The prevalence of tooth wear in a cluster sample of adolescent schoolchildren and its relationship with potential explanatory factors

UK National Clinical Guidelines in Paediatric Dentistry: diagnosis, prevention and management of dental erosion

This revised Clinical Guideline in Paediatric Dentistry replaces the previously published ninth guideline (Shaw L, O'Sullivan E. Int J Paediatr Dent 2000; 10: 356-365). The process of guideline production began in 1994, resulting in first publication in 1997. Each guideline has been circulated widely for consultation to all UK consultants in paediatric dentistry, council members of the British Society of Paediatric Dentistry (BSPD), and to people of related specialities recognized to have expertise in the subject. The final version of this guideline is produced from a combination of this input and thorough review of the published literature. In the case of the present guideline, an internationally recognized expert in the field was invited to be a co-author (AM). The intention is to encourage improvement in clinical practice and to stimulate research and clinical audit in areas where scientific evidence is inadequate. Evidence underlying recommendations is scored according to the SIGN classification and guidelines should be read in this context. Further details regarding the process of paediatric dentistry guideline production in the UK is described in the Int J Paediatr Dent 1997; 7: 267-268.

Pathological or physiological erosion--is there a relationship to age?

This conventional literature review discusses whether pathological tooth wear is age dependant. It briefly reviews the components of tooth wear and the prevalence of tooth wear in children, adolescents and adults. The emphasis on terminology relating to tooth wear varies. In some countries, the role of erosion is considered the most important, whereas others consider the process to be a combination of erosion, attrition and abrasion often with one being more dominant. The importance of tooth wear or erosion indices in the assessment and the evidence for progression within subject and within lesions is described. The data from the few studies reporting pathological levels of wear reported in children and adults are discussed, in particular its relationship with age. There is little evidence to support the concept that pathological levels of erosion or wear are age dependant. There is, however, some evidence to suggest that normal levels of erosion or wear are age dependant.

How valid are current diagnostic criteria for dental erosion?

In principle, there is agreement about the clinical diagnostic criteria for dental erosion, basically defined as cupping and grooving of the occlusal/incisal surfaces, shallow defects on smooth surfaces located coronal from the enamel–cementum junction with an intact cervical enamel rim and restorations rising above the adjacent tooth surface. This lesion characteristic was established from clinical experience and from observations in a small group of subjects with known exposure to acids rather than from systematic research. Their prevalence is higher in risk groups for dental erosion compared to subjects not particularly exposed to acids, but analytical epidemiological studies on random or cluster samples often fail to find a relation between occurrence or severity of lesions and any aetiological factor. Besides other aspects, this finding might be due to lack of validity with respect to diagnostic criteria. In particular, cupping and grooving might be an effect of abrasion as well as of erosion and their value for the specific diagnosis of erosion must be doubted. Knowledge about the validity of current diagnostic criteria of different forms of tooth wear is incomplete, therefore further research is needed.

The evolution of tooth wear indices

Tooth wear--attrition, erosion and abrasion-is perceived internationally as an ever-increasing problem. Clinical and epidemiological studies, however, are difficult to interpret and compare due to differences in terminology and the large number of indices that have been developed for diagnosing, grading and monitoring dental hard tissue loss. These indices have been designed to identify increasing severity and are usually numerical. Some record lesions on an aetiological basis (e.g. erosion indices), others record lesions irrespective of aetiology (tooth wear indices); none have universal acceptance, complicating the evaluation of the true increase in prevalence reported. This article considers the ideal requirements for an erosion index. It reviews the literature to consider how current indices have evolved and discusses if these indices meet the clinical and research needs of the dental profession.

A case report of patient practising yoga leading to dental erosion

The article presents the case of a patient who was practising Yoga (Kunjal kriya) which led to dental erosion. Dental erosion can be due to extrinsic or intrinsic causes. The intrinsic causes include vomiting due to anorexia nervosa, regurgitation due to abnormality in gastro-intestinal tract or rumination. A 38-year-old male patient presented with a rare aetiology of dental erosion. He had practiced kunjal kriya one of the yogic exercises described in ancient India. In kunjal kriya the patient vomits on an empty stomach in order to clean his or her gastro-intestinal tract. The patient had practiced this form of exercise for over 12 years which had led to severe dental erosion. A proper case history should be evaluated for every patient so that they can be counselled for any factors that could be detrimental to dental health. Early diagnosis is paramount in recognising the aetiology of dental erosion so that detrimental effects on the dentition can be prevented.

A New Look at Erosive Tooth Wear in Elderly People

BACKGROUND

The author describes the clinical appearance of and the outcomes associated with erosive tooth wear, particularly that in older people.

TYPES OF STUDIES REVIEWED

The author conducted a traditional clinical review that was based on a synopsis of the current literature on dental erosion. He found that intrinsic and extrinsic acids are known to be associated with acid erosion and tooth wear. He also explored the etiology and pathogenesis of tooth wear and compared the longevity of restorations to the option of monitoring and preventing tooth wear. He found that preventive measures, which included limiting the frequency of acid exposure and using fluoride toothpastes and dentin-bonding agents, could prolong tooth life.

RESULTS

Tooth wear and acid erosion are common clinical findings in patients of all ages. The results of tooth wear can cause significant damage to teeth, which can require complex and costly prosthodontic treatment.

CLINICAL IMPLICATIONS

Diagnosing the cause of a patient's tooth wear can help prevent further damage.

