Tooth hypersensitivity and Dental erosion DR. KÁROLY BARTHA

Tooth hypersensitivity and Dental erosion DR. KÁROLY BARTHA

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Why Is Erosion an Issue Now? Changing dietary habits Higher consumption of acidic beverages (colas, sport drinks) Higher incidence of xerostomia from medications for chronic conditions Low salivary flow clears acids less quickly More people retain teeth for a lifetime, and we are living longer Damage to permanent teeth in childhood/adolescence may compromise dentition and impact restorative care for lifetime 3

Results of demineralization: caries erosion etched enamel 4

Effects of acids caries incipient opaque white surface body of the lesion remineralisation is possible (limited) erosion without discoloration, glossy surface dissolved in layers prevention of dissolution etching during adhesive technique opaque white surface deeper effect, typical surface 5

Erosion vs. Caries: ph Dependence Anionic fluoride (F - ) provides limited protection from demineralization under ph of 4.5 Fluroapatite may withstand caries acids, but it does not resist more acidic conditions Erosion Caries ph neutral Erosion requires unique protection mechanisms beyond what fluoride alone can provide ph Scale 3 4 5 6 7 8 Figure adapted From Featherstone et al. 2010 6

Enamel Erosion vs. Caries: Caries Erosion Weak acids Pellicle protects enamel surface Sub-surface phenomenon Buffering by saliva helps to neutralize Reversible in early stages A role for treatment of early lesions Strong acids (citric acid) Pellicle can t protect under such harsh acid conditions Surface damage Buffering of saliva is overwhelmed Irreversible surface damage Prevention is key for managing the condition 7

Types of tooth structure-loss Demastication Attrition Abrasion Abfraction Erosion Caries 8

The role of saliva Pellicle lubricant protect from acids (tooth brushing) 9

Erosion - characteristics at very low ph acids without bacterial origin solubility of apatite at ph 3 100x times bigger than at ph 5 beside ph value the acid content is also important 10

What is Dental Erosion? An irreversible loss of enamel due to dissolution by acid of the tooth surface without involvement of bacteria Extrinsic acid sources: Acidic beverages Citrus fruits Intrinsic acid sources: Gastric reflux Vomiting 11

Extrinsic acids Beverages cola soft drinks sport drinks wine juices Fruits Occupational disease Medicaments (Vitamin-C, Aspirin) Water of swimming pool 12

Acid composition of different beverages (g/l) Dental erosion. ed. Lussi A. Karger 2006. 13

Intrinsic acids Gastric acid Reflux Eating disorders Anorexia nervosa Bulimia Chronic alcoholism Pregnancy 14

Dental erosion. ed. Lussi A. Karger 2006. 15

Critical ph value the solution containing given amount of ions will unsaturated, saturated or oversaturated depending of ph value at critical ph value the oversaturated solution will saturated below will unsaturated 16

Effect of ph on saturation oversaturated critical ph saturated unsaturated solution 17

De- and remineralisation (enamel) erosion caries remineralisation saliva is unsaturated to hydroxyapatite and to fluorapatite saliva is unsaturated to hydroxyapatite and oversaturated to fluorapatite calculus formation saliva is oversaturated to hydroxyapatite and to fluorapatite 18

Solubility of enamel, HAP and FAP Dental erosion. ed. Lussi A. Karger 2006. 19

Effects of Fluoride Fluorhydroxiapatite formation below 50 ppm acidic environment (ph over 4.5) 20

Effects of Fluoride over 100 ppm Ca-fluoride formation precipitated on the surface as small balls unsaturated to saliva will dissolved 21

Fluoride varnishes Fluoride leakage to: saliva enamel dental plaque carious tissues because of high fluoride concentration Calcium-fluoride will formed 22

The clinical crown enamel cementum dentine cementum is softer and more soluble than enamel dentinal tubules will opened 23

Effects of fluoride on crystallization small amount of fluoride during the dissolution of hydroxiapatite makes the solution strongly oversaturated to fluorapatite - remineralisation this is the scientific base of primacy of low fluoride concentrations against dental caries 24

Clinical Presentation of Dental Erosion Dull tooth surfaces Loss of tooth contour Exposure of yellow, underlying dentin Irreversible loss of enamel 25

30 years old patient soft drinks (sip.- wise), reflux bottom: 5 years later Dental erosion. ed. Lussi A. Karger 2006. 26

14 years old child, reflux, ice tea, acidic beverages right: 2,5 years later Dental erosion. ed. Lussi A. Karger 2006. 27

28 years old patient, acidic drinks, reflux Dental erosion. ed. Lussi A. Karger 2006. 28

35 years old patient, acidic fruits and fresh squeezed lemon and orange juice Dental erosion. ed. Lussi A. Karger 2006. 29

