Public Health · patient case question
What advice should Patient A be given about the lemons?
Patient case: Two conversations about habits
Patient: Two patients
Chief Complaint: A: “My teeth are getting thinner and they are sensitive to everything.” B: “I want to stop smoking this year.”
Background: A, 26-year-old female: eats five to seven whole lemons a day and has done for two years. Also grinds at night. No reflux symptoms, no history of disordered eating on direct questioning. Brushes immediately after eating. B, 45-year-old male: 25-year smoking history, roughly a pack a day. Two previous unaided quit attempts.
Findings: A: generalised loss of enamel with cupped occlusal surfaces, shortened incisors and a glassy appearance; the palatal surfaces of the maxillary anteriors are relatively spared.
Show answer and explanation
Correct answer: B. Reduce the frequency of consumption, rinse with water or milk afterwards, and delay brushing for about an hour
- A. Enamel already lost cannot be regrown, but PROGRESSION is entirely preventable — which is the whole point of the consultation. Doing nothing in a 26-year-old with this rate of loss is indefensible.
- B. CORRECT. Two levers matter. FREQUENCY of the acid challenge matters more than total quantity, so reducing how often she eats them is the primary intervention. And what happens immediately AFTER each exposure matters nearly as much: rinse with plain water, milk or a fluoride mouthrinse to neutralise and clear the acid, and DELAY BRUSHING for about an hour to let the softened surface remineralise before any mechanical contact.
- C. This is worse rather than better. Turning the fruit into a drink sipped through the day MULTIPLIES the number of separate acid exposures, and frequency is the variable that matters most. A drink taken quickly at a mealtime, ideally through a straw, is less damaging than the same volume sipped over an hour.
- D. This is the specific error the question exists to test, and it is what the patient is currently doing. After an acid challenge the enamel surface is transiently SOFTENED, and brushing it immediately mechanically removes that softened layer — converting erosion into erosion PLUS abrasion and accelerating the loss substantially.
Note: Add high-fluoride toothpaste (5000 ppm), a soft brush with a non-abrasive paste, and monitoring with study casts or standardised photographs so progression can actually be measured. Her bruxism compounds the loss, so a hard splint is indicated. And note the distribution: SPARED palatal surfaces argue for an EXTRINSIC dietary source rather than an intrinsic one. Where the palatal surfaces ARE affected, exclude gastro-oesophageal reflux and disordered eating.