Evaluation Of Cervical Wear And Occlusal Wear In Subjects With Chronic Periodontitis - A Cross Sectional Study

Introduction :

Periodontitis is a multi-factorial infectious disease of the supporting tissues of the teeth. ⁽¹⁾ Microbial dental plaque as the initiator of periodontal disease, however the manifestation and progression of periodontitis is influenced by wide variety of determinants and factors including subject characteristics social behavioral factors, systemic factors genetic factors, tooth factors, microbial composition of dental plaque and other emerging factors . ⁽²⁾ Clinically, patients suffer from gradual loss of tooth attachment in the alveolar bone leading to periodontal pockets, receeding gums, loose teeth, and eventually tooth exfoliation. ⁽³⁾

Gingival recession is defined clinically as exposure of the root surface by an apical shift in the position of the gingiva and may involve one or more tooth surfaces.

Causative factors include periodontal disease, mechanical action of aggressive tooth brushing, uncontrolled orthodontic movement, improper restoration, tooth mal position and frenum pull. Root exposure resulting from gingival recession leads to tooth sensitivity, root abrasion, chemical erosion, root caries and adverse esthetics. in many instances, cervical lesions involve both the crown and the exposed root causing the disappearance of the anatomic cemento- enamel junction. ⁽⁴⁾

Tooth wear (attrition, erosion and abrasion) is perceived internationally as a growing problem. The loss of tooth substance at the cemento- enamel junction because of causes other than dental caries has been identified as non-carious cervical lesion (NCCLs) or cervical wear. NCCLs can lead to hypersensitivity, plaque retention, pulpal involvement, root fracture and aesthetic problems. The increasing prevalence of NCCLs with the ageing of population represents a challenge in dental profession, and several etiologic factors such as abrasion, erosion and abfraction may be implicated in the initiation and progression of NCCLs .Abrasion is the physical tooth wear that may arise from excessive tooth brushing and abrasive contents in tooth pastes. Erosion is defined as the chemical tooth wear caused by acids, acting on plaque-free tooth surfaces, of intrinsic or extrinsic origin .Abfraction has been hypothetically described as the micro fracture and loss of tooth substance in the cervical region owing to stress induced flexure created by non-axial occlusal forces has also been considered to be involved in NCCLs. ⁽⁵⁾

Aims and objective of the study:

To evaluate association of gingival recession and NCCLs in individuals with chronic periodontitis.

To evaluate association of cervical wear with occlusal wear from periodontal prospective.

Materials and methods :

This study was conducted on 20 subjects selected from department of Periodontics, A.B. Shetty Memorial Institute of Dental Sciences, Deralakatte Mangalore. The study was approved by institutional ethical committee, and an informed written consent was obtained. Subjects aged 30–60 years, presenting with multiple NCCLs were included in this cross-sectional retrospective study. Subjects with present or past history of gastro esophageal reflux disease, heartburn, frequent vomiting, xerostomia, bruxism or parafunctional habits (e.g. bruxomania) were excluded from this study. Subjects with minimum compliment of 20 natural teeth excluding third molars were included, those with artificial crowns or extensive occlusal fillings were excluded from the study. Subjects diagnosed with chronic generalised Periodontitis based on gingival index score of >/=1 and attachment loss of >/=3mm in more than 30% of the sites were included in the study. The teeth of which the level of cervical wear corresponded to Smith and Knight tooth wear index level 2 or more (defect depth more than 2 mm) were considered to have NCCLs in this study. The bucco-lingual depth of NCCLs was measured by means of a periodontal probe. No further classification of NCCLs was made with respect to their clinical appearances whether wedge-shaped or rounded.

The screening examination included:

The periodontal examination in subjects was carried out by using a Williams periodontal probe. To assess the severity of gingival inflammation, gingival index (LOE AND SILLNESS):1963, Gingival recession (GR) was determined by Millers Index for recession. The assessment of tooth mobility was determined according to Miller Tooth Mobility index 1938. PLAQUE INDEX (SILLNESS AND LOE): 1964. To assess the extent and severity of dental erosion, attrition, abrasion as well as any combination of these conditions- Tooth Wear Index - B.G.N. Smith and J.K. Knight in 1984.⁽⁵⁾(Table 1)

All measurements were carried out by the same examiner.

Results :

All subjects brushed twice a day, used manual toothbrush, out of 20 subjects 15(75%) were using horizontal brushing technique and 5 subjects (25%) were using circular brushing technique.

Total of 510 teeth of 20 subjects were clinically examined in the study of which 210 teeth exhibited NCCLs (41.1%) these teeth displayed signs of cervical and occlusal wear in varying degree no pulal exposure was observed .47.6% (100) of NCCLs were on right side of the jaw and 52.3%(110) were on left side of jaw. 42.15% (215) of teeth exhibited recession and 99% of teeth examined were firm and nonmobile. Significant association of NCCLs with gingival recession (Table 2). Premolars (5.7) were significantly more affected with cervical wear than incisors (1.6) and molars (3.15) (Table 3). The mean of teeth with both occlusal and cervical wear was (1.75) less compared to mean of teeth with only cervical wear (7.7) only occlusal wear (0.8) inferring that cervical wear and occlusal wear are not associated with each other.(table 4 and 5)

Discussion :

In the present study our findings demonstrated that premolars were more influenced with NCCLs .The teeth with more gingival recession and non-mobile teeth developed deeper NCCLs .The teeth with both cervical wear and occlusal wear was not significant.

It is preferred to brush 3 teeth initially would develop more cervical wear besides hardness of bristles and content of toothpaste, stiffness of filament would be the etiology of cervical wear. It's been said that aggravation of abrasion at the tooth cervix is mainly because of combined action of abrasion and erosion, hence forceful brushing of tooth surface softened by acidic substances of intrinsic or extrinsic origin is an etiology of NCCLs .⁽⁶⁾

Gingival crevicular fluid is shown to be more acidic and may be erosive when in contact with teeth in cervical region. The food substances with ph of value less than 5.5 can become erosive and de mineralize the teeth .⁽⁷⁾

Occlusal loading force applied to the teeth are transmitted through them to PDL supporting structure which may cushion and dissipate the resultant stress thus mobile teeth are less likely to develop stress concentration that can cause abfraction indicating correlation of cervical tooth surface lesion with tooth stability and PDL support. ⁽⁸⁾

Stress that concentrate to produce abfraction in teeth usually are transmitted by occlusal loading force. Occlusal interference, premature contacts, habits of bruxisim and clenching all may act as stressors. Tooth contact during swallowing occurs 1500 times daily according to Shore these repetitive static and cyclic occlusal loads also could contribute to the formation of erosive, an abrasive or both the odontolytic effect may become highly significant . ⁽⁹⁾

Conclusion:

Gingival recession leading to denudation of root surface which in turn could lead to abrasion and erosion, aggressive tooth brushing could be the possible, predisposing factor for NCCLs initiation and progression. NCCL can lead to hypersensitivity, plaque retention, pulpal involvement, root fracture and aesthetic problems .The increasing prevalence of NCCLs with the ageing of population represents a challenge in management of the same in dental profession.