Evaluation of Tooth Wear and its Causative Risk Factors Amongst Patients Attending Dental Hospital of Karachi



Ayesha Zafar                              BDS
Samira Adnan                            BDS, FCPS, MHPE
Naseer Ahmed                           BDS, FCPS
Maria Shakoor Abbasi              BDS, FCPS
Muhammad Adeel Ahmed        BDS, FCPS, MFDS RCSEd
Rizwan Jouhar                          BDS, FCPS
Saqib Hameed                           BDS, FCPS


OBJECTIVE: To assess the perception of patients visiting a dental OPD in Karachi regarding cross infection control measures
that should be taken in dental practice.
METHODOLOGY: A cross-sectional study was conducted at the OPD of Altamash Institute of Dental Medicine from January
to August 2020. A total of 546 patients aged 20-75 years of either gender coming for routine dental check-ups were included
in the study using non-probability convenience sampling. A well-structured and validated questionnaire was used to assess the
knowledge, attitude and practices of patients regarding cross infection measures that should be present in dental practices.
SPSS-25 was used to analyse the data. Descriptive statistics was used to calculate frequency and percentage of qualitative
(gender, socioeconomic and education status, knowledge attitude and practice levels of patients) and quantitative variables
(age groups). Chi-square test was used to detect the relation of patient's knowledge levels with potential factors like the age
groups, gender, socioeconomic and education status. The p-value of (< 0.05) was considered as significant.
RESULTS: Out of the total participants, 79.1% had good knowledge about cross infection control measures in dental practice.
Majority of the patients (84.6%) agreed that dentists should wear gloves during treatment, though majority were of the opinion
that a dentist can treat several patients with the same set of gloves. About 4.9% of the patients said that they ask the dentist to
wear face mask and gloves while treating them, and only 3.3% said that they ask the dentist about sterilization of instruments.
The knowledge level of patients showed variation with their education status but not with respect to socioeconomic status, age
and gender.
CONCLUSION: Although overall the patients visiting dental clinics had good perception and showed positive attitudes towards
cross infection control, the dental health practitioners need to disseminate basic technical information about the infection-control
practices required for safe dental practice to dental patients and the community at large.
KEYWORDS: cross infection, knowledge, dentist, dental patients, perception
HOW TO CITE: Zafar A, Adnan S, Ahmed N, Abbasi MS, Ahmed MA, Jouhar R, Hameed S . Evaluation of cross infection
control in dentistry; A patients’ perception study. J Pak Dent Assoc 2021;30(4):249-254.
DOI: https://doi.org/10.25301/JPDA.304.249
Received: 01 January 2021, Accepted: 15 June 2021

Tooth wear is a term defined as the loss of dental hard tissue in a damaged tooth if there is no existing dental caries or trauma.1 Tooth wear can be sub-classifies as attrition, erosion, abrasion and abfraction.2 Attrition is a mechanical type of wear, which results due to the grinding of teeth. Abrasion is also mechanical wear caused by oral hygiene measures and biting habits. Erosion is chemical wear that results from the ingestion of acidic foods /drinks/ gastroesophageal reflux.3-5 Abfraction is a non carious tooth loss which is characterized by v shaped notch
or wedge shaped at the cervical area of tooth.
inically and experimentally in combination.6 It might be unnoticeable in its initial developmental stage but it may affect aesthetics and appearance in some patients especially if anterior teeth are involved.7,8 Excessive tooth wear leads to hypersensitivity and exposed dentin.9
The prevalence of tooth wear varies with wide-ranging values reported due to different study populations, methodologies, recording indices used.10 These studies reported that the prevalence of tooth wear varies from one population to another. It was reported 38.6% in Pakistani
population11, 64% in Norway12,13 75% in Sweden14 and 95% in Saudi Arabia.7
There are many techniques to measure tooth wear both in vitro and in vivo. Techniques to quantify tooth wear in vitro are profilometry, microradiography, scanning electron microscopy, atom force microscopy, nano- and microhardness test, iodide permeability test.15,16 To measure tooth wear in vivo, many indices are used like the Eccles index of dental erosion, Smith and Knight index, and Erosion index by
Lussi.17 Some of these indices measure tooth wear on every surface of each tooth, some measures selected sites and specific surfaces.17 Smith and Knight19 introduced tooth wear index (TWI) which is capable of measuring all four visible surfaces (buccal, cervical, lingual, and occlusalincisal) of all teeth present. Except for a few studies, not much work has been done in Pakistan on this topic. Toufique H et al 201719 in a study reported that only 10% of the patients had tooth wear whereas in the present study 92.4% of them had tooth wear. Therefore, the present cross-sectional study was done to Evaluate Tooth wear and its causative risk factors amongst Patients Attending the Dental Hospital
of Karachi

