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Tooth Tissue Loss - Erosion,

Abrasion, Attrition and


Abfraction; we wonder why
our teeth are sensitive!
Sonia Jones RDH CFET
South West Post Graduate Dental Deanery
DCP Advisor Devon/Cornwall
sonijones@hotmail.co.uk
www.bristol.ac.uk/dentalpg

Aims and Objectives


Aim: to ensure delegates understand how tooth tissue
loss can be detrimental to dentine hypersensitivity
Objectives:
By the end of the session you should be able to:
Distinguish between erosion, abrasion, attrition and
abfraction
Determine the causative factors of tooth tissue loss
Describe how to prevent further tooth tissue loss
Discuss sensitivity theories and explain the way they
work
List topical medicaments available to relieve sensitivity

Tooth tissue loss


Tooth surface loss can arise as the
result of:
Erosion
Abrasion
Attrition
Abfraction

Erosion

Abrasion

Attrition

Abfraction

Tooth tissue loss

Patients often seek treatment for pain


Function can be altered
Compromised aesthetics
All ages

Tooth tissue loss

The 4 types of tooth tissue loss all have


their own characteristic appearance
However, the wear of a persons teeth is
usually from a mixture of all 4, with one
type of TTL predominating.
Sometimes difficulty in determining the
dominant aetiology
The thickness of the pellicle and the
pressure of the tongue contribute to the
extent of the condition

Tooth Tissue Loss

Relatively slow progression

Study models
Indices
Photographs
Can all be helpful

Restorative treatment
Difficult to control
Very different to dental caries in
appearance and causation

Erosion

Described as early as 1892 among Sicilian


lemon pickers

Definition: The loss of tooth tissue by a


chemical process that does not involve
bacteria, acids are most commonly
involved in the dissolution process

Non carious pathological loss of tooth


tissue
Plaque not involved in the process

Clinical Presentation

Occurs most frequently on the palatal


and labial surfaces of the incisor
teeth
The effected surfaces appear smooth
and highly polished with a scooped
out depression
The lesion primarily occurs in the
enamel
In more severe cases the dentine
becomes exposed
As enamel loss progresses sensitivity

Erosion

Erosion

Causes of erosion

Extrinsic factors
Intrinsic factors
Idiopathic factors

Extrinsic causes of erosion

Habitual consumption of highly


acidic, low pH carbonated drinks,
sports drinks or concentrated fruit
juices
Alco pops, fruit flavoured alcoholic
beverages and strong ciders
Causing a wide shallow lesion
effecting the labial and palatal
surfaces of the upper teeth

Extrinsic causes of erosion

Swishing or holding drinks in the


mouth
Modern packaging has also been
blamed, tetra pack, plastic bottles
and cans directional flow onto teeth
Can extend from the labial and
palatal lesions of the upper teeth to
all surfaces of all teeth

Chemicl pH

Acids involved

The principal ingredient linked with erosion is


citric acid, found in most fruit juices and soft
drinks
Other fruit acids have an effect
The erosive effect is due to its low chemical pH
Also by chelation, the acids demineralise the
enamel by binding to the calcium and removing
it from the enamel
Cola type drinks may also contain phosphoric
acids
While the pH of a drink is an indicator of its
erosive potential, a measure called total
titratable acidity is a better guide of how a
liquid can dissolve a mineral

Total Titratable Acidity

Titratable acidity

How long it takes for the saliva to


compensate
How much saliva (flow)
Buffering capabilities of the saliva
Citric acid the biggest culprit
Thickness of the pellicle can protect
to a degree
Higher temperatures increase
titratable acidity

Extrinsic causes of erosion


Habitual sucking of citrus fruits
The lesion may occur in either the upper
or lower anterior teeth
Depending on the way the fruit is eaten
(Remember fruit eaten as a whole unit
does not generally cause a problem)

Acidic foods
Pickles, sauces, vinegars, yoghurts,
roasted vegetables

Extrinsic causes of erosion

Industrial atmospheric pollution


Chemical workers, battery
manufacturers, crystal glass workers
Less common now due to stricter
working conditions and regulations
(H&S at work act 1978)
Acidic fumes effect the labial surfaces
of the upper and lower anterior teeth
When talking or the mouth is at rest

