Shahid Ali Mirani1 BDS, PhD
Feroze Ali Kalhoro2 BDS, FCPS
Naresh Kumar3 BDS, PhD
Abdul Bari Memon4 BDS, PhD
Faisal Bhangar5 BDS, FCPS
OBJECTIVE: The aims of this study were to determine the relationship between dietary habits and dental erosion (DE) and to determine the prevalence of DE and degree of severity in dental students of LUMHS, Jamshoro, Pakistan.
METHODOLOGY: Two hundred dental students fulfilling the inclusion criteria were selected with convenient sampling. The design of the study was cross sectional. The Dental students with age from 18-25 years of either gender were included. All the information regarding variables of study like age, gender and dietary habits were obtained using a pre designed questionnaire. DE and its severity were recorded for anterior and posterior teeth.
RESULTS: The prevalence of dental erosion was 32 % (34 males and 30 females) being higher in males than females. Total 136 (68 %) students were at normal level, Moreover 37 subjects (58%) had DE in anterior teeth only. However 08 subjects (12 %) were seen with DE in posterior teeth only. In addition total 19 subjects (30%) were found to have DE in both anterior as well as posterior teeth. Out of 64 study subjects with DE 61 (95 %) had mild DE, only 03 (5%) subjects had moderate DE. No case of severe DE was observed in either anterior or posterior dentition. Association between dietary habits and DE was found statistically non significant in this study.
CONCLUSIONS: It is concluded that prevalence of DE is 32%, more common in male students and anterior teeth and there was no any case of severe DE. No significant association was found between DE and dietary habits.
KEY WORDS: Dental erosion, Prevalence, Lussi index, Dental students, Diet
HOW TO CITE: Mirani SA, Kalhoro FA, Kumar N, Memon AB, Bhangar F. Dietary Habits And Prevalence of Dental Erosion Among Dental Students Of Lumhs Jamshoro. J Pak Dent Assoc 2014;23(2):61-65.
Dental erosion (DE) is an acid-related loss of dental hard tissues that does not involve bacteria and is not induced with dental plaque. The etiological factors of dental erosion are divided into two groups, extrinsic and intrinsic factors . The dietary factors are the most common extrinsic erosive causes, which include acidic drinks, either pure fruit juices or carbonated soft drinks with added hydroxy organic and phosphoric acids. Time, type of drinks and its frequency of consumption have major influence in the development of an erosive tooth surface loss. In addition, bed time intake of fruit juices can cause severe tooth loss because of decreased salivary flow2, . The acids from dietary sources have distinct erosive potential. Citric acid has a significant destructive effect to teeth as it can chelate calcium in hydroxyapatite and form soluble citrates even after the pH rises. Some beers and herbal teas with low pH values have been reported to cause potential DE in vitro , . Frequent consumption of pickled foods can lead to tooth destruction as a result of high titratable acidity and a pH of 3.0 or even more acidic6. In literature, the intrinsic factors such as gastro esophageal reflux, vomiting and regurgitation related to gastroesophageal reflux disease, anorexia nervosa and bulimia have been reported to be account for up to 25% of all cases of DE 7. The loss of detailed surface microanatomy, rounded and glazed appearance, hypersensitivity of teeth especially among younger persons are considered as common effects of DE. In extensive cases, DE can compromise aesthetic and performance of the pulp5.
Epidemiologic studies with regard to DE have been carried out worldwide. The findings of such studies revealed that the prevalence of DE varies noticeably across the world and between age and gender groups6. Dugmore and Rock and Al-Dlaigan et al. identified a significantly higher prevalence of DE in boys than girls8,9. In contrast, Bartlett et al.10 found a higher prevalence of DE in females. Since the number of DE cases is increasing; this could be possibly as a result of variation in dietary habits. The data of DE and its relationship with dietary habits in dental students are scarce, so the purpose of this study was to determine the relationship between dietary habits and DE and prevalence of DE and degree of severity among dental students of LUMHS Jamshoro. The findings of this study will be beneficial for developing the future policies against the various factors in preventing the dental erosion and promoting healthy diet.