The current study was a cross-sectional study conducted on adult patients recruited from the Out-Patient Department of Oral Diagnosis from May 2018 – December 2018. Patients were examined for the presence of tooth surface loss by using the Tooth Wear Index (TWI). The Ethical Review Board (ERB ) DC/ERB/2018/010), Baqai Dental College, gave ethical approval to proceed with this study. Patients with the complaint of tooth surface loss aged 18-45 years were included in the study.A consecutive sampling technique was used and 250 adult patients were selected for the study. Open Epi version 3.01software was used to calculate the sample size. Keeping a 20% prevalence rate with a 95% confidence interval with a 5% error, n=250 sample size was calculated based on the prevalence tooth wear reported by
Daly et al.20
Oral and Dental examinations were performed using the dental chair with a sterile mouth mirror and dental probe after signing a written consent by the patient. The chief examiner examined the patients while the dental chair assistant recorded the readings. A structured questionnaire prepared by those skilled in the restorative subject was used, which included etiological aspects of parafunctional habits, oral
hygiene measures, eating habits, and clinical history. Tooth wear was assessed by using Smith and Knight Tooth Wear Index (TWI index).18 The surfaces were designated as cervical surface (C), buccal surface (B), the lingual surface (L) or palatal surface (P) Incisal surface (I) or, occlusal surface (O). Patients who reported having symptoms of sensitivity were further assessed by a blast of air from the air-water syringe for 3 sec at a distance of 1cm from the tooth surface. Any uncomfortable feeling aroused by the blast was recorded on the clinical form according to different tooth surfaces.21 Data was entered and analyzed for Descriptive analysis (frequency and percentages). A Chi-square test was performed to assess the association between gender and its etiological factors by using IBM SPSS version 20.

The subject populations of 250 adult patients were assessed for tooth surface loss by using the Tooth wear index. According to Smith and Knight TWI, 201018 reported that 7.6% scored 0, 11.6% scored 1, 24.4% scored 2, 25.2% scored 3 and 31.2% scored 4. Out of which 178 were male (71.2%) and 72 (28.8%) were females aged 18 to 48 years old. Table 1 showed the Demographic profile.
In table 2,association of gender with etiological factors is mentioned which shows insignificant association that is 42 (23.6%) males and 17 (23.6%) females reported sensitivity, followed by 20 (11.2) males and 9 (12.5%)females with poor previous tooth aesthetics. (p = 0.535), 33 (18.5%) of males and 19 (26.4%) females reported a history of scaling. (p = 0.110). A significant association was seen when 89
(50%) of males and 24 (33.3%) of women had a history of pan/ betel nut chewing, (p<0.001). No significant association was reported regarding toothbrush technique and 121 (68%) men and 52 (72.2%) women used horizontal brush technique (p = 0.136)
Regarding tooth wear and dentin sensitivity, it was found that dentinal sensitivity increased with the age group. This
difference was not found to be statistically significant. (p=0.10) Table 3.
It was found that tooth wear increased with age group. For the age group, 18-28, 29-39 and 40-50 scores 2 and 4,

