TEERTHANKER MAHAVEER DENTAL COLLEGE AND RESEARCH CENTRE

DEPARTMENT OF ORAL PATHOLOGY

:-Seminar Topic:-

REGRESSIVE ALTERATIONS OF THE TEETH

Guided by:Presented by Dr. Kunal shah Sharib ali khan

MDS BDS 3rd year

INTRODUCTION:

Regressive changes in the dental tissues include a variety of alterations that are not necessarily related either etiologically or pathologically. Some of the changes to be considered here are associated with the general aging process of the individual.

Others arise as a result of injury to the tissues. Still other regressive changes of teeth occur with such frequency that there is some doubt whether they should actually be considered pathologic.

ATTRITION, ABRASION AND EROSION

Mechanical wear and tear of tooth substance is a consequence pathological situation. of means both and physiological therefore and different

adaptive strategies have evolved to tackle this

 A disease state arises when this delicate balance goes away resulting in early dissolution and loss of tooth substance with subsequent involvement of pulpal and periapical tissues.

It

is currently

acknowledged

that

there

are

several mechanisms that contribute to there are several mechanisms that contribute to tooth wear.

These include abrasion resulting from the friction of exogenous material forced over tooth surfaces (e.g. masticating food) or the use of teeth as tools; erosion resulting from the chemical dissolution of tooth surfaces (e.g. effects of acid from various sources or from a highly acidic diet), and attrition from tooth-to-tooth contact (e.g. night grinding ).

These mechanisms most often occur together, each acting at different intensity and duration in a continuously hanging salivary medium, and producing immensely variable patterns

degrees of wear.

ATTRITION

Definition:Attrition may be defined as, the physiologic wearing away of a tooth as a result of tooth-totooth contact, as in mastication.

This occurs only on the occlusal, incisal, and proximal surfaces of teeth, not other surfaces unless a very unusual occlusal relation or malocclusion exist.

This

phenomenon

is

physiologic

rather

than

pathologic, and it is associated with the aging process. The order a person becomes, the more attrition is exhibited. Attrition commences at the time contact or occlusion occurs between adjacent or opposing teeth.

It may be seen in the deciduous dention as well as in the permanent, but severe attrition is seldom seen in primary teeth because they are not retained normally for any great period of time Occasionally, however, children may suffer from either dentinogenesis imperfecta or amelogenesis imperfecta, and in both diseases

pronounced attrition may result from ordinary masticatory stresses.

Clinical features
o The first clinical manifestation of attrition may be the appearance of a small polished facet on a cusp tip or ridge or a slight flattening of an incisal edge.
o

Because of the slight mobility of the teeth in their sockets, of a the manifestation periodontal of the resiliency ligament,

similar facets occur at the contact points on the proximal surfaces of the teeth. o As the person becomes older and the wear continues, there is gradual reduction in cusp height and consequent flattening of the occlusal inclined planes. o According to Robinson and his associates, there is also shortening of the length of the dental arch due to reduction in the mesiodistal diameters of the teeth through proximal attrition.

o Only minor variation in the hardness of tooth enamel exists between individuals; nevertheless considerable variation in the degree of attrition is observed clinically. o Men usually exhibit more severe attrition than women of comparable age, probably as a result of the greater masticatory force of men. o Variation also may be a result of differences in the coarseness of the diet or of habits such as chewing tobacco or bruxism either of which would predispose to more rapid attrition.
o

Certain occupations, in which the person is exposed to an atmosphere of abrasive dust and cannot avoid getting the material into his mouth, also are important in the etiology of severe attrition.

Advanced attrition, in which the enamel has been completely worn away in one or more areas, sometimes results in an extrinsic yellow or brown staining of the exposed dentin from food or tobacco.

o Provided there is no premature loss of the teeth, attrition may progress to the point of complete loss of cuspal interdigitation. In some cases the teeth may be worn down nearly to the gingiva, but this extreme degree is unusual even in elderly persons.
o

The exposure of dentinal tubules and the subsequent irritation of odontoblastic processes result in formation of secondary dentin , pulpal to the primary dentin, and this serves as an aid to protect the pulp from further injury.

o The rate of secondary dentin deposition is usually sufficient to preclude the possibility of pulp exposure through attrition alone.

ABRASION

Definition:Abrasion is the pathologic wearing away of tooth substance through some abnormal mechanical process.

