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NON CARIOUS LESIONS

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REVATHY M NAIR

Prevalence of tooth loss Tooth wear and causes Tooth wear indices Classification of tooth wear Non carious cervical lesions include attrition, abrasion, abfraction, erosion and their combined lesion developmental defects resorption trauma and fractures

Health & Medicine
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NON – CARIOUS LESIONS
CONTENTS ‡ INTRODUCTION ‡ DEFINITION ‡ PREVALENCE OF TOOTH SURFACE LOSS ‡ CLINICAL MEASUREMENT OF TOOTH WEAR ‡ NON – CARIOUS CERVICAL LESIONS  ATTRITION  ABRASION  ABFRACTION  EROSION ‡ MANAGEMENT OF WORN DENTITION ‡ COMBINED LESIONS
‡ DEVELOPMENTAL DEFECTS  LOCALIZED NON – HEREDITARY ENAMEL HYPOPLASIA  LOCALIZED NON – HEREDITARY ENAMEL HYPOCALCIFICATION  LOCALIZED NON – HEREDITARY DENTIN HYPOPLASIA  LOCALIZED NON – HEREDITARY DENTIN HYPOCALCIFICATION  AMELOGENSIS IMPERFECTA  DENTINIGENESIS IMPERFECTA ‡ TRAUMA AND FRACTURES ‡ RESORPTION ‡ CONCLUSION ‡ REFERNCES
Gradual loss of tooth structure occurs throughout the life, most often it is so slow that it rarely poses any problem to the patient However, pathological loss of tooth structure due to non-carious reasons can produce unacceptable esthetics, compromise oral functions, cause pain and sensitivity and negatively impact quality of life. These lesions are difficult to diagnose and treat successfully as the loss is exhibited in different patterns and on different surfaces of teeth for varying types of tooth surface loss INTRODUCTION
Determining the etiology and preventing further tooth surface loss, which requires using proper preventive methods, good management and the appropriate restorations is necessary for the successful management of non-carious lesions
DEFINITION ‘Tooth surface loss’ or 'tooth wear' refers to the pathological loss of tooth tissue by a disease process other than dental caries - Eccles, 1982 “Non carious tooth tissue loss” is defined as surface loss due to a disease process which does not involve bacteria. - Pual A Brunton ,Decision making in Operative Dentistry “Non-carious cervical lesions (cervical wear)” are defined as the loss of tooth substance at the cemento- enamel junction - Mair, 1992
PREVALENCE OF TOOTH WEAR The Adult Dental Health Survey of 2009 reported that tooth wear extending into the dentin with over three quarters (77%) of dentate adults showing tooth wear in the anteriors. However, 15% showed moderate wear and 2% with severe wear. The Child Dental Health Survey of 2013 identified that 21% of 15- year-olds had evidence of erosion affecting the palatal surfaces of their permanent incisors (less when compared to the survey on 1993 – 32%) The prevalence of tooth wear is likely to escalate as life expectancy continues to increase. Adult Dental Health Survey 2009: Common oral health conditions and their impact on the population. British Dental Journal, 2012
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
TOOTH SURFACE LOSS PHYSIOLOGICAL PATHOLOGICAL A. Warreth et al. Tooth surface loss: A review of literature. Saudi Dental Journal. 2019
Physiological Tooth Surface Loss • It occurs as a result of mastication and adjustment, which is required for the teeth to function correctly • Physiological TSL may also occur at interproximal tooth surfaces due to friction between the adjacent teeth (Davies et al., 2002, Kaidonis, 2008). Pathological Tooth Surface Loss • It represents unacceptable levels of dental hard tissue loss • Etiology - multifactorial • It is characterized by abnormal destruction, which may require treatment (Van’t Spijker et al., 2009; Bartlett et al., 2011)
Pathological TSL is considered to be a common clinical finding in both children and adults, and its prevalence increases with age This prevalence was found to increase from 3% at the age of 20 years to 17% at the age of 70 years (Van’t Spijker et al., 2009) The increase in prevalence of moderate tooth wear in adults is of little concern but, younger age groups affected by moderate and severe tooth wear may warrant some attention
NON- CARIOUS DEFECTS DEVELOPMENTAL HEREDITARY NON- HEREDITARY ACQUIRED TOOTH WEAR TRAUMA RESORPTION
CLINICAL MEASUREMENT OF TOOTH WEAR QUANTITATIVE QUALITATIVE • Rely on physical measurements • Depth of groove, area of facet or Height of lesion • Objective • Rely on clinical descriptions • Mild, Moderate or Severe • Subjective • Tooth Wear Indices (TWI) have been designed to identify increasing severity and extent of the lesions • They are usually numerical. • Some record lesions on an aetiological basis (e.g. erosion indices), others record lesions irrespective of aetiology (tooth wear indices);
SMITH AND KNIGHT TOOTH WEAR INDEX (TWI) - 1984
Smith and Knight Index - a comprehensive system whereby all four visible surfaces (buccal, cervical, lingual and occlusal–incisal) of all teeth present are scored for wear, irrespective of how it occurred. • This index was the first one designed to measure and monitor multifactorial tooth wear; • This index avoids the confusion associated with terminology and translation or differences in opinion for diagnosis of aetiology based on clinical findings Most commonly used but has limitations such as • Rely only on the ability of clinician to visually identify exposed dentin (interexaminer bias) • Does not relate etiology to the outcome of wear seen on the teeth. This makes it inaccurate to provide a complete picture of the clinical problem • Time consuming • Full use of the index as a research tool is not feasible without computer assistance Bardsley et al. The evolution of tooth wear indices. Journal of clinical oral investigation. 2008
SIMPLIFIED SCORING CRITERIA FOR TOOTH WEAR INDEX - Bardsley et al, 2004
NON – CARIOUS CERVICAL LESIONS (NCCLs)
ATTRITION It is defined as physiological wearing away of tooth as a result of tooth to tooth contact as in mastication - Shafer It may be defined as surface tooth structure loss resulting from direct frictional forces between contacting teeth - Marzouk Attrition is defined as the mechanical wear of incisal and occlusal surfaces as a result of functional or parafunctional movements of mandible (Tooth-to tooth contact) - Sturdevant Every in 1972, described it is wear caused by endogenous material such as microfine particles of enamel prisms caught between two opposing tooth surfaces.
 Its an Age dependent continuous process  Usually physiologic.  Any contacting tooth surface is subjected to the attrition process, beginning from the time it erupts in the mouth and makes contact with reciprocating tooth surface.  Mostly affects occlusal surfaces of the teeth  It also includes the proximal surface wear at the contact area because of the physiologic tooth movement  Accelerated by parafunctional movements such as bruxism  Men > women
ETIOLOGY USE OF STIFF OR HARD TOOTH BRUSHES OR FLOSS ABRASIVE DENTIFRICES PARAFUNCTIONAL HABITS LIKE BRUXISM AGEING AGGRESSIVE TOOTHBRUSING
There are three theories regarding the etiology of attrition: • Functional theory • Parafunction initiated by occlusal interferences • Central nervous system aetiology. Rees et al. A guide to the clinical management of attrition. BRITISH DENTAL JOURNAL , 2018 Functional theory This suggests that tooth wear occurs due to prolonged contact of the teeth and the patient having a broad envelope of function. They found that the broader grinding type chewing pattern had significantly greater levels of occlusal wear compared to the ‘chopping’ type.
Parafunction initiated by occlusal interferences The theory states that parafunction can be initiated by occlusal interferences and therefore managed clinically by occlusal adjustments or extensive rehabilitations. Unfortunately, the evidence in the literature does not support this theory. Studies have found that occlusal interferences could not cause bruxism or stop it.
Central nervous system Etiology Bruxism is a neurological problem and the tooth damage is a consequence of a neurologically initiated activity manifesting as grinding and tooth surface loss. Essentially, sleep bruxism occurs following sleep-related micro-arousals that originate in the brain stem. These micro-arousals cause the heart rate to increase following which brain activity increases. This is followed by activation of the suprahyoid muscle which is followed by rhythmic masticatory muscle activity resulting in bruxism
In addition to the causes of attrition, there are a number of other factors which may accelerate the process of attrition Habitual chewing on hard food stuffs • Habitual chewing on hard foods or unusual food stuffs such as bone chewing may exacerbate tooth surface loss. Lack of posterior support • Many clinicians consider that a lack of posterior support can eventually lead to more tooth wear on the remaining anterior teeth. • While other authors found no relationship between the number of missing posterior teeth and anterior tooth wear • This is often controversial and therefore further studies are needed to prove this theory
Ecstasy • Around 1.5% of the population use ecstacy (Amphetamine) and it is the second most popular recreational drug in 16–24 year olds. • The main side effects of this drug are bruxism and a profound xerostomia that last for around 6–8 hours. • This is a good example of a combined attrition and erosion aetiology Selective 5-hydroxytryptamine reuptake inhibitors (SSRIs) • It is the commonest type of antidepressants used to manage anxiety and depression • Recent reports suggest that SSRIs may cause bruxism,
CLINICAL MANIFESTATION The first manifestation:  appearance of a small facet on cusp tip or ridge or a slight flattening of incisal edge. In severe cases:  “a reverse cusp” situation might be created in place of the cusp tips and inclined planes
Attrition can predispose to or precipitate any of the following :- Proximal surface attrition (proximal surface faceting) Occluding surface attrition (occlusal wear)  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  When surface attrition is SLOWER - compensated by, intrapulpal deposition of secondary & tertiary dentin  Severe attrition leads to pulp exposure
PROXIMAL SURFACE ATTRITION (PROXIMAL SURFACE FACETS) 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 arch. The interproximal space is reduced, interfering with physiology of dental papilla, leading to periodontitis
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 If the LOSS IS SEVERE & accomplished in a relatively SHORT TIME No chance for 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.
If the loss occurs in a LONG PERIOD OF TIME the alveolar bone can grow occlusally, bringing the teeth to their original occlusal termination vertical dimension loss will be confined to teeth but not imparted to face.
EFFECTS OF ATTRITION  Deficient masticatory capabilities  Blunting of the cusps needs more force to shear food items.  Cheek biting and gingival irritation  Decay  Hypersensitivity  TMJ problems - extreme strain on the muscles of stomatognathic system
TREATMENT MODALITIES In developing a treatment plan the dentist should consider the following factors:  Whether the wear is localised or generalised.  Degree of attrition – mild, moderate or severe  Factors affecting the patient’s speech, function and orofacial aesthetics.  The behavioural, psychological, anatomical, developmental and physiological limitations of the patient.  Observation and palliative strategies
Management Of Localized Anterior Tooth Wear
Management Of Localized Posterior Tooth Wear
Management Of Generalized Tooth Wear
BASED ON THE DEGREE OF ATTRITION MILD ATTRITION MODERATE ATTRITION SEVERE ATTRITION • Instructions for oral hygiene • Fluoride application • Use of desensitizing toothpaste • Use of temporary restorations • Restoration of the vertical dimension to improve function and esthetics. • Treatment options include Endodontic therapy followed by crown placement or extraction of affected teeth and replacement with conventional dentures, overdentures and overlay prosthesis, etc.
Treatment depends upon the following categories: Category I: Appearance is satisfactory Category II: Appearance is unsatisfactory and there is no need to raise the vertical height Category III: Appearance is unsatisfactory but there is need to raise the vertical height, which in turn depends on the availability of space, whether it is present or needs to be created. BASED ON APPEARANCE
Category I (Appearance is satisfactory) A. Counselling is required in patients with parafunctional habits. Habit breaking appliance should be given in patients with bruxism or clenching. B. Conventional Restorative Treatment • Exposed pits are filled • Occlusal disharmony is corrected • Consideration to be given to crown lengthening procedure
Category II (Appearance is unsatisfactory but there is no need to raise the vertical height). Teeth are restored, preferably with all ceramic crowns or laminates. The crowns can manage occlusal attrition as well as fractured cusps. Occlusal guard for protection against nocturnal clenching like bleaching trays, etc.
Category III (Appearance is unsatisfactory and there is a need to raise the vertical height • Generalized increase in vertical height is required. • Orthodontic tooth movement can be used for over-eruption of posterior teeth creating space for the anterior teeth.
Sequence of treatment: 1. Management of dentinal hypersensitivity 2. Pulpally involved teeth - based on restorability endodontic therapy or extracted 3. Parafunctional activities, notably bruxism, should be controlled with the proper disoccluding-protecting occlusal splints. 4. Myofunctional, TMJ, or any other symptoms in the stomato- gnathic system should be diagnosed and resolved. 5. Occlusal equilibration should be performed after all notable symptoms are relieved  Occlusal equilibration, by selective grinding of tooth surfaces.  Rounding and smoothing the peripheries of the occlusal tables.
MANAGEMENT OF DENTIN HYPERSENSITIVITY Nerve desensitization  Potassium nitrate Protein precipitation  Gluteraldehyde  Silver nitrate  Zinc chloride  Strontium chloride hexahydrate Plugging dentinal tubules  Sodium fluoride and Stannous fluoride  Strontium chloride  Potassium oxalate  Calcium phosphate  Calcium carbonate  Bio active glasses
Dentin hypersensitivity: Recent trends in management, Journal of Conservative dentistry, 2015 Dentine adhesive sealers  Fluoride varnishes  Oxalic acid and resin  Glass ionomer cements  Composites  Dentin bonding agents Lasers  Nd-YAG and Er-YAG laser  GaAlAs (galium-aluminium-arsenide laser) Natural medication  Propolis Periodontal surgical procedures
Restoration therapy is needed in cases  Where there is loss of vertical dimension.  Or a progressive loss of tooth structure is observed compromising the tooth strength .  Caries ,if present  Defect which may contribute 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 RESTORATION
• Adhesive Composite Resin LESS SEVERE ANTERIOR WEAR • Bonded Porcelain veneers • Direct Composite resin • Adhesive cast metal restorations • Reconstruction with crowns and bridges (Occlusion is severely attrited) MORE SEVERE ANTERIOR WEAR
They should be accomplished very cautiously and carefully in the following sequence. 1. Verify and re-verify its necessity, i.e., be sure that the alveolar bone did not grow occlusally at the same pace that attrition occurred. 2. Estimate how much vertical dimension lost. 3. Estimate how much additional vertical dimension the stomato- gnathic system can accommodate without untoward effects RVD = VD at Rest OVD = VD at Occlusion FWS = Freeway Space
Vertical Dimension • It gives an estimate up to what should be the height of the worn clinical crowns be increased . • The additional V.D. that the stomatognathic system can accommodate without untoward effects is estimated Increasing the Vertical dimension of occlusion can lead to • Clenching (increased muscle activity) • Muscle fatigue • Soreness of teeth, muscle and joints • Problems in phonetics • Occlusal instability • Intrusion of teeth Therefore, periodic monitoring and assessment is required for a period of time until the patient is no more uncomfortable to the new dimension of occlusion
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.
• 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 . The splint would need to be relined with cold cure acrylic resin to improve the retention of the appliance and for occlusal adjustments
In case of inadequate anterior clearance for restoration/ crown placement, space can be created by 1. Occlusal adjustment 2. Orthodontic extrusion 3. Crown lengthening 4. Dahls appliance 5. Extraction or surgical repositioning Dahls Appliance • The Dahl Concept refers to the relative axial tooth movement that is observed when a localised appliance or localised restorations are placed in supra-occlusion and the occlusion re-establishes full arch contacts over a period of time. • 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)
Other phrases used for this process are  ‘minor axial tooth movement’  ‘fixed orthodontic intrusion appliances’  ‘localised inter-occlusal space creation’, and  ‘relative axial tooth movement  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, Poyser NJ et al. The Dahl Concept: past, present and future. British Dental Journal, 2005
The objectives of the Dahl concept are to either create sufficient inter-occlusal space for the placement of restorations or the re-establishment of occlusal contacts following the placement of restorations that have intentionally been placed in supra-occlusion. Requirements:-  The material should be placed on the incisal/occlusal aspect of those teeth where the creation of interocclusal space is necessary.  The thickness of this material placed should directly relate to the amount of inter-occlusal space that is required. This will determine the increase in the vertical dimension of occlusion as measured at that particular site in the mouth.
 Ideally an occlusal bite platform should be constructed to ensure that occlusal forces are directed along the long axis of the teeth.  Stable inter-occlusal contacts should be provided.  The appliance should not impede the movement of the disoccluded teeth The occlusion tends to re-establish after about six months on average but it can take up to a period of 18-24 months.
• More eruption than intrusion was seen in the younger age group. In some cases the time taken for tooth movement to occur is faster than that which could be achieved with orthodontic tooth movement • 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 .
A one-stage Dahl procedure • Involves the placement of definitive indirect laboratory constructed restorations in supra-occlusion, whereby no interim appliance is used to create the inter-occlusal space. • Adjustment of the restorations may be required but this may lead to weakening of the restoration, possible perforation, microleakage, sensitivity, and loss of the restoration. It is for this reason that the authors advocate a Two-stage Dahl procedure using direct composite resin as the interim Dahl appliance. Composite is a useful material for the creation of inter-occlusal space in two stage Dahl procedures. Once sufficient space has occurred, its followed by placement of laboratory constructed definitive restorations.
Direct composite restorations placed as fixed Dahl appliances Conventional metal-ceramic restorations placed once sufficient inter-occlusal space created. Advantage of using composite:- • Inexpensive, simple to use and adjust • Has favourable wear characteristics. • It can be easily removed for subsequent definitive extra-coronal restorations,
‘Double Dahl’ technique - where both the upper and lower anterior teeth are restored simultaneously Rees et al. A guide to the clinical management of attrition. British Dental Journal. 2018
Hemmings et al. 2000 (30 months) Direct composite 94% Gough and Setchell 1999 (4 years) Cemented Interim Appliance 96% success rate Dahl and Krogstad 1982 (14 months) Removable Co-Cr anterior bite plane 70-80% success rate Redman et al. 2003 (5mnths – 6yrs) Direct and indirect Artglass and composite retsoration 100% (61% complete and 39% partial) Indirect Art Glass restorations 83% Hemmings et al. 2000 (30 months) Direct composite 94% Gough and Setchell 1999 (4 years) Cemented Interim Appliance 96% success rate Dahl and Krogstad 1982 (14 months) Removable Co-Cr anterior bite plane 70-80% success rate Gow and Hemmings 2002 (2 months) Redman et al. 2003 (4yrs) Direct and indirect Artglass and composite retsoration 100% (61% complete and 39% partial) Hemmings et al. 2000 (30 months) Direct composite 94% Gough and Setchell 1999 (4 years) Cemented Interim Appliance 96% success rate Dahl and Krogstad 1982 (14 months) Removable Co-Cr anterior bite plane 70-80% success rate
Djulaeha and Sukaedi: The management of over closured anterior teeth due to attrition. Dental journal 2009 Preoperative view Patient had missing posterior teeth and severe attrition of maxillary anteriors. Because of which vertical dimension was lost or reduced. The heightening of the occlusal vertical dimension must be done gradually in order to let the muscles of the mastication adapt to the new occlusal vertical dimension. At first stage, the restoration of the anteriors were done by lengthening incisal, 2 mm, with composite restoration to improve the aesthetics and heighten the occlusal vertical dimension. Then the patient was evaluated for two weeks. The patient had no problems with her temporomandibular joint After Composite restoration
Tooth preparation was done for placing temporary bridge (self cure acrylic) followed by the heightening process of occlusion about 2 mm of the temporary bridge in order not only to maintain the aesthetics and to improve the vertical dimension of occlusion After evaluating the patient for 2 more weeks, the long span bridge with 12 units made of porcelain materials fused to metal materials was processed for upper jaw. An acrylic removable partial denture was given for missing lower teeth A) The long span bridge of upper jaw; B) lower acrylic removable partial denture. Temporary bridge of upper anterior teeth Postoperative view
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 Tooth surface loss resulting from direct frictional forces between teeth and external objects, or from frictional forces between contacting teeth components in presence of abrasive medium. - Marzouk - Shafer ABRASION Abrasion is defined as the pathological wear of tooth substance through some abnormal mechanical process.