Squamous cell carcinoma of the oral cavity: a case series analysis of clinical presentation and histological grading of 1,425 cases from Iraq

Peoples in Iraq face a mixture of health hazards associated with poverty. Oral cancer is a major public health issue worldwide; it remains a highly lethal and disfiguring disease. It is primarily a disease of epithelial origin. A total of 1,425 cases of histologically diagnosed squamous cell carcinoma collected from the main centers of pathology in Iraq were analyzed according to age, sex, site, patient complaints at the time of presentation, and histological grading. Patients at their fifth decade of life were the most commonly affected with a male-to-female ratio of 2:1. The lower lip was the most commonly affected site followed by the tongue. The most common clinical complain was ulceration and swelling. More than 70% of the cases were well-differentiated squamous cell carcinoma. Oral cancer is increasingly seen as a major health problem-In line with general trend in the region, the need for interprofessional health care delivery approaches for reducing oral cancer mortality and improving patient's quality of life.

Dental erosion amongst 13- and 14-year-old Brazilian schoolchildren

OBJECTIVES

To assess the prevalence of dental erosion in a sample of 13- and 14-year-old Brazilian schoolchildren and to assess the relationship of dental erosion and socio-demographic characteristics.

METHODS

A convenience sample of 458 children (190 boys and 268 girls) from 14 schools in Três Corações, south east Brazil, was examined. Socio-demographic data were collected by self-completion questionnaires.

RESULTS

Dental erosion was observed in 34.1% of subjects, involving enamel only and showing a symmetrical distribution. The palatal surfaces of the upper incisors were the most commonly affected surfaces. Erosion experience was higher in boys; pupils from Government funded schools; those resident in rural areas and those from the high economic class, but none of these were statistically significant.

CONCLUSION

These data are the first to show that in a cohort of 13-14-year old Brazilian schoolchildren, approximately one third of those examined showed mild erosion, requiring clinical preventive counselling. No statistically significant association was observed between erosion, gender and socioeconomic factors.

A critical review of non-carious cervical (wear) lesions and the role of abfraction, erosion, and abrasion

The terms 'abfraction' and 'abrasion' describe the cause of lesions found along the cervical margins of teeth. Erosion, abrasion, and attrition have all been associated with their formation. Early research suggested that the cause of the V-shaped lesion was excessive horizontal toothbrushing. Abfraction is another possible etiology and involves occlusal stress, producing cervical cracks that predispose the surface to erosion and abrasion. This article critically reviews the literature on abrasion, erosion, and abrasion, and abfraction. The references were obtained by a MEDLINE search in March, 2005, and from this, hand searches were undertaken. From the literature, there is little evidence, apart from laboratory studies, to indicate that abfraction exists other than as a hypothetical component of cervical wear.

Prevalence of erosive tooth wear and associated risk factors in 2-7-year-old German kindergarten children

OBJECTIVES

The aims of this study were to (1) investigate prevalence and severity of erosive tooth wear among kindergarten children and (2) determine the relationship between dental erosion and dietary intake, oral hygiene behaviour, systemic diseases and salivary concentration of calcium and phosphate.

MATERIALS AND METHODS

A sample of 463 children (2-7 years old) from 21 kindergartens were examined under standardized conditions by a calibrated examiner. Dental erosion of primary and permanent teeth was recorded using a scoring system based on O'Sullivan Index [Eur J Paediatr Dent 2 (2000) 69]. Data on the rate and frequency of dietary intake, systemic diseases and oral hygiene behaviour were obtained from a questionnaire completed by the parents. Unstimulated saliva samples of 355 children were analysed for calcium and phosphate concentration by colorimetric assessment. Descriptive statistics and multiple regression analysis were applied to the data.

RESULTS

Prevalence of erosion amounted to 32% and increased with increasing age of the children. Dentine erosion affecting at least one tooth could be observed in 13.2% of the children. The most affected teeth were the primary maxillary first and second incisors (15.5-25%) followed by the canines (10.5-12%) and molars (1-5%). Erosions on primary mandibular teeth were as follows: incisors: 1.5-3%, canines: 5.5-6% and molars: 3.5-5%. Erosions of the primary first and second molars were mostly seen on the occlusal surfaces (75.9%) involving enamel or enamel-dentine but not the pulp. In primary first and second incisors and canines, erosive lesions were often located incisally (51.2%) or affected multiple surfaces (28.9%). None of the permanent incisors (n = 93) or first molars (n=139) showed signs of erosion. Dietary factors, oral hygiene behaviour, systemic diseases and salivary calcium and phosphate concentration were not associated with the presence of erosion.

CONCLUSIONS

Erosive tooth wear of primary teeth was frequently seen in primary dentition. As several children showed progressive erosion into dentine or exhibited severe erosion affecting many teeth, preventive and therapeutic measures are recommended.

Non-carious tooth conditions in children in the UK, 2003

BACKGROUND

The 2003 Children's Dental Health Survey is the fourth of the 10-yearly surveys of children's oral health.

AIM

To report the prevalence of three non-carious tooth conditions in children in the UK.

METHOD

A representative sample of children five, eight, 12 and 15 years of age were examined by calibrated examiners in schools across the UK. The dental examination included accidental damage to incisors, tooth surface loss (TSL) and enamel opacities (age 12 only). A postal questionnaire sought parental and child views on marks on teeth which could not be removed by brushing.

RESULTS

The proportion of children sustaining accidental damage to permanent incisors decreased to 11% of 12 and 13% of 15-year-olds, but the majority of accidental damage remained untreated. TSL was found on 53% of five-year-olds and on approximately a third of 12 and 15-year-olds. There was a statistically significant change for TSL on permanent teeth at age 15 where 27% upper incisors had TSL palatally in 1993 compared to 33% in 2003. Thirty-four per cent of 12-year-old children had enamel opacities on one or more of their teeth compared with 36% in 1993.

CONCLUSIONS

Tooth surface loss remains a common finding in children in the UK. A large proportion of accidental damage to teeth remains untreated.

Dental erosion in 12-year-old schoolchildren: a cross-sectional study in Southern Brazil

OBJECTIVE

The aim of this study was to assess the prevalence and severity of dental erosion among 12-year-old schoolchildren in Joaçaba, southern Brazil, and to compare prevalence between boys and girls, and between public and private school students.