25 years old patien, lemon slices under the lip, fruit juices Dental erosion. ed. Lussi A. Karger 2006. 30

29 years old patient, soft drinks, sipping of 0,5-1 acidic drinks per day Dental erosion. ed. Lussi A. Karger 2006. 31

29 years old patient, soft drinks, sipping of 0,5-1 acidic drinks per day Dental erosion. ed. Lussi A. Karger 2006. 32

29 years old patient, reflux Dental erosion. ed. Lussi A. Karger 2006. 33

29 years old patient, reflux Dental erosion. ed. Lussi A. Karger 2006. 34

28 years old patient, reflux Dental erosion. ed. Lussi A. Karger 2006. 35

29 years old patient, eating disorder Dental erosion. ed. Lussi A. Karger 2006. 36

Indices of dental Erosion 37

Simplified scoring criteria for TWI - 2004 Score Criteria 0 No wear into dentine 1 Dentine just visible (including cupping) or dentine exposed for less than 1/3 of surface 2 Dentine exposure greater than 1/3 of surface 3 Exposure of pulp or secondary dentine 38

Basic Erosive Wear Examination BEWE - 2008 Score Criteria 0 No erosive tooth wear 1 Initial loss of surface texture 2 * Distinct defect, hard tissue loss <50% of the surface area 3 * Hard tissue loss =50% of the surface are *in scores 2 and 3 dentine often is involved 39

Epidemiology of dental erosion 40

Erosion on buccal surface (26-30 years = black, 46-50 = white) Dental erosion. ed. Lussi A. Karger 2006. 41

Erosion on buccal surface with involvement of dentine (26-30 years = black, 46-50 = white) Dental erosion. ed. Lussi A. Karger 2006. 42

Erosion on occlusal surface (26-30 years = black, 46-50 = white) Dental erosion. ed. Lussi A. Karger 2006. 43

Erosion on occlusal surface with involvement of dentine (26-30 years = black, 46-50 = white) Dental erosion. ed. Lussi A. Karger 2006. 44

Progression of erosion in 6 years on the buccalis surface(46-50 years) Dental erosion. ed. Lussi A. Karger 2006. 45

Progression of erosion in 6 years on the occlusal surface(46-50 years) Dental erosion. ed. Lussi A. Karger 2006. 46

Prevention and treatment of the dental erosion 47

Enamel hardness Dental erosion. ed. Lussi A. Karger 2006. 48

Mechanism of Action Stannous complexes, like stannous fluorophosphate, form on enamel surface and block acid-susceptible sites These stannous complexes Coat enamel surface Form acid resistant layer Lowers reactivity of binding sites on enamel surface (e.g. Ca ++ ) Jordan Arch Oral Biol 1971;16:241-246 49

Barrier Function of Different Fluorides Objective: Assess the ability of various fluoride salts to deposit protective barrier layer on enamel surface Study Design: Tooth specimens were conditioned in human saliva (1 hr) and etched in citric acid (10 min) Treated in dentifrice slurry (2 min) and rinsed Soaked in a calcium-selective dye (Alizarin Red S) O O Alizarin Red S OH OH SO 3 Na Alizarin Red S reacts with free Ca ++ binding sites on hydroxyapatite Alizarin Ca ++ complex is red Faller and Eversole. IDJ 2014;16(suppl 1):16-21. 50

Endpoint: Using a 5 point scale, the amount of dye deposition was assessed by two experienced graders GRADING SCALE 100% Protection 75% Protection 50% Protection 25% Protection 0% Protection 0 1 2 3 4 No free Ca ++ sites for dye attachment 100% dye attachment 51

Test Dentifrices: Fluoride (ppm) Fluoride Source Abrasive 1100 SnF 2 silica 1100 NaF silica 1000 NaMFP dicalcium phosphate dihydrate 1400 AmF silica SnF 2 : NaF: NaMFP: AmF: Stabilised Stannous Fluoride Sodium Fluoride Sodium Monofluorophosphate Amine Fluoride 52

Relative Ability to Deposit Protective Barrier REPRESENTATIVE TOOTH IMAGES SnF 2 NaF NaMFP AmF Score = 0.25 3.4 3.4 3.7 SnF 2 was significantly different vs. NaF, NaMFP, and AmF (p<0.05) at forming a protective barrier to dye attachment Faller and Eversole IDJ 2014;64 suppl 1;16-21 53

Erosion Protection of Different Fluorides Objective: Compare erosive protective effects of different fluoride sources in marketed dentifrices Study Design: The following products were compared in an in vitro erosion cycling model: Fluoride Source F - Concentration Sodium Fluoride 1100 ppm Sodium Monofluorophosphate 1100 ppm Stabilised Stannous Fluoride 1100 ppm Faller et al Am J Dent 2011;24:205-210. 54

