Dental Fistulas in Primary Teeth: Diagnosis & Treatment

A dental fistula is a small channel that develops when an infection inside a tooth or around its root needs a way to drain.

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In children, dental fistulas are most often associated with untreated dental caries that have progressed to pulp necrosis and a chronic dental abscess.

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Although the fistula itself is usually painless, it is an important warning sign that the underlying tooth is infected and requires dental treatment.
Early diagnosis is essential because untreated infections in primary teeth may affect the child's comfort, chewing, speech, and even the development of the permanent successor tooth.

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✅ What Is a Dental Fistula?
A dental fistula (also called a sinus tract) is a narrow pathway that allows pus from a chronic dental infection to drain from the bone toward the oral mucosa or, less commonly, the skin.
Because the infection can drain continuously, the pressure inside the tissues decreases, which explains why many children do not complain of severe pain, despite having an infected tooth.

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✅ Why Do Dental Fistulas Develop?
The most common causes include:

▪️ Deep untreated dental caries
▪️ Pulp necrosis (death of the dental pulp)
▪️ Chronic periapical infection
▪️ Dental trauma causing pulp damage
▪️ Failed pulp therapy in a primary tooth
▪️ Among these, dental caries remains by far the leading cause.

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✅ Clinical Signs and Symptoms
Children with a dental fistula may present with:

▪️ Small pimple-like lesion on the gum
▪️ Yellow or white drainage point
▪️ Intermittent discharge of pus
▪️ Mild swelling around the affected area
▪️ History of previous toothache
▪️ Tooth discoloration
▪️ Little or no pain after the fistula forms
▪️ Occasionally tenderness when chewing
The fistula often appears near the root of the infected primary tooth.

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✅ How Is a Dental Fistula Diagnosed?
Diagnosis is based on clinical examination combined with radiographic evaluation.
The dentist typically performs:

Clinical Examination
▪️ Identification of the draining sinus tract
▪️ Evaluation of dental caries
▪️ Percussion and palpation tests
▪️ Assessment of tooth mobility
▪️ Examination of soft tissues

Radiographic Examination
▪️ Periapical or bitewing radiographs help detect:
▪️ Periapical radiolucency
▪️ Bone destruction
▪️ Root resorption
▪️ Relationship with the permanent tooth germ
When the origin of the fistula is uncertain, a gutta-percha cone may be gently inserted into the sinus tract before taking a radiograph to trace its source.

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✅ Differential Diagnosis
A dental fistula should be differentiated from:

▪️ Parulis
▪️ Periodontal abscess
▪️ Gingival abscess
▪️ Eruption cyst
▪️ Mucocele
▪️ Pyogenic granuloma
▪️ Traumatic ulcers with secondary infection
Accurate diagnosis ensures the correct treatment is provided.

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✅ Treatment
The primary goal is to eliminate the source of infection rather than simply treating the fistula.
Treatment depends on the condition of the tooth.

Pulpectomy
Recommended when:
The primary tooth is restorable.
Adequate root structure remains.
There is no excessive pathological root resorption.
Pulpectomy removes infected pulp tissue and fills the canals with a resorbable material appropriate for primary teeth.

Extraction
▪️ Extraction is indicated when:
▪️ The tooth cannot be restored.
▪️ There is extensive root resorption.
▪️ The infection is severe.
▪️ The permanent successor is close to eruption.
▪️ The tooth has a poor prognosis.
If extraction is performed prematurely, a space maintainer may be required.

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✅ Are Antibiotics Necessary?
Routine antibiotics are not recommended for localized dental fistulas.
Systemic antibiotics should only be considered when there are signs of:
▪️ Facial cellulitis
▪️ Diffuse swelling
▪️ Fever
▪️ Systemic illness
▪️ Spread of infection
▪️ Immunocompromised patients
In most cases, definitive dental treatment is sufficient.

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✅ Possible Complications
Without treatment, a dental fistula may lead to:

▪️ Persistent chronic infection
▪️ Facial swelling
▪️ Pain recurrence
▪️ Bone destruction
▪️ Premature loss of the primary tooth
▪️ Damage to the developing permanent tooth
▪️ Space loss and future malocclusion

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💬 Discussion
A dental fistula is not the disease itself but a sign of chronic dental infection. Because the lesion often drains continuously, many parents mistakenly believe the problem has resolved when the child no longer experiences pain. In reality, the infection persists until the source is eliminated.
Current pediatric dentistry guidelines emphasize preserving primary teeth whenever possible through appropriate pulp therapy. However, when the tooth has a poor prognosis, extraction is the safest option to prevent further complications and protect the developing permanent dentition.

🎯 Recommendations
▪️ Never ignore a gum "pimple" in a child.
▪️ Seek prompt dental evaluation if drainage is observed.
▪️ Treat the infected tooth rather than the fistula alone.
▪️ Avoid self-medicating with antibiotics unless prescribed.
▪️ Maintain regular preventive dental visits every six months.

✍️ Conclusion
Dental fistulas in primary teeth are a common consequence of untreated pulp infection and should never be considered harmless. Although they are frequently painless, they indicate the presence of chronic infection that requires professional treatment. Early diagnosis, appropriate radiographic assessment, and timely management through pulpectomy or extraction help preserve oral health, prevent complications, and protect the normal development of the permanent dentition.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Use of non-vital pulp therapies in primary teeth. In The Reference Manual of Pediatric Dentistry (2024–2025 ed.). American Academy of Pediatric Dentistry.
✔ American Academy of Pediatric Dentistry. (2024). Best practices: Pulp therapy for primary and immature permanent teeth. In The Reference Manual of Pediatric Dentistry (2024–2025 ed.). American Academy of Pediatric Dentistry.
✔ Coll, J. A., Vargas, K., Marghalani, A. A., Chen, C. Y., Al Shamali, S., Dhar, V., ... & Seale, N. S. (2020). A systematic review and meta-analysis of nonvital pulp therapy for primary teeth. Pediatric Dentistry, 42(4), 256–461.
✔ Day, P. F., Flores, M. T., O'Connell, A. C., Abbott, P. V., Tsilingaridis, G., Fouad, A. F., ... & Levin, L. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: Injuries in the primary dentition. Dental Traumatology, 36(4), 343–359. https://doi.org/10.1111/edt.12576
✔ Schwendicke, F., Frencken, J. E., Bjørndal, L., Maltz, M., Manton, D. J., Ricketts, D., ... & Paris, S. (2021). Managing carious lesions: Consensus recommendations on carious tissue removal. Advances in Dental Research, 33(1), 12–18.

