Miniml intervention dentistry: prt 5. Ultr-conservtive pproch to the tretment of erosive nd rsive lesions P. Colon* 1 nd A. Lussi 2 IN BRIEF Stresses the importnce of conservtive pproch to the tretment of erosive nd rsive lesions. Explins how to pln n initil therpeutic pproch. Suggests there is no unique solution nd tretment plns must e mde on cse y cse sis. PRACTICE The therpeutic mngement of tooth wer lesions does not require the removl of disesed tissue. Nevertheless, diverse etiologicl fctors my e ssocited with the condition nd they could e difficult to eliminte; this hs to e considered when plnning therpy. Interceptive procedures should e reserved for such situtions while regulr monitoring is recommended for other cses, in ccordnce with dvice provided for using the Bsic Erosive Wer Exmintion (BEWE). Direct nd indirect dhesive procedures with composite resins llow tretment of most clinicl situtions, including even extensive restortions. The possiility of mnging susequent interventions should e considered when plnning the initil therpeutic pproch. INTRODUCTION Tooth wer lesions result from chronic ttcks on dentl tissues without cteril involvement. This process cn involve ttck from cids (erosions) or y mechnicl MINIMAL INTERVENTION DENTISTRY II 1. Contriution of the operting microscope to dentistry 2. Mngement of cries nd periodontl risks in generl dentl prctice 3. Mngement of non-cvitted (initil) occlusl cries lesions non-invsive pproches through reminerlistion nd therpeutic selnts 4. Miniml intervention techniques of preprtion nd dhesive restortions. The contriution of the sono-rsive techniques 5. Ultr-conservtive pproch to the tretment of erosive nd rsive lesions 6. Microscope nd microsurgicl techniques in periodontics 7. Miniml intervention in criology: the role of glss-ionomer cements in the preservtion of tooth structures ginst cries 8. Biotherpies for the dentl pulp This pper is dpted from: Colon P, Lussi A. Approche ultrconservtrice du ritement des lesions érosives et rsives. Rélités Cliniques 2012; 23: 213 222. 1 Université Pris Diderot, Service d Odontologie, Hôpitl Rothschild, AP HP, Pris, Frnce; 2 Zhnerhltung, Präventiv- und Kinderzhnmedicizin, Zhnmedizinische Kliniken der Universität, Bern, Switzerlnd *Correspondence to: Professor Pierre Colon Emil: pierre.colon@univ-pris-diderot.fr Refereed Pper Accepted 15 Novemer 2013 DOI: 10.1038/sj.dj.XXX British Dentl Journl XXXX; XXX: ruing of n externl element such s toothrush or other ggressive gents. It cn lso e due to simple teeth to teeth contct etween occlusl or proximl surfces nd is clled ttrition. 1,2 The incresing prevlence of these lesions hs een demonstrted y recent studies. 3,4 These three etiologicl processes of erosion, rsion nd ttrition give rise to extremely vrile clinicl situtions. This cn lso result in other diverse clinicl fetures when these three processes re comined. These lesions show three specific fetures: Asence of dentl, disesed tissue requiring removl s is the cse in dentl cries disese Loss of dentl tissues re lso consequence of physiologicl wer such s dily cid exposure, toothrushing nd interdentl contct. In certin cses, the distinction etween physiologicl nd pthologicl cn e difficult to determine The etiologicl fctors re sometimes difficult to control nd impossile to eliminte s they result t the sme time from norml physiologicl function. Consequently its mostly dverse pthologicl effects on the pulp cn result in invsive tretments, wheres totlly non-invsive restortion tretments should e recommended in the lrge mjority of clinicl situtions. Nevertheless, even with miniml loss of sustnce, this process will continue if the etiologicl fctors hve not een Fig. 1 Erosive nd rsive lesions could led to considerle defects. Here is the clinicl cse of womn, 35 yers old, with norexi nd ulimi when she presented to the consulttion eliminted, requiring complex reuilding of the two rches (Fig.1). Since the tooth wer lesions re cteri free, it is importnt to keep in mind tht these lesions could e ssocited with crious disese nd tht ultr-conservtive tretment my require the use of dditionl protocols focused on ptient enefits. Finlly, it hs een shown tht certin lesions re the direct consequence of eting disorders, osessive compulsive disorders (OCD), stress nd gstro-oesophgel reflux disese (GORD), which require comined medicl nd dentl intervention. 