GCase 60toothwear

SUMMARYA 35-year-old policeman presents having noticed that his anterior teeth are becoming shorter. Identify the cause and outline options for management.

Examination

Extraoral examinationThe patient is a fit-looking man and slightly overweight. No submandibular or cervical lymph nodes are palpable. The temporomandibular joints appear normal and there is no evidence of hypertrophy of the masseter muscles.

Intraoral examination

The appearance of the anterior teeth is shown inFigure 60.1. What do you see?

Thepalatalsurfacesandincisaledgesoftheupperincisorteethareworn.Thewearinvolvestheenamelanddentinebutnotthepulp.Thepalatalsurfacesoftheteethappearsmoothandunstained.Theincisaledgesarerough,smallchipsofunsupportedlabialenamelhavingfracturedaway.

If you were able to examine the patient, you would find that some of the upper and lower anterior teeth do not contact each other in the retruded contact and the intercuspal posi-tions. All other teeth appear normal and the palatal surfaces of the upper posterior teeth are unaffected.

What does this appearance signify?

Thisistoothwear,thelossofdentaltissuesthroughtheprocessesoferosion,attritionandabrasion.Althougheachprocessmayactalone,significanttoothwearisusuallytheresultofacombinationoftheseprocessesanderosionisoftendominant.

Thesmoothsurfacessuggestthaterosionisafactorinthiscaseandthedistributionofenamellosssuggeststhatregurgitationofgastricacidmaybethecause.Dietaryacidsareusuallyassociatedwitherosiononthebuccalorlabialsurfacesoftheupperanteriorteethbutifthepatientrinsesorswillsacidicdrinksinthepalatalvaultpriortoswallowing,thepatternoferosionisverysimilartothatseenwhengastricacidisregurgitated.Eithersourceofacidmightbethecause.

Define erosion, abrasion and attrition.

Erosionisthechemicaldissolutionofteethbyacids.

Attritionisthewearoftoothagainsttooth.Milddegreesofattritionarenormal.

Abrasionisthewearofteethbyphysicalmeansotherthantheteeth.

Differential diagnosis

What is your differential diagnosis for this patient?

1. Dentalerosioncausedbygastricacidcombinedwithattrition

2. Dentalerosioncausedbydietaryacidscombinedwithattrition

3. Attritionalone4. Industrialerosion.

History

ComplaintThe patient has become increasingly aware of his shorten-ing front teeth. He is not greatly concerned about the appearance but feels that continued wear will eventually destroy the teeth completely.

History of complaintHe has noticed that his teeth have become worse over the last 35 years but cannot remember when he first noticed the signs. The patient has always attended a dentist regu-larly and has relatively few, small restorations and good oral hygiene.

Medical historyThe patient is generally fit and well. He drinks about 1020 units of alcohol each week.

Fig. 60.1 Palatalviewoftheupperanteriorteeth.

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Investigations

What investigations would you perform?

Athoroughdietaryrecordshouldbetakenbythepatienttodeterminethetrueconsumptionofacidicfoodsanddrinks.Dietanalysissheetsneedtobefilledinfor4ormoredays,includingaweekend,anditisemphasizedthatthepatientshouldwritedownallthefoodsanddrinkstakenoverthattime,includingbetween-mealsnacks.Bothfrequencyandamountneedtobenotedandthepatientshouldbespecificallytoldtonotesuspectfoodssuchascarbonateddrinks,citrusfruitsanddrinks,vinegarandwhitewine,toensurethatnoneismissed.

Studycastsofthepatientsteethshouldbetaken.Thesewillprovideabaselinerecordagainstwhichprogressionoferosioncanbedetected.Testsoftoothvitalityandintraoralradiographsmightbetakenifitissuspectedthatthewearhascompromisedthevitalityofthepulpinanyteeth.

Diet analysis confirms the patients statement that he has a low consumption of acidic food and drink. This excludes dietary acid as a cause, leaving gastric acid as the only other source. Regurgitation erosion occurs when the stomach juice passes from the stomach into the mouth. The pH of stomach juice is around 1 or 2, and if regurgitation occurs frequently the damage to teeth can be catastrophic.

Further differential diagnosis

How might gastric acid enter the mouth?

1. Gastro-oesophagealrefluxdisease2. Eatingdisorders3. Chronicalcoholism4. Rumination.

What features of these conditions might aid definitive diagnosis?

