Preventive and Restorative Therapy Lussi A, Ganss C (eds): Erosive Tooth Wear. Monogr Oral Sci. Basel, Karger, 2014, vol 25, pp 253–261 DOI: 10.1159/000360562
Restorative Therapy of Erosive Lesions Anne Peutzfeldt · Thomas Jaeggi · Adrian Lussi
Abstract
Early Diagnosis and Prevention
When substance loss caused by erosive tooth wear reaches a certain degree, oral rehabilitation becomes necessary. Until some 20 years ago, the severely eroded dentition could only be rehabilitated by the provision of extensive crown and bridge work or removable overdentures. As a result of the improvements in resin composite restorative materials, and in adhesive techniques, it has become possible to rehabilitate eroded dentitions in a less invasive manner. However, even today advanced erosive destruction requires the placement of more extensive restorations such as overlays and crowns. It has to be kept in mind that the etiology of the erosive lesions needs to be determined in order to halt the disease, otherwise the erosive process will continue to destroy tooth substance. This overview presents aspects concerning the restorative materials as well as the treatment options available to rehabilitate patients with erosive tooth wear, from minimally invasive direct composite reconstructions to adhesively retained all-ceramic restorations. Restorative treatment is dependent on individual circumstances and the perceived needs and concerns of the patient. Long-term success is only possible when the cause is eliminated. In all situations, the restorative preparations have to follow the principles of minimally inva© 2014 S. Karger AG, Basel sive treatment.
In order to plan adequate preventive and therapeutic measures, a thorough case history and diagnosis of each patient is mandatory. The teeth of all new patients and patients who are scheduled for a recall appointment (children as well as adults) should not only be examined for caries and periodontal diseases but also for noncarious tooth surface loss. Special consideration should be given to the following: dietary habits, drinking habits and sport activities, as well as gastric or esophageal problems. Furthermore, in patients judged to be at risk, the salivary flow rates and its buffering capacity should be measured. Patients with presumed reflux or vomiting problems require to be referred to a gastroenterologist or psychologist for further examination and therapy. If erosive tooth wear is diagnosed at an early stage it may be possible to protect the dentition against further damage. Local preventive measures may provide some protection against erosive challenge [1, 2]. For more information see chapter by Huysmans et al. [this vol., pp. 230–243]. Downloaded by: Nanyang Technological Univ. 155.69.4.4 - 5/31/2015 11:56:39 AM
Department of Preventive, Restorative and Pediatric Dentistry, School of Dental Medicine, University of Bern, Bern, Switzerland
Initially, erosive tooth wear is limited to enamel. At this stage of the erosive process, the teeth are not hypersensitive. Restorations may be inserted because of esthetic needs and/or to prevent further progression. Direct resin composite coverage or, in more advanced cases, ceramic veneers should be considered as the treatment of choice. This seals the enamel, re-establishes the tooth contour and minimizes further enamel loss by acid exposure. Both treatment options rely on effective adhesive bonding for clinical success. Reportedly, the structure of eroded enamel resembles that of enamel etched with phosphoric acid as a step in the adhesive procedure for the bonding of resin materials, i.e. a superficially softened layer with exposed enamel prisms [3, 4]. It appears that no information is available comparing bond strength to eroded enamel with the bond strength to normal, phosphoric acid-etched enamel, but it seems probable that there will be no difference [4]. In advanced cases, dentine becomes exposed, and there could be several reasons for treatment need, such as: (1) the structural integrity of the tooth is threatened, (2) the exposed dentine is hypersensitive, (3) the erosive defect is esthetically unacceptable to the patient or (4) pulpal exposure is likely to occur [5]. Most often the preferred treatment involves adhesive bonding. As a result of erosive processes dentine gradually becomes sclerotic, displaying a hypermineralized shiny surface along with tubular occlusion [6]. Although a few studies, using bovine dentine, have found no difference between resin bond strength to normal and sclerotic dentine [7, 8], most studies, using human dentine, have reported bond strength to sclerotic dentine to be lower than the bond strength to normal dentine [4, 9–13]. The decrease is thought to result from the tubular occlusion by mineral salts, preventing resin tag formation [6]. Two fundamentally different ap-
