Epidemiology of Erosive Tooth Wear, Dental Fluorosis and Molar Incisor Hypomineralization in the American Continent

Development and content validation of the Childhood Early Oral Aging Syndrome (CEOAS) index for the deciduous dentition: Research protocol

Premature, non-physiological tooth wear in childhood has numerous repercussions for oral health. This is a growing problem with multifactorial causes and associated with the current lifestyle. The introduction of new concepts and indices is crucial for enhancing the understanding and management of dental conditions. In this context, we present the Childhood Early Oral Aging Syndrome (CEOAS) and the associated index, which aim to assess early enamel wear in the primary dentition. Rather than focusing solely on isolated etiologies, the index proposes a comprehensive evaluation of signs and symptoms, considering various factors that contribute to the premature and non-physiological loss of dental structure, including wear of both intact and hypomineralized enamel. Indices that evaluate the main factors of early oral aging in childhood and their interactions are fundamental for understanding the condition and developing effective control and treatment strategies, particularly given that there is currently no global index encompassing this information. The aim of the present study was the development and determination of content validity of the Childhood Early Oral Aging Syndrome (CEOAS) index for the primary dentition as a diagnostic and epidemiological survey tool. Trial registration: ClinicalTrials.gov ID: NCT06378385.

Masking efficacy of bleaching and/ or resin infiltration of fluorotic spots on anterior teeth - a systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review and meta-analysis was to evaluate the masking success of bleaching and/or resin infiltration treatment of fluorotic lesions in anterior teeth of adults and adolescents.

DATA SOURCES

PubMed, Cochrane Library, and Embase were systematically searched from the beginning of documentation to December 31, 2023.

PRIMARY OUTCOME WAS THE NUMBER OF MASKED TEETH

A tooth was considered masked when the color difference (ΔE CIE76) between fluorotic areas and the surrounding sound enamel was ≤3.7 and unmasked if ΔE > 3.7. Secondary outcomes were mean ΔE values between fluorotic and sound enamel reported for a treatment group at baseline and after any intervention as well as patient satisfaction.

STUDY SELECTION

Of 1575 search results 4 publications met the inclusion criteria, comprising 230 treated anterior teeth with fluorosis in 47 patients. Meta-analyses were performed comparing the result after treatment (bleaching, resin infiltration, or bleaching followed by resin infiltration) to baseline.

RESULTS

Bleaching and resin infiltration were suitable intervention strategies to improve the esthetics of fluorosis affected anterior teeth, with a combination of both treatment approaches being particularly effective in reducing the color difference between fluorotic defects and the surrounding sound enamel below the acceptability thresholds of 3.7 (success rate [95 %CI]: 0.75 [0.44, 1.06]). Patient satisfaction increased after treatments, indicating a beneficial impact on their mental health. The overall bias of the included studies was 2.5 (ROBINS-I analysis tool).

CONCLUSION

There is evidence that resin infiltration with preceding bleaching therapy is more effective in masking fluorotic lesions in anterior teeth than bleaching alone. The combination therapy also showed a tendency towards higher success rates compared to infiltration alone. However, this difference was statistically not significant, and more studies are needed to further assess the efficacy of specific treatments and their combinations as well as the certainty in the evidence. The methodologic heterogeneity of study designs regarding estimation of color difference before and after treatment and bleaching protocols calls for unification in future studies.

CLINICAL SIGNIFICANCE

Results of this systematic review and meta-analysis revealed the combination of bleaching followed by resin infiltration as efficacious approach for masking fluorotic lesions in young adults. While resin infiltration alone improves the aesthetic appearance of fluorotic lesions, dentists should consider a combined bleaching-infiltration regimen to achieve more favorable clinical outcome for their patients.

Erosive Tooth Wear and Associated Risk Indicators in Schoolchildren from Rural and Urban Areas of the State of Mexico: A Cross-Sectional Study

BACKGROUND AND OBJECTIVE

Limited access to health services and low educational levels are factors in the rural population that are associated with the development of oral pathologies. However, the specific risk indicators contributing to erosive tooth wear (ETW) in these populations remain unclear. The objective of this study was to identify risk indicators associated with the prevalence of erosive tooth wear (ETW) in schoolchildren aged 8-12 years from rural and urban areas in the State of Mexico.

METHODS

A cross-sectional study was carried out in public schools in rural and urban areas. The prevalence of ETW was evaluated using the Basic Erosive Wear Examination (BEWE). The risk indicators studied were gastroesophageal reflux, vomiting, vitamin C, food, beverages, dental hygiene, bruxism, and hyposalivation. Logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The prevalence of ETW was higher in the rural area (77.3%) compared to the urban area (51.2%) (p = 0.001). The odds of presenting ETW were more than twice in schoolchildren from rural areas compared to those from urban areas (OR: 2.25, 95% CI: 1.11-3.98). Risk indicators varied between rural and urban populations, with different factors such as the consumption of fresh tomato sauce, orange, tangerine, atole (artisanal corn-based drink), and teeth grinding in the rural area, and lemon, soft drink, fruit juice consumption, and the simplified oral hygiene index in the urban area (p < 0.05).

