NON CARIOUS LESIONS AND THEIR

MANAGEMENT

DR. APPLU ATREYPG PART IDEPT OF CONSERVATIVE DENTISTRY AND ENDODONTICS

INDEX

INTRODUCTION DIFFERENT TYPES OF NON CARIOUS

LESIONS CONSEQUENCES OF TOOTH WEAR TREATMENT MODALITIES OF TOOTH

SURFACE LOSS CONCLUSION REFERENCES

INTRODUCTION

Normal physiologic process that occurs

throughout life.

Problems arise when the rate of loss

becomes excessive causing functional or

esthetic problems or sensitivity for the

patient.

Enamel is one of the few tissues in the body

that does not regenerate or replace itself in the

way that skin, blood cells, and fractured bones do.

Fortunately, the dentine does show some

reparative mechanisms as reactionary or

reparative dentine which is laid down in the pulp

chamber as a response to tooth wear

Traditionally, the terms erosion, abrasion and attrition were used to describe non carious pathologic loss of tooth structure.

Tooth wear Smith and Knight advocated the use of term

tooth wear . Tooth wear is defined as the surface loss

of dental hard tissues other them by

caries or trauma .

Tooth wear is a cumulative lifetime process which is irreversible .

Clinically tooth wear appears to progress very slowly over years

The features of different types of tooth

Tooth wear has the multi-factorial aetiology, but certain clinical features may suggest a major contributory factor.

Traditionally, cervical lesions caused purely by abrasion have sharply defined margins and a smooth, hard surface.

The lesion may become more rounded and shallow if there is an element of erosion present

Flattening of cusps or incisal edges and localized facets on occlusal or palatal surfaces would indicate a primarily attritional aetiology.

Once dentine is exposed, the clinical appearance is determined by the relative contribution of the etiological factors.

If wear is primarily attritional, then dentine tends to wear at the same rate as the surrounding enamel. Erosive lesions cause ‘cupping’ to form in the dentin.

Consequences

Change in appearance of teeth

Exposure of dentin normally covered by enamel

Dentin Hypersensitivity

Loss in occlusal vertical dimension

Loss in posterior occlusal stability resulting in

Mechanical failure of teeth or restorations

Hypermobility and drifting

Exposure of pulp

Pulpitis and loss of vitality

Methods and instruments to measure tooth wear

In-vitro measurement

• Macroscopic changes• Polarized light microscopy• Surface profilometry• Microhardness tests• Scanning electron

microscopy• Microradiography• Digital image analysis• Iodine permeability• Synthetic hydroxyapattite

powders/discs• Calcium and phosphorus

dissolution

Newer methods• Scanning tunneling microscope

• Atomic force microscope

• Finite element analysis

In-vivo measurem

ent• Macroscopic

changes• Replica

technique• Intra-oral

carcinogenicity test

TYPES OF NON CARIOUS LESIONS1. Attrition2. Erosion3. Abrasion 4. Abfraction5. Localized non hereditory Enamel hypoplasia6. Localized non hereditory enamel hypocalcification7. Localized non hereditory dentin hypoplasia8. Localized non hereditory dentin hypocalcification9. Discolourations10. Malformations11. Amelogenesis imperfecta12. Dentinogenesis imperfecta13. Trauma

ATTRITION

Derived from Latin word - ATTRITIM meaning “action of rubbing against something”

DEFINITIONS The physiologic wearing of the teeth resulting from

tooth to tooth contact as in mastication.

Shafer

Wear caused by endogenous material such as microfine particles of enamel prisms caught between two opposing tooth surfaces.

Every (1972)

Loss by wear of surface of tooth or restoration caused by tooth to tooth contact during mastication or parafunction

Milosevic, 1998

Attrition occurs at an ultra structural level

It can be caused by direct contact between

surfaces or the action of an intervening slurry

Attrition can be hastened by coarse diet and

abrasive dust

Some para-functional habits like Bruxism may

also contribute to attrition

Distribution of attrition is influenced by the type of occlusion, the geometry of stomatognathic system and grinding pattern of the individual.