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Riva Star: Complete Guide to Uses, Benefits, and Clinical Application

Riva Star is a silver diamine fluoride (SDF)-based desensitizing system widely used in modern dentistry. It is designed to reduce dentin hypersensitivity and help arrest dental caries without the need for invasive procedures.

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Because treatment is quick, simple, and minimally invasive, it is especially valuable for children, older adults, patients with special healthcare needs, and individuals who have difficulty tolerating conventional restorative treatment.

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This guide explains what Riva Star is, how it works, when it should be used, its advantages, limitations, and current scientific evidence in clear and accessible language.

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🔘 What Is Riva Star?
Riva Star is a two-step dental treatment system manufactured by SDI Limited. It contains:
▪️ Step 1: Silver diamine fluoride (38% SDF), which provides antibacterial activity and strengthens tooth structure.
▪️ Step 2: Potassium iodide (KI), applied immediately afterward to reduce the amount of dark staining that may occur after SDF application.
The combination is intended to manage dentin hypersensitivity and assist in arresting active dentinal caries while improving esthetics compared with SDF used alone.

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🔘 How Does Riva Star Work?
Riva Star acts through several complementary mechanisms:
▪️ Silver ions eliminate bacteria responsible for tooth decay.
▪️ Fluoride ions promote remineralization and increase resistance to future acid attacks.
▪️ Silver compounds help seal exposed dentinal tubules, reducing pain caused by temperature or touch.
▪️ Potassium iodide reacts with free silver ions to reduce visible staining, although discoloration may still occur in some situations.
Together, these effects provide both therapeutic and preventive benefits.

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🔘 Main Clinical Indications
Riva Star is commonly recommended for:

▪️ Dentin hypersensitivity
▪️ Active dentinal caries arrest
▪️ Root caries
▪️ Early childhood caries
▪️ Geriatric dentistry
▪️ Patients with limited cooperation
▪️ High-caries-risk individuals
▪️ Temporary management when definitive restorative treatment must be delayed

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🔘 Clinical Benefits
Among its main advantages are:

▪️ Minimally invasive treatment
▪️ Fast application
▪️ No drilling in many cases
▪️ Excellent antibacterial activity
▪️ Promotes remineralization
▪️ Reduces tooth sensitivity
▪️ Useful in community and preventive dentistry
▪️ Cost-effective compared with many restorative procedures

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🔘 Limitations
Despite its advantages, clinicians should consider several limitations:

▪️ Black staining may still occur on arrested carious dentin.
▪️ It does not restore missing tooth structure.
▪️ Additional restorative treatment may still be required.
▪️ Temporary soft tissue staining can occur if accidental contact happens.
▪️ Proper case selection is essential.

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🔘 Basic Clinical Application
A simplified clinical protocol includes:

1. Clean and isolate the tooth.
2. Dry the treatment area.
3. Apply Riva Star Step 1 (38% SDF).
4. Immediately apply Step 2 (Potassium Iodide) according to the manufacturer's instructions.
5. Remove excess material.
6. Re-evaluate the tooth during follow-up visits.
Clinical protocols may vary depending on the indication and manufacturer recommendations.

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🔘 Safety Considerations
Current evidence indicates that 38% SDF is generally safe when used appropriately by trained dental professionals.

However, clinicians should:
▪️ Avoid contact with eyes and skin.
▪️ Prevent ingestion.
▪️ Use careful isolation.
▪️ Avoid use in patients with silver allergy.
▪️ Follow the manufacturer's instructions carefully.

🔘 Riva Star vs Conventional Desensitizers

Feature	Riva Star	Conventional Desensitizers
Antibacterial action	Excellent	Usually limited
Caries arrest	Yes	No
Dentin hypersensitivity	Excellent	Good
Fluoride release	Yes	Variable
Possible staining	Yes (reduced with potassium iodide)	Rare
Invasive procedure	No	No
Clinical longevity	Long-lasting with periodic follow-up	Often requires more frequent reapplication
Best clinical use	Hypersensitivity and caries arrest	Hypersensitivity only

🔘 Scientific Evidence
Recent systematic reviews and clinical guidelines consistently report that 38% silver diamine fluoride is highly effective in arresting dentinal caries, particularly in primary teeth and root caries.
Studies also demonstrate that SDF significantly reduces dentin hypersensitivity by occluding dentinal tubules and decreasing bacterial activity. While the addition of potassium iodide may reduce immediate discoloration, current evidence indicates that its long-term ability to prevent staining remains limited, and some darkening may still develop over time.
Overall, Riva Star remains one of the best-supported minimally invasive options for managing hypersensitivity and non-restorative caries treatment.

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💬 Discussion
The increasing popularity of Riva Star reflects the shift toward minimally invasive dentistry. Instead of removing large amounts of tooth structure, clinicians now focus on preserving healthy tissues while controlling disease.
One important aspect to discuss with patients is the possibility of tooth discoloration, especially when treating active dentinal caries. Clear communication improves patient satisfaction and informed consent.
For many patients—including children, older adults, medically compromised individuals, and those with dental anxiety—the benefits of disease control often outweigh cosmetic concerns.