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proaches have been investigated as to how to avoid impaired adhesion to sclerotic and/or erosively altered dentine: a chemical approach and a mechanical approach. Contradictory results exist as to the effect of the chemical approach. Whereas doubling the phosphoric acid etching time prior to application of a 2-step etch-and-rinse adhesive system increased the bond strength to sclerotic dentine [14], doubling the phosphoric acid or the primer etching time prior to application of a 2- or 3-step etch-and-rinse adhesive system or of a 1- or 2-step self-etching adhesive system had no effect on the bond strength to either normal or sclerotic dentine [15]. As regards the mechanical approach, a recent study found minimal roughening of eroded dentine with a diamond bur to be the pretreatment which caused the least drop in 1-year bond strengths compared to normal dentine [12]. Another recent study has reported pretreatment with an ER,Cr:YSGG laser to be just as effective or, depending on the adhesive system, even more effective than roughening with a diamond bur or pretreatment with an Er:YAG laser [16]. Thus, the published studies, although limited in number, indicate that adhesion to eroded dentine can be improved by a mechanical roughening pretreatment. Numerous studies have shown tin-containing fluoride mouth rinses to be effective against erosive wear [17–20], the incorporated tin having a stabilizing effect on the eroded surface. It has been speculated that this positive effect is accompanied by a negative one. The incorporated tin might interfere with the adhesive applied during the following restorative procedure and thus impair the adhesion of the resin composite, reducing the longevity of the restoration. However, using an MDP-containing 2-step self-etching adhesive system (Clearfil SE Bond; Kuraray, Tokyo, Japan), bond strength to eroded dentine has been found not to decrease as a consequence of previous treatment with a tin-containing fluoride mouth rinse [13]. Indeed, bond strength increased. Subsequent studies investigated the ef-
Peutzfeldt · Jaeggi · Lussi Lussi A, Ganss C (eds): Erosive Tooth Wear. Monogr Oral Sci. Basel, Karger, 2014, vol 25, pp 253–261 DOI: 10.1159/000360562
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Erosive Tooth Wear and Adhesion of Restorative Materials
Longevity of Restorative Materials under Acidic Conditions
The longevity of dental restorations depends on the durability of the material per se, the durability of the interface between tooth substance and restoration, and the extent of tooth destruction and its location and load, as well as on patient-related factors such as bruxism, dietary and tooth-cleaning habits. Although it would be preferable to eliminate the cause of the erosions and the erosive tooth wear before commencing restorative treatment, this approach is rarely feasible, implying that the restorations are bound to be exposed to erosive challenges. A little more than a handful of studies have investigated and compared the behavior of various direct restorative materials under acidic and erosive conditions. Shabanian and Richards [23] measured, in vitro, the wear rates of a conven-
tional glass-ionomer cement, a resin-modified glass-ionomer cement and a resin composite under different loads and varying pH. All three materials were more resistant to acid than enamel, with the resin composite demonstrating the highest resistance to acid. The acid and load resistance of the resin-modified glass-ionomer cement was less than that of the resin composite and higher than that of the conventional glass-ionomer cement. In a study of the interaction of restorative materials with acidic beverages, all materials evaluated were found to reduce the pH of the 0.9% NaCl solution (control) but to increase the pH of the acidic beverages [24]. Furthermore, the conventional glass-ionomer cement dissolved completely in apple and orange juice but survived in Coca-Cola despite a significant reduction in hardness after a 1-year immersion time. The resin-modified glass-ionomer cements and the compomers survived in apple and orange juice, but showed greater reductions in surface hardness in these beverages than in Coca-Cola. Fruit juices were thus shown to pose a greater erosive threat to the restorative materials than Coca-Cola, something that was claimed to be true also for enamel and dentine. The influence of different dietary solvents (0.02 M citric acid, 50% ethanolwater solution, heptane, distilled water as control) on the shear punch strength of a conventional glass-ionomer cement, a compomer and three types of resin composites has been determined in a study by Yap et al. [25]. The results showed lower strength for the nanofilled and the ormocer resin composites than for the minifilled resin composite, but higher strengths than those achieved for the compomer and the highly viscous, conventional glass-ionomer cement. Another investigation measured the effect of pH on the microhardness of a resin composite, a compomer and a so-called giomer. The results showed a material dependency: the compomer and the giomer were more affected by acids than was the resin composite [26]. Determining the effect of a prolonged erosive pH cycling procedure on mi-
Restorative Therapy of Erosive Lesions Lussi A, Ganss C (eds): Erosive Tooth Wear. Monogr Oral Sci. Basel, Karger, 2014, vol 25, pp 253–261 DOI: 10.1159/000360562
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fect on resin composite adhesion to enamel and dentine of including into the adhesive procedure a pretreatment with a 35% tin-chloride solution [21, 22]. Partial or total replacement of phosphoric acid etching with tin-chloride etching reduced bond strengths obtained with a 3-step etch-andrinse adhesive (Optibond FL; Kerr, Orange, Calif., USA). In contrast, including an extra phosphoric acid or tin-chloride etching step prior to application of the self-etching primer increased bond strengths obtained with the MDP-containing 2-step self-etching adhesive system (Clearfil SE Bond) – etching with tin-chloride being more effective than etching with phosphoric acid. Consequently, it was concluded that the MDP-containing adhesive system seems to have a bondpromoting capacity to tin compounds incorporated in the enamel or dentine [21, 22]. However, further improvements, for example as regards concentration and stability of the tin-chloride solution, are needed before the tin-chloride treatment can be used in clinical practice.
