It took a bevy of specialists and faculty members at the New York University (NYU) College of Dentistry to unravel the mystery of how a 52-year-old male patient lost nearly all the enamel on his teeth in five months.
The bizarre case, to be published in the September 2011 Journal of Prosthetic Dentistry, has prompted warnings about the impact improperly maintained swimming pools can have on tooth enamel.
The patient -- suffering from extreme, rapid enamel loss, dark staining, and tooth sensitivity so severe that even breathing became painful -- was referred to the faculty practice at NYU in October 2010 after previous consultation with two dentists and two physicians. At NYU he was seen first by an oral pathologist, then Leila Jahangiri, BDS, DMD, MMSc, a clinical associate professor and chair of the department of prosthodontics at the College of Dentistry.
— Leila Jahangiri, BDS, DMD, MMSc
Dr. Jahangiri and her colleagues observed that the facial and occlusal surfaces of maxillary and mandibular anterior teeth extending to the second premolars bilaterally displayed a lack of enamel. They also noticed a loss of tooth structure resulting in diastemata. The remaining structure was "heavily stained, partially porous, partially glossy and with definitive 'finish lines' along the free gingival margins," Dr. Jahangiri noted. In addition, the staining returned despite professional dental prophylaxis.
"Every time that I would go to an academy meeting, everybody was puzzled," Dr. Jahangiri said. "This was so aggressive. The enamel portion of his tooth structure was completely removed."
However, the patient did not suffer decay, pulpal pathology, developmental defects, or changes in the periodontal ligament.
Finding the source of the erosion sparked debate and suspicion about the patient, according to Dr. Jahangiri. For example, from the appearance of his anterior teeth -- which looked like they had been prepped for that particular restoration -- "some dentists suggested that he was in the middle of laminated veneer therapy, quit before it was completed, and then came to us for treatment," she recalled. "But he didn't even know what they were talking about or anything about that type of treatment."
Others suggested that the patient might be bulimic or anorexic, Dr. Jahangiri added.
"He was losing weight and he's a very fit individual; he looked like somebody who could be anemic, bulimic, or anorexic because he was very thin and tall," she said.
The possibility of acid reflux also was discussed.
"I knew that was incorrect right off the bat because the pattern of the location of the erosion would be different," Dr. Jahangiri explained. "It would be on the inner surfaces of the teeth, not the outer surfaces."
A gastroenterologist scoped the patient and confirmed that he did not suffer from any regurgitation disease. Then a referral to a psychiatrist ruled out eating disorders. The patient was a self-described "office type," so the erosion also could not be attributed to his occupation, Dr. Jahangiri said.
Highly acidic environment
Stumped, she sat down with the patient for 90 minutes of history-taking. In the course of their conversation, she found out that he had been diagnosed with multiple hemangiomas in his liver five months prior. As a safeguard against spontaneous bleeding, his physician had recommended that he refrain from jogging.
The fitness-minded patient decided that he would swim instead, and did so for 90 minutes a day over the course of the summer in the pool at his home. With all the other possibilities eliminated, Dr. Jahangiri determined that the cause of the enamel erosion was likely an improperly chlorinated swimming pool.
"It's a highly acidic environment," she said. "He was swimming an hour and a half a day; therefore, his fitness level was high. He was getting sensitive teeth so he didn't want to eat or talk because even the air from breathing would hurt his teeth. That's where the weight loss came from."
She also learned that he had a rash on the side of his abdomen, the source of which baffled his dermatologist.
"After we diagnosed him, I asked him to go back to the dermatologist and see if it could be from the acidity from the pool chlorination, and they absolutely confirmed it," Dr. Jahangiri said.
The patient's pool had not been professionally maintained. Instead, a gardener who had assured him that he was capable of treating the pool took care of it. To test their theory, weekly maintenance records were examined.
"We saw that it was highly, highly acidic," Dr. Jahangiri said.
As a former competitive swimmer, Dr. Jahangiri was stunned that such dramatic erosion could take place over a five-month period.
"So we looked at the literature and found a report from 1982 that had similar but not as aggressive findings," she said. "And there was an announcement from the U.S. Centers for Disease Control [and Prevention] in the 1980s about local dentists reporting milder erosions in competitive swimmers."
A properly chlorinated pool should have a pH between 7.2 and 7.8; the reports stated that significant pool-related dental erosion can take place when the pH of the water is in a range of 2.7 to 7.
"Ultimately, we restored him," Dr. Jahangiri said. "The issues were resolved, but it was a very expensive restoration."
Dentists should be aware that similar problems can arise from significant amounts of time spent in the pool, she noted.
"I am certain that the community of dental professionals isn't going to come across the extent and aggressiveness of the case that I saw," Dr. Jahangiri said. "But dentists should be aware."