🎯 Recommendations
▪️ Use Riva Star for patients with dentin hypersensitivity who need rapid symptom relief.
▪️ Consider it for arresting active dentinal caries, especially when conventional treatment is difficult.
▪️ Explain the possibility of staining before treatment.
▪️ Schedule periodic follow-up visits to monitor treatment success.
▪️ Combine Riva Star with good oral hygiene, fluoride exposure, dietary counseling, and regular dental examinations for optimal long-term outcomes.

✍️ Conclusion
Riva Star is a scientifically supported, minimally invasive treatment for managing dentin hypersensitivity and arresting dental caries. Its combination of 38% silver diamine fluoride and potassium iodide provides antibacterial activity, promotes remineralization, and helps reduce sensitivity while attempting to minimize discoloration.
Although it does not replace restorative dentistry when tooth structure has been significantly lost, Riva Star represents an effective, safe, and evidence-based option for preventive and minimally invasive dental care.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Use of silver diamine fluoride for dental caries management in children and adolescents. The Reference Manual of Pediatric Dentistry. https://www.aapd.org/research/oral-health-policies--recommendations/
✔ Crystal, Y. O., Marghalani, A. A., Ureles, S. D., Wright, J. T., Sulyanto, R., Divaris, K., Fontana, M., & Graham, L. (2023). Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions. Journal of the American Dental Association, 154(7), 587–609.
✔ Horst, J. A., Ellenikiotis, H., & Milgrom, P. L. (2016). UCSF protocol for caries arrest using silver diamine fluoride: Rationale, indications and consent. Journal of the California Dental Association, 44(1), 16–28.
✔ Schmoeckel, J., Gorseta, K., Splieth, C., & Santamaria, R. M. (2020). How to intervene in the caries process in children: A systematic review of nonrestorative caries treatment. Journal of Clinical Medicine, 9(11), 3557.
✔ Seifo, N., Robertson, M., MacLean, J., Blain, K., Grosse, S., Milne, R., & Innes, N. P. T. (2020). The use of silver diamine fluoride (SDF) in dental practice. British Dental Journal, 228(2), 75–81.

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Sagittal Malocclusions in Primary, Mixed, and Permanent Dentition

Sagittal malocclusions are among the most frequently diagnosed bite problems in orthodontics and can appear during primary, mixed, or permanent dentition.

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They occur when the upper and lower teeth or jaws are not properly aligned from front to back, potentially affecting oral function, facial aesthetics, and long-term dental health.

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Early recognition is essential because many sagittal discrepancies can be corrected or significantly improved while a child is still growing. This guide explains the different types of sagittal malocclusions, their causes, clinical features, and the most appropriate treatment options for each stage of dental development, helping patients and parents better understand when orthodontic intervention may be beneficial.

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🔹 What Are Sagittal Malocclusions?
Sagittal malocclusions are bite problems that occur in the front-to-back (anteroposterior) relationship between the upper and lower dental arches. They affect chewing, facial appearance, speech, and long-term oral health.
These malocclusions may result from genetic factors, abnormal jaw growth, oral habits, or premature loss of primary teeth. Early diagnosis is important because some conditions respond much better when treated during growth.

According to Angle's Classification, sagittal malocclusions are divided into:
▪️ Class I malocclusion
▪️ Class II malocclusion
▪️ Class III malocclusion

1. Class I Malocclusion

➤ Definition
Class I malocclusion occurs when the molars have a normal relationship, but the teeth are improperly aligned. Common findings include:
▪️ Dental crowding
▪️ Spacing
▪️ Rotated teeth
▪️ Mild protrusion or retrusion of incisors
This is the most common type of malocclusion worldwide.

➤ Main Causes
▪️ Tooth-size and jaw-size discrepancy
▪️ Premature loss of primary teeth
▪️ Supernumerary teeth
▪️ Ectopic eruption
▪️ Genetic factors
▪️ Oral habits

➤ Treatment by Dentition Stage

Primary Dentition (3–6 years)
Treatment is usually preventive.
▪️ Monitor eruption and jaw development
▪️ Eliminate harmful oral habits
▪️ Preserve primary teeth
▪️ Use space maintainers if teeth are lost early

Mixed Dentition (6–12 years)
The ideal time for interceptive treatment.
Possible treatments include:
▪️ Space maintainers
▪️ Space regaining appliances
▪️ Limited orthodontics
▪️ Serial extraction (selected cases)
▪️ Maxillary expansion if transverse deficiency exists

Permanent Dentition (12+ years)
Treatment focuses on comprehensive orthodontics.
Options include:
▪️ Fixed braces
▪️ Clear aligners
▪️ Interproximal enamel reduction (IPR)
▪️ Extraction therapy when indicated

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2. Class II Malocclusion

➤ Definition
Class II malocclusion occurs when the lower dental arch or mandible is positioned behind the upper arch.
Two main divisions exist:

Class II Division 1
▪️ Upper incisors protrude forward.
▪️ Increased overjet.
▪️ Higher risk of dental trauma.

Class II Division 2
▪️ Upper central incisors tilt backward.
▪️ Deep overbite is common.
▪️ Less noticeable protrusion.

➤ Main Causes
▪️ Mandibular retrusion (most common)
▪️ Maxillary protrusion
▪️ Genetic growth pattern
▪️ Thumb sucking
▪️ Mouth breathing
▪️ Prolonged pacifier use

➤ Treatment by Dentition Stage

Primary Dentition
Usually observation unless severe.
Management includes:
▪️ Habit control
▪️ Monitoring jaw growth
▪️ Parent education

Mixed Dentition
This is often the best period for growth modification.
Common appliances:
▪️ Twin Block
▪️ Herbst appliance
▪️ Bionator
▪️ Functional appliances
▪️ Headgear (selected maxillary protrusion cases)
Early treatment can reduce trauma risk and improve jaw relationships.