Abrasion usually occurs on the exposed root surfaces of teeth, but under certain circumstances it may be seen elsewhere, such as on incisal or proximal surfaces.

Robinson stated that the most common cause of abrasion of root surfaces is the use of an abrasive dentifrice.

Although modern dentifrices are not sufficiently abrasive to damage intact enamel severely, they can cause remarkable wear of cemented and dentin if the toothbrush carrying the dentifrice is injudiciously used, particularly in a horizontal rather than vertical direction.

Clinical features:o

Abrasion caused by a dentifrice manifests itself usually as a V-shaped or wedge-shaped ditch on the root side of the cementoenamel junction recession. in teeth with some gingival

The angle formed in the depth of the lesion, as well as that at the enamel edge, is a rather sharp one, and the exposed dention appears highly polished.

It has been shown by Kitchin and by Ervin and Bucher that some degree of tooth root exposure is a common clinical finding, and a 66 per cent incidence of abrasion among 1252 patients examined was reported by Ervin and Bucher.

Abrasion was more common on the left side of the mouth in right-handed people, and vice versa, suggested that improper tooth brushing caused abrasion.

The habitual opening of bobby pins with the teeth may result in a notching of the incisal edge of one maxillary central incisor

Similar notching may be noted in carpenters, shoemakers, their teeth. Habitual pipe smokers may develop the pipe stem

The

improper may

use

of

dental

floss on

and the

toothpicks

produce

lesions

proximal exposed root surface, which also should be considered a form of abrasion.

o It is apparent that pathogenesis under these different conditions is essentially identical. o The loss of tooth substance that occurs by one means or another is certainly pathologic but should present no problem in diagnosis
o

The exposure of dentinal tubules and the consequent irritation of the odontoblastic processes stimulate the formation of secondary dentin similar to that seen in cases of attrition.

Unless the form of abrasion is an extremely severe and rapidly progressive one, the rate of secondary dentin formation is usually sufficient to protect the tooth against pulp exposure.

EROSION

Definition:Dental erosion is defined as, irreversible loss of dental hard tissue by a chemical process that does not involve bacteria.

Dissolution of mineralized tooth structure occurs upon contact with acids that are introduced into the oral cavity from intrinsic (e.g. gastroesophageal reflux, vomiting) or extrinsic sources (e.g. acidic beverages, citrus fruits).

This form of tooth surface loss is part of a large picture of tooth wear, which also consists of attrition, abrasion and possibly abfraction.

CAUSES
Extrinsic causes. :
Erosion of tooth substance is mainly due to contact with acidic media either by way of food stuff or by iatrogenic exposure. There could be either extrinsic or intrinsic

sources of acid that could cause this mode of tooth substance loss.

 Examples of extrinsic acids. (Source outside the body ) are acidic beverages, foods, medications or environmental acids. The most common of these are dietary acids. It can be seen that most fruits and fruit juices have a very low pH (high acidity).acidic.

Several studies have found that the frequency of consumption of acidic drinks was significantly higher is patients with erosion than without.

This finding is of concern, particularly since children and adolescents are the primary consumers of these drinks.

With consumption of acidic drinks identified as a risk factor in erosion, this amount of soft drink consumption will likely lead to an increase in prevalence of erosion.

The erosive potential of beverages does not depend on pH alone. Other components of beverages, such as calcium, phosphates, and fluoride, may lessen erosive potential .

Also, factors such as frequency and method

of

intake of acidic beverages as well as the tooth brushing frequency after intake may influence susceptibility to erosion.

Therefore, the role of confounders like oral hygiene status, complicate the role of acids per se which necessitates further investigation to clarify the relationship between acidic beverage intake and dental erosion.

Medications that the acidic in nature can also cause erosion via direct contact with the teeth when the medication is chewed or held in the mouth prior to swallowing.

Numerous case reports exist describing extensive erosion secondary to chewing vitamin C preparations or hydrochloric acid supplements. Less common sources of extrinsic erosive acids are related to occupational and recreational exposure. Chromic, hydrochloric, sulfuric and nitric acids have been identified as erosion-causing acid vapors. They are released into the work environment during industrial electrolytic processes.

However current work safety standards make this type of erosion very rare. Dental erosion has been reported in swimmers who work out

regularly in pools with excessive acidity as well as individuals who are occupational wine-tasters.

INTRINSIC CAUSES Intrinsic causes (acid source inside the body), for erosion are gastric acids regurgitated into the esophagus and mouth.