Two hundred dental students fulfilling the inclusion criteria were selected from July 2011 to December 2011 with a convenient sampling technique. The design of the study was cross sectional. The dental students with age from 18-25 years of either gender were included and those with gross dental defects such as amelogenesis imperfecta, dentinogenesis imperfecta, rampant caries, fixed orthodontic appliances and medically compromised conditions were excluded. Informed written consent was obtained from the students. All the information regarding variables of study like age, gender and dietary habits were obtained through a pre designed questionnaire 11 consisting of close ended questions. The clinical examination was performed on dental chair using examination instruments: mirror, tweezer and probe. DE and its severity were recorded for anterior and posterior teeth using modified index of Lussi et al 12. The data were analyzed by SPSS statistical version 16. The variables analyzed were prevalence of dental erosion, its severity and dietary habits. The association between DE and dietary habits was established using chi-square test. P value < 0.05 was taken as significant.
Out of 200 study subjects, 89 (44.5 %) were males and 111 (55.5%) were females. In this study prevalence of DE was found 32 % in study participants (Table I).
Table I: Prevalence of Dental erosion
According to Modified Lussi Index severity of DE was categorized into four groups from normal to severe DE in anterior and posterior teeth respectively. Total 37 subjects (58%) had DE in anterior teeth only, all those subjects had mild DE (Grade 1) . However 08 subjects (12%) were seen with DE in posterior teeth only with Grade 1 DE . In addition total 19 subjects (30% ) were found to have DE in both anterior as well as posterior teeth (Table II,III and IV ). Prevalence of DE was more common in anterior teeth compared to posterior teeth
Table II: Dental Erosion Severity in Anterior Teeth only
Table III: Dental Erosion Severity in Posterior Teeth only
Table IV: Dental Erosion Severity in Anterior and Posterior teeth both
(p=0.000). Out of 64 study subjects with DE 61 (95 %) had mild DE, only 3 (5%) subjects had moderate DE, none of study subjects had severe DE. The frequencies of drinks and foods intake were divided into three categories; once a week, more than once a week or no consumption. The majority of students i.e. 58 (5%) consumed carbonated drinks more than once a week, however intake of lemon tea and sports drinks was rare; total 75% and 56 % of students reported no intake of sport drinks and lemon tea respectively. Consumption of fruits and fruit juices was common in study participants. Total 72 % of students consumed fruits more than once a week and 70 % of students took fruit juices more than once a week. Use of lemon tea and acidic drinks was not frequent. Consumption of drinks through straw was reported by 68 % of students whereas 32% did not use straw. No statistically significant association was observed between DE and various dietary habits such as intake of carbonated drinks, sport drinks, acidic drinks (Table V).
In the current study, the prevalence of DE was found 32%. This prevalence is comparable with the results of Caglar et al. 13 and Correr et al. 14 who identified 28% of 11-year-old children and 26% of 12-year-old children affected by DE, respectively. On the other hand, recent surveys highlighted that the prevalence of DE ranging from 11.6 to 100% on the permanent dentition of children in different countries9,15. The variation in prevalence among these studies may be in part elucidated by differences in the diagnostic criteria and indices. Furthermore, outcome of prevalence data may be influenced by socio-economic, cultural, and geographic aspects.
The severity of DE in our study demonstrated that the loss of enamel contour (Grade 1) occurred most frequently (95 %) in anterior and posterior teeth, and
Table V: Frequency of consumption of drinks
only a small proportion of tooth surfaces were affected with dentine exposure (Grade 2) (5%) in anterior as well as posterior teeth, this is in accordance with results of Wang et al. and Peres et al 11,16. None of the 64 students with DE presented with Grade 3 DE which supports the results of Jensdottir et al 12.