Clinical features of Abrasion  Males are comparatively more affected than females.  Premolars and canines are more susceptible to abrasion probably because they are placed slightly protruded in the dental arch.  Right-handed individuals show a preponderance of lesions on the left side and vice versa.  It occurs most frequently on the cervical neck of the teeth.  The labial or buccal surfaces is most affected in case of tooth brush abrasion and lingual surfaces ( in case of poorly fitted clasps and artificial dentures )  Incisal surfaces are affected in certain cases – habits/occupation
Morphology of abrasive lesions Abrasion lesions are of varying morphology and may be classified as : Notch/V- shaped defects: where oblique occlusal and cervical walls intersect at a certain depth with no definite axial wall in between them. C-shaped defects(C): where cross section of the defect is C-shaped with rounded floors. Under cut concave (UC): where occlusal and cervical walls intersect with a definite axial wall in between them. Divergent box (DB): where a definite axial wall is present with the occlusal and cervical walls diverging towards the surface.
CLINICAL SIGNS AND SYMPTOMS  It results in saucer shaped or wedge shaped indentation on the tooth surface  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 .
ETIOLOGY AND PATHOGENESIS • Different foreign substances produce different patterns of tooth abrasion • Though the etiology is varied, the pathogenesis under these different conditions is essentially different Various types of abrasion:  TOOTHBRUSH ABRASION  OCCUPATIONAL ABRASION  HABITUAL ABRASION  PROSTHETIC ABRASION
TOOTHBRUSH ABRASION It is mostly due to 1. Improper oral hygiene practices 2. Oral hygiene products Improper oral hygiene practices  Aggressive tooth brushing  Improper brushing technique i.e by using horizontal brushing method  Vigorous use of toothpicks or tooth floss may result in abrasion in proximal surfaces  Frequency; time and forces applied during brushing also affects the occurrence of lesion
Oral hygiene products : Tooth brush abrasion depends on • Type of the toothbrush used – soft, medium, hard • Shape of tooth bristles used • Flexibility and length of the tooth brush handle affecting the grip of the tooth brush • The grittiness, pH and amount of dentifrice used. • Abrasiveness of dentifrice • Tooth powder is generally five times more abrasive than its dentifrice counterparts Robinsonstatedthatthemostcommoncauseofabrasionoftoothsurfaceistheuseofabrasivedentifrice.
The extent, depth and rate of formation of toothbrush abrasion depends on  The size of the abrasive: larger and more irregular  The direction of brushing strokes: Horizontal directions are the most detrimental.  The percentage of abrasives : higher the percentage is, the more abrasion  The type of abrasives: Silica abrasives are more abrading than phosphate and carbonate ones.  The diameter of brush bristles: greater the diameter, the more the abrasion.  The type of bristles : Natural bristles are more abrasive than synthetic (mylar) ones.
 The forces used in brushing: more the force, the more abrasion there will be. (average manual brushing force = 1.6+0.3N)  The type of tooth tissues being abraded. Generally, enamel is quite hard and not easily abraded therefore it serves as a protection for the underlying dentin, which is abraded 25 times faster. Cementum is the softest of all tissues and shows an abrasion rate of 35 times higher than enamel.
OCCUPATIONAL ABRASION • Notching of incisal edge of maxillary anteriors may be seen in carpenters, shoemakers, tailors who hold nails, tacks or pins between their teeth. HABITUAL ABRASION  Habitual pipe smokers may develop notching of teeth that confirms to the shape of pipe stem – Shafers
 Habitual opening of bobby pins may also result in notching of the incisal edge of maxillary anteriors Also called Depression abrasion - where one can see an abraded depression on the occluding surfaces of teeth at a latero-anterior portion of the arch, coinciding with intra oral location of the pipe stem.
 Oral piercings Lingual (tongue) piercings may result in abnormal tooth wear. Biting or chewing of the device can lead to severe abrasion accompanied by hypersensitivity. It involves enamel, dentin and may also lead to pulp involvement. Holding the device between the teeth over an extended period of time may also lead to widening of interdental spaces and tooth migration L.L Francu. Lingual piercing : Dental anatomical changes induced by trauma and abrasion. Romanian journal of anatomical functional, clinical, microscopy and anthropology, 2012
PROSTHETIC ABRASION • Dentures with porcelain teeth opposing natural teeth. Porcelain causes more abrasion to the natural teeth than other restorative materials. The proximate damage can include loss of natural tooth structure, reduced longevity of opposing restorations and even unfavourable changes to the vertical dimension of occlusion. • Extremely rough occluding surface of the restoration enhancing its abrasive capability . • ill fitting dentures and clasps ,producing a constant wear of the affected surfaces.
 In case of tooth brush abrasion, patient should be advised or educated about the brushing technique and the tooth brush, dentifrice to be used.  Instituting proper oral hygiene measures  Prevent the patient from practicing causative habits. The objective should be to prevent any further destruction of the tooth.  Prosthetic/ iatrogenic causes for abrasion to be avoided. In case of such abrasion, early diagnosis and proper management to be carried out such as Correcting or avoiding ill fitting metal clasps and dentures Treatment modalities for abrasion: Diagnose the cause of abrasion and take necessary steps to eliminate the etiological factor
Abrasive lesions at non-occluding tooth surfaces should be evaluated critically for the need for restoring them.  Edges of the defect should be eradicated to a smooth, non- demarcating pattern relative to adjacent tooth surface.  Tooth surface then should be treated by fluoride solution to improve caries resistance If there is involvement of cementum / enamel only If the lesions are multiple, shallow( not exceeding 0.5 mm in dentin) and wide Restoration not needed
• If the abrasive lesion involves an anterior tooth or facially conspicuous area of a posterior tooth, at a non occluding tooth surface, restoration done with Direct tooth colored materials • If the involved teeth is extremely sensitive - Desensitize the exposed dentin before restoration . Desensitization is done by • 8-10% sodium/stannous fluorides for 4-8 minutes. • Iontophoresis- --using an electrolyte containing fluorides If lesion is wedge (V) shaped and exceeds 0.5 mm into dentin Restoration needed
Restoring cervical abrasions In many instances no treatment is necessary but restoration is 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 partial denture.  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
Restorative materials used are: • Glass ionomer restorative material. • Resin modified glass ionomer. • Polyacid-modified resin composites. • Resin composites. 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 cavity . (Heymann HO ,Sturdevant Jr ,Baynes S ,JADA,122(2) 41- 57 ) 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 )
Materials with low elastic modulus for restoring cervical abrasion such as  Microfilled composites (Heymann and others ,1991 :Levitch and others ,1994 )  Flowable resins (Unterbink ,Liebenberg ,1999: Li and others 2006 )  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 .
ABFRACTION Abfraction represents the mechanical flexure theory where tooth bending and flexing during function and parafunction create flexural stress in the cervical area of the tooth resulting in microfractures of the crystalline structure of the enamel and dentin in that area. - K.B. Troendle and K.M. Gureckis. Noncarious Cervical Lesions: Prevalence, Etiology, and Management. Textbook of Erosion and its clinical management. Grippo in 1991, coined the term “abfraction” to describe the pathologic loss of both enamel and dentin caused by biomechanical loading forces. - Milosevic A. Dent Update, 1998 Loss of tooth surface at the cervical areas of the teeth caused by tensile and compressive forces during tooth flexure
Clinical features  The lesion is typically wedge shaped with clearly defined internal and external line angles  Affects buccal/labial cervical areas of teeth  Deep, narrow V-shaped notch  Can manifest as C-shaped lesions with rounded floors or mixed shaped lesions with flat, cervical, and semicircular occlusal walls  Commonly affects single teeth with excursive interferences or eccentric occlusal loads  Contributing factors can also modify the clinical appearance of these lesions by making the angles less sharp and the outline broader and more saucer-shaped.
 Moreover, abfraction lesions may be deeper than wider depending on the stage of progression and related causal factors  In early stages, the lesion appears as a minor irregular crack or fracture line on the enamel surface. In late stages, it appears as notch extending into the dentin
El-Marakby AM et al. Noncarious Cervical Lesions as Abfraction: Etiology, Diagnosis, and Treatment Modalities of Lesions: A Review Article. Journal of Dentistry. 2017
Etiology and Pathogenesis  Some authors explain the formation of cervical, wedge shaped defect by the heavy force in eccentric occlusion resulting in flexuring (elastic bending) of the tooth.  Grippo et al in 1991 suggested that static or cyclic forces created tooth loss at the cervical area  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 .  The flexure may lead to breaking away of extremely thin enamel rods ,as well as microfractures of cementum and dentin .
 Later Lee and Eakle in 1984 proposed a multifactorial etiology, with a combination of occlusal stresses, abrasion and erosion.  Once micro fracture occurred, water and other small molecules penetrate the broken hydroxyapatite chemical bonds and makes the tooth susceptible for chemical erosion and toothbrush  The resulting defect has a smooth surface .  Also known as idiopathic erosion (Lee WC, Eakle WS, J Prosthet Dent 52(3): 374-380, 1984.)
 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)  Occlusal interferences, premature contacts, habits of bruxism and clenching all may act as stressors. (Pintado MR, DeLong R, Ko C, Sakaguchi RL, Douglas WH. Correlation J Prosthet Dent 2000) Differences in support provided by the bony socket, gross morphology of the tooth, the presence or absence of restorations, and the microscopic structure of the tooth are all confounding variables that could influence the occurrence of lesion.
Grippo et al. ABFRACTION, ABRASION, BIOCORROSION, AND THE ENIGMA OF NCCLS. Journal of Restorative and Esthetic Dentistry. 2012 ETIOLOGICALFACTORS
Theories of Abfraction Abfraction lesions: etiology, diagnosis, and treatment options. Journal of Clinical, Cosmetic and Investigational Dentistry, 2016  The theory of abfraction sustains that tooth flexure in the cervical area is caused due to occlusal compressive forces and tensile stresses, resulting in microfractures of the hydroxyapatite crystals of the enamel and dentin with further fatigue and deformation of the tooth structure.  The theory suggests that the lesion would continue to enlarge as the bending and flexing is repeated finally resulting in chipping away of the hard tissue Separation of enamel from dentin Disruption of bonds b/w HA crystals Tensile stress Compressive stress
. • Some researchers even proposed that the occlusal forces on the tooth from chewing and swallowing leading to concentration of stress and flexion in the area where the enamel and cementum meet, as the etiological factor of Abfraction • Others have suggested that abrasive agents like tooth brushes, abrasive paste and or erosion also contribute to abfractive lesions • Recent studies have suggested that there is weak relation between the occlusal factors and the occurrence of cervical lesions. El-Marakby AM et al. Noncarious Cervical Lesions as Abfraction: Etiology, Diagnosis, and Treatment Modalities of Lesions: A Review Article. Journal of Dentistry. 2017
 Abfraction lesions are also said to be facilitated by the thin structure of the enamel and the low packing density of the Hunter–Schreger band (HSB) at the cervical area. Lynch CD et al. Hunter-Schreger band patterns in human tooth enamel. J Anat. 2010 • Dentin demineralization promotes the formation of NCCLs from an early stage, whereas occlusal stress is an etiological factor that contributes to the progression of these lesions Wada I et al. Clinical assessment of non carious cervical lesions using swept source optical coherence tomography. J Biophotonics. 2015
Diagnosis of Abfractive lesions • Proper diagnosis can be achieved by complete patient anamnesis accompanied by a careful clinical examination • If a tooth has an abfraction, the occlusal loading on the tooth can be tested in centric occlusion and in excursive movements with occlusal marking paper. The tooth with abfraction will show a heavy marking on one of the inclines of the tooth • Mainly seen in malaligned tooth Abfraction lesions: etiology, diagnosis, and treatment options. Journal of Clinical, Cosmetic and Investigational Dentistry, 2016
Assessment of activity of abfractive lesions  Approaches to determine lesion activity include the use of standardized intra-oral photographs, study models, and measurement of lesion dimensions over time.  Activity assessment can also be performed by using a scratch test. Scratch test - Its a novel method for determining the activity of abfraction lesions over time ( 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 structure loss • Loss of scratch definition or loss of the scratch altogether signifies active tooth structure loss.
 Furthermore, several indices of tooth wear have been proposed for recording and monitoring the progression of abfraction lesions such as Smith and Knight index.  Another index has been recently proposed that includes not only lesion depth but also the width and angle between the lesion and the occlusal and cervical walls, with a scale (DAW index by Loomba et al)  With the recent introduction of digital dentistry, future studies should also test if CADCAM systems may be useful for diagnosis and monitoring of NCCL activity
DAW (DEPTH, ANGLE and WIDTH) Classification Loomba K et al. proposal for clinical classification of multifactorial noncarious cervical lesions. Gen Dent 2014
Management of Abfraction Monitoring the lesions  when abfraction lesions are painless and do not affect esthetics, i.e are shallow in depth (,1 mm or less), it is advisable to monitor the progression of these lesions at regular intervals without any treatment intervention.  The assessment of lesion activity can be performed every 6 months to 12 months and during regular hygiene visits.  If the tooth wear is likely to compromise the long-term prognosis of the tooth, operative intervention may be required Abfraction lesions: etiology, diagnosis, and treatment options. Journal of Clinical, Cosmetic and Investigational Dentistry, 2016
Occlusal adjustments and Occlusal Splints  Occlusal adjustment has been proposed as an alternative treatment to prevent the initiation and progression of these lesions and to minimize failure of cervical restorations.  Occlusal adjustment may involve  Altering cuspal inclines  Reducing heavy contacts, and  Removing premature contacts  Occlusal splints to reduce the amount of nocturnal bruxism and nonaxial tooth forces have also been recommended to prevent the initiation and progression of abfraction lesions.
Issue of hypersensitivity  The chronic nature of abfraction, which is accompanied by the natural process of dentinal remineralization, will slowly relieve tooth sensitivity.  If sensitivity persists, the exposed dentin may require therapeutic treatment to relieve or eliminate discomfort.  Various cost-effective and non-invasive treatments like application of desensitizers on to the exposed dentinal tubules or use of desensitizing toothpastes, which might partially or completely occlude the open dentinal tubules  Different types of lasers have also been introduced as an alternative option for treating tooth sensitivity  Other non-invasive treatments include temporary sealants such as Varnishes and Dentin bonding agents.  In extreme cases of Hypersensitivity unresponsive to non-invasive procedures, a restoration might be required.
Restorative treatment Restorative treatment of abfraction lesions should be considered only when one or more of the following conditions are present: 1. Active, cavitated carious lesions associated with abfraction lesions 2. Cervical margins or all lesion margins are located subgingivally and preclude plaque control, hence increasing the risk for caries and periodontal disease, 3. Extensive tooth structure loss, which compromises the integrity of the tooth, or the defect is in close proximity to the pulp, or the pulp has been exposed, 4. Persistent dentinal hypersensitivity, in which noninvasive therapeutic options have failed, 5. Prosthetic abutment, and 6. Esthetic demands.
 Authors have suggested that during the selection of restorative materials for cervical lesions, materials with a low modulus of elasticity, good adhesion to dentin, resistance to wear, and ability to endure acid dissolution should be considered.  Of the available restorative techniques, adhesive systems, specifically Resin Based Composites, are the preferred choice of dentists to restore NCCLs, likely due to their esthetic and more conservative components.  Although the use of GICs, RMGICs, and the lamination technique of GIC⁄RMGIC with RBC has been advocated for NCCL restorations
Tyas recommended that RMGIC should be the first preference In esthetically demanding cases, RMGIC/GIC liner laminated with resin composite. (Tyas MJ. The class V lesion –aetiology ,restoration,Aust. Dental Journal.1995) Vandelwalle and Vigil recommended the use of Microfilled resin composite(low modulus of elasticity ) as it will flex with tooth and not compromise retention (KS Vandelwalle. Guidelines for the restoration of class V lesions. Gen Dent 1997)
Root coverage surgical procedures  In most cases of lesions associated with gingival recession, there is a loss of the hard tissues of the tooth crown causing the CEJ to disappear, and root coverage procedures are not effective at treating these crown defects.  Consequently, a combined restorative-surgical approach may be indicated in these clinical situations. In this approach, the restoration must be placed prior to the surgical procedure for better visibility of the operative field and to provide a stable, hard, and convex substrate for the Coronally Advanced Flap (CAF)  Recent studies have pointed out that the combination of Coronally Advanced Flap with connective tissue graft (CTG) provides the best clinical outcomes for root coverage when appropriately performed.
