorly fitted
clasps and artificial dentures ) .
Causes of abrasion :
• Traumatic occlusion .
• Improper brushing technique .
• Occupational (Habits such as holding bobby pins in between
the teeth .)
• Tobacco chewing /tobacco pipe .
• Vigorous use of tooth picks between the adjacent teeth.
• Excessive mastication of coarse foods .
Dentures with porcelain teeth opposing natural teeth.
• Extremely rough occluding surface of the restoration
enhancing its abrasive capability .
• ill fitting dentures and clasps ,producing a constant
wear of the affected surfaces.
Tooth brush abrasion results in a
horizontal cervical notches on the
buccal surfaces of exposed radicular
cementum and dentin .
Notching in right central incisor caused
by improper use of bobby pins .
The clinical signs and symptoms of an
abrasion are :
• The surface of the lesion is extremely smooth and polished
and it seldom has any plaque accumulation or caries activity
in it .
• The surrounding walls tend to make a V shape ,by meeting at
an acute angle axially.
• Peripheries of the lesion are angularly demarcated from the
adjacent tooth surface.
• Probing or stimulating the lesion can elicit pain .
• Hypersensitivity may be intermittent in character appearing and
disappearing at occasional or frequently repeated periods .
Diagnose the cause of the presented abrasion.
A detailed history is to be taken considering various factors such
• Oral hygiene techniques ( use of abrasive tooth cleaning techniques
• Habits- pipe smoking, chewing tobacco, professional habits
• Iatrogenic causes,if any.
Avoidance or counteraction of the causes which may lead to its
Instituting proper oral hygiene measures.
Judiciously tooth brushing with a dentifrice i.e. incorporating
correct method of tooth brushing .
Have the habit of chewing tobacco ,toothpick , etc
discontinued . If successful in breaking the habit proceed
with the restorative treatment as planned.
Correcting or avoiding ill fitting metal clasps and dentures
Abrasive lesions at non-occluding tooth surfaces should be:
Evaluated critically for the need for restoring them.
• If the lesions are multiple, shallow( not exceeding 0.5 mm in
dentin) and wide → no need to restore them .
• If there is involvement of cementum / enamel only → no
need to restore .
• If lesion is wedge (V) shaped and exceeds 0.5 mm into
dentin → restoration is performed .
If restoration is not indicated for a lesion, then :
• Edges of the defect should be eradicated to a smooth, nondemarcating pattern relative to adjacent tooth surface.
• Tooth surface then should be treated by fluoride solution
to improve caries resistance
If the involved teeth→ extremely sensitive:
• Desensitize the exposed dentin before restoration .
• 8-10%sodium/stannous fluorides for 4-8 minutes.
• Iontophoresis- --using an electrolyte containing
fluorides( galvanic energy supplied to the tooth in the
presence of electrolyte, drives ions deep into the
Restoring cervical abrasions
In many instances no treatment is necessary but
indicated when :
• Caries ,if present .
• Sensitivity is present.
• Lesion is esthetically objectionable .
• If the defect contributes to a periodontal problem
• The area to be involved in the design of a removable
• When the depth of defect is found to be close to pulp
• Or a progressive loss of tooth structure is observed
compromising the tooth strength .
• High modulus restorative materials are unable to flex
in the cervical regions when the tooth structure is
deformed under occlusal load and ,therefore the
restorative materials can be displaced from the
(Heymann HO ,Sturdevant Jr ,Baynes S ,JADA,122(2) 4157 )
An intermediate material with reduced elastic
modulus may function as a stress absorbing layer
and improve marginal sealing .
• (Kemp-Scholte CM ,Davidsson,CL complete marginal seal of
class V resin composite restorations affected by increased
flexibility .JDR 1990 ;69:1240 -3 )
As a result materials with low elastic modulus such as :
Microfilled composites (Heymann and others ,1991 :Levitch
and others ,1994 )
Flowable resins (Unterbink ,Liebenberg ,1999: Li and others
Glass ionomer cements (Loguercio and others ,2003:Burgess
and others ,2004)
Have been used in restoring cervical lesions ,with the aim of
absorbing the stresses generated during the polymerization
shrinkage of composites and mechanical loading in which the
teeth are subjected during function .
