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PRO S T H .0 DON TIC S The Etiology and Pathogenesis of Tooth Wear H istorically, the most common reason for tooth loss and dental hard tissue loss has been dental caries. Since the intro- duction of fluoride, the prevalence, incidence and severity of caries has declined and the dental life expectancy has increased. One of the most common problems associ- ated with this prolonged dental life expectancy is tooth wear. Tooth wear is an irreversible, non carious, destructive process, which results in a functional loss of dental hard tissue. It can manifest as abrasion, attrition, abfraction and erosion. l This article will describe the etiol- ogy of pathogenesis of tooth wear. ETIOLOGY Tooth wear can manifest as abra- sion, attrition, abfraction and ero- sion. The distinct definitions of the patterns of dental wear tend to reinforce the traditional view that these processes occur indepen- dently. However, a combination of etiologies probably reflects the true clinical situation. 2 Identification of the etiology of tooth wear is essen- tial for its successful management. PART 1 by Effrat Habsha, DDS ABRASION The term abrasion is derived from the Latin verb abradere (to scrape ofD. I It describes the pathological wearing away of dental hard tissue through abnormal mechanical processes involving foreign objects or substances repeatedly intro- duced in the mouth. Abrasion pat- terns can be diffuse or localized, depending on the etiology. Exten- sive oral hygiene has been incrimi- nated as a main etiologic factor in dental abrasion. Both patient and material factors influence the prevalence of abrasion. Patient fac- tors include brushing technique, frequency of brushing, time and force applied while brushing. Material factors refer to type of material , stiffness of toothbrush bristles, abrasiveness, pH and FIGURE 1 Dental abrasion due to horizontal brushing technique ORAL HEALTH· OCTOBER 1999 Ell
Transcript

PRO S T H 0 DON TIC S

The Etiology and Pathogenesis

of Tooth Wear

H istorically the most common reason for tooth loss and dental hard tissue loss has

been dental caries Since the introshyduction of fluoride the prevalence incidence and severity of caries has declined and the dental life expectancy has increased One of the most common problems associshyated with this prolonged dental life expectancy is tooth wear Tooth wear is an irreversible non carious destructive process which results in a functional loss of dental hard tissue It can manifest as abrasion attrition abfraction and erosion l

This article will describe the etiolshyogy of pathogenesis of tooth wear

ETIOLOGY Tooth wear can manifest as abrashysion attrition abfraction and eroshysion The distinct definitions of the patterns of dental wear tend to reinforce the traditional view that these processes occur indepenshydently However a combination of etiologies probably reflects the true clinical situation2 Identification of the etiology of tooth wear is essenshytial for its successful management

PART 1

by Effrat Habsha DDS

ABRASION The term abrasion is derived from the Latin verb abradere (to scrape ofD I It describes the pathological wearing away of dental hard tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introshyduced in the mouth Abrasion patshyterns can be diffuse or localized depending on the etiology Extenshy

sive oral hygiene has been incrimishynated as a main etiologic factor in dental abrasion Both patient and material factors influence the prevalence of abrasion Patient facshytors include brushing technique frequency of brushing time and force applied while brushing Material factors refer to type of material stiffness of toothbrush bristles abrasiveness pH and

FIGURE 1 Dental abrasion due to horizontal brushing technique

ORAL HEALTHmiddot OCTOBER 1999 Ell

amount of dentifrice used 3 The most commonly cited effect of abrashysion is the V-shaped defect which usually is ascribed to the use of an intensive horizontal brushing techshynique (Figure 1) Cervical areas are susceptible to toothbrush abrashysion particularly cuspids and first premolars where thin buccal plates gingival recession and exposed root surfaces predispose cervical notching Habits involving other intraoral objects (eg pipe smoking toothpick use threadbitshying) can cause defects on the incisal and occlusal surfaces 4

Dietary abrasion is not very promishynent in modern days as the typical western diet tends to be very soft as opposed to primitive mans diet which was more abrasive and thus contributed greatly to tooth wear

ABFRACllON The term abfraction derived from the Latin verb frangere (to break) describes a wedge shaped defect at the cementoenamel junction of a tooth 5 These lesions are someshytimes located subgingivally beyond the influence of toothshybrush abrasion and are hypotheshysized to be the result of eccentrishycally applied occlusal forces leading to tooth flexure rather than to be the result of abrasion alone According to the tooth flexshyure theory masticatory or parashyfunctional forces in areas of hyper or malocclusion expose one or sevshyeral teeth to strong tensile comshypressive or shearing stress These forces are focused at the CEJ where they provoke microfracshytures in enamel and dentine The microfractures are thought to slowly propagate perpendicular to the long axis of the stressed teeth until enamel and dentine break away resulting in wedge shaped defects with sharp rims The scishyentific basis of the tooth flexure theory has not yet sufficiently been explored and it is often diffishycult to differentiate between abrashysion and abfraction lesions l

AlTRmON Attrition is the term used to describe the physiological wearing

II ORAL HEALTHmiddot OCTOBER 1999

PRO ST HODONTI CS

The term abfraction derived

from the Latin verb frangere

(to break) describes a wedge

shaped defect at the cementoshy

enamel junction of a tooth

away of dental hard tissue as a tooth grinding such as with parashyresult of tooth to tooth contact with function mastication swallowing no foreign substance intervening It and speech A typical presentation is derived from the Latin verb of attrition is the presence of extenshyatterere which is defined as the sively demarcated facets which usushyaction of rubbing against someshy ally match the opposing arch facets thing 1 Such contact occurs with in excursive contact positions (Fig-

Table 1 Sources of extrinsic acids

Environmental Diet Medicaments

atmospheric sulfuric acids citrus fruit juices vitamin C

HCL In gas-chlorinated swimming pools

acidic carbonated beverages

aspirin

acidic uncarbonated beverages

acidic oral hygiene products

wines acidic saliva substitutes

citrus fruits

RGURE 2 Attrition due to parafunction Note matching wear facets

PROSTHODONT I CS

FIGURE 3 Sixty year-old male with advanced tooth wear A deep vertical overbite

FIGURE 3 B wear at palatal of maxillary anteriors

FIGURE 3 C wear of mandibular incisors

ure 2) Attrition occurs almost entirely on occlusal and incisal surshyfaces although it may also affect the buccal and palatal surfaces of the maxillary and mandibular anteshyrior teeth in deep vertical overlap relationships6 (Figures 3A B C)

EROSION The term erosion describes the process of gradual destruction of the surface of something usually by electrolytic or chemical processes It is derived from the Latin verb eroder (to corrode)1 Dental erosion is the result of a pathologic chronic painless loss of dental hard tissue chemically etched away from the tooth surface by acid andor chelashytion without bacterial involvement7

The acids responsible for erosion are not products of the intraoral flora they stem from extrinsic or intrinsic sources

Extrinsic sources of acid Extrinsic acids may stem from environmental sources diet and medication (Table 1)8 Dental eroshysion has been reported in battery factory workers exposed to atmosshypheric sulfuric acids 9 There have also been reports of competitive swimmers suffering dental erosion from swimming in gas-chlorinated pools Large swimming pools genshyerally use gas chlorination which results in the formation of hydrochloric acid that requires neutralization and buffering to maintain the recommended pH range of 72-80 Therefore inadeshyquate monitoring of pool pH has been associated with dental eroshysion lO Though extrinsic environshymental sources of acids exist improved industrial safety regulashytions have gradually diminished the extent of environmental dental health hazardss

The role of diet in the etiology of erosion has received the most attention II Certain products espeshycially citrus fruits exhibit a low pH and when consumed freshyquently and excessively may lead to dental erosion It appears that dietary substances with a pH above 45 have a low potential to

ORAL HEALTHmiddot OCTOBER 1999 iii

cause dental erosion However foods and beverages containing acids with calcium chelating propshyerties such as citrate may cause tooth damage at higher pH levels Several reports have associated medicaments and oral health prodshyucts (rinses) with erosionl2131415 Many such products exhibit a low pH and may be erosive when used frequently In most cases the risk associated with a product could be reduced by either product modifishycation (such as encapsulation of acidic medicaments) or altering consumption habits Special attenshytion should be given to saliva subshystitutes aimed at patients with reduced salivary secretion or xerostomia These substitutes often have a low pH and may be detrimental to patients whose lack of saliva leads to prolonged clearshyance times Factors to be considshyered with exposure to extrinsic sources of acid include the durashytion of contact with the teeth (which is influenced by swallowing habits motions of the lips and cheeks saliva) frequency of ingesshytion amount ingested buffering capacity of saliva the chemical and physical properties of enameJ8

Intrinsic sources of acid Dental erosion due to intrinsic facshytors is caused by gastric acid reaching the oral cavity and the teeth as a result of vomiting pershysistent gastroesophageal reflux regurgitation or rumination Since the clinical manifestation of denshytal erosion does not occur until gastric acid has acted on the denshytal hard tissues regularly over a period of several years dental eroshysion caused by intrinsic factors has been observed only in those conditions which are associated with chronic vomiting or persisshytent gastroesophageal reflux Examples of such conditions are listed in Tables 2 and 3

Bulimic eating disorder is the underlying cause in most cases of dental erosion due to chronic vomitshying Recent studies suggest that approximately 90 of bulimic patients are affected by dental ero-

II ORAL HEALTHmiddot OCTOBER 1999

PR O STHODO N TICS

sion16 ather possible causes of long (GaR) GaR is the movement of term regular vomiting resulting in stomach acids through the lower dental erosion are disorders of the esophageal sphincter In healthy alimentary tract metabolic and individuals small amounts of gasshyendocrine disorders or medication tric acids reflux into the esophashyside effects (Table 2) gus This physiological GaR usushy

ally occurs after eating and may be Another possible etiologic inshy associated with eructation In

trinsic factor of dental erosion is healthy people most of the refluxshypersistent gastroesophageal reflux ate is returned to the stomach by

Table 2 Potential causes of vomiting

Disorders of the alimentary tract

bull chronic gastrit is bull peptic ulcer bull intestinal obstruction

Neurologic disorders

bull migraine headaches bull benign recurrent vertigo bull diabetic or alcoholic

polyneuropathia

Metabolic or Endocrine disorders

bull uremia bull hyperparathyroidism bull diabetic ketoacidosis bull adrenal insufficiency bull hypo-hyperparathyroidism

Psychosomatic disorders

bull eating disorders (bulimia anorexia)

bull stress induced psychogenic vomiting

Tahle 3 Causes of oastroesophaaeal reflux and reaurclitationo -

Incompetence of the gastroesophageal sphincter

bull Idiopathic

bull impairment of sphincter

bull neurohumoral induced decrease of gastroesophageal sphincter pressure

bull destruction of sphincter by surgical resection

Increased intraabdominal pressure

bull obesity

bull pre9nancy

Increased Intragastric volume

bull after meals

bull pyloric spasm

bull obstruction due to peptic ulcer

bull gastric stasis syndrome

PRO ST H O DO NTICS

the peristalsis stimulated by swalshylowing 17 It is estimated that 60 of the population suffer from this phenomenon at some stage of their lives If the clearance mechanisms cannot return the refluxate to the stomach and the symptoms become chronic the condition is known as pathological GOR or GOR disease (GORD) In some patients the refluxate breaks through the lower and upper esophageal sphincter and oral regurgitation occurs Oral regurgishytation may cause severe damage to the dentition lB (Figures 4A B) Causes of gastroesophageal reflux and regurgitation are listed in Table 3 Often the erosion is most severe on palatal tooth surfaces but other surfaces may also be affected when the gastric contents are chewed or kept in the buccal sulci before reswallowing

PATHOGENESIS Since the critical pH of dental enamel is approximately 55 any solution with a lower pH value may cause erosion particularly if the attack is of long duration and repeated over time Saliva and the salivary pellicle counteract the acid attacks but if the challenge is severe a total destruction of the tooth tissue follows Erosive

FlGURE4 Forty six-year-old male with Gastroesophageal reflux AampB Dental erosion of maxil- lesions are seen as characteristic lary and mandibular anteriors demineralization patterns within

the enamel In dentine the first area to be affected is the peritubushylar dentine With progressing lesions the dentinal tubules become enlarged but disruption is also seen in the intertubular areas If the erosion process is rapid increased sensitivity of the teeth is the presenting symptom However in cases with slower proshygression the patient may remain asymptomatic even though the whole dentition may become severely damaged 19

CONCLUSION The interrelationship of the four modes of tooth wear and individshyual susceptibility influence the degree of tooth wear Recognition of the multifactorial nature of tooth wear is the first step in man-