Resin composite plus connective tissue graft to treat single maxillary gingival recession associated with non-carious cervical lesion: Randomized clinical trial. J Clin Periodontol 2016 AIM : to evaluate clinically, the esthetics and the patient centered parameters after the treatment of gingival recession associated with non-carious cervical lesions by connective tissue graft (CTG)alone or combined with nanofilled resin composite restoration METHODOLOGY In the CTG Group, In the combined group (COMPOSITE + CTG) Flap Elevation Connective Tissue Graft placed Flap sutured 1mm coronally to the cervical lesion Flap Elevation Nanofilled Resin Composite placed Connective Tissue Graft placed Flap coronally placed and sutured
Pre-operative view After flap elevation and rubber dam isolation Nanofilled resin composite placed CTG placed and flap was coronally advanced & sutured 1 year follow-up. RESULTS Both groups can successfully treat gingival recession associated with cervical lesions. Reduction of dentinal sensitivity was more in the combined approach (CTG + Composite)- sensitivity reduced from 88.8% of sites to 5.5% of sites whereas reduction was 94.45 to 44.4% in CTG group. Also, the groups that received restoration presented better marginal contour while the other group often showed flattened margins
DISCUSSION Most of the cervical lesions did not achieve complete coverage with gingival tissues. Thus part of the cervical lesion was still exposed to the oral environment in the CTG group. While in the combined group, the defect is completely restored, sealing the dentinal tubules and thereby effective in reducing symptoms The teeth with cervical lesions often presents a flattened marginal contour . This may be the reason for flattened gingival margins in the CTG group following the healing period. Restorations may help to achieve a better anatomical outcome, helping to modulate the marginal contour and give a good final esthetic result
Loss of surface tooth structure by chemical action in the continued presence of demineralizing agents(acids). - Sturdevant Erosion can be defined as the loss of tooth structure resulting from chemico- mechanical acts in the absence of specific microorganisms. - Marzouk Loss of tooth substance by chemical process that does not involve known bacterial action. - Shafer EROSION
Affect of erosion in enamel Acid diffusing into the narrow pores between the crystals results in partial loss of mineral, increased porosity and reduction of mechanical strength of the outer layer of enamel, which is hence referred to as the ‘softened layer’. Textbook of Erosion and its Clinical Management, Bennett T
Affect of erosion in dentin  Erosion of dentin leaves behind a persistent layer of demineralised collagenous matrix.  Demineralization of dentin is firstly apparent at the interface between inter- and peritubular dentin.  With increasing exposure time, the erosive attack results in a hollowing and funneling of the tubules.  Finally, the peritubular dentin is completely dissolved.  Erosive demineralization results in exposure of an outer layer of fully demineralized organic matrix followed by a partly demineralized zone until the sound inner dentin is reached Insights into preventive measures for dental erosion. Journal of applied oral science. 2009
Textbook of Erosion and its Clinical Management, Bennett T Factors controlling erosive demineralization 1. Chemical factors a) Enamel - Degree of saturation with respect to hydroxyapatite Degree of saturation with respect to fluorapatite pH Buffer capacity Fluoride concentration Phosphate concentration b) Dentin – Buffer capacity Carbonate concentration 2. Physical factors – Temperature Fluid movement
 Dissolution also tends to be reduced or even abolished in undersaturated solutions in which the calcium concentration is much higher than the phosphate concentration.  Calcium addition to acidic solutions can reduce erosive potential.  The factors that have been most consistently identified as significant factors in erosive potential are pH and buffer capacity  The higher the buffer capacity, the pH of the solution within the pores will rise and the lesser the overall rate of erosion.  pH - Laboratory experiments show that erosion of enamel is very rapid at pH of about 2.5 but slows down as the pH increases
 Fluorapatite is less soluble than hydroxyapatite, indicating that replacement of all the OH− ions in hydroxyapatite by F− ions causes a large decrease in solubility.  Temperature - Temperature affects the rate of most chemical reactions and erosion is no exception. Studies show that both early erosion (measured by softening) and later erosion (loss of surface) increase over the range 4–75 °C  Fluid Movement – In active fluid movement – the static interfacial layer of liquid becomes thinner and there is an improved supply of H+ ions and removal of mineral-ion end products. Increased movement of fluid thus speeds up dissolution. Erosion of enamel increases very rapidly at low flow rates and then increases more slowly, whereas dentin erosion increases gradually with flow rate
CLASSIFICATION OF DENTAL EROSION Based on Etiology 1. Extrinsic Erosion 2. Intrinsic Erosion 3. Idiopathic Erosion Idiopathic erosion is the result of acids of unknown origin, i.e. an erosion-like pathology where neither tests nor anamnesis are capable of providing an etiologic explanation. Imfeld T: Dental erosion. Definition, classification and links. Eur J Oral Sci 1996:
Based on Pathogenetic activity – Mannerberg, J Odout Revv 1961 Manifest erosion:  An actively progressing erosion, is clinically diagnosed by its enamel border zones.  These are thin where they meet the exposed dentin.  In the scanning electron microscope (SEM), they show a honeycomb  enamel prism pattern, resembling that seen in acid etched enamel. latent erosion:  It is an inactive stage and here the prisms are much less obvious.  Through a change in the etiologic factor, are no longer subject to further decalcification,  Have prominent thick enamel borders and do not show a honeycomb enamel prism
Based on Clinical severity – ECCLES in 1979 EccLES JD. Dental erosion of nonindustrial origin. A clinical survey and classification. J Prosthet Dent 1979 Class I: Superficial lesion, involving enamel only; Class II: Localized lesion, <l/3 of surface involving dentin; Class III: Generalized lesion, >l/3 of surface involving dentin. Based on these three classes, Lussi and co-workers in 1991 have published a similar, more detailed index of erosion for epidemiologic use Lussi A. Schaffner M. Hotz P. Suter P. Dental Erosion in a population of swiss adults. Community Denatl Oral Epidemiology, 1991
Grading of severity for facial surfaces - Lussi and co-workers in 1991 Grade 0: No erosion. Surface with a smooth, silky-glazed appearance and absence of developmental ridges possible. Grade I: Loss of surface enamel. Intact enamel found cervical lo the erosion and concavity on enamel whose width clearly exceeds its depth, thus distinguishing them from toothbrush abrasion. Dentin is not involved. Grade 2: Involvement of dentin for less than one half of the attacked area of tooth surface Grade 3 : Involvement of dentin for more than one half of the attackcd area of tooth surface
For other surfaces Grade 0: No erosion. Surface with a smooth, silky-glazed appearance and absence of developmenlal ridges possible. Grade I: Slight erosion, rounded cusps, edges of restorations rising above the level of adjacent tooth surface, grooves on occlusal aspects, loss of surface enamel. Dentin is not involved. Grade 2: Severe erosion, more pronounced signs than in grade I. Dentin is involved.
ETIOLOGY Erosion can be due to Intrinsic or Extrinsic factors Intrinsic factors a) Recurrent vomiting disorders b) Gastroesophageal reflux diseases Eating disorders Medical conditions Psychogenic vomiting syndrome Chronic alcoholism Side effect of drugs Pregnancy induced vomiting Cyclic vomiting syndrome
Extrinsic factors a) Dehydrated items b) Acidic foods c) Medications Wines Alcoholic Beverages Soda and Soft Drinks Sports Drink Fruit Juices Tobacco Citrus Fruits Analgesics Vitamins Antisialogogues Drug abuse Asthamatic medications
d) Oral Health care Low pH toothpaste and mouthrinse Abrasive toothpaste Toothbrushing technique e) Occupation Industrial workers Swimmers Professional wine tasters f) Other factors include :- • Bleaching • Chewing gums • Lifestyle or behavioural factors
Eating Disorders • An eating disorder can be defined as an unusual eating behavior with insufficient or excessive food intake, which is associated with distress about weight or body shape • Among the eating disorders, bulimia nervosa is the condition most closely related to dental erosion. Another eating disorder - anorexia nervosa. • Labial surfaces of the incisors, which is the first surface that the acid gets in contact during ingestion. • Another report observed severe lingual and moderate buccal erosion in almost all anorexic patients with recurrent vomiting A Rosten and T Newton. The impact of bulimia nervosa on oral health: a review of literature. British Dental Journal. 2017
 Other features include parotid enlargement, decreased salivary secretions and xerostomia.  Also, bulimic patients had lower stimulated salivary flow rates and lower bicarbonate concentrations Medical Conditions The main medical conditions associated with vomiting include • Gastrointestinal disorders (peptic ulcer, c/c gastritis, and gastric motility problems) • Metabolic and endocrine disorders (diabetes mellitus, chronic renal failure and hyperthyroidism), • Dry mouth conditions (diseases of the salivary gland, sjogrens syndrome, head and neck radiation, etc) and • Neurological and central nervous system disorders (migraine headaches and intracranial neoplasms)
Cyclic Vomiting Syndrome • Cyclic vomiting syndrome is characterized by recurrent attacks of nausea and vomiting that may last for periods of a few days to several months, which is separated by symptom-free periods • Among the common triggering factors are stress, emotional excitement, and infections Side Effect of Drugs Opiate analgesics and chemotherapeutics agents. Other drugs can induce vomiting secondary to gastric irritation, such as aspirin, diuretics, and alcohol
Psychogenic Vomiting Syndrome Psychogenic vomiting syndrome affects mostly young women, and it involves recurrent vomiting, which may be caused by an underlying emotional disturbance. Chronic alcoholism • Alcoholism can result in a series of dental implications, such as high caries incidence due to neglected oral hygiene, dental attrition due to alcohol-stimulated bruxism, and oral cancer • Dental erosion due to alcohol abuse can be caused by both intrinsic factors (vomiting and regurgitation) and extrinsic factors, depending on the erosive potential of the alcoholic drink that is ingested.
• For example, wines and alcohols have a low pH and may be highly erosive to the teeth. • Erosive lesions were most commonly found at the palatal surfaces of the anterior teeth Pregnancy-Induced Vomiting Not a major risk factor for dental erosion. Certain studies have shown association with palatal erosion who had severe and prolonged vomiting during pregnancies
Gastroesophageal reflux diseases (GERDs) • GERD has been defined as “a condition that develops a reflux of gastric contents into the esophagus or beyond: larynx, oral cavity or lung • The potential for tooth erosion is variable and depends on the  Composition and pH of the refluxate;  Frequency and the form it reaches the mouth (either through regurgitation or belching acidic vapors)  Flow rate  Buffer capacity,  Clearance action of saliva; and  Brushing after the regurgitation episodes.
• Erosive wear in GERD patients appears to be found more frequently on palatal surfaces of the maxillary anterior teeth and on the molar teeth. • It was suggested that during reflux the gastric juice passes over the dorsum of the posterior third of the tongue, reaching the palatal surfaces of the upper molar teeth, and then passes over the buccal surfaces of the lower molars. • The lingual surfaces of the lower molars remain protected by the ventral surface of the tongue. The acid also passes over the dorsum of the tongue, reaching the palatal surfaces of the maxillary anterior teeth
Acidic foods  Acidic foods like vinegar, citric fruits, acidic berries, and other fruits (apple, pears, and plums)  Acidic candies - contain organic acids such as citric acid and malic acid to develop the characteristic sour flavor.  Sucking on sour candies can reduce the salivary pH levels below to the critical value for dental demineralization, therefore posing a risk for erosion of dental surfaces  size of the candy is an important aspect, since it will determine the total length of exposure to the erosive challenge. As they dissolve slowly, they can be kept in the mouth for extended periods of time. This allows for prolonged and continuous exposure of the teeth to acids.
Several factors may actually vary the erosive response in individuals consuming acidic fluids. - manner in which the fluids consumed - tooth surfaces that come in contact with the fluid - duration of contact with the teeth - pH, buffering effect and content of calcium and phosphate in the drink. - swallowing habits - access to saliva - soft tissue movements. - roughness of individual food consumed. - prolonged contact of an acid with tooth surface increases its damaging potential.
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)
Medications • Aspirin, ascorbic acid (vitamin C), iron tonics, cocaine, have been implicated in dental erosion • Asthamatic medications (cortisol inhaler) present erosive potential due to their acidic nature. In addition, they can decrease the salivary buffering capacity and flow rate Low pH oral care products • Three acidic mouthrinses: acidified sodium chlorite mouthrinse (pH 3.02), essential oil mouthrinse (Listerine®, pH 3.59), and a hexetidine mouthrinse (0.1 %, pH 3.75), were shown to cause progressive enamel surface loss over time, similar to that of an orange juice and higher than that of mineral water.
• Non – fluoridated toothpaste contributed more to dental erosion than fluoride containing toothpastes. This finding was attributed to both the presence of citric acid/citrate and absence of fluoride in the toothpaste. Abrasive Toothpaste  Highly abrasive toothpastes may facilitate the disruption of the acquired dental pellicle as well as abrade away dental surfaces previously softened by an erosive challenge. This is even more relevant in the presence of exposed root dentin surfaces.  Dentin is more susceptible to abrasive and erosive insults and less responsive to remineralization.  whitening toothpastes causes more erosion than regular toothpastes
Toothbrushing  Prolonged and frequent toothbrushing has been shown to increase the probability of erosive wear  Brushing performed right after the erosive attack by acidic beverages, not allowing the eroded surfaces to remineralize and regain its physical strength, also contribute to erosion
Dental Bleaching • It has been shown that some hydrogen peroxide-based gels may influence enamel surface morphology and softening suggesting erosive potential. • This is substantiated by the high content of hydrogen peroxide and a low pH value of some bleaching agents Saliva Substitutes Some of these products such as Biotene® with a pH of 4.15 and Glandosane® with a pH of 4.08 are considered potentially erosive
Occupational factors Industrial workers  Any industrial processing procedures that expose workers to acidic fumes or aerosols have the potential to cause dental erosion.  The incisal edges of anterior teeth are primarily affected, although an increased rate of tooth wear of posterior teeth has also been reported.  Sulfuric, nitric, acetic, and hydrochloric acids have all been implicated  Occupations involved with galvanizing, electroplating, metal and glass etching, printing, and mouth pipetting of laboratory acids as well battery, fertilizer, and chemical manufacturing are all at risk of dental erosion unless appropriate safeguards are taken.
Occupational wine tasters  The pH of wine was reported to range from 2.8 to 3. Professional wine taster tasting an average of 30 wines a day over 23 years showed extensive palatal erosion Competitive Swimmers  Several case reports have associated competitive swimmers using improperly pH- regulated swimming pools with dental erosion  Gas chlorinated swimming pools require daily pH monitoring and adjustment to maintain pool water in the recommended pH range of 7.2 to 8.0
Lifestyle factors  Healthier lifestyle that includes a diet high in acidic fruits and vegetables may subject teeth to an increased risk of erosion.  Frequent dieting with high consumption of citrus fruits and fruit juices as part of a weight-reducing plan may also be a risk factor.  lactovegetarians showed signs of dental erosion and they were mostly associated to the consumption of vinegar and vinegar conserves, citrus fruits, and acidic berries.  Strenuous sporting activities and exercise may lead to higher risk of erosion if frequent intake of acidic sport drinks, fruit juices, and other acidic beverages are used for fluid and energy replacement.
Chewing Gum • Frequent use of some of the acidic chewing gums may present potential for dental erosion development, especially on the occlusal surfaces of posterior teeth • For instance, replacement of gum every 4 min was able to cause significant erosive tooth wear on dentin, as it keeps the low pH values at tooth surfaces for longer time, increasing the risk for dental erosion
CLINICAL MANIFESTATIONS OF EROSIVE WEAR  Erosive wear can be observed on the buccal/labial and lingual/palatal surfaces, which are not affected by wear in a purely abrasive environment.  These surfaces typically appear glossy or silky because of the loss of small-scale surface features such as perikymata.  When abrasion has occurred on erosion-softened surfaces, the occlusal wear surfaces tend to have rounded borders and a smooth transition to the adjacent tooth surface  Active erosive wear may be associated with dental hypersensitivity, when the dentinal tubules remain patent
 The same vulnerability to friction underlies the ‘cupping’ due to loss of dentin from cuspal areas and the loss of tissue from the occlusal surfaces which causes restorations to stand proud of the surface. Extensive loss of buccal and occlusal tooth structure with raised amalgam restorations Multiple cupped out depressions corresponding to the cusp tip
Clinical signs and symptoms of Erosive wear of Intrinsic origin  Wear of the palatal surfaces of the upper incisors is a very common characteristic of intrinsic erosion, whether it is caused by frequent vomiting or by regurgitation.  With lesion progression the lingual surfaces of the premolars and molars become affected, and in more advanced stages, the process extends to the occlusal surfaces of the molars and to the facial surfaces of all teeth  Incisal edges of the maxillary central incisors had their height reduced through a combination of erosion and attrition Palatal surfaces of maxillary dentition in which the exposed dentin exhibits a concave surface and a peripheral white line of enamel Extensive loss of enamel and dentin on the Buccal surface of maxillary bicuspids
 On the occlusal surfaces, rounding of marginal ridges and cups was observed in addition to cupping characterized by localized exposure of the dentin Occlusal view of maxillary dentition exhibiting concave dentin depressions surrounded by elevated rims of enamel  On the buccal aspect of the maxillary and mandibular teeth, these lesions were characterized by a silk- like appearance of the enamel surface with shortened appearance of the maxillary front teeth.
 On the palatal aspect of the maxillary teeth, erosive lesions with complete loss of the enamel were readily identified by the presence of a thin band of enamel at the gingival margin and exposure of dentin on both anterior and posterior teeth  In severe cases, almost complete loss of enamel, along with exposure of dentin
Perimylosis  Decalcification of the teeth caused by exposure to gastric acid in patients with chronic vomiting  Mostly seen at the palatal and occlusal surfaces in upper arch, buccal and occlusal surfaces of lower premolars and molars  Loss of lingual enamel and dentin due to acid regurgitation aggravated by circular movements of tongue.  Associated with stress reflux syndrome
Monitoring Tooth Erosion 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 . Inactive wear Stained Active Wear Smooth, stained clean tooth surfaces Erosion around restorations Restoration- resistant to acid, but the tooth is gradually dissolved
TOOTH WEAR INDICES FOR EROSIVE LESIONS The objective of tooth wear indices is to classify and record the severity of tooth wear or dental erosion in prevalence and incidence studies. Eccles Index in 1978 originally classified lesions broadly as  Early,  Small and  Advanced Later, the index was refined and expanded, with greater emphasis on the descriptive criteria. It breaks down into three classes of erosion, denoting the type of lesion, assigned to four surfaces, representing the surface where erosion was detected (Eccles index for dental erosion of non-industrial origin in 1979) Bardsley et al. The evolution of tooth wear indices. Journal of clinical oral investigation. 2008
BEWE (BASIC EROSIVE WEAR EXAMINATION) – Bartlett et al in 2008 The BEWE is a partial scoring system recording the most severely affected surface in a sextant and the cumulative score guides the management of the condition for the practitioner • Simple, • Reproducible • Transferable scoring system Bartlett et al. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clin Oral Invest (2008)
TREATMENT MODALITIES  Proper diagnosis of the cause of erosion is the first step  A complete analysis of diet, occlusion, habits, vomiting, and environmental factors should be taken into consideration.  The cause should be identified and be should eliminated.  There should not be any rush to attempt restorative modalities, except in extremely symptomatic or disfiguring lesions.  Tooth colored materials such as GIC or composite, capable of chemico-phyiscal bonding to tooth structure can be used with minimum or no tooth preparation.
PREVENTION AND CONTROL OF DENTAL EROSION Preventive Strategies Based On Lifestyle And Behavioral Modification Preventive Strategies Based On The Self- applied Preventive Agents Preventive Strategies Based On Proffesionally Applied Agents Textbook of Erosion and its Clinical Management, Bennett T
Role of saliva: Saliva plays an important role in modifying the erosive effects of dietary foods and beverages by the following mechanisms.  Dilution and clearance of an erosive agent from the oral cavity  Neutralization and buffering of dietary acids by the salivary bicarbonate, phosphate and proteins  Formation of a pellicle layer on the surface of enamel which protects it from demineralization by dietary acids. A. Warreth et al. Tooth surface loss: a review of literature. Saudi Dental Journal. 2020  Reduce the demineralization rate by providing calcium, phosphate and fluoride ions to restore eroded enamel and dentine  Both quantity and quality of saliva are known to control the extent of dental erosion.
Dietary Recommendations to Prevent Erosion 1. Reduce the intake of highly acidic foods and drinks, and if possible limit their intake to mealtimes Such foods and drinks as: • Carbonated soft drinks to include diet and sports drinks • Fresh citrus fruit juices and fruit juice drinks • Wine, cider, and spirits consumed with mixers • Some herbal teas (citrus and berry types) • Fresh citrus fruits (if consumed in large quantities) • Vinegar, sauces, ketchup, pickles, and chilies • Acidic sweets such as fruit drops • Chewable vitamin C tablets • Acidic candy that is hard or sticky, instead use sugar-free gum • Powdered drinks with a tangy, fizzy, or acidic flavor Preventive Strategies Based On Lifestyle And Behavioral Modification
2. Reduce erosive impact of food and drinks by observing the following • Drink acidic drinks quickly and use a straw in order to reduce the contact of the drink with your teeth. • Do not swish drink around or hold them in your mouth for long periods. • After consuming food or drink that is high in acid content, rinse with water to dilute the acid, and wait an hour before brushing your teeth. • Or finish the meal with something to neutralize acid, like cheese or milk. • As salivary flow is almost nil at night, avoid acidic food and drink especially before going to bed. • Chew sugar-free gum to produce more saliva so your teeth can remineralize. • Brush with a soft toothbrush and be sure your toothpaste contains a high amount of fluoride
Change in Frequency and Method of Beverage Intake  Clearly, a reduction in acid exposure would be the best preventive strategy to be applied in high-risk patients.  The consumption of potentially erosive foods and beverages, should be limited to main meals only  The straw, when appropriately used, might be a viable alternative to reduce the contact of the acid with the teeth  The temperature of an acidic drink also influences its erosive potential. Taking the drink ice-cold reduces its erosive effect
Change in Oral Hygiene Method and Materials  The time of toothbrushing after an erosive attack as well as the applied force and type of dentifrice used should be controlled.  Thus, an important recommendation is to avoid brushing the teeth immediately after episode of acidic challenge such as vomiting or reflux or intake of acidic beverage.  Rather patients should be advised to rinse their mouth with water or, more effectively, to use antacid products or fluoridated mouthrinse immediately after acidic challenge.  Regular toothpastes are most recommended rather than whitening,  It may be recommended for patients at high risk for erosion soft-bristle toothbrushes, especially if exposed dentin surfaces are present.
