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1 Why restore teeth?

with the surface plaque-free after home cleaning. If this is consistently not achieved, consideration should be given to ssure sealing the surface with a resin to obliterate the groove fossa system, thus aiding plaque control. Where a bitewing radiograph shows an approximal lesion in the outer enamel, the patient should be shown how to use dental oss. Root surface lesions are just as amenable to control by mechanical plaque control as coronal lesions. Pay particular attention to the approximal surfaces of teeth next to a denture. Patients need to be shown how to angle the toothbrush to reach these areas or, alternatively, use strips of cotton gauze or cloth in a similar manner to ossing to remove the gross plaque from these hard-to-reach areas (Fig. 1.18).

articial sweetener (sorbitol or xylitol) should be chosen in preference to a sugar-containing gum. Of the two articial sweeteners, xylitol seems the better as this product may suppress counts of some acidogenic micro-organisms. Sometimes patients with a dry mouth suck sweets or sip sweet drinks to alleviate the problem. This is obviously very unwise in patients who are already at high risk to caries because they are short of saliva.

Operative treatment
The role of operative dentistry in the management of dental caries is to facilitate plaque control. Tooth restoration also restores: appearance form function.

Use of uoride
The dentist should check that the patient is using a uoride toothpaste. Some products formulated for sensitive teeth and some herbal toothpastes do not contain uoride. The paste should be used twice daily and cleared from the mouth by spitting rather than vigorously rinsing. A uoride mouthrinse (0.05% sodium uoride) used every day is a useful uoride supplement in a high risk patient, although the cost of the product may preclude its use by some patients. Surgery application of uoride varnish is a sensible preventive measure and particularly valuable in those unlikely to comply with a daily mouthwash regime.

Caries in pits and ssures

Uncavitated lesions can be controlled by mechanical plaque control with a uoride-containing toothpaste. Where a patient cannot or will not remove plaque, a ssure sealant is a wise intervention to prevent plaque stagnation. Cavitated lesions should be visible in dentine on a bitewing radiograph and should be treated operatively because the patient will be unable to clean plaque out of the hole in the tooth.

Dietary advice
Dietary advice should be given based on a diet sheet. Figure 1.36 shows a diet sheet completed by a middle-aged patient with a high incidence of caries. The sugar attacks have been highlighted. Note the frequency of sugar intake. This gives the dentist the opportunity to explain the Stephan curve (Fig. 1.2) and the importance of decreasing the frequency of sugar intake. The dentist should try to get the patient to suggest changes. This approach helps the patient to set realistic goals and enables the dentist to see whether the relationship between diet and caries has been understood by the patient. The dentist should check that the main meals are adequate, and a list of foods that are safe for teeth may be helpful here. The negotiated dietary change should be recorded on paper so that the patient can take this away and ponder at leisure. The dentist should record the goals agreed in the notes so that specic enquiry can be made at the next visit. A reasonable aim for this patient would be to try to conne sugar to mealtimes.

Approximal lesions
The diagnosis of cavitation was discussed on p. 14. Cavitated lesions need operative treatment because even the most fastidious of ossers cannot clean plaque out of the hole the oss simply skates over the top. In anterior teeth, approximal lesions may be unsightly because the demineralized dentine appears black or brown. This would be a reason to restore, even if no cavity was present.

Smooth surfaces and root caries

Many smooth surface lesions, including cavitated ones, can be arrested by preventive, non-operative treatment. Lesions which are plaque traps or unsightly should be restored.

Tooth wear
Tooth wear is dened as the surface loss of dental hard tissues other than by caries or trauma, and is sometimes called tooth surface loss (TSL). This distinguishes it from early enamel caries that is characterized by subsurface loss of minerals beneath a relatively intact surface zone. The term tooth wear is preferred to tooth surface loss because it is easily understood by patients and because the extensively

Salivary ow
Salivary ow should be measured because a feeling of a dry mouth may be subjective rather than actual. When the salivary glands are capable of secreting, chewing gum stimulates salivary ow. A chewing gum with an

Fig. 1.36 A diet sheet completed by a middle-aged patient with a high incidence of caries. The frequent sweet drinks, sweets, and the pre-bed sweet drink and snack are a potential cause of caries in this mouth. Note the frequency of sugar intake eight times per day.