Gastro-oesophageal reflux diseaseisusuallyassociatedwithheartburn(intermittentretrosternalpainradiatingalongtheoesophagus,worsenedbylyingdownorarecentlargemeal),orepigastricpain(centredoverthexiphisternum).Whensymptomsarerelatedtomeals,thetermdyspepsiaissometimesused.Inmostpatientssymptomsofgastro-oesophagealrefluxareself-limitingandlittleornoacidentersthemouth.Inotherscompleteregurgitationintothemouthisfrequent,painbecomespersistentandpatientsseekmedicaladvice.Asmallproportionofpatientstreattheirpainwithover-the-counterantacidsandareunawareofthepotentialfordamagetotheirteethoroesophagus.Ahistoryoftakingantacidpreparationsisausefulindicatorfortheactivityofgastro-oesophagealrefluxdisease,andthispatienthasalreadyindicatedthathehasnoticedsomeregurgitation.Thisisthemostlikelycause.

Eating disordersareacauseoferosioninyoungerpatients.Bothanorexianervosaandbulimianervosatendtoaffectyoung,adolescent,intelligentfemaleswithahistoryofoverprotectiveparents.Anorexiaisself-destructive.Suffererslosebodyweightbystarvingthemselvesand/orvomitingto

Which of these causes would you exclude? Explain why.

Attritionasasinglefactorismostunlikelytobethecause,becausesurfacesoftheteethdonotcontactintheintercuspalorretrudedcontactposition.Itwouldalsobemostunlikelythatocclusalwearcouldaffectthewholeofthepalatalsurfacesofallincisorsequally.Attritionisoftenassociatedwithmarkedbruxismbutthereisnoevidenceofmasseterichypertrophyonexamination.

Industrial erosionisnowveryuncommon.Acidpresentintheairoftheworkingenvironmentcausesdentalerosionbutimprovementsinhealthandsafetyatworkhavealmosteradicatedthiscondition.Carbatteryacidworkersusedtosuffererosion,particularlyaffectingthebuccalsurfacesoftheteeth.Thepatientsprofessionaspolicemanmeansheisunlikelytobeexposedtoanacidicenvironmentthoughsomepatientsmaybeexposedtovolatileacidsthroughhobbyactivities.

What specific questions would you ask? Explain why.

Toothwearisoftenmultifactorialandthepatientmustbequestionedaboutallcauses.

Do you suffer acid regurgitation from the stomach?Regurgitationofstomachacidcanbenoticedbythepatientbecauseofthetaste.However,itmaybeunnoticedifithappensatnight,andmayormaynotbeassociatedwithsymptomsofgastricdisease.Occasionalmildrefluxintotheoesophagusorpharynxisrelativelycommon.

What is your alcohol intake and what is the pattern of consumption?Thepatienthasindicatedanintakeof1020unitsofalcoholeachweek.Patientsoftenunder-representtheirintakeanditwouldbeworthcheckingthiswiththepatient.Manyalcoholicdrinksareacid,contributingtodietaryacid(below),andbingepatternsofdrinkingareoftenassociatedwithvomiting.Thepossibilityofahistoryofchronicalcoholismshouldbeconsidered.

Do you have a high consumption of acidic foods or drinks?Thisisacommoncauseofdentalerosion.Theintakeofbothacidfoodsanddrinksmustbeascertained,togetherwiththewayinwhichtheyareconsumed.

Do you grind or clench your teeth during the day or at night?Bruxismorotherparafunctionalhabitsarecommoncausesofincreasedwear.

Have you ever suffered from an eating disorder such as anorexia or bulimia nervosa?Thesecausesofgastricregurgitationneedtobeexcluded.Sucheatingdisordersareuncommoninmalesbuttheirincidenceisincreasing.

In response to your questioning, the patient denies frequent acid intake, vomiting or bruxism. However, he indicates that he does suffer some acid regurgitation associated with his dyspepsia (heartburn) and that alcohol is sometimes associated with the attacks. He has had heartburn and regurgitation for 20 years but is not taking any regular medication to relieve the symptoms. He had not considered this significant enough to mention on his medical history questionnaire.

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symptoms.Refluxmaybecausedbyareductioninpressurearoundtheloweroesophagealsphincter(asforinstanceinhiatushernia)orabnormaloesophagealmotility.Referralisnecessarytodetectsuchassociatedconditionsand,ifsymptomsmerit,toconsidertreatmentwithdrugswhichblockacidsecretion.

