Epidemiology, aetiology and prevention of tooth wear.

Tooth wear is a commonly reported finding globally; however, many patients are unaware of having tooth wear. Identifying early signs of erosion, abrasion or attrition and determining the risk factors contributing to a patient's tooth wear may help to prevent further loss of enamel and dentine in the future. Appropriate prevention should be instigated, or appropriate referral made to other health professionals, when conditions such as gastroesophageal reflux or eating disorders are suspected. This paper presents the epidemiology and aetiological factors for tooth wear, as well as identifying the common clinical presentations of tooth wear. Patient perspectives on tooth wear and preventive techniques that can be utilised are also discussed.

Minimally invasive rehabilitation of the worn dentition: a case report utilising adhesive additive techniques and digital technologies.

The management of the worn dentition presents an increasing challenge that is encountered more frequently in daily dental practice. The consequences of tooth wear tend to be multifactorial and while they may initially only involve the loss of surface enamel it can progressively lead to significant destruction of the dentition. This paper discusses the management of a tooth wear case where a significant amount of tooth structure has been lost from both the anterior and posterior teeth. Protocols for assessment, treatment planning and restorative management of the tooth wear case are presented demonstrating the use of adhesive additive techniques and digital technologies to achieve functional and aesthetic rehabilitation of the dentition.

Lesiones cervicales no cariosas / Non-carious cervical lesions

El objetivo de este trabajo consiste en describir las distintas lesiones cervicales no cariosas, la abrasión, la erosión y la abfracción. Se desarrollarán en detalle su etiología, localización y características clínicas. Se mencionarán los diferentes procedimientos a realizar para su prevención y los materiales a utilizar para su restauración.

This article describes the different types of non-cariouscervical lesions, for example abrasion, erosionand abfraction. We will discuss their etiology, location and clinical features in detail. We will describe the procedures to prevent them, aswell as the materials used for their restoration.

Oral astringent stimuli alter the enamel pellicle's ultrastructure as revealed by electron microscopy.

OBJECTIVES: This electron microscopic study aimed at investigating effects of oral astringent stimuli on the enamel pellicle's morphology. METHODS: Pellicles were formed in situ within 30min on bovine enamel slabs, fixed to individuals' upper jaw splints. The pellicle-coated specimens were immersed in vitro in seven diverse astringent solutions and subsequently analyzed by scanning electron microscopy (SEM), energy dispersive X-ray (EDX) spectroscopy, as well as transmission electron microscopy (TEM). Four biocompatible astringents, namely the polyphenol epigallocatechin gallate, the metal salt iron(III) sulfate, the basic protein lysozyme, and the aminopolysaccharide chitosan, were additionally applied in situ. After rinsing the oral cavity with these compounds, the pellicle's ultrastructure was imaged by SEM and TEM, respectively. Untreated pellicle samples served as controls. RESULTS: Exposure to polyphenols and lysozyme induced particularly thicker and electron-denser pellicles in comparison to the control pellicle with similar characteristics in vitro and in situ. In contrast, acidic chitosan and metal salt solutions, respectively, revealed minor pellicle alterations. The incorporation of Fe and Al into the pellicles treated with the corresponding inorganic salts was verified by EDX analysis. CONCLUSIONS: Astringent-induced pellicle modifications were for the first time visualized by TEM. The ultrastructural alterations of the dental pellicle may partly explain the tooth-roughening effect caused by oral astringent stimuli. CLINICAL SIGNIFICANCE: Astringents might modify the pellicle's protective properties against dental erosion, attrition, as well as bacterial adhesion, and by this means may influence tooth health. The findings may thus be particularly relevant for preventive dentistry.

The tooth wear evaluation system: a modular clinical guideline for the diagnosis and management planning of worn dentitions.

Tooth wear is a multifactorial condition, leading to the loss of dental hard tissues, viz. enamel and dentine. Tooth wear can be divided into the subtypes mechanical wear (attrition and abrasion) and chemical wear (erosion). Because of its multifactorial aetiology, tooth wear can manifest itself in many different representations, and therefore, it can be difficult to diagnose and manage the condition. A systematic approach is a sine qua non. In the below-described tooth wear evaluation system (TWES), all necessary tools for a clinical guideline are present in different modules. This allows the dental clinician, in a general practitioner setting as well as in a referral practice setting, to perform a state-of-the-art diagnostic process. To avoid the risk of a too cumbersome usage, the dental clinician can select only those modules that are appropriate for a given setting. The modules match with each other, which is indispensable and essential when different modules of the TWES are compared. With the TWES, it is possible to recognise the problem (qualifying), to grade its severity (quantifying), to diagnose the likely causes and to monitor (the progress of) the condition. In addition, a proposal for the classification of tooth wear is made. Further, it is possible to determine when to start a treatment, to make the decision which kind of treatment to apply and to estimate the level of difficulty of a restorative treatment.