ORAL HEALTHmiddot OCTOBER 1999 Ell

FlGURE 4 C Occlusal view of palatal erosion

nisIe A AIN F AT net TM AINE 4

Pr ure Vlu m T lOose lion

5-3 oral sur 1D-S4

Astracainee

ot1icoine hydnxNoride and epineplri Injedion THERAPEUTIC CLASSIACATION Local AnesIheIic lor Dental Use INDICATIONS AND CUNICAl USE ASTRACAINE (articaire hyliochloridll) isrolCalOOlaitolJDlnnslhesiamneMltlltXiltMleS1hesiainclirOCaldentistry CONlRAJNDlCATlONS Ar1icaile hjdrochloride iscooainOlcaJOO in patieols with aknowl hypersens~ivi1y 10 local areslheics 01100 amide type AI wiIh all vasocoostricIoo epir~lIire is rortraildicaIed in hypertensionlhyroloxicosis orseoereheartdiseaseprtirularlywhentKhjca((flaispresert LocalaneslhElics should noI be used in seoereshltXiltorheart block TheyshouldaJsonoibeused vilenhere is inlmlmalion or5ellSis in Ihe region 0I1he proposed injection WARNINGS RESUSCITATIVE EQUIPMENT AND DRUGS SHOULD BE IMMEDIATElY AVAIlABLE WHEN ANY LOCAl ANESTHEnC IS USED AI wilh oIher local aneslhellcs articaire hydrochloride is capable 01 prodLCing rneIheshymoglobinemia This has been obserEd wilh epidural anesIhesia txA no when used as dilllcled in denial procedures Methemoglobinemia values 01 less lhan 20 usuaHydo noI produce any clinical S)111lIoms The usual clinical signs 01 meItEmlgIobinemia arecyanosis 0I1he nail beds m lips Allhough Ihe possibilily 01 meIhemoglobinemiaoaooing indlnalpaIiamp1s isextremelyrlre RI3l be rapidly IeIlSedbylheuseoll-2~bodyweiltlolrrShyleneblllladminisleredln1Jashywnously OYer a5-miou1e period Because ASTRACAINE cOOains avasocooshyS1ricIor nshouldbe usedwilhexlrerrecautlon in palienis reeMng drugs known 10 prtxlJce blOOd pressurealieraUons (lor ~IeMAO inhibilolSlrtyclicanUshydepressanlS phenOlhiazires) as eiIhei seYere m SUSlaired hypotension orillershyifflSioomayoaur PRECAUTIONS General Thesafelyandelectivenessol kxaliIlflSItfIicsdepend~IlWlI~W18d~~~ andrtldinessloremerlJnies THE LOWESTOOSETHATRESUlTS IN EffiCTIVE Igtl-lSTHESIASHOULDBE USEDTOAVOIDHIGHPlASMALEVElSAAIlSElllOUS UNOESIRABLEAOVERSEEFFECTS INJECTIONSSHOULOBEMAOESlOWlY WITH FREQUENT ASPlRAnONSBEFOREANDOURINGTHEINJECTION nblOOd isaspiraledlhereedleshouldbe relocated TolerancevarieswilhlhesIaIUs 0I1he palient Oebililaledorelderly paUenlS acutely ill palienIs mchildren should be giwn redltud doses COfTIrerISUrale with lheir age and physical slalus Use In Pregnancy Sale use 01 articaine hylioch Ioride in preo-ool warren has nol been eslablished hOwever animal sludies have nol demonstraled leralogenic or embryoloxic eHecis Nursing Mothers Articaine hydrocllioride is rapidly fTEtIboIi2ed and eliminaledand is 1hereI0re unlilltlllylo be lransferredlo the rOOhers mil Patientswlth Spectal Dlseasesand Coodlllons ASTRACAINECOOIains avasocoostricIa and should Iherefore be used wiIh caution in Ihe presence 01 diseasesvilichmayaltMlSeyalfecllhepatienmiddotscardiovascularsytem Thedrug shoold be usedwih caJioo in persoos wiIh known drug sensRi~1ies ASTRACAINE corDnssOOlITlrnlal)isumle Sullalesmaycausealiefyicreactionsinsusceplib~ ~ The prevalence 01 sulfilesenslUvily in Ihe ~ populatioo is unknown m Plotmiy kPw1xlt i is seen morefreQuenly in~tswith broochial asthma Reations 131 ircl~~adic S)111lIorns and lile-threatening or less ~ ashmalic episodes Many drugs used during he conducl of anesthesia are consideIed poIeniiai triggering agents lor lamilial malljlnanl hyperlhenm~ II has 00en shown IhaltOO use 01 amide local anestheics in malignant h)perthenmia patients is safe HC7gtWWlhere is no guaooIee Ihat reural blocllade will prewol Ihe ~opmenl 01 malignant hyperthemlia during surgery HIs also diffKu1t 10 (Jf(fictlhereedlorSllfllen6llagereralltreilhesia ThereIoreaslandardtxttocol lor Ihe managemenl 01 malignant hyperthermia should be available Drug Interadlons Serious cardiac anl1~mias may oourn preparalionscootaining avasocoostridor are errj)loyed in palients duringorlollawing tOOadministralioo 01 chlaoform halothane Cldoproprnlrichloro-ehytere orother reialedageots Caution should be exercised when administering articaine hydrochloride cooshycanilalliy W11h oIher medicalions vilich are poIenliai prodocers 01 rmhemoghr bin (eg sulphooamkles) ADVERSE REACTIONS ReaciionstoASTRACAINE (articaine hyliochloride) are characteristic 0I11lose associated wilh ami~ local anesIheIics Adwrse reaclons may result Irom hi9l plasma lewis dill 10 excessiw dcsage rapid absorpIion a inaltMrten1 inlr3vascular injectioo or rriJy result from ah)persenslUviIy idiosyrcasy or diminished lolerance oolhepart 01 loopatienL SIdl reaclions are systemic in natureandifllOlwlhecerr31 nervous systemanVorlhecardiOVolSClJlarsystem Cenlnl NervousSystem CNS rmnishylestaionsareeamyandlor~mmaybecllRttJizedby~ dizziess blimdvisionandlrermrs loIIuoedbydrlrltlsinessCOfMJlsions uncooshysciousnessand possibly respiratory arrest The excilalory reaclions may be wry briel or may not oaur at all invilich case1he first rmnifeslallons oItoxicily may be~rrsgingnollUJldousressilllrespirmy_ CanfiovasaJIar System CanflOvaSCUlar reaclions are depresm and may be characterized by ~ion myocardial depressjooixattaroJaand possibly cardiac arrest Allergic Aliefyic reaclonsarechiYacllri2ad byataneous lesions urticara edenIa oranaphylactoid reaclionsThedeteclion 01 sensitivilyby sIltin tesling isoldoubtful value Sweiling m pelSistenl paresthesia 01100 lips and oral lissues haw been reported after blocking he interior alveolar rerve fOIl SYMPTOMS AND TREATMENT OF OVERDOSAGE PlEASE REFEII TO THE PRODUCT MONshyGRAPH DOSAGE AND ADMINISTlIA110N AI with all local aneslhetics Ihe dcsage varies and 00perds LlOOIhe area to beareslhei2ed1he vascularily 0I1he IissuesIhe nurrbel 01 nexonaI segments 10 be blocllted indiviWaitoleranceand lhe~dnstEsia TheIaestdosagereededIOpureellectiwnslhes~

Adults lis dosageshouldnolexceed7 1111 in adulls and in generallhe rmximllTllotat dose should nOI exceed 500 mg (125 ml or7 cartridges) Chllden Dosages in children shouldbereOOedcornshymensuralewilh IheirageandlWlghL Experience in childrenyomgerlhan 4year 01 ~ has noI been doaJmenied The dosage shoold no exceed S~ body weight in Children betwee1IOO ages 014 and 12 Stability and Storage RecommendaUons Store aI coriroIled room IemperabJre (15-3OC) Protecl trom li~ Do nol use tl soIWon is jjrlltish or darIlter lhall slighUy yellow or ~ ~ cootalnsaprecipitale ASlRACAINEsolulionsarewilhoulpreseMiwandareior sing~ useooly OilcltyendtruSedportioo AVAIlABlUTY OF DOSAGE FORMS ASTRACAINE 4 FORTE (artcaine hydrochloride 40 mwmL and epinephrine inj8ion 1100XXJ) and ASTRACAINE4 (articaire hjdrochloride 40 ~ and epineltlrire injeclion l200XXJ)areavailable in denial cartridges 0I18ni in boxes 0150 Prodld Mooograph avallab~ upon request

ASTRA

ORAL HEALTHmiddot OCTOBER 1999

PROSTHODONTICS

agement as failure to appreciate this may lead to inappropriate management and ultimate failure of restorative therapy The second part of this publication will disshycuss the management of tooth wear Treatment planning strateshygies as well as case presentations will be presented W

Dr Effrat Habsha DDS completed her DDS and Prosthodontic training at the Univershysity of Toronto_ She is currently researching the effects of smoking on osseointegration She is staffprosthodonshytist at Mount Sinai Hospital an Associshyate in Dentistry University of Toronto Her practice is limited to prosthodontics and implant dentistry in Toronto

Oral Health welcomes this original article

Part II will appear in our November 1999 issue of Oral Health

REFERENCES 1 Imfeld T Dental erosion Definnion classification and

links Eur J Oral Sci 104151-155 1996 2 Smtth BGN and Knight JK M index for measuring

the wear of teeth Sr Dent J 156435-436 1984 3 Dahl BJ Carlsson GE and Ekfeldt A Occlusal

wear of teeth and restorative materials Acta Odonto Scand 51 299-311 1993

4 Johansson A and Ridwaan O Identification and Man-

Watch for these articles coming soon in the November issue of Oral Health

bull Prosthodontics bull Continuing Education

agernentoftoothwearlntJ Prosth 7506-515 1994 5 Grippo JO Abfractions A new classification of hard

tissue lesions of teeth J Esthet Dent 314-19 1991 6 Smith BG Some facets of tooth wear Ann R Aust

Coli Dent Surg 11 37-51 1991 7 Zipkin I McClure FJ Salivary citrate and dental eroshy

sion J Dent Res 28613-626 1949 8 Zero DT Etiology dental erosion-extrinsic factors

EurJOraISci104162-1771996 9 Petersen P E and Gormsen C Oral conditions

among German battery factory workers Community Dent Oral Epldemiol 19-104-106 1991

10 Centerwall BS Armstrong Cw Funkhouser GS Etzay RP Erosion of dental enamel among competishytive swimmers al a gas-chlorinated swimming pool Am J Epidemiol 123641-647 1986

11 Ecctes JD Jenkins wG Dental erosion and diet J Dent 2153-159 1974

12 James PMC Parlitt GJ Local effects of certain medicaments on the teeth Br Med J 2 1252-1253 1953

13 Smtth BGN Tooth wear aetiology and diagnosis Dent Update 16204-2121989

14 Giunta JL Dental erosion resulting from chewable vitshyamin Ctablets JAm Dent Assoc 107253-256 1983

15 Bhatti SA Walsh IF Douglas WL Ethanol and pH levels of proprietary mouthrinses Comm Dent Health 1171-741994

16 Schewel P Etiology of dental erosion-intrinsic facshytors EurJ Oral Sci 104178-1901996

17 Dodds WJ The pathogeneSis of gastroesophageal reflux disease AJR 151 49-56 1988

18 Bartlett Dand Smtth B Clinical investigations of gasshytro-oesophageal reflux Part 1 Dental update 205shy208 1996

19 Meurman JH ten Cate JM Pathogenesis and modifying factors of dental erosion Eur J Oral Sci 104199-2061996

20 Clearfield HR Roth JLA Morexia nausea and vomiting In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198548-58

21 Friedman LS KJ of Internal Medicine 12th edition New York McGraw Hili 1991 251-256

22 Goyal RK Diseases of the esophagus In Wilson JD et aI Harrisons Principles of Internal Medicine 12th edition New York McCiraw I-Ell 19911222-1229

23 Ouyang A Cohen SHeartbum regurgitation and dysshyphagia In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198559-64

III

amount of dentifrice used 3 The most commonly cited effect of abrashysion is the V-shaped defect which usually is ascribed to the use of an intensive horizontal brushing techshynique (Figure 1) Cervical areas are susceptible to toothbrush abrashysion particularly cuspids and first premolars where thin buccal plates gingival recession and exposed root surfaces predispose cervical notching Habits involving other intraoral objects (eg pipe smoking toothpick use threadbitshying) can cause defects on the incisal and occlusal surfaces 4

Dietary abrasion is not very promishynent in modern days as the typical western diet tends to be very soft as opposed to primitive mans diet which was more abrasive and thus contributed greatly to tooth wear

ABFRACllON The term abfraction derived from the Latin verb frangere (to break) describes a wedge shaped defect at the cementoenamel junction of a tooth 5 These lesions are someshytimes located subgingivally beyond the influence of toothshybrush abrasion and are hypotheshysized to be the result of eccentrishycally applied occlusal forces leading to tooth flexure rather than to be the result of abrasion alone According to the tooth flexshyure theory masticatory or parashyfunctional forces in areas of hyper or malocclusion expose one or sevshyeral teeth to strong tensile comshypressive or shearing stress These forces are focused at the CEJ where they provoke microfracshytures in enamel and dentine The microfractures are thought to slowly propagate perpendicular to the long axis of the stressed teeth until enamel and dentine break away resulting in wedge shaped defects with sharp rims The scishyentific basis of the tooth flexure theory has not yet sufficiently been explored and it is often diffishycult to differentiate between abrashysion and abfraction lesions l

AlTRmON Attrition is the term used to describe the physiological wearing

II ORAL HEALTHmiddot OCTOBER 1999

PRO ST HODONTI CS

The term abfraction derived

from the Latin verb frangere

(to break) describes a wedge

shaped defect at the cementoshy

enamel junction of a tooth

away of dental hard tissue as a tooth grinding such as with parashyresult of tooth to tooth contact with function mastication swallowing no foreign substance intervening It and speech A typical presentation is derived from the Latin verb of attrition is the presence of extenshyatterere which is defined as the sively demarcated facets which usushyaction of rubbing against someshy ally match the opposing arch facets thing 1 Such contact occurs with in excursive contact positions (Fig-

