A 4 year prospective longitudinal study of progression of dental erosion associated to lifestyle in 13 – 14 year-old Swedish adolescents
Agneta Hasselkvist
a,c, Anders Johansson
b, Ann-Katrin Johansson
c,*
aPublicDentalService,Nora,RegionÖrebroCountyCouncil,Sweden
bDepartmentofClinicalDentistry—Prosthodontics,FacultyofMedicineandDentistry,UniversityofBergen,Norway
cDepartmentofClinicalDentistry—Cariology,FacultyofMedicineandDentistry,UniversityofBergen,Norway
ARTICLE INFO Articlehistory:
Received3December2015
Receivedinrevisedform1February2016 Accepted6February2016
Keywords:
Adolescent Diseaseprogression Incidencestudies Lifestyle Softdrinks Tootherosion
ABSTRACT
Objectives:To evaluate theprogression of dentalerosion in 13–14 year-oldsafter 4 years, andits associationwithlifestyleandoralhealth.
Methods:227randomlyselected13–14year-oldsfromaPublicDentalClinic,Örebro,Sweden,were investigated.Aclinicalexaminationwasperformedwhichincludeddentalcaries/gingival/plaquestatus, aswellasgradingofdentalerosionatthetoothsurfaceandparticipantlevelsin“markerteeth”,including buccal/palatalsurfacesof6maxillaryanteriorteeth(13–23),andocclusalsurfacesoffirstmolars.An interviewandaquestionnaireregardingdrinkinghabitsandotherlifestylefactorswerecompleted.All investigationswererepeatedatfollow-up.Theparticipantsweredividedintohighandlowprogression erosiongroupsandlogisticregressionstatisticswereapplied.
Results:175individualsparticipatedatfollow-up.Progressionoccurredin35%ofthe2566toothsurfaces.
32%ofthesurfaceshaddeterioratedbyoneseveritygrade(n=51individuals)and3%bytwogrades (n=2individuals).Boysshowedmoresevereerosionthangirlsatthefollow-up.Amongthevariables predictinggreaterprogression,alowerseverityoferosivewearatbaselinehadthehighestOR(13.3), followed in descendingorder bya“retaining”drinkingtechnique, morefrequent intake ofdrinks betweenmeals,lowGBIandlessersourmilkintake,withreferencetothebaselinerecording.Usingthese fivevariables,sensitivityandspecificitywere87%and67%respectively,forpredictingprogressionof erosion.
Conclusions:ProgressionoferosivelesionsinSwedishadolescentsaged13–14yearsfolloweduptoage 17–18yearswascommonandrelatedtocertainlifestylefactors.
ClinicalSignificance:Inpermanentteeth,dentalerosionmaydevelopearlyinlifeanditsprogressionis common.Dentalhealthworkersshouldbemadeawareofthisfactandregularscreeningsforerosionand recordingofassociatedlifestylefactorsshouldbeperformed.
ã2016TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1.Introduction
Since the mid-90s, dental erosion among children and adolescents has been investigated in many parts of the world andfoundtobeacommoncondition[1].Arecentmeta-analysis estimatedtheprevalenceoferosivewearinpermanentteethof childrenandadolescentstobeabout30%[2].
Ingroupsof12–14year-olds,theprevalenceoferosionvaries widelybetween8–65%[3–10].InDanish15–17year-olds,14%had
morethanthreesurfaceseroded[11],whilefiguresfor15year-old Icelanders and 15–19 year-old Brazilians were 22% and 21%
respectively [12,13]. The variations in prevalence in the above mentioned reports, aside fromparticipant selection, may most likelybeaccountedforbythemethodologyandgradingcriteria appliedinthedifferentstudies.Theavailabilityofstudiesapplying moredefinedcriteriaforscoringerosivedamage,aswellasstudies conductedonolderadolescents,arerelativelyrare.In20year-old Saudi men, the prevalence of dental erosion with dentin involvementwas16%[14],while22%ofSwedish18–19year-olds and 15% ofNorwegian16–18 year-oldshad erosivelesionsinto dentin[15].Ina recentstudyonSwedish20 year-olds,18% had severeerosionintodentin[16].