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dation of glass ceramic veneers and a glaze material [33]. Whereas exposure to a basic pH buffer (pH = 10) led to substantial release of Si over time and to subsequent breakdown of the glass phase, exposure to an acidic pH (pH = 2) caused ‘only’ selective ionic leaching of the glass matrix. To conclude, under acidic conditions all restorative materials show degradation over time (surface roughness, decrease of surface hardness, substance loss). However, it seems that ceramic materials and resin composites present much better durability than conventional glass-ionomer cements, resin-modified glass-ionomer cements and compomers, and that the latter materials should not be used in erosion patients. Treatment Strategies
Initial restorative treatments should be conservative, using adhesive materials [34]. Modern therapeutic concepts determine that minimal amounts of healthy tooth substance should be sacrificed. Reconstructive restorative treatments should be adapted to the tooth and not vice versa. However, when teeth wear, the alveolar bone and the associated tissues adapt to some degree to the change with alveolar compensation [35]. Despite losing crown height, teeth maintain their occlusal contact and this may lead to problems for their reconstruction because there is not enough space for the restorative material. To prevent an invasive, full-mouth rehabilitation, it can be convenient to gain interocclusal space through orthodontic measures, especially if mainly groups of teeth (e.g. all teeth in the anterior region) are involved in the erosive tooth wear. The orthodontic treatment can be achieved with fixed or removable appliances such as the Dahl appliance [35]. Following orthodontic treatment, the eroded teeth can then be reconstructed [36]. Until some 20 years ago, the severely eroded dentition could only be rehabilitated by the provision of extensive crown and bridge work or, in more severe cases, by means of
Peutzfeldt · Jaeggi · Lussi Lussi A, Ganss C (eds): Erosive Tooth Wear. Monogr Oral Sci. Basel, Karger, 2014, vol 25, pp 253–261 DOI: 10.1159/000360562
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crohardness and erosive wear of three restorative materials, Honorio et al. [27] found that the resin composite was much less sensitive to the erosive procedure than the resin-modified glass-ionomer cement, which performed better than the conventional glass-ionomer cement. In a study of the effect of erosion and/or toothbrush abrasion, the three resin composites tested presented higher durability under erosive and/or abrasive attacks than did the compomer and the conventional glass-ionomer cement evaluated. Human enamel presented higher substance loss than any of the restorative materials [28]. In their study of the susceptibility of five restorative materials to damage by common erosive acids, Wan Bakar and McIntyre [29] found in vitro restorations of resin composite or porcelain not to be affected at all by the erosive challenges, while restorations of the resin-modified glass ionomer cement were moderately damaged and the two conventional glassionomer cements were severely damaged. Besides confirming that resin composites have higher resistance to erosive attack than conventional glassionomer cement and compomer as well as reporting resin composite also to have higher resistance to topical fluoride application, Yu et al. [30] found the application of a high-concentrated AmF solution at native pH to increase the acid resistance of conventional glass-ionomer cement and compomer. Only few studies have investigated the influence of dietary acids on ceramic materials. One study tested the effect of intermittent immersion in a carbonated beverage (Coca-Cola) on the wear of three ceramics and of human enamel specimens serving as antagonists. Exposure to Coca-Cola was found to accelerate enamel wear and to decrease the wear resistance of two of the ceramics [31]. Another study, simulating vomiting through 24 h using a simulated vomit solution (pH = 3.8), reported no effect on various surface roughness parameters for the three ceramic materials tested [32]. Finally, a very recent study investigated the effect of pH and time on the degra-
Minimal Loss of Vertical Dimension: Sealant or Resin Composite Treatment of erosive tooth wear should be performed at an early stage in order to prevent the development of functional and esthetic problems. The most minimally invasive measure is the sealing of the tooth surface. In one study [50], Seal and Protect (Dentsply DeTrey, Konstanz, Germany) and Optibond Solo (Kerr, Orange, Calif., USA) were each applied to extracted teeth and then subjected to an erosion/abrasion wear regime. It was concluded that both adhesive systems provided effective protection of the teeth. Another in vitro study examined the protective effect of adhesive systems on dentine after acid exposure and brushing abrasion in a cycling model. Twelve dentine samples were each pretreated with K-106 experimental varnish (Dentsply DeTrey), Prime & Bond 2.1 (Dentsply DeTrey), Syntac Classic with Heliobond (Vivadent, Schaan, Liechtenstein) or Gluma Desensitizer (Heraeus
Kulzer, Dormagen, Germany). Another twelve samples served as the untreated control group. Each test sample was subjected 120 times to the following procedure: 5 min of demineralization (Sprite Light), 1 h of storage in artificial saliva, and brushing abrasion (100 brush strokes) in an automatic brushing machine. Surface substance loss was measured by laser profilometry. It was concluded that adhesive systems can protect dentine from erosive tooth wear for a limited period of time [51]. In an in situ study, Azzopardi et al. [52] investigated the surface effects of erosion and abrasion on dentine with and without a protective layer (Seal and Protect or Optibond Solo). Dentine samples were attached to an appliance and worn 8 h per day for 20 consecutive days. Every day the samples were removed and immersed in citric acid for 24 min. The effects of the acid exposure and the mechanical influence of the soft tissues, especially the tongue, on tooth surface substance loss were measured using four assessment techniques. Results showed that the sealing materials remained in place despite the vigorous wear regime and therefore protected the tooth surface. The authors concluded that applying a dentine adhesive to exposed dentine in patients with erosive tooth wear is a practical measure which prevents further damage. This finding was later confirmed in vivo as a one-bottle sealant and a classic fissure sealant both showed good protection for up to 9 months [53, 54]. This is in corroboration with the in vitro study of Wegehaupt et al. [55], who found surface sealants to reduce erosive dentine mineral loss and to maintain the erosive-preventing efficacy during the entire erosive/abrasion cycling procedure applied, simulating 8 months in vivo. Thus, the sealing procedures have to be repeated periodically; fortunately, it has been shown that no additional pretreatment of previously sealed dentine is necessary to ensure stability of the new sealant [56]. The sealing of numerous lesions in one patient may also be time consuming because of the lightcuring time needed to cure each sealant. Howev-
Restorative Therapy of Erosive Lesions Lussi A, Ganss C (eds): Erosive Tooth Wear. Monogr Oral Sci. Basel, Karger, 2014, vol 25, pp 253–261 DOI: 10.1159/000360562
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removable overdentures [37–39]. As a result of the improvements in resin composites and in adhesive techniques, it has become possible to rehabilitate eroded dentitions in a less invasive manner. The wear resistance of resin composites has gradually improved, and today direct resin composite restorations can provide excellent longevity, even in load-bearing situations [40–42]. Several case reports demonstrate the successful rehabilitation of (erosively) worn dentitions using adhesive techniques [43–46]. A very elegant method was described using direct resin composite build-up with the help of a vacuum-formed matrix template [47]. Good results were found after an average time in service of 5.5 years [48]. This method was later modified using the ‘stamp’ technique [49]. Tooth wear defects can be restored by copying the wax-up from the dental technician using silicone impressions. Both ‘semi-direct’ techniques facilitate the placement of large resin composite restorations and can be highly recommended.