Two-year clinical evaluation of four polyacidmodified resin composites and a resin-modified
glass-ionomer cement in Class V abrasion/erosion
lesions. Ermiş RB.. Quintessence Int. 2002 JulAug;33(7):542-8
• The aim of the study was to compare the clinical
performances of four polyacid-modified resin composites
(F2000, Dyract AP, Compoglass F, and Elan) and one resinmodified glass-ionomer cement (Vitremer) in Class V
• Retention levels at 2 years were 90% for F2000, 90% for
Dyract AP, 89% for Compoglass F, 84% for Elan, and 95%
for the Vitremer restorations. No statistically significant
differences were found among the materials after 2 years
for any evaluation category
• It is generally well accepted that glass-ionomer
cements have an inhibitory effect on secondary
caries, and the release of fluoride is considered to be
one of the major benefits associated with glassionomer cements,
• However, it bas been demonstrated that polyacidmodified resin composites may not be recharged again
with fluoride as are glassionomer cements.
comparative analysis of techniques of restoring
cervical lesions- (Quintessence Int 1993:24:553-
• The clinical significance of this investigation is that two of the
techniques tested, ie, the sandwich technique and the glassionomer cement restoration, have definite potential to
successfully restore cervical lesions, from the standpoint of
While glass-ionomer cement may not have as good esthetic
properties as resin materials, the sandwich technique does not
have universal application, because it requires space and hence
may not be the technique of choice in relatively shallow cavities.
• When the lesion is relatively shallow and esthetic demands
necessitate the use of a resin material, the all-composite
restoration would be a compromise in terms of marginal seal.
• This result should be kept in mind when cervical lesions are to
be restored with these materials.
The success of modern-day restorative materials depends,
on the ability to stop marginal leakage. Within the
limitations of this study, the following conclusions may be
1. The acid-etch technique was effective in reducing marginal
leakage along the tooth - composite resin interface in
2- None of the techniques studied consistently provided a
complete seal at the gingival aspect of cervical restorafions.
3. The dentina! adhesive used with the composite resin did not
always provide a leak-free seal at the gingival margins of
4.Composite resin restorations inserted over a
glassionomer liner demonstrated significantly
less leakage than when the liner was not used.
5. In general, the use of the sandwich technique
or glass-ionomer restorative material alone
provided the most effective seals in cervical
wedge-shaped cavities, compared to the allcomposite restoration.
6. There was no significant difference between
the marginal leakage of glass-ionomer cement
and sandwich technique restoration
5-year clinical performance of resin composite versus
resin modified glass ionomer restorative system in
non-carious cervical lesions.
Franco Eb, Benetti A , SK Ishikiriama,SL Santiago
AIM: To comparatively assess the 5-year clinical
performance of a resin composite system with a
resin-modified glass ionomer restorative in noncarious cervical lesions.
METHOD AND MATERIALS: One operator placed 70
restorations (35 resin modified glass ionomer
restorations and 35 resin composite restorations) in
30 patients under rubber dam isolation.
• CONCLUSIONS : After 5 years of evaluation, the
clinical performance of resin modified glass ionomer
restorations was superior to resin composite
• Loss of surface tooth structure by chemical action in the
continued presence of demineralizing agents(acids).
(Sturdevant- 5 th edition)
• It is one of the most predominant oral pathologic changes .
• There is no convincing etiology ,and multiple factors have
been theorized for its pathogenesis:
The action of the muscles of lips and cheeks , and of tooth
brush against affected surfaces .
Chemical factors :
• Ingested acids : citric acids (lemon and citrus fruits
) esp. if use in large amounts , can precipitate or
initiate erosive lesion
• Secreted acids : the acidity of crevicular fluid has
been correlated to cervical erosion
(Bodecker CF. Local acidity: a cause of dental erosionabrasion.Ann Dent 1945)
• Acid fumes : acid vapours from nitric acid and
sulphuric acids, acting in the mouths of workers in
the factories ,where these acids are largely used or
manufactured ( Miller)
• Refused acids : as a result of chronic , frequent
regurgitation ,the stomach‘s hydrochloric acid can hit
the teeth at specific locations ( atypical pattern of
erosion affecting buccal surfaces of lower posterior
The latter defective surfaces are associated with
gastro esophageal reflux .(GERD)
• Extensive loss of buccal and
occlusal tooth structure
• Raised amalgam restoratins .
