2022, Number 1
Complete oral rehabilitation in a patient with dental erosion caused by gastroesophageal reflux
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ABSTRACT
Introduction: dental erosion is the irreversible loss of tooth structure due to a chemical process, without the presence of bacteria; caused by the action of acids that can be of extrinsic or intrinsic origin or both. Some of the signs of dental erosion include smooth, flat facets on the palatal and buccal surfaces and superficial concavities on the occlusal surfaces. An intrinsic cause is the presence of acid from gastroesophageal reflux; extrinsic causes have to do with a high intake of acidic foods. Gastroesophageal reflux disease (GERD) has been associated with dental problems such as erosion, halitosis, mucosal pathology, and bruxism. Different procedures can be found for the oral rehabilitation of patients with GERD; among them are adhesive procedures that preserve a healthier tooth structure. Objective: to report the case of a patient with dental erosion caused by GERD. Case presentation: a 32-year-old male patient was attended at the Prosthodontics Clinic During the intraoral examination, attrition due to bruxism and generalized erosions caused by gastrointestinal reflux were observed. Restoration of dental erosion should be based on a conservative and minimally invasive approach. Complete rehabilitation was performed based on the three-step technique described by Francesca Vailati, Urs Cristoph Belser; it is structured to achieve a complete adhesive rehabilitation with predictable results and with a minimal amount of tooth preparation. Conclusions: restorative therapy of dental erosion should be based on a minimally invasive approach. Gastroesophageal reflux disease has been associated with dental problems such as dental erosion, halitosis, mucosal pathology, and bruxism. In general, patients with GERD report oral manifestations of the disease, revealing the importance of multidisciplinary treatment and follow-up to the patients.INTRODUCTION
Dental erosion has been studied and described as a multifactorial non-carious dental lesion that causes irreversible loss of dental structures, enamel, and/or dentin, due to a chemical process, without the participation of bacteria. Acids can come from extrinsic sources, such as food and beverages; diet plays an important role. Consumption frequency, contact time with the acid, and unusual consumption patterns are also relevant factors that influence the erosive effect. The intrinsic source is the presence of gastric acid (hydrochloric acid) in the oral cavity due to gastroesophageal reflux problems or eating disorders.1
Characteristic signs of dental erosion include flat and smooth facets on the palatal and buccal surfaces of the teeth, as well as superficial concavities located on the occlusal surfaces. Depending on the origin of the problem (extrinsic or intrinsic) 3 clinical signs of gastroesophageal reflux in the mouth may be described and they are rounded cusps, restorations that rise above the level of adjacent tooth surfaces and morphology of the enamel loss.1,2 When erosion is the dominant factor, the labial and palatal surfaces of the upper incisors appear smooth and shiny with a generalized loss of anatomy. The exposed dentin is smooth and often has an enamel halo around the lesion, usually in the area of the gingival margin.3 In patients with eroded and abraded teeth due to bruxism, the main cause of tooth structure loss should be determined to eliminate etiologic factors before rehabilitation is performed. Therefore, regardless of the etiology, tooth wear is considered pathologic.4
Adhesive procedures preserve more tooth structure by avoiding endodontic treatments and teeth rehabilitated with adhesive restorations are more esthetic than those rehabilitated with cemented restorations.5 Several authors have proposed different techniques for the treatment of patients with tooth erosion to achieve maximum preservation of tooth structure and the most predictable and functional esthetic result. Hence, an innovative concept has been developed: "The three-step technique".6
The objective of this manuscript was to report the case of a patient with dental erosion, where the necessary studies were performed to confirm the presumptive diagnosis of gastroesophageal reflux, for subsequent planning and oral rehabilitation with an increase in the vertical dimension of occlusion (VDO), using ceramic and composite resin restorations for the completion of the case.
CASE PRESENTATION
A 32-year-old male patient, who works in a restaurant, came to the dental clinic of the Postgraduate Program of the Autonomous University of Guadalajara and commented that his main reason for consultation was that his teeth were very worn, and he had sensitivity in some of them (Figure 1A-B). The patient claimed to be obsessive-compulsive and to suffer from Tourette's syndrome, which is a developmental neuropsychiatric disorder in early childhood, characterized by brief, stereotyped, but not rhythmic "jerking" movements and vocalizations called "tics". At the time of the consultation, he reported that he was not taking medications for his condition because he had stopped taking them for five years ago. The patient's health was considered to be good, and he did not present any type of allergy.
