1.Non-Carious Tooth Substance LossDr. Manil Fonseka BDS, MS (Restorative Dentistry)Department of Restorative Dentistry 27th January 2011

2. DefinitionLoss of dental hard tissue due tocauses NOT attributed to bacterial action on fermentable carbohydrates 3. Historical Perspective Normal physiologic process Some tooth-wear essential for efficientfunction of teeth which is seen in manyherbivores Important to establish unhindered guidanceduring mastication However the level of tooth wear minimal 4. Rates of tooth-wear 2500 years for 1mm of enamel wear withnormal function Estimated the level of tooth wear to be 29mfor molars and 15m for premolars(Lambrechts et al, 1989) Physiological wear poses minimal problems If the rate of wear challenges the viability ofteeth TSL considered pathologic 5. Factors precipitating wear 6. Factors precipitating tooth-wear Multi-factorial aetiology Increase in life expectancy Increased functional demand Longer exposure to erosive foods Recession and exposure of relatively weaker cementum Increased use of medication Quantitative and qualitative reduction in salivary flow Loss of teeth increases demand on the remaining teeth 7. Diet Dietary changes have resulted in the dietsbeing less abrasive Should theoretically reduce the levels oftooth-wear Excessive consumption of erosive beveragesand foods has had a potentiating effect on theincreased prevalence of NCTSL 8. Implicated foods Fizzy drinks (pH 2.2 3.8) Fruit juices (pH 3.0 4.0) Wines (pH 3.2 4.8) Cider and Beer (pH 3.5 4.0) Citrus fruits Increased prevalence among children andadolescents in the UK (35%) Condition of affluent in Sri Lanka (Ratnayake N& Ekanayake L. 2010) 9. Extrinsic Acid ErosionIntrinsic Acid Erosion 10. Intrinsic Acid pH of Gastric acid is 1-2Gastric RegurgitationBulaemia and anorexiaVomittingClassically presents as palatal/lingual erosivedefects 11. Para-function Stress induced parafunction Bruxism Object biting 12. Problems of para-function 700 times the normal masticatory load Force used is considerably greater than duringnormal mastication Seen as wear in non functional cusps Molars may be severely affected Prominant masseters Marked antigonial notching Tenderness of muscles of mastication 13. Other factors contributing to tooth surface loss Defective enamel and dentine deposition andmaturation ( E.g AI, DI, Hypoplasias) Abrasive restorative material (Unglazedporcelain) Abrasive dentifrices and hard brushing inhorizontal strokes Habits Instrument biting, Needles etc 14. Defective enamel formation 15. Scale of the Problem 98% of individuals in the UK have someamount of tooth wear Increased prevalence amongchildren, deciduous teeth 30% of individuals in the UK have severe toothwear (Tooth Wear Index scores of 3 & 4) Problem of affluent in Sri Lanka 16. Types of tooth-wear Erosion -Intrinsic or Extrinsic acid Attrition -Tooth to tooth contact Abrasion-Due to foreign objects Abfraction - Repeated cyclic flexion of teeth Mostly multi-factorial thus cannot home-in onone cause 17. Erosion Due to intrinsic or extrinsic acid Intrinsic acid regurgitation due to gastric refluxdisease (Bullaemia, Anorexia, Gastritis, GORD) Extrinsic acid consumption (Coke, Fizzydrinks, Fruit juices, tamarind) Increasingly seen in young due to change inlifestyles 18. Extrinsic Acid ErosionBuccal and Labial surfacesLingual and palatal spared Intrinsic Acid ErosionPalatal and lingual surfacesLower incisors sparedEtched like appearanceCuppingDiscoloured if historicalProud restorations 19. Attrition Tooth to tooth contact Accelerated due to para-function Wear on non-functional cusps Seen in anterior teeth when posteriors are lost No loss of OVD due to dento-alveolarcompensation Erosion potentiates attrition (De-mastication) 20. Attrition 21. Abrasion Due to improper brushing technique Abrasive dentifrices Foreign objects (e.g. Needles, Clips etc) Erosion may potentiate abrasion (Abrosion) 22. Abrasion 23. Abfraction Continuous cyclic loading of teeth Enamel micro-fractures in the cervical regions Precipitated by premature contact of teeth Seperation of enamel rods V shaped defects 24. Abfraction 25. Effects of NCTSL Sensitivity of teeth Pulpal and Periodontal complications Poor aesthetics Impeded function Prone to fracture Low self esteem (OHRQoL) 26. Aides to Diagnosis Detailed history Occupation, Social, Dietary analysis, Medical history Examination Masticatory apparatus, MAN, Wear facets and theirlocation, proud restorations Investigations Radiographs, Photographs, Dated study casts 27. Strategies in the management ofNCTSL Psycho-social support Medical referrals (GERD) Habit intervention Reduction in consumption of erosivebeverages Using a straw Soft mouth guards to protect teeth duringgastric regurgitation (Addition of Fluoride gel) Michigan splints to reduce effects of bruxism 28. Soft bite guards/ Michigan splints 29. Challenges in management Lack of vertical space due to dento-alveolarcompensation mechanisms Excessive loading of restorations If the cause continues tooth-wear would continue Frequent recall and maintenancePrimary aim in treatment prevent/reduce thecauses and replace what is lost 30. Methods of Gaining Space Conforming to existing occlusion Re-organising the occlusion Concept of Dahl Crown lengthening Orthodontic intrusionHow to gain space would depend onWhere space is neededAssessment of each individual caseShould be based on principles of occlusion 31. Dahl Appliance 32. Management of Localized tooth wear 33. Re-organization of occlusion Case 1 34. Re-organization of occlusion Case 2 35. Re-organization Case 3 36. Re-organization Case 4 37. Thanks