METHODS

A cross-sectional study was carried out involving all of the municipality's 499, 12-year-old schoolchildren. The dental erosion index proposed by O'Sullivan was used for the four maxillary incisors. Data analysis included descriptive statistics, location, distribution, and extension of affected area and severity of dental erosion.

RESULTS

The prevalence of dental erosion was 13.0% (95% confidence interval = 9.0-17.0). There was no statistically significant difference in prevalence between boys and girls, but prevalence was higher in private schools (21.1%) than in public schools (9.7%) (P < 0.001). Labial surfaces were less often affected than palatal surfaces. Enamel loss was the most prevalent type of dental erosion (4.86 of 100 incisors). Sixty-three per cent of affected teeth showed more than a half of their surface affected.

CONCLUSION

The prevalence of dental erosion in 12-year-old schoolchildren living in a small city in southern Brazil appears to be lower than that seen in most of epidemiological studies carried out in different parts of the world. Further longitudinal studies should be conducted in Brazil in order to measure the incidence of dental erosion and its impact on children's quality of life.

Dental erosion: possible approaches to prevention and control

OBJECTIVES

To discuss the key elements for establishment of a preventive programme for dental erosion.

DATA AND SOURCES

The data discussed are primarily based on published scientific studies and reviews from case reports, clinical trials, epidemiological, cohort, animal, in vitro and in vivo studies. References have been traced manually or by MEDLINE.

STUDY SELECTION

The aetiology, pathogenesis and modifying factors of dental erosion were reviewed. Strategies to either prevent the occurrence or limit the damage of dental erosion or protect the remaining tooth tissues from further erosive destruction were reviewed and discussed. These includes: (A) measures to (1) enhance remineralisation and acid resistance of enamel surface softened by erosive challenge, (2) reduce the erosive potential of acidic products, (3) enhance salivary flow, (4) protect and restore erosively damaged tooth, and (5) provide mechanical protection against erosive challenge. (B) Health education geared towards (1) diminution of frequency of intake of dietary acids, and (2) change of habits and lifestyles that predispose teeth to erosion development.

CONCLUSIONS

It may be easier to gain patients' compliance with the advice that immediately following an acidic challenge, a remineralising agent, such as fluoride mouthrinses, fluoride tablets, fluoride lozenges or dairy milk, should be administered to enhance rapid remineralisation of the softened tooth surface as well as serve as a mouth refresher, or an alternative, a neutralising solution should be used. Effective counselling on erosion preventive regimes should involve all healthcare personnel, dentists, doctors, pharmacist, nurses/hygienists and clinical psychologists.

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

OBJECTIVE

To determine the strength of association (expressed as Odds Ratios) of potential risk factors with erosion and tooth wear in 14-year-old schoolchildren.

DESIGN

A random sample of 2,385 children were selected by a stratified two-stage technique based on schools and children.

SETTING

Schools in NW England.

METHODS

Tooth wear was assessed by one examiner on three surfaces of all 12 anterior teeth (labial, incisal and palatal) and the occlusal surface of all four first molars using a four-point scale. Enamel wear was scored 0, dentine exposure <1/3 scored 1, >1/3 scored 2 and secondary dentine or pulpal exposure, scored 3. A questionnaire enquired about general health, dental health, habits and the frequency of intake of a wide range of foods and drinks.

RESULTS

The Odds Ratios for tooth wear on any surface for habits, reflux and certain foods were: bruxism, 1.10; stomach upset, 1.45; pickles 1.86; vinegar 1.36; salt and vinegar crisps 1.33; brown/other sauces 1.57. Similarly, the odds ratios for potentially erosive drinks were: fizzy drinks 1.32; sport drinks 1.58; herbal/lemon tea 3.97. The frequency of intake was bi-modal with 397 children drinking a can per day and 207 drinking two cans per day. A significant number drank acidic beverages at bedtime but this was not associated with dental erosion.

CONCLUSION

Although odds ratios greater than unity indicate an association, this was not high for carbonated beverages and many other acidic foods or drinks. Examining at fourteen years may not be ideal, as the determinants of erosion/tooth wear have not acted for long, the indices do not discriminate sufficiently and proportionately few subjects have dentine exposed on smooth surfaces.

Epidemiological studies of tooth wear and dental erosion in 14-year-old children in North West England. Part 1: The relationship with water fluoridation and social deprivation

OBJECTIVE

The effect of water fluoridation upon dental erosion/tooth wear in the UK has not been investigated. This study aimed to compare the prevalence of tooth wear in 14-year-old schoolchildren in non-fluoridated and fluoridated districts of North West (NW) England. The influence of deprivation and tooth brushing was also investigated.

DESIGN

A random sample of 10% of the 14-year-old population in NW England was selected and stratified according to fluoridation status as determined from water authority postcode listings.

METHODS

Tooth wear was scored on the labial, incisal and palatal/lingual surfaces of the 12 anterior teeth and the occlusal surfaces of the first molars. Enamel wear was scored 0, dentine was scored 1 or 2, dependent on whether less than or more than a third of the surface had exposed dentine. Secondary dentine or pulpal exposure scored 3. Townsend deprivation scores were gained from residential post codes.

RESULTS

A total of 2,351 children were examined, of which 637 (27%) lived in the one fluoridated district of South Cheshire and 1,714 (73%) lived in 11 non-fluoridated districts. Fifty-three per cent of the children had exposed dentine with significantly more males affected than females (p<0.001). In the fluoridated district, significantly fewer children had exposed dentine on labial and palatal smooth surfaces (p<0.001) but no differences were found for incisal and occlusal surfaces. The interaction of fluoridation and tooth brushing twice per day resulted in a significant (30%) reduction in erosion. Smooth surface wear was more prevalent in children resident in affluent areas.