CONCLUSIONS

To prevent ETW, strategies offering tailored dietary and hygiene advice should be proposed, considering the specific conditions of each geographic area.

Epigallocatechin-3-gallate attenuates fluoride induced apoptosis via PI3K/FoxO1 pathway in ameloblast-like cells

Fluoride is a double-edged sword. It was widely used for early caries prevention while excessive intake caused a toxicology effect, affected enamel development, and resulted in dental fluorosis. The study aimed to evaluate the protective effect and mechanism of Epigallocatechin-3-gallate (EGCG) on the apoptosis induced by fluoride in ameloblast-like cells. We observed that NaF triggered apoptotic alterations in cell morphology, excessive NaF arrested cell cycle at the G1, and induced apoptosis by up-regulating Bax and down-regulating Bcl-2. NaF activated the insulin-like growth factor receptor (IGFR), and phosphatidylinositol-3-hydroxylase (p-PI3K), while dose-dependently down-regulating the expression of Forkhead box O1 (FoxO1). EGCG supplements reversed the changes in LS8 morphology, the cell cycle, and apoptosis induced by fluoride. These results indicated that EGCG possesses a protective effect against fluoride toxicity. Furthermore, EGCG suppressed the activation of p-PI3K and the down-regulation of FoxO1 caused by fluoride. Collectively, our findings suggested that EGCG attenuated fluoride-induced apoptosis by inhibiting the PI3K/FoxO1 signaling pathway. EGCG may serve as a new alternative method for dental fluorosis prevention, control, and treatment.

Pretreatments to bonding on enamel and dentin disorders: a systematic review

INTRODUCTION

This systematic review focuses on structural anomalies of enamel and dentin such as fluorosis (F), molar-incisor hypomineralization (MIH), amelogenesis imperfecta (AI), dentinogenesis imperfecta (DI), osteogenesis imperfecta (OI), and X-linked hypophosphatemia (XLH). These pathologies affect up to 31% of the population, posing challenges in the adhesion of direct restorations. The primary objective of this analysis is to examine the survival rate and/or bonding resistance of direct restorations on tissues affected by enamel and dentin disorders in humans. We aim to provide precise clinical recommendations for dentists to choose the appropriate bonding pretreatment for various enamel and dentin disorders.

METHODS

We systematically searched the medical literature to identify abstracts of interest indexed between 1993 and May 2024, from 4 databases (PubMed, PMC-PubMed, Web of Science and Cochrane Library). The results are reported following the PRISMA statement. The GRADE approach was used to assess the risk of bias.

RESULTS

The two authors included 27 studies out of the 600 identified. The data extracted from these studies are highly heterogeneous, and the mentioned bonding protocols are all different. 15 articles pertain to F, 7 to MIH, 5 to AI, and none focus on HSPM, dentin disorders and XLH. We identified 12 pretreatments of enamel or dentin (7 for F, 2 for MIH, and 3 for AI), including 3 strong recommendations. Additional studies are necessary to confirm the effectiveness of certain pretreatments. In developmental enamel defects, the main recommendation we collected is to bond on enamel with an etch-and-rinse technique on F and MIH. Considerations with lower strength of evidence include a deproteinization step on enamel on F, MIH and AI and modifications of the etching parameters on F and AI. The research strategy was registered on the Prospero platform (CRD42023447502).

Which are the clinical consequences of Molar Incisor hypomineralization (MIH) in children and adolescents? Systematic review and meta-analysis

OBJECTIVE

This systematic review was conducted to address the following research question: "What are the clinical consequences (outcome) of Molar Incisor Hypomineralization (MIH) (exposure) in children and adolescents (population/patient)?".

MATERIAL AND METHODS

After defining the strategy, a search was performed in different databases (MEDLINE via Pubmed, Cochrane Library, BBO, LILACS, Scopus, Web of Science, Embase) and Grey literature in August 2023. Cross-sectional observational studies that identified clinical consequences of MIH (dental caries, post-eruptive structural loss, atypical restorations, hypersensitivity and tooth extraction) were included. The risk of bias was assessed following the Joanna Briggs Institute protocol for cross-sectional studies. Meta-analyses were conducted for each outcome, taking into account the number of patients and teeth. The effect measure considered was the prevalence; random-effects model was adopted. Heterogeneity was assessed using I2 statistics and prediction intervals (PI).