Tooth wear 21

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1 Why restore teeth?

Fig. 1.37 Extensive wear. (a)

worn teeth lose a good deal more than just their surface (Fig. 1.37). Tooth wear occurs naturally throughout life and so it is common to nd moderate degrees of wear in older people. What is remarkable is that they do not wear more. 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 insofar that reactionary or reparative dentine will be laid down in the pulp chamber as a response to tooth wear, even though it cannot of course replace itself once worn away from an exposed surface in the mouth. Teeth are in use every day and it is an impressive feat of nature that in most patients they do not wear out, even after several decades of use. However, sometimes the wear becomes excessive as a result of one or more of the following causes: erosion, attrition, and abrasion.

(b) Fig. 1.38 (a) Regurgitation erosion affecting the palatal surfaces of the upper incisor and premolar teeth. This was due, in this case, to bulimia nervosa. The patients commonly overeat and then deliberately vomit in an attempt to maintain a low body weight. (b) Posterior teeth with severe palatal erosion, particularly of the rst molar teeth. The patient was a chronic alcoholic.

Erosion
This is dened as the loss of dental hard tissue as a result of a chemical process not involving bacteria. The chemical is acid and the source is either regurgitated stomach acid or acid from the diet. Regurgitated acid is the most common cause of erosion and causes the most damage. Previously dentists thought that dietary erosion was the most common. This is because it is easy to take a dietary history from a patient and they are likely to be truthful about their diet. In contrast, many of the conditions which cause regurgitation erosion are embarrassing and some patients do not readily talk about them. These include eating disorders (Fig. 1.38a), chronic alcoholism (Fig. 1.38b), and even the less polite symptoms of indigestion. Some patients suffer from gastro-oesophageal reux disease (GORD), which can cause dental erosion, and yet they have no other symptoms other than their tooth wear. Gastroenterologists call these patients silent reuxers and they can be identied by tests carried out by these specialists. There is also a group of patients who voluntarily regurgitate their stomach contents, chew, and then swallow. These ruminants may be embarrassed to admit to a habit

that is natural to them but others may nd strange. The dental devastation is extreme. Although regurgitation usually rst affects the palatal surfaces, it often also causes strange unexplained cuppedout lesions in molar teeth, starting with the tips of cusps (Fig. 1.39). Dietary acid does produce erosion but it is not entirely clear that this is always the result of the acid entering the mouth and contacting the teeth. In some cases there may be a secondary effect, particularly with zzy drinks which introduce gas into the stomach which, in turn, comes back into the mouth carrying not only the acidic zzy drink but also the stomach acid. In chronic alcoholic patients there is good evidence that the alcohol produces damage to the stomach lining, which in turn results in regurgitation of acid. Therefore it is the acid coming back rather than the alcohol itself which causes the erosion (Fig. 1.38b). In the past, industrial acids in the form of vapour or droplets in the air caused dental erosion and this was investi-

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Fig. 1.41 Incisal wear which is the result of a combination of erosion and attrition. The incisal edges are cupped out and do not make contact with the opposing teeth in any excursion of the mandible.

(a) Fig. 1.39 Cupped-out erosion lesions on the occlusal surfaces of another patient with an eating disorder.

gated in car battery manufacturers and other industrial processes. As a result of these investigations, health and safety legislation to prevent exposure to industrial acid was introduced in most countries: consequently, industrial erosion is now very rarely seen.

Attrition
This is dened as mechanical wear between opposing teeth (Fig. 1.40) and commonly occurs in combination with erosion. By denition, attrition can only be present on contacting occlusal or incisal surfaces, or surfaces that were once in contact. Where erosion and attrition coexist, some areas of the worn occlusal surface may not make contact in any mandibular excursion. This pattern shows that attrition cannot be entirely responsible for the tooth wear and that an erosive element must also be present (Fig. 1.41). The physical effect of food wearing the tooth surface is not well understood, but it is thought to have little effect in contemporary diets in Western countries. It may be of more relevance in particularly abrasive diets (e.g. some vegetarians).

