Sonia Jones RDH CFET South West Post Graduate Dental Deanery DCP Advisor Devon/Cornwall sonijones@hotmail.co.uk www.bristol.ac.

uk/dentalpg

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

Patients often seek treatment for pain Function can be altered Compromised aesthetics All ages

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

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

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

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 to thermal changes are noticed More persistent pain occurs in severe cases

Extrinsic factors Intrinsic factors Idiopathic factors

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

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

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

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

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

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

Chlorine, from gas chlorinated swimming pools Professional swimmers If the chemicals are not properly regulated Less common now due to regulations

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

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

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

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

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

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

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

Worn, shiny often yellow/brown areas at the cervical margin Worn notches on the incisal surfaces of the anterior teeth

Seamstresses pins, Carpenters nails, Hairdressers hairgrips Pipe smokers, nail biters, causing notching

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

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

Polished facets on enamel surfaces Cupping dentine is exposed Occasional full loss of enamel, dentine is exposed and stains heavily

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

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

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

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

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

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

Take a detailed history from the patient Examination Radiographs Vitality testing Patients wishes/needs Study models Photographs Indices

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

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

Women more pre disposed than men Age 20-40 Ranges from 15-70

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

Larger tubules = more pain More open tubules = more sesitivity

3 theories as to how we feel the pain of dentine hypersensitivity

1. 2. 3.

Dentine Innervation Theory Odontoblast receptor theory Hydrodynamic 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 pass on impulses

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 the impulse)

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

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

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

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 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

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

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

Nerve Depolarising Toothpastes Tubule Occluding Toothpastes

Each manufacturer claims that their toothpaste has the best technology Do they work?

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

Claims to reharden softened enamel - be low in abrasives to prevent further tooth tissue loss Active ingredient Potassium Nitrate + Sodium Fluoride ?

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

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

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

Treatment of active tooth tissue loss Fluoride toothpastes/ mouthwashes/gels De sensitising toothpastes Study models Photographs Indices Identify causative factors

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

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