May 2005 DentaIUpdate 2l3

RestorativeDentistry
Gregory Antonarakis
|ncisor Toothwear caused by a
Dietary Habit |nvolving Chillies -
A Case Peport
Abstract: Toothwear cases can vary dramatically in their presentation, with some displaying quite peculiar patterns. This case report
outlines a patient's unusual eating habit that had led to a localized pattern of toothwear affecting his maxillary and mandibular central
incisors. The patient had a habit of eating fresh chillies between his incisors after most evening meals, this was followed by immediate
toothbrushing, which he had done for many years. This case illustrates that, not only is diet analysis important in identifying aetiological
factors in toothwear cases, but also dietary habits.
CIinicaI ReIevance: Discovering the aetiological factors associated with toothwear cases can often be difficult. This case demonstrates
that a thorough history is required to identify associated factors, and the use of diet analysis sheets can be useful when questioning alone
provides little information about the possible causes of toothwear.
Dent Update 2005, 32: 213-216
Toothwear and its management is an
increasingly common clinical problem.
l

This non-carious destructive process is
likely to be multifactorial in nature.
2
Thus
identifying specific causative factors can
often be difficult in patients with toothwear.
|t is recommended that the first stage of
management in toothwear cases is to try
and identify the cause(s). This information
may have an impact on the long-term
prognosis of the affected dentition and any
restorations subsequently provided.
3
Toothwear is either associated
with erosion, abrasion, attrition or
abfraction acting singly or in combination.
Lxtrinsic acids found commonly in the
western diet are considered important
aetiological factors in the process of
erosion. |t is therefore not surprising that a
lot of research interest has been centred on
this, particularly acidic drinks.
4
|dentifying
dietary factors is therefore considered
an import part of history taking. |t is also
considered important to discover how
acidic foods and drinks are consumed, as
well as the quantity and frequency.
Case Report
A self-referred 59-year-old male
attended the Department of |ntegrated
Dental Health at the University of wales
College Dental School in 2002. The patient
presented complaining of sensitivity and
aesthetic concerns associated with his
maxillary and mandibular central incisors.
The patient had been aware of these
Cregory S Antonarakis, 8DS, 8Sc,
Dental Practitioner, Clinique Dentaire
de la 1eunesse, Glacis de Pive ll, l2ll
Geneva, Switzerland and Liam D Addy,
8DS, MPDS, MPhil, Specialist Pegistrar in
Pestorative Dentistry, Cardiff University,
Dental School, wales College of Medicine,
Heath Park, Cardiff, CPl4 4X.
problems for a number of years and was
concerned by the progressive deterioration
in his dental appearance.
Clinical examination revealed
localized toothwear on both maxillary and
mandibular central incisors. The mandibular
central incisors had lost all the labial enamel
Liam Addy
Figure 1. The clinical presentation with wear
affecting the maxillary and mandibular central
incisors.
2ESTORATIVE$ENTISTRY
2l4 $ENTALUpdate May 2005
and the dentine appeared stained, possibly
by dietary foods. This stained appearance
was similar on the maxillary central incisors
but was confined to the mesial part of the
labial surface. A vertical region of toothwear
was apparent in the midline, approximately
8 mm wide. Some incisal edge chipping
was visible on the mesial edge of both
maxillary incisors (Pigure l). All four incisors
responded positively to pulp testing and
there was no radiographic evidence of
periapical change. Clinical photographs and
silicone impressions for study models were
taken, providing a permanent record of the
state of wear at presentation.
The medical history provided
no definitive aetiological factors for this
presentation. The patient had a myocardial
infarct in l99l and suffers from angina and
hypercholesterolemia. He is also a type
|| diabetic and suffers from a duodenal
ulcer. He takes a number of medications
to control these, including soluble aspirin
(75 mg/day), lipostat, GTN spray, metformin
and omeprazole. A chairside history did
not identify any possible habits, oral
hygiene practices or dietary causes for the
presentation. The patient was then given a
diet analysis sheet to keep for three days.
He was asked to record everything he ate
and drank, the quantity, and the time of
consumption over a three-day period.
Analysis of the diet sheet did
not identify anything out of the ordinary,
with the exception of eating fresh chillies
after most evening meals. On further
consultation with the patient it was
disclosed that he ate one fresh green chilli
after every meal and that he had done this
for a number of years. (Pigure 2 shows the
type of chillies he ate.) This habit included
holding the chillies against his central
incisors and chewing them in this position
for a prolonged period of time. This was
subsequently followed by toothbrushing
with toothpaste.