Permanent Dentition
Growth modification becomes limited.
Treatment options include:
▪️ Fixed orthodontic appliances
▪️ Class II elastics
▪️ Temporary anchorage devices (TADs)
▪️ Premolar extractions (selected patients)
▪️ Orthognathic surgery for severe skeletal discrepancies

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3. Class III Malocclusion

➤ Definition
Class III malocclusion occurs when the lower jaw is positioned ahead of the upper jaw, creating an underbite.
It may be:
▪️ Dental
▪️ Skeletal
▪️ Functional (pseudo-Class III)
Early diagnosis is particularly important.

➤ Main Causes
▪️ Maxillary deficiency
▪️ Mandibular excess
▪️ Family history
▪️ Craniofacial syndromes
▪️ Functional mandibular shift

➤ Treatment by Dentition Stage

Primary Dentition
Early intervention is recommended if a functional shift exists.
Treatment may include:
▪️ Elimination of occlusal interference
▪️ Observation
▪️ Habit correction

Mixed Dentition
This is the optimal stage for orthopedic correction.
Common treatments include:
▪️ Rapid Maxillary Expansion (RME)
▪️ Facemask (Reverse Pull Headgear)
▪️ Expansion combined with facemask
▪️ Functional appliances (selected cases)
Treatment before puberty generally produces better skeletal outcomes.

Permanent Dentition
Treatment depends on severity.
Options include:
▪️ Orthodontic camouflage
▪️ Fixed braces
▪️ Class III elastics
▪️ Orthognathic surgery for severe skeletal Class III

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🔹 Early Warning Signs
Parents should seek an orthodontic evaluation if a child has:

▪️ Difficulty biting food
▪️ Teeth that do not meet correctly
▪️ Protruding upper teeth
▪️ Underbite
▪️ Facial asymmetry
▪️ Persistent thumb sucking
▪️ Early loss of baby teeth
The American Association of Orthodontists (AAO) recommends an orthodontic evaluation by age 7, even if no obvious problem is present.

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💬 Discussion
Most sagittal malocclusions have a strong genetic component, but environmental factors can worsen their severity. Scientific evidence consistently shows that early interceptive treatment is most beneficial for Class III malocclusion and for selected Class II skeletal cases during active growth.
Not every child requires immediate orthodontic treatment. Many patients benefit from regular observation until the ideal treatment window is reached. Careful diagnosis is essential to avoid unnecessary interventions while taking advantage of periods of facial growth.

🎯 Recommendations
▪️ Schedule the first orthodontic evaluation around age 7.
▪️ Treat harmful oral habits as early as possible.
▪️ Maintain healthy primary teeth to preserve arch space.
▪️ Monitor eruption during mixed dentition.
▪️ Treat skeletal discrepancies during growth whenever possible.
▪️ Consult an orthodontist if bite changes or facial asymmetry develop.

✍️ Conclusion
Sagittal malocclusions are among the most common orthodontic problems and may affect oral function, facial balance, and long-term dental health. Their management depends on the patient's age, growth potential, and the type of skeletal or dental discrepancy. Early diagnosis during primary and mixed dentition offers the greatest opportunity for interceptive treatment, while comprehensive orthodontics or orthognathic surgery may be necessary in permanent dentition for more severe cases. Regular dental examinations and timely orthodontic referrals remain the best strategy for achieving stable, healthy outcomes.

📊 Summary Table

Malocclusion	Definition	Primary Dentition	Mixed Dentition	Permanent Dentition
Class I	Normal molar relationship with crowding or spacing.	Observation, habit control, preserve space.	Space maintainers, limited orthodontics, serial extraction.	Braces, aligners, extraction if needed.
Class II	Lower jaw positioned behind the upper jaw.	Observation and habit correction.	Twin Block, Herbst, Bionator, functional appliances.	Braces, elastics, TADs, extractions or surgery.
Class III	Lower jaw positioned ahead of the upper jaw.	Correct functional shifts, monitor growth.	RME, facemask therapy, orthopedic treatment.	Orthodontic camouflage or orthognathic surgery.

📚 References

✔ American Association of Orthodontists. (2025). Age 7 orthodontic check-up. https://aaoinfo.org
✔ Graber, L. W., Vanarsdall, R. L., Vig, K. W. L., & Huang, G. J. (2023). Orthodontics: Current Principles and Techniques (7th ed.). Elsevier.
✔ Proffit, W. R., Fields, H. W., Larson, B., & Sarver, D. M. (2019). Contemporary Orthodontics (6th ed.). Elsevier.
✔ American Academy of Pediatric Dentistry. (2024). Management of the developing dentition and occlusion in pediatric dentistry. The Reference Manual of Pediatric Dentistry. https://www.aapd.org/research/oral-health-policies--recommendations/
✔ World Health Organization. (2022). Oral health. https://www.who.int/news-room/fact-sheets/detail/oral-health

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Orthodontic Archwire Selection Guide: Types and Functions

Orthodontic treatment depends on many components, but archwires are one of the most important. They are the metal wires placed inside the brackets that apply gentle forces to move teeth into healthier and more functional positions.

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Different archwires have different properties. Some are flexible and ideal for the beginning of treatment, while others are stronger and provide precise tooth control during the final stages.

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Choosing the correct wire at the right time helps improve treatment efficiency, patient comfort, and long-term stability.

🔰 What Are Orthodontic Archwires?
An orthodontic archwire is a specially designed wire that connects all brackets and guides tooth movement throughout treatment.

