Journal of Oral Rehabilitation, 1990, Volume 17, pages 173-177

Wear of teeth in a mentally retarded population G. 0 I L O , G. HATLE*, A-L. G A D * and B.L. DAHLf NIOM, Scandinavian Institute of Dental Materials, Haslum, Norway, *Emma Hjorts Hjem, Sandvika, Norway and fDepartment of Prosthetic Dentistry, Dental Faculty, University of Oslo, Norway ;., •

Summary The study includes an evaluation of dental wear in 69 individuals, 44 men and 25 women, of mean age 35 years and range 18-59 years, living in a home for mentally retarded persons. Wear was evaluated with a newly developed index based on Ryges' system, where the need for treatment is the key issue. The index consisted of three categories representing clinical situations from no wear to moderate, age dependent wear without problems for the patient, and two categories in which treatment was found to be necessary either to prevent future problems or to improve the present situation. A relatively large number of teeth showed considerable wear in the 20—29 year age group. Wear was observed predominantly in incisors and canines. Only 1% of cases were considered to require treatment. Wear increased with age, and more than 5% of teeth were diagnosed as needing treatment in the 30—39 year and 40—49 year age groups. Wear in the studied population was found to be more severe than that observed in an urban population from the same area in a parallel study. Introduction Bruxism followed by wear of teeth has been shown to be a problem in mentally retarded persons, and is somewhat dependent on their stage of development (Lindquist & Heijbel, 1974; Richmond, Rugh, Dolfi & Wasilewsky, 1984). It has also been shown that psychopharmacological therapy can cause side effects such as xerostomia and oral dyskinesias, resulting in increased wear of teeth (Rydgren, 1976). Tooth wear can cause functional problems and eventual sensitivity and pain. It may be difficult, however, for the dental personnel, especially in patient groups with limited ability to communicate, to decide upon the correct timing and type of treatment. Data concerning the need for treatment in such populations are hmited. Wear of teeth has mostly been studied by the use of indices in an attempt to quantify wear based on a subjective evaluation of wear facet areas or reduction in length of teeth. It is difficult to use the information obtained by such indices to estimate the need for treatment. An index for the evaluation of wear based on Ryge's system, where the need for treatment is the key issue, has recently been published (0ilo, Dahl, Hatle & Gad, 1987). It has been shown to be relatively easy to use, having a high sensitivity to differences in wear between groups of individuals (0ilo, et al, 1987; Dahl, 0ilo, Andersen & Bruaset, 1989). Correspondence: Dr Gudbrand 0ilo, NIOM, Scandinavian Institute of Dental Materials, Box 70, N-1344 Haslum, Norway.

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G.

et al.

The aim of the present study was to use this index to establish the degree of wear and the need for treatment in a population hospitalized in or daily visiting an institution for mentally retarded persons. * ,...-. y i , ; fj^ .; :5 Materials and methods

Sixty-nine individuals, 44 men and 25 women, hospitalized at or daily visiting Emma Hjorts Hjem in Baerum, Norway, were evaluated for dental wear. Twenty-five of them were evaluated by three of the authors (GH, A-LG and BLD). The results were used in a previous presentation of the aforementioned index (0ilo et al. 1987). A further 44 individuals were evaluated by two of the authors (GH and A-LG), using the same index. Both evaluators examined all patients, and any disagreements were recorded. A description of the various categories of the index is given in Table 1. The index contains three satisfactory categories: Romeo, Sierra and Mike, representing clinical situations in which treatment was not considered necessary. The three categories include clinical situations from no wear to moderate, age dependent wear without apparent problems for the patient. The index also contains two categories of non-acceptable wear, representing clinical situations in which treatment was found to be necessary either to prevent further Table 1. Rating system for occlusal wear Rating Satisfactory Romeo Sierra

Operational explanation

No visible wear or change in anatomical form Limited (normal) wear. Limited change in anatomical form

Code

No visible wear SOF SDF

Mike

Not acceptable Tango

Victor

Occlusal wear

Considerable wear with obvious change of anatomical form, but without need for treatment

MLR MED

Considerable wear with marked change in anatomical form. Further damage to the tooth and/or its surrounding tissues is likely to occur Excessive wear. Extreme change of anatomical form, aesthetics and function. Pain on chewing. Damage to the tooth and/or its surrounding tissues is now occurring.