RESULTS

A total of 903 studies were identified; 41 were selected for qualitative analysis and 38 for quantitative analysis. Twenty eight studies were classified as presenting uncertain risk of bias, 11 as low risk and 3 as high risk of bias. The prevalence levels, ranked from highest to lowest and considering the tooth and patient units, respectively, were: caries lesions (0.252 - 95% CI 0.158-0.375; 0.512 - 95% CI 0.385-0.639); hypersensitivity (0.286 - 95% CI 0.190-0.407; 0.417 - 95% CI 0.197-0.674), post-eruptive fracture (0.125 - 95% CI 0.099-0.158; 0.257 - 95% CI 0.145-0.412); atypical restorations (0.048 - 95% CI 0.030-0.077; 0.167 - 95% CI 0.096 - 0.274); tooth extraction (0.012 - 95% CI 0.007-0.019; 0.090 - 95% CI 0.019 - 0.331). All meta-analyses resulted in heterogeneity greater than 85%, with the exception of the outcome "tooth extraction" according to the tooth unit (I2 = 57.83). This heterogeneity may be attributed to factors such as differences in the location where the study was realized, the socioeconomic conditions of the studied population, the asymmetric nature of MIH, and patient age.

CONCLUSION

The most common consequences of MIH are caries lesions, hypersensitivity, and post-eruptive breakdown. (PROSPERO:CRD42020201410).

Prevalence of erosive tooth wear and associated risk factors in Colombian adolescents

Accurate determination of the prevalence of erosive tooth wear (ETW) and associated risk factors in adolescents can inform clinical management guidelines. The aim of this analytical cross-sectional study was to estimate the prevalence, severity, and risk factors of ETW in adolescents aged 12-15 years in the municipality of Usaquén in Bogotá, Colombia. Two calibrated examiners clinically assessed ETW using Basic Erosive Wear Examination (BEWE) Index (range: 0-3). All tooth surfaces (excluding proximal) were scored to allow estimation of the Highest (0-3) and Total BEWE (sum of Highest BEWE score per sextant: 0-18) scores per patient. Sociodemographic characteristics, ETW risk factors, and caries severity (ICDAS-epi-merged) were evaluated, and their association with the presence of ETW (indicated by a Highest BEWE score of 2-3) was examined using preliminary analyses and logistic regression models. The study sample included 454 adolescents (mean age: 13.5±1.1 years; female: 61.7%), and the prevalence of ETW was 71.6%. The majority of participants exhibited a Highest BEWE score of 3 (58.0%) and a Total BEWE score ≤8 (84.3%). The preliminary analysis showed an association between the presence of ETW and age, caries, and brushing teeth before eating (p-value < 0.05). Risk factors for ETW included always brushing teeth before eating [adjusted Prevalence Ratio (PRa) 1.31, p-value=0.014], presence of extensive carious lesions (PRa 1.23, p-value = 0.024), male gender (PRa 1.14, p-value = 0.028), and age > 14 years (PRa 1.17, p-value = 0.009). Although ETW was highly prevalent, most Colombian adolescents exhibited low Total BEWE scores. ETW was associated with frequent fruit intake, age, toothbrushing habits, caries lesions, and sex.

Co-exposure to fluoride and sulfur dioxide induces abnormal enamel mineralization in rats via the FGF9-mediated MAPK signaling pathway

Fluoride (F) and sulfur dioxide (SO2) contamination is recognized as a public health concern worldwide. Our previous research has shown that Co-exposure to F and SO2 can cause abnormal enamel mineralization. Ameloblastin (AMBN) plays a crucial role in the process of enamel mineralization. However, the process by which simultaneous exposure to F and SO2 influences enamel formation by regulating AMBN expression still needs to be understood. This study aimed to establish in vivo and in vitro models of F-SO2 Co-exposure and investigate the relationship between AMBN and abnormal enamel mineralization. By overexpressing/knocking out the Fibroblast Growth Factor 9 (FGF9) gene, we investigated the impact of FGF9-mediated Mitogen-Activated Protein Kinase (MAPK) signaling on AMBN synthesis to elucidate the mechanism underlying the induction of abnormal enamel mineralization by F-SO2 Co-exposure in rats. The results showed that F-SO2 exposure damaged the structure of rat enamel and ameloblasts. When exposed to F or SO2, gradual increases in the protein expression of FGF9 and phosphorylated p38 mitogen-activated protein kinase (p-P38) were observed. Conversely, the protein levels of AMBN, phosphorylated extracellular signal-regulated kinase (p-ERK), and phosphorylated c-Jun N-terminal kinase (p-JNK) were decreased. AMBN expression was significantly correlated with FGF9, p-ERK, and p-JNK expression in ameloblasts. Interestingly, FGF9 overexpression reduced the levels of p-ERK and p-JNK, worsening the inhibitory effect of F-SO2 on AMBN. Conversely, FGF9 knockout increased the phosphorylation of ERK and JNK, partially reversing the F-SO2-induced downregulation of AMBN. Taken together, these findings strongly demonstrate that FGF9 plays a critical role in F-SO2-induced abnormal enamel mineralization by regulating AMBN synthesis through the JNK and ERK pathways.