• Occlusal view of maxillary dentition
exhibiting concave dentin depressions
surrounded by elevated rims of enamel
Multiple cupped out depressions
corresponding to the cusp tips
Extensive loss of enamel and dentin on
the Buccal surface of maxillary
bicuspids. ( pt had sucked chronically
on tamarinds )
Palatal surfaces of maxillary dentition
in which the exposed dentin exhibits a
concave surface and a peripheral
white line of enamel
Perimylosis (decalcification of the teeth caused
by exposure to gastric acid in patients with
chronic vomiting, as may occur in anorexia or
• Loss of lingual enamel and dentin due to acid
regurgitation aggravated by circular movements of
• Associated with stress reflux syndrome
• A similar appearance is found in patients with eating
disordersAnorexia ( is an eating disorder characterized by immoderate
food restriction and irrational fear of gaining weight, as well
as a distorted body self-perception)
Bulimia nervosa (is an eating disorder characterized by
consuming a large amount of food in a short amount of time
followed by an attempt to rid oneself of the food consumed
, typically by vomiting)
Rumination ( a chronic condition characterized by effortless
regurgitation of most meals following consumption) have all
been closely associated with dental erosion .
• Chronic alcoholism produces a similar pattern of erosion,
although usually more generalized.
( ND Robb and BGN Smith, Anorexia and bulimia nervosa (the eating
disorders): conditions of interest to the dental practitioner, J Dent
• It has been reported that any food substance with a
critical pH value of less than 5.5 can become a
corrodent and demineralize the teeth.
( Stephan RM, JADA 1940) ,( Gray JA, J Dent Res 1962) ,
(Zero DT. Cariology. Dent Clin North Am 1999)
• Holding ,swilling or retaining acidic drinks and foods
in the mouth prolongs the acid exposure on the teeth
increasing the risk of erosion .
(Mossazzez R ,Smith BGN,Barlett DW,Oral Ph and drinking
habit during the ingestion of carbonated drink in a group of
adolescents with dental erosion ,J Dent 2000)
• As reported by Lussi ,the corrosive potential of an
acidic drink does not depend exclusively on its ph
value, but also is strongly influenced by its buffering
capacity of the acid and by the frequency and
duration of ingestion.
(Lussi A. Dental erosion: clinical diagnosis and case
histor taking. Eur J Oral Sci 1996 )
The other substances that can corrode teeth.
• chewable vitamin C tablets
• aspirin tablets
• aspirin powders
• use of the amphetamine drug Ecstasy
have been associated with corrosion on the occlusal
surfaces of posterior teeth.
The potential effects of pH and buffering
capacity on dental erosion.
Gen Dent. 2007 Nov-Dec;55(6):527-31
This in vitro study sought to evaluate five different
soft drinks (Coca-Cola Classic, Diet Coke, Gatorade
sports drink, Red Bull high-energy drink, Starbucks
Frappucino coffee drink) and tap water (control) in
terms of initial pH and buffering capacity.
Initial pH was measured in triplicate for the six
beverages. The buffering capacity of each beverage
was assessed by measuring the weight (in grams) of
0.10 M sodium hydroxide necessary for titration to
pH levels of 5.0, 6.0, 7.0, and 8.3.
Mean ph values for each beverage
Coca-Cola Classic produced the lowest mean pH,
while Starbucks Frappucino produced the highest pH
of any of the drinks except for tap water.
Red Bull had the highest mean buffering capacity
(indicating the strongest potential for erosion of
enamel), followed by Gatorade, Coca-Cola Classic,
Diet Coke, and Starbucks Frappucino.
Buffering capacity is the measure of total no. of acid
molecules and determines the actual hydrogen ion
availability for interaction with tooth surface
• Beverages with high buffering capacities compete
with natural buffering characteristics of saliva and
resist ph changes as a result .
• Greater the buffering capacity , more time it takes
for saliva to restore the pH value ,which causes
beverage pH to decline to a sustained level --------prolonged periods of oral acidity ---- thus increasing
the erosive potential .