Use of Personal Protective Equipment  Personal protective equipment (e.g. respiratory masks for industrial workers or ‘bite-guards’ for professional swimmers) and adherence to threshold limit values recommended by occupational health legislations are considered an important preventive strategy to decrease occupational exposure to erosive acids  It is pertinent to mention that the bite guards suggested for professional swimmers should have the inside (tooth surface) coated with a small amount of sodium bicarbonate powder or milk of magnesia to neutralize any acidic water pooling in it. The guard should have occlusal coverage only, so that saliva flow to aid remineralization is maintained.
Control of Exposure to Intrinsic Acids  Management of erosive tooth wear in patients suffering from GERD or eating disorder requires a multidisciplinary intervention, including general medicine and psychological treatment, in order to decrease the exposure to intrinsic acids  The mainstay medical therapy for GERD includes  Antacids,  Histamine-2 Receptor Blockers (H 2 RB Or H 2 Blockers), And  Proton Pump Inhibitors (PPI). Over-the-counter antacids provide symptom relief by neutralizing refluxed gastric acid thereby increasing esophageal pH.
• Histamine-2 receptor antagonists or blockers inhibit the secretion of gastric acid competitively by blocking the H 2 receptors located on the gastric parietal cells. • Proton pump inhibitors (PPIs) are effective in controlling GERD symptoms that are refractory to antacids and H2 blockers
Use of Modified Products  The modification of beverages or foods is another preventive strategy to reduce the risk of dental erosion.  Reduction of the erosive potential of acidic beverages can be achieved by adding ions (calcium, phosphate and/or fluoride) that make the beverage more saturated in respect to tooth mineral, hydroxyapatite (HA) or by adding polymers (pectin, alginate and gum arabic polymers), which adsorb to the tooth surface to create physical barrier against acid erosion  The addition of calcium or polymer has been shown to reduce the erosive potential of acidic drinks.
Neutralizing Intraoral Acidity • In attempt to raise intra-oral pH, different products have been tested, including antacid tablets, lozenges, mineral water, milk and tap water, all used for 2 min immediately after the erosive challenge. • The use of different antacid suspensions and a bicarbonate solution after erosive challenge with hydrochloric acid also significantly reduced enamel surface loss. Thus, it is advisable to instruct the patients to rinse their mouth with water or, more effectively, to use antacid products immediately after vomiting or reflux episodes Preventive Strategies Based On The Self-applied Preventive Agents
Use of Fluoride Concentration Dentifrices • Improved enamel protection was observed with dentifrices containing titanium tetrafluoride (TiF4) and stannous fluoride (SnF2 ) when compared to NaF. • The improved protection by SnF2 and TiF4 was attributed to the stannous’ and titanium’s ability to interact with the tooth surfaces forming an acid-resistant film of insoluble compounds, thus increasing the tooth tissue resistance. • These compounds also demonstrated precipitation of CaF 2- like deposits (CaF 2 -globules) that behave as a physical barrier inhibiting the contact of the acid with enamel as well as acts as a fluoride.
Use of Paste/Cream Containing Recaldent (CPP-ACP) Technology  These are commercially available as Tooth Mousse (Asia/Australia) and MI paste (USA) and the fluoride-containing CPP-ACFP (with 900 ppm fluoride) as Tooth Mousse-plus and MI paste-plus.  In Recaldent, the calcium and phosphate ions in a soluble amorphous calcium phosphate is stabilized by the protein CPP into nanocomplexes, these nanocomplexes bind onto the tooth surfaces and dental pellicle to create a state of supersaturation of calcium and phosphate ions in the oral cavity.  When the oral pH drops during an acidic challenge, the calcium is released from the CPP to facilitate remineralization and inhibit demineralization
Use of Toothpaste Containing Functionalized Tricalcium Phosphate Technology • In this technology, by milling tricalcium phosphate (TCP) with organic materials (functionalization), the CaO in TCP become ‘protected’ by the organic materials, thus allowing the calcium and phosphate ions of the TCP to co-exist with fluoride ions in an aqueous dentifrice base (toothpaste) without premature TCP-fluoride interactions. • Once applied in the presence of saliva, calcium compound is activated by saliva that degrades the protective coating, releasing calcium at the tooth surface, resulting in high fluoride and calcium bioavailability on the lesion surface and subsequent diffusion into the lesion to promote remineralization. • Commercially available- Clinpro™ 5000 paste
Use of Toothpaste Containing Novamin Technology • It is a bio-active glass (calcium sodium phosphosilicate) that binds to the tooth surfaces, and when in contact with body fluid, such as saliva, releases calcium and phosphate ions, enabling the remineralization of tooth tissue, typically forming hydroxycarbonate apatite • The existing Bioactive glass (Novamin™) used in commercial toothpastes such as Sensodyne Repair & Protect and Sensodyne Complete Protection
Use of Polymer-Containing Toothpastes • Recently, some dentifrices containing polymers have been investigated due to their potential to form a protective layer on the tooth surface, strengthening the pellicle. • As active ingredients in toothpaste, organic polymers such as casein, ovalbumin, pectin, alginate and arabic gum, and inorganic polymers such as pyrophosphate, tripolyphosphate and polyphosphate have been studied Use of Chitosan-Containing Toothpastes • Incorporation of chitosan into dentifrices containing fluoride and tin or Sn significantly increased the anti-erosive/anti-abrasive effect of the dentifrice for both enamel and dentin.
Use of Mouth rinse Containing Protease Inhibitors • Mouthrinses containing protease inhibitors, such as chlorhexidine and green tea extract, or even rinses with green tea have been shown to reduce dentin loss (around 30–40 %). • Thus mouthrinses containing SnCl 2 /NaF/AmF, TiF 4 /NaF, or protease inhibitors might have potential to benefit patients that are frequently exposed to erosive challenges.
1. Remineralization methods for softened tooth surface a) Fluorides - gels and forms - varnishes b) calcium containing agents - Recaldent (CPP_ACP) - Tricalcium phosphate technology 2. Tooth surface protection a) Surface Protective Coatings with Remineralizing Potential - GIC - Resin modified GIC (RMGIC’s) a) Surface Protective Coatings without Remineralizing Potential - Nano filled light cured adhesive - Highly filled resin b) Surface Protection Using ‘Bite-Guards’ Preventive Strategies Based On Professionally Applied Agents
1. Dentin Desensitization 2. Restoration of non- cervical lesions Non - esthetic materials (not widely used) - Amalgam - Gold foil Gold inlay Minimal preparation Adhesive restoration - Resin composite (with dentin bonding system) - Resin composite (with glass-ionomer liner—sandwich technique) - Flowable resin composite - Glass ionomer - RMGI - Compomer 3. Ceramic veneer or full crowns 4. Conventional fixed restorations 5. Removable onlay / overlay prosthesis 6. Periodontal therapy MANAGEMENT OF DENTAL EROSION
Restorative materials for non-carious cervical lesions: A review. International Journal of Clinical Dental Science, 2018 RESTORATION OF NON-CARIOUS CERVICAL LESIONS  Restorations at the cervical region of teeth are frequently subjected to occlusal loads and flexural stress.  An ideal restorative material should present biomechanical features capable of resisting dislodgement under tension and exhibit good adhesion, retention, and marginal seal in the long run.  Significantly, the selection of the ideal restorative material is hence influenced by factors such as micromechanical retention, preservation of tooth structure, esthetics, and functional harmony
GLASS IONONMER CEMENTS • Superior retention due to chemical bonding • Secondary caries inhibition due to fluoride releasing ability • High abrasion resistance on final maturation • In scenarios where preserving tooth structure is a priority, GICs serve as a durable restoration, bonding chemically to the tooth structure, and avoiding unnecessary beveling of enamel One of the major limitations of conventional GICs is the inconvenient setting characteristics and low abrasive resistance that is overcome by resin-modified GICs (RMGICs)
RESIN MODIFIED GLASS IONOMERS (RMGIC’s)  Improved setting characteristics allowing sufficient working time that can be shortened by light curing to make it more resistant to effects of moisture while simultaneously developing rapid early strength.  In comparison to the conventional GICs, the translucency is markedly superior with better color matching.  RMGICs have a better adhesion to dentine and allow for easy repairs to defective or damaged surfaces of the restoration.  They also bond directly to composite resin making them ideal cement for “sandwich” technique  reduced superficial degradation, and increased wear resistance,  Superior fluoride release
Belluz M, Pedrocca M, Gagliani M. Restorative treatment of cervical lesions with resin composites: 4-year results. Am J Dent 2005;18:307-10 COMPOSITES • Exhibiting improved adhesion to the tooth • Higher abrasive resistance Disadvantages • Deficient marginal seal and progressive degradation of adhesion • The polymerization shrinkage of the composites is the main cause for microleakage, poor marginal adaptation, and low retention rates • Loss of retention due to cervical stress/flexure Flowable composites have been introduced that has low quantities of filler, low modulus of elasticity, and more flexible to dislodging forces
COMPOMERS • The main aim of using compomers is to avoid the use of acid etching of enamel while retaining the elasticity of composites, hydrophilic, and fluoride-releasing properties of the GICs. • Increased elasticity in comparison to GIC – better performance in stress bearing areas Brackett WW et al. 1-year clinical evaluation of compoglass and fuji II LC in cervical erosion/abfraction lesions. Am J Dent 1999 Disadvantage The lack of enamel etching has lead to decreased bond strength and less retention rates Folwaczny M, Loher C, Mehl A, Kunzelmann KH, Hickel R. Class V lesions restored with four different tooth- colored materials--3-year results. Clin Oral Investig 2001
GIOMERS AND ORMOCERS Giomers are fluoride-releasing resin materials with “prereacted glass,” a hybrid of glass-ionomer and resin- based composite. • Better color match, decreased microleakage, and increased fluoride release. • They have a better surface finish and esthetic properties comparable to composites (Sunico MC, Shinkai K, Katoh Y. Two-year clinical performance of occlusal and cervical giomer restorations. Oper Dent 2005)
Ormocers are organically modified ceramics consisting of a polycondensed three- dimensional cross-linked organic/inorganic network (polysiloxanes), organic polymers, and glass/ceramic filler particles. • Better marginal adaptation and integrity. Hennig AC, Helbig EB, Haufe E, Richter G, Klimm HW. Restoration of class V cavities with the ormocer-based filling system admira. 2004
Activa BIOACTIVE RESTORATIVE (Pulpdent corporation, Watertown, MA)  Dual cured material  It is the first dental material with bioactive resin matrix, shock absorbing resin component and reactive glass ionomer fillers designed to mimic physical and chemical proeprties of natural teeth  Highly esthetic bioactive hydrophilic composite that bonds chemically to the tooth, seals against microleakage and releases more Ca. PO4 and F ions  It is more bioactive than GIC and more durable and fracture resistant than composites  It is well preferred for cervical lesions Bioactive Restorative vs GIC modified glass ionomer in restoration of cervical lesions: A randomized controlled trial. 2020
Conventional Fixed Restoration’s The main options either individually or in combination are:  Opposing tooth reduction  Elective endodontic treatment and post retention  Occlusal adjustment  Periodontal surgical crown lengthening  Localized orthodontic tooth movement (Conventional Fixed Appliance or ‘Dahl’  appliance)  Overall increase in occlusal vertical dimension
Removable Onlay/Overlay Prostheses The use of a removable onlay/overlay prosthesis can be a valuable means of rehabilitating patients with moderate/severe tooth wear, particularly when there are also missing strategic teeth to be replaced. Advantages:-  Simple  Non – invasive  Cost effective The construction of a provisional acrylic resin removable prosthesis is recommended initially, allowing the opportunity to carry out modifications to the shape, position and occlusal relationship of the prosthetic teeth and soft tissues, as well as assessing the patient’s tolerance of a removable prosthesis.
• This does not require tooth preparation but long term use requires tooth preparation often incorporating a cobalt-chromium framework. • It is possible to achieve an increase in occlusal vertical dimension with the use of a removable posterior onlay prosthesis in combination with anterior fixed crown restorations Disadvantages:- • Maintenance demands are relatively high • Material wear and fracture • Complex design • Unesthetic
Examples of overlay removable prostheses: ( a ) Full labial flange, ( b ) gingival fitting anterior tooth facings The use of a metal framework incorporating incisal and occlusal coverage used to strengthen removable onlay/overlay prostheses for patients demonstrating signifi cant parafunctional clenching/grinding habits
Periodontal Therapy Periodontal therapy is required when non – carious lesions are associated with considerable gingival recession and mucogingival defects. Treatment protocol is as follows: - 1. Supragingival and subgingival scaling 2. Restorative treatment for non carious lesions 3. Frenectomy and fenestration procedure for deepening the vestibule 4. Evaluation of increase in the width of attached gingiva 5. Root coverage procedures a) Using free gingival grafts or connective tissue grafts b) Using non grafting procedures like rotational or coronally advanced flaps or guided tissue regeneration (Interdisciplinary approach for the management of Non – Carious lesions, Journal of Indian Society of Periodontology, 2015)
Classification and Treatment of the Anterior Maxillary Dentition Affected by Dental Erosion: The ACE Classification Francesca Vailati. The International journal of periodontics & restorative dentistry · 2010
• Yellowish at the centre due to the underlying dentin and whitish periphery due to thick enamel • 100% recovery possible • Preventive measures – guard, Fluoride • Determining the etiology is essential • To protect remaining enamel and dentin – D/I composite • If interocclusal space is less- VDO increased by ortho intervention • Direct or indirect composite can be given based on severity and financial aspect • Direct composite or onlays in posteriors • Palatal veneers when there is adequate interocclusal space
• At this stage, posteriors (especially premolars) are also involved • Palatal aspect restored with composite veneers and facial aspect with ceramic veneers • Sandwich technique is called experimental because ceramic facial veneers are bonded to reduced dentin surface • Prognosis may be unfavourable • Sandwich approach can still be used to preserve pulp vitality, preserve rem tooth structure • If pulp vitality s lost thereafter, endodontic treatment through palatal veneer
COMBINED LESIONS Grippo et al. ABFRACTION, ABRASION, BIOCORROSION, AND THE ENIGMA OF NCCLS. Journal of Restorative and Esthetic Dentistry. 2012
Attrition- Abfraction. Attrition- abfraction is the joint action of stress and friction when teeth are in tooth-to-tooth contact, as in bruxism.
Abrasion-abfraction. • Abrasion-abfraction is the loss of tooth substance caused by friction from an external material on an area in which stress concentration due to loading forces may cause tooth substance to break away. • Such a synergistic tooth-destructive effect may be observed cervically when toothbrushing abrasion exacerbates abfraction to produce wedge-shaped lesions.
Erosion-abfraction • Erosion (Bio Corrosion)-abfraction is the loss of tooth substance due to the synergistic action of a chemical corrodent on areas of stress concentration. • This physicochemical mechanism may occur as a result of either sustained or cyclic loading and leads to static stress corrosion or cyclic stress corrosion
Attrition-Corrosion • Attrition-corrosion is the loss of tooth substance due to the action of a corrodent in areas in which tooth-to-tooth wear occurs. • This process may lead to a loss of vertical dimension, especially in patients with GERD or gastric regurgitation. An occlusal or incisal pattern of wear develops.
Abrasion-corrosion • Abrasion-corrosion is the synergistic activity of corrosion and friction from an external material. • This could occur from the frictional effects of a toothbrush on the superficially softened surface of a tooth that has been demineralized by a corrosive agent. • Teeth that are out of occlusion could be affected by this mechanism and develop cervical lesions
Biocorrosion-abfraction • Biocorrosion (caries)-abfraction is the pathological loss of tooth structure associated with the caries process, where an area is micromechanically and physicochemically breaking away due to stress concentration. • A common site for this synergistic activity is the cervical area of the tooth, where it may be manifested as root or radicular caries.
MANAGEMENT OF WORN DENTITON Cervical Tooth Wear  Materials can either be composite resin or glass ionomer-based, or a combination of both; either in a layered technique with the individual materials or with formulated Resin- Modified glass-ionomer cements. Textbook of Erosion and its Clinical Management, Bennett T • Acid etching of enamel • Composite restoration ENAMEL • Dentin bonding agent + Composite • Self adhesive Composite ROOT DENTIN/ CEMENTUM
 Alternatively, a glass-ionomer cement restoration with inherent bonding properties to both dentin and enamel may be considered. The new generation of light-activated resin-modified glass-ionomer combines superior properties of both composite resin and conventional glass-ionomer cements. Esthetics Composite Not prominent area or extending below Gingival margin Glass Ionomer cements
Palatal Tooth Wear • This pattern of tooth wear is usually characteristic of acid erosion, possibly combined with a degree of attrition • Often, the labial and incisal surfaces are relatively intact and the main indications for restorative treatment are to offer some resistance to further palatal tooth wear which will reduce the risk of significant enamel fractures • The use of resin-bonded palatal metal alloy veneers is an acceptable method to manage this form of tooth wear and has been shown to be a relatively durable technique.