Identifying the oral microbiome of adolescents with and without dental fluorosis based on full-length 16S rRNA gene sequencing

Dental fluorosis, resulting from long-term environmental exposure to fluoride, is prevalent among diverse populations worldwide. Severe fluorosis not only compromises the aesthetic appeal of teeth but also impairs their functionality. This study aims to investigate the oral microbiome in dental fluorosis and the health individuals of adolescents living in the endemic fluorosis area of Guizhou, China through full-length 16S rDNA sequencing. Fourty-six individuals meet the sampling criteria, and we divided these samples into the following groups: a healthy group (H = 23) and a dental fluorosis group (F = 23), and two subgroups of Miao ethnicity: a healthy Miao group (Hm = 13) and a dental fluorosis Miao group (Fm = 15). A total of 660,389 high-quality sequences were obtained, and 12,007 Amplicon Sequence Variants (ASVs) were identified, revealing significant variations in oral microbiome between Fm and Hm groups. The composition of oral microbiota was similar between the H and F groups. At the genus level, Pseudopropionibacterium and at the species level, Streptococcus oralis_subsp.dentisani_clade_058 were less abundant in group F than in group H (P < 0.05). Further analysis revealed that the abundance of Capnocytophaga gingivalis and Kingella denitrificans was significantly lower in Fm fluorosis patients than in the Hm group (P < 0.05). Based on the LEfSe analysis, the potential core biomarkers in the oral of Fm fluorosis patients were identified at different taxonomic levels, ranging from phylum to species. These include Gammaproteobacteria, Prevotella sp_HMT_304, Gemella sanguinis, and Gracilibacteria_(GN02). Network analysis revealed that the microbiota in the fluorosis group exhibited more complex interactions with each other than the healthy group. Notably, within the Hm group, the potential biomarkers Capnocytophaga gingivalis and Kingella denitrificans exhibited a positive correlation. Finally, we employed PICRUSt2 analysis to explore the abundance clustering of the top 30 functional units in each sample, and we found that the metabolic pathway compositions of the four groups were similar. In summary, our findings suggest that the microbial composition of plaque in Hm patients with dental fluorosis is significantly altered, and we identified the potential marker microorganisms that contribute to these changes.

Association between psychological factors and molar-incisor hypomineralization: A cross-sectional study

BACKGROUND

Molar-incisor hypomineralization (MIH) is a developmental enamel defect characterized by opacities from white to brownish color. A suspected multifactorial etiology has been suggested, whereas psychological factors during pregnancy have only been limitedly analyzed.

AIM

We assessed the association between stress, depression, and anxiety in pregnancy and the presence of MIH in children at a later age.

DESIGN

Using a cross-sectional Web-based questionnaire, we included 384 mothers who had children aged 6 and 12 years from Pasto, Colombia. Data were collected between October 2021 and March 2022. Sociodemographic variables; maternal and child factors related to prenatal, natal, or postnatal problems; and psychological factors such as stress and symptoms of anxiety and depression in pregnancy were inquired. Utilizing photographs depicting MIH lesions, mothers assessed their child's MIH status. A directed acyclic graph (DAG) analysis was performed to create causal assumptions, and logistic regression models were estimated to evaluate these assumptions. p-value was set at p < .05.

RESULTS

The prevalence of MIH was 33.3%; 12.8% of the participants exhibited hypomineralization in both molars and incisors. DAG analysis and logistic regression models determined that MIH (present or not) was associated with symptoms of maternal depression (ORadj  = 3.26, 95% CI: 1.92-5.52, p < .001), and MIH (both molars and incisors) was associated with symptoms of maternal anxiety (ORadj  = 3.49, 95% CI: 1.80-6.76, p < .001).

CONCLUSION

Psychological factors, among others, were significantly associated with the presence of MIH.

Treatment Approaches to Molar Incisor Hypomineralization: A Systematic Review

AIM

This systematic review aimed to comprehensively evaluate the available literature on treating molar incisor hypomineralization (MIH) or enamel hypomineralization published between 2013 and 2023, focusing on identifying relevant studies and their characteristics.

MATERIALS AND METHODS

The search process encompassed reputable academic databases, including PubMed, Scopus, Cochrane Library, and Web of Science, using a precise keyword strategy ("((molar incisor hypomineralization) OR (enamel hypomineralization)) AND (treatment)"). A total of 637 articles were initially retrieved, followed by a strict selection process adhering to PRISMA guidelines. The inclusion criteria encompassed Randomized Control Trials (RCTs), case series with more than five clinical cases (CSs), studies involving human participants, availability as free full-text or accessible with university credentials, and English-language publications. Exclusion criteria included systematic or literature reviews, editorials, single-case reports, studies conducted in vitro, those involving animals, paid articles, and non-English-language publications.

RESULTS

The search yielded 864 articles, of which 23 met the stringent inclusion criteria after a meticulous selection process. These studies will serve as the basis for a comprehensive analysis of MIH treatment approaches. The systematic review ensures the quality and relevance of the chosen studies for a detailed assessment of MIH treatment strategies.