Aconservativeapproachshouldbetakentotreatmentoftheerosion.Noimmediatetreatmentisrequirediftheerosionisrelativelyminor,asthepatientishappywiththeappearanceoftheteeth.Ifthecauseisidentifiedandtreated,erosionwillceaseorprogressmoreslowly.Studymodelstakenatyearlyintervalsmaybecomparedtothosetakenattheinitialvisittoassessprogression,andifthetoothwearprogresses,restorationsmaybeconsidered.

Intheearlystagesoferosionprovisionalplasticrestorationswillprotectthepalatalsurfacesfromfurtherdamage.Howevertheshortlifespanofsuchrestorationscommitsthepatienttofurthertreatment.Alternativelypalatalveneersofporcelain,compositeormetalprovidealongertermrestorationifthereissufficientspaceocclusallyfortherestorations.

What precautions must be taken to prevent iatrogenic damage when restoring worn teeth?

Accuratediagnosisisessential.Ifattritionratherthanerosionisdiagnosed,occlusalsplintsmightbeprescribed.ThesewouldworsenerosioncausedbygastricregurgitationbecauseacidwouldbetrappedbeneaththesplintawayfromthepH-neutralizingeffectofsaliva.Thereisalsothepotentialforunglazedorunpolishedporcelaintoweartheenameloftheopposingteeth.Thismightbecomesignificantifthereisanelementofattritioncausingthewearoriftherestorationwereallowedtooccludeagainstdentine.

loseweightinanattempttoimprovetheirbodyself-image.Asmallproportionofpatientswithsevereanorexiadiefromthedisorder.Unlikeanorectics,bulimicpatientsusuallyhaveastablebodyweight.Theyeatanddrinkinbingesandvomittocontroltheirbodyweight.Theremaybeanaccompanyinghistoryofdrugandalcoholabuse.

Alcoholism.Asnotedabove,alcoholismisassociatedwithdentalerosion,eitherthroughvomitingorthelowpHofsomealcoholicdrinks.

Ruminationisanunusualpractice,beingthehabitualchewingoffood,swallowingandthenregurgitatingitmixedwithstomachacidtobechewedandswallowedagain.Itisconsideredrarebutthereisnoaccurateinformationonitsprevalenceanditisthoughttoaffectyoung,healthyandmainlyprofessionalpeople.Ifthehabitiscontinueditcancausesignificantdamagetoteeth.

The patient gives a clear history of regular heartburn and symptomatic regurgitation. He denies rumination and alco-holism and there is no suggestion of an eating disorder, an unlikely possibility in this age group.

Diagnosis

What is your diagnosis?

Thediagnosisistoothwearcausedprimarilybyerosion.Thecauseoftheerosionisgastricacidrefluxsecondarytogastro-oesophagealrefluxdisease.

TreatmentHow will you manage the patient?

Thepatientshouldbereferredtoagastroenterologistorhisgeneralmedicalpractitionerforfurtherinvestigationofhis

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Case 20: A lump in the neckSUMMARYHistoryExaminationDifferential diagnosisInvestigationsDiagnosisTreatmentAnother possibility

Case 21: Trauma to an immature incisorSUMMARYHistoryExaminationDifferential diagnosisInvestigationsDiagnosisTreatment

Case 22: HypoglycaemiaSUMMARYHistoryExaminationTreatmentOther possibilitiesFurther points

Case 23: A tooth lost at teatimeSUMMARYHistoryExaminationDiagnosisInvestigationsTreatment

Case 24: A problem overdentureSUMMARYHistoryExaminationDiagnosis

Case 25: Impacted lower third molarsSUMMARYHistoryExaminationInvestigationsAnother case

Case 26: A phone call from schoolSUMMARYHistoryExaminationTreatmentFollow upOther possibilities

Case 27: Discoloured anterior teethSUMMARYHistoryExaminationInvestigationDifferential diagnosisTreatmentPrognosisPrevention

Case 28: A very painful mouthSUMMARYHistoryExaminationDiagnosisInvestigationsTreatmentPrognosisFinal outcome

Case 29: Caution X-raysSUMMARYHistory

Case 30: Whose fault this time?SUMMARYFirst patientDiagnosisSolutions What can you do to save the patient a further appointment and yourself the additional cost of extra trays? What you can do about the upper tray? There are a number of options but all have problems (Table 30.1). The only alternative would be The next patientSUMMARYHistoryExaminationSolutionTreatmentAcknowledgement