CONCLUSION

Children in non-fluoridated districts are 1.5 times more likely to have smooth surface wear compared with children in fluoridated districts. Fluoridation and use of fluoridated toothpaste twice a day provide added protection from dental erosion. The risk of tooth wear is greater with increasing affluence.

Modification of soft drinks with xanthan gum to minimise erosion: a study in situ

OBJECTIVE

To compare the erosive effect of a new blackcurrant/calcium drink with xanthan gum, on enamel in situ, with a low erosive product, a conventional fruit beverage and water.

DESIGN

The study was single centre, randomised, single blind, 4 treatment crossover design.

SETTING

This study, conducted in 2000, employed volunteers working at the Bristol Dental Hospital, UK.

SUBJECTS, MATERIALS AND METHODS

16 subjects (>or=18 years) wore two enamel samples in a removable acrylic appliance. The drinks tested were (A) New blackcurrant/calcium/gum drink (test product), (B) Original blackcurrant/calcium drink, (C) Conventional blackcurrant drink (positive control) and (D) Water (negative control), for 15 day study periods. Drinking was supervised, with 250 ml imbibed four times/day between 9.00am-5.00pm. Profile measurements of specimens were made at baseline, 5, 10 and 15 days.

MAIN OUTCOME MEASURES

Paired t-tests compared erosion by surfometry with selected pairs of formulations.

RESULTS

Of 16 screened subjects (3 male, 13 female), mean age 34.2 years, 1 subject failed to complete the study. A caused significantly less enamel loss than C, with no statistically significant differences from B at any time points measured. Of 43 treatment emergent adverse events, none were considered related to the study formulations.

CONCLUSIONS

A retained low erosive properties similar to B, with additional benefits of taste flexibility and beverage stability.

A multifactorial analysis of factors associated with dental erosion

OBJECTIVES

This study prospectively examines the relationship of possible aetiological factors to the presence of tooth erosion in a cohort of children.

PATIENTS AND METHODS

A random sample of 1,753 children was examined at age 12 and 1,308 of the same children were re-examined at age 14 years. The children were asked to complete questionnaires on both occasions, 1,149 subjects gave usable replies. The erosion index used was based upon the 1993 Survey of Children's Dental Health. Results were analysed using logistic regression.

RESULTS

At age 12 significant positive associations were found between erosion and decay experience (odds ratio [OR] = 1.48), drinking fruit juice (OR = 1.42) or fizzy pop (OR = 1.59-2.52, depending on amount and frequency). The presence of calculus (OR 0.48) or eating fruit other than apples or citrus fruit (OR 0.48) reduced the chances of erosion. High consumption of carbonated drinks increased the odds of erosion being present at 12 years by 252% and was a strong predictor of the amount of erosion found at age 14.

CONCLUSIONS

Of the factors investigated, a history of dental caries and a high consumption of carbonated drinks were most closely related to the presence of dental erosion. The risk of erosion bore a strong relationship to the amount and frequency of carbonated drink consumption.

The prevalence of tooth erosion in 12-year-old children

OBJECTIVES

To establish the prevalence of tooth erosion in a representative sample of 12-year-old children in Leicestershire and Rutland. To determine if gender, ethnic group, deprivation or caries experience influences the prevalence of erosion.

METHODS

A random sample of 1,753 12-year-olds resident in Leicestershire and Rutland were examined in 62 schools; 906 were boys and 847 girls; 1,379 were Caucasian and 316 Asian. Tooth erosion was assessed using the index employed in the survey of Children's Dental Health in England and Wales (1993). The Townsend index was used to record deprivation.

RESULTS

Tooth erosion was found in 59.7% of the children, with 2.7% exhibiting exposed dentine. Significantly more boys than girls; Caucasian than Asian children; and those with caries experience, had erosion present (chi-square for all P<0.01). Overall no significant difference was found between deprivation categories, however socio-economically advantaged Caucasian children had significantly less tooth erosion than other groups.

CONCLUSIONS

There was a high prevalence of tooth erosion in 12-year-old children. Significantly more erosion occurred in boys than girls, and culture appeared to influence prevalence. Children with caries experience had a higher prevalence of erosion than those without caries, which may reflect a lower level of dietary care. Deprivation seemed to affect the prevalence of tooth erosion in Caucasian children.

The prevalence of non-carious cervical lesions in permanent dentition

A non-carious cervical lesion (NCCL) is the loss of hard dental tissue on the neck of the tooth, most frequently located on the vestibular plane. Causal agents are diverse and mutually interrelated. In the present study all vestibular NCCL were observed and recorded by the tooth wear index (TWI). The aim of the study was to determine the prevalence and severity of NCCL. For this purpose, 18555 teeth from the permanent dentition were examined in a population from the city of Rijeka, Croatia. Subjects were divided into six age groups. The teeth with most NCCL were the lower premolars, which also had the largest percentage of higher index levels, indicating the greater severity of the lesions. The most frequent index level was 1, and the prevalence and severity of the lesions increased with age.

Brushing Abrasion of Softened and Remineralised Dentin: An in situ Study

The aim of the present in situ study was to evaluate the effect of different periods of intra-oral remineralisation on the susceptibility of softened dentin to toothbrushing abrasion. Groups of 6 human dentin specimens (A-F) were recessed in the buccal aspects of intra-oral appliances which were worn for 21 days by 11 volunteers. The samples were demineralised twice a day extra-orally in the acidic beverage Sprite Light (pH 2.9) for 90 s. Subsequently, the dentin specimens were brushed at different times. Specimen A was brushed immediately after demineralisation. Specimens B-E were brushed after the intra-oral appliances had been worn for various periods in the mouth: specimen B for 10 min, C for 20 min, D for 30 min and E for 60 min. Specimen F was not brushed (control). After 21 days, dentin wear was measured with a profilometer. The following values (means +/- standard deviation) were recorded (microm): A, 23.6 +/- 16.7; B, 37.9 +/- 29.7; C, 31.8 +/- 26.5; D, 18.5 +/- 10.5; E, 15.3 +/- 11.6; F, 12.6 +/- 6.7. There was a statistically significantly increased dentin loss for groups A, B and C as compared to the controls (U test: p < 0.05). However, after intra-oral periods of 30 and 60 min, wear was not significantly higher than in unbrushed controls. It is concluded that for protection of dentin surfaces at least 30 min should elapse before toothbrushing after an erosive attack.