The consumption of fruits and fruit juices was common in students. Total 72 % of students consumed fruits more than once a week and 70 % of students took fruit juices more than once a week. However, this study could not find a significant association between symptoms of DE and frequency of consumption of fruit and fruit juices. Some researchers have also reported no relationship between DE and consumption of fruit as well as fruit juices17. On contrary, others have found a significant association19. In case control studies, a substantial risk of DE was observed when citrus foods were consumed more than twice a day20.
Fruit juices are more likely to cause DE compared to fruit itself 21. Conversely, we did not find any significant association between fruit juices and DE (p=0.225). This may be possibly due to low consumption of fruit juice and acidic foods in study participants. This study observed that there was no association between DE and frequency and amount of acidic drinks consumption. DE is more often reported to be related with acidic drinks in children22, adolescents,23 and adults24 when the utilization was high. However, such association did not occur in children25 when the consumption of acidic drinks was low. In this study, the number of subjects with frequent consumption of acidic drink was low, thereby resulted in a lack of significant association with DE occurrence. An additional possible reason is that current study used cross-sectional design which only
assessed dietary pattern for past two to three months. Dietary patterns during the data collection may not be the same with the dietary pattern when DE occurred. Moreover, DE is a progressive disease which results from frequent and long-term exposure to acidic drinks. This study did not specify whether acidic drinks were consumed with meal or as snack. It has been recommended that acidic food and drinks may be consumed with meals to reduce the risk of tooth erosion as saliva flow is high during meal time26. Finally, risk of DE is a multi-factorial in nature which is also influenced by the tooth composition, structure, saliva composition and milk intake which were not examined in this study due to time limitation. Further studies are highly recommended to get further insight into the above-said variables.
Limitations Of Study
This study was conducted in the specific geographic area of only one University, not the whole country. It was a single operator based study so operator bias could not be eliminated. There were no data on all potential causes of DE like gastro esophageal reflux disease (GERD). However, it has been tried in the current study to provide some information about the prevalence of DE and its association with dietary habits.
Our study provides evidence that DE is becoming a significant problem in adult University students. DE should receive more attention that promotes awareness in dentists to make an early diagnosis and to evaluate the different etiologic factors that identify children and adults at risk in Pakistan.
- Bargen J, Austin L. Decalcification of teeth as a result of obstipation with long continued vomiting. J Am Dent Assoc 1937; 24:1271-1273.
- Hunter ME,West NX, Hughes JA, Newcombe RG, Addy M. Erosion of deciduous and permanent dental hard tissue in the oral environment. J Dent 2000;28:257263.
- West NX, Hughes JA, Addy M. Erosion of dentine and enamel in vitro by dietary acids: The effect of temperature, acid character,concentration and exposure time. J Oral Rehabil 2000;27:875-880.
- Brunton PA,Hussain A. The erosive effect of herbal tea on dental enamel. J Dent 2001;29:517-520.
- Sushma Shankar Nayak et al. Dental Erosion among 12 Year Old School Children in Belgaum City- A Cross Sectional Study. Pak Paed J 2009;33: 48-57.
- Jarvinen V, Rytomaa I, Meurman JH . Localisation of dental erosion in referred population. Caries Res ,1992; 26:391-396.
- Donachie MA,Walls AWG. The tooth wear index: A flawed epidemiological tool in an ageing population group.Community Dent Oral Epidemiol 1996;24:152158.
- Dugmore CR, Rock WP. The prevalence of tooth erosion in 12-year-old children. Br Dent J. 2004 ;196: 279-282.
- Al-Dlaigan YH, Shaw L, Smith A. Dental erosion in a group of British 14-year-old, school children. Part I: Prevalence and influence of differing socioeconomic backgrounds. Br Dent J. 2001;190:145-149.
- Bartlett DW, Coward PY, Nikkah C, Wilson RF. The prevalence of tooth wear in a cluster sample of adolescent schoolchildren and its relationship swith potential Explanatory factors. Br Dent J. 1998;184: 125-129.
