You Got ME!

This 58-year-old male recently came into my practice for a restorative evaluation. He has a history of nocturnal bruxism and also has evidence of some erosive process that is affecting the facial surfaces of his teeth. If you note where the lesions are present, mostly on the facial surfaces and more cervical, that would indicate an extrinsic acid source. There is no palatal erosive pattern that would indicate either GERD or an eating disorder. He denies fruit mulling, fruit sucking, soda swishing, or any other common cause of erosion. I am out of ideas for the causes of his erosion; in addition I'd love to know what you all think about the very prominent texture of his maxillary anteriors. Is it related to his erosion? I need your help here, I really don't know what is happening, and all ideas are welcome!

Front top teeth, lips retracted.

Side view of upper and lower teeth, lips retracted.

Underneath of upper teeth and roof of mouth.

Comments

Barry Polansky
February 3rd, 2012

Steve-- I copied some info on erosion from a website (address included). You seem to have covered all the causes of erosion but I was curious about "fruit mulling" so I looked it up. How about a dentrifice creating these patterns that look like NCLs and what we are seeing is the pattern caused by the abfractions, and bruxism? I still would like to see him eat an orange. http://www.doctorspiller.com/Tooth_wear/erosion-3.htm Erosion Erosion of tooth structure means the dissolving of hard tooth structures, both enamel and dentin, due to frequent exposure of the teeth to acidic solutions. There are three major forms of erosive processes in the mouth. These are Regurgitation of stomach contents into the mouth, Soda Swishing, and Fruit Mulling. There are other unusual habits that can cause tooth erosion, but they are very patient specific and, taken as separate entities, are fairly rare. Barry Polansky TAOofDentistry.com

Steve
February 3rd, 2012

Happy Birthday Barry! Thanks for the reference. You know, I should have him brush his teeth in front of me to see what that looks like. I am still really stumped by the texture of his upper anteriors though

Barry Polansky
February 3rd, 2012

Thanks Steve--I was thinking of that too. Thanks for the birthday wishes-- now a real present will be a Giant win on Sunday. Brad is on his way to Inday--and I'm jealous.

Brandon Helgeson
February 3rd, 2012

I would agree that abrfraction coupled with tooth brush abrasion would be a likely cause due to the appearance of the NCL's on numbers 5 and 6. Centric Bruxing is quite evident, yet I would have a hard time believing that an acidic food product wasn't also a contributing factor for loss of enamel.

Kam
February 3rd, 2012

I would ask if he swims a lot. Swimming in an improperly chlorinated pool with a lower pH than normal can cause tooth wear. Just another question to ask him.

Jeff Lineberry
February 3rd, 2012

Steve Thanks for sharing a very interesting case. I find erosion patterns and some wear patterns can be a real puzzle to figure out especially when you have to rely on patient recall. You all have covered the obvious and I would also have been thinking when it occurred. Often times it can occur early on in life and gets forgotten by the patient. Can you tell me a history of what he does for a living as well as job history? Thanks for sharing. Jeff

David Ehrenfeld
February 4th, 2012

Steve, how about swimming in heavily chlorinated water. As a swimmer a ran across several articles describing this situation. One was a women visited Cuba and it happened over a short period of time The other was in virgina. I think I just put. In tooth erosion, chlorinated water. Hope all is well with you, I am still plugging along. Dave

Steve
February 12th, 2012

Hi Jeff and David He isn't a swimmer and he is a financial planner. Not much help hunh?

Jeff Lineberry
February 13th, 2012

Steve Thanks for the response. What did he do growing up? Another thought is whether he is a wine drinker. I have seen wine drinkers that like to "swish and swallow" a lot have some cervical erosion. Just another thought....thanks. Jeff

Larry Gottesman
February 14th, 2012

Steve: You don't provide enough information to make even a good guess. Medical history, dental history, dietary habits, parafunctional habits, medication history, full arch photos in a case like this. Have you evaluated his cuticles and nails for biting habits, or the inside of his cheeks? Have you sent him for an evaluation to a GI specialist? Did you perform a pH test on his saliva? Have you requested a sleep study for validation of his nocturnal bruxism habit? I think the cornerstone of treatment depends on a good diagnosis. You don't have one yet! You need to get more information for the Medical profession and a patient interview which is more detailed. Thanks, Larry Gottesman, DDS

Larry Gottesman
February 14th, 2012

Steve: You may also want to put Celiac Disease on your "rule out" list with investigation by a GI specialist. Celiac Disease is reported to contribute significantly to enamel defects. While you don't report the possibility of tetracycline staining, the loss of enamel gloss and grooving of the teeth on the facial may warrant further investigation. Best, Larry Gottesman

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