Case scenario #3 Jessica presents to her dentist, Dr. Merriam, with the chief complaint of a throbbing toothache on the lower left side of her mouth. Jessica is 33 years old and has been a patient in Dr. Merriam’s practice for the past eight years, although her visits have been infrequent. She explains to Dr. Merriam that she began having sensitivity on the left side of her mouth several months ago and that in the past week that part of her mouth has begun to throb periodically and keep her awake at night. She cannot tolerate any contact with cold and hot liquids in that area. Reviewing past x-rays, Dr. Merriam notes that tooth #19 was planned to receive an occlusal composite restoration four years ago, and a periapical radiograph now confirms that decay has extended to the pulp, causing irreversible pulpitis. Additionally, Dr. Merriam notes generalized moderate to severe inflammation of Jessica’s gingival tissues and bright red lesions on her palate. Compared to photographs in her electronic record from eight years ago, her teeth appear more yellow, with generally thin enamel. The lingual surfaces of her upper teeth, from tooth #4 to tooth #12, exhibit the most pronounced enamel loss, with the incisors having a shovel-shaped lingual surface. Dr. Merriam recognizes that Jessica is experiencing dental erosion beyond what is normal for her age and suspects that she may be struggling with bulimia. She decides to first explain to Jessica the need for root canal therapy on tooth #19. Next, Dr. Merriam informs Jessica that she is noticing significant tissue inflammation and enamel erosion that is happening at an alarming rate, and she is concerned about the processes causing it. Jessica states that she is aware that her teeth are changing and admits to an ongoing struggle with bulimia over several years. She has been working with her doctor and is trying to stop and recover from the disorder. Points to Consider Conclusion Dental erosion is an important cause of tooth tissue loss in both children and adults and must be distinguished from the destruction caused by other processes, such as attrition, abrasion, and abfraction. To initiate adequate preventive and therapeutic measures for their patients, dental professionals must understand the etiology of all tooth wear and the pathogenic processes involved in each. Early recognition and diagnosis of tooth wear, and dental erosion in particular, are essential to the successful management and prevention of disease progression. This requires that dental professionals follow the proper assessment protocol and that they be able to identify possible chemical, biological, and behavioral risk Alruthea, M. S. (2020, January 21). Intrinsic dental erosion: Review of dental management. Journal of International Dental and Medical Research, 13 (2). https://www.researchgate.net/publication/343787341_ Intrinsic_Dental_Erosion_Review_of_Dental_Management Alshahrani, M. T., Haralur, S. B., & Mohammed, A. (2017, July 30). Restorative rehabilitation of a patient with dental erosion. Case Reports in Dentistry . https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5554 566/ American Dental Association. (2021, August 31). Dental erosion. Department of Scientific Information, Evidence Synthesis and Translation Research, ADA Science and Research Institute, LLC. https://www.ada.org/ resources/research/science-and-research-institute/oral-health-topics/dental-erosion Badavannavar, A. N., Sneha, A., & Krishna, N., & Shahnawaz, K. (2020). Abfraction: Etiopathogenesis, clinical aspect, and diagnostic-treatment modalities. A review. Indian Journal of Dental Research, 31 (2), 305-311. https//www.ijdr.in>article References Burgess, J. (2018, May 2). Salivary stimulation: Could it play a role in GERD management? Journal of Otolaryngology: ENT Research. https://medcraveonline.com/JOENTR/JOENTR-10-00328.php Carvalho, T. S., & Karger, L. A. (2020). Chapter 9: Acidic beverages and foods associated with dental erosion and erosive tooth wear. In F. V. Zohoori & R. M. Duckworth (Eds.), The impact of nutrition and diet on oral health (pp. 91-98). Cesario, S., Scida, S., Chiara, M., et. al. (2018). Diagnosis of GERD in typical and atypical manifestations. Acta Biomed, 89 (Suppl 8), 33-39. https://www.ncbi.nlm.nih.gov>articles>PMC6506502210 Chockattu, SJ, Deepak BS, Sood A, Niranjan NT, Jayasheel A and Goud MK. (2018, February). Management