CONCLUSIONS

This systematic review will provide valuable insights into the characteristics of selected studies, patient profiles, and available treatment options for molar incisor hypomineralization, contributing to a better understanding of this dental condition's management.

Acquired pellicle engineering with the association of cystatin and vitamin E against enamel erosion

OBJECTIVE

Evaluate CaneCPI-5 associated with Vitamin E in acquired enamel pellicle (AEP) engineering to prevent dental erosion.

METHODS

180 human enamel specimens were divided into 12 groups and treated with the following solutions: Cane+VitT and Cane+VitS- CaneCPI-5 + Vit E; Vit+CaneT and Vit+CaneS- Vit E + CaneCPI-5; VitT and VitS- Vit E; CaneT and CaneS- CaneCPI-5; ControlT and ControlS - AmF/NaF/SnCl2; WaterT and WaterS- Deionized water. Groups' name followed by "T" were first treated (200 μl; 2 min) and then incubated in human saliva (200 μl; 1 h) to form the AEP. For groups followed by "S", the AEP was formed and then treatment was applied. The erosive challenge consisted of immersion in 1% citric acid (1 min, 1x/day, for 3 days). The percentage of superficial hardness loss (%SHL) and the relative surface reflection intensity (%SRI) were subjected to normality and homogeneity tests, Shapiro-Wilk and Levene tests, respectively. Subsequently, the data were analyzed using two-way ANOVA, Tukey's test and Pearson's correlation (p < 0.005).

RESULTS

For%SHL and%SRI, water controls showed significantly lower protective capacity. Cane+VitT, Cane+VitS, and Vit+CaneS presented the lowest%SHL, and VitT and VitS did not differ from Vit+CaneT, but they were different from the other groups (p = 0.002). The greatest%SRI was found for the Cane+VitT, Vit+CaneT, VitT, Cane+VitS, Vit+CaneS, and VitS groups, which did not significantly differ. CaneT and ControlT, showed similar reflections compared to CaneS and ControlS.

CONCLUSION

CaneCPI-5 and Vitamin E demonstrated a synergistic protective effect against initial erosion.

CLINICAL SIGNIFICANCE

The results open up new possibilities for preventive approaches against erosion through the acquired pellicle engineering, with the combination of CaneCPI-5 and Vitamin E, which demonstrated to be more effective than commercial stannous mouthwash. Further research is warranted to explore the potential of this combination in diverse clinical settings.

Susceptibility of fluorotic enamel to dental erosion-abrasion

Dental hard tissue conditions can be of pre- or post-eruptive nature, such as enamel fluorosis and erosive tooth wear (ETW), respectively. Dental enamel fluorosis is caused by the chronic and excessive intake of fluoride during enamel development, leading to increased fluoride concentration and increased porosity. ETW has become a common clinical condition and often impairs dental function and aesthetics. This in vitro study tested the hypothesis that fluorotic enamel presents different susceptibility to dental erosion-abrasion. It consisted of a 3×3×2 factorial design, considering a) fluorosis severity: sound (TF0), mild (TF1-2), moderate (TF3-4); b) abrasive challenge: low, medium, and high; and c) erosive challenge: yes or no. A total of 144 human teeth were selected according to the three fluorosis severity levels (n=48), and subdivided into six groups (n = 8) generated by the association of the different erosive and abrasive challenges. Enamel blocks (4×4 mm) were prepared from each tooth and their natural enamel surfaces subjected to an erosion-abrasion cycling model. After cycling, the depth of the lesions in enamel was assessed by profilometry. ANOVA showed that the three-way and two-way interactions among the factors were not significant (p > 0.20). Enamel fluorosis level (p=0.638) and abrasion level (p = 0.390) had no significant effect on lesion depth. Acid exposure caused significantly more enamel surface loss than water (p < 0.001). Considering the limitations of this in vitro study, fluorosis did not affect the susceptibility of enamel to dental erosion-abrasion.

A Bibliometric Analysis of the Top 100 Most-Cited Papers Concerning Dental Fluorosis

A high number of citations can indicate the potential of any specific paper to influence other research and generate changes in clinical practice. Analyzing the most-cited papers in a certain scientific field may assist researchers to identify the influential papers as well their main characteristics. The present study aimed to analyze the 100 most-cited papers concerning dental fluorosis (DF) through a bibliometric review. A search was performed in the Web of Science Core Collection (WoS-CC) database in November 2021. The papers were displayed in descending order according to the number of citations in WoS-CC. Two independent researchers performed the selection. Scopus and Google Scholar were used to compare the number of citations with WoS-CC. The following data were extracted from the papers: title, authors, number and density of citations, institution, country, continent, year of publication, journal title, keywords, study design, and theme. Collaborative networks were generated using the VOSviewer software. The top 100 most-cited papers were published between 1974 and 2014 and were cited 6,717 times (ranging from 35 to 417). Community Dentistry and Oral Epidemiology (24%), Journal of Dental Research (21%), Journal of Public Health Dentistry (17%), and Caries Research (13%) published the most papers. Observational studies (60%) and literature reviews (19%) were the most common study designs. The main topics were epidemiology (44%) and fluoride intake (32%). The countries with the highest number of papers were the USA (44%), Canada (10%), and Brazil (9%). The University of Iowa (USA) had the most papers (12%). Levy SM was the author with the highest number of papers (12%). The 100 most-cited papers on DF were mainly observational studies focused on epidemiology and originated in North America. There were few interventional studies and systematic reviews among the most-cited papers concerning this topic.

