Discuss why dentitions may fail and the principles of their management

Student ID: 1150831 Word Count: 3689

INTRODUCTION:

Despite the advances in Mans knowledge of the human physiology and in this case the oral cavity and the tooth; we have still yet to fully overcome the problems associated with it. Failure of dentition is still a major problem now as it was in the past. The dentition can be considered a failure if it is unable to perform proper function, be a cause of constant pain and discomfort and has lost its natural aesthetics. Even though the major causes of failure in dentition are widely known, there prevention and management is still a very important part of the dental professionals job. The following assignment will attempt to highlight the major causes of failure in dentition and discuss steps in their management.

DISCUSSION: Problems related to the dentition which causes them to fail can be roughly divided in the following categories 1. 2. 3. 4. 5. 6. Dental Caries Periodontal disease. Endodontic problems. Tooth wear. Trauma. Genetic.

DENTAL CARIES:

Dental caries may be defined as a bacterial disease of the calcified tissues of the teeth characterized by demineralization of the inorganic and destruction of the organic substance of the tooth (Soames 2005). It is a complex and dynamic process involving, for example, physicochemical processes associated with the movements of ions across the interface between the tooth and the external environment, as well as biological processes associated with the interaction of bacteria in dental plaque with host defense mechanisms (Soames 2005). Dental caries is usually termed as a chronic disease as its rate of growth is slow over time. It can affect the surface of enamel as well as dentine and cementum. The caries process must be thought of as a dynamic alteration between demineralization and remineralization phases (Selvitz et al 2007). This represents a competition between the pathologic factors (such as bacteria and carbohydrates) and the protective factors (such as saliva, calcium, phosphate and fluoride)(Selvitz et al 2007).

The Keyes diagram (above) shows that cavities are the result of the interaction between a susceptible tooth, a dietary substrate (sugar), a chronic bacterial infection, and time. A persons risk factor for caries varies over time so they are subject to change. The risk factors are listed below: Risk Factors Physical Variations in tooth enamel; deep pits and fissures; anatomically susceptible areas. Gastric reflux High mutans streptococci count Special health care needs Previous caries experience History of baby bottle tooth decay (early childhood caries) Behavioral Bottle used at night for sleep or at will while awake Frequent snacking Inadequate oral hygiene Eating disorders, including self-induced vomiting (bulimia) Socio environmental Inadequate floride Poor family oral health Poverty High parental levels of bacteria (mutans streptococci) Protective factors Sealants (if possible) or observation

Management of condition Reduction of mutans streptococci Preventive intervention to minimize effect Increased frequency of supervision visits Increased frequency of supervision visits

Prevention of bottle habit and weaning from bottle by age 12 Reduction in snacking frequency Improve oral hygiene Referral for counseling

Optimal systemic and /or topical fluoride Access to care and good oral hygiene Access to care Good parental oral health and hygiene

Disease or treatment related Special carbohydrate diet Preventive intervention to minimize effects Frequent intake of sugared medications Alternate medications or preventive Reduced saliva flow from medication or intervention to minimizeeffects irradiation Saliva substitutes Orthodontic appliances Good oral hygiene for appliances DM Krol, Dental caries, oral health, and pediatricians. Curr Probl Pediatr Adolesc Health Care, 33 (2003), pp. 253270 3

Clinical Photographs Showing Dental Caries

http://www.zhub.com/pathology/listings/52.jpg Although the risk factors listed in Table 1 are for children, in most cases these risk factors remain the same for adults as well. The principle method used for management of dental caries is usually by a restoration. However in recent times more emphasis is being put on preventive measure to control dental caries. This is a better option for most dental practitioners as it allows for control of the disease in its infancy and reduces excessive trauma to the tooth caused by cavity preparation (Pitts 2004). This approach relies heavily on accurate diagnosis of the disease and preventive measures taken to reduce risk to the tooth.