Extrinsic causes of erosion

Chlorine, from gas chlorinated


swimming pools
Professional swimmers
If the chemicals are not properly
regulated
Less common now due to regulations

Intrinsic causes of erosion


From within the body
Usually hydrochloric acid from the
stomach (pH 2)
Reflux
Regurgitation
Vomiting
Rumination

Rumination
The term rumination is derived from
the Latin word ruminare, which
means to chew the cud. Rumination
is characterized by the voluntary or
involuntary regurgitation and
rechewing of partially digested food
that is either reswallowed or
expelled. This regurgitation appears
effortless, may be preceded by a
belching sensation, and typically

Reflux, Regurgitation and Vomiting


of gastric contents

Anorexia
Bulimia
Hiatus Hernia
Pregnancy/Hormones
Motion sickness
Obesity
Eating too much
Drinking too much
Alcoholism

Anorexia

Bulimia

Saturday Night?

Habitual regurgitation of gastric


contents

Heavily acidic diet increases gastric


erosion
The palatal surfaces of the upper
anteriors and premolars are eroded
Produces wide shallow lesions
Enamel may be completely lost
Tackle the problem with care!
Patient might not admit to
unattractive aspect of psychological
illness

Idiopathic causes of
erosion

Unknown cause
Patient will not admit to or be aware
of intrinsic or extrinsic causes
Vigorous tooth brushing can
contribute to an over polished
appearance - shiny

Abrasion
Definition: The abnormal wearing
away of tooth tissue by a mechanical
process
The location and pattern of abrasion
is directly dependent upon its course
It usually occurs on the exposed root
surfaces when gingival recession has
exposed the cementum
It may be seen on the incisal or
inteproximal surfaces of the teeth

Causes of Abrasion
Incorrect

or destructive use of a toothbrush


Use of an abrasive detrifice
The enamel and dentine is worn away to produce a
V shaped notch at the neck of the tooth
Areas most affected are the labial and buccal
surfaces of the canines and premolars
Powerful back hand, RHS of right handed person
LHS of Left handed person
Para

functions, habits, occupations

Mainly affects the incisal edges of the anterior teeth

Clinical appearance of
Abrasion

Worn, shiny often yellow/brown areas


at the cervical margin
Worn notches on the incisal surfaces
of the anterior teeth

Abrasion

Abrasion

Causes of Abrasion

Seamstresses pins, Carpenters


nails, Hairdressers hairgrips
Pipe smokers, nail biters, causing
notching

Attrition
Definition: The physiological wearing away
of the tooth surface as a result of tooth to
tooth contact as in mastication
Occlusal and incisal surfaces of the teeth
most commonly affected
May also affect the proximal surfaces of
the teeth due to slight movement of the
teeth in their sockets during mastication
Age related process
Varies from person to person

Attrition
Causes:
Bruxism
Abrasive (gritty) diet
Constant chewing tobacco/ betel
nut
Marked malalignment or
malocclusion
Loss of posterior teeth
Occupational, dust/grit mixed with
saliva

Clinical appearance of
Attrition

Polished facets on enamel surfaces


Cupping dentine is exposed
Occasional full loss of enamel,
dentine is exposed and stains heavily

Attrition

Attrition

Ranges from part of the enamel


being worn away in the early stages
to the full thickness of the enamel
wearing away in advanced attrition
The dentine may be exposed and
stained
In extreme cases the teeth may be
worn down to the gingivae

Attrition

Attrition

Process of attrition is slow


Secondary dentine is laid down to protect the
pulp chamber and the pulp chamber narrows
Pain is rarely associated with attrition
Men usually show a greater degree of attrition
than women
Severe attrition is seldom seen in deciduous
teeth, (not retained for long)
However if a child suffers from dentinogenesis
imperfecta (an hereditary disorder of the
dentine) pronounced attrition may result from
mastication

Abfraction
Definition: The pathological loss of enamel
and dentine due to occlusal stresses
Recently interest has grown in the
development of cervical abrasive lesions
The term abfraction has been used to
describe these cervical lesions