5 Tooth wer lesions cn lso e ssocited with ruxism phenomen. 6 Ultrconservtive tretment should include: Mximum preservtion of remining dentl structures Future therpeutic intervention under the sme conditions (repir, replcement) Control of etiologicl fctors Tretment of ny generl systemic fctors y medicl tem. BRITISH DENTAL JOURNAL VOLUME xxx NO. x MON xx 2014 1
It is importnt to recll tht this suject does not hve simple methodologicl pproch involving specific restortion techniques. More precisely it involves glol ttitude of the clinicin, resulting from good knowledge of etiopthologicl fctors llowing erly dignosis, recll, protection, stilistion, temporistion, interception efore undertking specific restortive procedures in selected cses. This clinicl pproch is good exmple of wht we cll in Frnce médecine ucco-dentire nd in Switzerlnd médecine dentire (dentl medicine) EARLY DIAGNOSIS Nowdys it is usul to detect erly proximl cries y retrocoronl X-ry. Detiled exmintions of cries predilection sites re well documented. The process llowing erly identifiction of erosive nd rsive lesions is generlly poorly pplied, s it remins controversil nd more often ssocited with identifying one or more risk fctors. Erly erosive nd rsive lesions re normlly symptomtic with the exception of cervicl uccl lesions, which cn cuse hypersensitivity symptoms. In fct, the erly lesions remin n enmel defect without ny symptomology. Yet erly dignosis is the est method in eliminting custive fctors t this erly stge whether they originte from limenttion, trumtic rushing or systemic pthology. The dignostics tools ville re fr less sophisticted thn those ville for the erly detection of initil cries such s lser fluorescence, nd only eye nd prctitioner s determintion re essentil. EXAMINATION SCREENING Actully, the trined eye of the prctitioner remins the min wy for erly dignosis. However, it requires good knowledge of initil tooth wer sites nd of the medicl context. While it is simple to recognise n estlished tooth wer lesion, erly lesions often escpe from usul clinicl exm focused on cries. Drying the teeth efore oservtion is required in the sme wy s dentl cries. The min sites to oserve re: The cusp tops for cup lesions (Fig. 2) The uccl surfces of the mxillry teeth to revel erly tooth wer lesions y depressing surrounding gums (Fig.3) The uccl surfces of the nterior mxillry teeth for erly tooth wer lesions of extrinsic nture (Fig.4) The lingul surfces of the nterior mxillry region round the cingulum re chrcteristic of intrinsic erosion (Fig. 5). Fig. 2 Initil erosive lesion is loclized in this typicl cse on the cusp tops of posterior teeth with cup lesion Fig. 3 Clinicl exm highlights severl initil cervicl erosive lesions for this young ptient with norexi A sextnt exm cn e used to pply the BEWE clssifiction criteri (Tles 1 nd 2), 7 which provides reference for following exmintions. This clssifiction is simple enough for dily use of generl prctitioner. It is lso possile tht pre-identified risk fctors will guide the dentl exm. Tle 3 is sed on clinicl oservtions involving round 200 ptients who presented for specilised consulttion focused on eting disorders. It could e help for generl prctitioner to guide the initil clinicl exm. The ultimte im of erly dignosis is to formulte recll strtegy, identifiction of etiologicl fctors nd eliminting them wherever possile nd finlly to intercept with mesures designed to protect dentl tissues. Other dignostic tools re of limited use. However, plster cst models llow ssessment of quntittive sustnce loss nd provide n ojective future reference. Mcro photos, if ville, lso permit ojective ssessment to follow lesion development nd motivte the ptient to modify hrmful