Abstract
Objectives
To evaluate the progression of dental erosion in 13–14 year-olds after 4 years, and its association with lifestyle and oral health.
Methods
227 randomly selected 13–14 year-olds from a Public Dental Clinic, Örebro, Sweden, were investigated. A clinical examination was performed which included dental caries/gingival/plaque status, as well as grading of dental erosion at the tooth surface and participant levels in “marker teeth”, including buccal/palatal surfaces of 6 maxillary anterior teeth (13–23), and occlusal surfaces of first molars. An interview and a questionnaire regarding drinking habits and other lifestyle factors were completed. All investigations were repeated at follow-up. The participants were divided into high and low progression erosion groups and logistic regression statistics were applied.
Results
175 individuals participated at follow-up. Progression occurred in 35% of the 2566 tooth surfaces. 32% of the surfaces had deteriorated by one severity grade ( n = 51 individuals) and 3% by two grades ( n = 2 individuals). Boys showed more severe erosion than girls at the follow-up. Among the variables predicting greater progression, a lower severity of erosive wear at baseline had the highest OR (13.3), followed in descending order by a “retaining” drinking technique, more frequent intake of drinks between meals, low GBI and lesser sour milk intake, with reference to the baseline recording. Using these five variables, sensitivity and specificity were 87% and 67% respectively, for predicting progression of erosion.
Conclusions
Progression of erosive lesions in Swedish adolescents aged 13–14 years followed up to age 17–18 years was common and related to certain lifestyle factors.
Clinical Significance
In permanent teeth, dental erosion may develop early in life and its progression is common. Dental health workers should be made aware of this fact and regular screenings for erosion and recording of associated lifestyle factors should be performed.
1
Introduction
Since the mid-90s, dental erosion among children and adolescents has been investigated in many parts of the world and found to be a common condition . A recent meta-analysis estimated the prevalence of erosive wear in permanent teeth of children and adolescents to be about 30% .
In groups of 12–14 year-olds, the prevalence of erosion varies widely between 8–65% . In Danish 15–17 year-olds, 14% had more than three surfaces eroded , while figures for 15 year-old Icelanders and 15–19 year-old Brazilians were 22% and 21% respectively . The variations in prevalence in the above mentioned reports, aside from participant selection, may most likely be accounted for by the methodology and grading criteria applied in the different studies. The availability of studies applying more defined criteria for scoring erosive damage, as well as studies conducted on older adolescents, are relatively rare. In 20 year-old Saudi men, the prevalence of dental erosion with dentin involvement was 16% , while 22% of Swedish 18–19 year-olds and 15% of Norwegian 16–18 year-olds had erosive lesions into dentin . In a recent study on Swedish 20 year-olds, 18% had severe erosion into dentin .
Higher prevalence and severity of dental erosion are more frequently observed in boys than in girls , although a few studies have also found the opposite or no gender differences . Dietary factors, especially consumption of acidic drinks, have in a large number of studies been found to be the main etiological factor of dental erosion , while others have not . Besides consumption of acidic drinks, a lifestyle that may be conducive to such consumption, such as sedentary living, excessive screen viewing activity, as well as being overweight, may contribute to the development of erosive wear . But, it is clear that other factors may also contribute to erosive damage, for instance method of drinking and the consumption of sour sweets . Intake of medicines and oral hygiene practices are regarded as risk factors for erosive wear .
The progression of dental erosion has not been thoroughly studied and reports in the literature are scant. In British children, progression of erosion was seen in 27% of those between the ages of 12–14 years . In a 3-year longitudinal study of Dutch children between 11–15 years of age, the progression was common in those with dental erosion .
Our aim was to study prospectively the progression of dental erosion over four years in a group of 13–14 year-old adolescents, and its association with some lifestyle and oral health factors. The hypothesis was that dental erosion would progress during the study period, among both genders and especially so in boys, and also be associated with a certain lifestyle and oral health.
2
Methods
2.1
Participants and procedures
The baseline study for this follow-up took place during 2005–2007 . In that study, 303 adolescents aged 13–14 years at the Public Dental Service in Nora and Storå, Region Örebro County Council, Örebro, Sweden, were offered to participate of which 227 accepted. The present study is a follow-up after 4 years, and all of the original 227 participants (who had remained as recall patients within the Public Dental Service during the study period, May 2009–January 2012) were invited to participate. Data collection took place during the participant’s regular dental examination. Clinical and questionnaire examinations were identical to the baseline study except for addition of recording of consumption of alcoholic beverages to the questionnaire .