Table 1 Sources of extrinsic acids

Environmental Diet Medicaments

atmospheric sulfuric acids citrus fruit juices vitamin C

HCL In gas-chlorinated swimming pools

acidic carbonated beverages

aspirin

acidic uncarbonated beverages

acidic oral hygiene products

wines acidic saliva substitutes

citrus fruits

RGURE 2 Attrition due to parafunction Note matching wear facets

PROSTHODONT I CS

FIGURE 3 Sixty year-old male with advanced tooth wear A deep vertical overbite

FIGURE 3 B wear at palatal of maxillary anteriors

FIGURE 3 C wear of mandibular incisors

ure 2) Attrition occurs almost entirely on occlusal and incisal surshyfaces although it may also affect the buccal and palatal surfaces of the maxillary and mandibular anteshyrior teeth in deep vertical overlap relationships6 (Figures 3A B C)

EROSION The term erosion describes the process of gradual destruction of the surface of something usually by electrolytic or chemical processes It is derived from the Latin verb eroder (to corrode)1 Dental erosion is the result of a pathologic chronic painless loss of dental hard tissue chemically etched away from the tooth surface by acid andor chelashytion without bacterial involvement7

The acids responsible for erosion are not products of the intraoral flora they stem from extrinsic or intrinsic sources

Extrinsic sources of acid Extrinsic acids may stem from environmental sources diet and medication (Table 1)8 Dental eroshysion has been reported in battery factory workers exposed to atmosshypheric sulfuric acids 9 There have also been reports of competitive swimmers suffering dental erosion from swimming in gas-chlorinated pools Large swimming pools genshyerally use gas chlorination which results in the formation of hydrochloric acid that requires neutralization and buffering to maintain the recommended pH range of 72-80 Therefore inadeshyquate monitoring of pool pH has been associated with dental eroshysion lO Though extrinsic environshymental sources of acids exist improved industrial safety regulashytions have gradually diminished the extent of environmental dental health hazardss

The role of diet in the etiology of erosion has received the most attention II Certain products espeshycially citrus fruits exhibit a low pH and when consumed freshyquently and excessively may lead to dental erosion It appears that dietary substances with a pH above 45 have a low potential to

ORAL HEALTHmiddot OCTOBER 1999 iii

cause dental erosion However foods and beverages containing acids with calcium chelating propshyerties such as citrate may cause tooth damage at higher pH levels Several reports have associated medicaments and oral health prodshyucts (rinses) with erosionl2131415 Many such products exhibit a low pH and may be erosive when used frequently In most cases the risk associated with a product could be reduced by either product modifishycation (such as encapsulation of acidic medicaments) or altering consumption habits Special attenshytion should be given to saliva subshystitutes aimed at patients with reduced salivary secretion or xerostomia These substitutes often have a low pH and may be detrimental to patients whose lack of saliva leads to prolonged clearshyance times Factors to be considshyered with exposure to extrinsic sources of acid include the durashytion of contact with the teeth (which is influenced by swallowing habits motions of the lips and cheeks saliva) frequency of ingesshytion amount ingested buffering capacity of saliva the chemical and physical properties of enameJ8

Intrinsic sources of acid Dental erosion due to intrinsic facshytors is caused by gastric acid reaching the oral cavity and the teeth as a result of vomiting pershysistent gastroesophageal reflux regurgitation or rumination Since the clinical manifestation of denshytal erosion does not occur until gastric acid has acted on the denshytal hard tissues regularly over a period of several years dental eroshysion caused by intrinsic factors has been observed only in those conditions which are associated with chronic vomiting or persisshytent gastroesophageal reflux Examples of such conditions are listed in Tables 2 and 3

Bulimic eating disorder is the underlying cause in most cases of dental erosion due to chronic vomitshying Recent studies suggest that approximately 90 of bulimic patients are affected by dental ero-

II ORAL HEALTHmiddot OCTOBER 1999

PR O STHODO N TICS

sion16 ather possible causes of long (GaR) GaR is the movement of term regular vomiting resulting in stomach acids through the lower dental erosion are disorders of the esophageal sphincter In healthy alimentary tract metabolic and individuals small amounts of gasshyendocrine disorders or medication tric acids reflux into the esophashyside effects (Table 2) gus This physiological GaR usushy

ally occurs after eating and may be Another possible etiologic inshy associated with eructation In

trinsic factor of dental erosion is healthy people most of the refluxshypersistent gastroesophageal reflux ate is returned to the stomach by

Table 2 Potential causes of vomiting

Disorders of the alimentary tract

bull chronic gastrit is bull peptic ulcer bull intestinal obstruction

Neurologic disorders

bull migraine headaches bull benign recurrent vertigo bull diabetic or alcoholic

polyneuropathia

Metabolic or Endocrine disorders

bull uremia bull hyperparathyroidism bull diabetic ketoacidosis bull adrenal insufficiency bull hypo-hyperparathyroidism

Psychosomatic disorders

bull eating disorders (bulimia anorexia)

bull stress induced psychogenic vomiting

Tahle 3 Causes of oastroesophaaeal reflux and reaurclitationo -

Incompetence of the gastroesophageal sphincter

bull Idiopathic

bull impairment of sphincter

bull neurohumoral induced decrease of gastroesophageal sphincter pressure

bull destruction of sphincter by surgical resection

Increased intraabdominal pressure

bull obesity

bull pre9nancy

Increased Intragastric volume

bull after meals

bull pyloric spasm

bull obstruction due to peptic ulcer

bull gastric stasis syndrome

PRO ST H O DO NTICS

the peristalsis stimulated by swalshylowing 17 It is estimated that 60 of the population suffer from this phenomenon at some stage of their lives If the clearance mechanisms cannot return the refluxate to the stomach and the symptoms become chronic the condition is known as pathological GOR or GOR disease (GORD) In some patients the refluxate breaks through the lower and upper esophageal sphincter and oral regurgitation occurs Oral regurgishytation may cause severe damage to the dentition lB (Figures 4A B) Causes of gastroesophageal reflux and regurgitation are listed in Table 3 Often the erosion is most severe on palatal tooth surfaces but other surfaces may also be affected when the gastric contents are chewed or kept in the buccal sulci before reswallowing

PATHOGENESIS Since the critical pH of dental enamel is approximately 55 any solution with a lower pH value may cause erosion particularly if the attack is of long duration and repeated over time Saliva and the salivary pellicle counteract the acid attacks but if the challenge is severe a total destruction of the tooth tissue follows Erosive

FlGURE4 Forty six-year-old male with Gastroesophageal reflux AampB Dental erosion of maxil- lesions are seen as characteristic lary and mandibular anteriors demineralization patterns within

the enamel In dentine the first area to be affected is the peritubushylar dentine With progressing lesions the dentinal tubules become enlarged but disruption is also seen in the intertubular areas If the erosion process is rapid increased sensitivity of the teeth is the presenting symptom However in cases with slower proshygression the patient may remain asymptomatic even though the whole dentition may become severely damaged 19

CONCLUSION The interrelationship of the four modes of tooth wear and individshyual susceptibility influence the degree of tooth wear Recognition of the multifactorial nature of tooth wear is the first step in man-

ORAL HEALTHmiddot OCTOBER 1999 Ell

FlGURE 4 C Occlusal view of palatal erosion

nisIe A AIN F AT net TM AINE 4

Pr ure Vlu m T lOose lion

5-3 oral sur 1D-S4

Astracainee

ot1icoine hydnxNoride and epineplri Injedion THERAPEUTIC CLASSIACATION Local AnesIheIic lor Dental Use INDICATIONS AND CUNICAl USE ASTRACAINE (articaire hyliochloridll) isrolCalOOlaitolJDlnnslhesiamneMltlltXiltMleS1hesiainclirOCaldentistry CONlRAJNDlCATlONS Ar1icaile hjdrochloride iscooainOlcaJOO in patieols with aknowl hypersens~ivi1y 10 local areslheics 01100 amide type AI wiIh all vasocoostricIoo epir~lIire is rortraildicaIed in hypertensionlhyroloxicosis orseoereheartdiseaseprtirularlywhentKhjca((flaispresert LocalaneslhElics should noI be used in seoereshltXiltorheart block TheyshouldaJsonoibeused vilenhere is inlmlmalion or5ellSis in Ihe region 0I1he proposed injection WARNINGS RESUSCITATIVE EQUIPMENT AND DRUGS SHOULD BE IMMEDIATElY AVAIlABLE WHEN ANY LOCAl ANESTHEnC IS USED AI wilh oIher local aneslhellcs articaire hydrochloride is capable 01 prodLCing rneIheshymoglobinemia This has been obserEd wilh epidural anesIhesia txA no when used as dilllcled in denial procedures Methemoglobinemia values 01 less lhan 20 usuaHydo noI produce any clinical S)111lIoms The usual clinical signs 01 meItEmlgIobinemia arecyanosis 0I1he nail beds m lips Allhough Ihe possibilily 01 meIhemoglobinemiaoaooing indlnalpaIiamp1s isextremelyrlre RI3l be rapidly IeIlSedbylheuseoll-2~bodyweiltlolrrShyleneblllladminisleredln1Jashywnously OYer a5-miou1e period Because ASTRACAINE cOOains avasocooshyS1ricIor nshouldbe usedwilhexlrerrecautlon in palienis reeMng drugs known 10 prtxlJce blOOd pressurealieraUons (lor ~IeMAO inhibilolSlrtyclicanUshydepressanlS phenOlhiazires) as eiIhei seYere m SUSlaired hypotension orillershyifflSioomayoaur PRECAUTIONS General Thesafelyandelectivenessol kxaliIlflSItfIicsdepend~IlWlI~W18d~~~ andrtldinessloremerlJnies THE LOWESTOOSETHATRESUlTS IN EffiCTIVE Igtl-lSTHESIASHOULDBE USEDTOAVOIDHIGHPlASMALEVElSAAIlSElllOUS UNOESIRABLEAOVERSEEFFECTS INJECTIONSSHOULOBEMAOESlOWlY WITH FREQUENT ASPlRAnONSBEFOREANDOURINGTHEINJECTION nblOOd isaspiraledlhereedleshouldbe relocated TolerancevarieswilhlhesIaIUs 0I1he palient Oebililaledorelderly paUenlS acutely ill palienIs mchildren should be giwn redltud doses COfTIrerISUrale with lheir age and physical slalus Use In Pregnancy Sale use 01 articaine hylioch Ioride in preo-ool warren has nol been eslablished hOwever animal sludies have nol demonstraled leralogenic or embryoloxic eHecis Nursing Mothers Articaine hydrocllioride is rapidly fTEtIboIi2ed and eliminaledand is 1hereI0re unlilltlllylo be lransferredlo the rOOhers mil Patientswlth Spectal Dlseasesand Coodlllons ASTRACAINECOOIains avasocoostricIa and should Iherefore be used wiIh caution in Ihe presence 01 diseasesvilichmayaltMlSeyalfecllhepatienmiddotscardiovascularsytem Thedrug shoold be usedwih caJioo in persoos wiIh known drug sensRi~1ies ASTRACAINE corDnssOOlITlrnlal)isumle Sullalesmaycausealiefyicreactionsinsusceplib~ ~ The prevalence 01 sulfilesenslUvily in Ihe ~ populatioo is unknown m Plotmiy kPw1xlt i is seen morefreQuenly in~tswith broochial asthma Reations 131 ircl~~adic S)111lIorns and lile-threatening or less ~ ashmalic episodes Many drugs used during he conducl of anesthesia are consideIed poIeniiai triggering agents lor lamilial malljlnanl hyperlhenm~ II has 00en shown IhaltOO use 01 amide local anestheics in malignant h)perthenmia patients is safe HC7gtWWlhere is no guaooIee Ihat reural blocllade will prewol Ihe ~opmenl 01 malignant hyperthemlia during surgery HIs also diffKu1t 10 (Jf(fictlhereedlorSllfllen6llagereralltreilhesia ThereIoreaslandardtxttocol lor Ihe managemenl 01 malignant hyperthermia should be available Drug Interadlons Serious cardiac anl1~mias may oourn preparalionscootaining avasocoostridor are errj)loyed in palients duringorlollawing tOOadministralioo 01 chlaoform halothane Cldoproprnlrichloro-ehytere orother reialedageots Caution should be exercised when administering articaine hydrochloride cooshycanilalliy W11h oIher medicalions vilich are poIenliai prodocers 01 rmhemoghr bin (eg sulphooamkles) ADVERSE REACTIONS ReaciionstoASTRACAINE (articaine hyliochloride) are characteristic 0I11lose associated wilh ami~ local anesIheIics Adwrse reaclons may result Irom hi9l plasma lewis dill 10 excessiw dcsage rapid absorpIion a inaltMrten1 inlr3vascular injectioo or rriJy result from ah)persenslUviIy idiosyrcasy or diminished lolerance oolhepart 01 loopatienL SIdl reaclions are systemic in natureandifllOlwlhecerr31 nervous systemanVorlhecardiOVolSClJlarsystem Cenlnl NervousSystem CNS rmnishylestaionsareeamyandlor~mmaybecllRttJizedby~ dizziess blimdvisionandlrermrs loIIuoedbydrlrltlsinessCOfMJlsions uncooshysciousnessand possibly respiratory arrest The excilalory reaclions may be wry briel or may not oaur at all invilich case1he first rmnifeslallons oItoxicily may be~rrsgingnollUJldousressilllrespirmy_ CanfiovasaJIar System CanflOvaSCUlar reaclions are depresm and may be characterized by ~ion myocardial depressjooixattaroJaand possibly cardiac arrest Allergic Aliefyic reaclonsarechiYacllri2ad byataneous lesions urticara edenIa oranaphylactoid reaclionsThedeteclion 01 sensitivilyby sIltin tesling isoldoubtful value Sweiling m pelSistenl paresthesia 01100 lips and oral lissues haw been reported after blocking he interior alveolar rerve fOIl SYMPTOMS AND TREATMENT OF OVERDOSAGE PlEASE REFEII TO THE PRODUCT MONshyGRAPH DOSAGE AND ADMINISTlIA110N AI with all local aneslhetics Ihe dcsage varies and 00perds LlOOIhe area to beareslhei2ed1he vascularily 0I1he IissuesIhe nurrbel 01 nexonaI segments 10 be blocllted indiviWaitoleranceand lhe~dnstEsia TheIaestdosagereededIOpureellectiwnslhes~