Each archwire differs in:
▪️ Material
▪️ Shape
▪️ Flexibility
▪️ Strength
These characteristics determine how much force is delivered and which stage of treatment the wire is best suited for.

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🔰 Main Types of Orthodontic Archwires

1. Nickel-Titanium (NiTi) Archwires
NiTi archwires are the most commonly used wires during the early stages of orthodontic treatment.

Main characteristics
▪️ Highly flexible
▪️ Excellent shape memory
▪️ Superelastic
▪️ Deliver light and continuous forces
▪️ Increase patient comfort

Main functions
▪️ Initial alignment
▪️ Leveling crowded teeth
▪️ Correcting mild rotations
▪️ Beginning tooth movement safely
Because they continue applying gentle force even after bending, NiTi wires reduce excessive pressure on teeth and surrounding tissues.

2. Stainless Steel Archwires
Once teeth become better aligned, orthodontists usually replace NiTi wires with stainless steel archwires.

Main characteristics
▪️ Very strong
▪️ Less flexible
▪️ Excellent dimensional stability
▪️ Easy to bend into customized shapes

Main functions
▪️ Space closure
▪️ Finishing tooth alignment
▪️ Detailed tooth positioning
▪️ Maintaining treatment control
These wires allow orthodontists to make precise adjustments before treatment is completed.

3. Titanium Molybdenum Alloy (TMA) Archwires
TMA archwires combine some advantages of both NiTi and stainless steel.

Main characteristics
▪️ Moderate flexibility
▪️ Good springback
▪️ Easier to bend than stainless steel
▪️ Lower stiffness than steel

Main functions
▪️ Moderate tooth movement
▪️ Finishing procedures
▪️ Loop mechanics
▪️ Controlled space closure
▪️ Situations requiring customized wire bends
TMA wires are frequently selected when more control is needed without using the greater stiffness of stainless steel.

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🔰 Round vs. Rectangular Archwires
Many people think round and rectangular wires are different materials, but they simply describe the wire's shape.
The same material (NiTi, stainless steel, or TMA) can be manufactured as either round or rectangular.

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🔰 Round Archwires
Round wires have a circular cross-section.

Advantages
▪️ Very flexible
▪️ Easier to insert into brackets
▪️ Produce lighter forces
▪️ Improve patient comfort

Main uses
▪️ Initial alignment
▪️ Leveling teeth
▪️ Correcting crowding
▪️ Early stages of treatment
Round wires move crowns efficiently while allowing greater freedom of movement inside the bracket.

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🔰 Rectangular Archwires
Rectangular wires fill more of the bracket slot.

Advantages
▪️ Greater control over tooth movement
▪️ Better control of tooth angulation
▪️ Better control of root position
▪️ Improved torque expression

Main uses
▪️ Working phase
▪️ Space closure
▪️ Root positioning
▪️ Finishing treatment
▪️ Final detailing
Because they contact more of the bracket slot, rectangular wires provide the precision needed for ideal tooth positioning.

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🔰 Quick Comparison

Archwire Type	Main Properties	Primary Function	Treatment Stage
NiTi	Highly flexible, superelastic, excellent shape memory	Initial alignment and leveling	Initial Phase
Stainless Steel	High strength, rigid, excellent dimensional stability	Space closure, finishing and detailing	Working and Finishing Phases
TMA	Moderate flexibility, good springback, easily customized	Controlled mechanics, loop activation and space closure	Working Phase
Round Archwires	More flexible and deliver lighter forces	Initial alignment, leveling and early tooth movement	Early Treatment
Rectangular Archwires	Greater control of torque, angulation and root position	Root control, space closure and finishing	Mid to Final Treatment

🔰 Why Does the Sequence of Archwires Matter?
Orthodontic treatment is usually performed using a progressive sequence of archwires.

A typical progression is:
▪️ Round NiTi → initial alignment
▪️ Rectangular NiTi → beginning root control
▪️ Rectangular TMA (when additional flexibility is desirable)
▪️ Rectangular Stainless Steel → finishing, detailing, and stabilization
This sequence allows teeth to move efficiently, comfortably, and safely while minimizing unnecessary forces.

📥 Downloadable Clinical Summary

💬 Discussion
Scientific evidence shows that no single archwire is ideal for every stage of orthodontic treatment. Each material has unique mechanical properties that make it more suitable for specific clinical objectives.
NiTi archwires are preferred during the alignment phase because they deliver light, continuous forces and excellent flexibility. As treatment progresses, stainless steel archwires provide greater control for finishing and detailing. TMA archwires occupy an intermediate position, offering a balance between flexibility and control, particularly when customized bends or loop mechanics are required.
Likewise, round and rectangular archwires are complementary rather than competing designs. Round wires simplify initial alignment, whereas rectangular wires improve three-dimensional tooth control and optimize final treatment results.

🎯 Recommendations
▪️ Begin treatment with round NiTi archwires for efficient alignment and leveling.
▪️ Switch to rectangular NiTi once initial alignment has been achieved to improve root control.
▪️ Use TMA archwires when moderate stiffness and customized mechanics are required.
▪️ Finish with rectangular stainless steel archwires for maximum precision and treatment stability.
▪️ Individualize archwire selection according to each patient's clinical needs rather than following a fixed sequence.

✍️ Conclusion
Orthodontic archwires are the driving force behind tooth movement throughout treatment. Understanding the differences between NiTi, stainless steel, and TMA archwires, as well as the role of round and rectangular designs, helps explain why orthodontists change wires during different treatment stages.
Selecting the appropriate archwire at the right time improves treatment efficiency, patient comfort, tooth control, and long-term stability, ultimately contributing to more predictable orthodontic outcomes.