TLR TED

VLR VTF

VSD VPE VCA VGM

Oeelusal or incisal wear facets in enamel Small areas of exposed dentine without change of hardness or sensitivity Obvious length reduction of tooth Large areas of exposed dentine, discoloured, but without change of hardness or sensitivity Considerable reduction in length of tooth Large areas of exposed dentine which is discoloured, soft and/ or sensitive Marked reduction in length of tooth Tooth structure and/or restorations fractured due to excessive wear Softening of exposed dentine Pulp exposure from wear Pain on chewing Irritation of gingiva and/or oral mucous membranes

Tooth wear in a mentally retarded population

175

problems (category Tango), or for immediate reasons (category Victor). fe^iw» ^ An individual 'state of wear' rating was recorded according to a method described previously (0ilo etal. 1987). The individual rating was based on 90% of each individual's tooth ratings, i.e. 10% of the teeth might receive a more severe wear rating than the individual rating. The dental status was recorded according to the index shown in Table 2. Statistics

Differences in the frequency of individual wear ratings between the groups were tested for significance by the Ridit method (Fleiss, 1973). , Results

The number of individuals and the dental status for the entire sample and for each age group from 20-29 years to 50—59 years are presented in Table 2. The mean age of the men was 35-5 years and of the women was 35-6 years, with ranges of 18—59 years and 22—56 years, respectively. The number of teeth for men and women in the various categories is shown in Table 3. The number of individual wear ratings for the total group and for women and men is shown in Table 4. No statistically significant difference was found. The mean Ridit score was 0-54 ± 0-09 for men and 0-42 ± 0-11 for women. The 95% confidence interval for both subgroups thus overlaps by 0-5. The percentage of teeth in each subcategory of wear for the different age groups is shown in Table 5. A relatively large number of teeth, i.e. more than 20%, showed Table 2. Dental status Group

n

Men Women Total 20-29 years 30-39 years 40-49 years 50-59 years

44 25 69 14 29 21 4

Lost or nonerupted teeth (%)

Unrestored teeth (%)

Teeth with tooth coloured fillings (%)

Teeth with amalgam fillings (%)

Teeth with crowns (single or bridge retainer) (%)

15-7 20-6 17-5 10-2 16-8 18-7 41-5

53-6 41-2 49-1 6M 40-9 53-1 37-7

2-2 4-2 2-9 1-3 3-8 3-4 0-8

26-2 31-4 28-0 26-7 35-4 22-2 16-9

2-1 2-5 2-3 0-2 3-0 2-8 1-5

Table 3. State of wear of teeth (number and percentage of evaluated teeth) Category

Romeo Sierra Mike Tango Victor

Men

Women

n

%

n

%

25 720 359 59

2-1 61-8 30-8 5-1 0-2

16 493

2-5 77-5 17-1 2-5 0-3

I

109 16 2

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G. 0ilo et al.

Table 4. Individual state of wear Number of mdividuals Men

Women

Total

Sierra Mike Tango

17 23 4

16

33 30 6

Total

44

Category

. . ,-,-7'

:

69

Table 5. Relative number of evaluated teeth (%) in the various subcategories of wear in relation to age group Category Age group 20-29 30-39 40-49 50-59

n

R

SOF

SDF

MLR

MED

TLR

TED

14 58 21 4

6-0 1-2 0-9 1-4

30-2 34-7 19-2 62-9

41-0 37-4 35-5 18-9

16-0 16-7 16-0 7-1

6-7 3-7 23-0 12-1

0-2 5-6 3-0 1-4

0 0 2-6 0

VLR 0-5 0-3 0 0

wear of category M in the 20—29 and 30—39 year age groups. A marked increase in the percentage of M scores, particularly MED, was seen in the 40-^49 year age group. The number of T and V scores was low, i.e. less than 1% in the 20—29 year age group, but above 5% in the 30—39 and 40—49 year age groups. The relative number of disagreements between the two examiners who evaluated the last group of 44 individuals was 1-4% for the main categories and 10-6% for the subcategories. Discussion