Mild dehydration: a risk factor for dental disease?

A review of the published international literature was undertaken to investigate whether dehydration is a risk factor for dental disease. Published evidence of associations between saliva and dental disease and between saliva and dehydration was observed, but the precise nature of these associations is unclear and no evidence of a direct link between dehydration and dental disease was found. It is concluded that no direct link between dehydration and dental disease has been proven, although there is considerable circumstantial evidence to indicate that such a link exists.

Dental erosion and soft drinks: a qualitative assessment of knowledge, attitude and behaviour using focus groups of schoolchildren. A preliminary study

OBJECTIVES

This qualitative study was designed to record the perception by Newcastle children of the influences on their choice of drinks and their knowledge of the dental health problems caused by acidic drinks.

METHODS

Four focus groups, each involving 8 Newcastle schoolchildren (4 boys and 4 girls) formed the basis of the study. Two age groups, 13-14-year-olds and 8-9-year-olds, and two socio-economic groups were investigated, using state schools in Newcastle upon Tyne. A moderator guided the children to discuss their choice of drink and its dental effects amongst themselves.

RESULTS

In total, 32 children participated in the focus groups and the results suggested that 8-9-year-olds preferred still, fruit-flavoured drinks whilst 13-14-year-olds preferred carbonated drinks. Taste was the most important influence on drink choice in all age groups. Parents and friends were more influential in younger children, whilst cost, availability and thirst were more important to older children. Younger children did not believe advertisements whilst older children thought they might work if seen enough times. Dental knowledge was confused in all age groups and only the 13-14-year-old-high socio-economic groups knew that acidic drinks were bad for the teeth. Different methods for addressing the problem of erosion were suggested by different age groups. There was very little difference between the socio-economic groups in the areas discussed.

CONCLUSIONS

The children's knowledge of dental diseases and the effect of drinks on the teeth were confused. The factors that influence drink choice appear to change with age, rather than socio-economic status.

The progression of tooth erosion in a cohort of adolescents of mixed ethnicity

OBJECTIVES

To establish the prevalence of tooth erosion in a sample of 12-year-old children and to monitor changes over the subsequent 2 years.

METHODS

A random sample of 1753 children aged 12 years was drawn from all 62 state maintained schools in Leicestershire. A total of 1308 were re-examined 2 years later. Erosion was recorded on incisors and first molars using an erosion index based upon that from the Children's Dental Health in the United Kingdom 1993 survey. A score was also allocated to each subject according to the most advanced lesion in the mouth.

RESULTS

Erosion was present in 56.3% of subjects at age 12 and 64.1% at age 14. Deep enamel or dentine was eroded in 4.9% and 13.1% of subjects, respectively, at the same ages. One hundred and sixty-one (12.3%) children who were erosion-free at 12 years of age developed erosion over the subsequent 2 years. Boys had more erosion than girls, as did white compared to Asian children. Associations were found between erosion experience and social deprivation.

CONCLUSION

New erosive lesions developed in 12.3% of the subjects between the ages of 12 and 14 years. New or more advanced lesions were seen in 27% of the children over the 2 years of the study. Males, white children and social deprivation were significantly associated with erosion experience.

Supraesophageal complications of gastroesophageal reflux in children: challenges in diagnosis and treatment

Gastroesophageal reflux (GER) occurs throughout the day in healthy infants, children, and adolescents, as well as in adults. However, regurgitation into the pharynx and vomiting are more common in infants than in adults. This places the infant at particular risk for supraesophageal complications of GER. Despite recognition of this risk, a lack of good control data in children and an absence of placebo-controlled treatment trials provide only marginal evidence to support GER as a cause of any supraesophageal disorder in infants or children. An association of GER with "awake apnea," reactive airway disease, and recurrent pneumonia has been demonstrated. Although there is no good evidence to support the efficacy of medical therapy, surgical therapy for GER has been demonstrated to improve symptoms in selected cases with each of these symptom presentations. Although clinical experience and case series suggest that GER may possibly contribute to laryngeal disorders, sinusitis, and otitis media, convincing data are lacking. No studies have definitively demonstrated symptom improvement with medical or surgical therapy for the latter symptom presentations.

Prevention. Part 3: prevention of tooth wear

Non-carious destruction of teeth has been observed in archaeological material from various parts of the world and clearly pre-dates the first appearance of dental caries. Attrition, abrasion and erosion are also described in the classic text of Pindborg on the pathology of the dental hard tissues. Whilst the dental profession, at least in affluent parts of the world, was engaged in diagnosing, treating and later preventing dental caries these other causes of tooth destruction were largely ignored.

Development of low erosive carbonated fruit drinks 2. Evaluation of an experimental carbonated blackcurrant drink compared to a conventional carbonated drink

OBJECTIVE

Previous studies demonstrated that a non-carbonated blackcurrant juice drink with added calcium produced little erosion of enamel in vitro and in situ by comparison with other low pH fruit drinks. The aim of this study is to evaluate the erosive effects in situ of an experimental formulation carbonated drink with added calcium, compared to a conventional carbonated drink over a 20 day period using a similar design as in previous studies.

