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Erosion Abrasion Attrition and Abfrcation1

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Erosion, Abrasion, Attrition and Abfraction; we wonder why our teeth are sensitive! Sonia Jones RDH CFET South West Post Graduate Dental Deanery DCP Advisor Devon/Cornwall [email protected] www.bristol.ac.uk/dentalpg

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

Tooth Tissue Loss - Erosion, Abrasion, Attrition and Abfraction; we wonder why our teeth are sensitive!Sonia Jones RDH CFETSouth West Post Graduate Dental Deanery DCP Advisor Devon/Cornwall

[email protected]/dentalpg Aims and ObjectivesAim: to ensure delegates understand how tooth tissue loss can be detrimental to dentine hypersensitivity

Objectives:By the end of the session you should be able to:Distinguish between erosion, abrasion, attrition and abfraction Determine the causative factors of tooth tissue lossDescribe how to prevent further tooth tissue lossDiscuss sensitivity theories and explain the way they workList topical medicaments available to relieve sensitivityTooth tissue lossTooth surface loss can arise as the result of:ErosionAbrasion Attrition AbfractionErosion




Tooth tissue lossPatients often seek treatment for painFunction can be alteredCompromised aestheticsAll ages

Tooth tissue lossThe 4 types of tooth tissue loss all have their own characteristic appearanceHowever, the wear of a persons teeth is usually from a mixture of all 4, with one type of TTL predominating.Sometimes difficulty in determining the dominant aetiologyThe thickness of the pellicle and the pressure of the tongue contribute to the extent of the condition Tooth Tissue LossRelatively slow progression

Study modelsIndicesPhotographsCan all be helpful

Restorative treatmentDifficult to controlVery different to dental caries in appearance and causation

Erosion Described as early as 1892 among Sicilian lemon pickers

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

Non carious pathological loss of tooth tissuePlaque not involved in the process

Clinical PresentationOccurs most frequently on the palatal and labial surfaces of the incisor teethThe effected surfaces appear smooth and highly polished with a scooped out depressionThe lesion primarily occurs in the enamelIn more severe cases the dentine becomes exposedAs enamel loss progresses sensitivity to thermal changes are noticedMore persistent pain occurs in severe cases



Causes of erosionExtrinsic factorsIntrinsic factorsIdiopathic factorsExtrinsic causes of erosionHabitual consumption of highly acidic, low pH carbonated drinks, sports drinks or concentrated fruit juicesAlco pops, fruit flavoured alcoholic beverages and strong cidersCausing a wide shallow lesion effecting the labial and palatal surfaces of the upper teeth

Extrinsic causes of erosion Swishing or holding drinks in the mouthModern packaging has also been blamed, tetra pack, plastic bottles and cans directional flow onto teethCan extend from the labial and palatal lesions of the upper teeth to all surfaces of all teeth

Chemicl pH

Acids involvedThe principal ingredient linked with erosion is citric acid, found in most fruit juices and soft drinksOther fruit acids have an effectThe erosive effect is due to its low chemical pHAlso by chelation, the acids demineralise the enamel by binding to the calcium and removing it from the enamelCola type drinks may also contain phosphoric acidsWhile the pH of a drink is an indicator of its erosive potential, a measure called total titratable acidity is a better guide of how a liquid can dissolve a mineral

Total Titratable Acidity

Titratable acidityHow long it takes for the saliva to compensateHow much saliva (flow)Buffering capabilities of the salivaCitric acid the biggest culprit

Thickness of the pellicle can protect to a degreeHigher temperatures increase titratable acidityExtrinsic causes of erosionHabitual sucking of citrus fruitsThe lesion may occur in either the upper or lower anterior teethDepending on the way the fruit is eaten(Remember fruit eaten as a whole unit does not generally cause a problem)

Acidic foodsPickles, sauces, vinegars, yoghurts, roasted vegetablesExtrinsic causes of erosionIndustrial atmospheric pollutionChemical workers, battery manufacturers, crystal glass workersLess common now due to stricter working conditions and regulations (H&S at work act 1978)Acidic fumes effect the labial surfaces of the upper and lower anterior teethWhen talking or the mouth is at rest

Extrinsic causes of erosionChlorine, from gas chlorinated swimming poolsProfessional swimmersIf the chemicals are not properly regulatedLess common now due to regulationsIntrinsic causes of erosionFrom within the bodyUsually hydrochloric acid from the stomach (pH 2)Reflux RegurgitationVomitingRumination

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

Reflux, Regurgitation and Vomiting of gastric contentsAnorexiaBulimiaHiatus HerniaPregnancy/HormonesMotion sicknessObesityEating too muchDrinking too muchAlcoholism



Saturday Night?

