Gastroesophageal reflux disorder (GORD), or gastroesophageal reflux disease (GERD), can significantly impact oral health, especially in young patients.
The condition causes stomach acid to flow back into the oesophagus and mouth. If the damage worsens, this acid can erode the enamel, increasing tooth sensitivity, cavities and tooth loss.
Continuous exposure to stomach acid causes multiple dental concerns. Acidic environments in the mouth from frequent reflux can promote the growth of bacteria that cause tooth decay. Enamel erosion and bacterial activity increase the risk of developing cavities.
As enamel erodes, teeth become more sensitive to hot, cold and sweet stimuli. This sensitivity can make it uncomfortable for patients to maintain good oral hygiene, further exacerbating dental problems.
Dentists may be the first clinicians to detect signs of GORD and, therefore, play an important role in its screening (Howard et al, 2023). Early detection may prevent long-term gastro-oesophageal complications and progression of the tooth wear condition.
Dr Ash Soneji, known as ‘The Magic Dentist’ for his skills as a close-up card magician, is a general dentist at Queen Square Dental Clinic in Bristol. He recently tackled a challenging case of severe erosive tooth wear in a young patient in his 30s. The primary challenge was to create restorative space while addressing the root cause of erosion – GORD.
Ash’s approach involved a collaborative multidisciplinary effort that included an orthodontist and the patient’s GP. His restorative plan used transitional composite build-ups as a template for orthodontic movement and future indirect restorative work. Preventive measures, including VOCO’s Remin Pro and fluoride varnishes, were also employed to stabilise the oral environment and address underlying issues. Here, he answers questions about the case.
How did you approach this case?
A man in his early 30s came to me after exhausting all other options. He had consulted several dentists, who indicated he was at risk of losing some of his anterior teeth. The damage, particularly to the upper 2-2 and UR3, was severe, and the likelihood of pulpal exposure was very high. This deterioration was progressing rapidly.
Understandably, the patient was anxious and demotivated. We took an extensive history, carefully considering his medical background, diet and lifestyle. Once we established trust, the patient shared more personal information. He confirmed he often woke up with a dry cough and suffered from reflux.
Given that the erosion was localised to the upper anterior teeth, it seemed likely that gastric acid was the culprit. While generalised erosion is typically caused by external or environmental factors, localised erosion in this area often points to vomiting or gastric reflux. This detail was crucial, and we collaborated closely with the patient’s GP.
Once we had a plan to manage the reflux, we could begin the restorative dentistry. Composite restoration emerged as an excellent option. Even though the reflux wasn’t entirely under control, ethically, we had a duty to prevent further damage to his teeth, so we took decisive action.
Why choose the injection moulding technique and GrandioSO Heavy Flow?
Familiarity with products and techniques often informs my clinical decision-making. A few years back, my routine approach to this case was a semi-direct method where I created a wax-up, used it to produce a stent, and then fabricated palatal shells from that stent. This helps me to achieve the correct occlusion while free-handing the restoration’s buccal aspect.
In recent years, with advancements in digital technology, we can now design and print models and create mock-ups directly in the patient’s mouth, allowing for a trial smile and occlusal analysis before finalising treatment.
In this pre-orthodontic case, I used the injection moulding technique to help both the orthodontist and myself towards the desired tooth movement endpoint. This approach aims to prevent further damage and allow for orthodontic treatment to achieve specific restorative goals.
Although injection moulding may have its aesthetic limitations, especially with layering techniques, it remains reliable for addressing tooth wear and is a more widely used approach.
What are the benefits of these methods and materials?
GrandioSO Heavy Flow is a composite restorative material with a high filler content of 83%, making it very durable. It’s beneficial for patients who put a lot of stress on their teeth, and I often use it to handle heavy occlusal pressure. Although it might not be ideal for every patient with these restorations ultimately being replaced in ceramic, it provides an interim and more affordable solution for patients.
My experience with GrandioSO Heavy Flow has been very positive. Its durability in restorations has been consistently impressive, and I appreciate its viscosity, which works well with injection moulding and performs excellently when used with a well-fabricated stent.
What part did digital planning and pre-restorative orthodontics play in the success of this treatment?
Digital planning played a crucial role. It allowed the patient to preview the outcome and provide feedback, while allowing me to review the case and adjust the design before proceeding. This planning also helped ensure a precise occlusal scheme. Carrying out most of the planning in advance made the actual chairside work less stressful.
Visual aids, especially 3D models, are highly effective, and printing models and creating stents from them streamlined the process. Thanks to efficient techniques like injection moulding, building up a worn tooth – which could take me up to an hour – can now be performed in less than 15 minutes, including clean-up. This efficiency reduces costs for patients and simplifies my workflow.
Please elaborate on how you offer minimally invasive methods for treating tooth wear and discrepancies in tooth shape.
The approach is often additive, especially when managing tooth wear and using the IM to build up the bite or increase the vertical dimension. This is considered minimally invasive because it allows for a test-drive with composite restorations before converting to ceramic. This way, the final shape and position are already set, so I mainly adjust the composite once in function in the patient’s own mouth – the best articulator!
I use this additive method to create space while preserving tooth structure.
How have digital smile design and intra-oral mock-ups enhanced your communication with patients?
Digital smile design is a highly adaptable tool in modern dentistry, combining photography with assessing a patient’s natural resting position. It involves analysing factors like tooth display at rest to guide the creation of a youthful or more age-appropriate smile. The process includes adjusting tooth shapes based on patient preferences, which improves communication and involvement in the treatment plan.
A key advantage is the ability to make adjustments before any irreversible treatment. This approach, often involving intra-oral mock-ups, allows patients to experience a preview of the outcome, enhancing satisfaction and confidence. For instance, using materials like GrandioSO Heavy Flow for an injection moulded mock-up can be an invaluable visual communication tool.
What are the benefits of using VOCO’s GrandTEC material for splinting teeth?
I frequently use VOCO’s GrandTEC and GrandioSO Heavy flow materials for splinting teeth, especially periodontally involved teeth. GrandTEC’s fibre-reinforced composite, GrandiSO’s high filler content (83%) and advanced nanohybrid technology ensure excellent strength and durability when splinting teeth.
You run training workshops on advanced composite restorative techniques. Tell us more…
My two-day course showcases contemporary techniques and offers clinical tips and tricks. I share the mistakes I’ve made and the valuable lessons I have learned through my case workflows. These workshops focus on critical development areas such as photography, smile design, isolation and anterior and posterior teeth restoration.
My approach is designed to simplify complex techniques, aiming to inspire and accelerate the progress of dental professionals, whether they are just starting in restorative and aesthetic dentistry, looking for a refresher or needing to reignite their passion. We combine case-based scenarios, video demonstrations and hands-on practices to reinforce these techniques. It’s an immersive two-day experience filled with energy and a touch of magical entertainment.
For more information about GrandioSO Heavy Flow, visit www.voco.dental.
Fill in the form to join the waitlist for a hands-on course with Dr Ash Soneji www.voco.dental/en/form/selection-hands-on-course.aspx.
This article is sponsored by Voco.
Reference
- https://www.nature.com/articles/s41415-023-5677-0