METHOD

The study was a single centre, single blind, randomised placebo controlled three cell crossover design involving 15 volunteers. The test drinks were an experimental carbonated ready-to-drink (RTD) blackcurrant drink, a conventional carbonated RTD orange drink and water. Two enamel samples were retained in situ, in the midline of the hard palate on an upper removable acrylic appliance. Drinks were 250 ml volumes consumed four times per day during 20 working days. Measurements of enamel loss were made on enamel samples after days 2, 5, 10, 15 and 20 by profilometry.

RESULTS

The experimental carbonated blackcurrant drink caused significantly less enamel loss than the conventional carbonated orange drink at all time points measured, but was not significantly different from water at days 2, 5 and 20.

CONCLUSIONS

This study has shown that it is possible to modify carbonated soft drinks in a manner similarly shown with non-carbonated soft drinks, to minimise dental erosion.

Preliminary in vitro assessment of erosive potential using the ultra-micro-indentation system

The aim of this study was to measure the change in hardness and modulus of elasticity of enamel and dentine in primary teeth using the ultra-micro-indentation system (UMIS) after exposure to potentially erosive beverages and to relate the changes to the chemical composition of the test beverages. Primary molar teeth were sectioned and polished. Indentations were made in enamel and dentine prior to and then after exposure to one of four beverages: distilled water (control), orange juice, Orange Cordial, Fanta((R)) and a 'toothfriendly' Tropical Orange Cordial (Ribena((R))). Each beverage was then analysed. Fanta and Orange Cordial were the only test beverages to show a statistically significant reduction in the enamel hardness in comparison to the control and only Fanta showed a significant reduction in dentine hardness. None of the test beverages significantly reduced the modulus of elasticity of either enamel or dentine. Statistically the pH, phosphate and fluoride concentrations of the beverages were correlated with softening of enamel. Calcium concentration and titratable acidity were correlated with softening of dentine. The UMIS offers another method of measuring the basic mechanical properties of enamel and dentine. This is useful in predicting the erosive potential of substrates. It is likely that the pH, titratable acidity, fluoride, phosphate and calcium content of beverages are all important in determining the potential erosiveness of beverages.

Development of low erosive carbonated fruit drinks. 1. Evaluation of two experimental orange drinks in vitro and in situ

OBJECTIVES

To determine the in vitro erosive potential and in situ erosive effect of two new formulation low calorie carbonated orange drinks with that of two conventional diet products and water.

METHODS

In the in vitro study, six specimens of deciduous and permanent enamel were randomly allocated to each of the five products and a '4h' protocol employed. In the in situ study, 15 healthy volunteers participated in a single centre, single blind, 5-phase crossover study, conducted according to Good Clinical Practice, and employing a validated model.

RESULTS

The in vitro erosive potential of the experimental formulations was less than that of the comparators at all time points. Conversely, the observed erosive potential of both experimental formulations was greater than that of the control. Consistent statistically significant differences were found in relation to permanent enamel only. Unfortunately, the in situ study did not produce results entirely consistent with those of the in vitro study. Notably, a generally progressive loss of enamel was observed in specimens exposed to the control.

CONCLUSIONS

The data from the in vitro study show the experimental formulations to have low comparative erosivity. However, the methodologies in vitro and in situ somewhat unusually do not correlate in ranking the erosivity of drinks. The results of this study should therefore be viewed with caution, further research being clearly warranted.

Influence of abrasion in clinical manifestation of human dental erosion

The influence of abrasion from oral soft tissues on softened enamel lesion remineralization and erosion development was investigated. Using orange juice, softened enamel lesions were produced on 20 human premolars assigned randomly to 10 volunteers. Sections used as control and two test slabs were cut from each tooth. One of the two slabs from each tooth had an appliance built on it, which protected the lesion from abrasion. The two slabs (with/without appliance) were bonded to the palatal surfaces of upper right and left lateral incisor teeth of the participants who chewed sugar-free gum four times daily. After 28-day intra-oral exposure, mineral loss (Delta Z) and lesion depth (ld) in both control and test samples were quantified using transverse microradiography, and the data was analysed by paired t-test. Delta Z was significantly lower in lesions with appliance (protected), but higher in lesions without appliance (unprotected) when compared with control (unexposed). Similar pattern was observed with lesion depth. In unprotected slabs the lesions were abraded resulting in eroded enamel lesions. It was concluded that erosion observed clinically is the combined effect of demineralization of the tooth surface by an erosive agent and abrasion of the demineralized surface by surrounding oral soft tissues and through food mastication. Abrasion from oral soft tissues can contribute to site-specificity of dental erosion.

Dental erosion -- changing prevalence? A review of British National childrens' surveys

OBJECTIVES

To investigate the change in the prevalence of dental erosion, over time, by a review of the data from the published national dental surveys of young people in the UK. A subsidiary objective was to investigate the relationship between erosion and possible associated risk factors.

DESIGN

The review was based on cross-sectional prevalence studies incorporating a clinical dental examination and structured interviews.

SAMPLE

The data were collated from the 1993 UK childrens' dental health survey and the dental report of the two National Diet and Nutrition Surveys (NDNS) of children aged 1(1/2)-4(1/2) in 1992/3 and 4-18 years in 1996/7. The criteria used for data collection were comparable between the three different studies.

RESULTS

Comparing the data from the different studies, the prevalence of erosion was seen to increase from the time of the childrens' dental health survey in 1993 and the NDNS study of 4-18-year-olds in 1996/7. There was a trend towards a higher prevalence of erosion in children aged between 3(1/2) and 4(1/2) and in those who consumed carbonated drinks on most days compared with toddlers consuming these drinks less often. Drinks overnight were associated with an increased prevalence of erosion. More 4-6-year-olds with reported symptoms of gastro-oesophageal reflux had erosion compared with symptom-free children. On multivariate analysis, the strongest independent association with erosion was geography, with children living in the North having twice the odds of having erosion compared with those in London and the South-east.