Adults lis dosageshouldnolexceed7 1111 in adulls and in generallhe rmximllTllotat dose should nOI exceed 500 mg (125 ml or7 cartridges) Chllden Dosages in children shouldbereOOedcornshymensuralewilh IheirageandlWlghL Experience in childrenyomgerlhan 4year 01 ~ has noI been doaJmenied The dosage shoold no exceed S~ body weight in Children betwee1IOO ages 014 and 12 Stability and Storage RecommendaUons Store aI coriroIled room IemperabJre (15-3OC) Protecl trom li~ Do nol use tl soIWon is jjrlltish or darIlter lhall slighUy yellow or ~ ~ cootalnsaprecipitale ASlRACAINEsolulionsarewilhoulpreseMiwandareior sing~ useooly OilcltyendtruSedportioo AVAIlABlUTY OF DOSAGE FORMS ASTRACAINE 4 FORTE (artcaine hydrochloride 40 mwmL and epinephrine inj8ion 1100XXJ) and ASTRACAINE4 (articaire hjdrochloride 40 ~ and epineltlrire injeclion l200XXJ)areavailable in denial cartridges 0I18ni in boxes 0150 Prodld Mooograph avallab~ upon request

ASTRA

ORAL HEALTHmiddot OCTOBER 1999

PROSTHODONTICS

agement as failure to appreciate this may lead to inappropriate management and ultimate failure of restorative therapy The second part of this publication will disshycuss the management of tooth wear Treatment planning strateshygies as well as case presentations will be presented W

Dr Effrat Habsha DDS completed her DDS and Prosthodontic training at the Univershysity of Toronto_ She is currently researching the effects of smoking on osseointegration She is staffprosthodonshytist at Mount Sinai Hospital an Associshyate in Dentistry University of Toronto Her practice is limited to prosthodontics and implant dentistry in Toronto

Oral Health welcomes this original article

Part II will appear in our November 1999 issue of Oral Health

REFERENCES 1 Imfeld T Dental erosion Definnion classification and

links Eur J Oral Sci 104151-155 1996 2 Smtth BGN and Knight JK M index for measuring

the wear of teeth Sr Dent J 156435-436 1984 3 Dahl BJ Carlsson GE and Ekfeldt A Occlusal

wear of teeth and restorative materials Acta Odonto Scand 51 299-311 1993

4 Johansson A and Ridwaan O Identification and Man-

Watch for these articles coming soon in the November issue of Oral Health

bull Prosthodontics bull Continuing Education

agernentoftoothwearlntJ Prosth 7506-515 1994 5 Grippo JO Abfractions A new classification of hard

tissue lesions of teeth J Esthet Dent 314-19 1991 6 Smith BG Some facets of tooth wear Ann R Aust

Coli Dent Surg 11 37-51 1991 7 Zipkin I McClure FJ Salivary citrate and dental eroshy

sion J Dent Res 28613-626 1949 8 Zero DT Etiology dental erosion-extrinsic factors

EurJOraISci104162-1771996 9 Petersen P E and Gormsen C Oral conditions

among German battery factory workers Community Dent Oral Epldemiol 19-104-106 1991

10 Centerwall BS Armstrong Cw Funkhouser GS Etzay RP Erosion of dental enamel among competishytive swimmers al a gas-chlorinated swimming pool Am J Epidemiol 123641-647 1986

11 Ecctes JD Jenkins wG Dental erosion and diet J Dent 2153-159 1974

12 James PMC Parlitt GJ Local effects of certain medicaments on the teeth Br Med J 2 1252-1253 1953

13 Smtth BGN Tooth wear aetiology and diagnosis Dent Update 16204-2121989

14 Giunta JL Dental erosion resulting from chewable vitshyamin Ctablets JAm Dent Assoc 107253-256 1983

15 Bhatti SA Walsh IF Douglas WL Ethanol and pH levels of proprietary mouthrinses Comm Dent Health 1171-741994

16 Schewel P Etiology of dental erosion-intrinsic facshytors EurJ Oral Sci 104178-1901996

17 Dodds WJ The pathogeneSis of gastroesophageal reflux disease AJR 151 49-56 1988

18 Bartlett Dand Smtth B Clinical investigations of gasshytro-oesophageal reflux Part 1 Dental update 205shy208 1996

19 Meurman JH ten Cate JM Pathogenesis and modifying factors of dental erosion Eur J Oral Sci 104199-2061996

20 Clearfield HR Roth JLA Morexia nausea and vomiting In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198548-58

21 Friedman LS KJ of Internal Medicine 12th edition New York McGraw Hili 1991 251-256

22 Goyal RK Diseases of the esophagus In Wilson JD et aI Harrisons Principles of Internal Medicine 12th edition New York McCiraw I-Ell 19911222-1229

23 Ouyang A Cohen SHeartbum regurgitation and dysshyphagia In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198559-64

III

PROSTHODONT I CS

FIGURE 3 Sixty year-old male with advanced tooth wear A deep vertical overbite

FIGURE 3 B wear at palatal of maxillary anteriors

FIGURE 3 C wear of mandibular incisors

ure 2) Attrition occurs almost entirely on occlusal and incisal surshyfaces although it may also affect the buccal and palatal surfaces of the maxillary and mandibular anteshyrior teeth in deep vertical overlap relationships6 (Figures 3A B C)

EROSION The term erosion describes the process of gradual destruction of the surface of something usually by electrolytic or chemical processes It is derived from the Latin verb eroder (to corrode)1 Dental erosion is the result of a pathologic chronic painless loss of dental hard tissue chemically etched away from the tooth surface by acid andor chelashytion without bacterial involvement7

The acids responsible for erosion are not products of the intraoral flora they stem from extrinsic or intrinsic sources

Extrinsic sources of acid Extrinsic acids may stem from environmental sources diet and medication (Table 1)8 Dental eroshysion has been reported in battery factory workers exposed to atmosshypheric sulfuric acids 9 There have also been reports of competitive swimmers suffering dental erosion from swimming in gas-chlorinated pools Large swimming pools genshyerally use gas chlorination which results in the formation of hydrochloric acid that requires neutralization and buffering to maintain the recommended pH range of 72-80 Therefore inadeshyquate monitoring of pool pH has been associated with dental eroshysion lO Though extrinsic environshymental sources of acids exist improved industrial safety regulashytions have gradually diminished the extent of environmental dental health hazardss

The role of diet in the etiology of erosion has received the most attention II Certain products espeshycially citrus fruits exhibit a low pH and when consumed freshyquently and excessively may lead to dental erosion It appears that dietary substances with a pH above 45 have a low potential to

ORAL HEALTHmiddot OCTOBER 1999 iii

cause dental erosion However foods and beverages containing acids with calcium chelating propshyerties such as citrate may cause tooth damage at higher pH levels Several reports have associated medicaments and oral health prodshyucts (rinses) with erosionl2131415 Many such products exhibit a low pH and may be erosive when used frequently In most cases the risk associated with a product could be reduced by either product modifishycation (such as encapsulation of acidic medicaments) or altering consumption habits Special attenshytion should be given to saliva subshystitutes aimed at patients with reduced salivary secretion or xerostomia These substitutes often have a low pH and may be detrimental to patients whose lack of saliva leads to prolonged clearshyance times Factors to be considshyered with exposure to extrinsic sources of acid include the durashytion of contact with the teeth (which is influenced by swallowing habits motions of the lips and cheeks saliva) frequency of ingesshytion amount ingested buffering capacity of saliva the chemical and physical properties of enameJ8

Intrinsic sources of acid Dental erosion due to intrinsic facshytors is caused by gastric acid reaching the oral cavity and the teeth as a result of vomiting pershysistent gastroesophageal reflux regurgitation or rumination Since the clinical manifestation of denshytal erosion does not occur until gastric acid has acted on the denshytal hard tissues regularly over a period of several years dental eroshysion caused by intrinsic factors has been observed only in those conditions which are associated with chronic vomiting or persisshytent gastroesophageal reflux Examples of such conditions are listed in Tables 2 and 3

Bulimic eating disorder is the underlying cause in most cases of dental erosion due to chronic vomitshying Recent studies suggest that approximately 90 of bulimic patients are affected by dental ero-

II ORAL HEALTHmiddot OCTOBER 1999

PR O STHODO N TICS

sion16 ather possible causes of long (GaR) GaR is the movement of term regular vomiting resulting in stomach acids through the lower dental erosion are disorders of the esophageal sphincter In healthy alimentary tract metabolic and individuals small amounts of gasshyendocrine disorders or medication tric acids reflux into the esophashyside effects (Table 2) gus This physiological GaR usushy

ally occurs after eating and may be Another possible etiologic inshy associated with eructation In

trinsic factor of dental erosion is healthy people most of the refluxshypersistent gastroesophageal reflux ate is returned to the stomach by

Table 2 Potential causes of vomiting

Disorders of the alimentary tract

bull chronic gastrit is bull peptic ulcer bull intestinal obstruction

Neurologic disorders

bull migraine headaches bull benign recurrent vertigo bull diabetic or alcoholic

polyneuropathia

Metabolic or Endocrine disorders

bull uremia bull hyperparathyroidism bull diabetic ketoacidosis bull adrenal insufficiency bull hypo-hyperparathyroidism

Psychosomatic disorders

bull eating disorders (bulimia anorexia)

bull stress induced psychogenic vomiting

Tahle 3 Causes of oastroesophaaeal reflux and reaurclitationo -

Incompetence of the gastroesophageal sphincter

bull Idiopathic

bull impairment of sphincter

bull neurohumoral induced decrease of gastroesophageal sphincter pressure

bull destruction of sphincter by surgical resection

Increased intraabdominal pressure

bull obesity

bull pre9nancy

Increased Intragastric volume

bull after meals

bull pyloric spasm

bull obstruction due to peptic ulcer

bull gastric stasis syndrome

PRO ST H O DO NTICS

the peristalsis stimulated by swalshylowing 17 It is estimated that 60 of the population suffer from this phenomenon at some stage of their lives If the clearance mechanisms cannot return the refluxate to the stomach and the symptoms become chronic the condition is known as pathological GOR or GOR disease (GORD) In some patients the refluxate breaks through the lower and upper esophageal sphincter and oral regurgitation occurs Oral regurgishytation may cause severe damage to the dentition lB (Figures 4A B) Causes of gastroesophageal reflux and regurgitation are listed in Table 3 Often the erosion is most severe on palatal tooth surfaces but other surfaces may also be affected when the gastric contents are chewed or kept in the buccal sulci before reswallowing

PATHOGENESIS Since the critical pH of dental enamel is approximately 55 any solution with a lower pH value may cause erosion particularly if the attack is of long duration and repeated over time Saliva and the salivary pellicle counteract the acid attacks but if the challenge is severe a total destruction of the tooth tissue follows Erosive

FlGURE4 Forty six-year-old male with Gastroesophageal reflux AampB Dental erosion of maxil- lesions are seen as characteristic lary and mandibular anteriors demineralization patterns within

the enamel In dentine the first area to be affected is the peritubushylar dentine With progressing lesions the dentinal tubules become enlarged but disruption is also seen in the intertubular areas If the erosion process is rapid increased sensitivity of the teeth is the presenting symptom However in cases with slower proshygression the patient may remain asymptomatic even though the whole dentition may become severely damaged 19

CONCLUSION The interrelationship of the four modes of tooth wear and individshyual susceptibility influence the degree of tooth wear Recognition of the multifactorial nature of tooth wear is the first step in man-

