Tooth Surface Loss in Children

• Non-carious tooth surface loss:

  • 3 main processes make up the contribution to the phenomenon of non-carious tooth surface loss = abrasion, attrition, erosion
  • With children:
  • Abrasion = uncommon
  • Attrition = common, particularly in the primary dentition
  • Erosion = predominant process
• Non-carious tooth surface loss in children:

  • Although the causation of non-carious tooth surface loss is known to be multifactorial in children, the most likely aetiology is erosion.
  • Erosive changes are more evident on lingual and buccal surfaces, TSL is therefore recorded on both of these surfaces for upper incisors. The first permanent molar is the most likely posterior tooth to be affected by TSL as it is usually the first permanent tooth to erupt in a child, typically at 6 years.

  
• Erosion = "chemical dissolution of tooth substance without the presence of dental plaque"

  • Moderate to strong acids (pH 1.2-5)
  • Act over short time frames (seconds)
  • Affect tooth surface with very little subsurface damage
• Intrinsic erosion = caused by gastric acid (intrinsic or endogenous erosion)

  • Vomiting: generally, the palatal surfaces of all the maxillary teeth are affected most because the tongue usually covers the mandibular teeth during vomiting. Immediately after the episode, gravity and the actions of the cheeks and lips during swallowing will distribute the vomitus residue to other parts of the mouth including the mandibular arch until, over time, most of the tooth surfaces are affected.
• Intrinsic erosion = caused by gastric acid (intrinsic or endogenous erosion)

  • Gastro-oesophageal reflux disease (GORD): the refluxate rises to the back of the throat and soft palate. Usually, the palatal surfaces of the maxillary posterior teeth are affected.
  • Children with cerebral palsy are more likely to have acid reflux, and therefore more likely to have erosion
• Intrinsic erosion = caused by gastric acid (intrinsic or endogenous erosion)

  • Rumination, where the refluxate enters the mouth and is chewed, has been noted among bulimics and infants. Erosive pattern is more generalised and, in particular, includes the occlusal tooth surfaces.
  • Eructation (burping) where moist 'acidic air' enters the oral cavity also will have an effect. Though the palatal surfaces of the maxillary teeth are generally involved, other surfaces certainly can be affected depending whether the mouth is opened or closed during the burping action.
• Extrinsic erosion = caused by dietary, environmental or occupational aids (extrinsic or exogenous erosion)

  • Dietary: if the occlusal surfaces of the mandibular teeth are affected more than the maxillary teeth, then the agent is usually a liquid that floods the mandibular teeth. If the occlusal surfaces of both arches are equally affected, then the agent is usually solid acidic food that is masticated.
  • Actions of drinking directly from a bottle or from a glass also will produce erosion variations.
  • Swishing behaviours
  • Want to encourage straw use
• Attrition = "occurs from tooth-to-tooth contact without the presence of food" - tooth grinding either nocturnally while asleep or diurnally.

  • Commonly the grinding stroke is from centric occlusion (maximum intercuspal position) to eccentric lateral positions
  • Can cause pathological tooth damage such as enamel flaking and cusp fracture
  • Matching wear facts, flat no scooping
  • Symptoms of TMD
• Abrasion = "wear that occurs by the friction of exogenous material (anything foreign to the tooth) that is forced over the surfaces of the tooth"

  • Commonly produced by food/aggressive toothbrushing
  • Can be related to occupation
  • Wear pattern is generally distributed throughout the arch
  • Exposed dentine has scooped out appearance
  • Not sensitive due to presence of a smear layer
  • Often superimposed by erosion
• Unusual patterns of tooth surface loss:

  • Differential wear rate of enamel and dentine
  • Head position when vomiting
  • GORD (gastro-oesophageal reflux disease)
  • Gastric reflux fluid pools during sleeping
• High risk groups for tooth surface loss:

  • Regular and frequent acidic drink consumption - 4 or more acidic dietary intakes per day
  • Pts suffering from chronic medical conditions and taking regular oral medication with erosive potential
  • Pts suffering from xerostomia, hyposalivation and previous head & neck radiation
  • Alcoholics, professional wine taster
  • GI and eating disorders
• Clinical signs of tooth wear:

