Babul - Enamel Erosion Early detection and treatment 2014

A c id E r os ion
E ar ly D etec tio n and T r eatment
Dr. Amin Babul. D.D.S
Although tooth wear is multifactorial and
is comprised of…
1
Abrasio n
Attritio n
Ero s io n
1: Ann-Katrin Johansson, Ridwaan Omar, Gunnar E. Carlsson, and Ande rs Johansson. De ntal Erosion and Its Growing Importance in Clinical Practice : From
Past to Pre se nt. Inte rnational Journalof De ntistry. Vol. 2012, Article ID 632907, 17 page s.
There is ample evidence that the contributing factor
for all types of tooth wear is erosion.
Ename l s o fte ne d by acid is mo re pro ne
to de s tructio n whe n me chanical
1,2
fo rce s are applie d.
1.Ann-K atrin Johansson, Ridwaan Omar, Gunnar E. C arlsson, and Anders Johansson. Dental Er osion and I ts Gr owing I mpor tanc e in C linic al P r ac tic e: Fr om P ast to P r esent.
I nternational Journal of Dentistry. Vol. 2012, Article I D 632907, 17 pages.
2.Addy M, Shellis RP: I nter ac tions between attr ition, abr asion and er osion in tooth wear . I n Dental Erosion (Monographs in Oral Science 20) Ed. A L ussi. Basel: K arger, 2006, pp.
17-31.
3
Erosion
Enamel exposed to
lemon juice for
5 minutes
No enamel exposure
to lemon juice
3. Lussi A, Schaffne r M, Jae ggi T. De ntale rosion: diagnosis and pre ve ntion in childre n and adults. Int De nt J. 2007;57:385-98.
How long does it take for enamel to wear away?
Pure abras io n
2,500 years to remove 1mm of enamel
Abras io n and to o thpas te
100 years to remove 1mm of enamel
Abras io n and e ro s io n
2 years to remove 1mm of enamel
Data re produce d from a pre se ntation by Dr. David Bartle tt. 2012.
Definition Since 2006
Definition by Adrian Lussi
T he loss of tooth
structure by chemical
dissolution without the
involvement of
bacteria.4
4. Lussi A(e d). De ntal Erosion from Diagnosis to The rapy. Monographs in OralScie nce . 2006; 20:1-214.
4,5
Causes of Acid Erosion
Intrinsic factors
Composition of saliva
GERD
Eating disorders
Extrinsic factors
Dietary
Medications
Parafunction habits
4. Lussi A(e d). De ntal Erosion from Diagnosis to The rapy. Monographs in OralScie nce . 2006; 20:1-214.
5. Barbour. M, The Role of Erosion, Abrasion and Attrition in Tooth We ar. JCD 2006 Volume 17 Numbe r 4
Why is erosion a growing concern?
Pre vale nc e of this c o nditio n is o n the ris e wo rldwide .1
Advanc e s in de ntis try and hyg ie ne me an te e th are lasting
lo ng e r.5
Mode rn- day die t is c hang ing and the re s ult is a g re ate r numbe r
o f ac id c halle ng e s o n a daily bas is.6
Childre n and ado le s c e nts are be ing mo re affe c te d by this
c onditio n –1 o ut o f 3 affe c te d by e ro s io n.7
Eros io n is e vide nt as e arly as 36 to 4 8 mo nths o f life .8
1. Ann-K atrin Johansson, Ridwaan Omar, Gunnar E. C arlsson, and Anders Johansson. Dental Erosion and I ts Growing I mportance in C linical Practice: From Past to Present. I nternational
Journal of Dentistry. Vol. 2012, Article I D 632907, 17 pages.
5. Barbour. M. The Role of Erosion, Abrasion and Attrition in Tooth Wear. JC D 2006 Volume 17 Number 4.
6. Zero, D, L ussi, A. Erosion-chemical and biological factors of importance to the dental practitioner. I nternational Dental Journal 2005.
7.Bartlett DW, L ussi A, West NX , Bouchard P, Sanz, M, Bourgeois D. Prevalence of tooth wear on buccal and lingual surfaces and possible risk factors in young European adults, Journal of
Dentistry 2013.
8.Huang, L .L . et al. Association of erosion with timing of detection and selected risk factors in primary dentition: A longitudinal study, I nternational journal of pediatric dentistry, April
2014.