An internet search identified the
fact that chillies have a varied pH, ranging
from 3.5 to 4.3 and they contain up to three
times the amount of ascorbic acid found
in many citrus fruits.
5,6
Purther questioning
into the reason for this habit identified that
he did it for health reasons. He suggested
that the chillies have an anticoagulant effect
and that is why he had taken up eating
them, following his heart attack. A Pub-
Med search identified that the capsaicin in
chillies prevents blood platelet aggregation
and thus reduces the risk of cardiovascular
disease.
7
The effect of this eating habit
on his dentition was discussed and he
was provided with preventive advice
with regards to diet and the timing of
toothbrushing following eating and
drinking. The patient's chief complaint with
regards to aesthetics was then dealt with.
He was provided with ceramic veneers
on his lower central incisors and direct
placement composite was applied to the
areas affected on the upper central incisors
(Pigure 3).
$ISCUSSION
This case illustrates a number
of interesting issues in the management of
toothwear cases, and some of the current
thoughts on the relationship between
erosion and abrasion. Diet analysis is
considered to be an important part of
history taking in toothwear cases, but
patients may not be forthcoming with
possible causes. This may, in part, be
owing to the line of questioning that is
used influencing their thought processes,
or because they do not relate an eating
habit with their toothwear. The use of diet
analysis sheets in these situations can be
very helpful. Not only can they identify
dietary intakes that could potentially be
involved in the process, but they enable
clinicians to discuss with patients the way in
which they eat or drink certain foods.
The patient's pattern of
toothwear was erosive in nature owing
to the low pH of the chillies being held in
close proximity to his incisors. The nature
in which he ate the chillies, rubbing on the
central incisors, probably had an abrasive
effect, worsening the tooth substance loss.
The degree of tooth substance loss was
also probably further accentuated by the
immediate toothbrushing. These clinical
findings relate well to much of the available
evidence from INVITRO and INVIVO studies
on dental erosion and the relation between
erosion and abrasion. During an erosive
challenge, behavioural factors may modify
the erosion process. The way dietary acids
are introduced into the mouth will affect
which teeth are contacted and, possibly, the
clearance pattern.
8
The conclusions of this
study are clearly illustrated in this case by
the band-like erosion of the incisors owing
to the chillies being localized to that area
during consumption.
Lisenburger ETAL. identified
in their INVITRO study that simultaneous
abrasion and erosion caused significantly
greater wear of enamel than sequential
erosion and abrasion. They also
hypothesized from these results that one
might expect the chewing of fibrous acidic
foods to be associated with a higher rate
of wear INVIVO.
9
The clinical presentation
of this case would seem to support this
hypothesis.
Aspirin has been implicated in
dental erosion but the localized nature of
this defect ruled it out as an aetiological
factor in this case.
l0
All patients, but particularly
those with problems of toothwear
suspected to be caused predominantly
by erosion, should be advised to delay
toothbrushing following an acid challenge.
&IGURE . Green chillies of the type eaten by the
patient.
&IGURE . Labial veneers were used to restore the
lower incisors and composite was added to the
maxillary central incisors.
RestorativeDentistry
2l6 DentaIUpdate May 2005
A number of authors have documented that
abrasion of eroded demineralized enamel
and dentine increases greatly the loss of
hard tissue compared with |ust exposure
to acid alone.
ll-l4
Attin ETAL. concluded
that, for the protection of exposed dentine,
teeth should not be brushed for a period
of at least 30 minutes following an acid
attack to allow for acid clearance and
remineralization to occur.
l4
The abrasion
resistance of enamel softened by acid,
however, has been shown to take up
to one hour to re-establish.
l5,l6
Patients
should therefore be advised to delay
brushing for at least an hour following
eating or drinking.
The causes of toothwear
should be considered a dynamic process.
what occurs before, during and after
an erosive challenge will determine if
permanent and progressive loss of tooth
substance will take place. The other
causes of toothwear, ie abrasion and
attrition, are accelerated by erosion and
vice versa.
l7
ConcIusion
Lstablishing the eating and
drinking habits of patients with toothwear
is important. |t is essential not only to
find out what they eat and drink, but also
how frequently and how they do it. A
discussion on the timing of toothbrushing
following the consumption of food or
drink should also make up an important
component of the history taking. This
information may aid the practitioner
in providing correct dietary advice and
for devising suitable provisional and
definitive treatment plans.
References
l. Kelleher M, 8ishop K. Tooth surface
loss: an overview. "R$ENT* l999, 186:
6l-66.
2. Smith 8GN, 8artlett Dw, Pobb
ND. The prevalence, etiology and
management of toothwear in the
United Kingdom. *0ROSTHET$ENT l997,
78: 367-372.