hits. PREVENTIONS, INTERCEPTION, PROTECTION, TEMPORISATION Initil lesions Erosive lesions not requiring deridement of pthologicl dentl tissues should e pproched with strictly ultrconservtive mesures. It just remins to determine the optimum dpted tretment plnning involving comintion of prevention, interception, Fig. 4 Extrinsic erosion lesions re preferly loclised on uccl side of mxillry incisors Fig.5 Reflux from vomiting led to cidic dissolution of the lingul side of mxillry incisors protection, temporistion nd restortion if necessry. The tretment pln corresponds to the BEWE score (Tles 1 nd 2). Importnt ptient recommendtions include suitle rushing method, the use of n electric toothrush tht stops when excessive pressure is pplied nd the use of specific mouthwshes nd toothpstes even in the current sence of sufficient supporting clinicl studies proving effectiveness (Fig. 6). 9 Resin trys contining fluorinted gels cn reduce sensitivity without ny effect on lesion development. However, ptients presenting with cries free lesions cn lso hve n incresed risk of developing cries, in prticulr in the cse of norexi nd ulimi. It is therefore good prctice to undertke n overll risk ssessment nd not to focus solely on the most ovious (Fig. 7). 10 Idelly, dentl surfces should e isolted from n ggressive cid environment y using lyer of dhesive resin. However, voiding proximl overloding when using this type of mteril requires delicte touch nd the low strength of these resins significntly limits their period of effectiveness. Nevertheless, the use of the recently ville 4-met resin (Bondfill SB Sun medicl) ppers promising, sed on personl evlution of its effectiveness in 15 severe cses. The mteril remins in plce three months fter ppliction nd sensitivities hve not reppered. The short setting time only llows one or two teeth to e treted in the sme time. This resin lyer, which cn e compred to Superond, ut 2 BRITISH DENTAL JOURNAL VOLUME xxx NO. x MON xx 2014
Tle 1 BEWE score interprettion Tle 2 Clinicl pproch sed on BEWE score 8 Score 0 No erosive tooth wer 1 Initil loss of surfce texture 2 3 Distinct defect, hrd tissue loss <50% of the surfce re Distinct defect, hrd tissue loss >50% of the surfce re In score 2 nd 3, dentine is often involved Cumultive score of ll sextnts 2 Risk level None 3 8 Low 9 13 Medium 14 High Mngement Routine mintennce nd oservtion Repet t three yer intervls Orl hygiene nd dietry ssessment, nd dvice, routine mintennce nd oservtion Repet t two-yer intervl review nd mintennce Orl hygiene nd dietry ssessment, nd dvice. Identify the min etiologicl fctor(s) for tissue loss nd develop strtegies to eliminte respective impcts. Consider fluoridtion mesures or other strtegies to increse the resistnce of tooth surfces Idelly, void the plcement of restortions nd monitor erosive wer with study csts, photogrphs, or silicone impressions Repet t 6 12 month intervls Orl hygiene nd dietry ssessment, nd dvice. Identify the min etiologicl fctor(s) for tissue loss nd develop strtegies to eliminte respective impcts Consider fluoridtion mesures or other strtegies to increse the resistnce of tooth surfces Idelly, void the plcement of restortions nd monitor erosive wer with study csts, photogrphs, or silicone impressions Especilly in cses of severe progression consider specil cre tht my involve restortions Repet t 6 12 month intervls Fig. 6 The use of n electric toothrush reduces rsion phenomen especilly if dmge is ssocited to the pressure Fig. 7 Unusul cervicl cries lesions loclised on nterior teeth re linked to sugry food efore vomiting. (Ptient with norexi nd ulimi) Fig. 8 Use of specific resin (Bondfill SB Sun medicl) is good wy to protect exposed dentinl surfces nd to remove sensitivity reinforced y orgnic fillers, 11 is n effective onding gent llowing, if indicted, conventionl direct or indirect dhesive procedure (Fig. 8). Given tht the systemtic restortion of sustnce loss resulting from tooth wer Tle 3 Reltion etween clinicl nd etiology signs of the erosive nd rsive lesions Aetiology Min site Secondry site Lesion