HANDS ON

Dental ErosionOverly chlorinated swimming pool water

Fig 1.—Frontal view of initial clinical presentation. (Courtesy ofJahangiri L, Pigliacelli S, Kerr AR: Severe and rapid erosion of dentalenamel from swimming: A clinical report. J Prosthet Dent 106:219-223, 2011.)

Background.—Dental erosion is the pathological lossof dental hard tissues caused by intrinsic or extrinsicacid without bacterial involvement. Among the extrinsicinfluences are those related to environment or occupa-tion. A patient with severe and rapid erosion of dentalenamel caused by improper chlorination of a swimmingpool was reported.

Case Report.—Man, aged 52 years, complained of ex-tremely sensitive teeth and had clinical evidence of darkstaining and rapid enamel loss. A photograph from 5months previously showed intact dentition, but the teethhad deteriorated despite professional dental prophylaxis.Two dentists found no obvious extrinsic causes, and a gas-troenterologist and psychiatrist ruled out intrinsic causes.

The initial evaluation revealed a lack of enamel on thefacial and occlusal surfaces of the maxillary and mandibularanterior teeth extending to the second premolars bilater-ally. Tooth structure appeared heavily stained, partially po-rous, and partially glossy, with definitive ‘‘finish lines’’along the free gingival margins (Fig 1). Diastemas produceda poor esthetic appearance, but the patient had no evi-dence of decay, pulpal pathology, changes in the periodon-tal ligament, or developmental defects.

The patient was assessed for the relationship betweenmaxillary and mandibular teeth in the physiologic rest posi-tion, occlusal vertical dimension, and vertical dimension ofspeech. He had reduced horizontal and vertical overlapsand demonstrated excessive minimum speech distance inthe canine and premolar regions of 3 to 4 mm. Esthetically,the patient’s smile revealed deficient length of the remain-ing tooth structure and exposed dentin. Severe, rapid,enamel erosion was diagnosed.

Neither occupational nor dietary factors appeared to besufficient to cause the enamel erosion. However, his physi-cian had advised him not to jog because of multiple heman-giomas of the liver, so he had begun an aggressiveswimming regimen of 90 minutes of breaststroke daily athis home pool. Tests of the pool revealed acidic pool waterresulting from improper chlorination.

Treatment was undertaken to manage the dental sensi-tivity and extrinsic staining and to halt the loss of toothstructure. The patient had dental prophylaxis under localanesthesia plus a jet of sodium bicarbonate powder toremove resilient extrinsic staining. He was also given a top-ical fluoride dentifrice and a paste containing caseinphosphopeptide-stabilized amorphous calcium phosphatecomplexes to apply at home.

The patient selected bonded labial veneers for the inci-sors and canines and adhesively bonded onlays for the pre-molars. Diagnostic casts and a facebow transfer were made,then casts were mounted in a semi-adjustable articulator.Condylar angles were set using lateroprotrusive records.A diagnostic waxing was performed, with interproximalcontacts used to determine ideal tooth proportions. Thecasts were duplicated in stone, and a 0.5-mm vacuum-formed matrix was fabricated. The mandibular anteriorregion had insufficient space to accommodate restorativematerial, so the vacuum-formed matrix was modified andused intraorally as an ideal reduction guide for the anteriormandibular area (Fig 5). After fabricating a custom incisalguide table, composite resin splinted provisional restora-tions were made.

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Fig 7.—Buccal view of porcelain veneer restorations after cemen-tation. (Courtesy of Jahangiri L, Pigliacelli S, Kerr AR: Severe andrapid erosion of dental enamel from swimming: A clinical report.J Prosthet Dent 106:219-223, 2011.)

Fig 5.—Vacuum-formed matrix as preparation reduction guide formandibular anterior teeth. (Courtesy of Jahangiri L, Pigliacelli S,Kerr AR: Severe and rapid erosion of dental enamel from swimming:A clinical report. J Prosthet Dent 106:219-223, 2011.)

Minimal preparations were needed because of theenamel loss from the facial and occlusal surfaces of the af-fected teeth. The remaining enamel margins were main-tained in the hope of improving bonding of therestorations. Tooth preparations were limited to smoothingsharp edges and slightly opening interproximal contacts tofacilitate restorative fabrication in the maxillary incisor andcanine regions.

After pronunciation, occlusion, and esthetics werechecked, the definitive impressions weremadewith an elas-tomeric impression material. Prefabricated interim com-posite resin restorations were spot etched and bonded tothe prepared teeth. Impressions were poured with stone,and dies were fabricated. The laminate veneer and onlayrestorations were waxed to anatomical contours, then cutback about 0.6 mm, so ceramic could be applied. Wax pat-terns were sprued and invested, ingots pressed, and lami-nates were fitted to the dyes and the margins werefinished. Porcelain was applied and glazed. Hydrofluoricacid was applied to the intaglio surfaces of the restorationsfor 20 seconds. Provisional restorations were removed, andteeth were polished with pumice and water, then definitiverestorations were adjusted to correct fit and occlusion. Ce-mentation was accomplished using a composite resin lutingagent (Fig 7).

Discussion.—The cause of the patient’s rapid and de-structive enamel erosion was identified as highly acidic

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water in the pool where he swam daily. Treatment involvedeliminating his pain and sensitivity, then applying laminateveneers and ceramic onlays. This approach restored the pa-tient’s esthetics, speech, and occlusion.

Clinical Significance.—Dental erosion is usu-ally the result of exposure to chemicals in foodor liquids but can come from intrinsic factorssuch as vomiting, regurgitation, and acid re-flux. Less commonly, the cause is occupationalor environmental. This unusual case involvedimproper chlorination of the patient’s swim-ming pool. Treatment with minimally invasiverestorations using laminates and ceramic on-lays addressed the patient’s extreme sensitivityand achieved both optimal esthetics andfunction.

Jahangiri L, Pigliacelli S, Kerr AR: Severe and rapid erosion of dentalenamel from swimming: A clinical report. J Prosthet Dent 106:219-223, 2011

Reprints available from L Jahangiri, New York Univ College of Den-tistry, 423 E 23rd St, 16 North, New York, NY 10010; fax: 212-995-4686; e-mail: lj14@nyu.edu