The group of patients examined is not representative of the total population of individuals with brain damage. Communication was relatively easy in many cases and dental treatment had been provided regularly by a specially trained team. The degree of dental wear in this group of individuals is significantly different from that of an urban population in the same geographical area who had sought regular dental care (Dahl et al, 1989). Evaluation of wear was performed with the same index in both studies, allowing a direct comparison of results. In the previous study, 1-2% of individuals had an individual state of wear rating of category T, whereas 8-9% of the subjects in the present study were given this rating. None of the teeth in the 30—39 year age group and only 0-5% of the teeth in the 40-49 year age group were given T or V ratings in the previous study (Dahl et al, 1989). In the present study, 5-9% of the teeth in the 30—39 year age group and 5-6% in the 40—49 year age group were given either a T or a V rating. Sixty-four per cent of the teeth in the 20—29 year age group showed wear facets exposing dentine (Table 5). The observed predominant location in incisors and canines is comparable with previous observations (Kampe, Hannerz & Strom, 1984; Dahl et al. 1989). However,

*

Tooth wear in a mentally retarded population

111

both the latter studies showed that wear through enamel is already relatively common in the 20—29 year age group. It is therefore apparently impossible to use this criterion alone as an indicator of the wear situation in certain groups of individuals, as has been reported in some previous publications (Lindquist & Heijbel, 1974;- Richmond, Rugh, Dolfi & Wasilewsky, 1984), and it should certainly not be used as an indicator of the need for treatment. The present study demonstrated that a certain amount of treatment was considered necessary due to dental wear based on common elinical criteria, especially in the 30—39 year and 40—49 year age groups. The increased wear might be a result of unconscious biting or bruxing habits, developed by those individuals who lacked personal contact, as a kind of self-stimulation. Regurgitation may also form part of this habit. In addition, it is possible that the psyehopharmacological treatment given to some of these individuals may have caused the aforementioned side effects of xerostomia and tardive dyskinesia (Rydgren, 1976). It has been shown that treatment with apomorphine increases biting, gnawing and bruxing habits in rats, especially when a foreign body is introduced as a trigger (Sunden-Koronen, 1984). Thus treatment of dental wear is most often futile in this group of individuals. Due to the increased sensitivity and awareness of the oral situation in autistic individuals, a restoration such as a crown, bridge or prosthesis may easily be perceived as a foreign object and act as a trigger, causing increased biting and bruxing habits, and thus giving such treatment a rather short lifetime. References B.L., 0tLO, G., ANDERSEN, A. & BRUASET, O . (1989) The suitability of a new index for the evaluation of dental wear. Acta Odontologica Scandinavica, 47, 205. FLEtss, J.L. (1973) Statistical Methods for Rates and Proportions, p. 102. John Wiley & Sons, New York, U.S.A. KAMPE, T H . , HANNERZ, H . & STROM, P. (1984) Facet pattern in intact and restored dentitions of young adults. A comparative study. Acta Odontologica Scandinavica, 42, 225. LtNDQUiST, B. & HEIJBEL J. (1974) Bruxism in children with brain damage. Acta Odontologica Scandinavica, 32, 313. 01LO, G., DAHL, B.L., HATLE, G . & GAD, A . - L . (1987) An index for evaluating wear of teeth. Acta Odontologica Scandinavica, 45, 361. RICHMOND, G . , RUGH, J., DoLFt, R. & WASILEWSKY, J.W. (1984) Survey of bruxism in an institutionalized mentally retarded population. American Journal of Mental Deficiency, 88, 418. RYDGREN, K . - O . (1976) Side-effects of odontological interest of psychopharmacotherapy. Swedish Dental Journal, 69, 85. SUNDEN-KORONEN, B . (1984) Experimental dyskinesias of the jaw: central and oral induction of the periodontal-masseteric reflex in the rat. Proceedings of the Finnish Dental Society, 80, Supplement XI. DAHL,

Manuscript accepted 6 March 1989

Wear of teeth in a mentally retarded population.

The study includes an evaluation of dental wear in 69 individuals, 44 men and 25 women, of mean age 35 years and range 18-59 years, living in a home f...
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