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Pickard's Manual-Tooth Wear (Dragged)

Pickard's Manual-Tooth Wear (Dragged)

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Published by Adit Mehta

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Published by: Adit Mehta on Sep 23, 2012
Copyright:Attribution Non-commercial


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1Why restore teeth?
with the surface plaque-free after home cleaning. Ifthis isconsistently not achieved, consideration should be given tofissure sealing the surface with a resin to obliterate thegroove fossa system, thus aiding plaque control.Where a bitewing radiograph shows an approximal lesionin the outer enamel, the patient should be shown how to usedental floss.Root surface lesions are just as amenable to control bymechanical plaque control as coronal lesions. Pay particularattention to the approximal surfaces ofteeth next to a den-ture. Patients need to be shown how to angle the toothbrushto reach these areas or, alternatively, use strips ofcottongauze or cloth in a similar manner to flossing to remove thegross plaque from these hard-to-reach areas (Fig. 1.18).
 Use of fluoride
The dentist should check that the patient is using a fluoridetoothpaste. Some products formulated for sensitive teeth andsome herbal toothpastes do not contain fluoride. The pasteshould be used twice daily and cleared from the mouth byspitting rather than vigorously rinsing. A fluoride mouth-rinse (0.05% sodium fluoride) used every day is a usefulfluoride supplement in a high risk patient, although the costofthe product may preclude its use by some patients.Surgery application offluoride varnish is a sensible pre-ventive measure and particularly valuable in those unlikelyto comply with a daily mouthwash regime.
 Dietary advice
Dietary advice should be given based on a diet sheet. Figure1.36 shows a diet sheet completed by a middle-aged patientwith a high incidence ofcaries. The sugar attacks have beenhighlighted. Note the frequency ofsugar intake. This gives thedentist the opportunity to explain the Stephan curve (Fig. 1.2)and the importance ofdecreasing the frequency ofsugarintake. The dentist should try to get the patient to suggestchanges. This approach helps the patient to set realistic goalsand enables the dentist to see whether the relationship betweendiet and caries has been understood by the patient. The dentistshould check that the main meals are adequate, and a list of foods that are safe for teeth may be helpful here. The negotiat-ed dietary change should be recorded on paper so that thepatient can take this away and ponder at leisure. The dentistshould record the goals agreed in the notes so that specificenquiry can be made at the next visit. A reasonable aim for thispatient would be to try to confine sugar to mealtimes.
Salivary flow
Salivary flow should be measured because a feeling ofa drymouth may be subjective rather than actual.When the salivary glands are capable ofsecreting, chew-ing gum stimulates salivary flow. A chewing gum with anartificial sweetener (sorbitol or xylitol) should be chosen inpreference to a sugar-containing gum. Ofthe two artificialsweeteners, xylitol seems the better as this product may sup-press counts ofsome acidogenic micro-organisms.Sometimes patients with a dry mouth suck sweets or sipsweet drinks to alleviate the problem. This is obviously veryunwise in patients who are already at high risk to cariesbecause they are short ofsaliva.
Operative treatment
The role ofoperative dentistry in the management ofden-tal caries is to facilitate plaque control. Tooth restorationalso restores:appearanceformfunction.
Caries in pits and fissures
Uncavitated lesions can be controlled by mechanical plaquecontrol with a fluoride-containing toothpaste. Where apatient cannot or will not remove plaque, a fissure sealant isa wise intervention to prevent plaque stagnation.Cavitated lesions should be visible in dentine on a bitew-ing radiograph and should be treated operatively becausethe patient will be unable to clean plaque out ofthe hole inthe tooth.
Approximal lesions
The diagnosis ofcavitation was discussed on p. 14.Cavitated lesions need operative treatment because even themost fastidious offlossers cannot clean plaque out ofthehole – the floss simply skates over the top.In anterior teeth, approximal lesions may be unsightlybecause the demineralized dentine appears black or brown.This would be a reason to restore, even ifno cavity waspresent.