A Systematic Review and Meta-Analysis of the Relationship Between the Severity of Dental Fluorosis and Fluoride Biomarkers in Endemic Areas

The intake of high concentrations of fluoride, mainly through drinking water, diet and fluoridated dentifrices, produces fluorosis, which in its early stages is manifested as dental fluorosis (DF). To recognize exposure to fluoride in endemic areas and to evaluate the risk of developing health impairment, the WHO has established several biomarkers that are used to determine systemic fluorine (F^-) exposure. Thus, the aim of this study was to conduct a systematic review and meta-analysis of the relationship between the severity of DF and fluoride biomarkers in endemic areas. The protocol of this study was previously registered as CRD42021244974. A digital search was carried out in PubMed/Medline, SpringerLink, Scopus, Cochrane and Google Scholar by employing the keywords "urine", "nails", "hair", "plasma", "saliva" and "dental fluorosis" for the original studies with content associated with F^- for the biomarkers and DF. The mean difference was established as the effect measure for the meta-analysis. Seven studies fulfilled the eligibility criteria, among which five assessed urine and two employed nails as fluoride biomarkers. A positive significant difference was found between the biomarkers and the severity of DF (0.27, p < 0.001) and individually for each biomarker (urine: 0.14, p = 0.001; nails: 0.88, p < 0.05). The F^- concentration in urine and nails is correlated with the severity of DF, with the most evident differences between healthy individuals and those with mild severity. Both biomarkers are adequate to assess this relationship in endemic areas of fluoride and DF.

Oral Health in 12- and 15-Year-Old Children in Serbia: A National Pathfinder Study

The aim of the paper is to present the oral health profile of 12- and 15-year-old schoolchildren in Serbia. Basic Methods for Oral Health Surveys of the WHO were implemented to record: Decayed, Missing, and Filled Teeth/Surfaces Index (DMFT/DMFS), gingival bleeding, enamel fluorosis and other structural anomalies, dental erosion, dental trauma, and oral mucosal lesions. In addition, Silness and Löe plaque index and orthodontic status were assessed. A total of 36% of 12-year-olds and 22% of 15-year-olds in Serbia were caries-free. The mean DMFT was 2.32 ± 2.69 for 12-year-olds and 4.09 ± 3.81 for 15-year-olds. DMFT was made up largely by the decayed component. Gingival bleeding was present in 26% of examined 12-year-old and 18% of 15-year-old children. Dental plaque was observed in 63% of both 12- and 15-year-olds. Fluorosis, structural anomalies, dental erosion, dental trauma, and oral mucosal lesion were rarely detected. Low prevalence of malocclusions was found. Oral disease is still a common public health problem among schoolchildren in Serbia. A significant increase in the prevalence of caries disease between 12- and 15-year-old groups implies that preventive care for adolescents requires special attention. Corrective actions and reforms to the current school-based oral health prevention program are needed to further improve oral health in Serbian children.

Prevalence and Risk of Dental Erosion in Patients with Gastroesophageal Reflux Disease: A Meta-Analysis

Aim: The present paper aims to systematize data concerning the prevalence and risk of dental erosion (DE) in adult patients with gastroesophageal reflux disease (GERD) compared to controls. Materials and methods: Core electronic databases, i.e., MEDLINE/PubMed, EMBASE, Cochrane, Google Scholar, and the Russian Science Citation Index (RSCI), were searched for studies assessing the prevalence and risk of DE in adult GERD patients with publication dates ranging from 1 January 1985 to 20 January 2022. Publications with detailed descriptive statistics (the total sample size of patients with GERD, the total sample size of controls (if available), the number of patients with DE in the sample of GERD patients, the number of patients with DE in the controls (if available)) were selected for the final analysis. Results: The final analysis included 28 studies involving 4379 people (2309 GERD patients and 2070 control subjects). The pooled prevalence of DE was 51.524% (95 CI: 39.742–63.221) in GERD patients and 21.351% (95 CI: 9.234–36.807) in controls. An association was found between the presence of DE and GERD using the random-effects model (OR 5.000, 95% CI: 2.995–8.345; I² = 79.78%) compared with controls. When analyzing studies that only used validated instrumental methods for diagnosing GERD, alongside validated DE criteria (studies that did not specify the methodologies used were excluded), a significant association between the presence of DE and GERD was revealed (OR 5.586, 95% CI: 2.311–13.503; I² = 85.14%). Conclusion: The meta-analysis demonstrated that DE is quite often associated with GERD and is observed in about half of patients with this extremely common disease of the upper gastrointestinal tract.