2.2
Clinical examination
Assessment of dental erosion was performed according to previously described methodology and grading was done according to a commonly used erosion scale ( Table 1 ) . An additional scale was used for grading molar cuppings ( Table 2 ) . The two scales were combined based on the highest erosion grades scored on the anterior teeth ( Table 1 ) and first molar teeth ( Table 2 ): no erosion (score 0), mild erosion (score 1), moderate erosion (score 2), severe erosion (score 3) and very severe erosion (score 4), ( Table 3 ). So, the severest score, either for incisors or molars, determined the “holistic” score in Table 3 . For example, if an individual had a molar with >1 mm cupping (grade 3) but only grade 1 affecting the incisors, the individual was graded as severe erosion (grade 3).
| Grade | Criteria |
|---|---|
| 0 | No visible changes, developmental structures remain, macro-morphology intact. |
| 1 | Smoothened enamel, developmental structures have totally or partially vanished. Enamel surface is shiny, matt, irregular, ”melted”, rounded or flat, macro-morphology generally intact. |
| 2 | Enamel surface as described in grade 1. Macro-morphology clearly changed, facetting or concavity formation within the enamel, no dentinal exposure. |
| 3 | Enamel surface as described in grades 1 and 2. Macro-morphology greatly changed (close to dentinal exposure of large surfaces) or dentin surface exposed by ≤1/3. |
| 4 | Enamel surface as described in grades 1, 2 and 3. Dentin surface exposed by >1/3 or pulp visible through the dentin. |
| Grade | Criteria |
|---|---|
| 0 | No cupping/intact cusp tip |
| 1 | Rounded cusp tip |
| 2 | Cupping ≤ 1 mm |
| 3 | Cupping > 1 mm |
| 4 | Fused cuppings: at least two cuppings are fused together on the same tooth |
| Grade | Localization | Criteria |
|---|---|---|
| 0 = No erosion | Anterior teeth | No visible changes, developmental structures remain, macro-morphology intact |
| Molars | No cupping/intact cusp tip | |
| 1 = Mild erosion | Anterior teeth | Smoothened enamel, developmental structures have totally or partially vanished. Enamel surface is shiny, matt, irregular, ”melted”, rounded or flat, macro-morphology generally intact |
| Molars | Rounded cusp tip | |
| 2 = Moderate erosion | Anterior teeth | Enamel surface as described in grade 1. Macro-morphology clearly changed, facetting or concavity formation within the enamel, no dentinal exposure |
| Molars | Cupping ≤ 1 mm | |
| 3 = Severe erosion | Anterior teeth | Enamel surface as described in grades 1 and 2. Macro-morphology greatly changed (close to dentinal exposure of large surfaces) or dentin surface exposed by ≤1/3 |
| Molars | Cupping > 1 mm | |
| 4 = Very severe erosion | Anterior teeth | Enamel surface as described in grades 1, 2 and 3. Dentin surface exposed by >1/3 or pulp visible through the dentin |
| Molars | Fused cuppings: at least two cuppings are fused together on the same tooth | |
All gradings were performed by the principal investigator (AH) and intra-examiner concordance was tested by performing two successive blind assessments after an interval of two to four weeks in 13 individuals, who did not participate in this study. The tooth surfaces were dried using compressed air and grading was performed in an ordinary clinical setting. In cases of difficulties with deciding the severity of dental erosion between two grades on the scale, the lower grade was chosen. Surfaces that were impossible to grade because of orthodontic brackets, retainers, fillings or enamel hypoplasia were excluded, which was also the case on some surfaces that had been intensely polished after removal of orthodontic brackets.
Visible plaque index (VPI) and Gingival bleeding index (GBI) were recorded as “yes” or “no” in maxillary anterior teeth, according to Ainamo and Bay . In order, VPI was assessed first followed by GBI, and if necessary, the teeth were then polished with prophy paste before grading of tooth wear. Dental caries, DMFT and DMFS, was recorded and radiographic examination performed on the basis of individual indication. The examiner (AH) was blinded from baseline data and the result from questionnaires during the follow-up examination.
2.3
Questionnaire investigation
The questionnaire was divided into two parts. The first part was a written inquiry, regarding some lifestyle factors. It was filled in by the patient at home, and returned by mail to the clinic. The questions comprised oral hygiene routines, oral or gastrointestinal symptoms (never/monthly/weekly/daily/always), intake of medicines (yes or no), general health (often sick—yes or no) and if they had a habit of retaining acidic soft drinks in the mouth before swallowing (yes or no). Other questions included: frequency of physical activity (frequency per week), screen-viewing habits (hours per day), body height/weight, whether they had tried to increase or reduce their weight (yes or no), and if either parent were born outside Sweden (Sweden/Nordic countries/Europe/Others). Types and frequency of intake of certain dietary items were estimated and recorded as numbers of times per month/week or day. These were: water, all types of acidic soft drinks, milk, yogurt, sour milk, tea, coffee, sweets, sour sweets, chewing gum, ice cream, popsicle, biscuits, snacks, cheese, dried and fresh fruits. The second part of the questionnaire was conducted as an oral interview by a specially trained dental assistant during the clinic visit. All current beverage consumption, and estimated previous consumption one year ago, was recorded in detail; carbonated soft drinks, still drinks, sport drinks, juice, water, milk, tea, coffee, and some alcoholic beverages (wine, beer, cider, alcopop). The amount and frequency of each portion was estimated, and the daily or weekly consumption was calculated as L/year. A more detailed description of the questionnaire examination is given elsewhere .