Common dental and periodontal diseases: evaluation and management.

Physicians may encounter patients with dental and periodontal diseases in the context of outpatient medical practice. It is important for physicians to be aware of common dental and periodontal conditions and be able to assess for the presence and severity of these diseases. This article reviews common dental and periodontal conditions, their cardinal signs and symptoms, outpatient-setting assessment techniques, as well as common methods of treatment. Physicians detecting gross abnormalities on clinical examination should refer the patient to a dentist for further evaluation and management.

Enamel mineral loss.

OBJECTIVES: To summarise the chemical, biological and host factors that impact enamel mineral loss, to highlight approaches to contemporary management of clinical conditions involving mineral loss and summarise emerging trends and challenges in this area. DATA SOURCES: "Medline" and "Scopus" databases were searched electronically with the principal key words tooth, enamel, *mineral*, caries and erosion. Language was restricted to English and original studies and reviews were included. Conference papers and abstracts were excluded. CONCLUSIONS: Enamel mineral loss leads to the degradation of the surface and subsurface structures of teeth. This can impact their shape, function, sensitivity and aesthetic qualities. Dental caries is a multifactorial disease caused by the simultaneous interplay of dietary sugars, dental plaque, the host and time. There is a steady decline in dental caries in developed countries and the clinical management of caries is moving towards a less invasive intervention, with risk assessment, prevention, control, restoration and recall. Tooth wear can be caused by erosion, abrasion and attrition. Dental erosion can be the result of acid from intrinsic sources, such as gastric acids, or extrinsic sources, in particular from the diet and consumption of acidic foods and drinks. Its prevalence is increasing and it increases with age. Clinical management requires diagnosis and risk assessment to understand the underlying aetiology, so that optimal preventative measures can be implemented. Overall, prevention of enamel mineral loss from caries and tooth wear should form the basis of lifelong dental management. Evidence based oral hygiene and dietary advice is imperative, alongside preventive therapy, to have a healthy lifestyle, whilst retaining hard tooth tissue.

Critical role for αvß6 integrin in enamel biomineralization.

Tooth enamel has the highest degree of biomineralization of all vertebrate hard tissues. During the secretory stage of enamel formation, ameloblasts deposit an extracellular matrix that is in direct contact with the ameloblast plasma membrane. Although it is known that integrins mediate cell-matrix adhesion and regulate cell signaling in most cell types, the receptors that regulate ameloblast adhesion and matrix production are not well characterized. We hypothesized that αvß6 integrin is expressed in ameloblasts where it regulates biomineralization of enamel. Human and mouse ameloblasts were found to express both ß6 integrin mRNA and protein. The maxillary incisors of Itgb6(-/-) mice lacked yellow pigment and their mandibular incisors appeared chalky and rounded. Molars of Itgb6(-/-) mice showed signs of reduced mineralization and severe attrition. The mineral-to-protein ratio in the incisors was significantly reduced in Itgb6(-/-) enamel, mimicking hypomineralized amelogenesis imperfecta. Interestingly, amelogenin-rich extracellular matrix abnormally accumulated between the ameloblast layer of Itgb6(-/-) mouse incisors and the forming enamel surface, and also between ameloblasts. This accumulation was related to increased synthesis of amelogenin, rather than to reduced removal of the matrix proteins. This was confirmed in cultured ameloblast-like cells, in which αvß6 integrin was not an endocytosis receptor for amelogenins, although it participated in cell adhesion on this matrix indirectly via endogenously produced matrix proteins. In summary, integrin αvß6 is expressed by ameloblasts and it plays a crucial role in regulating amelogenin deposition and/or turnover and subsequent enamel biomineralization.

Attrition and erosion: assessment and diagnosis.

The management of patients with extensively worn and badly broken down dentitions presents a difficult challenge in dental practice and restorative treatments are often complex, time consuming and costly to implement, so careful case selection and treatment planning is essential. Ultimately the success of any restorative intervention is very dependent on the stability of the oral environment and the status of the remaining tooth structure. Prior to the commencement of any restorative treatment an understanding of the importance of the disease process, the risk factors in the mouth, and the intrinsic and extrinsic factors which affect the oral balance is critical. While there is a growing range of materials and techniques available for cost effective and conservative management of these cases, failure to take a systematic approach to assessment and stabilization may result in early restorative failure, rapid recurrence of the problems and a repeat restoration cycle. Therefore successful management of these patients must include an appropriate mix of preventive and restorative strategies.