Higher prevalence and severity of dental erosion are more frequentlyobservedinboysthaningirls[3,4,8,15,17–20],although
* Correspondingauthorat:FacultyofMedicine andDentistry,Universityof Bergen,DepartmentofClinicalDentistry—CariologyÅrstadveien19,5009Bergen, Norway.Fax:+4755586489.
E-mailaddress:[email protected](A.-K.Johansson).
http://dx.doi.org/10.1016/j.jdent.2016.02.002
0300-5712/ã2016TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
ContentslistsavailableatScienceDirect
Journal of Dentistry
j o u r n a l h o m e p a g e : w w w . i n t l . e l s e v i e r h e al th . c o m / j o u r n al s / j d en
afewstudieshavealsofoundtheoppositeornogenderdifferences [5,16,21,22]. Dietary factors, especially consumption of acidic drinks,haveinalargenumberofstudiesbeenfoundtobethemain etiologicalfactorofdentalerosion[3,5,8,19,23–25],whileothers have not [12,26–27]. Besides consumption of acidic drinks, a lifestyle that may be conducive to such consumption, such as sedentaryliving,excessivescreenviewingactivity,aswellasbeing overweight,maycontributetothedevelopmentoferosivewear [28–35].But,itisclearthatotherfactorsmayalsocontributeto erosive damage, for instance method of drinking and the consumptionof soursweets [23,25,36–39].Intakeof medicines andoralhygienepracticesareregardedasriskfactorsforerosive wear[5,39,40].
The progression of dental erosionhas not been thoroughly studiedandreportsintheliteraturearescant.InBritishchildren, progressionoferosionwasseenin27%ofthosebetweentheages of12–14years[8].Ina3-yearlongitudinalstudyofDutchchildren between11–15yearsofage,theprogressionwascommoninthose withdentalerosion[17].
Ouraimwastostudyprospectivelytheprogressionofdental erosionoverfouryearsinagroupof13–14year-oldadolescents, anditsassociationwithsomelifestyleandoralhealthfactors.The hypothesis was that dental erosionwould progress during the studyperiod,amongbothgendersandespeciallysoinboys,and alsobeassociatedwithacertainlifestyleandoralhealth.
2.Methods
2.1.Participantsandprocedures
Thebaselinestudyforthisfollow-uptookplaceduring2005– 2007[3].Inthatstudy,303adolescentsaged13–14yearsatthe PublicDental Servicein Nora and Storå, Region ÖrebroCounty Council, Örebro, Sweden, were offered to participate of which 227accepted.Thepresentstudyisafollow-upafter4years,andall of the original 227 participants (who had remained as recall patientswithinthePublicDentalServiceduringthestudyperiod, May 2009–January 2012) were invited to participate. Data collection took place during the participant’s regular dental examination. Clinical and questionnaire examinations were identicaltothebaseline studyexcept for additionof recording ofconsumptionofalcoholicbeveragestothequestionnaire[3].
2.2.Clinicalexamination
Assessment of dental erosion was performed according to previouslydescribedmethodologyandgradingwasdoneaccord- ingtoacommonlyusederosionscale(Table1)[14].Anadditional scalewasusedforgradingmolarcuppings(Table2)[3].Thetwo scaleswerecombinedbasedonthehighesterosiongradesscored ontheanteriorteeth(Table1)andfirstmolarteeth(Table2):no erosion(score0),milderosion(score1),moderateerosion(score 2),severe erosion (score 3) and very severe erosion (score4),
(Table 3).So, the severest score, either for incisors or molars, determined the “holistic” score in Table 3. For example, if an individualhad amolarwith>1mm cupping(grade3)but only grade1affectingtheincisors,theindividualwasgradedassevere erosion(grade3).
Allgradingswereperformedbytheprincipalinvestigator(AH) and intra-examiner concordancewas tested byperformingtwo successiveblindassessmentsafteranintervaloftwotofourweeks in13individuals,whodidnotparticipateinthisstudy.Thetooth surfaces were dried using compressed air and grading was performedinanordinaryclinicalsetting.In casesofdifficulties withdecidingtheseverityofdentalerosionbetweentwogradeson the scale, the lower grade was chosen. Surfaces that were impossible tograde becauseof orthodontic brackets, retainers, fillingsorenamelhypoplasiawereexcluded,whichwasalsothe case on some surfaces that had been intensely polished after removaloforthodonticbrackets.