ORAL HEALTHmiddot OCTOBER 1999 Ell

FlGURE 4 C Occlusal view of palatal erosion

nisIe A AIN F AT net TM AINE 4

Pr ure Vlu m T lOose lion

5-3 oral sur 1D-S4

Astracainee

ot1icoine hydnxNoride and epineplri Injedion THERAPEUTIC CLASSIACATION Local AnesIheIic lor Dental Use INDICATIONS AND CUNICAl USE ASTRACAINE (articaire hyliochloridll) isrolCalOOlaitolJDlnnslhesiamneMltlltXiltMleS1hesiainclirOCaldentistry CONlRAJNDlCATlONS Ar1icaile hjdrochloride iscooainOlcaJOO in patieols with aknowl hypersens~ivi1y 10 local areslheics 01100 amide type AI wiIh all vasocoostricIoo epir~lIire is rortraildicaIed in hypertensionlhyroloxicosis orseoereheartdiseaseprtirularlywhentKhjca((flaispresert LocalaneslhElics should noI be used in seoereshltXiltorheart block TheyshouldaJsonoibeused vilenhere is inlmlmalion or5ellSis in Ihe region 0I1he proposed injection WARNINGS RESUSCITATIVE EQUIPMENT AND DRUGS SHOULD BE IMMEDIATElY AVAIlABLE WHEN ANY LOCAl ANESTHEnC IS USED AI wilh oIher local aneslhellcs articaire hydrochloride is capable 01 prodLCing rneIheshymoglobinemia This has been obserEd wilh epidural anesIhesia txA no when used as dilllcled in denial procedures Methemoglobinemia values 01 less lhan 20 usuaHydo noI produce any clinical S)111lIoms The usual clinical signs 01 meItEmlgIobinemia arecyanosis 0I1he nail beds m lips Allhough Ihe possibilily 01 meIhemoglobinemiaoaooing indlnalpaIiamp1s isextremelyrlre RI3l be rapidly IeIlSedbylheuseoll-2~bodyweiltlolrrShyleneblllladminisleredln1Jashywnously OYer a5-miou1e period Because ASTRACAINE cOOains avasocooshyS1ricIor nshouldbe usedwilhexlrerrecautlon in palienis reeMng drugs known 10 prtxlJce blOOd pressurealieraUons (lor ~IeMAO inhibilolSlrtyclicanUshydepressanlS phenOlhiazires) as eiIhei seYere m SUSlaired hypotension orillershyifflSioomayoaur PRECAUTIONS General Thesafelyandelectivenessol kxaliIlflSItfIicsdepend~IlWlI~W18d~~~ andrtldinessloremerlJnies THE LOWESTOOSETHATRESUlTS IN EffiCTIVE Igtl-lSTHESIASHOULDBE USEDTOAVOIDHIGHPlASMALEVElSAAIlSElllOUS UNOESIRABLEAOVERSEEFFECTS INJECTIONSSHOULOBEMAOESlOWlY WITH FREQUENT ASPlRAnONSBEFOREANDOURINGTHEINJECTION nblOOd isaspiraledlhereedleshouldbe relocated TolerancevarieswilhlhesIaIUs 0I1he palient Oebililaledorelderly paUenlS acutely ill palienIs mchildren should be giwn redltud doses COfTIrerISUrale with lheir age and physical slalus Use In Pregnancy Sale use 01 articaine hylioch Ioride in preo-ool warren has nol been eslablished hOwever animal sludies have nol demonstraled leralogenic or embryoloxic eHecis Nursing Mothers Articaine hydrocllioride is rapidly fTEtIboIi2ed and eliminaledand is 1hereI0re unlilltlllylo be lransferredlo the rOOhers mil Patientswlth Spectal Dlseasesand Coodlllons ASTRACAINECOOIains avasocoostricIa and should Iherefore be used wiIh caution in Ihe presence 01 diseasesvilichmayaltMlSeyalfecllhepatienmiddotscardiovascularsytem Thedrug shoold be usedwih caJioo in persoos wiIh known drug sensRi~1ies ASTRACAINE corDnssOOlITlrnlal)isumle Sullalesmaycausealiefyicreactionsinsusceplib~ ~ The prevalence 01 sulfilesenslUvily in Ihe ~ populatioo is unknown m Plotmiy kPw1xlt i is seen morefreQuenly in~tswith broochial asthma Reations 131 ircl~~adic S)111lIorns and lile-threatening or less ~ ashmalic episodes Many drugs used during he conducl of anesthesia are consideIed poIeniiai triggering agents lor lamilial malljlnanl hyperlhenm~ II has 00en shown IhaltOO use 01 amide local anestheics in malignant h)perthenmia patients is safe HC7gtWWlhere is no guaooIee Ihat reural blocllade will prewol Ihe ~opmenl 01 malignant hyperthemlia during surgery HIs also diffKu1t 10 (Jf(fictlhereedlorSllfllen6llagereralltreilhesia ThereIoreaslandardtxttocol lor Ihe managemenl 01 malignant hyperthermia should be available Drug Interadlons Serious cardiac anl1~mias may oourn preparalionscootaining avasocoostridor are errj)loyed in palients duringorlollawing tOOadministralioo 01 chlaoform halothane Cldoproprnlrichloro-ehytere orother reialedageots Caution should be exercised when administering articaine hydrochloride cooshycanilalliy W11h oIher medicalions vilich are poIenliai prodocers 01 rmhemoghr bin (eg sulphooamkles) ADVERSE REACTIONS ReaciionstoASTRACAINE (articaine hyliochloride) are characteristic 0I11lose associated wilh ami~ local anesIheIics Adwrse reaclons may result Irom hi9l plasma lewis dill 10 excessiw dcsage rapid absorpIion a inaltMrten1 inlr3vascular injectioo or rriJy result from ah)persenslUviIy idiosyrcasy or diminished lolerance oolhepart 01 loopatienL SIdl reaclions are systemic in natureandifllOlwlhecerr31 nervous systemanVorlhecardiOVolSClJlarsystem Cenlnl NervousSystem CNS rmnishylestaionsareeamyandlor~mmaybecllRttJizedby~ dizziess blimdvisionandlrermrs loIIuoedbydrlrltlsinessCOfMJlsions uncooshysciousnessand possibly respiratory arrest The excilalory reaclions may be wry briel or may not oaur at all invilich case1he first rmnifeslallons oItoxicily may be~rrsgingnollUJldousressilllrespirmy_ CanfiovasaJIar System CanflOvaSCUlar reaclions are depresm and may be characterized by ~ion myocardial depressjooixattaroJaand possibly cardiac arrest Allergic Aliefyic reaclonsarechiYacllri2ad byataneous lesions urticara edenIa oranaphylactoid reaclionsThedeteclion 01 sensitivilyby sIltin tesling isoldoubtful value Sweiling m pelSistenl paresthesia 01100 lips and oral lissues haw been reported after blocking he interior alveolar rerve fOIl SYMPTOMS AND TREATMENT OF OVERDOSAGE PlEASE REFEII TO THE PRODUCT MONshyGRAPH DOSAGE AND ADMINISTlIA110N AI with all local aneslhetics Ihe dcsage varies and 00perds LlOOIhe area to beareslhei2ed1he vascularily 0I1he IissuesIhe nurrbel 01 nexonaI segments 10 be blocllted indiviWaitoleranceand lhe~dnstEsia TheIaestdosagereededIOpureellectiwnslhes~

Adults lis dosageshouldnolexceed7 1111 in adulls and in generallhe rmximllTllotat dose should nOI exceed 500 mg (125 ml or7 cartridges) Chllden Dosages in children shouldbereOOedcornshymensuralewilh IheirageandlWlghL Experience in childrenyomgerlhan 4year 01 ~ has noI been doaJmenied The dosage shoold no exceed S~ body weight in Children betwee1IOO ages 014 and 12 Stability and Storage RecommendaUons Store aI coriroIled room IemperabJre (15-3OC) Protecl trom li~ Do nol use tl soIWon is jjrlltish or darIlter lhall slighUy yellow or ~ ~ cootalnsaprecipitale ASlRACAINEsolulionsarewilhoulpreseMiwandareior sing~ useooly OilcltyendtruSedportioo AVAIlABlUTY OF DOSAGE FORMS ASTRACAINE 4 FORTE (artcaine hydrochloride 40 mwmL and epinephrine inj8ion 1100XXJ) and ASTRACAINE4 (articaire hjdrochloride 40 ~ and epineltlrire injeclion l200XXJ)areavailable in denial cartridges 0I18ni in boxes 0150 Prodld Mooograph avallab~ upon request

ASTRA

ORAL HEALTHmiddot OCTOBER 1999

PROSTHODONTICS

agement as failure to appreciate this may lead to inappropriate management and ultimate failure of restorative therapy The second part of this publication will disshycuss the management of tooth wear Treatment planning strateshygies as well as case presentations will be presented W

Dr Effrat Habsha DDS completed her DDS and Prosthodontic training at the Univershysity of Toronto_ She is currently researching the effects of smoking on osseointegration She is staffprosthodonshytist at Mount Sinai Hospital an Associshyate in Dentistry University of Toronto Her practice is limited to prosthodontics and implant dentistry in Toronto

Oral Health welcomes this original article

Part II will appear in our November 1999 issue of Oral Health

REFERENCES 1 Imfeld T Dental erosion Definnion classification and

links Eur J Oral Sci 104151-155 1996 2 Smtth BGN and Knight JK M index for measuring

the wear of teeth Sr Dent J 156435-436 1984 3 Dahl BJ Carlsson GE and Ekfeldt A Occlusal

wear of teeth and restorative materials Acta Odonto Scand 51 299-311 1993

4 Johansson A and Ridwaan O Identification and Man-

Watch for these articles coming soon in the November issue of Oral Health

bull Prosthodontics bull Continuing Education

agernentoftoothwearlntJ Prosth 7506-515 1994 5 Grippo JO Abfractions A new classification of hard

tissue lesions of teeth J Esthet Dent 314-19 1991 6 Smith BG Some facets of tooth wear Ann R Aust

Coli Dent Surg 11 37-51 1991 7 Zipkin I McClure FJ Salivary citrate and dental eroshy

sion J Dent Res 28613-626 1949 8 Zero DT Etiology dental erosion-extrinsic factors

EurJOraISci104162-1771996 9 Petersen P E and Gormsen C Oral conditions

among German battery factory workers Community Dent Oral Epldemiol 19-104-106 1991

10 Centerwall BS Armstrong Cw Funkhouser GS Etzay RP Erosion of dental enamel among competishytive swimmers al a gas-chlorinated swimming pool Am J Epidemiol 123641-647 1986

11 Ecctes JD Jenkins wG Dental erosion and diet J Dent 2153-159 1974

12 James PMC Parlitt GJ Local effects of certain medicaments on the teeth Br Med J 2 1252-1253 1953

13 Smtth BGN Tooth wear aetiology and diagnosis Dent Update 16204-2121989

14 Giunta JL Dental erosion resulting from chewable vitshyamin Ctablets JAm Dent Assoc 107253-256 1983

15 Bhatti SA Walsh IF Douglas WL Ethanol and pH levels of proprietary mouthrinses Comm Dent Health 1171-741994

16 Schewel P Etiology of dental erosion-intrinsic facshytors EurJ Oral Sci 104178-1901996

17 Dodds WJ The pathogeneSis of gastroesophageal reflux disease AJR 151 49-56 1988

18 Bartlett Dand Smtth B Clinical investigations of gasshytro-oesophageal reflux Part 1 Dental update 205shy208 1996

19 Meurman JH ten Cate JM Pathogenesis and modifying factors of dental erosion Eur J Oral Sci 104199-2061996

20 Clearfield HR Roth JLA Morexia nausea and vomiting In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198548-58

21 Friedman LS KJ of Internal Medicine 12th edition New York McGraw Hili 1991 251-256

22 Goyal RK Diseases of the esophagus In Wilson JD et aI Harrisons Principles of Internal Medicine 12th edition New York McCiraw I-Ell 19911222-1229

23 Ouyang A Cohen SHeartbum regurgitation and dysshyphagia In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198559-64

III

cause dental erosion However foods and beverages containing acids with calcium chelating propshyerties such as citrate may cause tooth damage at higher pH levels Several reports have associated medicaments and oral health prodshyucts (rinses) with erosionl2131415 Many such products exhibit a low pH and may be erosive when used frequently In most cases the risk associated with a product could be reduced by either product modifishycation (such as encapsulation of acidic medicaments) or altering consumption habits Special attenshytion should be given to saliva subshystitutes aimed at patients with reduced salivary secretion or xerostomia These substitutes often have a low pH and may be detrimental to patients whose lack of saliva leads to prolonged clearshyance times Factors to be considshyered with exposure to extrinsic sources of acid include the durashytion of contact with the teeth (which is influenced by swallowing habits motions of the lips and cheeks saliva) frequency of ingesshytion amount ingested buffering capacity of saliva the chemical and physical properties of enameJ8

Intrinsic sources of acid Dental erosion due to intrinsic facshytors is caused by gastric acid reaching the oral cavity and the teeth as a result of vomiting pershysistent gastroesophageal reflux regurgitation or rumination Since the clinical manifestation of denshytal erosion does not occur until gastric acid has acted on the denshytal hard tissues regularly over a period of several years dental eroshysion caused by intrinsic factors has been observed only in those conditions which are associated with chronic vomiting or persisshytent gastroesophageal reflux Examples of such conditions are listed in Tables 2 and 3

Bulimic eating disorder is the underlying cause in most cases of dental erosion due to chronic vomitshying Recent studies suggest that approximately 90 of bulimic patients are affected by dental ero-

II ORAL HEALTHmiddot OCTOBER 1999

PR O STHODO N TICS

sion16 ather possible causes of long (GaR) GaR is the movement of term regular vomiting resulting in stomach acids through the lower dental erosion are disorders of the esophageal sphincter In healthy alimentary tract metabolic and individuals small amounts of gasshyendocrine disorders or medication tric acids reflux into the esophashyside effects (Table 2) gus This physiological GaR usushy

ally occurs after eating and may be Another possible etiologic inshy associated with eructation In

trinsic factor of dental erosion is healthy people most of the refluxshypersistent gastroesophageal reflux ate is returned to the stomach by

Table 2 Potential causes of vomiting

Disorders of the alimentary tract

bull chronic gastrit is bull peptic ulcer bull intestinal obstruction

Neurologic disorders

bull migraine headaches bull benign recurrent vertigo bull diabetic or alcoholic

polyneuropathia

Metabolic or Endocrine disorders

bull uremia bull hyperparathyroidism bull diabetic ketoacidosis bull adrenal insufficiency bull hypo-hyperparathyroidism

