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

2. Definition
Loss of dental hard tissue due to
causes NOT attributed to bacterial
action on fermentable carbohydrates

3. Historical Perspective
• Normal physiologic process
• Some tooth-wear essential for efficient
function of teeth which is seen in many
herbivores
• Important to establish unhindered guidance
during mastication
• However the level of tooth wear minimal

4. Rates of tooth-wear
• 2500 years for 1mm of enamel wear with
normal function
• Estimated the level of tooth wear to be 29µm
for molars and 15µm for premolars
(Lambrechts et al, 1989)
• Physiological wear poses minimal problems
• If the rate of wear challenges the viability of
teeth 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

8. Diet
• Dietary changes have resulted in the diets
being less abrasive
• Should theoretically reduce the levels of
tooth-wear
• Excessive consumption of erosive beverages
and foods has had a potentiating effect on the
increased prevalence of NCTSL

9. 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 and
adolescents in the UK (35%)
• Condition of affluent in Sri Lanka (Ratnayake N
& Ekanayake L. 2010)

10. Extrinsic Acid Erosion
Intrinsic Acid Erosion

11. Intrinsic Acid
• pH of Gastric acid is 1-2
Gastric Regurgitation
Bulaemia and anorexia
Vomitting
Classically presents as palatal/lingual erosive
defects

12. Para-function
• Stress induced parafunction
• Bruxism
• Object biting

14. Problems of para-function
• 700 times the normal masticatory load
• Force used is considerably greater than during
normal mastication
• Seen as wear in non functional cusps
Molars may be severely affected
Prominant masseters
Marked antigonial notching
Tenderness of muscles of mastication

15. Other factors contributing to tooth
surface loss
• Defective enamel and dentine deposition and
maturation ( E.g AI, DI, Hypoplasias)
• Abrasive restorative material (Unglazed
porcelain)
• Abrasive dentifrices and hard brushing in
horizontal strokes
• Habits – Instrument biting, Needles etc

16. Defective enamel formation

17. Scale of the Problem
• 98% of individuals in the UK have some
amount of tooth wear
• Increased prevalence among
children, deciduous teeth
• 30% of individuals in the UK have severe tooth
wear (Tooth Wear Index scores of 3 & 4)
• Problem of affluent in Sri Lanka

18. 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 on
one cause

19. Erosion
• Due to intrinsic or extrinsic acid
• Intrinsic acid regurgitation due to gastric reflux
disease (Bullaemia, Anorexia, Gastritis, GORD)
• Extrinsic acid consumption (Coke, Fizzy
drinks, Fruit juices, tamarind)
• Increasingly seen in young due to change in
lifestyles

20. Extrinsic Acid Erosion
•Buccal and Labial surfaces
•Lingual and palatal spared
Intrinsic Acid Erosion
•Palatal and lingual surfaces
•Lower incisors spared
•Etched like appearance
•Cupping
•Discoloured if historical
•“Proud” restorations

21. 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-alveolar
compensation
• Erosion potentiates attrition (De-mastication)

22. Attrition

23. Abrasion
• Due to improper brushing technique
• Abrasive dentifrices
• Foreign objects (e.g. Needles, Clips etc)
• Erosion may potentiate abrasion (Abrosion)

24. Abrasion

25. 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

26. Abfraction

27. Effects of NCTSL
• Sensitivity of teeth
• Pulpal and Periodontal complications
• Poor aesthetics
• Impeded function
• Prone to fracture
• Low self esteem (OHRQoL)

28. Aides to Diagnosis
• Detailed history
– Occupation, Social, Dietary analysis, Medical history
• Examination
– Masticatory apparatus, MAN, Wear facets and their
location, “proud” restorations
• Investigations
– Radiographs, Photographs, Dated study casts

30. Strategies in the management of
NCTSL
• Psycho-social support
• Medical referrals (GERD)
• Habit intervention
• Reduction in consumption of erosive
beverages
• Using a straw
• Soft mouth guards to protect teeth during
gastric regurgitation (Addition of Fluoride gel)
• Michigan splints to reduce effects of bruxism

31. Soft bite guards/ Michigan splints

32. Challenges in management
• Lack of vertical space due to dento-alveolar
compensation mechanisms
• Excessive loading of restorations
• If the cause continues tooth-wear would continue
• Frequent recall and maintenance
Primary aim in treatment prevent/reduce the
causes and replace what is lost

33. Methods of Gaining Space
• Conforming to existing occlusion
• Re-organising the occlusion
• Concept of “Dahl”
• Crown lengthening
• Orthodontic intrusion
How to gain space would depend on
Where space is needed
Assessment of each individual case
Should be based on principles of occlusion

34. Dahl Appliance

35. Management of Localized tooth wear

36. Re-organization of occlusion Case 1

37. Re-organization of occlusion Case 2

38. Re-organization Case 3

39. Re-organization Case 4

40. Thanks