Fig. 2. The groove-like defects of the molar were filled with resin composite after the cause (gastroesophageal reflux) had been treated. Control of the occlusion is important to prevent early contact on the groove restorations (same case as fig. 1); 2 years in situ.
er, a recent study found that reducing the lightcuring time while keeping the energy density constant did not hamper the mechanical stability or the permeability of three different sealants [57]. This indicates that light-curing times may be shortened provided a high energy density lightcuring unit is used. Occlusal erosions typically appear as groovelike defects and restoration margins stand proud of the adjacent tooth surfaces. Following an acid attack the pH in these grooves is depressed for a prolonged period of time [unpubl. data], which will lead to further progression of the erosive process at this site. In such cases, minimally invasive resin composite restorations are able to protect the affected region (fig. 1, 2).
anatomy (fig. 3–5). The advantages of direct resin composite restorations are that they are adaptable to the defect and that repair is straightforward. The situation is more problematic if the occlusal and vestibular erosions merge; the original tooth shape becomes hardly recognizable and the loss of vertical dimension tends to be greater. In general, less invasive reconstruction procedures such as direct adhesive methods are preferable to indirect methods, but they are not always possible. For example, if the upper front teeth are severely eroded and need to be reconstructed, ceramic or resin composite veneers may be applied (fig. 6, 7). If the defects (on posterior teeth) show an extension over two or more tooth surfaces and the vertical tooth substance loss is massive, then reconstruction with full ceramic overlays is convenient. In patients with severe tooth surface loss on more than two surfaces per tooth and pronounced loss of vertical dimension, a complex reconstruction with indirect restorations (ceramic crowns, bridges) is often inevitable (fig. 6, 7). This measure should be restricted to very advanced erosion cases. However, such treatment is expensive. Therefore, it is important to combine active treatment with preventive measures and
Distinct Loss of Vertical Dimension: Resin Composite or Ceramic As long as there is only a loss of about 3–4 mm of interocclusal space, the teeth can be reconstructed directly or semi-directly with resin composites or with ceramics. Patients usually tolerate such an increase in the vertical dimension without any problem. Teeth are rebuilt with semi-direct methods or ‘freehand’ according to their original
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Peutzfeldt · Jaeggi · Lussi Lussi A, Ganss C (eds): Erosive Tooth Wear. Monogr Oral Sci. Basel, Karger, 2014, vol 25, pp 253–261 DOI: 10.1159/000360562
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Fig. 1. Occlusal erosion with involvement of dentine. The margins of the amalgam restorations stand proud of the adjacent tooth surfaces.
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Fig. 3. Severe erosive tooth wear with involvement of dentine and loss of height. Fig. 4. The teeth were rebuilt freehandedly with direct resin composite restorations. Altogether, the vertical dimension was raised about 3 mm, which the patient tolerated without difficulty. Fig. 5. The situation after 3 years in situ.
Fig. 7. Completed restoration of the upper and lower arches with full ceramic crowns and veneers on the lower incisors. The vertical dimension had to be increased by 4 mm in the anterior region. This increase was accomplished and tested step-by-step by means of provisional crowns. The patient did not have any problems adapting to the new vertical dimension.
Restorative Therapy of Erosive Lesions Lussi A, Ganss C (eds): Erosive Tooth Wear. Monogr Oral Sci. Basel, Karger, 2014, vol 25, pp 253–261 DOI: 10.1159/000360562
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Fig. 6. Facial view of advanced dentinal erosive tooth wear. Also, the lower incisors have clearly eroded. The patient had a history of anorexia nervosa with unfavorable acidic nutrition.
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recall at regular intervals to ensure the long-term success. To conclude, the restorative treatment should be adapted to the extent of tooth substance loss. It should be further kept in mind that erosive tooth wear is a multifactorial condition, and in many cases it is not possible to determine and eliminate all etiological parameters. In such cases, the longterm success of the rehabilitation may be compromised. Only in rare cases may restorations be
inserted without treating the main causes (e.g. in patients with frequent vomiting, but who are already under psychological treatment). Acknowledgements The authors thank Drs. Matthias Strub and Anne Grüninger, Department of Preventive, Restorative and Pediatric Dentistry, University of Bern for providing some of the clinical pictures used in this chapter.
