How Have You Been Sleeping?

I specialize in and around the oral cavity, and honestly, if you asked me about your herniated disk or weird rash on your foot, my guess would be as good as yours. But sometimes systemic disorders appear in the mouth and that's when I come in handy.

Case in point: A long time patient who has not been in for about a year comes in for a cleaning and check up. He is a middle aged male with a non-contributory medical history and good oral hygiene. His dental history is only front veneers placed many years ago and still in good shape. The patient apologizes for "not coming in for so long because work has been crazy over the last year." His stress levels have risen dramatically. On exam, everything is within normal limits except for the inside part of his 3 front upper teeth. A close up picture is posted above. There is dramatic wear on the lingual aspect of 3 of his 4 incisors (1 tooth is crowns and thus covered in porcelain). None of his other teeth show this kind of wear.

So what's going on? I asked the patient how has he been sleeping the past few months? "Well, I probably get about 6 hours of sleep a night, but I don't think I've been sleeping all that well to be honest." Can you count the red flags so far?

1.Higher levels of stress
2.Not sleeping very well
3.New wear facets on upper teeth

I asked and the patient said he has not noticed any heart burn of late. I asked him if he has heard of Gastroesophageal reflux disease (GERD), condition in which the acidic stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach). Due to positioning of the body while sleeping, the acid tends to sit and wash at the backs of the front teeth. The patient said he's heard of it but he didn't think he had it. I recommended the patient see his physician regarding these new symptoms, but the patient said he was far too busy to do that. So I recommended him take an over the counter antacid before sleeping, and if he had a restful sleep than that might persuade him to see his physician for further testing.

Let's fast forward 6 months. The patient comes back for a cleaning and on asking him how things have been, he replies "really great. A few months ago, I took your advice because I was still sleeping poorly and felt pretty fatigued through the day. So I tried an antacid before sleep and I had my first good night sleep in months. The next week I saw my doctor and after some tests he diagnosed me with GERD. Working on my diet, my stress levels and taking medication, I've been doing really great and sleeping like a baby."

In the end, a little tooth wear was the beginning signs of a larger, more systemic medical disorder.