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Your Opinion: what is the etiology behind the erosion on the 7-4 and how would you treat it?

This case is presented by Dr. Matt Gilchrist

I am completely stumped as to the etiology behind the extreme wear/erosion on this child’s 7-4. The child is 9 years old and has generalized wear and early erosive-looking lesions on his occlusal/incisal surfaces. His mom admits to him having a grinding problem, which would account for the look of most of his teeth, but as for this 7-4, there has to be something more. We’ve been monitoring this tooth for the past 2 years and at every recall, it’s getting worse.

I’ve questioned the patient about any reflux or dietary habits that may be causing this, but to his knowledge, there is nothing significant. I was thinking at first a reflux issue and the possibility of patient sleeping on his left side with that tooth bathing in acid all night, but then I am not sure why the 7-5 is not damaged nearly as much.

His mom is concerned about this tooth. I on the other hand am not overly concerned, as it is asymptomatic and we will just wait for exfoliation (unless, of course, it does start to bother the child). There is no space present for any type of restoration.

Thanks,

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Tell us how you would have dealt with this case. If you have other interesting cases, email those to us at oasisdiscussions@cda-adc.ca 

 

39 comments

  1. VERY interesting. Clearly NOT normal bruxing. Pt is an anterior bruxer, to the left side. NOT bruxing in centric near as much as protrusive left. I suspect a night breathing obstructive problem. Tonsils? Adenoids? allergies? May be too late now, but I would have bonded filling into 74 a while ago to see what happened, AND do a thorough respiratory pathway assessment. He is likely sleeping on his right side, or stomach with head to the left. Does he snore?? Is s/he overweight? obese? thick neck?

    I’d be interested to see answers to these and any other questions that are contributed.

    • Normal sized kid. I’m unsure of the snoring issue, but once I gather all of the information from here, I will certainly sit down with the mother. I monitored it, as it looked the same as the 8-4 does a year or so ago. This took off so quickly and really caught me off guard.

  2. I would have restored with a stainless steel crown way back but same now and adjust occlusion as needed. Get medical consult ASAP to deal with the underlying problems as need to prevent the erosion of the permanent teeth.

    • I will certainly seek a medical consult. There HAS to be some reflux, even though there is no mention of heart burn symptoms. Probably happening at night when child is laying down?

    • Anthony de Souza

      The most conservative way to restore this tooth would be with a glass ionomer like Ketacfil or Ketacsilver and monitor it at recalls.

  3. There is a small thumbnail of the clinical photo to the right of the radiographs. It may aid with the diagnosis.

  4. Matt, I doubt acid reflux – it would not affect just one tooth, and it would be on many lingual surfaces, more to the anterior. The wear pattern on the 74 is more severe on lingual, and worse on distal end of 74 buccal remaining wall, indicative of the protrusive mandible bruxing to the left. Try it on your jaw. The deciduous cuspids are next worn, not the e’s.

    My gut responses re a stainless steel preformed crown – is contraindicated, due to bulk, if brux on it, could dislodge and go into throat, etc. WILL act as “irritant” –> more brux. The 74 situation is a RESPONSE, NOT the cause of the problem. MUST find the CAUSE, BEFORE treating the result, or could get a very unpleasant surprise.

    I well remember a situation many years ago. Mom brought in her 4 year old son, avid strong right thumb sucker, wanted me to put in an appliance TO STOP it. She had tried some drugstore stuff, etc without any success. I observed him, and refused, said he needed that comfort at this point, and if she could, to find cause & fix but likely in a year, will stop, or at age 6, I’d be willing to do appliance.
    She was NOT happy, and went off. Came back 6 months later for checkup with a BIG, NEW problem. She had forced him to stop by putting on pajama top backwards and sewing the sleeve end closed.
    So — he solved his need. He is now holding his private parts in a clenchgrip with his right hand, ALL THE TIME. I told her to see a psychologist. Never saw her again.

    If the kid has his own room, have the parent listen outside with door a bit open and see if snoring, how loud, regular or irregular – & if he is a decent sleeper, parent can be in the bedroom and see if breathing stops, does the kid move suddenly, twitch, shift, then breathe again. If there is a little light in the room, parent can see sleeping position, observe any bruxism movement of jaw, etc.

    Another thing, bruxism comes and goes with kids, due to “teething” discomfort. That’s why we do not make NG’s for kids. They “pick on” the bothersome tooth. Until it is gone.

    • Thank you for all of your input! I can conclude after this process that it is NOT a straight forward case!

      PS – the wear of the 7-4 is worse on the buccal, it is the lingual wall that is mostly intact. That is the buccal frenum showing in the picture.