📚 References

✔ Proffit, W. R., Fields, H. W., Larson, B. E., & Sarver, D. M. (2023). Contemporary Orthodontics (7th ed.). Elsevier.
✔ Graber, L. W., Vanarsdall, R. L., Vig, K. W. L., & Huang, G. J. (2022). Orthodontics: Current Principles and Techniques (7th ed.). Elsevier.
✔ Kusy, R. P. (2002). Orthodontic biomaterials: From the past to the present. The Angle Orthodontist, 72(6), 501–512.
✔ Kapila, S., & Sachdeva, R. (1989). Mechanical properties and clinical applications of orthodontic wires. American Journal of Orthodontics and Dentofacial Orthopedics, 96(2), 100–109.
✔ Burstone, C. J. (1981). Variable-modulus orthodontics. American Journal of Orthodontics, 80(1), 1–16.

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Primary Tooth Extraction Techniques: A Practical Guide

Extracting a primary (baby) tooth is not the same as extracting a permanent tooth. The roots of primary teeth are often thin, curved, and spread apart, and the developing permanent tooth lies very close to them. For this reason, the goal is not only to remove the tooth, but also to protect the permanent tooth germ and preserve the surrounding bone and soft tissues.

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This guide summarizes the most important clinical principles and atraumatic extraction techniques in simple, evidence-based language.

✅ Why Primary Teeth Require a Different Technique
Primary teeth have several anatomical features that change the extraction approach:

▪️ Physiologic root resorption (natural shortening of the roots)
▪️ Wide root divergence in molars
▪️ Thin alveolar bone
▪️ Close relationship with the developing permanent tooth
Because of these differences, controlled and gentle movements are preferred over strong or abrupt forces.

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✅ Key Extraction Techniques

1. Avoid Rotational Movements in Primary Molars
Rotational movements are generally avoided when extracting primary molars. Their roots are long and widely separated, so twisting the tooth increases the risk of root fracture or injury to the permanent tooth germ.
Use gentle side-to-side (buccal-lingual) movements instead of strong rotation.

2. Use Gentle Buccal-Lingual Luxation
The safest initial movement is usually a small, controlled buccal-lingual motion. This gradually loosens the periodontal ligament and slightly expands the socket.
Important: the movement should be slow and progressive, not forceful.

3. Minimize Apical Pressure
Excessive pressure toward the root tip should be avoided.
Strong apical pressure may traumatize or displace the developing permanent tooth.
This is especially important in children between 6 and 10 years of age, when the permanent successors are actively developing.

4. Use Elevators Conservatively
Elevators can be useful in selected cases, but they should be used with caution.
Clinical principles:
▪️ Do not insert the elevator deeply toward the apex.
▪️ Do not use the permanent tooth germ area as a point of support.
▪️ Do not use adjacent teeth as a fulcrum, because this may loosen or damage them.

5. Adapt the Movement to the Tooth Type

Tooth Type	Preferred Movement
Primary Incisors	Slight rotational movement may be acceptable because they usually have a single, conical root.
Primary Canines	Controlled rotational and gentle lateral movements are generally appropriate, depending on root anatomy.
Primary Molars	Gentle buccal-lingual luxation is recommended. Avoid excessive rotational movements because of the widely divergent roots and the proximity of the permanent tooth germ.

6. Respect Physiologic Root Resorption
Before extraction, radiographs help evaluate how much of the root has been naturally resorbed.
▪️ Advanced resorption: less force is needed.
▪️ Minimal resorption: the tooth may be more resistant and require careful luxation.
Understanding the resorption pattern helps prevent unnecessary force.

7. Do Not Chase Small Resorbed Root Fragments
If a small root fragment is already resorbed and there is no infection, aggressive attempts to remove it may cause more harm than benefit.
The decision should be based on symptoms, infection, mobility, and radiographic findings.

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✅ Common Technical Errors
Avoid these frequent mistakes:
▪️ Strong rotational force in primary molars
▪️ Deep elevator insertion
▪️ Using adjacent teeth as support
▪️ Sudden or jerky movements
▪️ Applying excessive force when the tooth does not move
▪️ Ignoring the radiographic position of the permanent successor

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💬 Clinical Discussion
Modern pediatric dentistry emphasizes atraumatic extraction techniques. The objective is to remove the tooth while preserving the permanent successor, maintaining alveolar bone integrity, and reducing postoperative discomfort.
Among all technical recommendations, the most important is:

🛡️ Protect the permanent tooth germ
This principle guides the choice of movements, the use of elevators, and the amount of force applied during every primary tooth extraction.

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🎯 Recommendations
▪️ Take a preoperative radiograph whenever root anatomy or the permanent successor position is uncertain.
▪️ Use pediatric forceps that adapt properly to the cervical area of the tooth.
▪️ Apply slow, controlled forces and reassess if resistance is excessive.
▪️ Maintain good visibility and soft-tissue protection throughout the procedure.
▪️ Inspect the extracted tooth to confirm that the expected root structure has been removed.

✍️ Conclusion
Primary tooth extraction techniques should be gentle, controlled, and anatomy-based. The clinician must avoid excessive rotational movements in primary molars, minimize apical pressure, and use elevators conservatively. By respecting physiologic root resorption and prioritizing protection of the permanent tooth germ, extractions can be performed safely, predictably, and with minimal trauma for the child.

📚 References

✔ American Academy of Pediatric Dentistry (2024). Behavior guidance for the pediatric dental patient. The Reference Manual of Pediatric Dentistry. AAPD policies and recommendations.
✔ American Academy of Pediatric Dentistry (2024)Management of dental patients requiring extraction of primary teeth. The Reference Manual of Pediatric Dentistry. AAPD policies and recommendations.
✔ Koch, G. & Poulsen, S.(2023). Pediatric Dentistry: A Clinical Approach (4th ed.). Wiley-Blackwell.
✔ Welburry, R., Duggal, M.S (2021). Paediatric Dentistry (5th ed.). Oxford University Press.