Monitoring tooth wear
• Recognizing how the appearance of teeth change with
tooth wear ,can be helpful in assessing the activity.
Most effective way to monitor wear is :
comparing the dated study casts to the clinical
conditions of teeth over time .
• It can also be used as a part of preventive regime .
• Active wear → smooth and unstained ,clean surfaces.
→ erosion of tooth around the existing
(Restoration is resistant to acid ,remains
unchanged ,but the tooth is gradually
dissolved leaving the restoration proud)
• Inactive wear — stained .
Protocol for the prevention of
progression of erosion
(Beatrice K,Edmond L ,J Contemp.Dental practise ,1999)
Diminish the frequency and severity of acid challenge.
• ↓ the amount and frequency of acidic foods or drinks
• Acidic drinks should be drunk quickly rather than sipped.
• Use of straw reduces erosive potential
Treating the underlying medical disorder or disease.
• GERD ,anorexia ,bulimia → refer to a physician
Enhance the defense mechanisms of body:
• Saliva provides buffering capacity→ increases with
salivary flow rate.
• Saliva supersaturated with Ca, P → inhibits
demineralization of tooth structure.
• Stimulation of salivary flow → sugarless lozenge,
candy/gum is recommended
Enhance acid resistance, remineralization and
rehardening of the tooth surfaces.
• Daily use topical flouride at home
• Fluoride application in office- 2-4 times a year
,flouride varnish recommended.
Decrease abrasive forces.
• Use a soft bristled toothbrush and brush gently.
• No brushing should be done immediately after
consuming acidic food and drink as teeth will be
Rinsing with water is better than brushing after
consuming acidic foods and drinks.
(Gandara, B.K; E.L Truelove ,Diagnosis and management of dental
erosio. Journal of Contemp.Dental Practice 1999)
Improve chemical protection
• Neutralize acids in mouth ---dissolving sugar free antacid tablets
5 times a day ,particularly after an intrinsic or extrinsic acid
• Dietary components- hard cheese ( provides Ca and PO4), held in
mouth after acidic challenge.
• By application of composites and direct bonding where
appropriate – to protect exposed dentin
• Occlusal guard /Acrylic splint in the form of stabilization splint
necessary to protect dentition from further damage due to
by use of casts /photos to document tooth wear
• Regular recall examinations to review diet, oral
hygiene methods, compliance with medications, topical
flouride and splint usage.
• Metallic restorations should be the choice of material
,if restoration indicated .
(more resistant to erosion )
• Tooth colored materials may also be used with minimal
or no tooth preparation, with the assumption that
restoration may require periodic replacement .
Some authors explain the formation of cervical,
wedge shaped defect by the heavy force in eccentric
occlusion resulting in flexuring (elastic bending) of the
When the tooth is loaded in long axis ,the forces are
dissipated with minimal stress on enamel and dentin .
If the direction of force changes laterally ,teeth are
flexed towards both the sides .
Changes in stress pattern continuously in the same area
compresssive ↔ tensile
(esp. ,underneath the enamel)reaches to the fatigue limit.
rupture of chemical bond between hydroxyapetite
crystals is termed as Abfractures . (Grippo JO,1991: Levitch
LC , Bader JD, Heymann HO ,1994 )
• This occurs most commonly in the cervical regions of the
tooth where the flexure may lead to breaking away of
extremely thin enamel rods ,as well as microfractures of
cementum and dentin .
Microfractures can foster loss of tooth structure
from tooth brush abrasion and from acids in the diet
or plaque or both .
The resulting defect has a smooth surface
• Also known as idiopathic erosion.
(Lee WC, Eakle WS, J Prosthet Dent 52(3): 374380, 1984.)
• Abfraction has a possibility of being the initial factor and
the dominant progressive modifying factor in producing
• Stresses that concentrate to produce abfractions in teeth
usually are transmitted by occlusal loading forces.
( Whitehead SA, Wilson NHF, Watts DC. J Esthet Dent
2000),(Pintado MR, DeLong R, Ko C, Sakaguchi RL, Douglas
WH. Correlation J Prosthet Dent 2000)
• Occlusal interferences, premature contacts, habits of
bruxism and clenching all may act as stressors.