Prevalence of Acid Erosion
“
Because of different scoring system s, sam ples and exam iners, it is difficult to com pare
and judge the outcom e of Incidence studies.”Lussi A: Dental Erosion 20069
9. Lussi A (e d). De ntalErosion from Diagnosis to The rapy. Monographs in Oral Scie nce . 2006; 20. Page 61.
E SC A R C E L
Study supported by a research grant from GSK
First and largest pan-European Epidemiology Study on Non-Carious Cervical Lesions (NCCL) and
Associated Risk Factors to date, providing scientific insight to understand prevalence and
associated risk factors of tooth wear and dentin sensitivity1
Devised and conducted by six of the world’
s leading dental experts in acid erosion1
Assessed 3,187 subjects, between 18 and 35 years old, for tooth wear1
Across seven European countries: UK, Italy, France, Spain, Finland, Latvia and Estonia1
Unveiled at the 101st Annual FDI World Dental Congress in Istanbul, August 2013
ESCARCEL Re ve als :
Almost one-third (29.4%) of 18–35 year olds have tooth wear or tooth enamel wear1
Erosive tooth wear is prevalent in young adults; even those as young as 18 years1
— Tooth wear was higher in 26–35 year olds compared to 18-25 year olds 1
Those with frequent acidic food intake had higher levels of tooth wear1
— Leading a modern lifestyle that includes a diet rich in acidic food such as fruits, juices,
tea and sodas is a likely contributor to the increase of the condition
7.Bartle tt DW, Lussi A, We st NX, Bouchard P, Sanz, M, Bourge ois D. Pre v ale nce of tooth we ar on buccaland lingual surface s and possible risk factors in y oung Europe an adults,
Journalof De ntistry 2013.
Google Trends
Google Search Data for Juicing
Google Search Data for L emon Water
Google Search Data for Juicing
If the data tells us that acid erosion is present in 30% of
the population7 , how many patients are being diagnosed
in Canada?
Under Diag nosed
7. Bartle tt DW, Lussi A, We st NX, Bouchard P, Sanz, M, Bourge ois D. Pre vale nce of tooth we ar on buccal and lingualsurface s and possible risk factors in young Europe an adults, Journal of
De ntistry 2013.
Consequences of Advanced
Erosion
So c ial
Patients may be embarrassed about their appearance
Func tio nal
TMJ problems due to loss of vertical dimension, loss of teeth, and bruxism
Sensitivity
Difficulty incising foods
Pain due to pulp exposure
Need for major rehabilitation including surgical crown lengthening,
full mouth reconstruction, multiple endodontic treatment, and extractions
Diag nosis
Dental professionals are sometimes confused by its signs and
symptoms, and its similarities and differences from the other
categories of tooth wear.4
E r os io n is the lo s s o f e name l and de ntin b y c he mic al
means no t inv olv ing b ac te r ia.
A br as io n is the lo s s o f e name l and de ntin b y we ar f r o m
s ur f ac e s o the r than te e th ( e .g ., hab its s uc h as b iting
p ens , holding pip e s with tee th).
A ttr itio n is the lo s s o f e name l and de ntin c aus e d b y we ar
o f to o th ag ains t to oth.
4. Lussi A ( ed). Dental Erosion from Diag nosis to Therapy. Mo n o g r Or a l S c i . 2006; 20:1- 214.
How to Diagnose?
Clinic al e xaminatio n
Use o f diag no s tic aids
Co nve rs atio n with the patie nt
—Diet assessment
—Behavioural assessment
C linic al E x amination
E ar ly c linic al s ig ns o f ac id er o s io n
E nam e l t r ans luc e nc y
L oss of
e nam e l
P alat al e r o s iv e t o o t h wear
Oc c lus al
c up p ing
Courtesy of
How to Diagnose: Diagnostic Aids
Diag no s tic Aids
Dental loupes
Multilux light –show through of enamel is highlighted with this light
Dental probe –measure the depth of erosive lesion or the height of
anterior teeth
Diag no s tic Me tric s
BEWE: Basic Erosive Wear Examination
Diag nostic Metrics
Basic Erosive Wear Examination
BEWE: Bas ic Eros ive We ar Examinatio n
Developed in 2008 by Dr. David Bartlett
(Head of Prosthodontics, King’
s College London) and
team
Dr. David Bartlett
King’
s College L ondon
Pe e r- to - Pe e r Fo rum o n Ac id Ero s io n,
Toro nto
Leveraged Dr. Bartlett’
s BEWE expertise and
ProNamel’
s role in acid erosion management
Collaboration of 11Canadian dentists to develop
a simple in-office patient identification tool with
the application of BEWE
Peer-to-Peer Forum in T oronto on Acid Erosion
July 2012
*I n sc ores 2 and 3 dentin is often involved
Courtesy of
Courtesy of
Manag ement of
Acid Wear
12
Management
of
Acid
Erosion
1. Pre ve ntative Tre atme nts
1. Pre ve ntative Tre atme nts
Nutritionalcounselling
Identifying parafunctional habits
Identifying quality of saliva
Preventive oral hygiene aids
—Rinses
—Fluoride varnishes
—Toothpaste
2 . Re s to rative Tre atme nts
Indirect or direct restorations:
veneers, inlays/ onlays, crowns,
composite, resins, etc.