 Either heat treated gold alloys or nickel-chromium alloys, as used in resin-bonded bridge frameworks, are currently the cast metal alloys of choice. The use of nickel/chromium alloy resin-bonded palatal veneers used to restore localised palatal tooth wear for maxillary incisor teeth
Combined Incisal and palatal tooth wear  In these circumstances, it is feasible to build up the incisal portion of the tooth with direct acid-etch retained composite resin and then construct a resin-bonded metal alloy palatal veneer to cover both the palatal tooth tissue and composite resin.  An alternative and very conservative approach is to restore both the incisal and palatal tooth surfaces with direct acid-etch retained composite resin at an increase in occlusal vertical dimension to accommodate the thickness of the restorative material  Modified porcelain laminate veneer restorations of both the incisal and palatal worn tissue have also been suggested
Restoration of incisal and palatal aspects of worn upper anterior teeth with direct composite resin restorations a,c-Before restoration b,d-After restoration
Combined Labial/Incisal/Palatal Tooth Wear  Use of a labial porcelain laminate veneer in conjunction with a metal alloy veneer for the palatal surface, or an adhesive metal- ceramic crown restoration.  All these techniques are relatively complex and would normally require some inter-occlusal space creation prior to completion of the restoration. In these circumstances, consideration should be given to the provision of a more conventional full coverage crown.  In case of advanced wear of anterior mandibular teeth, it may be advantageous to consider a degree of localized crown lengthening surgery in an attempt to capture all remaining tooth enamel
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NON CARIOUS LESIONS

  • 1. NON – CARIOUS LESIONS
  • 2. CONTENTS ‡ INTRODUCTION ‡ DEFINITION ‡ PREVALENCE OF TOOTH SURFACE LOSS ‡ CLINICAL MEASUREMENT OF TOOTH WEAR ‡ NON – CARIOUS CERVICAL LESIONS  ATTRITION  ABRASION  ABFRACTION  EROSION ‡ MANAGEMENT OF WORN DENTITION ‡ COMBINED LESIONS
  • 3. ‡ DEVELOPMENTAL DEFECTS  LOCALIZED NON – HEREDITARY ENAMEL HYPOPLASIA  LOCALIZED NON – HEREDITARY ENAMEL HYPOCALCIFICATION  LOCALIZED NON – HEREDITARY DENTIN HYPOPLASIA  LOCALIZED NON – HEREDITARY DENTIN HYPOCALCIFICATION  AMELOGENSIS IMPERFECTA  DENTINIGENESIS IMPERFECTA ‡ TRAUMA AND FRACTURES ‡ RESORPTION ‡ CONCLUSION ‡ REFERNCES
  • 4. Gradual loss of tooth structure occurs throughout the life, most often it is so slow that it rarely poses any problem to the patient However, pathological loss of tooth structure due to non-carious reasons can produce unacceptable esthetics, compromise oral functions, cause pain and sensitivity and negatively impact quality of life. These lesions are difficult to diagnose and treat successfully as the loss is exhibited in different patterns and on different surfaces of teeth for varying types of tooth surface loss INTRODUCTION
  • 5. Determining the etiology and preventing further tooth surface loss, which requires using proper preventive methods, good management and the appropriate restorations is necessary for the successful management of non-carious lesions
  • 6. DEFINITION ‘Tooth surface loss’ or 'tooth wear' refers to the pathological loss of tooth tissue by a disease process other than dental caries - Eccles, 1982 “Non carious tooth tissue loss” is defined as surface loss due to a disease process which does not involve bacteria. - Pual A Brunton ,Decision making in Operative Dentistry “Non-carious cervical lesions (cervical wear)” are defined as the loss of tooth substance at the cemento- enamel junction - Mair, 1992
  • 7. PREVALENCE OF TOOTH WEAR The Adult Dental Health Survey of 2009 reported that tooth wear extending into the dentin with over three quarters (77%) of dentate adults showing tooth wear in the anteriors. However, 15% showed moderate wear and 2% with severe wear. The Child Dental Health Survey of 2013 identified that 21% of 15- year-olds had evidence of erosion affecting the palatal surfaces of their permanent incisors (less when compared to the survey on 1993 – 32%) The prevalence of tooth wear is likely to escalate as life expectancy continues to increase. Adult Dental Health Survey 2009: Common oral health conditions and their impact on the population. British Dental Journal, 2012
  • 8. 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
  • 9. TOOTH SURFACE LOSS PHYSIOLOGICAL PATHOLOGICAL A. Warreth et al. Tooth surface loss: A review of literature. Saudi Dental Journal. 2019
  • 10. Physiological Tooth Surface Loss • It occurs as a result of mastication and adjustment, which is required for the teeth to function correctly • Physiological TSL may also occur at interproximal tooth surfaces due to friction between the adjacent teeth (Davies et al., 2002, Kaidonis, 2008). Pathological Tooth Surface Loss • It represents unacceptable levels of dental hard tissue loss • Etiology - multifactorial • It is characterized by abnormal destruction, which may require treatment (Van’t Spijker et al., 2009; Bartlett et al., 2011)
  • 11. Pathological TSL is considered to be a common clinical finding in both children and adults, and its prevalence increases with age This prevalence was found to increase from 3% at the age of 20 years to 17% at the age of 70 years (Van’t Spijker et al., 2009) The increase in prevalence of moderate tooth wear in adults is of little concern but, younger age groups affected by moderate and severe tooth wear may warrant some attention
  • 13. CLINICAL MEASUREMENT OF TOOTH WEAR QUANTITATIVE QUALITATIVE • Rely on physical measurements • Depth of groove, area of facet or Height of lesion • Objective • Rely on clinical descriptions • Mild, Moderate or Severe • Subjective • Tooth Wear Indices (TWI) have been designed to identify increasing severity and extent of the lesions • They are usually numerical. • Some record lesions on an aetiological basis (e.g. erosion indices), others record lesions irrespective of aetiology (tooth wear indices);
  • 14. SMITH AND KNIGHT TOOTH WEAR INDEX (TWI) - 1984
  • 15. Smith and Knight Index - a comprehensive system whereby all four visible surfaces (buccal, cervical, lingual and occlusal–incisal) of all teeth present are scored for wear, irrespective of how it occurred. • This index was the first one designed to measure and monitor multifactorial tooth wear; • This index avoids the confusion associated with terminology and translation or differences in opinion for diagnosis of aetiology based on clinical findings Most commonly used but has limitations such as • Rely only on the ability of clinician to visually identify exposed dentin (interexaminer bias) • Does not relate etiology to the outcome of wear seen on the teeth. This makes it inaccurate to provide a complete picture of the clinical problem • Time consuming • Full use of the index as a research tool is not feasible without computer assistance Bardsley et al. The evolution of tooth wear indices. Journal of clinical oral investigation. 2008
  • 16. SIMPLIFIED SCORING CRITERIA FOR TOOTH WEAR INDEX - Bardsley et al, 2004
  • 17. NON – CARIOUS CERVICAL LESIONS (NCCLs)
  • 18. ATTRITION It is defined as physiological wearing away of tooth as a result of tooth to tooth contact as in mastication - Shafer It may be defined as surface tooth structure loss resulting from direct frictional forces between contacting teeth - Marzouk Attrition is defined as the mechanical wear of incisal and occlusal surfaces as a result of functional or parafunctional movements of mandible (Tooth-to tooth contact) - Sturdevant Every in 1972, described it is wear caused by endogenous material such as microfine particles of enamel prisms caught between two opposing tooth surfaces.
  • 19.  Its an Age dependent continuous process  Usually physiologic.  Any contacting tooth surface is subjected to the attrition process, beginning from the time it erupts in the mouth and makes contact with reciprocating tooth surface.  Mostly affects occlusal surfaces of the teeth  It also includes the proximal surface wear at the contact area because of the physiologic tooth movement  Accelerated by parafunctional movements such as bruxism  Men > women
  • 20. ETIOLOGY USE OF STIFF OR HARD TOOTH BRUSHES OR FLOSS ABRASIVE DENTIFRICES PARAFUNCTIONAL HABITS LIKE BRUXISM AGEING AGGRESSIVE TOOTHBRUSING
  • 21. There are three theories regarding the etiology of attrition: • Functional theory • Parafunction initiated by occlusal interferences • Central nervous system aetiology. Rees et al. A guide to the clinical management of attrition. BRITISH DENTAL JOURNAL , 2018 Functional theory This suggests that tooth wear occurs due to prolonged contact of the teeth and the patient having a broad envelope of function. They found that the broader grinding type chewing pattern had significantly greater levels of occlusal wear compared to the ‘chopping’ type.
  • 22. Parafunction initiated by occlusal interferences The theory states that parafunction can be initiated by occlusal interferences and therefore managed clinically by occlusal adjustments or extensive rehabilitations. Unfortunately, the evidence in the literature does not support this theory. Studies have found that occlusal interferences could not cause bruxism or stop it.
  • 23. Central nervous system Etiology Bruxism is a neurological problem and the tooth damage is a consequence of a neurologically initiated activity manifesting as grinding and tooth surface loss. Essentially, sleep bruxism occurs following sleep-related micro-arousals that originate in the brain stem. These micro-arousals cause the heart rate to increase following which brain activity increases. This is followed by activation of the suprahyoid muscle which is followed by rhythmic masticatory muscle activity resulting in bruxism
  • 24. In addition to the causes of attrition, there are a number of other factors which may accelerate the process of attrition Habitual chewing on hard food stuffs • Habitual chewing on hard foods or unusual food stuffs such as bone chewing may exacerbate tooth surface loss. Lack of posterior support • Many clinicians consider that a lack of posterior support can eventually lead to more tooth wear on the remaining anterior teeth. • While other authors found no relationship between the number of missing posterior teeth and anterior tooth wear • This is often controversial and therefore further studies are needed to prove this theory
  • 25. Ecstasy • Around 1.5% of the population use ecstacy (Amphetamine) and it is the second most popular recreational drug in 16–24 year olds. • The main side effects of this drug are bruxism and a profound xerostomia that last for around 6–8 hours. • This is a good example of a combined attrition and erosion aetiology Selective 5-hydroxytryptamine reuptake inhibitors (SSRIs) • It is the commonest type of antidepressants used to manage anxiety and depression • Recent reports suggest that SSRIs may cause bruxism,
  • 26. CLINICAL MANIFESTATION The first manifestation:  appearance of a small facet on cusp tip or ridge or a slight flattening of incisal edge. In severe cases:  “a reverse cusp” situation might be created in place of the cusp tips and inclined planes
  • 27. Attrition can predispose to or precipitate any of the following :- Proximal surface attrition (proximal surface faceting) Occluding surface attrition (occlusal wear)  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  When surface attrition is SLOWER - compensated by, intrapulpal deposition of secondary & tertiary dentin  Severe attrition leads to pulp exposure
  • 28. PROXIMAL SURFACE ATTRITION (PROXIMAL SURFACE FACETS) 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 arch. The interproximal space is reduced, interfering with physiology of dental papilla, leading to periodontitis
  • 29. 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 If the LOSS IS SEVERE & accomplished in a relatively SHORT TIME No chance for 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.
  • 30. If the loss occurs in a LONG PERIOD OF TIME the alveolar bone can grow occlusally, bringing the teeth to their original occlusal termination vertical dimension loss will be confined to teeth but not imparted to face.
  • 31. EFFECTS OF ATTRITION  Deficient masticatory capabilities  Blunting of the cusps needs more force to shear food items.  Cheek biting and gingival irritation  Decay  Hypersensitivity  TMJ problems - extreme strain on the muscles of stomatognathic system
  • 32. TREATMENT MODALITIES In developing a treatment plan the dentist should consider the following factors:  Whether the wear is localised or generalised.  Degree of attrition – mild, moderate or severe  Factors affecting the patient’s speech, function and orofacial aesthetics.  The behavioural, psychological, anatomical, developmental and physiological limitations of the patient.  Observation and palliative strategies
  • 36. BASED ON THE DEGREE OF ATTRITION MILD ATTRITION MODERATE ATTRITION SEVERE ATTRITION • Instructions for oral hygiene • Fluoride application • Use of desensitizing toothpaste • Use of temporary restorations • Restoration of the vertical dimension to improve function and esthetics. • Treatment options include Endodontic therapy followed by crown placement or extraction of affected teeth and replacement with conventional dentures, overdentures and overlay prosthesis, etc.
  • 37. Treatment depends upon the following categories: Category I: Appearance is satisfactory Category II: Appearance is unsatisfactory and there is no need to raise the vertical height Category III: Appearance is unsatisfactory but there is need to raise the vertical height, which in turn depends on the availability of space, whether it is present or needs to be created. BASED ON APPEARANCE
  • 38. Category I (Appearance is satisfactory) A. Counselling is required in patients with parafunctional habits. Habit breaking appliance should be given in patients with bruxism or clenching. B. Conventional Restorative Treatment • Exposed pits are filled • Occlusal disharmony is corrected • Consideration to be given to crown lengthening procedure
  • 39. Category II (Appearance is unsatisfactory but there is no need to raise the vertical height). Teeth are restored, preferably with all ceramic crowns or laminates. The crowns can manage occlusal attrition as well as fractured cusps. Occlusal guard for protection against nocturnal clenching like bleaching trays, etc.
  • 40. Category III (Appearance is unsatisfactory and there is a need to raise the vertical height • Generalized increase in vertical height is required. • Orthodontic tooth movement can be used for over-eruption of posterior teeth creating space for the anterior teeth.
  • 41. Sequence of treatment: 1. Management of dentinal hypersensitivity 2. Pulpally involved teeth - based on restorability endodontic therapy or extracted 3. Parafunctional activities, notably bruxism, should be controlled with the proper disoccluding-protecting occlusal splints. 4. Myofunctional, TMJ, or any other symptoms in the stomato- gnathic system should be diagnosed and resolved. 5. Occlusal equilibration should be performed after all notable symptoms are relieved  Occlusal equilibration, by selective grinding of tooth surfaces.  Rounding and smoothing the peripheries of the occlusal tables.
  • 42. MANAGEMENT OF DENTIN HYPERSENSITIVITY Nerve desensitization  Potassium nitrate Protein precipitation  Gluteraldehyde  Silver nitrate  Zinc chloride  Strontium chloride hexahydrate Plugging dentinal tubules  Sodium fluoride and Stannous fluoride  Strontium chloride  Potassium oxalate  Calcium phosphate  Calcium carbonate  Bio active glasses
  • 43. Dentin hypersensitivity: Recent trends in management, Journal of Conservative dentistry, 2015 Dentine adhesive sealers  Fluoride varnishes  Oxalic acid and resin  Glass ionomer cements  Composites  Dentin bonding agents Lasers  Nd-YAG and Er-YAG laser  GaAlAs (galium-aluminium-arsenide laser) Natural medication  Propolis Periodontal surgical procedures
  • 44. Restoration therapy is needed in cases  Where there is loss of vertical dimension.  Or a progressive loss of tooth structure is observed compromising the tooth strength .  Caries ,if present  Defect which may contribute 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 RESTORATION
  • 45. • Adhesive Composite Resin LESS SEVERE ANTERIOR WEAR • Bonded Porcelain veneers • Direct Composite resin • Adhesive cast metal restorations • Reconstruction with crowns and bridges (Occlusion is severely attrited) MORE SEVERE ANTERIOR WEAR
  • 46. They should be accomplished very cautiously and carefully in the following sequence. 1. Verify and re-verify its necessity, i.e., be sure that the alveolar bone did not grow occlusally at the same pace that attrition occurred. 2. Estimate how much vertical dimension lost. 3. Estimate how much additional vertical dimension the stomato- gnathic system can accommodate without untoward effects RVD = VD at Rest OVD = VD at Occlusion FWS = Freeway Space
  • 47. Vertical Dimension • It gives an estimate up to what should be the height of the worn clinical crowns be increased . • The additional V.D. that the stomatognathic system can accommodate without untoward effects is estimated Increasing the Vertical dimension of occlusion can lead to • Clenching (increased muscle activity) • Muscle fatigue • Soreness of teeth, muscle and joints • Problems in phonetics • Occlusal instability • Intrusion of teeth Therefore, periodic monitoring and assessment is required for a period of time until the patient is no more uncomfortable to the new dimension of occlusion
  • 48. 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.
  • 49. • 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 . The splint would need to be relined with cold cure acrylic resin to improve the retention of the appliance and for occlusal adjustments
  • 50. In case of inadequate anterior clearance for restoration/ crown placement, space can be created by 1. Occlusal adjustment 2. Orthodontic extrusion 3. Crown lengthening 4. Dahls appliance 5. Extraction or surgical repositioning Dahls Appliance • The Dahl Concept refers to the relative axial tooth movement that is observed when a localised appliance or localised restorations are placed in supra-occlusion and the occlusion re-establishes full arch contacts over a period of time. • 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)
  • 51. Other phrases used for this process are  ‘minor axial tooth movement’  ‘fixed orthodontic intrusion appliances’  ‘localised inter-occlusal space creation’, and  ‘relative axial tooth movement  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, Poyser NJ et al. The Dahl Concept: past, present and future. British Dental Journal, 2005
  • 52. The objectives of the Dahl concept are to either create sufficient inter-occlusal space for the placement of restorations or the re-establishment of occlusal contacts following the placement of restorations that have intentionally been placed in supra-occlusion. Requirements:-  The material should be placed on the incisal/occlusal aspect of those teeth where the creation of interocclusal space is necessary.  The thickness of this material placed should directly relate to the amount of inter-occlusal space that is required. This will determine the increase in the vertical dimension of occlusion as measured at that particular site in the mouth.
  • 53.  Ideally an occlusal bite platform should be constructed to ensure that occlusal forces are directed along the long axis of the teeth.  Stable inter-occlusal contacts should be provided.  The appliance should not impede the movement of the disoccluded teeth The occlusion tends to re-establish after about six months on average but it can take up to a period of 18-24 months.
  • 54. • More eruption than intrusion was seen in the younger age group. In some cases the time taken for tooth movement to occur is faster than that which could be achieved with orthodontic tooth movement • 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 .
  • 55. A one-stage Dahl procedure • Involves the placement of definitive indirect laboratory constructed restorations in supra-occlusion, whereby no interim appliance is used to create the inter-occlusal space. • Adjustment of the restorations may be required but this may lead to weakening of the restoration, possible perforation, microleakage, sensitivity, and loss of the restoration. It is for this reason that the authors advocate a Two-stage Dahl procedure using direct composite resin as the interim Dahl appliance. Composite is a useful material for the creation of inter-occlusal space in two stage Dahl procedures. Once sufficient space has occurred, its followed by placement of laboratory constructed definitive restorations.
  • 56. Direct composite restorations placed as fixed Dahl appliances Conventional metal-ceramic restorations placed once sufficient inter-occlusal space created. Advantage of using composite:- • Inexpensive, simple to use and adjust • Has favourable wear characteristics. • It can be easily removed for subsequent definitive extra-coronal restorations,
  • 57. ‘Double Dahl’ technique - where both the upper and lower anterior teeth are restored simultaneously Rees et al. A guide to the clinical management of attrition. British Dental Journal. 2018
  • 58. Hemmings et al. 2000 (30 months) Direct composite 94% Gough and Setchell 1999 (4 years) Cemented Interim Appliance 96% success rate Dahl and Krogstad 1982 (14 months) Removable Co-Cr anterior bite plane 70-80% success rate Redman et al. 2003 (5mnths – 6yrs) Direct and indirect Artglass and composite retsoration 100% (61% complete and 39% partial) Indirect Art Glass restorations 83% Hemmings et al. 2000 (30 months) Direct composite 94% Gough and Setchell 1999 (4 years) Cemented Interim Appliance 96% success rate Dahl and Krogstad 1982 (14 months) Removable Co-Cr anterior bite plane 70-80% success rate Gow and Hemmings 2002 (2 months) Redman et al. 2003 (4yrs) Direct and indirect Artglass and composite retsoration 100% (61% complete and 39% partial) Hemmings et al. 2000 (30 months) Direct composite 94% Gough and Setchell 1999 (4 years) Cemented Interim Appliance 96% success rate Dahl and Krogstad 1982 (14 months) Removable Co-Cr anterior bite plane 70-80% success rate
  • 59. Djulaeha and Sukaedi: The management of over closured anterior teeth due to attrition. Dental journal 2009 Preoperative view Patient had missing posterior teeth and severe attrition of maxillary anteriors. Because of which vertical dimension was lost or reduced. The heightening of the occlusal vertical dimension must be done gradually in order to let the muscles of the mastication adapt to the new occlusal vertical dimension. At first stage, the restoration of the anteriors were done by lengthening incisal, 2 mm, with composite restoration to improve the aesthetics and heighten the occlusal vertical dimension. Then the patient was evaluated for two weeks. The patient had no problems with her temporomandibular joint After Composite restoration
  • 60. Tooth preparation was done for placing temporary bridge (self cure acrylic) followed by the heightening process of occlusion about 2 mm of the temporary bridge in order not only to maintain the aesthetics and to improve the vertical dimension of occlusion After evaluating the patient for 2 more weeks, the long span bridge with 12 units made of porcelain materials fused to metal materials was processed for upper jaw. An acrylic removable partial denture was given for missing lower teeth A) The long span bridge of upper jaw; B) lower acrylic removable partial denture. Temporary bridge of upper anterior teeth Postoperative view
  • 61. 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 Tooth surface loss resulting from direct frictional forces between teeth and external objects, or from frictional forces between contacting teeth components in presence of abrasive medium. - Marzouk - Shafer ABRASION Abrasion is defined as the pathological wear of tooth substance through some abnormal mechanical process.
  • 62. Clinical features of Abrasion  Males are comparatively more affected than females.  Premolars and canines are more susceptible to abrasion probably because they are placed slightly protruded in the dental arch.  Right-handed individuals show a preponderance of lesions on the left side and vice versa.  It occurs most frequently on the cervical neck of the teeth.  The labial or buccal surfaces is most affected in case of tooth brush abrasion and lingual surfaces ( in case of poorly fitted clasps and artificial dentures )  Incisal surfaces are affected in certain cases – habits/occupation
  • 63. Morphology of abrasive lesions Abrasion lesions are of varying morphology and may be classified as : Notch/V- shaped defects: where oblique occlusal and cervical walls intersect at a certain depth with no definite axial wall in between them. C-shaped defects(C): where cross section of the defect is C-shaped with rounded floors. Under cut concave (UC): where occlusal and cervical walls intersect with a definite axial wall in between them. Divergent box (DB): where a definite axial wall is present with the occlusal and cervical walls diverging towards the surface.
  • 64. CLINICAL SIGNS AND SYMPTOMS  It results in saucer shaped or wedge shaped indentation on the tooth surface  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 .