- Wang P, Lin H, Chen J, Liang H: The prevalence of dental erosion and associated risk factors in 12-13-yearold school children in Southern China BMC Public Health 2010;10:478. doi: 1186/1471-2458-10-478
- Jensdottir T, Arnadottir B, Thorsdottir I, Bardow A, Gudmundsson K, Theodors A ,Holbrook P: Relationship between dental erosion, soft drink consumption, and gastroesophageal reflux among Icelanders Clin Oral Invest 2004;8:91-96
- Caglar E, Kargul B, Tanboga I, Lussi A: Dental erosion among children in an Istanbul public school. J Dent Child (Chic) 2005;72:5-9.
- Correr GM, Alonso RC, Correa MA, Campos EA, Baratto-Filho F, Puppin-Rontani RM: Influence of diet and salivary characteristics on the prevalence of dental erosion among 12-year-old school children. J Dent Child (Chic) 2009;76:181-187.
- Ganss C, Klimek J, Giese K: Dental erosion in children and adolescents-a cross-sectional and longitudinal investigation using study models. Community Dent Oral Epidemiol 2001;29:264-271.
- Peres KG, Armenio MF, Peres MA, Traebert J, De Lacerda JT: Dental erosion in 12-year-old school children: a cross-sectional study in Southern Brazil. Int J Paediatr Dent 2005;15:249-255.
- Van Rijkom HM, Truin GJ, Frencken JE, Konig KG, van ‘t Hof MA, Bronkhorst EM, Roeters FJ: Prevalence, distribution and background variables of smoothbordered tooth wear in teenagers in the hague, the
Netherlands. Caries Res 2002;36:147-154.
- Al-Dlaigan YH, Shaw L, Smith A: Dental erosion in a group of British 14- year-old school children Part II: Influence of dietary intake. Br Dent J 2001;190:258261.
- Milosevic A, Bardsley PF, Taylor S: Epidemiological studies of tooth wear and dental erosion in 14-year old children in North West England Part 2: The association of diet and habits. Br Dent J 2004;197:479-483.
- Kunzel W, Cruz MS, Fischer T. Dental erosion in Cuban children associated with excessive consumption of oranges. Eur J Oral Sci. 2000;108:104-9.
- Grobler SR, Senekal PJ, Kotze TJ. The degree ofenamel erosion by five different kinds of fruit. Clin Prev Dent. 1989;11:23-28.
- O’Sullivan EA, Curzon ME. A comparison of acidicdietary factors in children with and without dental erosion. ASDC J Dent Child. 2000;67:186-192.
- Harding MA, Whelton H, O’Mullane DM, CroninM. Dental erosion in 5-year-old Irish school children and associated factors: a pilot study. Community Dent Health. 2003;20:165-170.
- Johansson AK, Lingstrom P, Birkhed D.Comparison of factors potentially related to the occurrence of dental erosion in high- and low-erosion groups. Eur J Oral Sci. 2002;110:204-211.
- Luo Y, Zeng XJ, Du MQ, Bedi R. The prevalenceof dental erosion in preschool children in J Dent. 2005;33:115-121.
- Moynihan PJ. The role of diet and nutrition in theetiology and prevention of oral diseases. Bull World Health Organ. 2005;83:694-699.
1. PhD Scholar, Dental Materials, Medical Research Centre, LUMHS, Jamshoro.
2. Associate Professor & Chairman, Department of Operative Dentistry, LUMHS, Jamshoro.
3. Assistant Professor & Incharge, Department of Science of Dental Materials, LUMHS, Jamshoro.
4. PhD Scholar, Community Dentistry, Medical Research Centre, LUMHS, Jamshoro.
5. Assistant Professor, Department of Operative Dentistry, LUMHS, Jamshoro.
Corresponding author: “Dr. Shahid Ali Mirani” < email@example.com >