ppernce Extrinsic erosion of limentry origin Arsion s result of trumtic rushing Erosion cused y G.O.R.D. Erosion cused y norexi/ ulimi Attrition Buccl surfces of nterior mxillry teeth. Cervicl res of nterior mndiulr nd mxillry teeth. Buccl cervicl res of mxillry teeth especilly premolrs Occlusl surfces of mndiulr molrs. Cusp points of mndiulr molrs. Lingul surfces of mxillry cnines nd incisors Premolr nd molr cusps nd incisl wedge of nterior teeth of the two rches Buccl surfce of nterior mndiulr teeth Cusp points of mndiulr teeth Buccl cervicl res of mndiulr teeth especilly premolrs Buccl surfces of mndiulr molrs. Cusp points of mxillry molrs. Lingul surfces of the nterior mxillry teeth; Lingul surfces of mxillry molrs nd premolrs. Occlusl surfces of premolrs nd molrs Mrginl ridge nd lingul surfces of the nterior mxillry teeth lesions is not routine, non-invsive restortion procedure should e pplied if risk fctors hve not een eliminted. This is especilly the sitution in severe poorly defined mrgins, sucer shpe Wedge shpe lesion Concve lesions strting on the cusp points; Incisors: Progressive form ltertion of the lingul side relief. Poorly defined shpe lesions of posterior teeth Flt surfces Scrtches re sometimes present Sensitivity Yes if cervicl dentine is exposed Minly on initil lesions formtion of sclerotic dentine is following. Yes, minly during mstiction in cse of dentine exposure Fickle ut cn e severe if dentine surfce is exposed No, if dentine exposed. Sclerotic dentine formtion Periodontl ppernce Good with sometimes erly rdiculr exposure Good with high level of kertinised gum Good, ut with rdiculr exposure in ffected res y erosion from frequent reflux Frequent rdiculr surfces exposed No moility Helthy periodontl tissues cse of norexi, ulimi nd persistent gstrointestinl reflux. Initil erosive lesions situted on the cusp tops require limited restortions ut for lrge defects complete BRITISH DENTAL JOURNAL VOLUME xxx NO. x MON xx 2014 3
Tle 4 Therpeutic clssifiction of tooth wer lesions 13 Ctegory Sustnce loss Tretment options* Group 1 Group 2 Superficil, enmel (crown), dentine (root) Moderte nd isolted, enmel nd dentine. No functionl disility Advice nd prophylctic mesures Restortion contr-indicted Direct dhesive restortion Periodontl tretments for rdiculr exposure Group 3 Group 4 (4 nd 4) Group 5 (5 nd 5) intermedite ffecting group of teeth without functionl disility Severe nd multiple deteriortion of rticulr reltionship without TMJ disorder Without (4) or with (4) loss of verticl dimension Severe nd generlized, loss of rticulr reltionship with TMJ disorders without (5) or with (5) loss of verticl dimension Direct or indirect dhesive restortion Periodontl rehilittion often required Restortion of lnced nd functionl occlusl reltionship Direct nd indirect dhesive restortions, prosthodontics. without or with incresing verticl dimension. Totl orl rehilittion of two rches in 2 stges: 1. Adhesive reconstruction of two rches to recover function nd esthetic. 2. Prosthodontic tretment sometimes with implnts 5. without incresing verticl dimension 5. incresing verticl dimension *Monitoring is required if erosion is detected, dvices re lwys included in tretment plnning protection of the occlusl surfces could e required (Fig. 9). c Fig. 9 Interceptive tretment of cup lesions loclised on the top of cusps. ) Initil sitution; ) direct composite restortion; c) ite control with rticulting pper Figs 10 nd Restortion of n occlusl surfce without ny invsive procedure (Sonicfill composite Kerr) RESTORATIVE TREATMENT (BASED ON SPECIFIC REQUIREMENTS) Sustnce loss coming from toothwer cn led to functionl, esthetic or even psychologicl prolems. Lrge, isolted lesions my require restortion y using comintion of procedures of dhesive dentistry (Fig. 10). In contrst, widespred lesions cn indicte complex reuilding of the two rches. There re few ville recommendtions on the est tretment pproch nd only cse reports exists. 12. It is therefore resonle to suggest specific tretment pln for ech clinicl sitution encountered in Tle 4. 