During the extraoral examination, a dolichofacial biotype was observed with hypertrophic musculature at the masseter level and apparently healthy skin tissues; at the intraoral examination, generalized erosions were observed in several teeth possibly caused by periods of gastrointestinal reflux and attrition. A thick periodontal phenotype and apparent periodontal health were observed. Upon radiographic examination, an adequate bone level was noted, and no caries or apparent pathology was observed; the only significant finding was the root canal treatment of tooth #36 with an apparent glass ionomer base. The patient was instructed to undergo a pH metric study to identify periods of reflux and changes in pH. The results of the study showed that the number of episodes of gastroesophageal reflux, in this case, 43, was considered capable of causing damage to the dental tissue. Even though the pH of 4 that the patient presented was considered physiological, time of evolution was also taken into account since the patient had had this problem without being aware of it. Thanks to these results we were able to confirm the diagnosis as dental erosion. The treatment plan was carried out in two parts, the prosthetic part, and the medical part.
Complete rehabilitation was performed by segments according to the 3-step technique by Francesca Vailati and Urs Cristoph Belser. In this technique, three laboratory steps are alternated with three clinical steps to achieve a more predictable result. In the first step, the esthetic evaluation was performed by establishing the position of the occlusal plane. In the second step, the posterior sector was restored with an increased occlusal vertical dimension. Finally, the third step consisted in reestablishing anterior guidance.5,6 The study models were mounted using a facial arch and an interocclusal registration in centric relation (Figure 2C). Subsequently, the diagnostic wax-up was performed establishing a VDO with the available space. A mock-up was made with a polyvinylsiloxane key taken from the diagnostic wax-up and bis acrylic resin material to evaluate the occlusal plane, incisal plane, esthetics and phonetics (Figure 1D).
Once the patient agreed to treatment after analyzing the mock-up, the teeth were prepped to receive future restorations. It was decided to make complete lithium disilicate crowns in the upper anterior teeth. No grinding was performed on the palatal side since only the lost structure was restored with ceramic. On the labial side and on the incisal edge a 0.8 mm deep preparation was performed; 0.5 mm was carved in the middle third and 0.3 mm in the incisal third of the crowns. These preparations were performed on a mock-up previously seated on the intact teeth to evaluate the final volume of the restoration and to calibrate the minimum tooth reduction. In the premolars and molars area of the upper arch, preparations for Vonlay-type restorations were made. These preparations were designed to cover the buccal and occlusal surface while keeping the interproximal contact point intact. Since the VDO was increased by 3 mm in the anterior region and 1.4 mm in the posterior, the removal of tooth structure in the occlusal facet was limited to 0.1 mm in the second molar. In the premolar area, there was no need to make a preparation. In general, in the upper jaw, conservative preparations were made to make full coverage restorations due to the amount of space and the short length of the teeth.
In the upper anterior teeth, it was possible to preserve the greatest amount of remaining enamel. The finishing line was positioned at the gingival level to optimize esthetic results and where not required; it was placed at the supragingival level. Incisal edges were made with resin on the mandibular incisors with the help of a silicone matrix according to the VDO established in the wax-up. For the Vonlays preparations, a 2 mm occlusal wear with a cusp inclination of 45° was made with a labial veneer preparation extending from the mesio-labial angle line to the disto-labial angle line. The temporaries were fabricated using the VDO established with the modified indirect technique and then relined directly in the mouth and cemented with temporary cement. Patient comfort, phonetics, dental esthetics, and physical appearance were evaluated; and after one month the final impression was taken. A double retraction cord was placed in the sulcus for the final impression which was taken with addition silicone (Imprint light ESPE 3M) and an individually made light-cured methyl methacrylate resin laminate impression tray and tray adhesive. Before taking the impression, the tooth surfaces were cleaned with pumice and a silicone cup to remove any provisional cement or plaque residue. After that, the impression was taken with the one-step double-mix technique using a heavy consistency material (3M Imprint II) and a light consistency material (3M Imprint II).
Subsequently, an interocclusal record was taken with a self-curing acrylic resin material (Pattern Resin LS, GC) in centric relation and in the established VDO, faithfully copying the tooth surfaces for proper repositioning. Type IV plaster was used for the working models. The alveolar model was used for the fabrication of the restorations in the laboratory in order to obtain a better registration of the soft tissues and thus prevent over contouring and achieve an adequate emergence profile. The restorations were made of lithium disilicate due to the optimum esthetic and physical properties of this material, using the waxing and pressing technique with IPS e.max MT. Monolithic crowns were fabricated with the staining technique. Once the upper restorations had been fabricated, they were adhesively cemented using the Pascal Magne technique. Before cementing the ceramic pieces, they should be meticulously tested in the mouth. After removing the temporary, the dental surfaces were cleaned with a silicone cup and a slightly abrasive paste using a rubber dam for isolation.