Some Clinicians do not believe that this is


the reason and that erosion and abrasion
cause the wear facets, research continues

Abfraction

Causes of Abfraction

Occlusal forces which cause the tooth to flex,


cause small enamel flecks to break off, inducing
the abrasive lesions
Usually wedge shaped lesions with sharp angles
found at the cervical margins
However can be found on the occlusal surfaces,
presenting as circular areas
These lesions can occur with occlusion alone or
as with most TTL cases which are multi factorial,
can be associated with toothbrush abrasion
These lesions are often diagnosed as toothbrush
abrasion, but they differ as their angles are
sharper

Abfraction
Common in patients with poor tooth
alignment
Can be associated with:
Anterior open bite
Occlusal restorations that change the
cuspal movements
Abnormal tongue movement

Treatment of Tooth Tissue


Loss
1.
2.

3.

4.
5.
6.

Relieve sensitivity and pain fluoride,


desensitising agents/toothpastes
Identify aetiological factors modify
diet/habits, eliminate acidic foods/drinks,
stop habitual practices, gentle tooth
brushing techniques
Protect the remaining tooth tissue
reconstruct the effected teeth, restorations,
inlays/onlays, crowns, check occlusion
Bite raising devices/splints
Referral to TTL Expert
Prevention of further episodes

Treatment Plan

Take a detailed history from the


patient
Examination
Radiographs
Vitality testing
Patients wishes/needs
Study models
Photographs
Indices

Indices BEWE

Basic Erosive Wear Examination

0 No Erosive Wear
1 Initial loss of Surface texture
2 Distinct defect, hard tissue <50% of
the surface area
3 Hard tissue loss >50% of the
surface area
* (2,3) dentine involved

Tooth wear index according to Smith and Knight


Score Surface Criteria
0
C
1
C
2
C
3
C
4
C

B/L/O/I No loss of enamel surface characteristics


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

Sensitivity
Dentine Hypersensitivity Dentine is the highly
sensitive part of the tooth
Patients suffering from dentine hypersensitivity
often think that they have developed a cavity or
lost a filling
On examination there is often no obvious reason for
their pain, gingival recession is sometimes evident
The amount of recession does not seem to correlate
with the amount of pain they are experiencing
c/o short sharp episodes of pain caused by
temperature, touch by metal, sweet foods/drinks
Patients can be very distressed by the pain of
dentine hypersensitivity and often avoid the
causative stimuli as much as possible

Sensitivity

Women more pre disposed than men


Age 20-40
Ranges from 15-70

Dentine

Made up of dentinal tubules


Looks like honeycomb under the
microscope
Similar in composition to bone
Can remodel itself and lay down
reparative and secondary dentine
When exposed to the oral
environment can be sensitive

Dentine

Larger tubules = more pain


More open tubules = more sesitivity

Dentinal tubules

Dentine Hypersensitivity
Theories
3 theories as to how we feel the pain
of dentine hypersensitivity
1.
2.
3.

Dentine Innervation Theory


Odontoblast receptor theory
Hydrodynamic theory

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

Odontoblast Receptor
Theory
Proposes that Odontoblasts receive
and pass on impulses and that when
they are touched cause the sensation
of pain
Not the most likely theory: as there are
no synapses between the
Odontoblasts and the Nerve Plexus of
Raschkow
(Synapses junctions between
neurones where chemicals transmit

Hydrodynamic Theory
Most likely theory: Answers more questions
Lymph like fluid inside the dentinal tubules is
stimulated by temperature, touch and sweet
sensations, causing it to flow backwards and forwards
within the tubules, this gives the sensation of pain
Hot/cold causes expansion/contraction causing the
fluid to flow
Salt/sweet causes osmotic pressure, flows towards
the concentrate
Tactile/Electrical (Touch) ?! contraction of the fluid?
Research continues, what they do know is how to treat
it

Dentine Hypersensitivity
Treatments
Most commonly treated by:
Mechanical Barriers
Stimulation of Peritubular or Reactive
Dentine
Increasing potassium concentrations