  • 65. ETIOLOGY AND PATHOGENESIS • Different foreign substances produce different patterns of tooth abrasion • Though the etiology is varied, the pathogenesis under these different conditions is essentially different Various types of abrasion:  TOOTHBRUSH ABRASION  OCCUPATIONAL ABRASION  HABITUAL ABRASION  PROSTHETIC ABRASION
  • 66. TOOTHBRUSH ABRASION It is mostly due to 1. Improper oral hygiene practices 2. Oral hygiene products Improper oral hygiene practices  Aggressive tooth brushing  Improper brushing technique i.e by using horizontal brushing method  Vigorous use of toothpicks or tooth floss may result in abrasion in proximal surfaces  Frequency; time and forces applied during brushing also affects the occurrence of lesion
  • 67. Oral hygiene products : Tooth brush abrasion depends on • Type of the toothbrush used – soft, medium, hard • Shape of tooth bristles used • Flexibility and length of the tooth brush handle affecting the grip of the tooth brush • The grittiness, pH and amount of dentifrice used. • Abrasiveness of dentifrice • Tooth powder is generally five times more abrasive than its dentifrice counterparts Robinsonstatedthatthemostcommoncauseofabrasionoftoothsurfaceistheuseofabrasivedentifrice.
  • 68. The extent, depth and rate of formation of toothbrush abrasion depends on  The size of the abrasive: larger and more irregular  The direction of brushing strokes: Horizontal directions are the most detrimental.  The percentage of abrasives : higher the percentage is, the more abrasion  The type of abrasives: Silica abrasives are more abrading than phosphate and carbonate ones.  The diameter of brush bristles: greater the diameter, the more the abrasion.  The type of bristles : Natural bristles are more abrasive than synthetic (mylar) ones.
  • 69.  The forces used in brushing: more the force, the more abrasion there will be. (average manual brushing force = 1.6+0.3N)  The type of tooth tissues being abraded. Generally, enamel is quite hard and not easily abraded therefore it serves as a protection for the underlying dentin, which is abraded 25 times faster. Cementum is the softest of all tissues and shows an abrasion rate of 35 times higher than enamel.
  • 70. OCCUPATIONAL ABRASION • Notching of incisal edge of maxillary anteriors may be seen in carpenters, shoemakers, tailors who hold nails, tacks or pins between their teeth. HABITUAL ABRASION  Habitual pipe smokers may develop notching of teeth that confirms to the shape of pipe stem – Shafers
  • 71.  Habitual opening of bobby pins may also result in notching of the incisal edge of maxillary anteriors Also called Depression abrasion - where one can see an abraded depression on the occluding surfaces of teeth at a latero-anterior portion of the arch, coinciding with intra oral location of the pipe stem.
  • 72.  Oral piercings Lingual (tongue) piercings may result in abnormal tooth wear. Biting or chewing of the device can lead to severe abrasion accompanied by hypersensitivity. It involves enamel, dentin and may also lead to pulp involvement. Holding the device between the teeth over an extended period of time may also lead to widening of interdental spaces and tooth migration L.L Francu. Lingual piercing : Dental anatomical changes induced by trauma and abrasion. Romanian journal of anatomical functional, clinical, microscopy and anthropology, 2012
  • 73. PROSTHETIC ABRASION • Dentures with porcelain teeth opposing natural teeth. Porcelain causes more abrasion to the natural teeth than other restorative materials. The proximate damage can include loss of natural tooth structure, reduced longevity of opposing restorations and even unfavourable changes to the vertical dimension of occlusion. • Extremely rough occluding surface of the restoration enhancing its abrasive capability . • ill fitting dentures and clasps ,producing a constant wear of the affected surfaces.
  • 74.  In case of tooth brush abrasion, patient should be advised or educated about the brushing technique and the tooth brush, dentifrice to be used.  Instituting proper oral hygiene measures  Prevent the patient from practicing causative habits. The objective should be to prevent any further destruction of the tooth.  Prosthetic/ iatrogenic causes for abrasion to be avoided. In case of such abrasion, early diagnosis and proper management to be carried out such as Correcting or avoiding ill fitting metal clasps and dentures Treatment modalities for abrasion: Diagnose the cause of abrasion and take necessary steps to eliminate the etiological factor
  • 75. Abrasive lesions at non-occluding tooth surfaces should be evaluated critically for the need for restoring them.  Edges of the defect should be eradicated to a smooth, non- demarcating pattern relative to adjacent tooth surface.  Tooth surface then should be treated by fluoride solution to improve caries resistance If there is involvement of cementum / enamel only If the lesions are multiple, shallow( not exceeding 0.5 mm in dentin) and wide Restoration not needed
  • 76. • If the abrasive lesion involves an anterior tooth or facially conspicuous area of a posterior tooth, at a non occluding tooth surface, restoration done with Direct tooth colored materials • If the involved teeth is extremely sensitive - Desensitize the exposed dentin before restoration . Desensitization is done by • 8-10% sodium/stannous fluorides for 4-8 minutes. • Iontophoresis- --using an electrolyte containing fluorides If lesion is wedge (V) shaped and exceeds 0.5 mm into dentin Restoration needed
  • 77. Restoring cervical abrasions In many instances no treatment is necessary but restoration is 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 partial denture.  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
  • 78. Restorative materials used are: • Glass ionomer restorative material. • Resin modified glass ionomer. • Polyacid-modified resin composites. • Resin composites. 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 cavity . (Heymann HO ,Sturdevant Jr ,Baynes S ,JADA,122(2) 41- 57 ) 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 )
  • 79. Materials with low elastic modulus for restoring cervical abrasion such as  Microfilled composites (Heymann and others ,1991 :Levitch and others ,1994 )  Flowable resins (Unterbink ,Liebenberg ,1999: Li and others 2006 )  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 .
  • 80. ABFRACTION Abfraction represents the mechanical flexure theory where tooth bending and flexing during function and parafunction create flexural stress in the cervical area of the tooth resulting in microfractures of the crystalline structure of the enamel and dentin in that area. - K.B. Troendle and K.M. Gureckis. Noncarious Cervical Lesions: Prevalence, Etiology, and Management. Textbook of Erosion and its clinical management. Grippo in 1991, coined the term “abfraction” to describe the pathologic loss of both enamel and dentin caused by biomechanical loading forces. - Milosevic A. Dent Update, 1998 Loss of tooth surface at the cervical areas of the teeth caused by tensile and compressive forces during tooth flexure
  • 81. Clinical features  The lesion is typically wedge shaped with clearly defined internal and external line angles  Affects buccal/labial cervical areas of teeth  Deep, narrow V-shaped notch  Can manifest as C-shaped lesions with rounded floors or mixed shaped lesions with flat, cervical, and semicircular occlusal walls  Commonly affects single teeth with excursive interferences or eccentric occlusal loads  Contributing factors can also modify the clinical appearance of these lesions by making the angles less sharp and the outline broader and more saucer-shaped.
  • 82.  Moreover, abfraction lesions may be deeper than wider depending on the stage of progression and related causal factors  In early stages, the lesion appears as a minor irregular crack or fracture line on the enamel surface. In late stages, it appears as notch extending into the dentin
  • 83. El-Marakby AM et al. Noncarious Cervical Lesions as Abfraction: Etiology, Diagnosis, and Treatment Modalities of Lesions: A Review Article. Journal of Dentistry. 2017
  • 84. Etiology and Pathogenesis  Some authors explain the formation of cervical, wedge shaped defect by the heavy force in eccentric occlusion resulting in flexuring (elastic bending) of the tooth.  Grippo et al in 1991 suggested that static or cyclic forces created tooth loss at the cervical area  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 .  The flexure may lead to breaking away of extremely thin enamel rods ,as well as microfractures of cementum and dentin .
  • 85.  Later Lee and Eakle in 1984 proposed a multifactorial etiology, with a combination of occlusal stresses, abrasion and erosion.  Once micro fracture occurred, water and other small molecules penetrate the broken hydroxyapatite chemical bonds and makes the tooth susceptible for chemical erosion and toothbrush  The resulting defect has a smooth surface .  Also known as idiopathic erosion (Lee WC, Eakle WS, J Prosthet Dent 52(3): 374-380, 1984.)
  • 86.  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)  Occlusal interferences, premature contacts, habits of bruxism and clenching all may act as stressors. (Pintado MR, DeLong R, Ko C, Sakaguchi RL, Douglas WH. Correlation J Prosthet Dent 2000) Differences in support provided by the bony socket, gross morphology of the tooth, the presence or absence of restorations, and the microscopic structure of the tooth are all confounding variables that could influence the occurrence of lesion.
  • 87. Grippo et al. ABFRACTION, ABRASION, BIOCORROSION, AND THE ENIGMA OF NCCLS. Journal of Restorative and Esthetic Dentistry. 2012 ETIOLOGICALFACTORS
  • 88. Theories of Abfraction Abfraction lesions: etiology, diagnosis, and treatment options. Journal of Clinical, Cosmetic and Investigational Dentistry, 2016  The theory of abfraction sustains that tooth flexure in the cervical area is caused due to occlusal compressive forces and tensile stresses, resulting in microfractures of the hydroxyapatite crystals of the enamel and dentin with further fatigue and deformation of the tooth structure.  The theory suggests that the lesion would continue to enlarge as the bending and flexing is repeated finally resulting in chipping away of the hard tissue Separation of enamel from dentin Disruption of bonds b/w HA crystals Tensile stress Compressive stress
  • 89. . • Some researchers even proposed that the occlusal forces on the tooth from chewing and swallowing leading to concentration of stress and flexion in the area where the enamel and cementum meet, as the etiological factor of Abfraction • Others have suggested that abrasive agents like tooth brushes, abrasive paste and or erosion also contribute to abfractive lesions • Recent studies have suggested that there is weak relation between the occlusal factors and the occurrence of cervical lesions. El-Marakby AM et al. Noncarious Cervical Lesions as Abfraction: Etiology, Diagnosis, and Treatment Modalities of Lesions: A Review Article. Journal of Dentistry. 2017
  • 90.  Abfraction lesions are also said to be facilitated by the thin structure of the enamel and the low packing density of the Hunter–Schreger band (HSB) at the cervical area. Lynch CD et al. Hunter-Schreger band patterns in human tooth enamel. J Anat. 2010 • Dentin demineralization promotes the formation of NCCLs from an early stage, whereas occlusal stress is an etiological factor that contributes to the progression of these lesions Wada I et al. Clinical assessment of non carious cervical lesions using swept source optical coherence tomography. J Biophotonics. 2015
  • 91. Diagnosis of Abfractive lesions • Proper diagnosis can be achieved by complete patient anamnesis accompanied by a careful clinical examination • If a tooth has an abfraction, the occlusal loading on the tooth can be tested in centric occlusion and in excursive movements with occlusal marking paper. The tooth with abfraction will show a heavy marking on one of the inclines of the tooth • Mainly seen in malaligned tooth Abfraction lesions: etiology, diagnosis, and treatment options. Journal of Clinical, Cosmetic and Investigational Dentistry, 2016
  • 92. Assessment of activity of abfractive lesions  Approaches to determine lesion activity include the use of standardized intra-oral photographs, study models, and measurement of lesion dimensions over time.  Activity assessment can also be performed by using a scratch test. Scratch test - Its a novel method for determining the activity of abfraction lesions over time ( 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 structure loss • Loss of scratch definition or loss of the scratch altogether signifies active tooth structure loss.
  • 93.  Furthermore, several indices of tooth wear have been proposed for recording and monitoring the progression of abfraction lesions such as Smith and Knight index.  Another index has been recently proposed that includes not only lesion depth but also the width and angle between the lesion and the occlusal and cervical walls, with a scale (DAW index by Loomba et al)  With the recent introduction of digital dentistry, future studies should also test if CADCAM systems may be useful for diagnosis and monitoring of NCCL activity
  • 94. DAW (DEPTH, ANGLE and WIDTH) Classification Loomba K et al. proposal for clinical classification of multifactorial noncarious cervical lesions. Gen Dent 2014
  • 95. Management of Abfraction Monitoring the lesions  when abfraction lesions are painless and do not affect esthetics, i.e are shallow in depth (,1 mm or less), it is advisable to monitor the progression of these lesions at regular intervals without any treatment intervention.  The assessment of lesion activity can be performed every 6 months to 12 months and during regular hygiene visits.  If the tooth wear is likely to compromise the long-term prognosis of the tooth, operative intervention may be required Abfraction lesions: etiology, diagnosis, and treatment options. Journal of Clinical, Cosmetic and Investigational Dentistry, 2016
  • 96. Occlusal adjustments and Occlusal Splints  Occlusal adjustment has been proposed as an alternative treatment to prevent the initiation and progression of these lesions and to minimize failure of cervical restorations.  Occlusal adjustment may involve  Altering cuspal inclines  Reducing heavy contacts, and  Removing premature contacts  Occlusal splints to reduce the amount of nocturnal bruxism and nonaxial tooth forces have also been recommended to prevent the initiation and progression of abfraction lesions.
  • 97. Issue of hypersensitivity  The chronic nature of abfraction, which is accompanied by the natural process of dentinal remineralization, will slowly relieve tooth sensitivity.  If sensitivity persists, the exposed dentin may require therapeutic treatment to relieve or eliminate discomfort.  Various cost-effective and non-invasive treatments like application of desensitizers on to the exposed dentinal tubules or use of desensitizing toothpastes, which might partially or completely occlude the open dentinal tubules  Different types of lasers have also been introduced as an alternative option for treating tooth sensitivity  Other non-invasive treatments include temporary sealants such as Varnishes and Dentin bonding agents.  In extreme cases of Hypersensitivity unresponsive to non-invasive procedures, a restoration might be required.
  • 98. Restorative treatment Restorative treatment of abfraction lesions should be considered only when one or more of the following conditions are present: 1. Active, cavitated carious lesions associated with abfraction lesions 2. Cervical margins or all lesion margins are located subgingivally and preclude plaque control, hence increasing the risk for caries and periodontal disease, 3. Extensive tooth structure loss, which compromises the integrity of the tooth, or the defect is in close proximity to the pulp, or the pulp has been exposed, 4. Persistent dentinal hypersensitivity, in which noninvasive therapeutic options have failed, 5. Prosthetic abutment, and 6. Esthetic demands.
  • 99.  Authors have suggested that during the selection of restorative materials for cervical lesions, materials with a low modulus of elasticity, good adhesion to dentin, resistance to wear, and ability to endure acid dissolution should be considered.  Of the available restorative techniques, adhesive systems, specifically Resin Based Composites, are the preferred choice of dentists to restore NCCLs, likely due to their esthetic and more conservative components.  Although the use of GICs, RMGICs, and the lamination technique of GIC⁄RMGIC with RBC has been advocated for NCCL restorations
  • 100. Tyas recommended that RMGIC should be the first preference In esthetically demanding cases, RMGIC/GIC liner laminated with resin composite. (Tyas MJ. The class V lesion –aetiology ,restoration,Aust. Dental Journal.1995) Vandelwalle and Vigil recommended the use of Microfilled resin composite(low modulus of elasticity ) as it will flex with tooth and not compromise retention (KS Vandelwalle. Guidelines for the restoration of class V lesions. Gen Dent 1997)
  • 101. Root coverage surgical procedures  In most cases of lesions associated with gingival recession, there is a loss of the hard tissues of the tooth crown causing the CEJ to disappear, and root coverage procedures are not effective at treating these crown defects.  Consequently, a combined restorative-surgical approach may be indicated in these clinical situations. In this approach, the restoration must be placed prior to the surgical procedure for better visibility of the operative field and to provide a stable, hard, and convex substrate for the Coronally Advanced Flap (CAF)  Recent studies have pointed out that the combination of Coronally Advanced Flap with connective tissue graft (CTG) provides the best clinical outcomes for root coverage when appropriately performed.
  • 102. Resin composite plus connective tissue graft to treat single maxillary gingival recession associated with non-carious cervical lesion: Randomized clinical trial. J Clin Periodontol 2016 AIM : to evaluate clinically, the esthetics and the patient centered parameters after the treatment of gingival recession associated with non-carious cervical lesions by connective tissue graft (CTG)alone or combined with nanofilled resin composite restoration METHODOLOGY In the CTG Group, In the combined group (COMPOSITE + CTG) Flap Elevation Connective Tissue Graft placed Flap sutured 1mm coronally to the cervical lesion Flap Elevation Nanofilled Resin Composite placed Connective Tissue Graft placed Flap coronally placed and sutured
  • 103. Pre-operative view After flap elevation and rubber dam isolation Nanofilled resin composite placed CTG placed and flap was coronally advanced & sutured 1 year follow-up. RESULTS Both groups can successfully treat gingival recession associated with cervical lesions. Reduction of dentinal sensitivity was more in the combined approach (CTG + Composite)- sensitivity reduced from 88.8% of sites to 5.5% of sites whereas reduction was 94.45 to 44.4% in CTG group. Also, the groups that received restoration presented better marginal contour while the other group often showed flattened margins
  • 104. DISCUSSION Most of the cervical lesions did not achieve complete coverage with gingival tissues. Thus part of the cervical lesion was still exposed to the oral environment in the CTG group. While in the combined group, the defect is completely restored, sealing the dentinal tubules and thereby effective in reducing symptoms The teeth with cervical lesions often presents a flattened marginal contour . This may be the reason for flattened gingival margins in the CTG group following the healing period. Restorations may help to achieve a better anatomical outcome, helping to modulate the marginal contour and give a good final esthetic result
  • 105. Loss of surface tooth structure by chemical action in the continued presence of demineralizing agents(acids). - Sturdevant Erosion can be defined as the loss of tooth structure resulting from chemico- mechanical acts in the absence of specific microorganisms. - Marzouk Loss of tooth substance by chemical process that does not involve known bacterial action. - Shafer EROSION
  • 106. Affect of erosion in enamel Acid diffusing into the narrow pores between the crystals results in partial loss of mineral, increased porosity and reduction of mechanical strength of the outer layer of enamel, which is hence referred to as the ‘softened layer’. Textbook of Erosion and its Clinical Management, Bennett T
  • 107. Affect of erosion in dentin  Erosion of dentin leaves behind a persistent layer of demineralised collagenous matrix.  Demineralization of dentin is firstly apparent at the interface between inter- and peritubular dentin.  With increasing exposure time, the erosive attack results in a hollowing and funneling of the tubules.  Finally, the peritubular dentin is completely dissolved.  Erosive demineralization results in exposure of an outer layer of fully demineralized organic matrix followed by a partly demineralized zone until the sound inner dentin is reached Insights into preventive measures for dental erosion. Journal of applied oral science. 2009
  • 108.