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47 Schmidlin PR, Filli T, Imfeld C, Tepper S, Attin T: Three-year evaluation of posterior vertical bite reconstruction using direct resin composite: a case series. Oper Dent 2009;34:102–108. 48 Attin T, Filli T, Imfeld C, Schmidlin PR: Composite vertical bite reconstructions in eroded dentitions after 5.5 years: a case series. J Oral Rehabil 2012;39:73–79. 49 Perrin P, Zimmerli B, Jacky D, Lussi A, Helbling C, Ramseyer S: The stamp technique for direct composite restoration. Schweiz Monatsschr Zahnmed 2013;123:111–129. 50 Azzopardi A, Bartlett DW, Watson TF, Sherriff M: The measurement and prevention of erosion and abrasion. J Dent 2001;29:393–400. 51 Schneider F, Hellwig E, Attin T: Einfluss von Säurewirkung und Bürstabrasion auf den Dentinschutz durch Adhäsivsysteme. Dtsch Zahnarztl Z 2002;57:302–306. 52 Azzopardi A, Bartlett DW, Watson TF, Sherriff M: The surface effects of erosion and abrasion on dentine with and without a protective layer. Br Dent J 2004; 196:351–354. 53 Sundaram G, Wilson R, Watson TF, Bartlett D: Clinical measurement of palatal tooth wear following coating by a resin sealing system. Oper Dent 2007;32: 539–543. 54 Bartlett D, Sundaram G, Moazzaz R: Trial of protective effect of fissure sealants, in vivo, on the palatal surfaces of anterior teeth, in patients suffering from erosion. J Dent 2011;39:26–29. 55 Wegehaupt FJ, Tauböck TT, Attin T: Durability of the anti-erosive effect of surfaces sealants under erosive abrasive conditions. Acta Odontol Scand 2013; 71:1188–1194. 56 Wegehaupt FJ, Tauböck TT, Attin T: How to re-seal previously sealed dentine? Am J Dent 2013;26:161–165. 57 Wegehaupt FJ, Tauböck TT, Sener B, Attin T: Influence of light-curing mode on the erosion preventive effect of three different resin-based surface sealants. Int J Dent 2012;2012:874359.
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Dr. A. Peutzfeldt, PhD Department of Preventive, Restorative and Pediatric Dentistry School of Dental Medicine, University of Bern Freiburgstrasse 7 CH–3010 Bern (Switzerland) E-Mail [email protected]
Restorative Therapy of Erosive Lesions Anne Peutzfeldt · Thomas Jaeggi · Adrian Lussi
Abstract
Early Diagnosis and Prevention
When substance loss caused by erosive tooth wear reaches a certain degree, oral rehabilitation becomes necessary. Until some 20 years ago, the severely eroded dentition could only be rehabilitated by the provision of extensive crown and bridge work or removable overdentures. As a result of the improvements in resin composite restorative materials, and in adhesive techniques, it has become possible to rehabilitate eroded dentitions in a less invasive manner. However, even today advanced erosive destruction requires the placement of more extensive restorations such as overlays and crowns. It has to be kept in mind that the etiology of the erosive lesions needs to be determined in order to halt the disease, otherwise the erosive process will continue to destroy tooth substance. This overview presents aspects concerning the restorative materials as well as the treatment options available to rehabilitate patients with erosive tooth wear, from minimally invasive direct composite reconstructions to adhesively retained all-ceramic restorations. Restorative treatment is dependent on individual circumstances and the perceived needs and concerns of the patient. Long-term success is only possible when the cause is eliminated. In all situations, the restorative preparations have to follow the principles of minimally inva© 2014 S. Karger AG, Basel sive treatment.
In order to plan adequate preventive and therapeutic measures, a thorough case history and diagnosis of each patient is mandatory. The teeth of all new patients and patients who are scheduled for a recall appointment (children as well as adults) should not only be examined for caries and periodontal diseases but also for noncarious tooth surface loss. Special consideration should be given to the following: dietary habits, drinking habits and sport activities, as well as gastric or esophageal problems. Furthermore, in patients judged to be at risk, the salivary flow rates and its buffering capacity should be measured. Patients with presumed reflux or vomiting problems require to be referred to a gastroenterologist or psychologist for further examination and therapy. If erosive tooth wear is diagnosed at an early stage it may be possible to protect the dentition against further damage. Local preventive measures may provide some protection against erosive challenge [1, 2]. For more information see chapter by Huysmans et al. [this vol., pp. 230–243]. Downloaded by: Nanyang Technological Univ. 155.69.4.4 - 5/31/2015 11:56:39 AM
Department of Preventive, Restorative and Pediatric Dentistry, School of Dental Medicine, University of Bern, Bern, Switzerland
Initially, erosive tooth wear is limited to enamel. At this stage of the erosive process, the teeth are not hypersensitive. Restorations may be inserted because of esthetic needs and/or to prevent further progression. Direct resin composite coverage or, in more advanced cases, ceramic veneers should be considered as the treatment of choice. This seals the enamel, re-establishes the tooth contour and minimizes further enamel loss by acid exposure. Both treatment options rely on effective adhesive bonding for clinical success. Reportedly, the structure of eroded enamel resembles that of enamel etched with phosphoric acid as a step in the adhesive procedure for the bonding of resin materials, i.e. a superficially softened layer with exposed enamel prisms [3, 4]. It appears that no information is available comparing bond strength to eroded enamel with the bond strength to normal, phosphoric acid-etched enamel, but it seems probable that there will be no difference [4]. In advanced cases, dentine becomes exposed, and there could be several reasons for treatment need, such as: (1) the structural integrity of the tooth is threatened, (2) the exposed dentine is hypersensitive, (3) the erosive defect is esthetically unacceptable to the patient or (4) pulpal exposure is likely to occur [5]. Most often the preferred treatment involves adhesive bonding. As a result of erosive processes dentine gradually becomes sclerotic, displaying a hypermineralized shiny surface along with tubular occlusion [6]. Although a few studies, using bovine dentine, have found no difference between resin bond strength to normal and sclerotic dentine [7, 8], most studies, using human dentine, have reported bond strength to sclerotic dentine to be lower than the bond strength to normal dentine [4, 9–13]. The decrease is thought to result from the tubular occlusion by mineral salts, preventing resin tag formation [6]. Two fundamentally different ap-