Attrition and erosion: restorative planning and performance.

The number of patients presenting with severe attrition and associated erosion is increasing in frequency. Treatment of this patient group is very challenging as it is simply not just a case of replacing lost tooth tissue, but also trying to identify and then eliminate the aetiological factors responsible for the loss of tooth structure. In most cases restorative treatment involves extensive rehabilitation of the dentition to restore the aesthetics and function and also to prevent further tooth loss. Such treatment often involves a multidisciplinary approach to eliminate and/or reduce causative factors prior to definitive restoration of teeth. Treatment needs to focus on quick intervention when the problem has been identified and diagnosed. Restorative treatment involves careful if not complex planning culminating in the establishment of a well defined and ongoing maintenance plan. Long-term success of treatment is centred on the maintenance phase. Current restorative options include the use of extensive resin composite build-ups. This is often the best initial starting point as it allows for adjustments, as well as being a reversible and more conservative procedure. The use of indirect restorations is likely to provide a longer lasting outcome after initial stabilization, whether it is metal- or ceramic-based or a combination.

A comprehensive and conservative approach for the restoration of abrasion and erosion. Part I: concepts and clinical rationale for early intervention using adhesive techniques.

Tooth wear represents a frequent pathology with multifactorial origins. Behavioral changes, unbalanced diet, various medical conditions and medications inducing acid regurgitation or influencing saliva composition and flow rate, trigger tooth erosion. Awake and sleep bruxism, which are widespread nowadays with functional disorders, induce attrition. It has become increasingly important to diagnose early signs of tooth wear so that proper preventive, and if needed, restorative measures are taken. Such disorders have biological, functional, and also esthetic consequences. Following a comprehensive clinical evaluation, treatment objectives, such as a proper occlusal and anatomical scheme as well as a pleasing smile line, are usually set on models with an anterior teeth full-mouth waxup, depending on the severity of tissue loss. Based on the new vertical dimension of occlusion (VDO), combinations of direct and indirect restorations can then help to reestablish anatomy and function. The use of adhesive techniques and resin composites has demonstrated its potential, in particular for the treatment of moderate tooth wear. Part I of this article reviews recent knowledge and clinical concepts dealing with the various forms of early restorative interventions and their potential to restrict ongoing tissue destruction.

Etiology and prevention of acid erosion.

Acid erosion is the chemical effect of dietary or gastric acids on enamel and dentine. Unlike dental caries, which is a bacterially mediated condition, acid erosion normally is combined with physical forms of attrition and abrasion. The clinical appearance of acid erosion in the early stages is seen characteristically as hollowed-out lesions on occlusal surfaces and on smooth surfaces as a subtle change in the tooth contour. As the condition progresses, the lesions coalesce and form widespread dentin exposure and coronal destruction. Dietary acids that are present in beverages and fruits potentially can cause acid erosion. However, dietary habits involving frequent consumption of acids are believed to be important determinants in the risk of developing clinical signs of acid erosion. Prevention using fluoride toothpastes, dietary modifications, and calcium-based products probably have a significant clinical effect in reducing the risk of developing acid erosion.

The effect of CPP-ACP on enamel wear under severe erosive conditions.

OBJECTIVE: In addition to its role as a remineralizing agent in preventing dental caries, recent evidence has shown that casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) can protect teeth against erosion. The aim of this study was to determine whether CPP-ACP could reduce enamel wear rates under severe erosive conditions simulating heavy attrition and gastric regurgitation. DESIGN: Enamel specimens were subjected to 10,000 wear cycles at a load of 100 N and pH 1.2 in a tooth wear machine. The machine was stopped every 2 min (160 cycles), and CPP-ACP in the form of a paste was applied for 5 min in experimental group 1. A paste with the same formulation but without CPP-ACP was applied in experimental group 2. No paste was applied in the control group. RESULTS: A linear mixed model analysis indicated that the mean wear rates in experimental group 1 (0.44+/-0.05 mm(3) per 1000 cycles) and in experimental group 2 (0.63+/-0.06 mm(3) per 1000 cycles) were significantly lower than that in the control group (0.92+/-0.11 mm(3) per 1000 cycles) (p<0.05). The mean wear rate in experimental group 1 was also lower than that in experimental group 2 (p<0.05). Wear facets in experimental groups 1 and 2 were noted to be smoother and more polished than those in the control group. CONCLUSIONS: Both remineralizing and lubricating properties of the paste containing CPP-ACP appear to contribute to wear reduction in enamel. These findings may lead to new strategies for the clinical management of tooth wear.