PERIODONTAL DISEASE:

Chronic plaque-associated gingivitis and periodontitis are destructive inflammatory diseases sometimes referred to together simply as chronic periodontal disease, although there is evidence that, at least clinically, several distinct types of chronic destructive periodontal diseases may exist. The term gingivitis is used to designate inflammatory lesions that are confined to the marginal gingiva. Once the lesions extend to include destruction of the connective tissue attachment of the tooth and loss of alveolar bone the disease is designated periodontitis (Soames 2005). A risk factor for periodontal disease is an environmental, behavioral, or biological factor which increases the chances of occurrence of the disease in a patient (Timmerman 2006). Abundant evidence exists to emphasize that risk factors are closely related to the occurrence of periodontal disease (Borrell 2005). Use of various tools can aid the dental practitioner in identifying the increased chances of a patient developing periodontal disease.

Flow chart for Risk factors involved in periodontal disease Clinical Photo Showing Periodontal Disease

http://moabdental.files.wordpress.com/2010/09/gum20disease2.jpg The risk calculator for periodontal disease is a good example of such a tool (Page et al 2002). This basically utilizes a grading system of examining patients on a scale of 1-5 (1 being the lowest risk and 5 the highest). This plays an important role in identifying risk factors specific to a patient and hence improves the management of the disease (Douglass 2006). The Management of periodontal disease is three fold, starting with regular visits to the dental hygienist for removal of plaque and calculus deposits, followed by instructions in proper oral hygiene maintenance with emphasis on brushing techniques and flossing regularly. Counseling the patient on any habits they might have that may be detrimental to the treatment plan. Regular follow up visits after the treatment has been completed to maintain the patients periodontal status are a must for good long term prognosis.

TRAUMA: Trauma to the tooth is also an important cause of failure of teeth, which results in either loss of functionality or complete removal of the tooth all together. The most common causes of trauma to the tooth are as a result of accidental falls, sports injuries and violence. New technology has led to a better understanding of the process of inflammation that occurs in the tooth after it experiences a trauma and led to a more conservative approach (Florres et al 2009). Separate guidelines have been developed for children and adults as the treatment protocols for both vary (Florres et al 2009).

Clinical Situation The tooth has already been replanted. o Clean affected areas with water spray, saline or chlorhexidine do not extract the tooth. o Suture gingival laceration, especially in the cervical area o Verify normal position of the replanted tooth radiographically. o Apply a flexible splint for 1 week. Administer systemic antibiotics: Doxycycline 2 per day for 7 days at appropriate dose for patient age and weight. o Refer to physician to evaluate need for a tetanus booster if avulsed tooth has come into contact with soil or tetanus coverage is uncertain o Initiate endodontic treatment after 710 days. Place calcium hydroxide as an intra-canal medicament. The tooth has been kept in special Extra-oral dry time 60 min storage media, milk, saline or saliva. o If contaminated clean the root surface with saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. Replant slowly with slight digital pressure. o Suture gingival laceration, especially in the cervical area o Verify normal position of the replanted tooth radiographically. o Apply a flexible splint for 1 week. Administer systemic antibiotics: Doxycycline 2 per day for 7 days at appropriate dose for patient age and weight. o Refer to physician to evaluate need for a tetanus booster if avulsed tooth has come into contact with soil or tetanus coverage is uncertain o Initiate endodontic treatment after 710 days. Place calcium hydroxide as an intra-canal medicament.

time is less than60 min o Remove debris and necrotic periodontal ligament. o Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. o Immerse the tooth in a 2.4% sodium fluoride solution acidulated to a pH 5.5for a minimum of 5 min. o Replant slowly with slight digital pressure. o Suture gingival laceration, especially in the cervical area o Verify normal position of the replanted tooth radiographically. o Apply a flexible splint for 1 week. Administer systemic antibiotics: Doxycycline 2 per day for 7 days at appropriate dose for patient age and weight. o Refer to physician to evaluate need for a tetanus booster if avulsed tooth has come into contact with soil or tetanus coverage is uncertain o Initiate endodontic treatment after 710 days. Place calcium hydroxide as an intra-canal medicament.