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proaches have been investigated as to how to avoid impaired adhesion to sclerotic and/or erosively altered dentine: a chemical approach and a mechanical approach. Contradictory results exist as to the effect of the chemical approach. Whereas doubling the phosphoric acid etching time prior to application of a 2-step etch-and-rinse adhesive system increased the bond strength to sclerotic dentine [14], doubling the phosphoric acid or the primer etching time prior to application of a 2- or 3-step etch-and-rinse adhesive system or of a 1- or 2-step self-etching adhesive system had no effect on the bond strength to either normal or sclerotic dentine [15]. As regards the mechanical approach, a recent study found minimal roughening of eroded dentine with a diamond bur to be the pretreatment which caused the least drop in 1-year bond strengths compared to normal dentine [12]. Another recent study has reported pretreatment with an ER,Cr:YSGG laser to be just as effective or, depending on the adhesive system, even more effective than roughening with a diamond bur or pretreatment with an Er:YAG laser [16]. Thus, the published studies, although limited in number, indicate that adhesion to eroded dentine can be improved by a mechanical roughening pretreatment. Numerous studies have shown tin-containing fluoride mouth rinses to be effective against erosive wear [17–20], the incorporated tin having a stabilizing effect on the eroded surface. It has been speculated that this positive effect is accompanied by a negative one. The incorporated tin might interfere with the adhesive applied during the following restorative procedure and thus impair the adhesion of the resin composite, reducing the longevity of the restoration. However, using an MDP-containing 2-step self-etching adhesive system (Clearfil SE Bond; Kuraray, Tokyo, Japan), bond strength to eroded dentine has been found not to decrease as a consequence of previous treatment with a tin-containing fluoride mouth rinse [13]. Indeed, bond strength increased. Subsequent studies investigated the ef-
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Erosive Tooth Wear and Adhesion of Restorative Materials
Longevity of Restorative Materials under Acidic Conditions
The longevity of dental restorations depends on the durability of the material per se, the durability of the interface between tooth substance and restoration, and the extent of tooth destruction and its location and load, as well as on patient-related factors such as bruxism, dietary and tooth-cleaning habits. Although it would be preferable to eliminate the cause of the erosions and the erosive tooth wear before commencing restorative treatment, this approach is rarely feasible, implying that the restorations are bound to be exposed to erosive challenges. A little more than a handful of studies have investigated and compared the behavior of various direct restorative materials under acidic and erosive conditions. Shabanian and Richards [23] measured, in vitro, the wear rates of a conven-
tional glass-ionomer cement, a resin-modified glass-ionomer cement and a resin composite under different loads and varying pH. All three materials were more resistant to acid than enamel, with the resin composite demonstrating the highest resistance to acid. The acid and load resistance of the resin-modified glass-ionomer cement was less than that of the resin composite and higher than that of the conventional glass-ionomer cement. In a study of the interaction of restorative materials with acidic beverages, all materials evaluated were found to reduce the pH of the 0.9% NaCl solution (control) but to increase the pH of the acidic beverages [24]. Furthermore, the conventional glass-ionomer cement dissolved completely in apple and orange juice but survived in Coca-Cola despite a significant reduction in hardness after a 1-year immersion time. The resin-modified glass-ionomer cements and the compomers survived in apple and orange juice, but showed greater reductions in surface hardness in these beverages than in Coca-Cola. Fruit juices were thus shown to pose a greater erosive threat to the restorative materials than Coca-Cola, something that was claimed to be true also for enamel and dentine. The influence of different dietary solvents (0.02 M citric acid, 50% ethanolwater solution, heptane, distilled water as control) on the shear punch strength of a conventional glass-ionomer cement, a compomer and three types of resin composites has been determined in a study by Yap et al. [25]. The results showed lower strength for the nanofilled and the ormocer resin composites than for the minifilled resin composite, but higher strengths than those achieved for the compomer and the highly viscous, conventional glass-ionomer cement. Another investigation measured the effect of pH on the microhardness of a resin composite, a compomer and a so-called giomer. The results showed a material dependency: the compomer and the giomer were more affected by acids than was the resin composite [26]. Determining the effect of a prolonged erosive pH cycling procedure on mi-
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fect on resin composite adhesion to enamel and dentine of including into the adhesive procedure a pretreatment with a 35% tin-chloride solution [21, 22]. Partial or total replacement of phosphoric acid etching with tin-chloride etching reduced bond strengths obtained with a 3-step etch-andrinse adhesive (Optibond FL; Kerr, Orange, Calif., USA). In contrast, including an extra phosphoric acid or tin-chloride etching step prior to application of the self-etching primer increased bond strengths obtained with the MDP-containing 2-step self-etching adhesive system (Clearfil SE Bond) – etching with tin-chloride being more effective than etching with phosphoric acid. Consequently, it was concluded that the MDP-containing adhesive system seems to have a bondpromoting capacity to tin compounds incorporated in the enamel or dentine [21, 22]. However, further improvements, for example as regards concentration and stability of the tin-chloride solution, are needed before the tin-chloride treatment can be used in clinical practice.