  • Pulp wear
  • Loss of vitality attributable to tooth wear
  • Exposure of secondary dentine
  • Exposure of dentine on buccal or lingual surfaces
  • Cupped occlusal or incisal surfaces
  • Wear in one arch more than the other
  • Restorations projecting above the surface of the tooth
  • Wear producing sensitivity
  • Reduction in length of incisal teeth so the length is out of proportion of the width
• Diagnosis of tooth surface loss - careful history taking:

  • Identify intake of foods, beverages, medications and use of oral health care products during four days and specifying the time points for intake/use of these -> diet diary
  • GI history - may need to refer to GMP for further investigations
  • History of parafunctional habits
  • Dental history
  • Potential loss of posterior support, tooth brushing habits/technique, toothpaste choice
  • Saliva testing
  • Clasps of URAs
  • Social history - employment, alcohol, drug use, sporting activities, musical instruments, stress
• Management of tooth surface loss:

  • Early diagnosis may stop the progression of erosion
  • A "wait and see" philosophy is recommended especially if patients have no complaints regarding pain/sensitivity, function or aesthetics
  • Pt information leaflets
  • Recording erosion:
  • Study casts
  • Photographs
  • Silicone putty impression (for sectional labio-palatal matrix)
  • Dietary analysis
  • Dietary counselling
  • Oral hygiene, remineralisation & desensitisation
• Oral hygiene, remineralisation & desensitisation:

  • Fluoride
  • Professional - gels/varnishes, fluoride releasing materials, slow release
  • Personal - over-the-counter toothpastes, prescribed toothpastes, mouthwash
  • Amorphous calcium phosphate
  • ToothMousse, Chewing gum, Xylitol
  • Novamin - 'Sensodyne Repair and Protect'
  • Dentine bonding agents
• Treatment objectives for tooth surface loss:

  • Resolve sensitivity
  • Restore missing tooth surface
  • Prevent further tooth surface loss
  • Maintain a balanced occlusion
• Operative treatment - primary dentition tooth surface loss:

  • Sign and symptom free
  • Restorative treatment not indicated
  • If teeth are sensitive either:
  • Cover with composite resin and/or stainless steel crowns
  • Extraction of the offending teeth
• Operative treatment - mixed dentition tooth surface loss:

  • Permanent dentition
  • Treat conservatively - long term monitoring or addition of composite resin to eroded surfaces
  • Dentine bonding agents can offer short-lived dentine protection (around 3 months), unfilled fissure sealants on palatal surfaces to maxillary upper incisors (around nine months)
• Operative treatment - permanent dentition tooth surface loss:

  • Composite - direct/indirect
  • Porcelain
  • Cast metal (nickel-chrome or gold)
• What you are expected to undertake in primary care & what you would be expected to refer:

  • Level 1 - conditions to be performed/managed by a dentist commensurate w/ level of competence as defined by the Curriculum for Dental Foundation Training or its equivalent
  • Restorations of primary & permanent teeth with the use of LA where appropriate, including pulp therapies of primary molars & pre-formed metal crowns where appropriate
  • Routine extraction of primary and permanent teeth under local anaesthesia
  • Appropriate referral of children requiring more complex treatment that is level 2, 3a or 3b.
• What you are expected to undertake in primary care & what you would be expected to refer:

  • Level 2 - care defined as procedural and/or pt complexity requiring a clinician w/ enhanced skills & experience who may be on a specialist register. This may require additional equipment/environment standards but can usually be provided in primary care
  • Management of hard tissue dental defects & disturbances of developing dentition not requiring specialist/multi-disciplinary management, eg early permanent TSL, developmental defects of primary/permanent teeth amenable to & stabilised by simple restoration
• What you are expected to undertake in primary care & what you would be expected to refer:

  • Level 2 - care defined as procedural and/or pt complexity requiring a clinician w/ enhanced skills & experience who may be on a specialist register. This may require additional equipment/environment standards but can usually be provided in primary care
  • Management of more complex problems affecting the developing dentition or dental hard tissues under the direction of a specialist or consultant in Paediatric Dentistry
  • Extraction of teeth under general anaesthesia
• What you are expected to undertake in primary care & what you would be expected to refer:

  • Level 3a - care & procedures/conditions to be performed or managed by a dentist recognised as a specialist in paediatric dentistry by the GDC
  • Moderate to severe tooth surface loss in the permanent dentition
  • Treatment planning, support and follow up for children requiring extractions under general anaesthesia