In Vitro Erosion Cycling Model Dentifrice Treatment Saliva Soak Saliva Soak Enamel cores cut from human specimens Mounted in acrylic rods Polished to expose flat, fresh surface Fingernail varnish applied to create control area Citric Acid Challenge Samples subjected to Erosion Cycling Protocol 55

Analysis by Transverse Microradiography 100 µm slice sectioned X-Ray Control Areas Microns of Mineral Surface Loss Treated Area 56

Erosion Benefits of Different Fluorides 30 25 Surface Enamel Loss (µm) 20 15 10 5 * 0 Sodium Fluoride Sodium MFP Stabilised Stannous Fluoride * Stannous fluoride was significantly less than NaF and MFP (p<0.05) Faller et al Am J Dent 2011;24:205-210. 57

Erosion Protection of High Concentration Fluoride Objective: Compare erosion protective effects of OTC stannous fluoride dentifrice to prescription-level fluoride (5000 ppm F) product Study Design: The following products were compared in an in vitro erosion cycling model: Fluoride Source Stabilised Stannous Fluoride F - Concentration 1100 ppm Sodium Fluoride 1100 ppm Sodium Fluoride 5000 ppm Eversole J Dent Res 2010 89 (Supp A) #527 58

Erosion Protection of High Fluoride Concentration 25 20 Surface Enamel Loss (µm) 15 10 5 * 0 1100 ppm F - as SnF 2 1100 ppm F - as NaF 5000 ppm F - as NaF * p<0.05 vs. both NaF products. The high and low F NaF products were not different Eversole J Dent Res 2010 89 (Supp A) #527 59

Commercial Dentifrice Performance In Vitro Objective: Assess the ability of common OTC marketed dentifrices to protect against the initiation and progression of enamel erosion Study Design: A stabilised SnF 2 dentifrice was compared to the following marketed NaF dentifrices in an in vitro erosion cycling model Product Fluoride source F - concentration Crest Pro-Health SnF 2 1100 ppm Crest Cavity Protection (ref control) NaF 1100 ppm Colgate Total NaF 1100 ppm Sensodyne ProNamel NaF 1150 ppm Arm & Hammer Enamel Care NaF 1100 ppm 60

Relative Anti-Erosive Effect of Marketed Dentifrices 30 Surface Enamel Loss (µm) 25 20 15 10 5 * 0 * Stabilised Stannous Fluoride in Crest Pro-Health was significantly different from reference control and all other treatments (p<0.05) 61 Faller et al Am J Dent 2011;24:205-210.

General Protocol for in situ Erosion Model Subjects fitted with intra-oral appliance to hold 2 enamel specimens in mid-palatal region Subjects randomized to receive test products in crossover study design Appliances worn 6-7 hrs/day, with 1 hr break for lunch Subjects rinse in morning with a slurry of test dentifrice 250 ml orange juice is consumed 1 and 3 hours post-treatment Treatment and acid challenges repeated in the afternoon Intra-oral appliance Specimens are removed and measured by profilometry at specified intervals (e.g. 5, 10 & 15 days) New enamel specimens are placed at the beginning of each study period Hooper et al J Dent 2007 35:476-481 62

In Situ Erosion Study of SnF2 vs. NaF Dentifrices n=15 Stabilised SnF 2 dentifrice (A) NaF dentifrice (B) Water Negative Control (C) 7 day washout 7 day washout 7 day washout B C A Baseline Day 5 Day 10 Day 15 Repeat Method 3X Total Randomized, blinded 3-treatment, 3-period crossover design 15 healthy volunteers Enamel loss measured by profilometry at BL, days 5, 10 and 15 Hooper et al J Dent 2007;35:476-481 63

Summary Neither sodium monofluorophosphate nor sodium fluoride (1100 ppm and 5000 ppm) provide the level of anti-erosion benefit provided by stabilised stannous fluoride This supports that the erosion benefit of stabilised stannous fluoride is driven by the stannous ion The protective effect of stabilised stannous fluoride over other fluorides has been demonstrated in laboratory and clinical studies 64

Dental hypersensitivity 65

Dental hypersensitivity Causes enamel is disappeared gingival recession loss of cementum bad oral hygiene dental erosion 66

Differential diagnosis tooth injuries leakage of fillings leakage of crowns dental caries prepared but not covered tooth surface abfraction due to overload 67

Pathomechanism hydrodinamical theory (Brännström és Äström 1964) toxins of plaque-bacteria (Wallace et al. 1990) 68

Treatment at home in the clinic with blocking of dentinal tubules blocking of nerve response 69

At home care Toothpaste Fluorides Strontium-chloride Potassium-nitrate 70

In the clinic local fluoridation fluoride varnishes bonding systems or similar filling 71

Nano-filled light cured material Seal and Protect - DeTreyDentsply 72

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Thank you for your attention! 74