of dental erosion induced by gastro-esophageal reflux disorder with direct composite veneering aided by a flexible splint matrix. Restorative Dentistry and Endodontics, 43 (1). or https://doi.org/10.5395/rde.2018.43. e13 Cleveland Clinic. (2022). Parotitis . https://my.clevelandclinic.org/health/diseases/23577-parotitis-parotid- gland-swelling Daou, E. E. (2015). Esthetic prosthetic restorations: Reliability and effects on antagonist dentition. The Open Dentistry Journal, 9 , 473-481. doi: 10.2174/1874210601509010473 Davis K, Low RY, & Rafeek R. (2019, October 31). A conservative approach to treatment of dental erosion. Open Journal of Stomatology, 9 , 241-248. . Delgado, A. J., & Olafsson, V. G. (2019, July 23). Erosive tooth wear: Etiology, diagnosis, risk factors and management. Decisions in Dentistry . Dental Health Foundation. (2019). Tooth wear . https://www.dentalhealth.ie/dentalhealth/causes/toothwear. html Erpacal B, Bahsi E, & Sonkaya, E. (2018, Autumn). Dental erosion and treatment methods. IBBJ, 4 (4). Gastrointestinal Society. (2019). GERD and dental erosion . https://badgut.org/information-centre/a-z- digestive-topics/gerd-dental-erosion/ Guignon, A. N. (2020, October 14). Muddy flooding and sinkholes: Understanding the difference between caries and erosive tooth wear. RDH . https://www.rdhmag.com/patient-care/article/14185397/muddy-flooding- and-sinkholes-understanding-the-difference-between-caries-and-erosive-tooth-wear Hasselkvist A., Johansson, A., & Johansson, A.-K. (2016). A 4-year prospective study of progression of dental erosion associated to lifestyle in 13- to 14-year-old Swedish adolescents. Journal of Dentistry, 47 , 55-62. Hussainy SN, Nassim I, Thomas T, & Ranjan M. (2018, September–October). Clinical performance of resin- modified glass ionomer cement, flowable composite, and polyacid-modified resin composite in noncarious cervical lesions: One-year follow-up. Journal of Conservative Dentistry, 21 (5), 510-515. https://www.ncbi.nlm. nih.gov/pmc/articles/PMC6161514/ Jarkander Skalsky M. , Grindefjord, M, & Carlstedt K. (2018). Dental erosion: Prevalence and risk factors among a group of adolescents in Stockholm County. European Archives of Paediatric Dentistry, 19 , 23-31. https:// www.ncbi.nlm.nih.gov>articles>PMC5807473 Johansson A, Arndottir I, Koch G. & Poulsen S. (2017, April 26). Dental erosion. Pocket Dentistry. .
1. What specific clinical signs in Jessica’s case are commonly seen in patients with bulimia? The most common sign is erosive wear on the enamel of maxillary teeth, particularly in the anterior as a result of higher contact with gastric contents than the lower and posterior teeth. Palatal hemorrhaging and gingival inflammation are also common signs. 2. What is the best approach for a dentist or hygienist to take when they suspect a patient has bulimia? The best approach is compassion, and the issue needs to be addressed directly. As Dr. Merriam did, the practitioner needs to educate the patient about the clinical consequences of erosion and question the patient about the practice of bulimia. The dental professional can be the gateway to a patient receiving the medical attention they need and can also serve a critical role in prevention, recovery, and restoration of dental damage. 3. Knowing that Jessica is in the process of recovery but may have an ongoing battle with bulimia, what can Dr. Merriam do to help prevent further damage? Education concerning the erosive process is fundamental to prevention. Jessica should be instructed not to brush her teeth soon after an episode of vomiting (because of the danger of brushing the abrasive stomach acid onto the teeth) and should be advised to rinse her mouth with water. Mixing baking soda with water can help counteract the acidic damage and neutralize the pH in her mouth. In addition, Dr. Merriam should recommend fluoride treatments at the office with a prescription fluoride gel or toothpaste to be used at home, possibly with custom trays for prolonged exposure. factors and their interplay. Once a diagnosis of dental erosion has been made, the dental team must consider possible preventive measures such as counseling the patient to avoid food choices that extend the contact time with acid on the teeth and encouraging the patient to choose safer food alternatives. Another preventive measure often suggested is the use of toothpastes or mouthwashes that contain fluoride. Once it is decided that restorative treatment is necessary, it is important for dental professionals to communicate the available options and courses of action to patients and make them active participants in their dental care. Joshi Mahasweta, Joshi Nikhil, Kathariya Rahul, Angadi Prabhakar and Raikar Sonal. Techniques to Evaluate Dental Erosion: A Systematic Review of the Literature. Journal of Clinical and Diagnostic Research. October 2016; 10(10): ZE01-ZE07. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5121877/ Marieb, E. N., & Hoehn, K. (2018). Human anatomy and physiology (11th ed.). Pearson Education. May L,and Seong L. (2020, August 4). Step-by-step occlusal rehabilitation for bulimic patient. Modern Approaches in Dentistry and Oral Health Care . https://lupinepublishers.com/dental-and-oral-health-journal/ fulltext/step-by-step-occlusal-rehabilitation-for-bulimic-patient.ID.000190.php Mitrani, R. (2018, June 27). Extrinsic dental erosion: Ccauses and diagnosis . Spear Education. Mitrani, R. (2019, December 30). Intrinsic dental erosion: Causes and diagnosis. Spear Education. https:// speareducation.com>2019/12>intrinsic-dental-erosion-causes-diagnosis Nijakowski, K., Zdrojewski, J., Nowak, M., Filpi, P., & Surdacka, A. (2022). Regular physical activity and dental erosion: A systematic review. Applied Sciences, 12 , 1099. https://www.mdpi.com>pdf Noble, W. H., & Faller, R. V. (2018, March). Protection from dental erosion: All fluorides are not equal. Compendium of Continuing Education in Dentistry, 29 (3). https://www.aegisdentalnetwork. com>cced>2018/03 Nor H, & Harun N. (2018). Conservative management of dental erosion in adolescents with medical conditions. Case Reports in Dentistry . https://www.hindawi.com>journals>crid Rappeport, S. A., & Coleman, T. A. (2018, November 6). Non-carious cervical lesions and the abfractive process. Decisions in Dentistry . https://decisionsindentistry.com>Articles Sakae, L. O., Bezerra, S. J. C., Joao-Souza, S. H., et al. (2018). An in vitro study on the influence of viscosity and frequency of application of fluoride/tin solutions on the progression of bovine enamel. Arch Oral Biol, 89 , 26-30. Santhiya B., Puranik Manjunath, P., & Uma, S. R. (2019). Risk factors, assessment and management of dental erosion in dental setting: A literature review. International Journal of Applied Dental Sciences, 5 (2), 28-36. https://www.ortaljournal.com>pdf>PartA Schlueter, N., & Luka, B. (2018). Erosive tooth wear: A review on global prevalence and on its prevalence in risk groups. Br Dent, 224 (5), 364-370. Schlossman, M., & Montana, M. (2017). Preventing damage to oral hard and soft tissues. In A. E. Spolarich & F. S. Panagakos (Eds.), Prevention across the lifespan: A review of evidence-based interventions for common oral conditions (pp. 97–120). Professional Audience Communications. Sengupta, A. (2018, November). Dental erosion: Etiology, diagnosis and management. ACTA Scientific Dental Sciences, 2 (11). Shroff P, Gondivkar M, Kumbhare S, Sarode S, Gadbail A, & Patil S. (2018, December). Analyses of the erosive potential of various soft drinks and packaged fruit juices on teeth. The Journal of Contemporary Dental Practice, 19 (12), 1547-1552. http://www.thejcdp.com>jp-journals-10024-2463 Sidhu, H. K., & Nicholson, J. W. (2016, September). A review of glass-ionomer cements for clinical dentistry. Journal of Functional Biomaterials, 7 (3), 16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5040989/ Tarca E., Cojocaru, E., Costina, L. A., et.al. (2022). Unusual case of masseter muscle hypertrophy in adolescence: Case report and literature overview. Diagnostics, 12, 505. https://doi.org/10.3390/ diagnostics12020505 Touyz, L. Z. G., & Nassani, L. M. (2018). Acidity and dental erosion from apple and grape juice (an in vitro and in vivo report). International Journal of Oral and Dental Health, 4, 61. https://nutritionj.biomedcentral. com>articles Warreth A, A, Almaghribi MA, Mahwal G and Ashawish A. (2020). Tooth surface loss: a review of literature. Saudi Dental Journal, 32, 53-60. Wu, Y.-Q., Arsecularartne, J., & Hoffman, M. (2017, December). Attrition-corrosion of human dental enamel: A review. Biosurface and Biotribology , 3(4), 196-210. https://www.sciencedirect.com/science/article/pii/ S2405451817300405
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