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What Is a Nance Appliance?

A Nance appliance is a fixed orthodontic device used to keep the upper molars from moving forward during or after orthodontic treatment. It is commonly used when space needs to be preserved after tooth extractions or while other teeth are being moved.

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The appliance is attached to the upper first molars with metal bands connected by a wire. In the center, an acrylic button rests gently against the roof of the mouth (the palate), providing additional support and helping maintain tooth position.

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Unlike removable retainers, a Nance appliance stays in place, making it effective because it does not depend on patient cooperation.

✅ Why Is a Nance Appliance Used?
Orthodontists recommend a Nance appliance to provide anchorage, meaning it helps prevent certain teeth from moving while others are being repositioned.

Common indications include:
▪️ Maintaining space after premolar extractions
▪️ Preventing upper molars from drifting forward
▪️ Supporting canine retraction
▪️ Helping correct crowded teeth
▪️ Maintaining arch length during treatment
▪️ Preserving treatment results in selected cases
Because the upper molars naturally tend to move forward during orthodontic treatment, controlling this movement improves treatment efficiency and predictability.

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✅ How Does a Nance Appliance Work?
The appliance works by combining:

▪️ Metal bands cemented to the upper molars
▪️ A stainless steel wire connecting both molars
▪️ An acrylic button that rests against the palate
The acrylic button distributes pressure over the palate, increasing resistance to unwanted molar movement while orthodontic forces are applied elsewhere.

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✅ Advantages of a Nance Appliance
Some important benefits include:

▪️ Provides reliable anchorage
▪️ Does not rely on patient compliance
▪️ Helps preserve extraction spaces
▪️ Improves control of tooth movement
▪️ Can shorten treatment by reducing unwanted tooth movement
▪️ Simple and durable design

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✅ Possible Disadvantages
Although generally safe, some patients may experience:

▪️ Temporary speech changes
▪️ Mild tongue irritation
▪️ Food accumulation around the acrylic button
▪️ Difficulty cleaning the palate
▪️ Plaque buildup if oral hygiene is poor
Long-term use without proper monitoring may occasionally cause irritation or mild inflammation of the palatal tissue, so regular orthodontic follow-up is important.

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✅ How to Care for a Nance Appliance
Good oral hygiene helps prevent cavities and gum problems.

Recommendations include:
▪️ Brush carefully around the bands and acrylic button
▪️ Use an interdental brush when recommended
▪️ Rinse after meals
▪️ Limit sticky and hard foods
▪️ Attend all orthodontic appointments
▪️ Report any loose bands or discomfort promptly
Proper cleaning significantly reduces plaque accumulation around the appliance.

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✅ Who Needs a Nance Appliance?
A Nance appliance may be recommended for:

▪️ Children and adolescents receiving comprehensive orthodontic treatment
▪️ Patients requiring maximum anchorage
▪️ Individuals with premolar extractions
▪️ Patients needing space maintenance during tooth movement
Not every orthodontic patient requires this appliance. The decision depends on the treatment plan and individual dental needs.

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💬 Discussion
The Nance appliance has remained an important anchorage device despite advances such as temporary anchorage devices (TADs). While skeletal anchorage can provide greater control in some complex cases, the Nance appliance continues to be a simple, cost-effective, and predictable option for many patients.
Current orthodontic practice emphasizes selecting anchorage methods based on the patient's age, treatment goals, oral hygiene, and the amount of tooth movement required. For routine anchorage reinforcement, the Nance appliance remains a well-established clinical choice.

🎯 Recommendations
▪️ Maintain excellent oral hygiene throughout treatment.
▪️ Avoid sticky candies, chewing gum, and hard foods that may loosen the appliance.
▪️ Attend regular orthodontic checkups to monitor appliance stability and oral health.
▪️ Follow your orthodontist's instructions regarding cleaning and maintenance.
▪️ Contact your orthodontist if the appliance becomes loose or causes persistent discomfort.

✍️ Conclusion
The Nance appliance is a reliable fixed orthodontic appliance designed to maintain upper molar position and preserve anchorage during treatment. Its fixed design minimizes dependence on patient cooperation while improving control of tooth movement. With proper oral hygiene and regular orthodontic monitoring, it remains a safe, effective, and widely used option for many orthodontic patients.

📚 References

✔ Alharbi, F., Almuzian, M., & Bearn, D. R. (2019). Anchorage effectiveness of orthodontic appliances for anterior tooth retraction: A systematic review. The Angle Orthodontist, 89(3), 443–457.
✔ Proffit, W. R., Fields, H. W., Larson, B. E., & Sarver, D. M. (2023). Contemporary Orthodontics (7th ed.). Elsevier.
✔ Graber, L. W., Vanarsdall, R. L., Vig, K. W. L., & Huang, G. J. (2023). Orthodontics: Current Principles and Techniques (7th ed.). Elsevier.
✔ Papadopoulos, M. A. (Ed.). (2021). Orthodontic Treatment of Malocclusion: Concepts, Techniques and Clinical Evidence. Springer.

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Dental Erosion vs Abrasion: Key Differences Explained

Dental erosion and dental abrasion are two of the most common causes of tooth wear, yet they are often confused because they can produce similar symptoms, such as tooth sensitivity and enamel loss.

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Although both conditions damage the tooth surface, their causes are completely different. Dental erosion results from repeated exposure to acids, while dental abrasion is caused by mechanical friction, such as aggressive tooth brushing or the use of abrasive products.

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✅ What Is the Difference Between Dental Erosion and Abrasion?
Dental erosion and dental abrasion are two common forms of tooth wear, but they have different causes.

