DENTAL EROSION—TOOTH WEAR

1. DENTAL EROSION—TOOTH WEAR Physiology, Etiology, Epidemiology, Diagnosis, and Treatment Reviewed by:

2. Dental Erosion: Tooth Wear After viewing this lecture, attendees should be able to: • understand the oral anatomy and physiology as they relate to dental erosion/tooth wear  • identify the etiology of and risk factors associated with dental erosion/tooth wear • describe the epidemiology and prevalence of dental erosion/tooth wear • make the correct differential diagnosis and understand the management of dental erosion/tooth wear

3. Oral Anatomy and Physiology Definition (teeth): There are two definitions • Primary (deciduous) • Secondary (permanent)

4. Oral Anatomy and Physiology Dentition (teeth): There are two dentitions Primary (deciduous) • Consist of 20 teeth • Begin to form during the first trimester of pregnancy • Typically begin erupting around 6 months • Most children have a complete primary dentition by 3 years of age 1. Oral Health for Children: Patient Education Insert. Compend Cont Educ Dent.

5. Oral Anatomy and Physiology Dentition (teeth): There are two dentitions Incisors Canine (Cuspid) Secondary (permanent) • Consist of 32 teeth in most cases • Begin to erupt around 6 years of age • Most permanent teeth have erupted by age 12 • Third molars (wisdom teeth) are the exception; often do not appear until late teens or early 20s Premolars Molars Maxilla Mandible

6. Oral Anatomy and Physiology Identifying Teeth Classification of Teeth: • Incisors (central and lateral) • Canines (cuspids) • Premolars (bicuspids) • Molars Incisor Canine Premolar Molar

7. Oral Anatomy and Physiology Teeth: Identification Tooth Surfaces • Apical • Labial • Lingual • Distal • Mesial • Incisal Apical Apical Labial Lingual Distal Mesial Incisal Incisal

8. Oral Anatomy and Physiology Anatomic Crown The 3 parts of a tooth: • Anatomic Crown • Anatomic Root • Pulp Chamber PulpChamber Anatomic Root

9. Oral Anatomy and Physiology Enamel Dentin Cementum The 4 main dental tissues: Dental Pulp • Enamel • Dentin • Cementum • Dental Pulp

10. Oral Anatomy and Physiology Dental Tissues—Enamel2 • Structure • Highly calcified and hardest tissue in the body • Crystalline in nature • Enamel rods • Insensitive—no nerves • Acid-soluble—will demineralize at a pH of 5.5 and lower • Cannot be renewed • Darkens with age as enamel is lost • Fluoride and saliva can help with remineralization

11. Oral Anatomy and Physiology Dental Tissues—Dentin2 • Softer than enamel • Susceptible to tooth wear (physical or chemical) • Does not have a nerve supply but can be sensitive • Is produced throughout life • Three classifications • Primary • Secondary • Tertiary • Will demineralize at a pH of 6.5 and lower

12. Oral Anatomy and Physiology Dentin Nerve Fibers Odontoblast Cell Fluid Tubule Dental Tissues—Dentin (Tubules)2 Pulp • Presence of tubules renders dentin permeable to fluoride • Number of tubules per unit area varies depending on the location because of the decreasing area of the dentin surfaces in the pulpal direction

13. Tubules Enamel Oral Anatomy and Physiology Odontoblast RecedingGingiva ExposedDentin Dental Tissues—Dentin (Tubules)2 Association between erosion and dentin hypersensitivity3 • Open/patent tubules – Greater in number – Larger in diameter • Removal of smear layer • Erosion/tooth wear

14. Oral Anatomy and Physiology Dental Tissue—Cementum2 • Thin layer of mineralized tissue covering the dentin • Softer than enamel and dentin • Anchors the tooth to the alveolar bone along with the periodontal ligament • Not sensitive

15. Oral Anatomy and Physiology Dental Tissue—Dental Pulp2 • Innermost part of the tooth • A soft tissue rich with blood vessels and nerves • Responsible for nourishing the tooth • The pulp in the crown of the tooth is known as the pulp chamber • Pulp canals traverse the root of the tooth • Typically sensitive to extreme thermal stimulation (hot or cold)

16. Oral Anatomy and Physiology Oral Cavity/Environment4,5 • Plaque • Saliva • pH Values • Demineralization • Remineralization