Monitoring abfraction lesions
• A novel method of determining the activity of abfraction
lesions over time ----Scratch test . ( Kaidonis JA.The tooth
wear :view of anthropologists ,Clin Oral Investig 2008)
• A no.12 scalpel blade is used to superficially scratch the
tooth surface .
• Visual observation gives an indication of rate of tooth
• Loss of scratch definition or loss of the scratch
altogether signifies active tooth structure loss.
• when clinical consequences (e.g. dentin
hypersensitivity ) have developed or likely to be
• Aesthetics demands are a concern .
Tyas recommended the RMGIC should be the first
(Tyas MJ,the class V lesion –aetiology ,restoration,Aust. Dental
• In esthetically demanding cases,
• RMGIC/GIC liner laminated with resin composite.
Vandelwalle and Vigil ( Gen Dent 1997)
• Recommended the use of microfilled resin composite(low
modulus of elasticity ) as it will flex with tooth and not
compromise retention .
Occlusal adjustment may involve (Piotrowski BT
JADA 2001 and Ichim IP Dent Mater 2007):
• Altering cuspal inclines,
• Reducing heavy contacts
• Removing premature contacts.
Aimed at reducing the amount of nocturnal bruxism
and non axial tooth loading when constructed properly
The cause of these fractures may include :
Repetitive heavy and stressful chewing
Resorption weakened teeth
Iatrogenic dental treatment
It has been suggested that the determination of a
fractured tooth is often more of a prediction rather
than a definitive diagnosis based on a collective analysis
of subjective and objective findings.
Five types of longitudinal fractures have been described
(American Association of Endodontists,2008 ):
(1) Craze line: affect only the enamel, originate on the
occlusal surface, are typically from occlusal forces or
and are asymptomatic .
2) Fractured cusp: occur on the cusps and cervical margins of
the root and can have acute pain to
mastication and cold.
3) Cracked tooth : occurs on the crown
and may extend into the root ,develop
from damaging occlusal forces or
weakened tooth structure
(4) Vertical root: occur and originate only in the roots,
have variable but a lesser degree of signs and
symptoms, and are caused by wedging forces within
the roots (i.e. root canal obturation or posts)
5) Split tooth: a fracture through the crown and roots,
developing from damaging occlusal forces or
weakened tooth structure, separating the tooth into
two segments, with the tooth typically being painful
• Cracked teeth are thought to occur as a result of
parafunctional habits or from weakened tooth
• The symptoms that develop subsequent to these cracks
have been termed as ―cracked tooth syndrome‖
• This has been described as acute pain that results
during the mastication (or release) of small hard food
substances and also exacerbates with cold.
(Cameron CE,JADA,1964 : American Association of
• However, the signs and symptoms of a cracked tooth
may also be consistent with an irreversible pulpitis or
• In summary there are two main groups of cracked
A) Tooth infarctions:(incomplete tooth fractures
extending partially through a tooth ) that includes :
B) Vertical root fractures : (that occur in
endodontically treated teeth )
Characteristics of tooth infarctions
Problems in diagnoses :
• Infarctions typically originate internally and extend
peripherally → not likely to be identified by percussion until the
fracture extends to involve the periodontal ligament .
• The fractures are incomplete, tend to present in a mesial distal
orientation and are generally centered on the occlusal table
,radiogarphs are not very diagnostic .
• Also difficult to differentiate masticatory pain /pain from
infarction /pain from microleakage associated with restorations .
• Infarctions ….not readily visualized without magnification (unless
they are at least 20um )
• Molars and premolars are the teeth are almost
• Teeth with restorations are most likely to develop
• Occurs when there is release of pressure from biting
(rebound pain or relief pain )
• Can be duplicate diagnostically by having the patient
bite on a moist cotton roll ( if rebound pain occurs
on release ,it is very likely that one of the two teeth
,maxillary or mandibular ,has an infarction )
Clinical test for detecting infarction :
• The patient bites onto the moist cotton roll
and on release the pain will often be quite noticeable .