The present study was done to evaluate tooth surface loss in patients attending the Out-Patient Department of Baqai Dental College. In this study, 92.4% of them reported tooth wear and only 31.2% has extended to severe stage of the tooth wear and men reported severe tooth wear than women did.
A study done in the Dutch population reported that tooth surface loss was a common condition amongst the adult population.22 In this present study, 7.6% of participants reported no tooth surface loss and 92.4% of them reported tooth wear however, only 31.2% had reached to severe stage of tooth wear. Toufique H et al. in 201719 reported dissimilar results that only 10% of participants had tooth wear while
90% did not have tooth wear in their study. A study by Van’t Spijker23 reported the frequency of patients with tooth surface loss was increased to 3 % at the age of 20 years, 17% increased at 70 years of age
The present study according to Smith and Knight TWI, 2010 18 reported that 7.6% scored 0, 11.6% scored 1, 24.4% scored 2, 25.2% scored 3 and 31.2% scored 4. R Wirdatul et al24 in a study reported different values, 17.4% surfaces had tooth wear; 80% scored 1, 18% scored 2 and
2% scored 3. Oral habits are repetitive behaviors within the oral range, leading to loss of dental structure, such as eating habits, brushing techniques, bruxism, functional habits, and regurgitation. The effect depends on the nature, manifestation, and duration of the habit. The role of acids in food and beverages can be important in the development of toot wear. Laboratory studies have shown that low acid foods and
beverages cause erosion of enamel and dentin which may lead to dentin sensitivity.25-27
Dentinal hypersensitivity (DH) is a common symptom which affects 8-57% of adult and is associated with the oral hygiene.28 The present study reported an association of tooth wear with dentin hypersensitivity and age groups. Deshpande S29 in a study reported that there is a connection between grades of tooth wear with dentin sensitivity. Ayer A et al30 in a study reported that dentin hypersensitivity is associated with tooth surface loss. Idon P et al31 in a study reported an association of dentin hypersensitivity with tooth surface loss. Kehua Q et al.21 in a study reported that there is an association between dentin hypersensitivity and age groups. Ali K et al.32 find abnormal tightening and bruxism with a significant relationship with tooth surface loss. The present study reported that only 7.6% experienced tooth surface loss due to tightening/ bruxism, while 45.2% experienced tooth surface loss due to chewing pan. As tooth surface loss is multifactorial, therefore the abrasive effect of tooth brushing can cause a tooth surface loss. The present study reported that people using a brush with medium bristles (41.2%) in horizontal technique (69.2) % with medium force (40.4) % tend to have more tooth surface loss which shows a correlation with the study reported by Ahmed et al32 that brushing with moderate type of brush (48.4) % shows relevant tooth surface loss. Another study reported by Mushtaq et al.33 also observed a substantial association between participants using different types of toothbrushes and hard tissue abrasive lesions was reported(p<0.05). The cause of these injuries is important to prevent further injuries and to prevent existing injuries. Enamel reduced by acids (erosion), may be scrubbed away with tooth brushing (abrasion) and damaged away by chewing or tooth grinding.25
Males in the present study were more liable to have tooth surface loss possibly due to majority of males assessed as compared to females and this result was similar to other various studies.7,34,35 The factors which result in more tooth surface loss in males were mainly due to age, biting force, reduced tendency for malocclusion, more muscle mass, decreased occlusal tactile sensitivity.36,37
Generally, patients are more concerned about their esthetics and wish that their age process could be delayed and evidence revealed that tooth wear is related to the aging process.28 The present study reported that tooth wear increase with increasing age. Deshpande S28 and Meshramkar R38 et al. in a study also reported similar results.
Proper steps need to be taken for immediate action, as they are essential to restore the form and function of teeth. Dental wear is a preventive and curable condition. To avoid the problem of getting worse in the future, we must try to fight the problem from its early stages. One of the methods to prevent and cure the condition is to increase awareness among practitioners and to develop general public prevention programs among individuals. The present study has some limitations, which include that it was a single centre study, there were more male participants, and lacks the inclusion of other demographic variables. Evaluation of tooth wear should be added as a component of regular dental checkups amongst patients attending dental hospitals.

Recognizing the multifactorial nature of the condition is the first step in managing it, as a misunderstanding, it can lead to inadequate management and the ultimate failure of rehabilitation therapy. The present study concluded that tooth surface loss is associated with its etiological factors and was observed more in males when compared to females. However, steps should be taken to increase awareness among people regarding their teeth and the management of several condition .

None to declare

The study Titled “A cross-sectional study: Evaluation of Tooth wear and its causative risk factors amongst Patients Attending Dental Hospital of Karachi.” is approved by the Ethical Review Board of Baqai Dental College under the reference # BDC/ERB/2018/010.

AS contributed in writing and tabulating research paper AW analyzed and interpreted the patients’ data TMS provided overall supervision MH and KA contributed to the collection of patients’ data.

Thanks to the institution for supporting the study.


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