17. Oral Anatomy and Physiology Oral Cavity Plaque:4,5 • is a biofilm • contains more than 600 different identified species of bacteria • there is harmless and harmful plaque • salivary pellicle allows the bacteria to adhere to the tooth surface, which begins the formation of plaque

18. Oral Anatomy and Physiology Oral Cavity Saliva:4,5 • complex mixture of fluids • performs protective functions: • lubrication—aids swallowing • mastication • key role in remineralization of enamel and dentin • buffering

19. Oral Anatomy and Physiology Oral Cavity pH values:4,5 • measure of acidity or alkalinity of a solution • measured on a scale of 1-14 • pH of 7 indicated that the solution is neutral • pH of the mouth is close to neutral until other factors are introduced • pH is a factor in demineralization and remineralization 3. Strassler HE, Drisko CL, Alexander DC.

20. Oral Anatomy and Physiology Oral Cavity Demineralization:4,5 • mineral salts dissolve into the surrounding salivary fluid: • enamel at approximate pH of 5.5 or lower • dentin at approximate pH of 6.5 or lower • erosion or caries can occur

21. Oral Anatomy and Physiology Oral Cavity Remineralization:4,5 • pH comes back to neutral (7) • saliva-rich calcium and phosphates • minerals penetrate the damaged enamel surface and repair it: • enamel pH is above 5.5 • dentin pH is above 6.5

22. Dental Erosion: Etiology Tooth Wear Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of physical loss, chemical dissolution, and/or multifactorial etiology.3,6

23. Dental Erosion: Etiology Tooth Wear • Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6 • Physical Loss • – Abrasion—mechanical • – Attrition—tooth-to-tooth contact • – Abfraction—lesions • Chemical dissolution • Multifactorial etiology

24. Dental Erosion: Etiology Tooth Wear • Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6 • Physical Loss • Chemical dissolution • – Erosion • -- Extrinsic acids • -- Intrinsic acids • Multifactorial etiology

25. Dental Erosion: Etiology Tooth Wear • Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6 • Physical Loss • Chemical dissolution • Multifactorial etiology • – Erosion • – Abrasion • – Attrition • – Abfraction

26. Dental Erosion: Etiology Abrasion The pathological wearing away of hard dental tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth.6 • Oral hygiene habits • Excessive brushing/flossing • Abrasives in dentifrices/toothpastes • Personal habits • Putting foreign objects in the mouth • Demastication • Wear from chewing food

27. Dental Erosion: Etiology Attrition The pathological wearing away of hard dental tissue as a result of tooth-to-tooth contact, with no foreign substance intervening.6 • Enamel wearing enamel • Occlusal wear • Malocclusion (buccal, lingual, and interproximal surfaces)

28. Dental Erosion: Etiology Abfraction Wedge-shaped defects at the cementoenamel junction of a tooth caused by eccentrically applied occlusal forces leading to tooth flexure that results in microfracture of enamel and dentin.6 • Loss of tooth in the cervical area • Tooth flexure – Chewing – Grinding (bruxism)

29. Dental Erosion: Etiology Erosion The physical results of a pathologic, chronic, localized loss of hard dental tissue that is chemically etched away from the tooth surface by acid and/or chelation without bacterial involvement.7 • Extrinsic acids—ingested • Food, beverages, medicine • Intrinsic acids—internal • Originate in the stomach

30. Dental Erosion: Etiology Multifactorial Tooth wear is multifactorial • One process typically impacts the other • Erosion and abrasion

31. Dental Erosion: Epidemiology Tooth erosion was described as a condition distinct from caries as early as the 18th century.8

32. Dental Erosion: Epidemiology Change in Perception In 1995, the European Journal of Oral Science stated that “dental erosion is an area of research and clinical practice that will undoubtedly experience expansion in the next decade.”9

33. Dental Erosion: Epidemiology Global Prevalence Global data on the prevalence of dental erosion is building. “Erosive tooth wear is a common condition in the developed countries.”10 UK The Netherlands Iceland Sweden Turkey Germany Ireland Japan Malaysia Switzerland China Brazil Canada United States India Saudi Arabia

34. Dental Erosion: Epidemiology Global Prevalence • European studies suggest prevalence of:11-13 • Up to 50% if all preschool children • Between 24% to 60% of school-aged children • As high as 82% in 18 to 88 years of age10 • Emerging prevalence studies providing data on gender, socio-economic status, ethnic, and culture difference in addition to the age factor will prove to be invaluable

35. Dental Erosion: Diagnosis “Diagnosis is the intellectual course that integrates information obtained by clinical examination of the teeth, use of diagnostic aids, conversation with the patient, and biological knowledge. A proper diagnosis cannot be performed without inspection of the teeth and their immediate surroundings.”14

36. Dental Erosion—Diagnosis Check list to unveil etiological factors for erosion15

37. Dental Erosion: Diagnosis Interaction of the different factors for the development of erosive tooth wear16,18 From: Lussi A. Dental Erosion: From Diagnosis to Therapy. Karger; 2006.

