Sonia Jones RDH CFET
South West Post Graduate Dental Deanery DCP
Advisor Devon/Cornwall
sonijones@hotmail.co.uk
www.bristol.ac.uk/dentalpg
Aim: to ensure delegates understand how tooth tissue
loss can be detrimental to dentine hypersensitivity
Objectives:
By the end of the session you should be able to:
 Distinguish between erosion, abrasion, attrition and
abfraction
 Determine the causative factors of tooth tissue loss
 Describe how to prevent further tooth tissue loss
 Discuss sensitivity theories and explain the way they
work
 List topical medicaments available to relieve sensitivity
Tooth surface loss can arise as the result of:
 Erosion
 Abrasion
 Attrition
 Abfraction
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Patients often seek treatment for pain
Function can be altered
Compromised aesthetics
All ages
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The 4 types of tooth tissue loss all have their
own characteristic appearance
However, the wear of a persons teeth is
usually from a mixture of all 4, with one type
of TTL predominating.
Sometimes difficulty in determining the
dominant aetiology
The thickness of the pellicle and the pressure
of the tongue contribute to the extent of the
condition
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Relatively slow progression
Study models
 Indices
 Photographs
Can all be helpful
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Restorative treatment
Difficult to control
Very different to dental caries in appearance and
causation
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Described as early as 1892 among Sicilian
lemon pickers
Definition: ‘The loss of tooth tissue by a
chemical process that does not involve
bacteria, acids are most commonly involved in
the dissolution process’
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Non carious pathological loss of tooth tissue
Plaque not involved in the process
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Occurs most frequently on the palatal and
labial surfaces of the incisor teeth
The effected surfaces appear smooth and
highly polished with a scooped out depression
The lesion primarily occurs in the enamel
In more severe cases the dentine becomes
exposed
As enamel loss progresses sensitivity to
thermal changes are noticed
More persistent pain occurs in severe cases
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Extrinsic factors
Intrinsic factors
Idiopathic factors
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Habitual consumption of highly acidic, low pH
carbonated drinks, sports drinks or
concentrated fruit juices
Alco pops, fruit flavoured alcoholic beverages
and strong ciders
Causing a wide shallow lesion effecting the
labial and palatal surfaces of the upper teeth
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Swishing or holding drinks in the mouth
Modern packaging has also been blamed, tetra
pack, plastic bottles and cans – directional
flow onto teeth
Can extend from the labial and palatal lesions
of the upper teeth to all surfaces of all teeth
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The principal ingredient linked with erosion is
citric acid, found in most fruit juices and soft
drinks
Other fruit acids have an effect
The erosive effect is due to its low chemical pH
Also by ‘chelation’, the acids demineralise the
enamel by binding to the calcium and removing it
from the enamel
Cola type drinks may also contain phosphoric
acids
While the pH of a drink is an indicator of its
erosive potential, a measure called ‘total
titratable acidity’ is a better guide of how a liquid
can dissolve a mineral
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How long it takes for the saliva to compensate
How much saliva (flow)
Buffering capabilities of the saliva
Citric acid the biggest culprit
Thickness of the pellicle can protect to a
degree
Higher temperatures increase titratable acidity
Habitual sucking of citrus fruits
 The lesion may occur in either the upper or
lower anterior teeth
 Depending on the way the fruit is eaten
(Remember fruit eaten as a whole unit does not
generally cause a problem)
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Acidic foods
Pickles, sauces, vinegars, yoghurts, roasted
vegetables
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Industrial atmospheric pollution
Chemical workers, battery manufacturers,
crystal glass workers
Less common now due to stricter working
conditions and regulations (H&S at work act
1978)
Acidic fumes effect the labial surfaces of the
upper and lower anterior teeth
When talking or the mouth is at rest
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Chlorine, from gas chlorinated swimming
pools
Professional swimmers
If the chemicals are not properly regulated
Less common now due to regulations
From within the body
 Usually hydrochloric acid from the stomach
(pH 2)
 Reflux
 Regurgitation
 Vomiting
 Rumination
The term rumination is derived from the Latin
word ruminare, which means to chew the cud.