If occlusal wear occurs at a rate faster than compensatory physiologic mechanisms, it is considered pathologic.

Vertical loss of enamel of 50-68 µm/year is considered physiologic

ATTRITION

PROXIMAL SURFACE ATTRITION (PROXIMAL SURFACE FACETING)

OCCLUDING SURFACE ATTRITION (OCCLUSAL WEAR)

CLINICAL FEATURES

1. Shiny wear facets with well defined borders2. The surface of wear facet is flat and flush

with the opposing tooth on contact 3. Enamel and dentin wear at the same rate 4. Possible fracture of cusps or restorations5. Pure attrition shows equal wear on both

arches. (unlike erosion)

ATTRITION INDEX

SCORE CLINICAL FEATURE

0 NO WEAR

1 MINIMAL WEAR

2 NOTICIBLE FLATTENING PARALLEL TO OCCLUDING PLANES

3 FLATTENING OF CUSPS AND GROOVES

4 TOTAL LOSS OF CONTOUR AND/OR DENTIN EXPOSURE

Richard and brown, 1981

MANAGEMENT

EROSION

Derived from Latin verb EROSUM meaning “to corrode”

DEFINITIONS Erosion is defined as superficial loss of hard tissue due to

chemical process not involving bacteria.

Every (1972)

Erosion is process of gradual destruction of tooth surface,

usually by a chemical or electrolytic process.

Imfeld T (1996)

Erosion is defined as the chemical dissolution of teeth by

acids

Martin

Dental erosion is defined as the progressive, irreversible loss of hard dental tissues due to a chemical process not involving bacteria

Gandara BK, Truelove EL. Diagnosis and management of dental erosion. J. ofContemporary Dental Practice 1999; 1(1): 1-17

SALIENT FEATURES Clinically, erosion is primarily a surface

phenomenon

The solubility of enamel is pH dependent

The rate at which apatite precipitates depends on

factors such as calcium binding in saliva.

The critical pH of enamel is 5.5, any solution with

a lower pH may cause erosion if the attack is

lengthy and intermittent over time.

In early stages, erosion effects enamel resulting in smooth, glazed surfaces

In advanced cases, restorations may project above the occlusal surfaces and exhibiting concavities known as cupping; increased incisal translucency

Rapid process may lead to sensitive teeth due to dentin exposure while slower progressive lesions may be asymptomatic

CLASSIFICATION I Class I – superficial lesion involving enamel

only

Class II – localized lesions that involve dentin or less than 1/3rd of the surface

Class III – generalized lesions involving dentin and more than 1/3rd of the surfaces

Eccles et al, 1979

CLASSIFICATION II Extrinsic (exogenous)

Environmental – by acid fumes and aerosols in occupational, swimmers

Diet – citrus fruits, carbonated drinks, vinegar Medication – aspirin, vit-C, calcium chelators Life style – fruits and diet drinks, bleaching agents

Intrinsic – conditions that lead to chronic vomiting

or persistent gastroesophageal reflux Anorexia and bulimia nervosa Chronic alcoholism Morning sickness associated with pregnancy

Clinical severity Superficial Localized Generalized

Activity of progression Active or manifest Inactive or latent

SUPERFICIAL EROSION

GENERALISED SEVERE EROSION

Mannerberg described 2 types of erosive lesions as viewed under SEM Active lesions – shows distinctive etched

enamel prisms resembling honeycomb Inactive or latent lesions – faint with

unrecognizable characteristics

CLINICAL FEATURES

Enamel erosion appears smooth and rounded and the surface contour is lost

Broad concavities within smooth surface enamel Cupping of occlusal surfaces,

(incisal grooving) with dentin exposure Increased incisal translucency Wear on non-occluding surfaces There is a difference in wear in opposing

arches

Biological Modifying Factors

Saliva – flow, composition, buffering capacity,

pH

Acquired pellicle – diffusion limiting

properties and thickness

Tooth composition and structure

Dental anatomy and occlusion

Physiologic soft tissue movements

Erosive potential of foods and beverages influenced by

pH Total acid level Type of acid (pKa) Calcium chelating properties Calcium phosphorus and fluoride content Physical and chemical properties affecting

adherence to the enamel surface and stimulation of saliva flow.