Assessing Fluorosis Incidence in Areas with Low Fluoride Content in the Drinking Water, Fluorotic Enamel Architecture, and Composition Alterations

There is currently no consensus among researchers on the optimal level of fluoride for human growth and health. As drinking water is not the sole source of fluoride for humans, and fluoride can be found in many food sources, this work aimed to determine the incidence and severity of dental fluorosis in Poland, in areas where a low fluoride content characterizes the drinking water, and to assess the impact of fluoride on the enamel composition and microstructure. The dental examination involved 696 patients (aged 15−25 years) who had since birth lived in areas where the fluoride concentration in drinking water did not exceed 0.25 mg/L. The severity of the condition was evaluated using the Dean’s Index. Both healthy teeth and teeth with varying degrees of fluorosis underwent laboratory tests designed to assess the total protein and fluoride content of the enamel. Protein amount was assessed spectrophotometrically while the level of fluoride ions was measured by DX-120 ion chromatography. The clinical study revealed 89 cases (12.8%) of dental fluorosis of varying severity. The enamel of teeth with mild and moderate fluorosis contained a significantly higher protein (p-value < 0.001 and 0.002, respectively) and fluoride level (p < 0.001) than those with no clinical signs of fluorosis. SEM images showed irregularities in the structure of the fluorotic enamel. An excessive fluoride level during amelogenesis leads to adverse changes in the chemical composition of tooth enamel and its structure. Moreover, dental fluorosis present in areas where drinking water is low in fluorides indicates a need to monitor the supply of fluoride from other possible sources, regardless of its content in the water.

The protective effect of the experimental TiF4 and chitosan toothpaste on erosive tooth wear in vitro

This study evaluated the protective effect of TiF₄ and chitosan toothpaste on erosive tooth wear (ETW) in vitro. Enamel and dentin samples were randomly assigned to toothpastes (n = 12): (G1) TiF₄ (1400 ppm F⁻), (G2) 0.5% chitosan (75% deacetylation, 500 mPas), (G3) TiF₄ (1400 ppm F⁻) plus 0.5% chitosan (75% deacetylation, 500 mPas), (G4) Placebo, (G5) Erosion Protection (Elmex-GABA, 1400 ppm F⁻). Twelve samples were only eroded. All samples were submitted to erosive pH cycles and G1 to G5 to abrasive challenges using toothpastes’ slurries plus 45 s of treatment, for 7 days. The final profile was overlaid to the baseline one for the ETW calculation (µm). The data were subjected to Kruskal–Wallis/Dunn tests. TiF₄ toothpastes, regardless of the presence of chitosan, were able to significantly reduce ETW compared to placebo, while chitosan alone was similar to placebo for both tissues. The toothpastes containing TiF₄ were even superior to the commercial Elmex toothpaste on enamel, while they were similar on dentin; both were also significantly different from placebo for both tissues. TiF₄ and Elmex toothpastes minimized the impact of brushing on eroded surface. In conclusion, TiF₄ toothpastes, regardless the presence of chitosan, showed to be effective in minimizing ETW in vitro.

Acquired pellicle engineering using a combination of organic (sugarcane cystatin) and inorganic (sodium fluoride) components against dental erosion

This study evaluated the combination of a sugarcane cystatin (CaneCPI-5) and sodium fluoride (NaF) in acquired pellicle engineering for the prevention of dental erosion in vitro. 75 human enamel specimens were prepared and divided into 5 treatment groups (n = 15/group): Deionized water (Control); Elmex™ (SnCl2/NaF/AmF); 0.1 mg/ml CaneCPI-5; 500 ppm NaF; and CaneCPI-5+NaF (Combination). The specimens were individually treated (200 μl; 2 min; 37 °C), then incubated in human saliva (200 μl; 1 h, at 37 °C) for acquired pellicle formation. Afterwards, the specimens were submitted to an erosive challenge (1% citric acid, pH 3.6, 10 ml, 2 min, 25 °C). This sequence was conducted 5 times. Percentage of surface microhardness change (%SMC), relative surface reflection intensity (rSRI) and calcium released to the citric acid (CR) were measured and analyzed by One-way ANOVA followed by Tukey's test (p<0.05). In general, all the treatments (SnCl2/NaF/AmF, CaneCPI-5, NaF and Combination) significantly protected the enamel when compared the control group. Regarding %SMC and rSRI, the Combination was the most effective treatment, reducing the %SMC significantly (p<0.01) when compared to all the other treatments, although this difference was not significant in the CR analysis. All treatments demonstrated a protective effect on enamel against dental erosion; however the combination of CaneCPI-5 with NaF showed a greater protection.

