Table of Contents
The five major causes of pathologic, non carious tooth wear:
- Toothpaste Abuse
- Acid Reflux Disease (Gastroesophageal Reflux Disease)
- Soda Swishing (Coke Swishing, Pepsi Swishing, etc.)
- Fruit Mulling
Erosion Page 1–Regurgitation
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.
Regurgitation of stomach contents into the mouth is the major cause of tooth wear from erosion, and as such, it constitutes the third major cause of non carious loss of tooth structure, after both forms of abrasion: Bruxism and Toothpaste Abuse.
There are two major conditions which cause regurgitation of stomach contents into the mouth. They are the eating disorder known as bulimia, and chronic acid reflux disease (ARD) formerly known as GERD–GastroEsophageal Reflux Disease
Bulimia is an eating disorder in which the patient (almost always female) wants to eat to satisfy hunger, but is afraid that she will get fat if she does. This leads to binge eating followed by intentionally vomiting the stomach contents in order to avoid gaining weight. These patients have a serious psychological disease which, once established, is essentially an addiction, and which is almost impossible to break without professional help.
Unfortunately, these patients almost NEVER admit to the habit, and when confronted, they will generally deny the habit, and may react by leaving your practice for good. To further complicate the issue, the dental stigmata of bulimia are permanent, unless repaired by a dentist, and remain with the patient forever, even if the patient has sought professional help to kick the habit. Often, an actively bulimic patient will lie about the status of their disease, saying that they have been “cured” and are no longer actively bulimic in order to get the treatment they came in for.
The best way to confront the patient is with extreme compassion. Most patients with bulimia know that they have a big problem and really want help. (Most bulimics are aware that their condition may lead to death–Which happens in about 6% of all cases.) Many large regional hospitals have eating disorder clinics, and it would be wise for each practitioner to know where the closest ones are located so a referral can be made.
Recognizing Bulimia–Wear patterns on the teeth
Loss of tooth structure is progressively worse toward the anterior teeth. This is because of the way the tongue is held in the mouth when the patient vomits. The vomitus is projected especially toward the palatal surfaces of the maxillary incisors with progressively less damage as you proceed posteriorly. As the palatal surfaces of the maxillary incisors erode, the incisal edges become more and more thin and translucent, eventually producing a knife-edge which is easily crazed and chipped. Note the image above. Nearly all of the palatal enamel has been dissolved by the acidic stomach contents which have been projected against the incisors. The canines are affected, but less so. This profile is pathognomonic of early bulimia.
Note especially in the image above that the loss of tooth structure is fairly even beginning at the free gingival margin. This is an important distinction which differentiates bulimics from heavy bruxers who may also have worn palatal enamel, but rarely as evenly distributed, or subsuming the entire palatal surface.
Compare this image with the one at the heading of this section. This is an image of the palatal aspects of the maxillary incisors. The severe wear might be mistaken for bulimia, but the position of the wear is above the free gingival margin, unlike bulimia in which the erosion goes exactly to the free gingival margin. Also note the irregularity of the margins themselves. Plaster models of the upper and lower teeth would show that the lower incisal edges fit exactly into the defects at the gingival margins.
Posterior teeth may be affected in long standing cases, but the maxillary posteriors will be more affected than the mandibular posteriors. Also, most of the damage to posterior maxillary teeth will be on the occlusal and palatal surfaces. Mandibular posteriors will be affected mostly on occlusals with minimal damage extending to the buccal surfaces due to the position of the tongue.
Mandibular anteriors are not affected, since they are protected from the acid by the position of the tongue during vomiting.
Cupping, or cratering is very common, especially on the maxillary posteriors. In the absence of bruxing or toothpaste abuse, the enamel edges of the cupping lesions are prone to be sharp, in contrast to those caused by toothpaste abrasion.
Silver and composite restorations may be elevated above the surface of the enamel in which they were placed. This is due to the dissolution of the enamel by the stomach acid as it speeds by the teeth.
Hand articulated study models will show that the occlusal wear on maxillary and mandibular arches do NOT coincide.
This type of wear frequently occurs in combination with abrasive attrition (bruxing and toothpaste abuse) but not generally with other forms of erosion ( soda swishing or fruit mulling).
Acid Reflux Disease (Gastroesophageal Reflux Disease)
Chronic Acid Reflux Disease (ARD), also known as Gastroesophageal Reflux Disease (GERD) is a very common problem. It involves the unintentional regurgitation of stomach contents into the mouth, with immediate swallowing. The extent of the damage to the teeth depends on the frequency of the reflux, and the amount that enters the mouth before swallowing. Since the vomitus is generally not ejected from the mouth, the pattern of tooth erosion differs significantly from that of bulimia in which the vomitus is always ejected. The damage to the anterior teeth is nearly identical to that caused by bulimia.
Recognizing ARD in the mouth
- Loss of tooth structure is progressively worse toward the more posterior teeth. This is exactly the reverse of the erosive pattern in bulimia in which the damage is worse on anterior teeth.
- The damage is principally to the palatal and occlusal-lingual surfaces of the maxillary molars.
- The lower teeth, and the maxillary anteriors remain relatively less affected due to protection from the tongue when swallowing.
- Silver and composite restorations in the affected teeth will be elevated above the surface of the enamel in which they were placed.
- Hand articulated study models will show that the occlusal wear on opposing upper and lower teeth do NOT coincide.
- Cupping, or cratering in maxillary molars is common.