Case 31: Ouch!SUMMARYHistory

Case 32: A swollen face and pericoronitisSUMMARYHistoryExaminationDiagnosisTreatment

Case 33: First permanent molarsSUMMARYHistoryExaminationInvestigationsDiagnosisFurther investigationTreatment planningFurther information

Case 34: A sore mouthSUMMARYHistoryExaminationInvestigationsDiagnosis

Case 35: A failed bridgeSUMMARYHistoryExaminationInvestigationsTreatment

Case 36: Skateboarding accident?SUMMARYHistoryExaminationInvestigationsDiagnosisTreatment

Case 37: An adverse reactionSUMMARYHistoryDifferential diagnosisAnother possibility

Case 38: Advanced periodontitisSUMMARYHistoryExaminationInvestigationsDiagnosisTreatment

Case 39: Fractured incisorsSUMMARYHistoryExaminationInvestigations

Case 40: An anxious patientSUMMARYHistoryInvestigation and diagnosisAnxiety managementTreatmentPrognosis

Case 41: A blister on the cheekSUMMARYHistoryExaminationDifferential diagnosisInvestigationsDiagnosisTreatment

Case 42: Will you see my son?SUMMARYHistoryExamination

Case 43: Bridge designSUMMARYHistoryExaminationDiagnosis

Case 44: Management of anticoagulationSUMMARYHistoryExaminationInvestigationsDiagnosisTreatmentPostoperative

Case 45: A white patch on the tongueSUMMARYHistoryExaminationDifferential diagnosisInvestigationsDiagnosisTreatmentPrognosis

Case 46: Another white patch on the tongueSUMMARYHistoryExaminationDifferential diagnosisInvestigationsDiagnosisTreatment

Case 47: Molar endodontic treatmentSUMMARYHistoryExaminationInvestigationsDiagnosisTreatment

Case 48: An endodontic problemSUMMARYHistoryExaminationInvestigationsTreatmentAcknowledgement

Case 49: A swollen faceSUMMARYHistoryExaminationInvestigationsDiagnosisTreatment

Case 50: Missing upper lateral incisorsSUMMARYHistoryExaminationInvestigationsTreatment

Case 51: Anterior crossbiteSUMMARYHistoryExaminationDiagnosisInvestigationsTreatment

Case 52: Refractory periodontitis?SUMMARYHistoryExaminationInvestigationsDifferential diagnosisFurther investigationsTreatment

Case 53: Unexpected findingsSUMMARYHistoryExaminationInvestigationsDifferential diagnosisTreatmentFurther investigations

Case 54: A gap between the front teethSUMMARYHistoryExaminationInvestigationsDiagnosisTreatment

Case 55: A lump in the palateSUMMARYHistoryExaminationDifferential diagnosisInvestigationsDiagnosisTreatmentPrognosis

Case 56: Rapid breakdown of first permanent molarsSUMMARYHistoryExaminationDifferential diagnosisInvestigationsDiagnosisTreatment

Case 57: Oral cancerSUMMARYHistoryExaminationDiagnosisPrinciples of treatmentFurther investigationsTreatment planningTreatment

Case 58: A complicated extractionSUMMARYHistoryExaminationDiagnosisTreatment

Case 59: Difficulty in opening the mouthSUMMARYHistoryExaminationDiagnosisInvestigationsTreatment

Case 60: ToothwearSUMMARYHistoryExaminationDifferential diagnosisInvestigationsFurther differential diagnosisDiagnosisTreatment

Case 61: Worn front teethSUMMARYHistoryExaminationInvestigationsDiagnosisTreatment planningTreatment

Case 62: A case of toothacheSUMMARYHistoryExaminationInvestigationsDiagnosis

Case 63: A child with a swollen faceSUMMARYHistoryExaminationInvestigationsDifferential diagnosisDiagnosisAetiologyTreatment

Case 64: A pain in the neckSUMMARYHistoryExaminationDiagnosisInvestigationsTreatmentAnother possibility

Case 65: Failed endodontic treatmentSUMMARYHistoryExaminationInvestigationsDiagnosisTreatment

Case 66: A pain in the headSUMMARYHistoryDifferential diagnosis

Index