  • 109. Textbook of Erosion and its Clinical Management, Bennett T Factors controlling erosive demineralization 1. Chemical factors a) Enamel - Degree of saturation with respect to hydroxyapatite Degree of saturation with respect to fluorapatite pH Buffer capacity Fluoride concentration Phosphate concentration b) Dentin – Buffer capacity Carbonate concentration 2. Physical factors – Temperature Fluid movement
  • 110.  Dissolution also tends to be reduced or even abolished in undersaturated solutions in which the calcium concentration is much higher than the phosphate concentration.  Calcium addition to acidic solutions can reduce erosive potential.  The factors that have been most consistently identified as significant factors in erosive potential are pH and buffer capacity  The higher the buffer capacity, the pH of the solution within the pores will rise and the lesser the overall rate of erosion.  pH - Laboratory experiments show that erosion of enamel is very rapid at pH of about 2.5 but slows down as the pH increases
  • 111.  Fluorapatite is less soluble than hydroxyapatite, indicating that replacement of all the OH− ions in hydroxyapatite by F− ions causes a large decrease in solubility.  Temperature - Temperature affects the rate of most chemical reactions and erosion is no exception. Studies show that both early erosion (measured by softening) and later erosion (loss of surface) increase over the range 4–75 °C  Fluid Movement – In active fluid movement – the static interfacial layer of liquid becomes thinner and there is an improved supply of H+ ions and removal of mineral-ion end products. Increased movement of fluid thus speeds up dissolution. Erosion of enamel increases very rapidly at low flow rates and then increases more slowly, whereas dentin erosion increases gradually with flow rate
  • 112. CLASSIFICATION OF DENTAL EROSION Based on Etiology 1. Extrinsic Erosion 2. Intrinsic Erosion 3. Idiopathic Erosion Idiopathic erosion is the result of acids of unknown origin, i.e. an erosion-like pathology where neither tests nor anamnesis are capable of providing an etiologic explanation. Imfeld T: Dental erosion. Definition, classification and links. Eur J Oral Sci 1996:
  • 113. Based on Pathogenetic activity – Mannerberg, J Odout Revv 1961 Manifest erosion:  An actively progressing erosion, is clinically diagnosed by its enamel border zones.  These are thin where they meet the exposed dentin.  In the scanning electron microscope (SEM), they show a honeycomb  enamel prism pattern, resembling that seen in acid etched enamel. latent erosion:  It is an inactive stage and here the prisms are much less obvious.  Through a change in the etiologic factor, are no longer subject to further decalcification,  Have prominent thick enamel borders and do not show a honeycomb enamel prism
  • 114. Based on Clinical severity – ECCLES in 1979 EccLES JD. Dental erosion of nonindustrial origin. A clinical survey and classification. J Prosthet Dent 1979 Class I: Superficial lesion, involving enamel only; Class II: Localized lesion, <l/3 of surface involving dentin; Class III: Generalized lesion, >l/3 of surface involving dentin. Based on these three classes, Lussi and co-workers in 1991 have published a similar, more detailed index of erosion for epidemiologic use Lussi A. Schaffner M. Hotz P. Suter P. Dental Erosion in a population of swiss adults. Community Denatl Oral Epidemiology, 1991
  • 115. Grading of severity for facial surfaces - Lussi and co-workers in 1991 Grade 0: No erosion. Surface with a smooth, silky-glazed appearance and absence of developmental ridges possible. Grade I: Loss of surface enamel. Intact enamel found cervical lo the erosion and concavity on enamel whose width clearly exceeds its depth, thus distinguishing them from toothbrush abrasion. Dentin is not involved. Grade 2: Involvement of dentin for less than one half of the attacked area of tooth surface Grade 3 : Involvement of dentin for more than one half of the attackcd area of tooth surface
  • 116. For other surfaces Grade 0: No erosion. Surface with a smooth, silky-glazed appearance and absence of developmenlal ridges possible. Grade I: Slight erosion, rounded cusps, edges of restorations rising above the level of adjacent tooth surface, grooves on occlusal aspects, loss of surface enamel. Dentin is not involved. Grade 2: Severe erosion, more pronounced signs than in grade I. Dentin is involved.
  • 117. ETIOLOGY Erosion can be due to Intrinsic or Extrinsic factors Intrinsic factors a) Recurrent vomiting disorders b) Gastroesophageal reflux diseases Eating disorders Medical conditions Psychogenic vomiting syndrome Chronic alcoholism Side effect of drugs Pregnancy induced vomiting Cyclic vomiting syndrome
  • 118. Extrinsic factors a) Dehydrated items b) Acidic foods c) Medications Wines Alcoholic Beverages Soda and Soft Drinks Sports Drink Fruit Juices Tobacco Citrus Fruits Analgesics Vitamins Antisialogogues Drug abuse Asthamatic medications
  • 119. d) Oral Health care Low pH toothpaste and mouthrinse Abrasive toothpaste Toothbrushing technique e) Occupation Industrial workers Swimmers Professional wine tasters f) Other factors include :- • Bleaching • Chewing gums • Lifestyle or behavioural factors
  • 120. Eating Disorders • An eating disorder can be defined as an unusual eating behavior with insufficient or excessive food intake, which is associated with distress about weight or body shape • Among the eating disorders, bulimia nervosa is the condition most closely related to dental erosion. Another eating disorder - anorexia nervosa. • Labial surfaces of the incisors, which is the first surface that the acid gets in contact during ingestion. • Another report observed severe lingual and moderate buccal erosion in almost all anorexic patients with recurrent vomiting A Rosten and T Newton. The impact of bulimia nervosa on oral health: a review of literature. British Dental Journal. 2017
  • 121.  Other features include parotid enlargement, decreased salivary secretions and xerostomia.  Also, bulimic patients had lower stimulated salivary flow rates and lower bicarbonate concentrations Medical Conditions The main medical conditions associated with vomiting include • Gastrointestinal disorders (peptic ulcer, c/c gastritis, and gastric motility problems) • Metabolic and endocrine disorders (diabetes mellitus, chronic renal failure and hyperthyroidism), • Dry mouth conditions (diseases of the salivary gland, sjogrens syndrome, head and neck radiation, etc) and • Neurological and central nervous system disorders (migraine headaches and intracranial neoplasms)
  • 122. Cyclic Vomiting Syndrome • Cyclic vomiting syndrome is characterized by recurrent attacks of nausea and vomiting that may last for periods of a few days to several months, which is separated by symptom-free periods • Among the common triggering factors are stress, emotional excitement, and infections Side Effect of Drugs Opiate analgesics and chemotherapeutics agents. Other drugs can induce vomiting secondary to gastric irritation, such as aspirin, diuretics, and alcohol
  • 123. Psychogenic Vomiting Syndrome Psychogenic vomiting syndrome affects mostly young women, and it involves recurrent vomiting, which may be caused by an underlying emotional disturbance. Chronic alcoholism • Alcoholism can result in a series of dental implications, such as high caries incidence due to neglected oral hygiene, dental attrition due to alcohol-stimulated bruxism, and oral cancer • Dental erosion due to alcohol abuse can be caused by both intrinsic factors (vomiting and regurgitation) and extrinsic factors, depending on the erosive potential of the alcoholic drink that is ingested.
  • 124. • For example, wines and alcohols have a low pH and may be highly erosive to the teeth. • Erosive lesions were most commonly found at the palatal surfaces of the anterior teeth Pregnancy-Induced Vomiting Not a major risk factor for dental erosion. Certain studies have shown association with palatal erosion who had severe and prolonged vomiting during pregnancies
  • 125. Gastroesophageal reflux diseases (GERDs) • GERD has been defined as “a condition that develops a reflux of gastric contents into the esophagus or beyond: larynx, oral cavity or lung • The potential for tooth erosion is variable and depends on the  Composition and pH of the refluxate;  Frequency and the form it reaches the mouth (either through regurgitation or belching acidic vapors)  Flow rate  Buffer capacity,  Clearance action of saliva; and  Brushing after the regurgitation episodes.
  • 126. • Erosive wear in GERD patients appears to be found more frequently on palatal surfaces of the maxillary anterior teeth and on the molar teeth. • It was suggested that during reflux the gastric juice passes over the dorsum of the posterior third of the tongue, reaching the palatal surfaces of the upper molar teeth, and then passes over the buccal surfaces of the lower molars. • The lingual surfaces of the lower molars remain protected by the ventral surface of the tongue. The acid also passes over the dorsum of the tongue, reaching the palatal surfaces of the maxillary anterior teeth
  • 127. Acidic foods  Acidic foods like vinegar, citric fruits, acidic berries, and other fruits (apple, pears, and plums)  Acidic candies - contain organic acids such as citric acid and malic acid to develop the characteristic sour flavor.  Sucking on sour candies can reduce the salivary pH levels below to the critical value for dental demineralization, therefore posing a risk for erosion of dental surfaces  size of the candy is an important aspect, since it will determine the total length of exposure to the erosive challenge. As they dissolve slowly, they can be kept in the mouth for extended periods of time. This allows for prolonged and continuous exposure of the teeth to acids.
  • 128. Several factors may actually vary the erosive response in individuals consuming acidic fluids. - manner in which the fluids consumed - tooth surfaces that come in contact with the fluid - duration of contact with the teeth - pH, buffering effect and content of calcium and phosphate in the drink. - swallowing habits - access to saliva - soft tissue movements. - roughness of individual food consumed. - prolonged contact of an acid with tooth surface increases its damaging potential.
  • 129. 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)
  • 130. Medications • Aspirin, ascorbic acid (vitamin C), iron tonics, cocaine, have been implicated in dental erosion • Asthamatic medications (cortisol inhaler) present erosive potential due to their acidic nature. In addition, they can decrease the salivary buffering capacity and flow rate Low pH oral care products • Three acidic mouthrinses: acidified sodium chlorite mouthrinse (pH 3.02), essential oil mouthrinse (Listerine®, pH 3.59), and a hexetidine mouthrinse (0.1 %, pH 3.75), were shown to cause progressive enamel surface loss over time, similar to that of an orange juice and higher than that of mineral water.
  • 131. • Non – fluoridated toothpaste contributed more to dental erosion than fluoride containing toothpastes. This finding was attributed to both the presence of citric acid/citrate and absence of fluoride in the toothpaste. Abrasive Toothpaste  Highly abrasive toothpastes may facilitate the disruption of the acquired dental pellicle as well as abrade away dental surfaces previously softened by an erosive challenge. This is even more relevant in the presence of exposed root dentin surfaces.  Dentin is more susceptible to abrasive and erosive insults and less responsive to remineralization.  whitening toothpastes causes more erosion than regular toothpastes
  • 132. Toothbrushing  Prolonged and frequent toothbrushing has been shown to increase the probability of erosive wear  Brushing performed right after the erosive attack by acidic beverages, not allowing the eroded surfaces to remineralize and regain its physical strength, also contribute to erosion
  • 133.
  • 134. Dental Bleaching • It has been shown that some hydrogen peroxide-based gels may influence enamel surface morphology and softening suggesting erosive potential. • This is substantiated by the high content of hydrogen peroxide and a low pH value of some bleaching agents Saliva Substitutes Some of these products such as Biotene® with a pH of 4.15 and Glandosane® with a pH of 4.08 are considered potentially erosive
  • 135. Occupational factors Industrial workers  Any industrial processing procedures that expose workers to acidic fumes or aerosols have the potential to cause dental erosion.  The incisal edges of anterior teeth are primarily affected, although an increased rate of tooth wear of posterior teeth has also been reported.  Sulfuric, nitric, acetic, and hydrochloric acids have all been implicated  Occupations involved with galvanizing, electroplating, metal and glass etching, printing, and mouth pipetting of laboratory acids as well battery, fertilizer, and chemical manufacturing are all at risk of dental erosion unless appropriate safeguards are taken.
  • 136. Occupational wine tasters  The pH of wine was reported to range from 2.8 to 3. Professional wine taster tasting an average of 30 wines a day over 23 years showed extensive palatal erosion Competitive Swimmers  Several case reports have associated competitive swimmers using improperly pH- regulated swimming pools with dental erosion  Gas chlorinated swimming pools require daily pH monitoring and adjustment to maintain pool water in the recommended pH range of 7.2 to 8.0
  • 137. Lifestyle factors  Healthier lifestyle that includes a diet high in acidic fruits and vegetables may subject teeth to an increased risk of erosion.  Frequent dieting with high consumption of citrus fruits and fruit juices as part of a weight-reducing plan may also be a risk factor.  lactovegetarians showed signs of dental erosion and they were mostly associated to the consumption of vinegar and vinegar conserves, citrus fruits, and acidic berries.  Strenuous sporting activities and exercise may lead to higher risk of erosion if frequent intake of acidic sport drinks, fruit juices, and other acidic beverages are used for fluid and energy replacement.
  • 138. Chewing Gum • Frequent use of some of the acidic chewing gums may present potential for dental erosion development, especially on the occlusal surfaces of posterior teeth • For instance, replacement of gum every 4 min was able to cause significant erosive tooth wear on dentin, as it keeps the low pH values at tooth surfaces for longer time, increasing the risk for dental erosion
  • 139. CLINICAL MANIFESTATIONS OF EROSIVE WEAR  Erosive wear can be observed on the buccal/labial and lingual/palatal surfaces, which are not affected by wear in a purely abrasive environment.  These surfaces typically appear glossy or silky because of the loss of small-scale surface features such as perikymata.  When abrasion has occurred on erosion-softened surfaces, the occlusal wear surfaces tend to have rounded borders and a smooth transition to the adjacent tooth surface  Active erosive wear may be associated with dental hypersensitivity, when the dentinal tubules remain patent
  • 140.  The same vulnerability to friction underlies the ‘cupping’ due to loss of dentin from cuspal areas and the loss of tissue from the occlusal surfaces which causes restorations to stand proud of the surface. Extensive loss of buccal and occlusal tooth structure with raised amalgam restorations Multiple cupped out depressions corresponding to the cusp tip
  • 141. Clinical signs and symptoms of Erosive wear of Intrinsic origin  Wear of the palatal surfaces of the upper incisors is a very common characteristic of intrinsic erosion, whether it is caused by frequent vomiting or by regurgitation.  With lesion progression the lingual surfaces of the premolars and molars become affected, and in more advanced stages, the process extends to the occlusal surfaces of the molars and to the facial surfaces of all teeth  Incisal edges of the maxillary central incisors had their height reduced through a combination of erosion and attrition Palatal surfaces of maxillary dentition in which the exposed dentin exhibits a concave surface and a peripheral white line of enamel Extensive loss of enamel and dentin on the Buccal surface of maxillary bicuspids
  • 142.  On the occlusal surfaces, rounding of marginal ridges and cups was observed in addition to cupping characterized by localized exposure of the dentin Occlusal view of maxillary dentition exhibiting concave dentin depressions surrounded by elevated rims of enamel  On the buccal aspect of the maxillary and mandibular teeth, these lesions were characterized by a silk- like appearance of the enamel surface with shortened appearance of the maxillary front teeth.
  • 143.  On the palatal aspect of the maxillary teeth, erosive lesions with complete loss of the enamel were readily identified by the presence of a thin band of enamel at the gingival margin and exposure of dentin on both anterior and posterior teeth  In severe cases, almost complete loss of enamel, along with exposure of dentin
  • 144. Perimylosis  Decalcification of the teeth caused by exposure to gastric acid in patients with chronic vomiting  Mostly seen at the palatal and occlusal surfaces in upper arch, buccal and occlusal surfaces of lower premolars and molars  Loss of lingual enamel and dentin due to acid regurgitation aggravated by circular movements of tongue.  Associated with stress reflux syndrome
  • 145. Monitoring Tooth Erosion 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 . Inactive wear Stained Active Wear Smooth, stained clean tooth surfaces Erosion around restorations Restoration- resistant to acid, but the tooth is gradually dissolved
  • 146. TOOTH WEAR INDICES FOR EROSIVE LESIONS The objective of tooth wear indices is to classify and record the severity of tooth wear or dental erosion in prevalence and incidence studies. Eccles Index in 1978 originally classified lesions broadly as  Early,  Small and  Advanced Later, the index was refined and expanded, with greater emphasis on the descriptive criteria. It breaks down into three classes of erosion, denoting the type of lesion, assigned to four surfaces, representing the surface where erosion was detected (Eccles index for dental erosion of non-industrial origin in 1979) Bardsley et al. The evolution of tooth wear indices. Journal of clinical oral investigation. 2008
  • 147.
  • 148. BEWE (BASIC EROSIVE WEAR EXAMINATION) – Bartlett et al in 2008 The BEWE is a partial scoring system recording the most severely affected surface in a sextant and the cumulative score guides the management of the condition for the practitioner • Simple, • Reproducible • Transferable scoring system Bartlett et al. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clin Oral Invest (2008)
  • 149. TREATMENT MODALITIES  Proper diagnosis of the cause of erosion is the first step  A complete analysis of diet, occlusion, habits, vomiting, and environmental factors should be taken into consideration.  The cause should be identified and be should eliminated.  There should not be any rush to attempt restorative modalities, except in extremely symptomatic or disfiguring lesions.  Tooth colored materials such as GIC or composite, capable of chemico-phyiscal bonding to tooth structure can be used with minimum or no tooth preparation.
  • 150. PREVENTION AND CONTROL OF DENTAL EROSION Preventive Strategies Based On Lifestyle And Behavioral Modification Preventive Strategies Based On The Self- applied Preventive Agents Preventive Strategies Based On Proffesionally Applied Agents Textbook of Erosion and its Clinical Management, Bennett T
  • 151. Role of saliva: Saliva plays an important role in modifying the erosive effects of dietary foods and beverages by the following mechanisms.  Dilution and clearance of an erosive agent from the oral cavity  Neutralization and buffering of dietary acids by the salivary bicarbonate, phosphate and proteins  Formation of a pellicle layer on the surface of enamel which protects it from demineralization by dietary acids. A. Warreth et al. Tooth surface loss: a review of literature. Saudi Dental Journal. 2020  Reduce the demineralization rate by providing calcium, phosphate and fluoride ions to restore eroded enamel and dentine  Both quantity and quality of saliva are known to control the extent of dental erosion.
  • 152. Dietary Recommendations to Prevent Erosion 1. Reduce the intake of highly acidic foods and drinks, and if possible limit their intake to mealtimes Such foods and drinks as: • Carbonated soft drinks to include diet and sports drinks • Fresh citrus fruit juices and fruit juice drinks • Wine, cider, and spirits consumed with mixers • Some herbal teas (citrus and berry types) • Fresh citrus fruits (if consumed in large quantities) • Vinegar, sauces, ketchup, pickles, and chilies • Acidic sweets such as fruit drops • Chewable vitamin C tablets • Acidic candy that is hard or sticky, instead use sugar-free gum • Powdered drinks with a tangy, fizzy, or acidic flavor Preventive Strategies Based On Lifestyle And Behavioral Modification
  • 153. 2. Reduce erosive impact of food and drinks by observing the following • Drink acidic drinks quickly and use a straw in order to reduce the contact of the drink with your teeth. • Do not swish drink around or hold them in your mouth for long periods. • After consuming food or drink that is high in acid content, rinse with water to dilute the acid, and wait an hour before brushing your teeth. • Or finish the meal with something to neutralize acid, like cheese or milk. • As salivary flow is almost nil at night, avoid acidic food and drink especially before going to bed. • Chew sugar-free gum to produce more saliva so your teeth can remineralize. • Brush with a soft toothbrush and be sure your toothpaste contains a high amount of fluoride
  • 154. Change in Frequency and Method of Beverage Intake  Clearly, a reduction in acid exposure would be the best preventive strategy to be applied in high-risk patients.  The consumption of potentially erosive foods and beverages, should be limited to main meals only  The straw, when appropriately used, might be a viable alternative to reduce the contact of the acid with the teeth  The temperature of an acidic drink also influences its erosive potential. Taking the drink ice-cold reduces its erosive effect
  • 155. Change in Oral Hygiene Method and Materials  The time of toothbrushing after an erosive attack as well as the applied force and type of dentifrice used should be controlled.  Thus, an important recommendation is to avoid brushing the teeth immediately after episode of acidic challenge such as vomiting or reflux or intake of acidic beverage.  Rather patients should be advised to rinse their mouth with water or, more effectively, to use antacid products or fluoridated mouthrinse immediately after acidic challenge.  Regular toothpastes are most recommended rather than whitening,  It may be recommended for patients at high risk for erosion soft-bristle toothbrushes, especially if exposed dentin surfaces are present.
  • 156. Use of Personal Protective Equipment  Personal protective equipment (e.g. respiratory masks for industrial workers or ‘bite-guards’ for professional swimmers) and adherence to threshold limit values recommended by occupational health legislations are considered an important preventive strategy to decrease occupational exposure to erosive acids  It is pertinent to mention that the bite guards suggested for professional swimmers should have the inside (tooth surface) coated with a small amount of sodium bicarbonate powder or milk of magnesia to neutralize any acidic water pooling in it. The guard should have occlusal coverage only, so that saliva flow to aid remineralization is maintained.