Mechanical Barriers

Applied over the open ends of the


Dentine Tubules
Restorations Glass ionomers,
Composites, Inlays/Onlays, Dentine
bonding agents that form a chemical
bond with the dentine locking into
the tubules, Resins/Adhesives
Tubule occluding toothpastes need
to be replaced daily

Stimulation of Peritubular or
Reactive Dentine
The dentine lays down a protective
layer
High concentration fluoride
Duraphat Varnish, Gel Kam
(Fluorigard gel)
Siloxane Esters Tresiolan, Sensitrol
etc
Both will wear off so need to be
reapplied

Fluoride

Fluoride irritates the dentine


It irritates the dentine sufficiently for it to
lay down a secondary layer and therefore
protect the tooth from further stimuli
It does this by occluding the tubules
Mouthwashes daily 0.05% and weekly
0.2% solutions
High fluoride toothpastes - Duraphat
2800, 5000
Varnishes Duraphat 2.26% 22,000ppm
Gels 0.4% stannous fluoride

Increase Potassium Concentrations


Nerve Depolarising
Potassium chloride, Potassium
Nitrate, Potassium Citrate found in
desensitising toothpastes increase
the potassium concentrations around
the nerve plexus
This prevents action potentials being
transmitted (nerve impulses)
By keeping the sodium outside the
cell wall

Nerve Impulses

Sodium is attracted to Potassium


By increasing the Potassium levels
outside the nerve cell walls, the
Sodium stays outside and doesnt
diffuse in
This stops the nerve impulse
Depolarisation

Action Potentials Nerve Impulses

Sodium Potassium
Exchange

Toothpaste Claims

Nerve Depolarising Toothpastes


Tubule Occluding Toothpastes

Each manufacturer claims that their


toothpaste has the best technology
Do they work?

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

Sensodyne Pronamel

Claims to reharden softened enamel


- be low in abrasives to
prevent further tooth tissue loss

Active ingredient Potassium Nitrate


+ Sodium Fluoride
?

Sensodyne new Occluding


toothpaste

Sensodyne Rapid Relief


Active Ingredient Strontium Acetate +
Sodium Mono-fluorophosphate
Published studies support the mode of
action and tubular occlusion occurs

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

Colgate Sensitive Pro


Relief

Pro Argin Technology


Active Ingredients: Arginine, Calcium
Carbonate, Hydroxyapatite, Sodium Monofluorophosphate
The Arginine complex binds to the tooth
surface, it is positively charged this is
attracted to the negatively charged dentine
It encourages a calcium rich mineral layer
into the open (exposed) dentine tubules
This acts as an effective plug (tubular
occlude)
Resistant to acid attacks
Needs to be reapplied twice daily

Other Brands
Enamel Care toothpaste - Amorphous Calcium
Phosphate ACP (soluble salts of Calcium and
Phosphate): highly soluble and there is limited
data in the treatment of Dentine Hypersensitivity
Recaldent (Toothmoose) CCP-ACP Casein
Phosphates, derived from milk proteins mixed with
the calcium and phosphate salts: no apparent
published clinical data on its effects of reducing
Dentine Hypersensitivity
Blanx, Biorepair- Hydroxyapatite + Sodium Monofluorophosphate: tubular occlusion but limited
published data

Monitoring

Treatment of active tooth tissue loss


Fluoride toothpastes/
mouthwashes/gels
De sensitising toothpastes
Study models
Photographs
Indices
Identify causative factors

Prevention

Limit acidic food and drink to meal times


Eliminate from diet
Cut down on carbonated beverages
Eat citrus fruits whole not sucked in 1/4s
Do not hold/swish drinks
Use a straw
Refer to specialist
Refer to councillor for eating
disorders/alcohol addiction
Refer to GP gastric problems
Milk or cheese after meals to neutralise acids
Avoid toothbrushing after an acid attack

Aims and Objectives


Aim: to ensure delegates understand how tooth tissue
loss can be detrimental to dentine hypersensitivity
Objectives:
By the end of the session you should be able to:
Distinguish between erosion, abrasion, attrition and
abfraction
Determine the causative factors of tooth tissue loss
Describe how to prevent further tooth tissue loss
Discuss sensitivity theories and explain the way they
work
List topical medicaments available to relieve sensitivity

Thank you