• Excessively large and incorrectly designed
• Use of pins for supporting large restorations ,esp.
self threading and friction locked )
• Abrasion ,erosion ,caries ,along with age changes in
• Act of chewing is also implicated
Biting onto hard objects ,bruxism and clenching ,
wedging effect of the cusp in the opposing fossa
• Use of both high speed handpieces and course
diamond burs can lead to infarctions
• Acute trauma to the teeth.
• Begins with the chief complaint i.e. pain on chewing
,elevated sensitivity to cold food and sweets
• Absence of carious etiology …trigger a suspicion of
• Visual examination by …….Transillumination and
…..Dyes (methylene blue)
• Any existing restoration in the tooth should be
removed to reveal the infarction lines
Removal of the restoration and
highlighting with the dye to
• Use of optic light source to identify an
•Note that the beam of light does not
cross the infarction
Biting test :
• Biting on rubber wheels, cotton tip applicators ,moist
cotton, commercial biting appliances like tooth slooth.
• Tooth slooth …….. Differentiates biting pain from
restorations with microleakage /pain from infarction
……pressure is placed first onto the restoration
followed by tooth cusps .
Use of tooth Slooth to test biting sensitivity to differentiate between
pain from infarction and pain from micro leakage related to a restoration
• Significant response to biting ….when pain is experienced
release of biting pressure (rebound pain ) /relief pain
• Pain …….with the release of pressure ……due to fluid
movement as the crack rapidly closes .
• Cold stimulus application and Electric pulp testing(EPT ) :
Gives information about the pulpal status ,teeth with
infarctions respond to a lower threshold to cold and EPT as
compared to the non cracked teeth.
• Cameron suggested the use of thin sharp explorer tip to
probe around the cervical circumference of the suspected
teeth….the click of the explorer‘s tip and the patient ‗s
response can provide a clue
The fractures are incomplete, tend to present in a
mesial --distal orientation and are generally centered
on the occlusal table ,radiographs are not very
Even cone beam volumetric tomography (CBVT) scans
cannot consistently visualize these fractures, the
coronal-apical progression of fractures cannot always
be objectively assessed until the tooth has been
Preventing the separation of the hard tissue entities ,
Keeping the bacteria's from colonizing the space
caused by infarction
It is not clear whether all the teeth with infarction
require root canal therapy, it depends on the extent
of the fracture .
• Orthodontic band was placed to bind
the crown together .
• After 3 weeks the tooth was
completely asymptomatic and the
patient chose to restore it with a crown
Treatments designed to bind the infarcted segments of
teeth together .,that includes the use of adhesives , full
coverage crowns .
Localized Non Hereditary Enamel Hypoplasia
During enamel formation ,
metabolic product i.e
enamel matrix, would not
be properly formed
resulting in formation of
either hypoplastic or
Isolated pits to
depressions, or loss
of a segment in
the enamel .
In contrast with
the caries and
When the teeth
erupt,these defects will
be apparent in the
crown portion of teeth NutritionaL
(tooth) which is called
as localized non
A,C and D)
areas will have
If defects are
minimum ( narrow
lines /isolated pits
depressions) then selective
reshaping can be
e.g . (syphilis)
b) Localized disorders- These
include periapical infections of
the preceding deciduous tooth
(Turner‘s hypoplasia ),
traumatic intrusion of the
preceding deciduous tooth etc
If odontomy and esthetic
reshaping of the tooth
enamel can‘t produce a
c) Fluorides :
Metabolizing fluorides in
excessive amounts could poison
the ameloblasts and disturb
their activities to variable
degrees, leading too slightly
mottled enamel or a completely
disfigured crown in its enamel
Direct tooth colored
is inserted with /without
Localized Non Hereditary Enamel Hypocalcification
enamel results when
normal amount of
enamel matrix fails to
mineralization and is a
usual consequence of
damage to ameloblasts
stages of tooth
If diagnosis is made
early in tooth‘s life
,while the uncalcified
enamel is still intact
an attempt at
should be made .
4. If extensivethese lesions
chipped if lesion
Can be done usingA)fluoride
C)strict prevention of
in these areas .