3. watson ML, 8urke P1T. |nvestigation of
patients with teeth affected by tooth
substance loss: a review. $ENT5PDATE
2000, 27: l75-l83.
4. 8artlett D, Smith 8GN. Definition,
classification and clinical assessment
of attrition, erosion and abrasion of
enamel and dentine. |n: 4OOTH7EARAND
3ENSITIVITY. Addy M, Lmbery G, Ldgar
wM, Orchardson, eds. London: Martin
Dunitz, 2000, pp.87-93.
5. www.independantliving.co.uk/
vitamins3.htlm.
6. Giunta 1L. Dental erosion resulting from
chewable vitamin C tablets. *!M$ENT
!SSOC l983, 107: 253-256.
7. Tsuchiya H. 8iphasic membrane effects
of capsaicin, an active component in
Capsicum species. *%THNOPHARMACOL
200l, 75: 295-299.
8. Millward A, Shaw L, Harrington L,
Smith A1. Continuous monitoring of
salivary flow rates and pH at the surface
of the dentition following consumption
of acidic beverages. #ARIES2ES l997, 31:
44-49.
9. Lisenburger M, Shellis PP,
Addy M. Comparative study of wear
of enamel induced by alternating
and simultaneous combinations of
abrasion and erosion INVITRO. #ARIES
2ES 2003, 37: 450-455.
l0. Sullivan PL, Kramer wS. |atrogenic
erosion of teeth. *$ENT#HILD l983, 50:
l92-l96.
ll. Davies w8, winter P1. The effect of
abrasion on enamel and dentine after
exposure to dietary acid. "R$ENT* l980,
148: 253-256.
l2. Attin T, Putz 8, 8uchalla w. )NVITRO
evaluation of different remineralization
periods in improving the resistance of
previously eroded bovine dentine against
tooth-brushing abrasion. !RCH/RAL"IOL
200l, 46: 87l-874.
l3. Attin T, Knofel S, 8uchalla w, Tutuncu P. )N
SITU evaluation of different remineralization
periods to decrease brushing abrasion of
demineralised enamel. #ARIES2ES 200l, 35:
2l6-222.
l4. Attin T, Siegel S, 8uchalla w, Lennon AM,
Hannig C, 8ecker K. 8rushing abrasion of
softened and remineralised dentin: an INSITU
study. #ARIES2ES 2004, 38, 62-66.
l5. 1aeggi T, Lussi A. Toothbrush abrasion of
erosively altered enamel after intraoral
exposure to saliva: An INSITU study. #ARIES
2ES l999, 33: 455-46l.
l6. Attin T, 8uchalla w, Gollner M, Hellwig L.
Use of variable remineralization periods
to improve the abrasion resistance of
previously eroded enamel. #ARIES2ES 2000,
34: 48-52.
l7. Zero DT, Lussi A. Ltiology of enamel erosion:
intrinsic and extrinsic factors. |n: 4OOTH7EAR
AND3ENSITIVITY. Addy M, Lmbery G, Ldgar
wM, Orchardson, eds. London: Martin
Dunitz, 2000, pp.l2l-l39.
Abstracts
SHDULD W DISPDS DF DISPDSAL
7RAYS FDR CRDWN AND RIDC WDRk!
Distortion of disposable plastic stock trays when
used with putty vinyl polysiloxane impression
materials. GC Cho and wwL Chee. *OURNALOF
0ROSTHETIC$ENTISTRY 2004, 92: 354-358.
| am delighted to report on this
paper, as the results are in accord with work | did
myself many years ago. The authors compared
the accuracy of impressions made in a rigid metal
stock tray with those made in six commercially
available disposable plastic stock trays. They
found a significant difference in all cases, and
concluded that impressions made in such trays
suffered distortion both across the arch and in
cross-section, resulting in serious flaws in the fit of
any restorations subsequently constructed.
The 1ournal states that the clinical
relevance of this research is as follows.'|f
commercially available disposable plastic trays
are unable to resist deformation when the trays
filled with high-viscosity impression materials
are placed over the dental arches, the resultant
impressions obtained may not be dimensionally
accurate. while the impressions may appear
adequate to visual inspection for completeness
and detail, the lack of rigidity of the tray may lead
to inaccuracies'.
This is one of those papers easy to
dismiss because it does not accord with one's own
beliefs, or because one doesn't use high viscosity
impression materials. The wise practitioner,
however, looking for greater accuracy and fewer
errors, may consider further the implications
reported here of the use of disposable plastic
impression trays.
Peter Carrotte
CIasgow DentaI SchooI