▪️ Dental erosion happens when acids dissolve the tooth's enamel, even without bacteria.
▪️ Dental abrasion occurs when mechanical forces gradually wear away the tooth surface, usually from repeated friction.
Understanding the difference helps you choose the right preventive measures and seek treatment before permanent tooth damage occurs.

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✅ What Is Dental Erosion?
Dental erosion is the gradual loss of enamel caused by acid exposure, not by tooth decay.
The acids may come from foods and drinks or from inside the body, such as stomach acid reaching the mouth during acid reflux.
Common Causes
▪️ Frequent consumption of soft drinks
▪️ Citrus fruits and fruit juices
▪️ Sports and energy drinks
▪️ Acid reflux (GERD)
▪️ Frequent vomiting associated with eating disorders
▪️ Certain acidic medications

Common Signs
▪️ Smooth, shiny enamel
▪️ Increased tooth sensitivity
▪️ Yellow appearance as dentin becomes exposed
▪️ Rounded tooth edges
Small depressions or "cupping" on chewing surfaces

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✅ What Is Dental Abrasion?
Dental abrasion is the loss of tooth structure caused by external mechanical friction rather than acid.
It usually develops slowly over time.

Common Causes
▪️ Brushing too hard
▪️ Using a hard-bristled toothbrush
▪️ Abrasive whitening toothpastes
▪️ Holding objects between the teeth
▪️ Improper use of toothpicks or dental tools

Common Signs
▪️ Notches near the gumline
▪️ V-shaped defects on exposed tooth surfaces
▪️ Tooth sensitivity
▪️ Localized wear affecting specific teeth
▪️ Rougher tooth surfaces compared with erosion

✅ Quick Comparison

Feature	Dental Erosion	Dental Abrasion
Main cause	Acid dissolution	Mechanical friction
Bacteria involved	No	No
Common location	Multiple tooth surfaces	Usually near the gumline
Surface appearance	Smooth and shiny	Rough or V-shaped defects
Common trigger	Acidic foods, drinks, GERD	Aggressive brushing, abrasive toothpaste
Tooth sensitivity	Common	Common
Prevention	Reduce acid exposure	Improve brushing technique

✅ Can Both Conditions Occur Together?
Yes. Many people experience both dental erosion and abrasion at the same time.
For example, enamel softened by acidic beverages becomes more vulnerable to damage if the teeth are brushed immediately afterward. This combination can speed up tooth wear.

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✅ How Are They Diagnosed?
Dentists identify tooth wear through:

▪️ Clinical examination
▪️ Medical and dietary history
▪️ Evaluation of oral hygiene habits
▪️ Photographs to monitor progression
▪️ Intraoral scans when available
▪️ Radiographs if additional problems are suspected
Early diagnosis allows treatment before extensive enamel loss occurs.

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✅ Treatment Options
Treatment depends on the severity of tooth wear.

Common approaches include:
▪️ Fluoride products to strengthen enamel
▪️ Desensitizing toothpaste for sensitive teeth
▪️ Dietary counseling to reduce acid exposure
▪️ Correct brushing technique
▪️ Soft-bristled toothbrushes
▪️ Composite resin restorations when tooth structure has been lost
▪️ Management of acid reflux when indicated

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✅ How to Prevent Dental Erosion and Abrasion
Simple daily habits can greatly reduce tooth wear:

▪️ Brush gently using a soft-bristled toothbrush.
▪️ Wait at least 30 minutes after consuming acidic foods or drinks before brushing.
▪️ Limit sugary and acidic beverages.
▪️ Drink water after acidic meals.
▪️ Use fluoride toothpaste.
▪️ Visit your dentist regularly for early detection.

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💬 Discussion
Although dental erosion and dental abrasion both result in tooth wear, they require different preventive strategies. Erosion is primarily linked to acid exposure, while abrasion results from repeated mechanical friction. Modern dentistry emphasizes identifying the underlying cause rather than only treating the damaged tooth, helping preserve natural tooth structure and prevent further wear.

✍️ Conclusion
Dental erosion and dental abrasion are different conditions with distinct causes but similar consequences if left untreated. Learning to recognize their signs, improving daily oral care habits, and seeking early professional advice can help preserve enamel, reduce tooth sensitivity, and maintain long-term oral health.

🎯 Recommendations
▪️ Limit frequent exposure to acidic foods and beverages.
▪️ Use a soft-bristled toothbrush and gentle brushing technique.
▪️ Avoid brushing immediately after consuming acidic drinks.
▪️ Choose fluoride toothpaste recommended by your dentist.
▪️ Seek evaluation if you notice sensitivity or unusual tooth wear.
▪️ Maintain regular dental check-ups for early diagnosis.

📚 References

✔ Eccles, J. D. (1979). Dental erosion of nonindustrial origin. A clinical survey and classification. Journal of Prosthetic Dentistry, 42(6), 649–653. https://doi.org/10.1016/0022-3913(79)90196-3
✔ Lussi, A., Carvalho, T. S., & Ganss, C. (2019). The Tooth Wear Index. In A. Lussi & T. S. Carvalho (Eds.), Erosive Tooth Wear: From Diagnosis to Therapy (2nd ed.). Karger.
✔ Lussi, A., Hellwig, E., Ganss, C., & Jaeggi, T. (2009). Dental erosion. Operative Dentistry, 34(3), 251–262. https://doi.org/10.2341/08-BL
✔ Shellis, R. P., Featherstone, J. D. B., & Lussi, A. (2014). Understanding the chemistry of dental erosion. In A. Lussi & T. S. Carvalho (Eds.), Monographs in Oral Science (Vol. 25, pp. 163–179). Karger.
✔ Schlueter, N., & Luka, B. (2018). Erosive tooth wear – A review on global prevalence and on its prevalence in risk groups. British Dental Journal, 224(5), 364–370. https://doi.org/10.1038/sj.bdj.2018.167

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