13 It could e surprising to discuss lrge occlusl restortions in pper devoted to miniml invsive procedures. However, the choice of tretment procedure should remin strictly non-invsive y the direct or indirect dhesion of composites. Certin scenrios will require prosthetic tretment t lter stte. Yet, fced with etiologicl fctors, which re difficult or impossile to control, this intervention should e treted s long-term interceptive tretment contriuting to improved orl helth of the ptient. 14 It is inccurte to ssume tht perfectly dpted procedure hs to e detiled for ech clinicl sitution. Nevertheless, certin numer of useful guidelines cn e followed sed on knowledge of iomterils nd of clinicl situtions. There is no evidence sed in this re nd only cse reports exist. Nture of exposed dentl tissues governing the choice of dhesive systems A slightly permele sclerotic dentine cn e Figs 11 nd Erosions consecutive to gstro esophgel reflux (GORD), cidic food nd trumtic tooth rushing. Ptient is 70 yers old. All teeth hve helthy pulp identified y its often smooth surfce without sensitivity when n ir jet is pplied during clinicl exmintion. The use of n etch nd rinse system for onding is justified, provided tht contmintion of dentl surfces y uccl fluids during the dhesion process is voided. It is essentil to hve seled operting field s the ruer dm. Adhesive systems require two steps (etch nd rinse two steps) or three (etch nd rinse three steps) if the promoter nd the dhesive resin re seprted. The etch nd rinse three steps remins the gold stndrd in terms of dhesion. 15 A permele dentine regulrly exposed to cids, s occurs in erosion, is chrcterised 4 BRITISH DENTAL JOURNAL VOLUME xxx NO. x MON xx 2014
Fig. 14 The ruer dm remins the est wy to preserve the long-term ehviour of dhesive restortions c Figs 12-c Restortive tretment of the previous clinicl cse with direct composite (Klore GC) y mtt ppernce, stined y exogenous colornts nd disply sensitivity when exposed to ir from syringe. This superficil dentine is prtilly deminerlised suffering from type of chronic etching effect. Under these conditions it would seem dvntgeous to use self-etching system, preferly two steps systems, which hve clerly een identified s superior in the interntionl literture. 16 Selection criteri nd composite ppliction Composite resins hve seen improvement in oth their esthetic nd physicl properties in recent yers. Nmely polymeristion shrinkge hs een reduced to 2% in good numer of cses, colour stility hs een improved, polishing ility is stisfctory even if the long-term results remins wek point. The mjor enefits of these mterils re: Re-intervention is possile y dding or removing mteril Possiility of using direct technique to pply thin lyer of mteril Possiility to use direct nd indirect techniques on the sme tooth. c Figs 13 Comintion of direct nd indirect dhesive restortions of nterior teeth of ptient with norexi nd ulimi. ) Initil sitution in occlusion; ) The spce ville for lingul veneers is evluted in the centric position; c) Aesthetic result fter the plcement of direct composite restortion on the uccl side. As reference, the cermic crown on the lterl incisor hs een preserved. Indirect composite mteril: Premise indirect Kerr, Direct composite mteril: Venus Dimond Hereus Figures 11 nd 12 represent the cse of ptient wishing to conserve teeth dmged y rsive nd erosive processes resulting from gstro-oesophgel reflux nd nutritionl cuses. Vitlity testing reveled helthy pulp for ll teeth. Only prosthetic cermic crowns nd post nd core restortions were suggested. A comintion of n opque nd two coloured micro-hyrid composites (GC Klore OA3, A3.5, A3) results in the preservtion of essentil dentl tissues nd n cceptle esthetic outcome. A direct technique ws used s the sole intervention to void ll cvity preprtion. A comintion of indirect nd direct techniques for the sme tooth hs een well documented. It is possile to pply comintion of cermic veneers with lingul composites on nterior teeth. In cses of Fig. 15 It is quite esy to uild indirect