38. Dental Erosion: Diagnosis Clinical Appearance There is no device available for the specific detection of dental erosion in routine practice. Therefore, the clinical appearance is the most important feature for dental professionals to diagnosis dental erosion.16

39. Dental Erosion—Diagnosis Tooth Wear—Clinical Appearance17

40. Dental Erosion: Diagnosis Erosion is multifactorial • Chemical factors—erosive potential of intrinsic and extrinsic acids • Biological factors—involve properties and characteristics of the oral cavity • Behavioral factors—personal and oral habits

41. Dental Erosion: Diagnosis Chemical Factors18 • pH and buffering capacity of the product • Type of acid (pKa values) • Intrinsic (gastric origin) • Extrinsic (environmental, dietary, medicinal) • Adhesion of the products to the dental surface • Chelating properties of the products • Calcium concentration • Phosphate concentration • Fluoride concentration

42. Dental Erosion: Diagnosis Biological Factors19 • Saliva: flow rate, composition, buffering, capacity, and stimulation capacity • Acquired pellicle: diffusion-limiting properties, composition, maturation, and thickness • Type of dental substrate (permanent and primary enamel, dentin) and composition (eg, fluoride content as FHAp or CaF2-like particles) • Dental anatomy and occlusion • Anatomy of oral soft tissues in relationship to the teeth • Physiologic soft tissue movements

43. Behavioral Factors20 Dental Erosion: Diagnosis Unusual eating and drinking habits Healthy lifestyle: diets high in acidic fruits and vegetables Unhealthy lifestyle: frequent consumption of “alcopops” and designer drugs Alcoholic disease Excessive consumption of acidic foods and drinks Nighttime baby bottle feeding with acidic beverages, including milk Oral hygiene practices: frequent toothbrushing, abrasive oral care products

44. Prevention Dental Erosion: Diagnosis Loss of tooth surface is a multifactorial process and education is the first step in the line of defense.4

45. Dental Erosion: Diagnosis/Management Dynamics of Dental Erosion21 Before During After Time (Frequency) Interactions between Behavioral and Biological Factors 21. Lussi A, Kohler N, Zero D, et al.

46. Dental Erosion:Management/Etiological Factors Awareness/Association/Education Dietary factors15 • Avoid radical changes in dietary habits • Reduce acid exposure by reducing frequency and contact time of acid • Avoid acidic foods and drinks late at night • Avoid high-acidity liquids via baby bottle for infants • Avoid low pH values in food and beverages

47. Dental ErosionManagement/Etiological Factors Awareness/Association/Education Dietary factors: generally, a pH value of 5.5 or lower is capable of softening the surface of enamel in only a few minutes.3 3. Strassler HE, Drisko CL, Alexander DC.

48. Dental Erosion:Management/Etiological Factors Awareness/Association/Education Behavioral/habits15 Do not hold or swish acidic drinks in your mouth Avoid sipping acidic drinks—use a straw Avoid toothbrushing immediately after an erosive challenge (vomiting, acidic diet) Avoid toothbrushing immediately before an erosive challenge, as the acquired pellicle provides protection against erosion Use a soft toothbrush

49. Dental Erosion:Management/Etiological Factors Awareness/Association/Education Behavioral/Habits15 Use a low-abrasion fluoride-containing toothpaste; high-abrasive toothpaste may destroy pellicle Avoid toothpastes or mouthwashes with too-low pH After acid intake, stimulate saliva flow with chewing gum or lozenges Use chewing gum to reduce postprandial reflux Refer patients or advise them to seek appropriate medical attention when intrinsic causes are involved

50. Dental Erosion:Management/Etiological Factors Awareness/Association/Education Gastroesophageal Origin22 • Heartburn and other symptoms of reflux • Regurgitation • Dysphagia • Asthma • Rumination • Eating disorders (anorexic or bulimia)