A 25-year-old man presented with the severe worn-out of the front teeth during the past 3 years. The patient reported that he had a history of drinking cola for more than 7 years and had a poor oral hygiene. In the first 3 years, he drank 0.5~0.75 L cola a day and toothbrushed once a day. During the period of 4~5 months into the 4th year, he drank 1.5 L cola a day and some fruit juices (especially grape and citric juices), and he brushed his tooth or gargled with water once a day, mostly in the morning. In the latest 3 years, he continued dranking 1.5 L cola a day and toothbrushed once or twice daily.
He described his job as a bank worker with no exposure to acid substances. The patient recalled a busy-working period of about 4 to 5 months 3 years ago when he started consuming cola much more frequently (a total of 1.5 L a day). He likes holding the drink in the mouth for several seconds and tasting before swallowing. He denied anything unusual in his diet, medical history, allergic history, and family history of dental problems. He also denied symptoms of gastroesophageal reflux, odontalgia, xerostomia, and bruxism.
Dental examination found that crescent-shaped lesions were present on the cervical region of the buccal and labial surfaces of the teeth of this patient (Figs.). No lesions were found in the palatal and lingual surfaces (Fig.). Different stages of lesions could be seen on the teeth. Severe decays (caries cavities shown by arrows in Figs.) were present in the incisors and the canines, while less severe lesions (white spot lesions shown by arrowheads in Figs.) were noted on the premolars and the molars. The pulpal surfaces of erosive lesions contained brown-colored, leathery, carious dentin. None of the pulp cavities were involved. The patient did not report pain or sensitivity associated with any of the affected teeth. A comprehensive periodontal examination revealed no signs of attachment loss, and plaque deposits and calculus were only found on the mandibular incisors, with minimal bleeding on probing. The maxillary front teeth remained asymptomatic on percussion, palpation, and cold testing.
The maxillary and mandibular teeth
Buccal caries had also impacted teeth 17 and 27. And more extensive buccal and occlusal caries were seen in teeth 18 and 28. Caries of tooth 27 had impacted the pulp, above which there were lots of grey debris. The patient reported no pain on cold testing and percussion, but a severe pain when probing into the pulp cavity.
The oral mucosa was moist, pink, and without lesions. There was no salivary gland enlargement bilaterally. The saliva was clear and flowed freely from salivary ducts bilaterally. Normal pooling of saliva was noted on the floor of the mouth. The remainder of the soft-tissue examination was normal.
Finally, the history and the symptoms of this patient confirmed the complex diagnosis of dental erosion and dental caries. On one hand, dental erosion is defined as the physical result of acid without bacterial involvement. Early stage of dental erosion includes a smooth surface. Advanced stages include developing enamel concavities, lesions with longer depth than width, undulating borders, and an intact border of enamel along the facial gingival margin. In severe cases of dental erosion, the entire occlusal morphology of the tooth disappears (Lussi et al., 1993
). The pattern of erosion is related to the frequency the dental tissue is exposed to acidic fluid. In this case, the patient likes holding the drink in around the vestibular groove. The erosive acid of drink may have demineralized the cervical region of the tooth. On the other hand, the high sugar intake and bad oral hygiene pattern of the patient also caused bacterial infection, i.e., the dental caries.
Considering that excessive intake of soft drink and poor oral hygiene pattern are likely etiologic factors, we recommended the patient to reduce soft drink intake and contact time of acids, not to hold drinks in the mouth, and to use fluoride or remineralizing toothpaste to brush the teeth at least twice a day, but avoid toothbrushing immediately after soft drink intake.
Since there was gingival hyperplasia around the lesions, treatment plan for the patient included gingivectomy and composite resin restoration. The high-frequency electrosurgery was used to remove excessive gingival tissue following a local anesthesia, and a composite resin Filtek™ Z350 (3M ESPE, St. Paul, MN, USA) was applied to restore the lost tooth structure.