Gastric acids, with pH levels that can be less than 1, reach the oral cavity and come in contact with the teeth in conditions such as gastroesophageal reflux and exessive vomiting related to eating disorders.

The

association

of

gastroesophageal

reflux

disease (GERD) with dental erosion has been established in a number of studies in adults is a common condition estimated to affect 7 %of the adult population on a daily basis and 36 % at least one time a month. In this condition gastric contents pass

involuntarily into the esophagus and can escape up into the mouth.

This is caused by increased abdominal pressure, inappropriate relaxation of the lower esophageal

sphincter or increased acid production by the stomach. However, GERD can also be silent with the patient unaware of his or her condition until dental changes elicit assessment for the condition. Chronic, excessive vomiting has long been

recognized as causing erosion of the teeth. The patient with an eating disorder such as anorexia example.

nervosa

or

bulimia

is

the

classic

The addition, treatment for bulimia may include use of antidepressants or other psychoactive medications hypofunction. that may cause salivary

Therefore,

the

cause

of

erosion

cannot

be

reliably determined from its location.

Erosion associated with alcoholism is caused by frequent vomiting. Other causes of vomiting that may cause erosion include gastrointestinal disorders such as peptic ulcers or gastritis, pregnancy, drug side effects, diabetes or nervous system disorders.

SALIVA AS A MODIFYING FACTOR.

The fluctuations in pH of saliva are mainly kept in balance by the buffering capacity of saliva.

This property is largely due to the bicarbonate content of the saliva which is in turn dependent on the salivary flow rate.

Bicarbonate concentration also regulates salivary pH. Therefore, there is a relationship between salivary pH, buffering capacity and flow rate increases.

Normally,

when

an

acid

enters

the

mouth,

whether from an intrinsic or extrinsic source, salivary flow rate increases, along with pH and buffer capacity. Within normal.

minutes,

the

acid

is neutralized

and

cleared from the oral cavity and the pH returns to

Patients with erosion were found to have lower salivary buffer capacity when compared with controls in several studies.

In other studies, low whole salivary flow rates in patients with erosion were determined to be the major difference.

Therefore,

salivary

function

is

an

important

factor in the etiology of erosion. Since many common medications and diseases can lower salivary flow rate (xerostomia), both whole and stimulated, it is important to assess salivary characteristics when evaluating a patient with erosion.

RISK FACTORS FOR DENTAL EROSION

Soft drinks consumed (4-6 or more per week) Eating disorder (weekly or more often)

Bruxism habit

Whole saliva unstimulated flow rate (0.1ml/min)

Sports drinks intake (weekly or more often)

Excessive attrition Vomiting Symptoms or history of gastroesophageal reflux disease

PREVENTION OF PROGRESSION OF EROSION Diminish the frequency and severity of the acid challange Enhance the defense mechanisms of the body (increase salivary flow and pellicle formation

Enhance

acid

resistence,remineralization

and

rehardening of the tooth surfaces Improve chemical protection Decrease abrasive forces Provide mechanical protection Moniter stability

MANAGEMENT OF EROSION Treatment of the etiology. Identification of the etiology is important as a first step in management of erosion . If excessive dietary intake of acidic foods or beverages is discovered, patient education and counseling are important.

If the patient has symptoms of GERD, then he/she should be referred to a medical doctor for complete evaluation and institution of therapy if indicated.

A patient with salivary hypofunction may benefit with the use of sugarless chewing gum of mints to increase residual salivary flow. The use of oral pilocarpine (Salagen) may be beneficial in patients with dry mouth caused by Sjogrens syndrome or post-therapeutic head and neck radiation. A patient suspected of an eating disorder should be referred to a medical doctor for evaluation. In some cases, an etiologic agent is not

identifiable. In other cases, the etiologic agent may be difficult to control, such as the problem of alcoholism. However, regardless of the cause, it is important to follow preventive measures to prevent the progress of erosion. There are several preventive measures that can be taken to control tooth erosion.

Much of erosion prevention depends on the compliance of the patient with dietary

modification, use of topical fluorides, use of occlusal splints, etc.

BIBILOGRAPHY:-

Robinson HBG. Abrasion, Attrition and erosion of the tteth. Health Center j Ohio State Univ. 3:21, 1949. Rudolph CE A Comparative study in root resumption in permanent teeth J am Dent Assoc. 23:822,1936.