Salivary flow patterns and the health of hard and soft oral tissues.

BACKGROUND: This nonsystematic review summarizes the effects of saliva on some of the diseases affecting the hard and soft oral tissues. RESULTS: Saliva enters the mouth at several locations, and the different secretions are not well-mixed. Saliva in the mouth forms a thin film, the velocity of which varies greatly at different sites. This variation appears to account for the site specificity of smooth-surface caries and supragingival calculus deposition. Saliva protects against dental caries, erosion, attrition, abrasion, candidiasis and the abrasive mucosal lesions seen commonly in patients with hyposalivation. These effects are the result of saliva's being a source of the acquired enamel pellicle; promoting the clearance of sugar and acid from the mouth; being supersaturated with respect to tooth mineral; containing buffers, urea for plaque base formation, and antibacterial and antifungal factors; and lubricating the oral mucosa, making it less susceptible to abrasive lesions. CLINICAL IMPLICATIONS: For optimal oral health, people should keep food and liquids in the mouth as briefly as possible. The most important time for toothbrushing is just before bedtime, because salivary flow is negligible during sleep and the protective effects of saliva are lost. Chewing sugar-free gum or sucking on sugar-free candies stimulates salivary flow, which benefits hard and soft oral tissues in many ways.

Diagnosis and management of the worn dentition: risk management and pre-restorative strategies for the oral and dental environment.

The incidence of tooth wear or non-carious tooth surface loss (NCTSL) is increasing and oral rehabilitation of patients with tooth tissue loss requires strategies that address all the factors relevant to the aetiology and pathogenesis of the disease. The multifactorial nature of the disease and the variability in its clinical presentation provides treatment challenges for the clinician. Management of tooth wear must be more than just restoration. Risk assessment, compliance and a commitment from both professional and patient underpin overall success of the treatment. Understanding that long term success is affected by the patient's oral environment and how diet, lifestyle and medical factors modify this environment. Improvements in the quantity and quality of saliva and remineralization strategies to enhance the remaining tooth structure are essential pre-restorative requirements. Successful management requires recognition of the problem, stabilization of the oral environment, remineralization of the tooth structure and when appropriate restoration.

Demolition experts: management of the parafunctional patient: 1. Diagnosis and prevention.

UNLABELLED: The first part of this paper discusses the clinical problems associated with providing predictable restorative dental care for parafunctional patients. The identification of patients with this problem is important, as is patient understanding and the optimization of preventive approaches, all of which are considered. In the second part, restorative strategies will be presented. CLINICAL RELEVANCE: Parafunctional patients need to understand the difficulties associated with managing their problem. The preservation of tooth tissue is of paramount importance to ensure long-term success.

[Case of occlusal reconstruction for severe attrition].

PATIENT: A 57-year-old female complained of aesthetic disturbance, dysmasesis and phonation disorder by attrition. She had severe attrition of almost teeth. To avoid metal color exposure and attrition of opposing teeth, hybrid ceramics were used for veneered crowns and fixed partial denture. Since the prosthetic treatment, the patient wears a night guard to prevent attrition of her teeth and prosthesis. DISCUSSION: There has been no specific trouble during the 4-year follow-up. CONCLUSION: It is considered that using hybrid ceramics for veneering crowns and fixed partial denture and night guard help to prevent the attrition of opposing teeth and abrasion of prosthesis.

[Destructive and protective factors in the development of tooth-wear]. / Destruktív és protektív tényezök szerepe a fogkopások kialakulásában.

The experience of the past decade proves that tooth wear occurs in an increasing number of cases in general dental practice. Tooth wear may have physical (abrasion and attrition) and/or chemical (erosion) origin. The primary physical causes are inadequate dental hygienic activities, bad oral habits or occupational harm. As for dental erosion, it is accelerated by the highly erosive foods and drinks produced and sold in the past decades, and the number of cases is also boosted by the fact that bulimia, anorexia nervosa and gastro-oesophageal reflux disease prevalence have become more common. The most important defensive factor against tooth wear is saliva, which protects teeth from the effect of acids. Tertiary dentin formation plays an important role in the protection of the pulp. Ideally, destructive and protective factors are in balance. Both an increase in the destructive forces, and the insufficiency of defense factors result in the disturbance of the equilibrium. This results in tooth-wear, which means an irreversible loss of dental hard tissue. The rehabilitation of the lost tooth material is often very difficult, irrespectively of whether it is needed because of functional or esthetic causes. For that reason, the dentist should carry out primary and secondary dental care and prevention more often, i.e. dental recall is indispensable every 4-6 months.