Localized Non Hereditary Dentin Hypoplasia
the specialized cells
,any disturbance in
It appears to be a
transmitted as an
There would be NO
destruction to be
treated ,till the
time the lesion is
that can be used
Zinc oxide eugenol
preparation for a
restoration , these
defects may get
of dentin matrix
Leads to the
localised nonhereditary dentin
LOCALIZED NON-HEREDITARY DENTIN HYPOCALCIFICATION
there is failure of
union of many
will be present in
would be softer
,more penetrable ,
and less resilient
There would be NO
destruction to be
treated ,till the
time the lesion is
that can be used
Zinc oxide eugenol
preparation for a
restoration , these
defects may get
alterations in the
structure of enamel in
the absence of a
HYPOPLASTIC AI•Thin enamel
• Open contact
•Enamel is glossy
•Enamel can look wrinkled.
• Signs of severe occlusal
• Missing teeth.
•Delay in eruption.
AIM OF TREATMENT•Reducing tooth
•Correcting or maintaining
4 MAIN TYPES1)Hypoplasia
Small yellowish teeth exhibiting
hard, glossy enamel with
numerous open contacts points
and anterior open bite
Temporary phase –
primary or mixed
Transitional phase –when
all the permanent teeth
Permanent phase –
occurs in adulthood
Reducing tooth sensitivitytopical fluoride products ,CPP-ACP
products , dietary modification
•Enamel is usually stained (yellow/Black)
• Enamel chips easily ,very soft in
•stains become darker with time
•Enamel- worn easily in life with all signs
and symptoms of severe attrition
Maintaining good oral hygiene
Correcting or maintaining vertical
Placement of GIC ( sensitivity ,if any )
on grossly worn down molars followed
by placement of composite restorations
,assist in restoring the occlusal vertical
Bonding direct or indirect resin
• Affected teeth ---normal in shape ,
but exhibit mottled, opaque white
brown –yellow discoloration .
• Enamel is softer than normal ,tends
to chip from underlying
Restoring masticatory function
• Performed by full veneering ,includes
2) Cast ceramic restorations
diffuse yellow white dentition
Caused by mutation
dominant disorder in the DSPP gene.
vary in color from
yellow brown –
/grey with a typical
Early diagnosis and
loss of enamel and
Primary teeth are
Atypical color of
teeth → dentin
In patients without
cracks and rapid
attrition of enamel,
Type I : dentin
night guard vital
bleaching ) with
peroxide has been
Type II: Hereditary
Type III: Brandy wine
type (Shell teeth )
Enamel tends to chip
and fracture off
from the tips of
teeth → exposed
dentin , leaving the
occlusal surface of
posterior teeth flat .
In anterior teeth →
stainless steel crowns with
composite facings may be
At a later stage porcelain
crowns are suggested .
Splinting between these
teeth- to avoid root
Loss of pulp chamber
ABFRACTION- Use of
FRACTURES- Bind the
infarcted segment &
hypersentivity using F ions, acrylicadjustments,
splints, treatment of bruxism,
restorative treatment with LN DENTIN HYPOPLASIA/
composite 7 cast metal
HYPOCALCIFICATION- intermediary basesZinc oxide eugenol, Calcium hydroxide ,Zinc
phosphate, Polycarboxylate cement
tooth brushing, use of
AMELOGENESIS IMPERFECTAtechnique, composite
LN ENAMEL HYPOPLASIA- F application,composite &
tablets, reduction in
Remineralisation, Vital bleaching
acidic drink consumtion. Laminated veneering,Composite bleaching
1. Art and science of operative dentistry- Sturdevant 5
2. Operative Dentistry- Modern Theory and Practice:
3. Shafer‘s Textbook of Oral Pathology- Shafer, Hine,
4. Abfraction : separating fact from fiction --ADJ 2009
Fracture necrosis :Diagnosis ,Prognosis assesment
and Treatment Recommendations –Louis H
6. Non carious cervical lesions and abfractions :A re –
evaluation –JADA 2003 ;134:845—850
7) Role of erosion in tooth wear :aetiology ,prevention
and management ---IDJ(2005) 55,277-284
8) Erosion –Chemical and biological factors of
importance –IDJ (2005 ) 55 285-290
9 ) Removable Orthodontic Appliances—K.G.Isaacson
10) Quintessentials 3 – Decision–Making in Operative
Dentistry Brunton, Paul A.