  5. Lisa Power-dunlavey

    Wow. That is pretty severe. I haven’t encountered such a case with so much wear predominantly on one tooth. Let me know what you determine the cause to be. I’ll show this to my hubby, who is also a dds , and see if he has any input

  6. Like Ron, i dont think reflux is the primary cause and the lesions are cupped, so it is acid-related. Any sign of wear/surface loss on the 6s?

    Sometimes with this type of asymetric wear, it is a habit – where does he place the straw when he drinks from a juice box or can of soft drink? Does he chew on something in that area? The 73 seems to have more loss than the 83, so some sign of wear pattern?

  7. Very interesting Matt. Have you checked with Mom about his diet? Maybe he is a big juice drinker and sucks in the straw just over the 74. Or he ciuld have a compulsive habit of chewing his pencil or something in that area especially. You never know…good luck!

  8. Does he chew a pencil?

  9. I had a case that was very similar, and in fact involved only the lower molars, with the 74 being the worst. The images are almost identical.
    This patient was diagnosed with GERD at a young age, and the parents claimed they could hear her stomach gurgling at night. I didn’t understand exactly how such heavy erosion could be on only one or two teeth, but that’s how it presented.

    The GERD is under good control now, the primary tooth has exfoliated and the permanent tooth shows no signs of acid erosion.

  10. If there is no space for a restoration and the max/mand teeth are an intimate and complementary fit it can only be a parafunctional issue. I saw a child recently with deciduous lateral and canine on left side that were almost identical to that; smooth and flat stumps. No way it is acid related if it is selective to one or two teeth.

    If you can’t get patient to replicate the parafuntion in chair (for some reason some don’t seem to be able to do it on command), take impressions and you will be able to see exactly what is going on. As long as it is a regular patient and you see no wear on permanent teeth at each exam, I wouldn’t worry about it too much.

  11. I think I would pursue whether this child is given vitamins to chew on on a daily basis. Some are very acidic and most people would chew them in a repetitive pattern ie holding them and crushing them between the same teeth.
    I have also read about asthma puffer medication causing this pattern of occlusal wear.

  12. does the child have a daily or ‘bed-time’ treat from grandma of a pepperment, or take a chewable

  13. last comment sent by accidental key-stroke–does child suck on ASA chew-tab or pepperment on this area by habit?

  14. Matt, I see a pattern of erosion on both sides, lower arch more than upper, left side more than right and buccal more than lingual. This leads me to suspect an external source (acidic food or beverage) as the causative factor when gravity ensures that mandibular teeth take the brunt of the damage. Further discussion with the patient and the parent(s) may reveal the cause.

  15. I’d agree with the diagnosis of GERD. You mention wondering about him sleeping on his left side, but have you asked his mother? The 73 seems to have some erosion. Is it possible he sleeps on his left side, but head down (head hanging over edge of bed) so the 75 is not affected, but 73 and 74 are and the incisors are new, so unaffected so far.

    • This looks like a case of toothpaste abrasion. The patient is probably right-handed and is aggressively brushing in a habitual pattern. Give the child a toothbrush and ask hin to brush for a few minutes while you watch. There is a good chance he will show the brushing pattern which has caused the problem.

  16. Hi Matt,

    Have you made mounted study models to better assess the occlusion? I’m wondering if the 6.4 is supra erupting to occlude with the 7.4? If so, could this issue have started with the 6.4? Does he have a habit of chewing on lemons?? Lol.

    I’ll be staying tuned!

    Marianne

  17. i agree with the acid comments…..
    and, in particular, with the possibility of a chewable vitamin which the child might be habitually chewing on that side….
    alternatively, a acidic candy or drinks….
    is the child a pop/juice drinker???
    once the enamel is gone (which it is), the dentin will be very vulnerable to quick disintegration…..

    and, there’s no room for a SSC now….if it becomes pulpally involved, you can remove and space maintain….

    but of course, the main issue is finding the cause to prevent future destruction….

    i’m not sure that parents/kids will always admit to pop/juice/candy use…..

    i remember a patient who had FULL upper and lower dentures who had created holes in acrylic of both posteriors from biting on candies….

    i really don’t think this has to do with bruxism (perhaps partially) or sleep apnea…..

  18. I can’t add to a solution to the underlying cause, as it is still quite questionable.

    What I do question is the treatment for the tooth. I assume that by the appearance of the photo, that the dentin has a very glassy-sclerosed type of appearance. How confident would any of us be to place a restoration on this tooth with any type of longevity?
    -no mechanical retention for amalgam
    -SSC – likely chew through/lack of bulk of tooth
    -Glass ionomer or composite resin bond – I wouldn’t be confident in having it last!