Habitual regurgitation of gastric contentsHeavily acidic diet increases gastric erosionThe palatal surfaces of the upper anteriors and premolars are erodedProduces wide shallow lesionsEnamel may be completely lostTackle the problem with care!Patient might not admit to unattractive aspect of psychological illnessIdiopathic causes of erosionUnknown causePatient will not admit to or be aware of intrinsic or extrinsic causesVigorous tooth brushing can contribute to an over polished appearance - shinyAbrasion Definition: The abnormal wearing away of tooth tissue by a mechanical processThe location and pattern of abrasion is directly dependent upon its courseIt usually occurs on the exposed root surfaces when gingival recession has exposed the cementumIt may be seen on the incisal or inteproximal surfaces of the teethCauses of AbrasionIncorrect or destructive use of a toothbrushUse of an abrasive detrifice

The enamel and dentine is worn away to produce a V shaped notch at the neck of the toothAreas most affected are the labial and buccal surfaces of the canines and premolarsPowerful back hand, RHS of right handed personLHS of Left handed person

Para functions, habits, occupations Mainly affects the incisal edges of the anterior teeth

Clinical appearance of AbrasionWorn, shiny often yellow/brown areas at the cervical marginWorn notches on the incisal surfaces of the anterior teethAbrasion


Causes of AbrasionSeamstresses pins, Carpenters nails, Hairdressers hairgripsPipe smokers, nail biters, causing notching

AttritionDefinition: The physiological wearing away of the tooth surface as a result of tooth to tooth contact as in masticationOcclusal and incisal surfaces of the teeth most commonly affectedMay also affect the proximal surfaces of the teeth due to slight movement of the teeth in their sockets during masticationAge related processVaries from person to personAttrition Causes: BruxismAbrasive (gritty) dietConstant chewing tobacco/ betel nutMarked malalignment or malocclusionLoss of posterior teethOccupational, dust/grit mixed with saliva

Clinical appearance of AttritionPolished facets on enamel surfacesCupping dentine is exposedOccasional full loss of enamel, dentine is exposed and stains heavily Attrition

AttritionRanges from part of the enamel being worn away in the early stages to the full thickness of the enamel wearing away in advanced attritionThe dentine may be exposed and stainedIn extreme cases the teeth may be worn down to the gingivae


Attrition Process of attrition is slowSecondary dentine is laid down to protect the pulp chamber and the pulp chamber narrowsPain is rarely associated with attritionMen usually show a greater degree of attrition than womenSevere attrition is seldom seen in deciduous teeth, (not retained for long) However if a child suffers from dentinogenesis imperfecta (an hereditary disorder of the dentine) pronounced attrition may result from masticationAbfractionDefinition: The pathological loss of enamel and dentine due to occlusal stressesRecently interest has grown in the development of cervical abrasive lesionsThe term abfraction has been used to describe these cervical lesions

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

Causes of AbfractionOcclusal forces which cause the tooth to flex, cause small enamel flecks to break off, inducing the abrasive lesionsUsually wedge shaped lesions with sharp angles found at the cervical marginsHowever can be found on the occlusal surfaces, presenting as circular areasThese lesions can occur with occlusion alone or as with most TTL cases which are multi factorial, can be associated with toothbrush abrasionThese lesions are often diagnosed as toothbrush abrasion, but they differ as their angles are sharperAbfractionCommon in patients with poor tooth alignmentCan be associated with: Anterior open biteOcclusal restorations that change the cuspal movementsAbnormal tongue movement