DIAGNOSTIC PROTOCOL FOR DENTAL EROSION

Medical History Excessive vomiting, rumination Gastroesophageal reflux disease (Symptoms of reflux) Frequent use of antacids Alcoholism

Dental History History of bruxism (grinding or clenching) Morning masticatory muscle fatigue or pain? Use of occlusal guard

Dietary History Acidic food and beverage frequency Method of ingestion (swish, swallow?)

Occupational/Recreational History Regular swimmer? Wine-tasting? Environmental work hazards? Sports energy drinks

Oral Hygiene Methods Tooth brushing method and frequency Type of dentifrice (abrasive?) Use of mouthrinses Use of topical fluorides

MANAGEMENT OF EROSION

Identification of the etiology

Preventive measures

Patients compliance.

Early recognition of erosion is important to successfully manage and prevent disease progression.

PROTOCOL FOR PREVENTION OF PROGRESSION OF

EROSION

Diminish the frequency and severity of the acid challenge.

Decrease amount and frequency of acidic foods or drinks. If undiagnosed Gastroesophageal reflux is suspected, refer

to a physician. A patient with alcoholism should be assisted in seeking

treatment in rehabilitation programs.

Enhance the defense mechanisms of the body (increase salivary flow and pellicle formation). Saliva buffering capacity resists acid attacks.  Saliva is also supersaturated with calcium and

phosphorus, which inhibits demineralization of tooth structure

Enhance acid resistance, remineralization and

rehardening of the tooth surfaces.

Daily topical fluoride at home.

Apply fluoride in the office 2-4 times a year. 

A fluoride varnish is recommended.

Improve chemical protection.

Neutralize acids in the mouth by dissolving sugar-

free antacid tablets.

Dietary components such as hard cheese (provides

calcium and phosphate) can be held in the mouth

after acidic challenge 

Decrease abrasive forces.

Use soft toothbrushes and dentifrices low in

abrasiveness in a gentle manner.

Do not brush teeth immediately after an acidic

challenge to the mouth, as the teeth will abrade

easily. Rinsing with water is better than brushing

immediately after an acidic challenge.

Provide mechanical protection.

Consider application of composites and direct

bonding where appropriate to protect exposed

dentin.

Construction of an occlusal guard is recommended if

a Bruxism habit is present.

ABRASSIONDerived from Latin verbABRASUM meaning “ Scrape off ”

DEFINITIONS Abrasion is wearing away of tooth substance or

structure through mechanical process.

Imfeld T (1996)

Abrasion is the wearing of tooth substance that results

from friction of exogenous material forced over the

surface by incisive, masticatory and grasping functions

Every (1972)

Loss by wear of dental tissue  caused by abrasion by

foreign substance

Milosevic, 1998

The location and pattern of abrasion may be

dependent on the cause

Most common area is cervical area, related to

improper tooth brushing technique, zealous and

vigorous methods, and use of abrasive dentrifice.

Notching of incisal edges in pipe smokers, nail

biters, hair pin biting

Notching of incisors in Tailors, carpenters,

musicians

Proximal tooth abrasion due to improper

flossing and use of tooth picks

CLINICAL FEATURES An abrasion area is generally not well

defined unlike in attrition. Abrasion tends to round off or blunt tooth

cusps or cutting edges. Where dentin is exposed, it may be scooped

out because it is softer than enamel.

PIPE SMOKERS

Tooth surface will have a pitted

appearance.

Microscopically an abraded

surface shows haphazardly oriented

scratch marks and numerous pits .