PATIENT INSTRUCTIONS: o Soft diet for 2 weeks o Brush teeth with a soft toothbrush after each meal o Use a chlorhexidine mouth rinse (0.1%) twice a day for 1 week (Flores, M. T., Andreasen, J. O. and Bakland, L. K. (2001), Guidelines for the evaluation and Management of traumatic dental injuries. Dental Traumatology, 17: 193196)

The other kind of trauma occurring to teeth is usually involved with the fracture of the crown or root or both of them depending on the extent of the injury. The examination of the fractured tooth should be done as indicated in most books. The radiographs recommended for use in this situation are peri apical from 3 different angles. i 90 degree horizontal ii occlusal view iii lateral view from mesial or distal aspect. The International Association of dental traumatology revised its guidelines for management of crown and root fractures, and the same are presented here as follows (Florres et al 2007).

Uncomplicated crown fracture Clinical finding Fracture involves enamel or dentin and enamel; the pulp is not exposed. Sensibility testing may be negative initially indicating transient pulpal damage; monitor pulpal response until a definitive pulpal diagnosis can be made.

Clinical Photograph of a Simple Non-complicated Crown Fracture

http://www.estetskastomatologija.rs/theme/images/ispuni_plombe/galerija/velike/15.prelom-krunice-zuba-crown-fracture.jpg Radiographic Finding The 3 angulations described in radiographic examination to rule out displacement or fracture of the root. Radiograph of lip or cheek lacerations is recommended to search for tooth fragments or foreign material. Treatment If tooth fragment is available, it can be bonded to the tooth. Urgent care option is to cover the exposed dentin with a material such as glass ionomer or a permanent restoration using a bonding agent and composite resin. Definitive treatment for the fractured crown may be restoration with accepted dental restorative materials.

Complicated Crown Fracture Clinical Finding Fracture involves enamel and dentin and the pulp is exposed. Sensibility testing is usually not indicated initially since vitality of the pulp can be visualized. Follow-up control visits after initial treatment includes sensibility testing to monitor pulpal status.

Clinical Picture and Radiograph of a complicated Crown Fracture

http://www.dentalindia.com/ccf1.jpg Radiographic Finding The 3 angulations described in radiographic examination to rule out displacement or fracture of the root. Radiograph of lip or cheek lacerations is recommended to search for tooth fragments or foreign material. The stage of root development can be determined from the radiographs.

Treatment In young patients with immature, still developing teeth, it is advantageous to preserve pulp vitality by pulp capping or partial pulpotomy. This treatment is also the choice in young patients with completely formed teeth. Calcium hydroxide and MTA (white) are suitable materials for such procedures. In older patients, root canal treatment can be the treatment of choice, although pulp capping or partial pulpotomy may also be selected. If too much time elapses between accident and treatment and the pulp becomes necrotic, root canal treatment is indicated to preserve the tooth. In extensive crown fractures a decision must be made whether treatment other than extraction is feasible

Crown Root Fracture Clinical Finding Fracture involves enamel, dentin and root structure; the pulp may or may not be exposed. Additional findings may include loose, but still attached, segments of the tooth. Sensibility testing is usually positive.

Radiograph of Crown Root Fracture

http://t0.gstatic.com/images?q=tbn:ANd9GcRMWujl9uycUUc4Ftvm02YF_1Hgtc5I8m0XyzPp WIgEuSqY63F-fDzdsOQL Radiographic Finding As in root fractures, more than one radiographic angle may be necessary to detect fracture lines in the root.

Treatment Treatment recommendations are the same as for complicated crown fractures (see above). In addition, attempts at stabilizing loose segments of the tooth by bonding may be advantageous, at least as a temporary measure, until a definitive treatment plan can be formulated.