Treatment of Tooth Tissue Loss Relieve sensitivity and pain fluoride, desensitising agents/toothpastesIdentify aetiological factors modify diet/habits, eliminate acidic foods/drinks, stop habitual practices, gentle tooth brushing techniquesProtect the remaining tooth tissue reconstruct the effected teeth, restorations, inlays/onlays, crowns, check occlusionBite raising devices/splintsReferral to TTL ExpertPrevention of further episodes

Treatment PlanTake a detailed history from the patientExaminationRadiographsVitality testingPatients wishes/needsStudy modelsPhotographs Indices

Indices BEWEBasic Erosive Wear Examination

0 No Erosive Wear1 Initial loss of Surface texture2 Distinct defect, hard tissue 50% of the surface area* (2,3) dentine involvedTooth wear index according to Smith and KnightScore Surface Criteria

0 B/L/O/I No loss of enamel surface characteristicsC No loss of contour1 B/L/O/I Loss of enamel surface characteristicsC Minimal loss of contour2 B/L/O Loss of enamel exposing dentine for less than one-third of the surface I Loss of enamel just exposing dentineC Defect less than 1mm deep3 B/L/O Loss of enamel exposing dentine for more than one-third of the surface I Loss of enamel and substantial loss of dentineC Defect less than 1-2mm deep4 B/L/O Complete loss of enamel, or pulp exposure, or exposure of secondary dentine I Pulp exposure or exposure of secondary dentineC Defect more than 2mm deep, or pulp exposure, or exposure of secondary dentine

Sensitivity Dentine Hypersensitivity Dentine is the highly sensitive part of the toothPatients suffering from dentine hypersensitivity often think that they have developed a cavity or lost a fillingOn examination there is often no obvious reason for their pain, gingival recession is sometimes evidentThe amount of recession does not seem to correlate with the amount of pain they are experiencing c/o short sharp episodes of pain caused by temperature, touch by metal, sweet foods/drinksPatients can be very distressed by the pain of dentine hypersensitivity and often avoid the causative stimuli as much as possibleSensitivity Women more pre disposed than menAge 20-40Ranges from 15-70DentineMade up of dentinal tubulesLooks like honeycomb under the microscopeSimilar in composition to boneCan remodel itself and lay down reparative and secondary dentineWhen exposed to the oral environment can be sensitive

DentineLarger tubules = more painMore open tubules = more sesitivityDentinal tubules

Dentine Hypersensitivity Theories3 theories as to how we feel the pain of dentine hypersensitivity

Dentine Innervation TheoryOdontoblast receptor theoryHydrodynamic theoryDentine Innervation TheoryNerve fibres from the Nerve Plexus of Raschkow (next to the dentine /pulp boundary, along side the Odontoblast activity) penetrate the dentinal tubules and cause impulsesNot the most likely theory: whilst the nerve fibres do penetrate the tubules, there are not enough of them and they do not penetrate deeply enough into the tubules to pass on impulses

Odontoblast Receptor TheoryProposes that Odontoblasts receive and pass on impulses and that when they are touched cause the sensation of painNot the most likely theory: as there are no synapses between the Odontoblasts and the Nerve Plexus of Raschkow(Synapses junctions between neurones where chemicals transmit the impulse) Hydrodynamic TheoryMost likely theory: Answers more questionsLymph like fluid inside the dentinal tubules is stimulated by temperature, touch and sweet sensations, causing it to flow backwards and forwards within the tubules, this gives the sensation of painHot/cold causes expansion/contraction causing the fluid to flowSalt/sweet causes osmotic pressure, flows towards the concentrateTactile/Electrical (Touch) ?! contraction of the fluid?

