Toothwear II

• How is erosion defined?

  Chemical dissolution of dental hard tissues by acids of non-bacterial origin
• What is the difference between intrinsic and extrinsic erosion?

  Intrinsic erosion:caused by gastric contents in the mouth

  Extrinsic erosion:caused by either diet or environmental factors
• What are some examples of environmental factors that can cause extrinsic erosion?

  Acid fumes in factories (veryrarefor erosion to be caused in this way)

  Inadequately maintained gas-chlorinated swimming pools (also veryrare)

  Dietary acid consumption is more common in causing extrinsic erosion
• What diet information do you need from your patients?

  The specific dietary acids

  How often they are having them (frequency)

  When they are having it, with meals, between meals etc. (timing)

  How much of the acid they're having (quantity)

  How long they are having it for (duration)

  Habits associated with intake (habits)
• What frequency of dietary acid intake can cause tooth wear?

  If you have 2 acids per day, your risk of having tooth wear is 2.33x greater than someone who doesn't

  
  

  If you have 3 acids per day, your risk of having tooth wear is 13.5x greater than someone who doesn't
• How can the timing of dietary acid intake cause tooth wear?

  Fruit with meals= no increased risk

  
  

  Fruit outside of meals: 1 per day= 1.95x more likely to get tooth wear; 2 per day= 5.35x more likely to get tooth wear

  
  

  Acidic drinks with and outside of meals showed increased risk of tooth wear

  
  

  Acidic drinks with meals: 1 per day= 1.81x more likely; 2 per day= 6.42x more likely

  
  

  Acidic drinks outside of meals: 1 per day= 2.49x more likely; 2 per day= 11.84x more likely
• What can stop acidic food/drink from damaging the enamel?

  Calcium and phosphate
• How can the quantity of dietary acid intake cause tooth wear?

  There is limited data on whether quantity vs frequency is the important thing but generally, increased quantity is associated with erosive tooth wear
• How does the duration of the dietary acid in your mouth influence tooth wear?

  
• In terms of intrinsic erosion, what are the 2 types?

  Voluntary:

  Vomiting eating disorders

  Involuntary:

  RefluxRuminationChronic alcoholismVomiting due to pregnancy/ pregnancy refluxHeavy abdominal exercise
• Describe the anatomy of the oesophageal tract.

  -muscular 25cm muscle with sphincter at each end.

  
  

  -Upper sphincter composed of strained muscle

  
  

  -As you descend there is a change from squamous cells to columnar cells = important because it's a common site for malignant transformations

  
• How can movement of gastric contents occur?

  Either because the lower oesophageal sphincter isn't tight, or because ofmotility disorders:

  Transient relaxations of the lower oesophageal sphincterIncompetent sphincterAbnormalities of peristalsisHiatus hernia
• When does the gastric-oesophageal reflux occur?

  When the oesophageal pressure is lower than the intragastic pressure
• What is the definition of reflux?


  Mild heartburn and/or regurgitation occurringat least 2 days per weekor moderate/severe heartburn and/or regurgitation occurringat least 1 day per weekshould lead to a symptom based diagnosis ofGERD (gastro-oesophageal reflux disease)
• What are the symptoms of reflux?

  HeartburnRegurgitation•Difficulty swallowingTooth wearChest painChronic coughSore throat/alteration of voice/hoarsenessGlobus (feeling of lump in throat)
• How common are eating disorders in the UK?

  1 in every 88 adults in UK have an eating disorder, 11% are male

  
  

  6.4% of adults show signs of a eating disorder & 25% of those are male

  
  

  More likely to drink diet soft drinks which can mask vomiting erosive wear
• What should you do if you suspect an eating disorder?

  - Refer to GP - only with their permission
• What are the NICE guidelines for helping someone with a vomiting eating disorder?

  Have regular dental and medical reviews

  
  

  Avoid brushing teeth immediately after vomiting

  
  

  Rinse gently with non-acid fluoride mouthwash

  
  

  Avoid highly acidic food and drinks
• How does fluoride affect erosive tooth wear?

  Residual fluoride from brushing teeth did not reduce erosive tooth wear

  
  

  High dose fluoride reduced erosive tooth wear in enamel but not dentine

  
  

  Stannous fluorides more effective at preventing erosion
• How could you encourage remineralisation?

  -Stannous fluorides are more effective

  
  

  -High dose fluoride varnish

  
  

  -Regular use of fluoride
• How can toothbrush abrasion lead to tooth wear?

  
• How does abrasivity of toothpastes affect tooth wear?

  The more abrasive the toothpaste, the greater the wear

  
  

  The lower the RDA value, the less abrasive it is

  
  

  Avoid whitening toothpastes since they're more abrasive, especially around dentine

  
• How does the type of toothbrush affect tooth wear?

  It was previously thought that hard toothbrushes cause more wear but recent studies suggest that softer toothbrushes retain more toothpaste and as a result, increase tooth wear
• What has been observed about toothbrushing after eating?

  Delayed toothbrushing after eating was associated with increased tooth wear

  However, brushing within 10 minutes of eating/drinking a dietary acid was associated with erosive wearbut notwhen the frequency of dietary acids were fully controlled for
• What are the actions of saliva?

  Dilutes the acid

  
  

  Assists with oral clearance

  
  

  Buffers the acid with minerals

  
  

  Salivary pellicle acts as physical barrier against erosion

  
  

  Remineralising effect of saliva unclear
• What advice should you give to a patient with xerostomia?

  Diet advice regarding acids and sugars

  
  

  Sugar free chewing gum to stimulate the saliva

  
  

  Prescribe high fluoride toothpaste and supplemental fluoride mouth rinse

  
  

  Advise to keep sufficiently hydrated and drink fluids throughout day
• What does attrition look like in teeth?

  Very flat surfaces (due to heavy bruxism)

  
  

  Attrition is usually associated with an acidic cause

  
• What is normal occlusal force in the mouth?

  27kg is normal force for last occlusal contact before swallowing

  
  

  42kg at higher end of the scale
• At what forces does attrition occur?

  Lower loads are strongly influenced by the amount of lubricant in the mouth

  
  

  Dry teeth will start to wear at <10 kg

  
  

  Saliva-lubricated teeth will start to wear at >14kg

  
  

  Dentine wears greater than enamel at smaller loads; at greater loads they are the same
• How is attrition affected when acid is also present?

  It will greatly increase the amount of attrition that will occur:

  
  

  A short exposure to a dietary acid increases rates of enamel attrition

  
  

  On dentine, citric acid exposure prior to abrasion resulted in 60% more wear

  
  

  There is a smoothening effect on enamel as acid can dissolve any abrasive tooth remnants
• What preventative advice would you give to someone with attrition (bruxism)?

  -Avoid frequent intake of acid food or drinks

  
  

  -keep acidic drinks to mealtimes and limit number of fruit drinks.

  
  

  -Do not brush immediately after vomiting

  
  

  -Advise patients to seek medical assistance for GORD and eating disorders.

  
  

  -Ensure regular medication is acid free and be aware of medications that reduce saliva flow and thus impact on clearance
• How do you identify active erosive tooth wear as opposed to inactive tooth wear?

  It's considered that if the tooth looks shiny, and there's a lack of staining, that is active tooth wear

  
• Tips for minimising risk:

  -ETW should be part of every routine oral health assessment to avoid a missed diagnosis.

  
  

  -Routinely record ETW using BEWE alongside BPE and document preventative advice given.

  
  

  -Patients should be fully informed about condition to be able to provide valid consent.

  
  

  -Patients need to understand importance of looking after their own oral health