Root Fracture Clinical Finding The coronal segment may be mobile and may be displaced. The tooth may be tender to percussion. Sensibility testing may give negative results initially, indicating transient or permanent pulpal damage; monitoring the status of the pulp is recommended. Transient crown discoloration (red or grey) may occur.

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Radiograph Showing Root Fracture in a tooth

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Radiographic Finding The fracture involves the root of the tooth and is in a horizontal or diagonal plane. Fractures that are in the horizontal plane can usually be detected in the 90 angle film with the central beam through the tooth. This is usually the case with fractures in the cervical third of the root. If the plane of fracture is more diagonal, which is common with apical third factures, an occlusal view is more likely to demonstrate the fracture including those located in the middle third.

Treatment Reposition, if displaced, the coronal segment of the tooth as soon as possible. Check position radiographically. Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near the cervical area of the tooth, stabilization is beneficial for a longer period of time (up to 4 months). It is advisable to monitor healing for at least 1 year to determine pulpal status. If pulp necrosis develops, root canal treatment of the coronal tooth segment to the fracture line is indicated to preserve the tooth. ( Flores, M. T., Andersson, L., Andreasen, J. O., Bakland, L. K., Malmgren, B., Barnett, F., Bourguignon, C., DiAngelis, A., Hicks, L., Sigurdsson, A., Trope, M., Tsukiboshi, M. and Von Arx, T. (2007), Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dental Traumatology, 23: 6671)

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TOOTH WEAR:

Tooth wear is the loss of tooth surface i.e. enamel with or without dentine loss due to a number of reasons which include Abrasion, attrition, erosion and abfraction. It is not always possible to differentiate between these terms hence they are usually used in combination to describe tooth wear in patients. An alternative term, tooth surface loss (TSL), has been proposed (Bernard et al 1997). However, this term has two significant disadvantages. First, it understates the severity of the condition by implying that only the surface of the tooth is lost, whereas in some situations, the wear can be very extensive (Bernard et al 1997). The second disadvantage of the term is its subtlety that escapes most patients and some dentists (Bernard et al 1997). Abrasion: This is the pathological wearing away of tooth substance by the friction of a foreign body independent of occlusion (Soames 2005). Different foreign bodies produce different patterns of abrasion. 1. Toothbrush abrasion is common and is seen most frequently on exposed root surfaces of teeth. It is commonly associated with tooth brushing in a horizontal rather than a vertical direction and is made worse by an abrasive dentifrice. 2. Habitual abrasion may be seen in pipe-smokers. 3. Occupational abrasion develops when objects are held between or against the teeth during work, for example hair-grips. 4. Ritual abrasion of the teeth is uncommon today and is confined mainly to Africa. Clinical Photograph Showing Abrasion

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Attrition: This is loss of tooth substance as a result of tooth-to-tooth contact (Soames 2005) .It may be physiological or pathological in origin, although clinically the distinction is often unclear (Soames 2005). The pattern of tooth loss in physiological attrition is fairly constant: the incisal edges of the incisors are worn first, followed by the occlusal surfaces of the molars, the palatal cusps of the maxillary teeth, and the buccal cusps of the mandibular teeth.

Clinical Photograph Showing Attrition 12

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Erosion: This is the loss of tooth substance by a chemical process that does not involve known bacterial action (Soames 2005). It may render the teeth more susceptible to attrition and abrasion. 1. Dietary erosion may follow the excessive intake of acidic beverages, such as fruit juices or carbonated soft drinks, or the habit of sucking citrus fruits. 2. Occupational (environmental) erosion is now relatively uncommon. It is seen in workers exposed to acids in their workplace and is usually due to atmospheric pollution. 3. Regurgitation of stomach contents or persistent vomiting causes erosion in which the palatal surfaces of the maxillary teeth are primarily affected. Clinical Photograph showing Erosion

http://drkam.files.wordpress.com/2009/10/dental-erosion.jpg Tooth wear is a condition that causes permanent damage to the dentition of the patient therefore a long term strategy for management of the problem is needed. For this however the exact cause of the tooth wear has to be first established by the dental professional so as to prevent further damage from occurring. This coupled with continuous monitoring of the 13

situation helps in measuring the effectiveness of the treatment. Restorative treatment is only indicated when the patient is concerned with the appearance of his or her dentition (Kehller and Bishop 1999). Consultation with a medical physician for treatment of medical problems related to the tooth wear (Kehller and Bishop 1999).