(b)

(c) Fig. 1.40 Attrition. The patient is making a right lateral excursion of the mandible and the upper and lower teeth t well together at this point. It is likely that the patient bruxes in this position at night. Note also that the upper and lower teeth are worn by approximately the same amount. Fig. 1.42 (a) Dish-shaped abrasionerosion lesions. Large areas of dentine are exposed at the base of saucer-shaped lesions. (b) and (c) V-shaped notch lesions which occur at the necks of teeth. Note also that all the enamel surfaces have been worn smooth.

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1 Why restore teeth?

Abrasion
This is the wearing away of tooth substance by mechanical means other than by opposing teeth, such as holding a pipe or perhaps over-vigorous toothbrushing. It is easy to understand how tooth tissue softened by acid is particularly susceptible to such wear, and it can be difcult to make a clear distinction between erosion and abrasion. Abrasionerosion lesions commonly present buccally at the cervical margin, and are either dish-shaped (Fig. 1.42a) or in the form of a sharp V-shaped notch (Fig. 1.42b and c). The reason for these two distinctly different presentations is not known. The V-shaped notches of the necks of teeth involving both enamel and dentine are sometimes called abfraction lesions and some dentists believe that these are caused by the tooth exing under occlusal forces, especially in lateral excursive movements. However, there is no reliable scientic evidence of this. The aetiology remains a mystery.

Some of these features require operative intervention to protect the pulp, reduce sensitivity, and improve appearance or function. However, restorations will not prevent further wear. Just as with dental caries, restoration can temporarily replace the lost tooth surface but wear will continue on any tooth surface exposed around the restoration if the cause is not identied and prevented.

Diagnosing and monitoring tooth wear

It is relatively easy to diagnose that teeth are worn, provided that they are viewed clean and dry. Differentiating between acceptable and pathological levels of wear can be more difcult because the decision depends on the age of the patient. Also, a single examination will not show whether the wear is static or progressing, nor the speed of any progression. Where a pathological rate of tooth wear is suspected, study models taken at six-monthly or yearly intervals will determine the rate of progression and the effectiveness of preventive measures. If these measures are not entirely successful, the series of models will help to decide if and when to intervene operatively. Assessing the aetiology Finding the cause of tooth wear can be very difcult, but a careful sympathetic history is helpful. Many of these patients have conditions which they nd difcult or embarrassing to discuss, such as eating disorders bulimia nervosa and anorexia nervosa or chronic alcoholism. Bulimia nervosa is a variation of anorexia nervosa in which the patient deliberately vomits repeatedly (often between 2 and 30 times a day) in an attempt to control body weight. Eating habits are bizarre and compulsive, and the patients tend to be secretive about them and do not regard themselves as ill. The repeated vomiting often causes very rapid erosion, occasionally so fast that vital pulps are exposed. Chronic alcoholism causes a chronic gastritis which in turn produces dental erosion in some patients, even without recurrent frank vomiting. The history might include questions on the following topics.
RELATING TO EROSION

Summary of the causes of tooth wear

These are set out in Fig. 1.43.

Acceptable and pathological levels of tooth wear

It is normal for teeth to wear, but the process is regarded as pathological if they become so worn that they function ineffectively or seriously mar appearance. The distinction between acceptable and pathological tooth wear at a given age is based on a prediction as to whether the tooth will survive that rate of wear in a functional and reasonable aesthetic state until the end of the patients normal lifespan.

Consequences of pathological tooth wear

There are several important clinical features that can result from pathological tooth wear. These include the following: exposure of dentine on buccal or lingual surfaces normally covered by enamel (Fig. 1.38) notched cervical surfaces (Fig. 1.42b and c) exposure of dentine on incisal or occlusal surfaces further erosion often results in preferential loss of dentine to produce a cupped surface (Fig. 1.39) restorations (which do not erode) left projecting above the tooth surface exposure of reparative dentine or pulp wear producing sensitivity pulpitis and loss of vitality attributable to tooth wear wear in one arch more than in the other inability to make contact between worn incisal or occlusal surfaces in any excursion of the mandible.