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

Dentine Hypersensitivity TreatmentsMost commonly treated by:Mechanical BarriersStimulation of Peritubular or Reactive DentineIncreasing potassium concentrations

Mechanical BarriersApplied over the open ends of the Dentine TubulesRestorations Glass ionomers, Composites, Inlays/Onlays, Dentine bonding agents that form a chemical bond with the dentine locking into the tubules, Resins/AdhesivesTubule occluding toothpastes need to be replaced dailyStimulation of Peritubular or Reactive DentineThe dentine lays down a protective layerHigh concentration fluoride Duraphat Varnish, Gel Kam (Fluorigard gel)Siloxane Esters Tresiolan, Sensitrol etcBoth will wear off so need to be reappliedFluoride Fluoride irritates the dentineIt irritates the dentine sufficiently for it to lay down a secondary layer and therefore protect the tooth from further stimuliIt does this by occluding the tubulesMouthwashes daily 0.05% and weekly 0.2% solutionsHigh fluoride toothpastes - Duraphat 2800, 5000Varnishes Duraphat 2.26% 22,000ppmGels 0.4% stannous fluorideIncrease Potassium ConcentrationsNerve DepolarisingPotassium chloride, Potassium Nitrate, Potassium Citrate found in desensitising toothpastes increase the potassium concentrations around the nerve plexusThis prevents action potentials being transmitted (nerve impulses)By keeping the sodium outside the cell wall

Nerve ImpulsesSodium is attracted to PotassiumBy increasing the Potassium levels outside the nerve cell walls, the Sodium stays outside and doesnt diffuse inThis stops the nerve impulse Depolarisation Action Potentials Nerve Impulses

Sodium Potassium Exchange

Toothpaste ClaimsNerve Depolarising ToothpastesTubule Occluding Toothpastes

Each manufacturer claims that their toothpaste has the best technology

Do they work?

SensodyneTraditionally Nerve depolarising toothpastesActive ingredients :- Potassium Nitrate + Sodium Fluoride- Potassium Chloride + Sodium fluoridePotassium keeps the sodium outside the cell wallBy adding the fluoride to the newer types of Sensodyne you get the tubule occlusion phenomenon caused by dentine irritation and laying down of a secondary layer

Sensodyne PronamelClaims to reharden softened enamel - be low in abrasives to prevent further tooth tissue loss Active ingredient Potassium Nitrate + Sodium Fluoride?Sensodyne new Occluding toothpasteSensodyne Rapid ReliefActive Ingredient Strontium Acetate + Sodium Mono-fluorophosphatePublished studies support the mode of action and tubular occlusion occurs

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

Colgate Sensitive Pro Relief

Pro Argin TechnologyActive Ingredients: Arginine, Calcium Carbonate, Hydroxyapatite, Sodium Mono-fluorophosphateThe Arginine complex binds to the tooth surface, it is positively charged this is attracted to the negatively charged dentineIt encourages a calcium rich mineral layer into the open (exposed) dentine tubulesThis acts as an effective plug (tubular occlude)Resistant to acid attacksNeeds to be reapplied twice dailyOther BrandsEnamel Care toothpaste - Amorphous Calcium Phosphate ACP (soluble salts of Calcium and Phosphate): highly soluble and there is limited data in the treatment of Dentine HypersensitivityRecaldent (Toothmoose) CCP-ACP Casein Phosphates, derived from milk proteins mixed with the calcium and phosphate salts: no apparent published clinical data on its effects of reducing Dentine HypersensitivityBlanx, Biorepair- Hydroxyapatite + Sodium Mono-fluorophosphate: tubular occlusion but limited published dataMonitoring Treatment of active tooth tissue lossFluoride toothpastes/ mouthwashes/gelsDe sensitising toothpastesStudy modelsPhotographs IndicesIdentify causative factors

PreventionLimit acidic food and drink to meal timesEliminate from dietCut down on carbonated beveragesEat citrus fruits whole not sucked in 1/4s Do not hold/swish drinksUse a strawRefer to specialistRefer to councillor for eating disorders/alcohol addictionRefer to GP gastric problemsMilk or cheese after meals to neutralise acidsAvoid toothbrushing after an acid attackAims and ObjectivesAim: to ensure delegates understand how tooth tissue loss can be detrimental to dentine hypersensitivity

Objectives:By the end of the session you should be able to:Distinguish between erosion, abrasion, attrition and abfraction Determine the causative factors of tooth tissue lossDescribe how to prevent further tooth tissue lossDiscuss sensitivity theories and explain the way they workList topical medicaments available to relieve sensitivityThank you