Rumination is characterized by the voluntary
or involuntary regurgitation and rechewing of
partially digested food that is either
reswallowed or expelled. This regurgitation
appears effortless, may be preceded by a
belching sensation, and typically does not
involve retching or nausea.
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Anorexia
Bulimia
Hiatus Hernia
Pregnancy/Hormones
Motion sickness
Obesity
Eating too much
Drinking too much
Alcoholism
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Heavily acidic diet increases gastric erosion
The palatal surfaces of the upper anteriors and
premolars are eroded
Produces wide shallow lesions
Enamel may be completely lost
Tackle the problem with care!
Patient might not admit to unattractive aspect
of psychological illness
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Unknown cause
Patient will not admit to or be aware of
intrinsic or extrinsic causes
Vigorous tooth brushing can contribute to an
over polished appearance - shiny
Definition: ‘The abnormal wearing away of
tooth tissue by a mechanical process’
 The location and pattern of abrasion is directly
dependent upon its course
 It usually occurs on the exposed root surfaces
when gingival recession has exposed the
cementum
 It may be seen on the incisal or inteproximal
surfaces of the teeth
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Incorrect or destructive use of a toothbrush
Use of an abrasive detrifice
The enamel and dentine is worn away to produce a ‘V’
shaped notch at the neck of the tooth
Areas most affected are the labial and buccal surfaces
of the canines and premolars
Powerful back hand, RHS of right handed person
LHS of Left handed person
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Para functions, habits, occupations
Mainly affects the incisal edges of the anterior teeth
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Worn, shiny often yellow/brown areas at the
cervical margin
Worn ‘notches’ on the incisal surfaces of the
anterior teeth
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Seamstresses – pins, Carpenters – nails,
Hairdressers – hairgrips
Pipe smokers, nail biters, causing ‘notching’
Definition: ‘The physiological wearing away of
the tooth surface as a result of tooth to tooth
contact’ as in mastication
 Occlusal and incisal surfaces of the teeth most
commonly affected
 May also affect the proximal surfaces of the
teeth due to slight movement of the teeth in
their sockets during mastication
 Age related process
 Varies from person to person
Causes:
 Bruxism
 Abrasive (gritty) diet
 Constant chewing – tobacco/ betel nut
 Marked malalignment or malocclusion
 Loss of posterior teeth
 Occupational, dust/grit mixed with saliva
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Polished facets on enamel surfaces
Cupping – dentine is exposed
Occasional full loss of enamel, dentine is
exposed and stains heavily
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Ranges from part of the enamel being worn
away in the early stages to the full thickness of
the enamel wearing away in advanced
attrition
The dentine may be exposed and stained
In extreme cases the teeth may be worn down
to the gingivae
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Process of attrition is slow
Secondary dentine is laid down to protect the
pulp chamber and the pulp chamber narrows
Pain is rarely associated with attrition
Men usually show a greater degree of attrition
than women
Severe attrition is seldom seen in deciduous
teeth, (not retained for long)
However if a child suffers from dentinogenesis
imperfecta (an hereditary disorder of the dentine)
pronounced attrition may result from mastication
Definition: ‘The pathological loss of enamel and
dentine due to occlusal stresses’
 Recently interest has grown in the
development of cervical abrasive lesions
 The term abfraction has been used to describe
these cervical lesions
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Some Clinicians do not believe that this is the
reason and that erosion and abrasion cause
the wear facets, research continues
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Occlusal forces which cause the tooth to flex,
cause small enamel flecks to break off, inducing
the abrasive lesions
Usually wedge shaped lesions with sharp angles
found at the cervical margins
However can be found on the occlusal surfaces,
presenting as circular areas
These lesions can occur with occlusion alone or as
with most TTL cases which are multi factorial, can
be associated with toothbrush abrasion
These lesions are often diagnosed as toothbrush
abrasion, but they differ as their angles are
sharper
Common in patients with poor tooth
alignment
Can be associated with:
 Anterior open bite
 Occlusal restorations that change the cuspal
movements
 Abnormal tongue movement
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5.
6.