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dation of glass ceramic veneers and a glaze material [33]. Whereas exposure to a basic pH buffer (pH = 10) led to substantial release of Si over time and to subsequent breakdown of the glass phase, exposure to an acidic pH (pH = 2) caused ‘only’ selective ionic leaching of the glass matrix. To conclude, under acidic conditions all restorative materials show degradation over time (surface roughness, decrease of surface hardness, substance loss). However, it seems that ceramic materials and resin composites present much better durability than conventional glass-ionomer cements, resin-modified glass-ionomer cements and compomers, and that the latter materials should not be used in erosion patients. Treatment Strategies
Initial restorative treatments should be conservative, using adhesive materials [34]. Modern therapeutic concepts determine that minimal amounts of healthy tooth substance should be sacrificed. Reconstructive restorative treatments should be adapted to the tooth and not vice versa. However, when teeth wear, the alveolar bone and the associated tissues adapt to some degree to the change with alveolar compensation [35]. Despite losing crown height, teeth maintain their occlusal contact and this may lead to problems for their reconstruction because there is not enough space for the restorative material. To prevent an invasive, full-mouth rehabilitation, it can be convenient to gain interocclusal space through orthodontic measures, especially if mainly groups of teeth (e.g. all teeth in the anterior region) are involved in the erosive tooth wear. The orthodontic treatment can be achieved with fixed or removable appliances such as the Dahl appliance [35]. Following orthodontic treatment, the eroded teeth can then be reconstructed [36]. Until some 20 years ago, the severely eroded dentition could only be rehabilitated by the provision of extensive crown and bridge work or, in more severe cases, by means of
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crohardness and erosive wear of three restorative materials, Honorio et al. [27] found that the resin composite was much less sensitive to the erosive procedure than the resin-modified glass-ionomer cement, which performed better than the conventional glass-ionomer cement. In a study of the effect of erosion and/or toothbrush abrasion, the three resin composites tested presented higher durability under erosive and/or abrasive attacks than did the compomer and the conventional glass-ionomer cement evaluated. Human enamel presented higher substance loss than any of the restorative materials [28]. In their study of the susceptibility of five restorative materials to damage by common erosive acids, Wan Bakar and McIntyre [29] found in vitro restorations of resin composite or porcelain not to be affected at all by the erosive challenges, while restorations of the resin-modified glass ionomer cement were moderately damaged and the two conventional glassionomer cements were severely damaged. Besides confirming that resin composites have higher resistance to erosive attack than conventional glassionomer cement and compomer as well as reporting resin composite also to have higher resistance to topical fluoride application, Yu et al. [30] found the application of a high-concentrated AmF solution at native pH to increase the acid resistance of conventional glass-ionomer cement and compomer. Only few studies have investigated the influence of dietary acids on ceramic materials. One study tested the effect of intermittent immersion in a carbonated beverage (Coca-Cola) on the wear of three ceramics and of human enamel specimens serving as antagonists. Exposure to Coca-Cola was found to accelerate enamel wear and to decrease the wear resistance of two of the ceramics [31]. Another study, simulating vomiting through 24 h using a simulated vomit solution (pH = 3.8), reported no effect on various surface roughness parameters for the three ceramic materials tested [32]. Finally, a very recent study investigated the effect of pH and time on the degra-
Minimal Loss of Vertical Dimension: Sealant or Resin Composite Treatment of erosive tooth wear should be performed at an early stage in order to prevent the development of functional and esthetic problems. The most minimally invasive measure is the sealing of the tooth surface. In one study [50], Seal and Protect (Dentsply DeTrey, Konstanz, Germany) and Optibond Solo (Kerr, Orange, Calif., USA) were each applied to extracted teeth and then subjected to an erosion/abrasion wear regime. It was concluded that both adhesive systems provided effective protection of the teeth. Another in vitro study examined the protective effect of adhesive systems on dentine after acid exposure and brushing abrasion in a cycling model. Twelve dentine samples were each pretreated with K-106 experimental varnish (Dentsply DeTrey), Prime & Bond 2.1 (Dentsply DeTrey), Syntac Classic with Heliobond (Vivadent, Schaan, Liechtenstein) or Gluma Desensitizer (Heraeus
Kulzer, Dormagen, Germany). Another twelve samples served as the untreated control group. Each test sample was subjected 120 times to the following procedure: 5 min of demineralization (Sprite Light), 1 h of storage in artificial saliva, and brushing abrasion (100 brush strokes) in an automatic brushing machine. Surface substance loss was measured by laser profilometry. It was concluded that adhesive systems can protect dentine from erosive tooth wear for a limited period of time [51]. In an in situ study, Azzopardi et al. [52] investigated the surface effects of erosion and abrasion on dentine with and without a protective layer (Seal and Protect or Optibond Solo). Dentine samples were attached to an appliance and worn 8 h per day for 20 consecutive days. Every day the samples were removed and immersed in citric acid for 24 min. The effects of the acid exposure and the mechanical influence of the soft tissues, especially the tongue, on tooth surface substance loss were measured using four assessment techniques. Results showed that the sealing materials remained in place despite the vigorous wear regime and therefore protected the tooth surface. The authors concluded that applying a dentine adhesive to exposed dentine in patients with erosive tooth wear is a practical measure which prevents further damage. This finding was later confirmed in vivo as a one-bottle sealant and a classic fissure sealant both showed good protection for up to 9 months [53, 54]. This is in corroboration with the in vitro study of Wegehaupt et al. [55], who found surface sealants to reduce erosive dentine mineral loss and to maintain the erosive-preventing efficacy during the entire erosive/abrasion cycling procedure applied, simulating 8 months in vivo. Thus, the sealing procedures have to be repeated periodically; fortunately, it has been shown that no additional pretreatment of previously sealed dentine is necessary to ensure stability of the new sealant [56]. The sealing of numerous lesions in one patient may also be time consuming because of the lightcuring time needed to cure each sealant. Howev-
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removable overdentures [37–39]. As a result of the improvements in resin composites and in adhesive techniques, it has become possible to rehabilitate eroded dentitions in a less invasive manner. The wear resistance of resin composites has gradually improved, and today direct resin composite restorations can provide excellent longevity, even in load-bearing situations [40–42]. Several case reports demonstrate the successful rehabilitation of (erosively) worn dentitions using adhesive techniques [43–46]. A very elegant method was described using direct resin composite build-up with the help of a vacuum-formed matrix template [47]. Good results were found after an average time in service of 5.5 years [48]. This method was later modified using the ‘stamp’ technique [49]. Tooth wear defects can be restored by copying the wax-up from the dental technician using silicone impressions. Both ‘semi-direct’ techniques facilitate the placement of large resin composite restorations and can be highly recommended.