Psychosomatic disorders

bull eating disorders (bulimia anorexia)

bull stress induced psychogenic vomiting

Tahle 3 Causes of oastroesophaaeal reflux and reaurclitationo -

Incompetence of the gastroesophageal sphincter

bull Idiopathic

bull impairment of sphincter

bull neurohumoral induced decrease of gastroesophageal sphincter pressure

bull destruction of sphincter by surgical resection

Increased intraabdominal pressure

bull obesity

bull pre9nancy

Increased Intragastric volume

bull after meals

bull pyloric spasm

bull obstruction due to peptic ulcer

bull gastric stasis syndrome

PRO ST H O DO NTICS

the peristalsis stimulated by swalshylowing 17 It is estimated that 60 of the population suffer from this phenomenon at some stage of their lives If the clearance mechanisms cannot return the refluxate to the stomach and the symptoms become chronic the condition is known as pathological GOR or GOR disease (GORD) In some patients the refluxate breaks through the lower and upper esophageal sphincter and oral regurgitation occurs Oral regurgishytation may cause severe damage to the dentition lB (Figures 4A B) Causes of gastroesophageal reflux and regurgitation are listed in Table 3 Often the erosion is most severe on palatal tooth surfaces but other surfaces may also be affected when the gastric contents are chewed or kept in the buccal sulci before reswallowing

PATHOGENESIS Since the critical pH of dental enamel is approximately 55 any solution with a lower pH value may cause erosion particularly if the attack is of long duration and repeated over time Saliva and the salivary pellicle counteract the acid attacks but if the challenge is severe a total destruction of the tooth tissue follows Erosive

FlGURE4 Forty six-year-old male with Gastroesophageal reflux AampB Dental erosion of maxil- lesions are seen as characteristic lary and mandibular anteriors demineralization patterns within

the enamel In dentine the first area to be affected is the peritubushylar dentine With progressing lesions the dentinal tubules become enlarged but disruption is also seen in the intertubular areas If the erosion process is rapid increased sensitivity of the teeth is the presenting symptom However in cases with slower proshygression the patient may remain asymptomatic even though the whole dentition may become severely damaged 19

CONCLUSION The interrelationship of the four modes of tooth wear and individshyual susceptibility influence the degree of tooth wear Recognition of the multifactorial nature of tooth wear is the first step in man-

ORAL HEALTHmiddot OCTOBER 1999 Ell

FlGURE 4 C Occlusal view of palatal erosion

nisIe A AIN F AT net TM AINE 4

Pr ure Vlu m T lOose lion

5-3 oral sur 1D-S4

Astracainee

ot1icoine hydnxNoride and epineplri Injedion THERAPEUTIC CLASSIACATION Local AnesIheIic lor Dental Use INDICATIONS AND CUNICAl USE ASTRACAINE (articaire hyliochloridll) isrolCalOOlaitolJDlnnslhesiamneMltlltXiltMleS1hesiainclirOCaldentistry CONlRAJNDlCATlONS Ar1icaile hjdrochloride iscooainOlcaJOO in patieols with aknowl hypersens~ivi1y 10 local areslheics 01100 amide type AI wiIh all vasocoostricIoo epir~lIire is rortraildicaIed in hypertensionlhyroloxicosis orseoereheartdiseaseprtirularlywhentKhjca((flaispresert LocalaneslhElics should noI be used in seoereshltXiltorheart block TheyshouldaJsonoibeused vilenhere is inlmlmalion or5ellSis in Ihe region 0I1he proposed injection WARNINGS RESUSCITATIVE EQUIPMENT AND DRUGS SHOULD BE IMMEDIATElY AVAIlABLE WHEN ANY LOCAl ANESTHEnC IS USED AI wilh oIher local aneslhellcs articaire hydrochloride is capable 01 prodLCing rneIheshymoglobinemia This has been obserEd wilh epidural anesIhesia txA no when used as dilllcled in denial procedures Methemoglobinemia values 01 less lhan 20 usuaHydo noI produce any clinical S)111lIoms The usual clinical signs 01 meItEmlgIobinemia arecyanosis 0I1he nail beds m lips Allhough Ihe possibilily 01 meIhemoglobinemiaoaooing indlnalpaIiamp1s isextremelyrlre RI3l be rapidly IeIlSedbylheuseoll-2~bodyweiltlolrrShyleneblllladminisleredln1Jashywnously OYer a5-miou1e period Because ASTRACAINE cOOains avasocooshyS1ricIor nshouldbe usedwilhexlrerrecautlon in palienis reeMng drugs known 10 prtxlJce blOOd pressurealieraUons (lor ~IeMAO inhibilolSlrtyclicanUshydepressanlS phenOlhiazires) as eiIhei seYere m SUSlaired hypotension orillershyifflSioomayoaur PRECAUTIONS General Thesafelyandelectivenessol kxaliIlflSItfIicsdepend~IlWlI~W18d~~~ andrtldinessloremerlJnies THE LOWESTOOSETHATRESUlTS IN EffiCTIVE Igtl-lSTHESIASHOULDBE USEDTOAVOIDHIGHPlASMALEVElSAAIlSElllOUS UNOESIRABLEAOVERSEEFFECTS INJECTIONSSHOULOBEMAOESlOWlY WITH FREQUENT ASPlRAnONSBEFOREANDOURINGTHEINJECTION nblOOd isaspiraledlhereedleshouldbe relocated TolerancevarieswilhlhesIaIUs 0I1he palient Oebililaledorelderly paUenlS acutely ill palienIs mchildren should be giwn redltud doses COfTIrerISUrale with lheir age and physical slalus Use In Pregnancy Sale use 01 articaine hylioch Ioride in preo-ool warren has nol been eslablished hOwever animal sludies have nol demonstraled leralogenic or embryoloxic eHecis Nursing Mothers Articaine hydrocllioride is rapidly fTEtIboIi2ed and eliminaledand is 1hereI0re unlilltlllylo be lransferredlo the rOOhers mil Patientswlth Spectal Dlseasesand Coodlllons ASTRACAINECOOIains avasocoostricIa and should Iherefore be used wiIh caution in Ihe presence 01 diseasesvilichmayaltMlSeyalfecllhepatienmiddotscardiovascularsytem Thedrug shoold be usedwih caJioo in persoos wiIh known drug sensRi~1ies ASTRACAINE corDnssOOlITlrnlal)isumle Sullalesmaycausealiefyicreactionsinsusceplib~ ~ The prevalence 01 sulfilesenslUvily in Ihe ~ populatioo is unknown m Plotmiy kPw1xlt i is seen morefreQuenly in~tswith broochial asthma Reations 131 ircl~~adic S)111lIorns and lile-threatening or less ~ ashmalic episodes Many drugs used during he conducl of anesthesia are consideIed poIeniiai triggering agents lor lamilial malljlnanl hyperlhenm~ II has 00en shown IhaltOO use 01 amide local anestheics in malignant h)perthenmia patients is safe HC7gtWWlhere is no guaooIee Ihat reural blocllade will prewol Ihe ~opmenl 01 malignant hyperthemlia during surgery HIs also diffKu1t 10 (Jf(fictlhereedlorSllfllen6llagereralltreilhesia ThereIoreaslandardtxttocol lor Ihe managemenl 01 malignant hyperthermia should be available Drug Interadlons Serious cardiac anl1~mias may oourn preparalionscootaining avasocoostridor are errj)loyed in palients duringorlollawing tOOadministralioo 01 chlaoform halothane Cldoproprnlrichloro-ehytere orother reialedageots Caution should be exercised when administering articaine hydrochloride cooshycanilalliy W11h oIher medicalions vilich are poIenliai prodocers 01 rmhemoghr bin (eg sulphooamkles) ADVERSE REACTIONS ReaciionstoASTRACAINE (articaine hyliochloride) are characteristic 0I11lose associated wilh ami~ local anesIheIics Adwrse reaclons may result Irom hi9l plasma lewis dill 10 excessiw dcsage rapid absorpIion a inaltMrten1 inlr3vascular injectioo or rriJy result from ah)persenslUviIy idiosyrcasy or diminished lolerance oolhepart 01 loopatienL SIdl reaclions are systemic in natureandifllOlwlhecerr31 nervous systemanVorlhecardiOVolSClJlarsystem Cenlnl NervousSystem CNS rmnishylestaionsareeamyandlor~mmaybecllRttJizedby~ dizziess blimdvisionandlrermrs loIIuoedbydrlrltlsinessCOfMJlsions uncooshysciousnessand possibly respiratory arrest The excilalory reaclions may be wry briel or may not oaur at all invilich case1he first rmnifeslallons oItoxicily may be~rrsgingnollUJldousressilllrespirmy_ CanfiovasaJIar System CanflOvaSCUlar reaclions are depresm and may be characterized by ~ion myocardial depressjooixattaroJaand possibly cardiac arrest Allergic Aliefyic reaclonsarechiYacllri2ad byataneous lesions urticara edenIa oranaphylactoid reaclionsThedeteclion 01 sensitivilyby sIltin tesling isoldoubtful value Sweiling m pelSistenl paresthesia 01100 lips and oral lissues haw been reported after blocking he interior alveolar rerve fOIl SYMPTOMS AND TREATMENT OF OVERDOSAGE PlEASE REFEII TO THE PRODUCT MONshyGRAPH DOSAGE AND ADMINISTlIA110N AI with all local aneslhetics Ihe dcsage varies and 00perds LlOOIhe area to beareslhei2ed1he vascularily 0I1he IissuesIhe nurrbel 01 nexonaI segments 10 be blocllted indiviWaitoleranceand lhe~dnstEsia TheIaestdosagereededIOpureellectiwnslhes~

Adults lis dosageshouldnolexceed7 1111 in adulls and in generallhe rmximllTllotat dose should nOI exceed 500 mg (125 ml or7 cartridges) Chllden Dosages in children shouldbereOOedcornshymensuralewilh IheirageandlWlghL Experience in childrenyomgerlhan 4year 01 ~ has noI been doaJmenied The dosage shoold no exceed S~ body weight in Children betwee1IOO ages 014 and 12 Stability and Storage RecommendaUons Store aI coriroIled room IemperabJre (15-3OC) Protecl trom li~ Do nol use tl soIWon is jjrlltish or darIlter lhall slighUy yellow or ~ ~ cootalnsaprecipitale ASlRACAINEsolulionsarewilhoulpreseMiwandareior sing~ useooly OilcltyendtruSedportioo AVAIlABlUTY OF DOSAGE FORMS ASTRACAINE 4 FORTE (artcaine hydrochloride 40 mwmL and epinephrine inj8ion 1100XXJ) and ASTRACAINE4 (articaire hjdrochloride 40 ~ and epineltlrire injeclion l200XXJ)areavailable in denial cartridges 0I18ni in boxes 0150 Prodld Mooograph avallab~ upon request

ASTRA

ORAL HEALTHmiddot OCTOBER 1999

PROSTHODONTICS

agement as failure to appreciate this may lead to inappropriate management and ultimate failure of restorative therapy The second part of this publication will disshycuss the management of tooth wear Treatment planning strateshygies as well as case presentations will be presented W

Dr Effrat Habsha DDS completed her DDS and Prosthodontic training at the Univershysity of Toronto_ She is currently researching the effects of smoking on osseointegration She is staffprosthodonshytist at Mount Sinai Hospital an Associshyate in Dentistry University of Toronto Her practice is limited to prosthodontics and implant dentistry in Toronto

Oral Health welcomes this original article

Part II will appear in our November 1999 issue of Oral Health

REFERENCES 1 Imfeld T Dental erosion Definnion classification and

links Eur J Oral Sci 104151-155 1996 2 Smtth BGN and Knight JK M index for measuring

the wear of teeth Sr Dent J 156435-436 1984 3 Dahl BJ Carlsson GE and Ekfeldt A Occlusal

wear of teeth and restorative materials Acta Odonto Scand 51 299-311 1993

4 Johansson A and Ridwaan O Identification and Man-

Watch for these articles coming soon in the November issue of Oral Health

bull Prosthodontics bull Continuing Education

agernentoftoothwearlntJ Prosth 7506-515 1994 5 Grippo JO Abfractions A new classification of hard

tissue lesions of teeth J Esthet Dent 314-19 1991 6 Smith BG Some facets of tooth wear Ann R Aust

Coli Dent Surg 11 37-51 1991 7 Zipkin I McClure FJ Salivary citrate and dental eroshy

sion J Dent Res 28613-626 1949 8 Zero DT Etiology dental erosion-extrinsic factors

EurJOraISci104162-1771996 9 Petersen P E and Gormsen C Oral conditions

among German battery factory workers Community Dent Oral Epldemiol 19-104-106 1991

10 Centerwall BS Armstrong Cw Funkhouser GS Etzay RP Erosion of dental enamel among competishytive swimmers al a gas-chlorinated swimming pool Am J Epidemiol 123641-647 1986