    I’d think that no treatment for the tooth and wait for exfoliation/extraction to be the lesser of two evils, though not knowing its etiology keeps me puzzled…. and it’s not exactly an isolated case either.

  19. Posted by the JCDA Oasis Team on behalf of Anonymous:

    This situation was most probably caused by the child chewing on licorice or something that fit very well into 74. I see something similar on the right side: excessive erosion of enamel in 84 and the opposing 54. The child may like to hold that item on the first primary molars and that has become a habit. Or, it is most likely something he is doing at home that he does not want to tell you about, knowing that his parents may get upset or angry, if they find out.

    The erosion is more pronounced on the left side. It may be that the child habitually uses that tooth much more than the others. I suspect some sort of sweets or licorice, something that is high in sugar and which sticks to the molar. This erosion seems to have accelerated once the upper layers of the enamel were removed. Now, the erosion of the lower layers that are less protected by fluoride and heavy metal ions and calcium from saliva has accelerated over the time period that you have been observing these teeth. But I definitely think it is something the child is habitually doing that is causing this loss of enamel.

  20. The word “erosion “should not be used because it implies a chemical cause to the origin of this problem. We do not know the cause,thus, abnormal tooth wear would be more accurate.

    • The undulating smoothness of the surfaces….seem almost highly polished is erosion not wear…wear has facets…angles…not smooth rounded and undulating surfaces…this is chemical erosion…not wear….the addition of bruxism to whatever degree would aid the more intense erosion effect to some degree….but this is definitely erosion of a chemical nature….

      • In addition the presence of dentin pools on the second primary molars and even the erupted first molars would give credence to acidic erosion ….but to wear a single tooth that much with one right next door seeing next to no wear attests to the suggestion that this is definitely chemical erosion of an acidic nature…

        • “Tooth wear” is defined as loss of tooth surface NOT caused by decay or trauma. There are 3 categories of tooth wear: 1) Attrition, 2) Abrasion and 3) Erosion. I would agree that this “looks” like erosion, but we don’t know for sure. My point was that the more general term “tooth wear”needs to be used until a definite diagnosis is made.

  21. A ground down 74 on one kid does not keep me up nights. Just point it out, note it down and have good night’s sleep.
    If the child has some crazy psychological problems it is out of my league.
    Refer to pediatrician re acid reflux or psycho habit.
    Since parents don’t listen and they all know way more than I and would never follow one thing I said-I will hopefully live long enough to see what it turns into in adolescence.

  22. This case is classic acid erosion with a somewhat unique presentation. I would suggest asking the child which is his favourite sour candy (many kids his age are somewhat addicted to them). Provide him one to show you what he likes to do with them and quite possibly he might demonstrate his favourite spot he likes to hold and suck on them. Good Luck

  23. Does this child also have the following problems
    -gummy smile
    -Deep bite
    -Low tongue posture
    -High arched palate
    -Bed wetting
    -tears sheets apart
    -Previous End to end bite on primary anterior with excessive grinding prior to exfoliation

    If so then I agree with the GERD diagnosis caused by insufficient airway space and childhood propensity to apnea
    Tough case…Good luck

  24. This is definitely a case of erosion of hypoplastic enamel. The only reasonable treatment is to protect the pulp and build the tooth into occlusion and wait for its replacement.

    • How are you so definite that it is associated with enamel hypoplasia? There’s nothing in the history provided or tooth structure left to make that diagnosis.

      • There is nothing in the history that points to erosion as the “culprit”, but the history may not be as exhaustive as it could have been because of certain circumstances. Conventionality and rationality should prompt us into some treatment and later observations at frequent intervals.The story may likely unfold unceremoniously.

      • I think this is just a case of toothpaste abrasion. The child is right-handed and brushing vigorously in a horizontal manner.

      • I am not absolutely sure of the diagnosis, but in this case the treatment is not entirely bound or dependent on the diagnosis.

  25. The child has been to the IWK in Halifax to see a GI specialist. It turns out that he HAS been diagnosed with REFLUX!

    • The child may indeed have reflux, but why such change on only one tooth. I still would be suspicious of a habit such as sucking on a candy or other agent to help erosion/wear on this tooth. Indeed, such a habit may be involved with the reflux process.

    • It is good that the diagnosis has been made, but I still suspect that a habit such as sucking on a candy or other agent which could promote erosion/abrasion could lead to this one tooth to be involved to such a degree. Indeed, such a habit may also contribute to the reflux.

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