composite restortions on model without ny dentl preprtion. However, depth of 0.8 mm is required (Mjesty posterior Kurry, shde A3) severe eting disorders, ruxism is often ssocited with erosive nd rsive fctors. An lterntive pproch is to pply direct vestiulr composite resin, 14 giving creful interception solution (Fig. 13) Composite elements cn therefore e elorted from conventionl lortory composites (Premise indirect Kerr) or with especilly resistnt direct composite (Mjesty posterior Kurry). The indirect dhesion procedure is simple provided tht the operting field is correctly plced (Fig.14). The lortory work is eqully simple wherever these elements re not visile nd do not extend proximlly. Figure 15 illustrtes mono shde construction (A3 Mjesty posterior Kurry) undertken t the sme time s ddressing the occlusl surfces of the premolrs. The cst plster model is not prepred, only specific vrnish is pplied. The esthetic result is chieved when finl lyer of composite is pplied to uccl surfces with the lingul veneers supporting the esthetic reconstruction. Presently, it seems surprising tht these clinicl restortion procedures require further development. However, given the prevlence of tooth wer lesions, future reserch should strive to provide non-invsive, cost effective nd esthetic solutions. Therefore there is no unique solution ut insted tretment pln tht systemticlly ims to preserve cteri-free tissues in contrst to crious tissue. Finlly when the etiopthologicl fctors re uncontrolled future re-intervention must e considered efore decision is mde. BRITISH DENTAL JOURNAL VOLUME xxx NO. x MON xx 2014 5
The uthors would like to thnk Cludie Dmour- Terrsson, pulishing director of the Groupe Informtion Dentire, Pris Frnce, for the uthoristion of trnsltion nd puliction of the series in the BDJ; Dr Avijit Bnerjee for his support. 1. Lussi A, Hellwig E, Gnss C, Jeggi T. Dentl erosion. Oper Dent 2009; 34: 251 262. 2. Lussi A. Dentl erosion. From dignosis to therpy. Bâle: Krger, 2006. 3. Arndottir I B, Holrook W P, Eggertsson H et l. Prevlence of dentl erosion in children: ntionl survey. Community Dent Orl Epidemiol 2010; 38: 521 526. 4. El Aidi H, Bronkhorst E M, Truin G J. A longitudinl study of tooth erosion in dolescents. J Dent Res 2008; 87: 731 735. 5. Lo Russo L, Cmpisi G, Di Fede O, Di Lierto C, Pnzrell V, Lo Muzio L. Orl mnifesttions of eting disorders: criticl review. Orl Dis 2008; 14: 479 484. 6. Ohmure H, Oikw K, Knemtsu K et l. Influence of experimentl esophgel cidifiction on sleep ruxism: rndomized tril. J Dent Res 2011; 90: 665 671. 7. Brndini D A, Pedrini D, Pnzrini S R, Benete I M, Trevisn C L. Clinicl evlution of the ssocition of non-crious cervicl lesions, prfunctionl hits, nd TMD dignosis. Quintessence Int 2012; 43: 255 262. 8. Brtlett D, Gns C, Lussi A. Bsic Erosive Wer Exmintion (BEWE) new scoring system for scientific nd clinicl needs. Clin Orl Invest 2008; 12: 15 19. 9. Wng X, Megert B, Hellwig E, Neuhus K W, Lussi A. Preventing erosion with novel gents. J Dent 2011; 39: 163 170. 10. Colon P. Atteintes dentires consécutives à l norexie: quelle ttitude préventive? Inf Dent 2011; 30: 31 33. 11. Nkmur M, Koizumi H, Nishimki M, Mtsumur H. Clinicl ppliction of tri n utylorne initited dhesive resin filled with prepolymerized composite prticles. Asin Pc J Dent 2011; 11: 61 65. 12. Kelleher M G, Bomfim D I, Austin R S. Biologiclly sed restortive mngement of tooth wer. Int J Dent 2012; 2012: 742, 509. 13. Lsfrgues J J, Colon P. Odontologie conservtrice resturtrice: une pproche médicle glole Tome 1. Pris: Ed CdP, 2010. 14. Colon P, Lecorre A. Tritement conservteur des destructions dentires non crieuses. Rel Clin 2005; 16: 53 62. 15. Ryou H, Niu L N, Di L et l. Effect of iomimetic reminerliztion on the dynmic nnomechnicl properties of dentin hyrid lyers. J Dent Res 2011; 90: 1122 1128. 16. Vnjsn P, Dhkshinmoorthy M, Su Ro C V. Fctors ffecting the ond strength of self-etch dhesives: met-nlysis of literture. J Conserv Dent 2011; 14: 62 67. 6 BRITISH DENTAL JOURNAL VOLUME xxx NO. x MON xx 2014