11 Ecctes JD Jenkins wG Dental erosion and diet J Dent 2153-159 1974

12 James PMC Parlitt GJ Local effects of certain medicaments on the teeth Br Med J 2 1252-1253 1953

13 Smtth BGN Tooth wear aetiology and diagnosis Dent Update 16204-2121989

14 Giunta JL Dental erosion resulting from chewable vitshyamin Ctablets JAm Dent Assoc 107253-256 1983

15 Bhatti SA Walsh IF Douglas WL Ethanol and pH levels of proprietary mouthrinses Comm Dent Health 1171-741994

16 Schewel P Etiology of dental erosion-intrinsic facshytors EurJ Oral Sci 104178-1901996

17 Dodds WJ The pathogeneSis of gastroesophageal reflux disease AJR 151 49-56 1988

18 Bartlett Dand Smtth B Clinical investigations of gasshytro-oesophageal reflux Part 1 Dental update 205shy208 1996

19 Meurman JH ten Cate JM Pathogenesis and modifying factors of dental erosion Eur J Oral Sci 104199-2061996

20 Clearfield HR Roth JLA Morexia nausea and vomiting In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198548-58

21 Friedman LS KJ of Internal Medicine 12th edition New York McGraw Hili 1991 251-256

22 Goyal RK Diseases of the esophagus In Wilson JD et aI Harrisons Principles of Internal Medicine 12th edition New York McCiraw I-Ell 19911222-1229

23 Ouyang A Cohen SHeartbum regurgitation and dysshyphagia In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198559-64

III

PRO ST H O DO NTICS

the peristalsis stimulated by swalshylowing 17 It is estimated that 60 of the population suffer from this phenomenon at some stage of their lives If the clearance mechanisms cannot return the refluxate to the stomach and the symptoms become chronic the condition is known as pathological GOR or GOR disease (GORD) In some patients the refluxate breaks through the lower and upper esophageal sphincter and oral regurgitation occurs Oral regurgishytation may cause severe damage to the dentition lB (Figures 4A B) Causes of gastroesophageal reflux and regurgitation are listed in Table 3 Often the erosion is most severe on palatal tooth surfaces but other surfaces may also be affected when the gastric contents are chewed or kept in the buccal sulci before reswallowing

PATHOGENESIS Since the critical pH of dental enamel is approximately 55 any solution with a lower pH value may cause erosion particularly if the attack is of long duration and repeated over time Saliva and the salivary pellicle counteract the acid attacks but if the challenge is severe a total destruction of the tooth tissue follows Erosive

FlGURE4 Forty six-year-old male with Gastroesophageal reflux AampB Dental erosion of maxil- lesions are seen as characteristic lary and mandibular anteriors demineralization patterns within

the enamel In dentine the first area to be affected is the peritubushylar dentine With progressing lesions the dentinal tubules become enlarged but disruption is also seen in the intertubular areas If the erosion process is rapid increased sensitivity of the teeth is the presenting symptom However in cases with slower proshygression the patient may remain asymptomatic even though the whole dentition may become severely damaged 19

CONCLUSION The interrelationship of the four modes of tooth wear and individshyual susceptibility influence the degree of tooth wear Recognition of the multifactorial nature of tooth wear is the first step in man-

ORAL HEALTHmiddot OCTOBER 1999 Ell

FlGURE 4 C Occlusal view of palatal erosion

nisIe A AIN F AT net TM AINE 4

Pr ure Vlu m T lOose lion

5-3 oral sur 1D-S4

Astracainee

ot1icoine hydnxNoride and epineplri Injedion THERAPEUTIC CLASSIACATION Local AnesIheIic lor Dental Use INDICATIONS AND CUNICAl USE ASTRACAINE (articaire hyliochloridll) isrolCalOOlaitolJDlnnslhesiamneMltlltXiltMleS1hesiainclirOCaldentistry CONlRAJNDlCATlONS Ar1icaile hjdrochloride iscooainOlcaJOO in patieols with aknowl hypersens~ivi1y 10 local areslheics 01100 amide type AI wiIh all vasocoostricIoo epir~lIire is rortraildicaIed in hypertensionlhyroloxicosis orseoereheartdiseaseprtirularlywhentKhjca((flaispresert LocalaneslhElics should noI be used in seoereshltXiltorheart block TheyshouldaJsonoibeused vilenhere is inlmlmalion or5ellSis in Ihe region 0I1he proposed injection WARNINGS RESUSCITATIVE EQUIPMENT AND DRUGS SHOULD BE IMMEDIATElY AVAIlABLE WHEN ANY LOCAl ANESTHEnC IS USED AI wilh oIher local aneslhellcs articaire hydrochloride is capable 01 prodLCing rneIheshymoglobinemia This has been obserEd wilh epidural anesIhesia txA no when used as dilllcled in denial procedures Methemoglobinemia values 01 less lhan 20 usuaHydo noI produce any clinical S)111lIoms The usual clinical signs 01 meItEmlgIobinemia arecyanosis 0I1he nail beds m lips Allhough Ihe possibilily 01 meIhemoglobinemiaoaooing indlnalpaIiamp1s isextremelyrlre RI3l be rapidly IeIlSedbylheuseoll-2~bodyweiltlolrrShyleneblllladminisleredln1Jashywnously OYer a5-miou1e period Because ASTRACAINE cOOains avasocooshyS1ricIor nshouldbe usedwilhexlrerrecautlon in palienis reeMng drugs known 10 prtxlJce blOOd pressurealieraUons (lor ~IeMAO inhibilolSlrtyclicanUshydepressanlS phenOlhiazires) as eiIhei seYere m SUSlaired hypotension orillershyifflSioomayoaur PRECAUTIONS General Thesafelyandelectivenessol kxaliIlflSItfIicsdepend~IlWlI~W18d~~~ andrtldinessloremerlJnies THE LOWESTOOSETHATRESUlTS IN EffiCTIVE Igtl-lSTHESIASHOULDBE USEDTOAVOIDHIGHPlASMALEVElSAAIlSElllOUS UNOESIRABLEAOVERSEEFFECTS INJECTIONSSHOULOBEMAOESlOWlY WITH FREQUENT ASPlRAnONSBEFOREANDOURINGTHEINJECTION nblOOd isaspiraledlhereedleshouldbe relocated TolerancevarieswilhlhesIaIUs 0I1he palient Oebililaledorelderly paUenlS acutely ill palienIs mchildren should be giwn redltud doses COfTIrerISUrale with lheir age and physical slalus Use In Pregnancy Sale use 01 articaine hylioch Ioride in preo-ool warren has nol been eslablished hOwever animal sludies have nol demonstraled leralogenic or embryoloxic eHecis Nursing Mothers Articaine hydrocllioride is rapidly fTEtIboIi2ed and eliminaledand is 1hereI0re unlilltlllylo be lransferredlo the rOOhers mil Patientswlth Spectal Dlseasesand Coodlllons ASTRACAINECOOIains avasocoostricIa and should Iherefore be used wiIh caution in Ihe presence 01 diseasesvilichmayaltMlSeyalfecllhepatienmiddotscardiovascularsytem Thedrug shoold be usedwih caJioo in persoos wiIh known drug sensRi~1ies ASTRACAINE corDnssOOlITlrnlal)isumle Sullalesmaycausealiefyicreactionsinsusceplib~ ~ The prevalence 01 sulfilesenslUvily in Ihe ~ populatioo is unknown m Plotmiy kPw1xlt i is seen morefreQuenly in~tswith broochial asthma Reations 131 ircl~~adic S)111lIorns and lile-threatening or less ~ ashmalic episodes Many drugs used during he conducl of anesthesia are consideIed poIeniiai triggering agents lor lamilial malljlnanl hyperlhenm~ II has 00en shown IhaltOO use 01 amide local anestheics in malignant h)perthenmia patients is safe HC7gtWWlhere is no guaooIee Ihat reural blocllade will prewol Ihe ~opmenl 01 malignant hyperthemlia during surgery HIs also diffKu1t 10 (Jf(fictlhereedlorSllfllen6llagereralltreilhesia ThereIoreaslandardtxttocol lor Ihe managemenl 01 malignant hyperthermia should be available Drug Interadlons Serious cardiac anl1~mias may oourn preparalionscootaining avasocoostridor are errj)loyed in palients duringorlollawing tOOadministralioo 01 chlaoform halothane Cldoproprnlrichloro-ehytere orother reialedageots Caution should be exercised when administering articaine hydrochloride cooshycanilalliy W11h oIher medicalions vilich are poIenliai prodocers 01 rmhemoghr bin (eg sulphooamkles) ADVERSE REACTIONS ReaciionstoASTRACAINE (articaine hyliochloride) are characteristic 0I11lose associated wilh ami~ local anesIheIics Adwrse reaclons may result Irom hi9l plasma lewis dill 10 excessiw dcsage rapid absorpIion a inaltMrten1 inlr3vascular injectioo or rriJy result from ah)persenslUviIy idiosyrcasy or diminished lolerance oolhepart 01 loopatienL SIdl reaclions are systemic in natureandifllOlwlhecerr31 nervous systemanVorlhecardiOVolSClJlarsystem Cenlnl NervousSystem CNS rmnishylestaionsareeamyandlor~mmaybecllRttJizedby~ dizziess blimdvisionandlrermrs loIIuoedbydrlrltlsinessCOfMJlsions uncooshysciousnessand possibly respiratory arrest The excilalory reaclions may be wry briel or may not oaur at all invilich case1he first rmnifeslallons oItoxicily may be~rrsgingnollUJldousressilllrespirmy_ CanfiovasaJIar System CanflOvaSCUlar reaclions are depresm and may be characterized by ~ion myocardial depressjooixattaroJaand possibly cardiac arrest Allergic Aliefyic reaclonsarechiYacllri2ad byataneous lesions urticara edenIa oranaphylactoid reaclionsThedeteclion 01 sensitivilyby sIltin tesling isoldoubtful value Sweiling m pelSistenl paresthesia 01100 lips and oral lissues haw been reported after blocking he interior alveolar rerve fOIl SYMPTOMS AND TREATMENT OF OVERDOSAGE PlEASE REFEII TO THE PRODUCT MONshyGRAPH DOSAGE AND ADMINISTlIA110N AI with all local aneslhetics Ihe dcsage varies and 00perds LlOOIhe area to beareslhei2ed1he vascularily 0I1he IissuesIhe nurrbel 01 nexonaI segments 10 be blocllted indiviWaitoleranceand lhe~dnstEsia TheIaestdosagereededIOpureellectiwnslhes~

Adults lis dosageshouldnolexceed7 1111 in adulls and in generallhe rmximllTllotat dose should nOI exceed 500 mg (125 ml or7 cartridges) Chllden Dosages in children shouldbereOOedcornshymensuralewilh IheirageandlWlghL Experience in childrenyomgerlhan 4year 01 ~ has noI been doaJmenied The dosage shoold no exceed S~ body weight in Children betwee1IOO ages 014 and 12 Stability and Storage RecommendaUons Store aI coriroIled room IemperabJre (15-3OC) Protecl trom li~ Do nol use tl soIWon is jjrlltish or darIlter lhall slighUy yellow or ~ ~ cootalnsaprecipitale ASlRACAINEsolulionsarewilhoulpreseMiwandareior sing~ useooly OilcltyendtruSedportioo AVAIlABlUTY OF DOSAGE FORMS ASTRACAINE 4 FORTE (artcaine hydrochloride 40 mwmL and epinephrine inj8ion 1100XXJ) and ASTRACAINE4 (articaire hjdrochloride 40 ~ and epineltlrire injeclion l200XXJ)areavailable in denial cartridges 0I18ni in boxes 0150 Prodld Mooograph avallab~ upon request

ASTRA

ORAL HEALTHmiddot OCTOBER 1999

PROSTHODONTICS

agement as failure to appreciate this may lead to inappropriate management and ultimate failure of restorative therapy The second part of this publication will disshycuss the management of tooth wear Treatment planning strateshygies as well as case presentations will be presented W

Dr Effrat Habsha DDS completed her DDS and Prosthodontic training at the Univershysity of Toronto_ She is currently researching the effects of smoking on osseointegration She is staffprosthodonshytist at Mount Sinai Hospital an Associshyate in Dentistry University of Toronto Her practice is limited to prosthodontics and implant dentistry in Toronto

Oral Health welcomes this original article

Part II will appear in our November 1999 issue of Oral Health

REFERENCES 1 Imfeld T Dental erosion Definnion classification and

links Eur J Oral Sci 104151-155 1996 2 Smtth BGN and Knight JK M index for measuring

the wear of teeth Sr Dent J 156435-436 1984 3 Dahl BJ Carlsson GE and Ekfeldt A Occlusal

wear of teeth and restorative materials Acta Odonto Scand 51 299-311 1993

4 Johansson A and Ridwaan O Identification and Man-

Watch for these articles coming soon in the November issue of Oral Health

bull Prosthodontics bull Continuing Education

agernentoftoothwearlntJ Prosth 7506-515 1994 5 Grippo JO Abfractions A new classification of hard

tissue lesions of teeth J Esthet Dent 314-19 1991 6 Smith BG Some facets of tooth wear Ann R Aust

Coli Dent Surg 11 37-51 1991 7 Zipkin I McClure FJ Salivary citrate and dental eroshy

sion J Dent Res 28613-626 1949 8 Zero DT Etiology dental erosion-extrinsic factors

EurJOraISci104162-1771996 9 Petersen P E and Gormsen C Oral conditions

among German battery factory workers Community Dent Oral Epldemiol 19-104-106 1991

10 Centerwall BS Armstrong Cw Funkhouser GS Etzay RP Erosion of dental enamel among competishytive swimmers al a gas-chlorinated swimming pool Am J Epidemiol 123641-647 1986