Full mouth reconstruction
12. Shaw L , Smith AJ. Dental erosion –the problem and some practical solutions. Br Dent J. 1998;186:115-18.
Nutritional Counselling
Why diet is a key factor
Frequent and high acidic food intake increases levels of tooth wear11
• Snacking, grazing, sipping, and swilling increase contact time of acidic
substance with the teeth
• pHis not the only factor
Manner in which food or
drink is consumed is more
important than the overall
quantity.
Nighttime exposure to acids
is thought to be particularly
destructive because of the
absence of salivary flow.4
4. Lussi A (e d). De ntalErosion from Diagnosis to The rapy. Monogr OralSci. 2006; 20:1-214.
11. Bourge ois, D. e t al. Is De ntal Erosion and De ntin Hype rse nsitivity a Public He alth Proble m: Rationale of the Europe an Collaborative Study. Pre se nte d at 101st FDI. Annual World De ntal Congre ss, 28
–31st August 2013, Istanbul, Turke y.
pHis not the only factor to take into consideration.12
Titratability relates to the amount of saliva required to neutralize acid.12
Tooth Enamel Can Dissolve at a pH of 5.5 or Below13
Item
pH
Titratable Acidity
Erosion Potential
Sparkling Water
5.3
0.1
L ow
Cola
2.6
0.7
Medium
Sparkling Orange Juice
2.9
2.0
Medium
Sports Drinks
2.8
2.1
Medium
White Wine
3.7
2.2
Medium
Apple Juice
3.4
4.5
High
Energy Drinks
2.8
6.5
High
Grapefruit Juice
3.2
9.3
High
12. Shaw L , Smith AJ. Dental erosion –the problem and some practical solutions. Br Dent J. 1998;186:115-18.
13. VON FRAUNHOFER Dissolution of dental enamel in soft drinks. Operative Dentitstry. Pages 308-312.
Courtesy of
Dietary C ounselling Advice
12
Limit acid foods and drinks to mealtimes.
Reduce frequency.
Avoid acidic substances last thing at night.
Finish meals with something alkaline such as a small piece
of cheese or milk.
Avoid tooth brushing after acidic substances.
Chewing gum has been shown to stimulate salivary flow
and increase buffering capacity, but may also cause
increased gastric secretion.
12. Shaw L , Smith AJ. Dental erosion –the problem and some practical solutions. Br Dent J. 1998;186:115-18.
Preventive Oral Hygiene Aids
Why Do Oral Care Product
Matters?
12
Rins e s
Varnis he s
To pical fluo ride
12. Shaw L , Smith AJ. Dental erosion –the problem and some practical solutions. Br Dent J. 1998;186:115-18.
Fluoride Penetration in Enamel
9
The Simplified Formula
Hydroxyapatite Ca10(PO4)6(OH)2
Fluoride
F
Fluorapatite Ca10(PO4)6F 2
Dynamic Secondary Ion Mass Spectrometry (DSIMS)
imag ery comparing fluoride penetration into enamel
containing erosive lesions after treatment with various
toothpastes14
9. L ussi A (ed). Dental Erosion from Diagnosis to Therapy. Monographs in Oral Science. 2006; 20. Page 67.
14. Fowler C E et al. I nhibition of enamel erosion and promotion of lesion rehardening by fluoride: A white light
interferometry and microindentation study. J C lin Dent. 2009;6:175-202.