Relieve sensitivity and pain – fluoride,
desensitising agents/toothpastes
Identify aetiological factors – modify diet/habits,
eliminate acidic foods/drinks, stop habitual
practices, gentle tooth brushing techniques
Protect the remaining tooth tissue – reconstruct
the effected teeth, restorations, inlays/onlays,
crowns, check occlusion
Bite raising devices/splints
Referral to TTL Expert
Prevention of further episodes
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Take a detailed history from the patient
Examination
Radiographs
Vitality testing
Patients wishes/needs
Study models
Photographs
Indices
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Basic Erosive Wear Examination
0 No Erosive Wear
1 Initial loss of Surface texture
2 Distinct defect, hard tissue <50% of the
surface area
3 Hard tissue loss >50% of the surface area
* (2,3) dentine involved
Tooth wear index according to Smith and Knight
Score Surface Criteria
0
C
1
C
2
C
3
C
4
C
B/L/O/I No loss of enamel surface characteristics
No loss of contour
B/L/O/I Loss of enamel surface characteristics
Minimal loss of contour
B/L/O Loss of enamel exposing dentine for less than one-third of
the surface
I Loss of enamel just exposing dentine
Defect less than 1mm deep
B/L/O Loss of enamel exposing dentine for more than one-third
of the surface
I Loss of enamel and substantial loss of dentine
Defect less than 1-2mm deep
B/L/O Complete loss of enamel, or pulp exposure, or exposure of
secondary dentine
I Pulp exposure or exposure of secondary dentine
Defect more than 2mm deep, or pulp exposure, or exposure
of secondary dentine
Dentine Hypersensitivity – Dentine is the highly sensitive
part of the tooth
Patients suffering from dentine hypersensitivity often
think that they have developed a cavity or lost a filling
On examination there is often no obvious reason for their
pain, gingival recession is sometimes evident
The amount of recession does not seem to correlate with
the amount of pain they are experiencing
c/o short sharp episodes of pain caused by temperature,
touch by metal, sweet foods/drinks
Patients can be very distressed by the pain of dentine
hypersensitivity and often avoid the causative stimuli as
much as possible
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Women more pre disposed than men
Age 20-40
Ranges from 15-70
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Made up of dentinal tubules
Looks like honeycomb under the microscope
Similar in composition to bone
Can remodel itself and lay down reparative
and secondary dentine
When exposed to the oral environment can be
sensitive
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Larger tubules = more pain
More open tubules = more sesitivity
3 theories as to how we feel the pain of dentine
hypersensitivity
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2.
3.
Dentine Innervation Theory
Odontoblast receptor theory
Hydrodynamic theory
Nerve fibres from the Nerve Plexus of Raschkow
(next to the dentine /pulp boundary, along
side the Odontoblast activity) penetrate the
dentinal tubules and cause impulses
Not the most likely theory: whilst the nerve
fibres do penetrate the tubules, there are not
enough of them and they do not penetrate
deeply enough into the tubules to pass on
impulses
Proposes that Odontoblasts receive and pass on
impulses and that when they are touched
cause the sensation of pain
Not the most likely theory: as there are no
synapses between the Odontoblasts and the
Nerve Plexus of Raschkow
(Synapses – junctions between neurones where
chemicals transmit the impulse)
Most likely theory: Answers more questions
Lymph like fluid inside the dentinal tubules is stimulated
by temperature, touch and sweet sensations, causing it
to flow backwards and forwards within the tubules, this
gives the sensation of pain
 Hot/cold causes expansion/contraction causing the
fluid to flow
 Salt/sweet causes osmotic pressure, flows towards the
concentrate
 Tactile/Electrical (Touch) ?! – contraction of the fluid?