DEVELOPMENTAL DEFECTS:

Another reason for failure of dentition is defects in the tooth structure during stages of development of the tooth. These defects can either be in the enamel, dentine or cementum. These changes although being permanent can be managed with proper

Amelogenisis Imperfecta: Amelogenesis imperfecta presents with abnormal formation of the enamel or external layer of teeth (Soames 2005). Enamel is composed mostly of mineral, which is formed and regulated by the proteins in it (Soames 2005). Amelogenesis imperfecta is due to the malfunction of the proteins in the enamel: ameloblastin, enamelin, tuftelin and amelogenin (Soames 2005). People afflicted with amelogenesis imperfecta have teeth with abnormal color: yellow, brown or grey (Soames 2005). The teeth have a higher risk for dental cavities and are hypersensitive to temperature changes. This disorder can afflict any number of teeth. The disorder may create unaesthetic appearance, dental sensitivity and attrition. Management of this condition usually involves ceramic crowns for compensation of the aesthetic drawbacks, as well as the maintenance of oral hygiene (Mobin and Tugsel 2002). Clinical Photograph showing Amelogenisis Imperfecta

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Dentinogensis Imperfecta: 14

Dentinogenesis imperfecta (hereditary Opalescent Dentin) is a genetic disorder of tooth development. This condition causes teeth to be discolored (most often a blue-gray or yellowbrown color) and translucent (Soames 2005). Teeth are also weaker than normal, making them prone to rapid wear, breakage, and loss. The main objectives of treatment include i) maintenance of dental health, form, size and vitality ii) improve aesthetics iii) improve function of the dentition iv) prevent loss of vertical dimension (Sapir and Shapira 2001). Clinical Photograph Showing Dentinogenesis Imperfecta

http://www.mchoralhealth.org/PediatricOH/images/dentio_imp.jpg

ENDODONTIC PROBLEMS: Although Endodontic problems are discussed here separately they result either from prolonged dental caries exposure or from periodontal problems occurring around a localized part of the oral cavity. The indication for the appropriate endodontic treatment depends on the causes, effects, and dynamics of pulpal pathosis (Baume 1970). This requires following a classification to correctly understand the cause of the pulpal injury. (Etiological Classification of Pulp Injury) (Local factors :) irritation Causative irritation Mechanical

Thermic

Inflammation irritation Systemic factors: Predisposing

Chemical irritation Bacterial

Severe general conditions Nutritional deficiencies Endocrine disturbances Periodontal conditions

Degeneration

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Diagnosing the exact cause requires taking a proper history Details of the patient's complaint should be considered together with the medical history. Questions like where is the pain? When was the pain first noticed? Description of the pain. Under what circumstances does the pain occur? Does anything relieve it? Any associated tenderness or swelling ? are good questions to start with (Carrote 2004). Particular note should be made of any disorders which may affect the differential diagnosis of dental pain, such as myofascial pain dysfunction syndrome (MPD), neurological disorders such as trigeminal neuralgia, vascular pain syndromes and maxillary sinus disorders (Carrote 2004). Diagnostic aids Periapical radiographs should be taken using paralleling technique. Electric pulp tester should be used for testing pulpal responses in the tooth. Ice sticks, hot gutta-percha, cold spray and hot water can be used for testing thermal responses. Periapical Radiolucency as seen in a Radiograph

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Management of the problem can vary in different a case, as the treatment plan cannot be developed on the diagnosis alone, indications and contraindications for root canal treatment exist which is the treatment of choice in such cases (Carrote 2004). Factors like adequate access, poor oral hygiene of the patient, any medical conditions the patient might have, noncooperative nature of the patient, poor condition of the tooth, root fractures, resorption can be a cause for concern for the prognosis if the treatment is carried out (Carrote 2004).