However…in Reality, Enamel Has a
Slightly Different Formula
Enamel is a calcium depleted –carbonated hydroxyapatite
Ca10 (PO4 )6 (OH)2
CO3 -
Na +
Ca===Na===(PO4)-OH===CO
3
This means that the hydroxyapatite in enamel has too many
chemical bonds that can be broken.
This is the reason why acid can attack and demineralize
enamel.
9. L ussi A (ed). Dental Erosion from Diagnosis to Therapy. Monographs in Oral Science. 2006; 20. Page 67.
Why Enamel Erodes
Ca===Na===PO4===OH===CO3
H+
H+
H+
CaF-CaF-CaF-CaF-CaF-CaF-CaF-CaF-CaF-CaF-CaF-CaF-CaF-CaF-CaF
When a large concentration of fluoride is added to the hydroxyapatite
surface the fluoride combines with Ca to make CaF.
This Ca-F acts to create a barrier to protect against acid and also works to
prevent the breakdown of hydroxyapatite.
9. L ussi A (ed). Dental Erosion from Diagnosis to Therapy. Monographs in Oral Science. 2006; 20. Page 67.
Fluoride Varnish
There is conclusive evidence from several
studies that fluoride varnish has a significant
role to play in protecting enamel.15
Newer studies show that it requires repeated
applications to be effective.
Great preventive measure but not very
convenient.
15. Danuta Waszkiel,a Gra yna Marczuk-K olada,a Ma gorzata Gr dzka-Dahlkeb, Bia ystok, Poland. EFFI C AC Y OF FL UORI DE VARNI SHES I N THE PROPHYL AX I S OF
DENTAL EROSI ON. Research report. Fluoride 39(1)49–52. January-March 2006
Fluoride Rinses
Has been shown to produce a significant anti-caries effectNot enough evidence to show effect on erosion.
New studies show great promise if fluoride rinse is
combined with other ingredients as tin or titanium.
Weekly versus daily:
Daily rinses show better efficacy.
Dr. Amin Babul to provide Reference.
Active Ingredients in Toothpaste
Fluo ride
Sodium fluoride
Sodium monofluorophosphate
Stannous fluoride
Calc ium De live ry
Amorphous calcium phosphate (ACP)17
Tri-calcium phosphate (TCP)17
Pro-arginine
17.Goldstep F. Proactive I ntervention Dentistry: A Model for Oral C are through L ife. C OMPENDI UM. 2012; Vol 33. N6.
Fluoridated Toothpaste
“
Toothpastes have a preventive effect.”
Toothpastes in the market that are specifically created for erosion must have:18
Maximum highly active sodium fluoride
—In the Canadian market the maximum concentration of sodium fluoride permitted in a daily
toothpaste is 1150 ppm
Low abrasion –to prevent further wear
Anti-sensitivity agent such as KN03 –erosive lesions often lead to sensitivity
A gentle detergent system to minimize irritation to soft tissues and reduce the
disruption of smear layer –this helps to reduce progression of erosion on root
surfaces
NOTE: Proper brushing techniques and soft
toothbrush are also key to reducing wear
18. L ayer.T. Formulation C onsiderations for Developing Toothpastes. JC D 2009 Volume X X Number 6
Formulation design and engineering is critical
when developing toothpastes suitable for
people at risk of acid erosion.
Ing re die nts that c an affe c t fluo ride o ptimizatio n
Positive Metal ions (e.g., calcium, aluminum)
Components such as chemical whitening and/ or antitartar agents (e.g. pyrophosphate ions)
RDA value
Toothpaste RDA values can range from 30 to >200
K
e
y
T
a
k
e
A
w
a
y
s
Patients are keeping their teeth longer.
Enamel erosion is on the rise and affects a large portion of the
population.
Acid is the main cause of the erosion.
This acid is most commonly associated with our modern day diet.
Combination of parafunction habits and dietary acids can lead to rapid
tooth wear. This leads to many dental problems ranging from minor
sensitivity to severe pain.
Diagnosing and treating the cause is in the practice of every
DENTALHYGIENIST.
Hygienists have a significant role to
play in diagnosing and managing
acid wear.
Its no t jus t abo ut pe rio do ntal dis e as e …
Its abo ut maintaining g o o d o ve rall de ntal he alth.
Dr. Amin Babul
[email protected]

Download Report