Research continues, what they do know is how to treat it
Most commonly treated by:
 Mechanical Barriers
 Stimulation of Peritubular or Reactive Dentine
 Increasing potassium concentrations
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Applied over the open ends of the Dentine
Tubules
Restorations – Glass ionomers, Composites,
Inlays/Onlays, Dentine bonding agents that
form a chemical bond with the dentine locking
into the tubules, Resins/Adhesives
Tubule occluding toothpastes – need to be
replaced daily
The dentine lays down a protective layer
 High concentration fluoride – Duraphat
Varnish, Gel Kam (Fluorigard gel)
 Siloxane Esters – Tresiolan, Sensitrol etc
Both will wear off so need to be reapplied
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Fluoride irritates the dentine
It irritates the dentine sufficiently for it to lay
down a secondary layer and therefore protect
the tooth from further stimuli
It does this by occluding the tubules
Mouthwashes daily 0.05% and weekly 0.2%
solutions
High fluoride toothpastes - Duraphat 2800,
5000
Varnishes – Duraphat 2.26% 22,000ppm
Gels – 0.4% stannous fluoride
Nerve Depolarising
 Potassium chloride, Potassium Nitrate,
Potassium Citrate found in desensitising
toothpastes increase the potassium
concentrations around the nerve plexus
 This prevents action potentials being
transmitted (nerve impulses)
 By keeping the sodium outside the cell wall
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Sodium is attracted to Potassium
By increasing the Potassium levels outside the
nerve cell walls, the Sodium stays outside and
doesn’t diffuse in
This stops the nerve impulse
Depolarisation
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Nerve Depolarising Toothpastes
Tubule Occluding Toothpastes
Each manufacturer claims that their toothpaste
has the best technology
Do they work?
Traditionally Nerve depolarising toothpastes
 Active ingredients :
- Potassium Nitrate + Sodium Fluoride
- Potassium Chloride + Sodium fluoride
 Potassium keeps the sodium outside the cell
wall
 By adding the fluoride to the newer types of
Sensodyne you get the tubule occlusion
phenomenon caused by dentine irritation and
laying down of a secondary layer
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Claims to – reharden softened enamel
- be low in abrasives to prevent
further tooth tissue loss
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Active ingredient – Potassium Nitrate +
Sodium Fluoride
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Sensodyne Rapid Relief
Active Ingredient Strontium Acetate + Sodium
Mono-fluorophosphate
Published studies support the mode of action and
tubular occlusion occurs
but:
 Strontium Chloride – Sensodyne Original,
occludes tubules! However as it reacts with
fluoride became less popular
Active Ingredients: Arginine, Calcium
Carbonate, Hydroxyapatite, Sodium Monofluorophosphate
The Arginine complex binds to the tooth surface,
it is positively charged this is attracted to the
negatively charged dentine
 It encourages a calcium rich mineral layer into
the open (exposed) dentine tubules
 This acts as an effective plug (tubular occlude)
 Resistant to acid attacks
 Needs to be reapplied twice daily
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Enamel Care toothpaste - Amorphous Calcium
Phosphate ACP (soluble salts of Calcium and
Phosphate): highly soluble and there is limited
data in the treatment of Dentine Hypersensitivity
Recaldent (Toothmoose) – CCP-ACP Casein
Phosphates, derived from milk proteins mixed
with the calcium and phosphate salts: no
apparent published clinical data on its effects of
reducing Dentine Hypersensitivity
Blanx, Biorepair- Hydroxyapatite + Sodium Monofluorophosphate: tubular occlusion but limited
published data
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Treatment of active tooth tissue loss
Fluoride toothpastes/ mouthwashes/gels
De sensitising toothpastes
Study models
Photographs
Indices
Identify causative factors
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Limit acidic food and drink to meal times
Eliminate from diet
Cut down on carbonated beverages
Eat citrus fruits whole not sucked in 1/4s
Do not hold/swish drinks
Use a straw
Refer to specialist
Refer to councillor for eating disorders/alcohol
addiction
Refer to GP – gastric problems
Milk or cheese after meals to neutralise acids
Avoid toothbrushing after an acid attack
Aim: to ensure delegates understand how tooth tissue
loss can be detrimental to dentine hypersensitivity
Objectives:
By the end of the session you should be able to:
 Distinguish between erosion, abrasion, attrition and
abfraction
 Determine the causative factors of tooth tissue loss
 Describe how to prevent further tooth tissue loss
 Discuss sensitivity theories and explain the way they
work
 List topical medicaments available to relieve sensitivity