underlying etiology. Nevertheless, recent studies demonstrate the effectiveness of adhesive strategies in this setting. Overall, the RMGIC demonstrated overall better performance in the restoration of these lesions compared to the other materials
(Hussainy et al., 2018). The long-term success of restoring erosive lesions couples a restorative technique and material that addresses the unique needs of the patient with the etiologic factors that have caused the development of these lesions.
CASE SCENARIOS
Case scenario #1 Gary is a 44-year-old attorney who presents to Dr. Chen’s office for a new patient evaluation and cleaning. He moved to his current address from a different city three years ago and is establishing care for the first time. Prior to his move, Gary had dental cleanings every one to two years. He currently has no major concerns about his oral health, but he does not like his smile and feels that his teeth are very yellow. However, he feels that the yellowing is just part of “getting older,” and he is not particularly interested in cosmetic treatment. He knows that he is overdue for a cleaning. Gary’s medical history indicates that he is taking medication for high blood pressure and depression. He rates his depression as severe and remarks to Dr. Chen that it is largely responsible for two previous divorces. Other than being somewhat overweight, there are no other significant findings in Gary’s medical history. In his initial interview with Dr. Chen, Gary also says that he is aware of clenching his teeth when he becomes stressed. In addition, he drinks coffee every morning and an average of three to four soft drinks daily, which he sips while working in his office. Intraoral examination of Gary’s mouth reveals flat incisal edges from cuspid to cuspid of both upper and lower teeth. The lower incisors and cuspids have a dished appearance on the incisal edges, and reparative dentin is visible where the pulp chamber was once located. The premolar and bicuspid areas of the maxillary teeth exhibit 2 to 3 mm of gingival recession with slight cupping of the root surfaces in the areas of recession. The exposed dentin has a smooth, glassy appearance. In addition, Gary has several older class I and class II amalgam restorations in the posterior whose margins appear slightly elevated but are otherwise intact. The cusp tips of his molars and premolars are relatively flattened and in some locations show small divots Case scenario #2 Maria is a 62-year-old woman who was born and raised in Mexico and immigrated to the U.S. approximately 10 years ago to live with her son’s family. Maria does not speak English and has little money. For that reason, she has avoided finding a dentist in the U.S., and her most recent dental care was received before she left Mexico. Recently, Maria began to develop sensitivity in the anterior of the upper left side of her mouth. It gradually became worse and is now a frequent throbbing pain. She is unable to tolerate eating or drinking anything cold. Her son decides to take her to his dentist, Dr. Jorgensen, for an evaluation. With her son translating, Maria is able to describe her history and symptoms to Dr. Jorgensen. She cannot localize the specific tooth causing pain, but points to the area around teeth #10 and #11. Dr. Jorgensen notices that Maria has very short anterior teeth that are barely visible when she speaks and smiles. He estimates that they are less than 50% of the normal clinical length. In addition, her upper and lower anterior teeth all exhibit thin (and sometimes absent) enamel with deep, dished-out incisal edges. A pinkish hue is visible through the incisal dentin on both tooth #10 and tooth #11, which Dr. Jorgensen presumes is the pulp. Both teeth seem equally hypersensitive to percussion and contact with ice, which elicits lingering pain. Radiographic examination reveals that teeth #7, #8, and #9 have previous root canals. While the wear is likely multifactorial, Dr. Jorgensen believes it is primarily secondary to chemical erosion. He questions Maria’s son about her dietary habits, and her son confirms that Maria consumes large quantities of citrus fruits. She particularly enjoys
into the dentin. Although Gary has known that his lower incisors looked worn, he was unaware that all of his teeth exhibit such wear. Points to Consider 1. What are some specific aspects of this scenario that could be contributing to the erosion of Gary’s teeth? Gary has a history of severe depression and admits to parafunctional habits (clenching) when stressed. The clinical evidence suggests that bruxism (grinding) is occurring without Gary’s awareness. His medications may be contributing to a reduction in saliva, which can accelerate erosion. In addition, his teeth spend a significant amount of time each day exposed to acidic beverages. 2. What areas of erosion-related wear should be restored, if any? The lower anterior teeth may benefit from composite resin restorations on the incisal edges to protect against pulpal damage and prevent further wear. As long as Gary’s existing restorations are free of new decay, there is no obvious need to replace them. 3. How should Dr. Chen manage Gary’s erosion from a preventive standpoint? He should educate Gary on the harm caused by frequent soft drink exposure and potential salivary reduction caused by his medications. Ideally, Gary should decrease soda consumption and increase water and mineral-rich foods and drinks. An occlusal splint should be considered to prevent acceleration of wear from bruxism. eating lime wedges with meals and will bite directly into the wedge to suck out the juice. Points to Consider 1. What is the primary cause of Maria’s severe erosion? Exposure to dietary acids, largely in the form of citric acid. Many citrus fruits have a pH of less than 3. Direct contact with the teeth will accelerate the process of erosion. 2. What treatments should Dr. Jorgensen recommend to restore damaged areas and prevent further damage to Maria’s teeth? First, teeth #10 and #11 need root canal therapy as a result of damage from acid erosion and to relieve Maria’s pain. Following that, ideal restorative treatment would involve crowns on all of the anterior teeth that are severely worn by erosion. This would help build up any lost vertical dimension and protect vulnerable dentin from continuing erosion. If crowns are not financially feasible, at a minimum composite resin could be used to cover eroded dentin and reduce further damage. 3. What dietary practices could Maria change without giving up citrus fruits? The main practice to avoid is biting directly into highly acidic fruits. Consuming them as juice or mixed with other foods, for example, would reduce direct and prolonged acid exposure on the anterior teeth. Additionally, increasing her consumption of foods and drinks rich in calcium and phosphates would help shift the balance away from demineralization. Finally, rinsing with water to dilute and wash away acids after consumption would be helpful.
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