Smooth surfaces and root caries
Many smooth surface lesions, including cavitated ones, canbe arrested by preventive, non-operative treatment. Lesionswhich are plaque traps or unsightly should be restored.
Tooth wear
Tooth wear is defined as the surface loss ofdental hard tis-sues other than by caries or trauma, and is sometimes called‘tooth surface loss’ (TSL). This distinguishes it from earlyenamel caries that is characterized by
loss ofmin-erals beneath a relatively intact surface zone. The term‘tooth wear’ is preferred to ‘tooth surface loss’ because it iseasily understood by patients and because the extensively
2    1    
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Fig. 1.36
A diet sheet completed by a middle-aged patient with a high incidence ofcaries. The frequent sweet drinks, sweets, and the pre-bed sweet drink and snack are a potential cause of caries in this mouth. Note the frequency ofsugar intake – eight times per day.
1Why restore teeth?
worn teeth lose a good deal more than just their surface(Fig. 1.37).Tooth wear occurs naturally throughout life and so it iscommon to find moderate degrees ofwear in older people.What is remarkable is that they do not wear more. Enamel isone ofthe few tissues in the body that does not regenerate orreplace itselfin the way that skin, blood cells, and fracturedbones do. Fortunately, the dentine does show some reparativemechanisms insofar that reactionary or reparative dentine willbe laid down in the pulp chamber as a response to tooth wear,even though it cannot ofcourse replace itselfonce worn awayfrom an exposed surface in the mouth. Teeth are in use everyday and it is an impressive feat ofnature that in most patientsthey do not wear out, even after several decades ofuse.However, sometimes the wear becomes excessive as a resultofone or more ofthe following causes: erosion, attrition, andabrasion.
This is defined as the loss ofdental hard tissue as a result of a chemical process not involving bacteria. The chemical isacid and the source is either regurgitated stomach acid oracid from the diet.
Regurgitated acid 
is the most common cause oferosionand causes the most damage. Previously dentists thoughtthat dietary erosion was the most common. This is becauseit is easy to take a dietary history from a patient and they arelikely to be truthful about their diet. In contrast, many oftheconditions which cause regurgitation erosion are embar-rassing and some patients do not readily talk about them.These include eating disorders (Fig. 1.38a), chronic alco-holism (Fig. 1.38b), and even the less polite symptoms of indigestion. Some patients suffer from gastro-oesophagealreflux disease (GORD), which can cause dental erosion, andyet they have no other symptoms other than their toothwear. Gastroenterologists call these patients ‘silent refluxers’and they can be identified by tests carried out by these spe-cialists. There is also a group ofpatients who voluntarilyregurgitate their stomach contents, chew, and then swallow.These ruminants may be embarrassed to admit to a habitthat is natural to them but others may find strange. The den-tal devastation is extreme.Although regurgitation usually first affects the palatalsurfaces, it often also causes strange unexplained cupped-out lesions in molar teeth, starting with the tips ofcusps(Fig. 1.39).
Dietary acid 
does produce erosion but it is not entirelyclear that this is always the result ofthe acid entering themouth and contacting the teeth. In some cases there may bea secondary effect, particularly with fizzy drinks whichintroduce gas into the stomach which, in turn, comes backinto the mouth carrying not only the acidic fizzy drink butalso the stomach acid.In chronic alcoholic patients there is good evidence that thealcohol produces damage to the stomach lining, which in turnresults in regurgitation ofacid. Therefore it is the acid comingback rather than the alcohol itselfwhich causes the erosion(Fig. 1.38b).In the past, industrial acids in the form ofvapour ordroplets in the air caused dental erosion and this was investi-
Fig. 1.38
(a)Regurgitation erosion affecting the palatal surfaces oftheupper incisor and premolar teeth. This was due, in this case, to bulimianervosa. The patients commonly overeat and then deliberately vomit in anattempt to maintain a low body weight.(b)Posterior teeth with severe palatal erosion, particularly ofthe firstmolar teeth. The patient was a chronic alcoholic.(a)(b)
Fig. 1.37
Extensive wear.

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