11 Ecctes JD Jenkins wG Dental erosion and diet J Dent 2153-159 1974

12 James PMC Parlitt GJ Local effects of certain medicaments on the teeth Br Med J 2 1252-1253 1953

13 Smtth BGN Tooth wear aetiology and diagnosis Dent Update 16204-2121989

14 Giunta JL Dental erosion resulting from chewable vitshyamin Ctablets JAm Dent Assoc 107253-256 1983

15 Bhatti SA Walsh IF Douglas WL Ethanol and pH levels of proprietary mouthrinses Comm Dent Health 1171-741994

16 Schewel P Etiology of dental erosion-intrinsic facshytors EurJ Oral Sci 104178-1901996

17 Dodds WJ The pathogeneSis of gastroesophageal reflux disease AJR 151 49-56 1988

18 Bartlett Dand Smtth B Clinical investigations of gasshytro-oesophageal reflux Part 1 Dental update 205shy208 1996

19 Meurman JH ten Cate JM Pathogenesis and modifying factors of dental erosion Eur J Oral Sci 104199-2061996

20 Clearfield HR Roth JLA Morexia nausea and vomiting In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198548-58

21 Friedman LS KJ of Internal Medicine 12th edition New York McGraw Hili 1991 251-256

22 Goyal RK Diseases of the esophagus In Wilson JD et aI Harrisons Principles of Internal Medicine 12th edition New York McCiraw I-Ell 19911222-1229

23 Ouyang A Cohen SHeartbum regurgitation and dysshyphagia In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198559-64

III

nisIe A AIN F AT net TM AINE 4

Pr ure Vlu m T lOose lion

5-3 oral sur 1D-S4

Astracainee

ot1icoine hydnxNoride and epineplri Injedion THERAPEUTIC CLASSIACATION Local AnesIheIic lor Dental Use INDICATIONS AND CUNICAl USE ASTRACAINE (articaire hyliochloridll) isrolCalOOlaitolJDlnnslhesiamneMltlltXiltMleS1hesiainclirOCaldentistry CONlRAJNDlCATlONS Ar1icaile hjdrochloride iscooainOlcaJOO in patieols with aknowl hypersens~ivi1y 10 local areslheics 01100 amide type AI wiIh all vasocoostricIoo epir~lIire is rortraildicaIed in hypertensionlhyroloxicosis orseoereheartdiseaseprtirularlywhentKhjca((flaispresert LocalaneslhElics should noI be used in seoereshltXiltorheart block TheyshouldaJsonoibeused vilenhere is inlmlmalion or5ellSis in Ihe region 0I1he proposed injection WARNINGS RESUSCITATIVE EQUIPMENT AND DRUGS SHOULD BE IMMEDIATElY AVAIlABLE WHEN ANY LOCAl ANESTHEnC IS USED AI wilh oIher local aneslhellcs articaire hydrochloride is capable 01 prodLCing rneIheshymoglobinemia This has been obserEd wilh epidural anesIhesia txA no when used as dilllcled in denial procedures Methemoglobinemia values 01 less lhan 20 usuaHydo noI produce any clinical S)111lIoms The usual clinical signs 01 meItEmlgIobinemia arecyanosis 0I1he nail beds m lips Allhough Ihe possibilily 01 meIhemoglobinemiaoaooing indlnalpaIiamp1s isextremelyrlre RI3l be rapidly IeIlSedbylheuseoll-2~bodyweiltlolrrShyleneblllladminisleredln1Jashywnously OYer a5-miou1e period Because ASTRACAINE cOOains avasocooshyS1ricIor nshouldbe usedwilhexlrerrecautlon in palienis reeMng drugs known 10 prtxlJce blOOd pressurealieraUons (lor ~IeMAO inhibilolSlrtyclicanUshydepressanlS phenOlhiazires) as eiIhei seYere m SUSlaired hypotension orillershyifflSioomayoaur PRECAUTIONS General Thesafelyandelectivenessol kxaliIlflSItfIicsdepend~IlWlI~W18d~~~ andrtldinessloremerlJnies THE LOWESTOOSETHATRESUlTS IN EffiCTIVE Igtl-lSTHESIASHOULDBE USEDTOAVOIDHIGHPlASMALEVElSAAIlSElllOUS UNOESIRABLEAOVERSEEFFECTS INJECTIONSSHOULOBEMAOESlOWlY WITH FREQUENT ASPlRAnONSBEFOREANDOURINGTHEINJECTION nblOOd isaspiraledlhereedleshouldbe relocated TolerancevarieswilhlhesIaIUs 0I1he palient Oebililaledorelderly paUenlS acutely ill palienIs mchildren should be giwn redltud doses COfTIrerISUrale with lheir age and physical slalus Use In Pregnancy Sale use 01 articaine hylioch Ioride in preo-ool warren has nol been eslablished hOwever animal sludies have nol demonstraled leralogenic or embryoloxic eHecis Nursing Mothers Articaine hydrocllioride is rapidly fTEtIboIi2ed and eliminaledand is 1hereI0re unlilltlllylo be lransferredlo the rOOhers mil Patientswlth Spectal Dlseasesand Coodlllons ASTRACAINECOOIains avasocoostricIa and should Iherefore be used wiIh caution in Ihe presence 01 diseasesvilichmayaltMlSeyalfecllhepatienmiddotscardiovascularsytem Thedrug shoold be usedwih caJioo in persoos wiIh known drug sensRi~1ies ASTRACAINE corDnssOOlITlrnlal)isumle Sullalesmaycausealiefyicreactionsinsusceplib~ ~ The prevalence 01 sulfilesenslUvily in Ihe ~ populatioo is unknown m Plotmiy kPw1xlt i is seen morefreQuenly in~tswith broochial asthma Reations 131 ircl~~adic S)111lIorns and lile-threatening or less ~ ashmalic episodes Many drugs used during he conducl of anesthesia are consideIed poIeniiai triggering agents lor lamilial malljlnanl hyperlhenm~ II has 00en shown IhaltOO use 01 amide local anestheics in malignant h)perthenmia patients is safe HC7gtWWlhere is no guaooIee Ihat reural blocllade will prewol Ihe ~opmenl 01 malignant hyperthemlia during surgery HIs also diffKu1t 10 (Jf(fictlhereedlorSllfllen6llagereralltreilhesia ThereIoreaslandardtxttocol lor Ihe managemenl 01 malignant hyperthermia should be available Drug Interadlons Serious cardiac anl1~mias may oourn preparalionscootaining avasocoostridor are errj)loyed in palients duringorlollawing tOOadministralioo 01 chlaoform halothane Cldoproprnlrichloro-ehytere orother reialedageots Caution should be exercised when administering articaine hydrochloride cooshycanilalliy W11h oIher medicalions vilich are poIenliai prodocers 01 rmhemoghr bin (eg sulphooamkles) ADVERSE REACTIONS ReaciionstoASTRACAINE (articaine hyliochloride) are characteristic 0I11lose associated wilh ami~ local anesIheIics Adwrse reaclons may result Irom hi9l plasma lewis dill 10 excessiw dcsage rapid absorpIion a inaltMrten1 inlr3vascular injectioo or rriJy result from ah)persenslUviIy idiosyrcasy or diminished lolerance oolhepart 01 loopatienL SIdl reaclions are systemic in natureandifllOlwlhecerr31 nervous systemanVorlhecardiOVolSClJlarsystem Cenlnl NervousSystem CNS rmnishylestaionsareeamyandlor~mmaybecllRttJizedby~ dizziess blimdvisionandlrermrs loIIuoedbydrlrltlsinessCOfMJlsions uncooshysciousnessand possibly respiratory arrest The excilalory reaclions may be wry briel or may not oaur at all invilich case1he first rmnifeslallons oItoxicily may be~rrsgingnollUJldousressilllrespirmy_ CanfiovasaJIar System CanflOvaSCUlar reaclions are depresm and may be characterized by ~ion myocardial depressjooixattaroJaand possibly cardiac arrest Allergic Aliefyic reaclonsarechiYacllri2ad byataneous lesions urticara edenIa oranaphylactoid reaclionsThedeteclion 01 sensitivilyby sIltin tesling isoldoubtful value Sweiling m pelSistenl paresthesia 01100 lips and oral lissues haw been reported after blocking he interior alveolar rerve fOIl SYMPTOMS AND TREATMENT OF OVERDOSAGE PlEASE REFEII TO THE PRODUCT MONshyGRAPH DOSAGE AND ADMINISTlIA110N AI with all local aneslhetics Ihe dcsage varies and 00perds LlOOIhe area to beareslhei2ed1he vascularily 0I1he IissuesIhe nurrbel 01 nexonaI segments 10 be blocllted indiviWaitoleranceand lhe~dnstEsia TheIaestdosagereededIOpureellectiwnslhes~

Adults lis dosageshouldnolexceed7 1111 in adulls and in generallhe rmximllTllotat dose should nOI exceed 500 mg (125 ml or7 cartridges) Chllden Dosages in children shouldbereOOedcornshymensuralewilh IheirageandlWlghL Experience in childrenyomgerlhan 4year 01 ~ has noI been doaJmenied The dosage shoold no exceed S~ body weight in Children betwee1IOO ages 014 and 12 Stability and Storage RecommendaUons Store aI coriroIled room IemperabJre (15-3OC) Protecl trom li~ Do nol use tl soIWon is jjrlltish or darIlter lhall slighUy yellow or ~ ~ cootalnsaprecipitale ASlRACAINEsolulionsarewilhoulpreseMiwandareior sing~ useooly OilcltyendtruSedportioo AVAIlABlUTY OF DOSAGE FORMS ASTRACAINE 4 FORTE (artcaine hydrochloride 40 mwmL and epinephrine inj8ion 1100XXJ) and ASTRACAINE4 (articaire hjdrochloride 40 ~ and epineltlrire injeclion l200XXJ)areavailable in denial cartridges 0I18ni in boxes 0150 Prodld Mooograph avallab~ upon request

ASTRA

ORAL HEALTHmiddot OCTOBER 1999

PROSTHODONTICS

agement as failure to appreciate this may lead to inappropriate management and ultimate failure of restorative therapy The second part of this publication will disshycuss the management of tooth wear Treatment planning strateshygies as well as case presentations will be presented W

Dr Effrat Habsha DDS completed her DDS and Prosthodontic training at the Univershysity of Toronto_ She is currently researching the effects of smoking on osseointegration She is staffprosthodonshytist at Mount Sinai Hospital an Associshyate in Dentistry University of Toronto Her practice is limited to prosthodontics and implant dentistry in Toronto

Oral Health welcomes this original article

Part II will appear in our November 1999 issue of Oral Health

REFERENCES 1 Imfeld T Dental erosion Definnion classification and

links Eur J Oral Sci 104151-155 1996 2 Smtth BGN and Knight JK M index for measuring

the wear of teeth Sr Dent J 156435-436 1984 3 Dahl BJ Carlsson GE and Ekfeldt A Occlusal

wear of teeth and restorative materials Acta Odonto Scand 51 299-311 1993

4 Johansson A and Ridwaan O Identification and Man-

Watch for these articles coming soon in the November issue of Oral Health

bull Prosthodontics bull Continuing Education

agernentoftoothwearlntJ Prosth 7506-515 1994 5 Grippo JO Abfractions A new classification of hard

tissue lesions of teeth J Esthet Dent 314-19 1991 6 Smith BG Some facets of tooth wear Ann R Aust

Coli Dent Surg 11 37-51 1991 7 Zipkin I McClure FJ Salivary citrate and dental eroshy

sion J Dent Res 28613-626 1949 8 Zero DT Etiology dental erosion-extrinsic factors

EurJOraISci104162-1771996 9 Petersen P E and Gormsen C Oral conditions

among German battery factory workers Community Dent Oral Epldemiol 19-104-106 1991

10 Centerwall BS Armstrong Cw Funkhouser GS Etzay RP Erosion of dental enamel among competishytive swimmers al a gas-chlorinated swimming pool Am J Epidemiol 123641-647 1986

11 Ecctes JD Jenkins wG Dental erosion and diet J Dent 2153-159 1974

12 James PMC Parlitt GJ Local effects of certain medicaments on the teeth Br Med J 2 1252-1253 1953

13 Smtth BGN Tooth wear aetiology and diagnosis Dent Update 16204-2121989

14 Giunta JL Dental erosion resulting from chewable vitshyamin Ctablets JAm Dent Assoc 107253-256 1983

15 Bhatti SA Walsh IF Douglas WL Ethanol and pH levels of proprietary mouthrinses Comm Dent Health 1171-741994

16 Schewel P Etiology of dental erosion-intrinsic facshytors EurJ Oral Sci 104178-1901996

17 Dodds WJ The pathogeneSis of gastroesophageal reflux disease AJR 151 49-56 1988

18 Bartlett Dand Smtth B Clinical investigations of gasshytro-oesophageal reflux Part 1 Dental update 205shy208 1996

19 Meurman JH ten Cate JM Pathogenesis and modifying factors of dental erosion Eur J Oral Sci 104199-2061996

20 Clearfield HR Roth JLA Morexia nausea and vomiting In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198548-58

21 Friedman LS KJ of Internal Medicine 12th edition New York McGraw Hili 1991 251-256

22 Goyal RK Diseases of the esophagus In Wilson JD et aI Harrisons Principles of Internal Medicine 12th edition New York McCiraw I-Ell 19911222-1229

23 Ouyang A Cohen SHeartbum regurgitation and dysshyphagia In Berk JE ed Bockus Gastroenterology 4th edition Vol 1 Philadelphia WB Saunders 198559-64

III


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