2.4
Statistical analyses
Sample size calculation, with 80% power and a 5% significance level and discordant proportion of 10%, resulted in a minimum of 127 participants in the study (McNemar’s test). The calculation is based on 7% of the individuals showing an expected progression of erosion to severe or very severe erosion (grade 3 and 4) between 13–14 and 18–19 years of age. The total baseline sample (aged 13–14 years) included 227 individuals, so even with some drop-outs during the follow-up period the original sample size was deemed to be adequately large.
In addition to scoring the severity of dental erosion on the marker teeth, Simplified Erosion Partial Recording System (SEPRS) was calculated. This system presents the highest erosion score from the palatal surfaces of central maxillary incisors (according to Table 1 ) (tooth numbers 11and 21) and from cupping scores (according to Table 2 ) of mandibular first permanent molars (tooth numbers 36 and 46) (four surfaces in all) . SEPRS thus provides one score per individual and is based on the highest score recorded on one of these four surfaces.
The erosion score assigned to each tooth surface on all the graded anterior teeth (buccal and palatal) was compared between baseline and follow-up, and registered as unchanged (0), one grade of progression (+1) and two grades of progression (+2). The mean progression was calculated and the material was divided into three groups according to the mean change: low progression group 0–0.2 scale steps, middle group >0.2–0.5 and high progression group >0.5 steps.
Differences between the high and low progression groups were tested by the Mann–Whitney U -test regarding the variables of gender, consumption of drinks, dietary habits, oral hygiene habits, physical activity, Body Mass Index (BMI), and oral and general health factors. Adjusted logistic regression analysis (forward conditional method) was performed with high and low progression of erosion as dependent variable using a selection of reported variables that had theoretical relevance or differed statistically significantly between the high and low progression groups according to the Mann–Whitney U -test. All independent variables were dichotomized into two categories before being entered into the logistic regression. Odds ratios (OR) with confidence interval (95%) were calculated for each independent variable. All analyses were performed using IBM SPSS Statistics 23 (IBM Corporation, 1 New Orchard Road, Armonk, New York). P <0.05 were considered statistically significant.
2.5
Ethical considerations
An informed consent was signed by the participants or by a parent in cases of under-aged adolescents. Approval from the Regional Ethical Review Board in Uppsala, Sweden, was obtained prior to the start of the study (no. 2009/031). If there was a diagnosis of dental erosion or some other oral pathology, the patient was informed about the condition and preventive or other treatment were carried out free of charge (both at the baseline and follow-up examination).
2
Methods
2.1
Participants and procedures
The baseline study for this follow-up took place during 2005–2007 . In that study, 303 adolescents aged 13–14 years at the Public Dental Service in Nora and Storå, Region Örebro County Council, Örebro, Sweden, were offered to participate of which 227 accepted. The present study is a follow-up after 4 years, and all of the original 227 participants (who had remained as recall patients within the Public Dental Service during the study period, May 2009–January 2012) were invited to participate. Data collection took place during the participant’s regular dental examination. Clinical and questionnaire examinations were identical to the baseline study except for addition of recording of consumption of alcoholic beverages to the questionnaire .
2.2
Clinical examination
Assessment of dental erosion was performed according to previously described methodology and grading was done according to a commonly used erosion scale ( Table 1 ) . An additional scale was used for grading molar cuppings ( Table 2 ) . The two scales were combined based on the highest erosion grades scored on the anterior teeth ( Table 1 ) and first molar teeth ( Table 2 ): no erosion (score 0), mild erosion (score 1), moderate erosion (score 2), severe erosion (score 3) and very severe erosion (score 4), ( Table 3 ). So, the severest score, either for incisors or molars, determined the “holistic” score in Table 3 . For example, if an individual had a molar with >1 mm cupping (grade 3) but only grade 1 affecting the incisors, the individual was graded as severe erosion (grade 3).
| Grade | Criteria |
|---|---|
| 0 | No visible changes, developmental structures remain, macro-morphology intact. |
| 1 | Smoothened enamel, developmental structures have totally or partially vanished. Enamel surface is shiny, matt, irregular, ”melted”, rounded or flat, macro-morphology generally intact. |
| 2 | Enamel surface as described in grade 1. Macro-morphology clearly changed, facetting or concavity formation within the enamel, no dentinal exposure. |
| 3 | Enamel surface as described in grades 1 and 2. Macro-morphology greatly changed (close to dentinal exposure of large surfaces) or dentin surface exposed by ≤1/3. |
| 4 | Enamel surface as described in grades 1, 2 and 3. Dentin surface exposed by >1/3 or pulp visible through the dentin. |
| Grade | Criteria |
|---|---|
| 0 | No cupping/intact cusp tip |
| 1 | Rounded cusp tip |
| 2 | Cupping ≤ 1 mm |
| 3 | Cupping > 1 mm |
| 4 | Fused cuppings: at least two cuppings are fused together on the same tooth |
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