For the conditioning of the restorations, 5% hydrofluoric acid was placed on the internal part for 20 seconds, the restorations were washed and placed in distilled water under ultrasound for 5 minutes and silane was applied. A layer of adhesive resin was applied followed by a soft and tenuous air flow and proceeded to be placed slowly following the insertion axis of the tooth with digital pressure. The excess was removed with a brush and polymerized for 60 seconds. A glycerin gel was applied, and light cured again. The occlusion was checked, and the posterior impression was taken with the same impression technique and materials. The restorations were fabricated in the same way and bonded with the same protocol (Figure 2A-B). For the lower anterior area, incisal edges were placed with composite resin, fabricated with absolute isolation, and a silicone key based on the wax-up, thus preserving the tooth structure as much as possible (Figure 2C-D). By minimally invasive grinding and only providing the necessary space for the restorative material, good esthetic and functional results were obtained, preserving the dental tissue without increasing the patient's VDO too much (Figure 3A-B).
DISCUSSION
Dental erosion is a common oral condition, and it is becoming increasingly present in recent decades. Gastroesophageal reflux disease (GERD) is a condition in which there is an involuntary passage of gastric contents into the esophagus leading to symptoms such as heartburn, chest pain, pyrosis, hoarseness, asthma, sore throat, and dental erosion.7 Early detection and intervention is recommended to prevent extensive damage to the dentition. Reports suggest that the high incidence of GERD in middle-aged men is attributed to work and personal stress, dietary habits, and family history. The dentist may be the first professional to suspect GERD due to dental erosion.8
Extrinsic erosion is routinely observed on the labial surfaces of upper anterior teeth, while intrinsic erosion lesions often occur on the palatal surface of anterior teeth.8 On smooth surfaces, erosive lesions occur coronal to the cementoenamel junction often leaving an intact cervical margin. Lesions are shallow and may affect the entire tooth surface.9 A thorough examination of the teeth should be made. Diagnosis is often made by visual inspection and observations for any opaque tooth surfaces, flattened enamel structures, development of distinct defects, hollowed cusps, flattening of tooth morphology making restorations more prominent, loss of occlusal contacts and decreased crown height.9 The evaluation of dental wear is subjective, this particular case was based on the Smith and Knight index where severe wear was evaluated with a loss of dental structure of approximately 2 mm. Considering the age of the patient and his needs, a conservative and additive restorative treatment was performed; we tried to leave intact as much healthy tissue as possible.10 Smith and Knight developed a tooth wear index, a system by which the four surfaces (labial, cervical, lingual, and occlusal-incisal) of all teeth are scored for wear, regardless of how it occurred; if in doubt, the lowest score is awarded. This index was the first designed to measure and monitor multifactorial tooth wear.11
Loss of the protective enamel covering of the teeth can lead to hypersensitivity, functional impairment, caries, as well as tooth fracture, particularly if there is associated bruxism.12 Traditionally, full-mouth rehabilitation has been the recommended treatment for patients affected by severe generalized tooth erosion. However, a restorative concept comprising full crown coverage of almost all teeth and extensive root canal treatment may be too aggressive for this generally young patient population. With improved and current adhesive techniques, the indications for crowns have decreased and a more conservative approach may be suggested to preserve tooth structure and postpone more invasive treatments until the patient is older.13 Using the three-step technique described above, the clinician can transform a complete oral rehabilitation into a single-quadrant rehabilitation for a more predictable outcome and improved function.6
CONCLUSION
Restorative therapy for dental erosion should be based on a minimally invasive approach. The three-step technique is a structured system to achieve full-mouth adhesive rehabilitation with the most predictable outcome, the least amount of tooth preparation, and the highest level of patient acceptance.
GERD has been associated with dental problems such as dental erosion, halitosis, mucosal pathology, and bruxism. Generally, patients with GERD report oral manifestations of the disease thus highlighting the importance of multidisciplinary treatment and follow-up of these patients.
REFERENCES
AFFILIATIONS
1 Posgrado prostodoncia. Facultad de Odontología, Universidad Autónoma de Guadalajara, Guadalajara, Jalisco, México.
2 Profesora investigadora. Facultad de Odontología, Universidad Autónoma de Guadalajara, Guadalajara, Jalisco, México.
CORRESPONDENCE
Andréa Dolores Correia Miranda Valdivia DDS, MSc, PhD. E-mail: andrea.correia@edu.uag.mxReceived: Octubre 2020. Accepted: Septiembre 2021.