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CONCLUSION: The knowledge of various causes of failure of dentition is an important tool in the correct diagnosis and treatment of patients. It helps in planning a successful treatment for the patient and predicting a good prognosis. Although the management of any of the problems mentioned above seems simple enough on paper, there is a large variety of other factors that have to be taken account as well, which include the expectations of the patient most importantly, what does he expect from you as his doctor, the socio-economic status of the patient which could in the end rule out some of your treatment options from the start. The habits of the patient e.g. smoking , alcohol use etc. can also effect the prognosis, any medical conditions the patient might have could also change the treatment modalities. Hence a large a number of factors exist which the dental professional must consider besides his diagnosis for proper management of the failed dentition and a good prognosis.

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REFRENCES:
Baume, L.J.(1970). Diagnosis of diseases of the Pulp. Journal of Oral Surgery. 29 (1), p102116. Bernard G.N. Smith, David W. Bartlett, Nigel D. Robb, The prevalence, etiology and management of tooth wear in the United Kingdom, The Journal of Prosthetic Dentistry, Volume 78, Issue 4, October 1997, Pages 367-372 Borrell, L. N. and Papapanou, P. N. (2005), Analytical epidemiology of periodontitis. Journal of Clinical Periodontology, 32: 132158 Carrote, P.. (2004). Endodontics: Diagnosis and Treatment planing. British Dental Journal. 197 (5), p231-238. Carrote, P.. (2004). Treatment of Endodontic Emergencies. British Dental Journal. 197 (1), p299304. DM Krol, Dental caries, oral health, and pediatricians. Curr Probl Pediatr Adolesc Health Care, 33 (2003), pp. 253270 Douglass, C.W.. (2006). Risk Assesment and Management of Periodontal Disease. JADA. 137 (1), p27-32. Flores, M. T., Andreasen, J. O. and Bakland, L. K. (2001), Guidelines for the evaluation and Management of traumatic dental injuries. Dental Traumatology, 17: 193196 Flores, M. T., Andersson, L., Andreasen, J. O., Bakland, L. K., Malmgren, B., Barnett, F., Bourguignon, C., DiAngelis, A., Hicks, L., Sigurdsson, A., Trope, M., Tsukiboshi, M. and Von Arx, T. (2007), Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dental Traumatology, 23: 6671 Kellher, M. and Bishop, K.. (1999). Tooth Surface Loss: an overview. British Dental Journal. 186 (2), 61-66 Mobin, U. and Tugsel, Z.. (2002). Management of Amelogensis Imperfecta. Journal of the Faculty of Dentistry. 5 (1), p31-32. NB Pitts, Are we ready to move from operative to non-operative/preventive treatment of dental caries in clinical practice?. Caries Res, 38 (2004), pp. 294304. Page RC, Krall EA, Martin J, Mancl L, Garcia RI. Validity and accuracy of a risk calculator in predicting periodontal disease. JADA 2002;133(5):56976 Robert H Selwitz, Amid I Ismail, Nigel B Pitts, Dental caries, The Lancet, Volume 369, Issue 9555, 6-12 January 2007, Pages 51-59 Timmerman, M. and van der Weijden, G. (2006), Risk factors for periodontitis. International Journal of Dental Hygiene, 4: 27 Sapir, S. and Shapira, J.. (2001). Dentinogenisis Imperfecta: An Early Treatment Strategy. American Academy of Pediatric Dentistry. 23 (3), p232-237 Soames,J.V. and Southam, J.C. (2005). Oral Pathology: Oxford University Press.

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