CONCLUSIONS

Comparing prevalence data from cross-sectional national studies indicates that dental erosion increases between different age cohorts of young people over time. Dietary associations with erosion are present but weak. Similarly, there is an association apparent between erosion, symptoms of gastro-oesophageal reflux and socio-demographic variables such as region of domicile, social class, and receipt of social benefits.

Retrospective long term monitoring of tooth wear using study models

OBJECTIVE

Tooth wear is recognised as a common feature of European dentitions. However, little is known about its progression in susceptible patients. The aim of this study was to assess the degree and progression of tooth wear in patients by examining study casts taken of their teeth on two separate occasions.

DESIGN

Over 500 sets of study casts taken during an 18-year period from patients referred for a variety of restorative procedures, were examined at Guy's Dental Hospital. Of these, 34 cases were found to have consecutive models taken at two time intervals and these were used to assess the progression of tooth wear. Study models from 19 females and 16 males, with an average age of 26 years (range 18-60) at the time of their first presentation and were all examined by a single operator. The Smith and Knight tooth wear index was used to assess the degree of tooth wear at presentation and then at another time which was a median of 26 months (interquartile range 14 - 50 months) later.

RESULTS

The most common initial TWI score per surface was 1, with 54% of surfaces affected at the first assessment and 57% at the second. Score 2 was less common (14% at both assessments) and the scores for 3 and 4 combined were relatively uncommon with 5% of surfaces effected. Minimal progression of tooth wear was observed on study casts with only 7.3% of surfaces involved.

CONCLUSION

In this sample, tooth wear was a slow, minimally progressive process.

Relationship between sports drinks and dental erosion in 304 university athletes in Columbus, Ohio, USA

Acidic soft drinks, including sports drinks, have been implicated in dental erosion with limited supporting data in scarce erosion studies worldwide. The purpose of this study was to determine the prevalence of dental erosion in a sample of athletes at a large Midwestern state university in the USA, and to evaluate whether regular consumption of sports drinks was associated with dental erosion. A cross-sectional, observational study was done using a convenience sample of 304 athletes, selected irrespective of sports drinks usage. The Lussi Index was used in a blinded clinical examination to grade the frequency and severity of erosion of all tooth surfaces excluding third molars and incisal surfaces of anterior teeth. A self-administered questionnaire was used to gather details on sports drink usage, lifestyle, health problems, dietary and oral health habits. Intraoral color slides were taken of all teeth with erosion. Sports drinks usage was found in 91.8% athletes and the total prevalence of erosion was 36.5%. Nonparametric tests and stepwise regression analysis using history variables showed no association between dental erosion and the use of sports drinks, quantity and frequency of consumption, years of usage and nonsport usage of sports drinks. The most significant predictor of erosion was found to be not belonging to the African race (p < 0.0001). The results of this study reveal no relationship between consumption of sports drinks and dental erosion.

Comparison of factors potentially related to the occurrence of dental erosion in high- and low-erosion groups

Soft drink intake, method of drinking, pH variations, plaque topography, and various salivary, microbial and clinical factors were compared in Saudi men with high (n = 10, mean = 20.5 yr) and low (n = 9, mean = 20.3 yr) dental erosion. pH-measurements were carried out with a microtouch electrode at six different intraoral locations after the subjects had consumed 330 ml of regular cola-type drink in their customary manner. The results showed that higher intake of cola-type drinks was more common in the high- (253 l yr(-1)) than in the low-erosion group (140 l yr(-1)). High erosion was associated with a method of drinking whereby the drink was kept in the mouth for a longer period (71 s vs. 40 s). pH after drinking did not differ between the groups for any of the six measuring sites. Plaque accumulation on the palatal surfaces of maxillary anterior teeth and urea concentration in unstimulated saliva were lower in high-erosion subjects. Aside from these, there were no differences in salivary and microbial factors between the groups. First molar cuppings, buccal cervical defects, and mouth breathing were more common in the high- than in the low-erosion group. In summary, consumption of cola-type drink, method of drinking, amount of palatal plaque on anterior teeth, and salivary urea concentration are factors associated with dental erosion.

Is there a relationship between asthma and dental erosion? A case control study

OBJECTIVES

The aims of this study were firstly to assess and compare the prevalence of dental erosion and dietary intake between three groups of children; children with asthma, those with significant tooth erosion but with no history of asthma, and children with no history of asthma or other medical problems. Secondly, to discover whether there was a relationship between medical history and dietary practises of these children and the levels of dental erosion. Thirdly, to measure and compare their salivary flow rates, pH and buffering capacity.

METHODS

The study consisted of 3 groups of children aged 11-18 years attending Birmingham Dental Hospital: 20 children with asthma requiring long-term medication, 20 children referred with dental erosion, and 20 children in the age and sex matched control group. Tooth wear was recorded using a modification of the tooth wear index (TWI) of Smith and Knight. Data on the medical and dietary history were obtained from a self-reported questionnaire supplemented by a structured interview. The salivary samples were collected under standard methods for measurements.

RESULTS

Fifty percent of the children in the control group had low erosion and 50% moderate erosion. However, high levels were recorded in 35% of children in the asthma group and 65% in the erosion group. There appeared to be no overall differences in diet between the groups. There was an association between dental erosion and the consumption of soft drinks, carbonated beverages and fresh fruits in all the three groups. More variables related to erosion were found in the erosion and asthma groups. A comparison between the three groups showed no significant differences in unstimulated and stimulated salivary flow rates, or pH and buffering capacity.

CONCLUSION

There were significant differences in the prevalence of erosion between the three groups, children with asthma having a higher prevalence than the control group. Although there was a relationship between the levels of erosion and some medical history and acidic dietary components, these did not explain the higher levels in asthmatic children. Further investigation is required into the factors affecting the increased prevalence of erosion in children with asthma.