Fig. 2. The groove-like defects of the molar were filled with resin composite after the cause (gastroesophageal reflux) had been treated. Control of the occlusion is important to prevent early contact on the groove restorations (same case as fig. 1); 2 years in situ.
er, a recent study found that reducing the lightcuring time while keeping the energy density constant did not hamper the mechanical stability or the permeability of three different sealants [57]. This indicates that light-curing times may be shortened provided a high energy density lightcuring unit is used. Occlusal erosions typically appear as groovelike defects and restoration margins stand proud of the adjacent tooth surfaces. Following an acid attack the pH in these grooves is depressed for a prolonged period of time [unpubl. data], which will lead to further progression of the erosive process at this site. In such cases, minimally invasive resin composite restorations are able to protect the affected region (fig. 1, 2).
anatomy (fig. 3–5). The advantages of direct resin composite restorations are that they are adaptable to the defect and that repair is straightforward. The situation is more problematic if the occlusal and vestibular erosions merge; the original tooth shape becomes hardly recognizable and the loss of vertical dimension tends to be greater. In general, less invasive reconstruction procedures such as direct adhesive methods are preferable to indirect methods, but they are not always possible. For example, if the upper front teeth are severely eroded and need to be reconstructed, ceramic or resin composite veneers may be applied (fig. 6, 7). If the defects (on posterior teeth) show an extension over two or more tooth surfaces and the vertical tooth substance loss is massive, then reconstruction with full ceramic overlays is convenient. In patients with severe tooth surface loss on more than two surfaces per tooth and pronounced loss of vertical dimension, a complex reconstruction with indirect restorations (ceramic crowns, bridges) is often inevitable (fig. 6, 7). This measure should be restricted to very advanced erosion cases. However, such treatment is expensive. Therefore, it is important to combine active treatment with preventive measures and
Distinct Loss of Vertical Dimension: Resin Composite or Ceramic As long as there is only a loss of about 3–4 mm of interocclusal space, the teeth can be reconstructed directly or semi-directly with resin composites or with ceramics. Patients usually tolerate such an increase in the vertical dimension without any problem. Teeth are rebuilt with semi-direct methods or ‘freehand’ according to their original
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Fig. 1. Occlusal erosion with involvement of dentine. The margins of the amalgam restorations stand proud of the adjacent tooth surfaces.
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Fig. 3. Severe erosive tooth wear with involvement of dentine and loss of height. Fig. 4. The teeth were rebuilt freehandedly with direct resin composite restorations. Altogether, the vertical dimension was raised about 3 mm, which the patient tolerated without difficulty. Fig. 5. The situation after 3 years in situ.
Fig. 7. Completed restoration of the upper and lower arches with full ceramic crowns and veneers on the lower incisors. The vertical dimension had to be increased by 4 mm in the anterior region. This increase was accomplished and tested step-by-step by means of provisional crowns. The patient did not have any problems adapting to the new vertical dimension.
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Fig. 6. Facial view of advanced dentinal erosive tooth wear. Also, the lower incisors have clearly eroded. The patient had a history of anorexia nervosa with unfavorable acidic nutrition.
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recall at regular intervals to ensure the long-term success. To conclude, the restorative treatment should be adapted to the extent of tooth substance loss. It should be further kept in mind that erosive tooth wear is a multifactorial condition, and in many cases it is not possible to determine and eliminate all etiological parameters. In such cases, the longterm success of the rehabilitation may be compromised. Only in rare cases may restorations be
inserted without treating the main causes (e.g. in patients with frequent vomiting, but who are already under psychological treatment). Acknowledgements The authors thank Drs. Matthias Strub and Anne Grüninger, Department of Preventive, Restorative and Pediatric Dentistry, University of Bern for providing some of the clinical pictures used in this chapter.
References
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Dr. A. Peutzfeldt, PhD Department of Preventive, Restorative and Pediatric Dentistry School of Dental Medicine, University of Bern Freiburgstrasse 7 CH–3010 Bern (Switzerland) E-Mail [email protected]
