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Case Conference Medically Compromised Patients Restorative Dentistry

Your Opinion: How would you treat this case?

This case is presented by Dr. Neel Joshi

I have a 17-year old female patient who has had viral gastroparesis for the past 4 years.  It’s a chronic condition that causes her to vomit and/or have stomach acids reflux in her mouth multiple times throughout the day.

I don’t believe there is an associated eating disorder – she was diagnosed at Sick Kids Hospital.

Her teeth have slowly eroded over time – not yet into the pulp or shortened, but I wish there was something I could suggest.  I have made custom Fluoride trays with neutral Fluoride and also have her use a remineralizing product (GC MI paste) which helps with sensitivity.

I have seen articles where full-mouth crowns are placed subgingivally in people with eating disorders, but I believe these patients have to stop their purging/vomiting habit.  My patient has been advised there’s not much anyone can do for her condition.

 Is there anything we can do?

Thanks, 

9 Comments

  1. Terry Shaw January 13, 2014

    Any pictures would be helpful. I have done several cases where I built the teeth up with composite and we are 7 years out and teeth are working well. Would post pictures, but not aware if we can on this website.

    Reply
  2. sheryl p lipton January 13, 2014

    I am always reticent to cut down teeth and put on full crowns although it sound like you might not have to cut much down…..
    Is there any treatment for her?? what causes the vomiting?
    In terms of prevention:
    Rinse after vomiting–>perhaps with milk or baking soda to neutralize the acid; chew trident extra care a lot…..MI paste is good…..
    perhaps you need to refer out…..
    But I suppose we can’t save everything and she may need to know that a consequence of her illness might be loss of teeth…..

    Reply
    1. Neel Joshi January 14, 2014

      Hi Sheryl – thanks for your reply.

      From what I gather the vomitting is caused by chronic delayed gastric emptying due to the nerves supplying the stomach being damaged by a virus. No one seems to know what causes it or what the virus is. It seems she will have this condition for life.

      Good suggestions re: after vomitting rinsing. I’ve also told her not to brush her teeth after vomitting to avoid wearing away any enamel.

      In terms of referral, which specialist would you suggest? Prosthodontist? Oral Medicine Specialist? Other?

      Reply
  3. Gabor Filo January 14, 2014

    If all other medical treatments have been exhausted, then a clinical psychologist familiar with hypnosis and the Paulsen’s IBS protocol might be able to offer the patient sufficient control to minimize some of her symptoms, thus giving the dental tx a chance.

    Reply
  4. Matias N Grimminck January 14, 2014

    I think more information is needed in order to suggest a treatment plan.

    Here some thoughts:

    1.Chief Complain, Motivation and Patient expectations?

    2. Diagnosis: Severity of the problem, Reflux treatment outcome, TMJ and facial muscle evaluation, canine and anterior guidance as a part of a complete occlusal evaluation.

    3.The severity of the problem, and patient motivation and expectations must be taken in consideration in your treatment plan

    4. It is important to determine if the Occlusal vertical Dimension will be modified during the treatment and transfer it to a set up, checking lateral and anterior guidance.

    5. If the treatment plan were a full mouth restoration, I’d start working on the posterior area , either with crowns or composites.

    6. If the treatment plan include plastic restorations, there are many factors to be considered, for instance: Outcome of the reflux, TMJ symptoms, presence of enamel, and patients expectations among others. If composites are indicated, a partial thin clear try from the set up would be helpful to build the teeth up on the last stage of the procedure.

    7. On the other hand, If crowns are indicated, in my opinion a Full metal or Pfm crown with posterior margins finished in gold at the gum line are a good choice. Also a thin clear try from the set up is useful for temporary crowns build up.

    8. Finally, I’d finished the anterior area. Aesthetic crowns suggested. Double check lateral and anterior guidance.

    9. 4 month recall, Topic fluoride suggested

    10. Night Guard if needed

    10. Intra and extraoral photos suggested

    In term of prevention, I agree with Sheryl about the milk and MI Paste, but I am not sure about the baking soda. I’d also include restorations procedures as needed. Follow up with his MD periodically.

    Regards,

    Reply
  5. Abbas January 14, 2014

    I had a similar case in the past. I made custom trays such as the ones for night whitening and instructed the pt to place a fluoride solution in them. It significantly retarded breakdown. Good luck.

    Reply
  6. tomasz pater January 14, 2014

    Yes, I agree that full crown coverage on all teeth that you want to keep may be the only resort other than implants and hybrid denture reconstructions. We constantly produce stomach acids and we need them for digestion. Not much else.

    Reply
  7. Lina Jung January 14, 2014

    I would recommend a preventive protocol similar to the one we use for our xerostomic patients at high risk of radiation caries at the BC Cancer Agency. In addition to the custom Fluoride trays and MI paste you have already started, and which is in our own regimen, we advocate use of high concentration Fluoride toothpastes and rinses, as well as Fluoride varnish and the X-Pur product line. However, I would recommend a reduced dosage of the xylitol products as the sugar alcohols may cause further GI upset and you may want to check if there’s any contraindications to use with your patient’s medical history. As for the restorative management, if the patient were wishing to have rehabilitation, I would offer the choices of composites vs. crown, but making sure the patient is well informed of the questionable prognosis associated with each as the bonding capability of the dentin may be compromised and the long-term integrity of the crown margins is questionable no matter where they may reside, supra-or sub-gingival. Similar to what John Kois has said about patients with parafunction and GERD, the teeth would probably benefit from a protective splint at night.

    Reply
  8. Maria Cristina Iova January 15, 2014

    I think you should suggest hypnotherapy to your patient . . many times patients have psychosomatic problems ,, it could be some past events that lead to this situation .
    Of course mounth treatment will be ph basic rinses , fluoride and full crowns

    Reply

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