  • 157. Control of Exposure to Intrinsic Acids  Management of erosive tooth wear in patients suffering from GERD or eating disorder requires a multidisciplinary intervention, including general medicine and psychological treatment, in order to decrease the exposure to intrinsic acids  The mainstay medical therapy for GERD includes  Antacids,  Histamine-2 Receptor Blockers (H 2 RB Or H 2 Blockers), And  Proton Pump Inhibitors (PPI). Over-the-counter antacids provide symptom relief by neutralizing refluxed gastric acid thereby increasing esophageal pH.
  • 158. • Histamine-2 receptor antagonists or blockers inhibit the secretion of gastric acid competitively by blocking the H 2 receptors located on the gastric parietal cells. • Proton pump inhibitors (PPIs) are effective in controlling GERD symptoms that are refractory to antacids and H2 blockers
  • 159. Use of Modified Products  The modification of beverages or foods is another preventive strategy to reduce the risk of dental erosion.  Reduction of the erosive potential of acidic beverages can be achieved by adding ions (calcium, phosphate and/or fluoride) that make the beverage more saturated in respect to tooth mineral, hydroxyapatite (HA) or by adding polymers (pectin, alginate and gum arabic polymers), which adsorb to the tooth surface to create physical barrier against acid erosion  The addition of calcium or polymer has been shown to reduce the erosive potential of acidic drinks.
  • 160. Neutralizing Intraoral Acidity • In attempt to raise intra-oral pH, different products have been tested, including antacid tablets, lozenges, mineral water, milk and tap water, all used for 2 min immediately after the erosive challenge. • The use of different antacid suspensions and a bicarbonate solution after erosive challenge with hydrochloric acid also significantly reduced enamel surface loss. Thus, it is advisable to instruct the patients to rinse their mouth with water or, more effectively, to use antacid products immediately after vomiting or reflux episodes Preventive Strategies Based On The Self-applied Preventive Agents
  • 161. Use of Fluoride Concentration Dentifrices • Improved enamel protection was observed with dentifrices containing titanium tetrafluoride (TiF4) and stannous fluoride (SnF2 ) when compared to NaF. • The improved protection by SnF2 and TiF4 was attributed to the stannous’ and titanium’s ability to interact with the tooth surfaces forming an acid-resistant film of insoluble compounds, thus increasing the tooth tissue resistance. • These compounds also demonstrated precipitation of CaF 2- like deposits (CaF 2 -globules) that behave as a physical barrier inhibiting the contact of the acid with enamel as well as acts as a fluoride.
  • 162. Use of Paste/Cream Containing Recaldent (CPP-ACP) Technology  These are commercially available as Tooth Mousse (Asia/Australia) and MI paste (USA) and the fluoride-containing CPP-ACFP (with 900 ppm fluoride) as Tooth Mousse-plus and MI paste-plus.  In Recaldent, the calcium and phosphate ions in a soluble amorphous calcium phosphate is stabilized by the protein CPP into nanocomplexes, these nanocomplexes bind onto the tooth surfaces and dental pellicle to create a state of supersaturation of calcium and phosphate ions in the oral cavity.  When the oral pH drops during an acidic challenge, the calcium is released from the CPP to facilitate remineralization and inhibit demineralization
  • 163. Use of Toothpaste Containing Functionalized Tricalcium Phosphate Technology • In this technology, by milling tricalcium phosphate (TCP) with organic materials (functionalization), the CaO in TCP become ‘protected’ by the organic materials, thus allowing the calcium and phosphate ions of the TCP to co-exist with fluoride ions in an aqueous dentifrice base (toothpaste) without premature TCP-fluoride interactions. • Once applied in the presence of saliva, calcium compound is activated by saliva that degrades the protective coating, releasing calcium at the tooth surface, resulting in high fluoride and calcium bioavailability on the lesion surface and subsequent diffusion into the lesion to promote remineralization. • Commercially available- Clinpro™ 5000 paste
  • 164. Use of Toothpaste Containing Novamin Technology • It is a bio-active glass (calcium sodium phosphosilicate) that binds to the tooth surfaces, and when in contact with body fluid, such as saliva, releases calcium and phosphate ions, enabling the remineralization of tooth tissue, typically forming hydroxycarbonate apatite • The existing Bioactive glass (Novamin™) used in commercial toothpastes such as Sensodyne Repair & Protect and Sensodyne Complete Protection
  • 165. Use of Polymer-Containing Toothpastes • Recently, some dentifrices containing polymers have been investigated due to their potential to form a protective layer on the tooth surface, strengthening the pellicle. • As active ingredients in toothpaste, organic polymers such as casein, ovalbumin, pectin, alginate and arabic gum, and inorganic polymers such as pyrophosphate, tripolyphosphate and polyphosphate have been studied Use of Chitosan-Containing Toothpastes • Incorporation of chitosan into dentifrices containing fluoride and tin or Sn significantly increased the anti-erosive/anti-abrasive effect of the dentifrice for both enamel and dentin.
  • 166. Use of Mouth rinse Containing Protease Inhibitors • Mouthrinses containing protease inhibitors, such as chlorhexidine and green tea extract, or even rinses with green tea have been shown to reduce dentin loss (around 30–40 %). • Thus mouthrinses containing SnCl 2 /NaF/AmF, TiF 4 /NaF, or protease inhibitors might have potential to benefit patients that are frequently exposed to erosive challenges.
  • 167. 1. Remineralization methods for softened tooth surface a) Fluorides - gels and forms - varnishes b) calcium containing agents - Recaldent (CPP_ACP) - Tricalcium phosphate technology 2. Tooth surface protection a) Surface Protective Coatings with Remineralizing Potential - GIC - Resin modified GIC (RMGIC’s) a) Surface Protective Coatings without Remineralizing Potential - Nano filled light cured adhesive - Highly filled resin b) Surface Protection Using ‘Bite-Guards’ Preventive Strategies Based On Professionally Applied Agents
  • 168. 1. Dentin Desensitization 2. Restoration of non- cervical lesions Non - esthetic materials (not widely used) - Amalgam - Gold foil Gold inlay Minimal preparation Adhesive restoration - Resin composite (with dentin bonding system) - Resin composite (with glass-ionomer liner—sandwich technique) - Flowable resin composite - Glass ionomer - RMGI - Compomer 3. Ceramic veneer or full crowns 4. Conventional fixed restorations 5. Removable onlay / overlay prosthesis 6. Periodontal therapy MANAGEMENT OF DENTAL EROSION
  • 169. Restorative materials for non-carious cervical lesions: A review. International Journal of Clinical Dental Science, 2018 RESTORATION OF NON-CARIOUS CERVICAL LESIONS  Restorations at the cervical region of teeth are frequently subjected to occlusal loads and flexural stress.  An ideal restorative material should present biomechanical features capable of resisting dislodgement under tension and exhibit good adhesion, retention, and marginal seal in the long run.  Significantly, the selection of the ideal restorative material is hence influenced by factors such as micromechanical retention, preservation of tooth structure, esthetics, and functional harmony
  • 170. GLASS IONONMER CEMENTS • Superior retention due to chemical bonding • Secondary caries inhibition due to fluoride releasing ability • High abrasion resistance on final maturation • In scenarios where preserving tooth structure is a priority, GICs serve as a durable restoration, bonding chemically to the tooth structure, and avoiding unnecessary beveling of enamel One of the major limitations of conventional GICs is the inconvenient setting characteristics and low abrasive resistance that is overcome by resin-modified GICs (RMGICs)
  • 171. RESIN MODIFIED GLASS IONOMERS (RMGIC’s)  Improved setting characteristics allowing sufficient working time that can be shortened by light curing to make it more resistant to effects of moisture while simultaneously developing rapid early strength.  In comparison to the conventional GICs, the translucency is markedly superior with better color matching.  RMGICs have a better adhesion to dentine and allow for easy repairs to defective or damaged surfaces of the restoration.  They also bond directly to composite resin making them ideal cement for “sandwich” technique  reduced superficial degradation, and increased wear resistance,  Superior fluoride release
  • 172. Belluz M, Pedrocca M, Gagliani M. Restorative treatment of cervical lesions with resin composites: 4-year results. Am J Dent 2005;18:307-10 COMPOSITES • Exhibiting improved adhesion to the tooth • Higher abrasive resistance Disadvantages • Deficient marginal seal and progressive degradation of adhesion • The polymerization shrinkage of the composites is the main cause for microleakage, poor marginal adaptation, and low retention rates • Loss of retention due to cervical stress/flexure Flowable composites have been introduced that has low quantities of filler, low modulus of elasticity, and more flexible to dislodging forces
  • 173. COMPOMERS • The main aim of using compomers is to avoid the use of acid etching of enamel while retaining the elasticity of composites, hydrophilic, and fluoride-releasing properties of the GICs. • Increased elasticity in comparison to GIC – better performance in stress bearing areas Brackett WW et al. 1-year clinical evaluation of compoglass and fuji II LC in cervical erosion/abfraction lesions. Am J Dent 1999 Disadvantage The lack of enamel etching has lead to decreased bond strength and less retention rates Folwaczny M, Loher C, Mehl A, Kunzelmann KH, Hickel R. Class V lesions restored with four different tooth- colored materials--3-year results. Clin Oral Investig 2001
  • 174. GIOMERS AND ORMOCERS Giomers are fluoride-releasing resin materials with “prereacted glass,” a hybrid of glass-ionomer and resin- based composite. • Better color match, decreased microleakage, and increased fluoride release. • They have a better surface finish and esthetic properties comparable to composites (Sunico MC, Shinkai K, Katoh Y. Two-year clinical performance of occlusal and cervical giomer restorations. Oper Dent 2005)
  • 175. Ormocers are organically modified ceramics consisting of a polycondensed three- dimensional cross-linked organic/inorganic network (polysiloxanes), organic polymers, and glass/ceramic filler particles. • Better marginal adaptation and integrity. Hennig AC, Helbig EB, Haufe E, Richter G, Klimm HW. Restoration of class V cavities with the ormocer-based filling system admira. 2004
  • 176. Activa BIOACTIVE RESTORATIVE (Pulpdent corporation, Watertown, MA)  Dual cured material  It is the first dental material with bioactive resin matrix, shock absorbing resin component and reactive glass ionomer fillers designed to mimic physical and chemical proeprties of natural teeth  Highly esthetic bioactive hydrophilic composite that bonds chemically to the tooth, seals against microleakage and releases more Ca. PO4 and F ions  It is more bioactive than GIC and more durable and fracture resistant than composites  It is well preferred for cervical lesions Bioactive Restorative vs GIC modified glass ionomer in restoration of cervical lesions: A randomized controlled trial. 2020
  • 177. Conventional Fixed Restoration’s The main options either individually or in combination are:  Opposing tooth reduction  Elective endodontic treatment and post retention  Occlusal adjustment  Periodontal surgical crown lengthening  Localized orthodontic tooth movement (Conventional Fixed Appliance or ‘Dahl’  appliance)  Overall increase in occlusal vertical dimension
  • 178. Removable Onlay/Overlay Prostheses The use of a removable onlay/overlay prosthesis can be a valuable means of rehabilitating patients with moderate/severe tooth wear, particularly when there are also missing strategic teeth to be replaced. Advantages:-  Simple  Non – invasive  Cost effective The construction of a provisional acrylic resin removable prosthesis is recommended initially, allowing the opportunity to carry out modifications to the shape, position and occlusal relationship of the prosthetic teeth and soft tissues, as well as assessing the patient’s tolerance of a removable prosthesis.
  • 179. • This does not require tooth preparation but long term use requires tooth preparation often incorporating a cobalt-chromium framework. • It is possible to achieve an increase in occlusal vertical dimension with the use of a removable posterior onlay prosthesis in combination with anterior fixed crown restorations Disadvantages:- • Maintenance demands are relatively high • Material wear and fracture • Complex design • Unesthetic
  • 180. Examples of overlay removable prostheses: ( a ) Full labial flange, ( b ) gingival fitting anterior tooth facings The use of a metal framework incorporating incisal and occlusal coverage used to strengthen removable onlay/overlay prostheses for patients demonstrating signifi cant parafunctional clenching/grinding habits
  • 181. Periodontal Therapy Periodontal therapy is required when non – carious lesions are associated with considerable gingival recession and mucogingival defects. Treatment protocol is as follows: - 1. Supragingival and subgingival scaling 2. Restorative treatment for non carious lesions 3. Frenectomy and fenestration procedure for deepening the vestibule 4. Evaluation of increase in the width of attached gingiva 5. Root coverage procedures a) Using free gingival grafts or connective tissue grafts b) Using non grafting procedures like rotational or coronally advanced flaps or guided tissue regeneration (Interdisciplinary approach for the management of Non – Carious lesions, Journal of Indian Society of Periodontology, 2015)
  • 182. Classification and Treatment of the Anterior Maxillary Dentition Affected by Dental Erosion: The ACE Classification Francesca Vailati. The International journal of periodontics & restorative dentistry · 2010
  • 183. • Yellowish at the centre due to the underlying dentin and whitish periphery due to thick enamel • 100% recovery possible • Preventive measures – guard, Fluoride • Determining the etiology is essential • To protect remaining enamel and dentin – D/I composite • If interocclusal space is less- VDO increased by ortho intervention • Direct or indirect composite can be given based on severity and financial aspect • Direct composite or onlays in posteriors • Palatal veneers when there is adequate interocclusal space
  • 184. • At this stage, posteriors (especially premolars) are also involved • Palatal aspect restored with composite veneers and facial aspect with ceramic veneers • Sandwich technique is called experimental because ceramic facial veneers are bonded to reduced dentin surface • Prognosis may be unfavourable • Sandwich approach can still be used to preserve pulp vitality, preserve rem tooth structure • If pulp vitality s lost thereafter, endodontic treatment through palatal veneer
  • 185. COMBINED LESIONS Grippo et al. ABFRACTION, ABRASION, BIOCORROSION, AND THE ENIGMA OF NCCLS. Journal of Restorative and Esthetic Dentistry. 2012
  • 186. Attrition- Abfraction. Attrition- abfraction is the joint action of stress and friction when teeth are in tooth-to-tooth contact, as in bruxism.
  • 187. Abrasion-abfraction. • Abrasion-abfraction is the loss of tooth substance caused by friction from an external material on an area in which stress concentration due to loading forces may cause tooth substance to break away. • Such a synergistic tooth-destructive effect may be observed cervically when toothbrushing abrasion exacerbates abfraction to produce wedge-shaped lesions.
  • 188. Erosion-abfraction • Erosion (Bio Corrosion)-abfraction is the loss of tooth substance due to the synergistic action of a chemical corrodent on areas of stress concentration. • This physicochemical mechanism may occur as a result of either sustained or cyclic loading and leads to static stress corrosion or cyclic stress corrosion
  • 189. Attrition-Corrosion • Attrition-corrosion is the loss of tooth substance due to the action of a corrodent in areas in which tooth-to-tooth wear occurs. • This process may lead to a loss of vertical dimension, especially in patients with GERD or gastric regurgitation. An occlusal or incisal pattern of wear develops.
  • 190. Abrasion-corrosion • Abrasion-corrosion is the synergistic activity of corrosion and friction from an external material. • This could occur from the frictional effects of a toothbrush on the superficially softened surface of a tooth that has been demineralized by a corrosive agent. • Teeth that are out of occlusion could be affected by this mechanism and develop cervical lesions
  • 191. Biocorrosion-abfraction • Biocorrosion (caries)-abfraction is the pathological loss of tooth structure associated with the caries process, where an area is micromechanically and physicochemically breaking away due to stress concentration. • A common site for this synergistic activity is the cervical area of the tooth, where it may be manifested as root or radicular caries.
  • 192. MANAGEMENT OF WORN DENTITON Cervical Tooth Wear  Materials can either be composite resin or glass ionomer-based, or a combination of both; either in a layered technique with the individual materials or with formulated Resin- Modified glass-ionomer cements. Textbook of Erosion and its Clinical Management, Bennett T • Acid etching of enamel • Composite restoration ENAMEL • Dentin bonding agent + Composite • Self adhesive Composite ROOT DENTIN/ CEMENTUM
  • 193.  Alternatively, a glass-ionomer cement restoration with inherent bonding properties to both dentin and enamel may be considered. The new generation of light-activated resin-modified glass-ionomer combines superior properties of both composite resin and conventional glass-ionomer cements. Esthetics Composite Not prominent area or extending below Gingival margin Glass Ionomer cements
  • 194. Palatal Tooth Wear • This pattern of tooth wear is usually characteristic of acid erosion, possibly combined with a degree of attrition • Often, the labial and incisal surfaces are relatively intact and the main indications for restorative treatment are to offer some resistance to further palatal tooth wear which will reduce the risk of significant enamel fractures • The use of resin-bonded palatal metal alloy veneers is an acceptable method to manage this form of tooth wear and has been shown to be a relatively durable technique.
  • 195.  Either heat treated gold alloys or nickel-chromium alloys, as used in resin-bonded bridge frameworks, are currently the cast metal alloys of choice. The use of nickel/chromium alloy resin-bonded palatal veneers used to restore localised palatal tooth wear for maxillary incisor teeth
  • 196. Combined Incisal and palatal tooth wear  In these circumstances, it is feasible to build up the incisal portion of the tooth with direct acid-etch retained composite resin and then construct a resin-bonded metal alloy palatal veneer to cover both the palatal tooth tissue and composite resin.  An alternative and very conservative approach is to restore both the incisal and palatal tooth surfaces with direct acid-etch retained composite resin at an increase in occlusal vertical dimension to accommodate the thickness of the restorative material  Modified porcelain laminate veneer restorations of both the incisal and palatal worn tissue have also been suggested
  • 197. Restoration of incisal and palatal aspects of worn upper anterior teeth with direct composite resin restorations a,c-Before restoration b,d-After restoration
  • 198. Combined Labial/Incisal/Palatal Tooth Wear  Use of a labial porcelain laminate veneer in conjunction with a metal alloy veneer for the palatal surface, or an adhesive metal- ceramic crown restoration.  All these techniques are relatively complex and would normally require some inter-occlusal space creation prior to completion of the restoration. In these circumstances, consideration should be given to the provision of a more conventional full coverage crown.  In case of advanced wear of anterior mandibular teeth, it may be advantageous to consider a degree of localized crown lengthening surgery in an attempt to capture all remaining tooth enamel

Editor's Notes

  1. Dental health survey – englnd, wales
  2. Interocclusal clearance = freeway space VDO = superoinferior relationship of maxilaa and mandible when teeth are occluded in maximum intercuspation(independent of condylar position) Centric relation = bone to bone contact (maxilla mandible relationship) independent of too contact. When condyles are placed supero anteriorly against the articular eminences Occlusion of opposing teeth in centric relation which may or may not coincide with maximum intercuspation
  3. It is usually 2-4mm. If this value is more – VDR is more that is overclosure.
  4. Indirect ceromer – indirect composite cont sialinized microhybrid inorgnc filler and polymerized organic matrix (ceramic optimized polymer)
  5. ADA recommends brushing teeth for 2 minutes twice a day with brushes that has soft bristles. Replace every 3-4 months, once it becomes matted or worn. Average brushing Force = 1.6+0.3N
  6. Due to loss of prism cores or interprismatic substance. Stiil exhibits honeycomb appearance becoz interperismatic substnc remains above the surface while prismatic enamel is completely dissolved
  7. Enamel demineralization at pH of 5.5 or less, dentin at pH of 6
  8. Anamnesis - history
  9. While some disorders involve only transient vomiting, such as motion sickness, others involve chronic vomiting.
  10. Blend of diurethane and other methacrylates with modified polyacrylic acid(44.6%) amorphous silica 6.7% and sodium fluoride 0.75%