Past and present diet, including questions on a series of food and drink items known to cause dietary erosion (Fig. 1.44). Digestive disorders which may produce a regurgitation erosion, including pregnancy sickness. Past and present slimming habits, including any tendency to anorexic or bulimic behaviour. Weight loss and cessation of periods in women that might be indicative of anorexia nervosa.

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Fig. 1.43 The most common causes of tooth wear.

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1 Why restore teeth?

Fig. 1.44 An aide-mmoire for use when taking a history relating to erosion.

Alcohol intake. Past and present medical history and medication, including vitamin C, iron preparations, and hydrochloric acid for achlorhydria.

The patients present and past occupation relevant to industrial erosion. Figure 1.44 provides a useful aide-mmoire for the inexperienced clinician who nds the variety and complexity of the questions a lot to remember.

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RELATING TO ATTRITION

Clenching and grinding habits. Has a sleeping partner heard grinding noises? Periods of stress or anxiety. Other habits, including pipe smoking, opening hairgrips, and biting thread. Has the patient a square jaw with over-developed muscles?
RELATING TO ABRASION

Attrition due to nocturnal bruxism may be helped by occlusal adjustment to remove interferences which trigger the grinding, and in other cases an acrylic bite plane is provided for use at night. This may reduce the grinding habit and will absorb the wear, with the acrylic being replaced periodically. Abrasion may be prevented by changing the abrasive activity, for instance: the brushing method the brushing frequency (no more than twice per day) the toothpaste used.

Oral hygiene techniques, including past and present use of abrasive tooth-cleaning techniques and materials. Habits which might abrade teeth, such as pipe smoking. On the basis of the answers to these questions it may be possible to dene the aetiology as one of the following: dietary erosion regurgitation erosion industrial erosion attrition abrasion combined aetiology (try to assess the importance of each aetiological factor) aetiology not determined.

The management of tooth wear

Unlike early caries, tooth wear is an irreversible process. Management should have the objective of maintaining a functional comfortable dentition of good appearance for life, so the emphasis should be on prevention and monitoring in the early stages, avoiding the temptation of placing restorations until they are necessary. They become necessary only when the patient becomes concerned about the appearance, or the teeth become sensitive, or the dentist becomes concerned about physical changes such as changes in occlusal vertical dimension or pulp exposure. If restorations are placed while the wear is progressing, particularly with erosion, they may accelerate rather than slow down the rate of wear in the surrounding tooth tissue. In advanced cases, crowns are required.

Preventing tooth wear

Prevention clearly depends primarily on making an accurate diagnosis of the cause. Some erosive causes, once identied, are easy to prevent, others are more difcult. When the problem is gastro-oesophageal reux disease or a milder form of indigestion then the condition can sometimes be controlled by prescribed medication or over-thecounter remedies. Patients with eating disorders are more difcult to treat successfully. Often the condition lasts for a few years and then burns itself out. The dental management should be to monitor and maintain and preferably not to provide too much interventive treatment unless there are strong indications, until after the condition has resolved: e.g. the cupped-out lesions shown in Fig. 1.39 do not usually cause sensitivity or problems with function or appearance. If they are lled without preventing the cause then further erosion will often continue around the margins of the llings or elsewhere on the tooth. Some patients may have 30 or 40 such lesions affecting all their occlusal surfaces and maintaining the restorations involves extensive treatment for which there is very little justication. An exception to this principle might be the use of adhesive composite restorations to support fragile enamel margins, especially where these have an impact on the patients appearance.

Trauma
While caries and tooth wear are diseases of slow onset, traumatic injuries are acquired suddenly, and when these involve the hard dental tissues and the pulp they usually require immediate operative management. Trauma to the mouth can produce these local injuries: lacerations to the lips, tongue, and gingival tissue alveolar fractures, so that a number of teeth become mobile within a block of bone complete or partial subluxation of a tooth root fracture damage to the apical blood vessels without fracture fracture of the crown of the tooth involving enamel alone, enamel and dentine, or exposure of the pulp. These injuries can, of course, occur in combination. Only the last one listed will be discussed in detail here.

Aetiology of trauma
Trauma is commonly caused by the following: falls