The cholinergic system, intelligence, and dental fluorosis in school-aged children with low-to-moderate fluoride exposure

Disruption of cholinergic neurotransmission can affect cognition, but little is known about whether low-to-moderate fluoride exposure affects cholinergic system and its effect on the prevalence of dental fluorosis (DF) and intelligence quotient (IQ). A cross-sectional study was conducted to explore the associations of moderate fluoride exposure and cholinergic system in relation to children's DF and IQ. We recruited 709 resident children in Tianjin, China. Ion selective electrode method was used to detect fluoride concentrations in water and urine. Cholinergic system was assessed by the detection of choline acetyltransferase (ChAT), acetylcholinesterase (AChE) and acetylcholine (ACh) levels in serum. Compared with children in the first quartile, those in fourth quartile the risk of either developing DF or IQ < 120 increased by 19% and 20% for water and urinary fluoride. The risk of having both increased by 58% and 62% in third and fourth quartile for water fluoride, 52% and 65% for urinary fluoride. Water fluoride concentrations were positively associated with AChE and negatively associated with ChAT and ACh, trends were same for urinary fluoride except for ACh. The risk of either developing DF or having non-high intelligence rose by 22% (95%CI: 1.07%, 1.38%) for the fourth quartile than those in the first quartile of AChE, for having the both, the risk was 1.27 (95%CI: 1.07, 1.50), 1.37 (95%CI: 1.17, 1.62) and 1.44 (95%CI: 1.23, 1.68) in second, third and fourth quartiles. The mediation proportion by AChE between water fluoride and either developing DF or IQ < 120 was 15.7%. For both to exist, the proportion was 6.7% and 7.2% for water and urinary fluoride. Our findings suggest low-to-moderate fluoride exposure was associated with dysfunction of cholinergic system for children. AChE may partly mediate the prevalence of DF and lower probability of having superior and above intelligence.

Tooth Wear Evaluation System (TWES) 2.0-Reliability of diagnosis with and without computer-assisted evaluation

BACKGROUND

Tooth wear is a multifactorial process, leading to the loss of dental hard tissues. Therefore, it is important to detect the level of tooth wear at an early stage, so monitoring can be initiated. The Tooth Wear Evaluation System (TWES) enables such a multistage diagnosis of tooth wear. The further developed TWES 2.0 contains a complete taxonomy of tooth wear, but its reliability has not yet been validated.

OBJECTIVES

The aim of the study was to examine in a randomised controlled trial (RCT) whether diagnoses made based on the TWES 2.0 are reproducible and whether this reproducibility is also achieved with computer-assisted diagnostics.

METHODS

44 dental students received extensive training in TWES 2.0 assessment and taxonomy. The students each evaluated at least 10 (of the present 14) anonymised patient cases using gypsum models and high-resolution intra-oral photographs according to TWES 2.0. One half initially evaluated on paper; the other half used dedicated software (CMDfact / CMDbrux). After half of the patient cases (5), the evaluation methods were switched (AB/BA crossover design). The diagnoses were then evaluated for agreement with the predefined sample solution.

RESULTS

Evaluation of agreement with the sample solution according to Cohen's kappa indicated a value of 0.46 for manual (traditional) evaluation; and 0.44 for computer-assisted evaluation. Evaluation of agreement between examiners was 0.38 for manual and 0.48 for computer-assisted evaluation (Fleiss' kappa).

CONCLUSION

The results of this study proved that the taxonomy of the TWES 2.0 has acceptable reliability and can thus be used by dentists. Accordingly, the system can be learned quickly even by untrained practitioners. Comparable results are achieved with computer-assisted evaluation.

Is Pediatric Dentistry a Topic of Interest for Pediatric Journals? A Scoping Review

Background: Pediatric dentistry shares many skills with pediatrics. This review evaluates the amount of literature on pediatric dentistry in the first 30 pediatric journals classified by the Web of Science in 2019. The aim was to perform a quantitative analysis of the main dental topics addressed. Methods: A scoping review with the PRISMA-ScR criteria was performed. The Clarivate Analytics Journal Citation Report was consulted for journals ranked in the category “Pediatrics” in 2019. Papers were searched in PubMed using an ad hoc prepared string. Results: A total of 504 papers were included. Papers on dental hard tissues were the most prevalent (45.6%), followed by dental public health (23.2%), orofacial development (15.3%), soft tissues related conditions (12.3%), and orofacial trauma (3.6%). Increasing trends have been observed for total papers published (R² = 0.9822) and total dental papers (R² = 0.8862), with no statistically significant differences (χ²(6) = 0.051 p > 0.05). The majority of papers (n = 292, 57.9%) were cited between 1 and 10 times, whilst less than 7% of papers received more than 40 citations. Discussion: It is desirable that papers on pediatric dentistry increase in the pediatric scenario, allowing the two related disciplines to intertwine more in the future.