Gastroesophageal reflux disease and dental erosion in children

Recurrent exposure to gastric acid as in children with bulimia and gastroesophageal reflux disease (GERD) may contribute to dental erosion. We performed a prospective study to evaluate the presence of GERD and dental erosions in children with primary and permanent dentition. Children undergoing elective endoscopy for possible GERD (n = 37) underwent evaluation of their teeth for the presence, severity, and pattern of erosion and stage of dentition: 24 patients had GERD. Dental erosions were identified in 20; all had GERD. Erosion patterns showed more involvement of the posterior teeth. Many affected patients had primary dentition.

Prevalence, distribution and background variables of smooth-bordered tooth wear in teenagers in the hague, the Netherlands

The purposes of the study were: (1) to assess the prevalence and distribution of smooth-bordered tooth wear in teenagers, and (2) to investigate the relationship between smooth-bordered tooth wear and social background, dietary pattern, drinking habits, oral hygiene practices and caries prevalence. In The Hague, The Netherlands, a sample of 345 10- to 13-year-olds and 400 15- and 16-year-olds was clinically examined. The criteria for the assessment of smooth-bordered tooth wear ('smooth wear') were in line with the diagnostic criteria for erosion developed by Lussi (1996). In the age group 10-13 years, the percentage of subjects with visible smooth wear (SW1 threshold) was 3% and in 1 subject (0.3%), deep smooth enamel wear was found. Due to the low prevalence, the results for this age group were not analysed further. In the age group 15-16 years, the proportion of subjects with visible smooth wear (SW1 threshold) was 30% and that with at least deep smooth enamel wear (SW2 threshold) 11%. Smooth wear into dentine was found in 1 subject. First molars and upper anterior teeth were affected predominantly. A significant effect on visible smooth wear (SW1 threshold) was found for gender and social background. At mouth level, no significant influence was found for dietary patterns, drinking habits or oral hygiene practices. The caries prevalence was similar in subjects with and without smooth wear.

Risk indicators for tooth wear in New Zealand school children

AIM

To investigate the prevalence and severity of tooth wear in the primary dentition of a representative sample of New Zealand school children and relate these to possible risk factors.

DESIGN

A cross-sectional study.

SETTING

Primary schools in Dunedin, New Zealand.

PARTICIPANTS

104 children of both sexes, aged between 5 and 8 years, randomly selected.

METHODS

Clinical examinations of the buccal, occlusal/incisal and lingual surfaces of deciduous canines and molars.

MAIN OUTCOME MEASURE

Degree of wear and the presence of dentinal cupping of teeth. Information on weaning and consumption of fruit-based drinks at bed time, frequency of consumption of fruits, yoghurt, pickled foods, fizzy and fruit-based drinks.

RESULTS

The prevalence of tooth wear was similar in boys and girls and there were no significant differences between sides of the arches. A high percentage (82%) of children had at least one primary tooth with dentine exposed. While maxillary canines showed the greatest prevalence of dentine exposed, maxillary molars displayed the greatest prevalence of cupping. Severe tooth wear was less prevalent among children weaned after 12 months (14.3%) than those weaned earlier (27.9% P < 0.01). There were no statistically significant associations between wear and the consumption of fruit, yoghurt, pickled foods, fizzy drinks or fruit-based drinks.

CONCLUSIONS

Tooth wear associated with dentine exposure is common in 5-8 year old children. This is not significantly associated with dietary factors, but appears to be related to early weaning from the breast.

Characteristics of tooth wear in relation to different nutritional patterns including contemporary and medieval subjects

The present study sought to evaluate the characteristics of tooth wear in subjects with an acidic diet in relation to subjects with substantially different nutritional patterns. The evaluation included medieval skulls (group 1, n = 102, abrasive nutrition), study models of individuals living on an acidic diet (group 2, n = 100) and randomly selected subjects (group 3, n = 100, average Western diet). Wear was visually recorded on oral, vestibular and occlusal/incisal surfaces using quantitative and morphological criteria. The mean age was 42.3 +/- 15.3 yr in group 1, 40.9 +/- 11.2 yr in group 2 and 36.7 +/- 11.7 yr in group 3. Group 1 exhibited the most pronounced substance loss, followed by groups 2 and 3. On occlusal surfaces, cupping was common in group 1 followed by group 2, but was rare in group 3. An inverse relation was found for facets. On buccal surfaces, no substance loss was observed in group 1, whereas in group 2, 63% had at least one tooth with a buccal lesion compared to 8% in group 3. The occlusal substance loss observed in subjects exposed to acids may be interpreted as increased abrasion/demastication of acid-softened dental hard tissues. The occurrence of concavities on smooth surfaces appears to be significant for the diagnosis of dental erosion.

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Tooth surface pH during drinking of black tea

OBJECTIVES

To investigate the composition of black tea in terms of its erosive potential. To determine the pH profile at the palatal surface of anterior and posterior sites of the dentition after drinking black tea.

METHODS

Tea solution was analysed for its pH and anion composition to provide information on its acid content. A group of ten healthy subjects, aged 21-23 years were monitored for tooth surface pH on the palatal aspects of the maxillary anterior dentition and the maxillary molar dentition after drinking tea using a micro-pH electrode mounted on a vinyl splint.

RESULTS

The pH of the tea solution was 4.9 and the major anions detected were oxalate and citrate. Tooth surface pH monitoring indicated that only small decreases in pH of less than 1 pH unit were observed after drinking tea and the minimum mean pH reached was 5.45. Maximum decrease in pH was observed after 20-25 seconds and resting pH levels were restored within approximately 2 minutes after drinking.

CONCLUSION

The pH and anion profile of black tea are indicative of low acid composition. The very small pH decreases observed at the tooth surface after drinking tea indicate that it may be safely recommended as a substitute for more acidic drinks as a part of preventive measures for dental erosion.