Visibleplaqueindex(VPI) andGingivalbleeding index(GBI) were recorded as “yes” or “no” in maxillary anterior teeth, accordingtoAinamoandBay[41].Inorder,VPIwasassessedfirst followedbyGBI,andifnecessary, theteethwerethenpolished withprophy pastebeforegrading of toothwear. Dentalcaries, DMFT and DMFS, was recorded and radiographic examination performedonthebasisofindividualindication.Theexaminer(AH) wasblindedfrombaselinedataandtheresultfromquestionnaires duringthefollow-upexamination.
2.3.Questionnaireinvestigation
Thequestionnairewasdividedintotwoparts.Thefirstpartwas awritteninquiry,regardingsomelifestylefactors.Itwasfilledinby the patient at home, and returned by mail to the clinic. The questionscomprisedoralhygieneroutines,oralorgastrointestinal symptoms(never/monthly/weekly/daily/always),intakeofmed- icines(yesorno),generalhealth(oftensick—yesorno)andifthey had a habitof retainingacidic soft drinksin themouth before swallowing (yes orno). Otherquestionsincluded: frequencyof physical activity (frequency per week), screen-viewing habits (hoursperday), bodyheight/weight,whethertheyhad triedto increaseorreducetheirweight(yesorno),and ifeitherparent were born outside Sweden (Sweden/Nordic countries/Europe/
Others).Types and frequencyof intakeofcertain dietaryitems wereestimated and recordedas numbers of timesper month/
weekorday.Thesewere:water,alltypesofacidicsoftdrinks,milk, yogurt,sourmilk,tea,coffee,sweets,soursweets,chewinggum, icecream,popsicle,biscuits,snacks,cheese,driedandfreshfruits.
Thesecond partof thequestionnairewas conductedasanoral interviewbyaspeciallytraineddentalassistantduringtheclinic visit.Allcurrentbeverageconsumption,andestimatedprevious consumptiononeyearago,wasrecordedindetail;carbonatedsoft drinks,stilldrinks,sportdrinks,juice,water,milk,tea,coffee,and somealcoholicbeverages(wine,beer,cider,alcopop).Theamount and frequency ofeach portionwas estimated, and thedaily or
Table1
Ordinalscaleusedforgradingseverityofdentalerosiononbuccalandlingualsurfacesofmaxillaryanteriorteeth[14].
Grade Criteria
0 Novisiblechanges,developmentalstructuresremain,macro-morphologyintact.
1 Smoothenedenamel,developmentalstructureshavetotallyorpartiallyvanished.Enamelsurfaceisshiny,matt,irregular,”melted”,roundedorflat,macro- morphologygenerallyintact.
2 Enamelsurfaceasdescribedingrade1.Macro-morphologyclearlychanged,facettingorconcavityformationwithintheenamel,nodentinalexposure.
3 Enamelsurfaceasdescribedingrades1and2.Macro-morphologygreatlychanged(closetodentinalexposureoflargesurfaces)ordentinsurfaceexposedby 1/3.
4 Enamelsurfaceasdescribedingrades1,2and3.Dentinsurfaceexposedby>1/3orpulpvisiblethroughthedentin.
Note:Approximalerosionandpresenceof“shoulder”shouldberecorded.
weeklyconsumption was calculated as L/year. A more detailed descriptionofthequestionnaireexaminationisgivenelsewhere [3].
2.4.Statisticalanalyses
Samplesizecalculation,with80%poweranda5%significance levelanddiscordantproportionof10%,resultedinaminimumof 127participantsinthestudy(McNemar’stest).Thecalculationis based on 7% [8] of the individuals showing an expected progression of erosion tosevere or very severe erosion (grade 3and4)between13–14and18–19yearsofage.Thetotalbaseline sample(aged13–14years)included227individuals,soevenwith somedrop-outsduringthefollow-upperiodtheoriginalsample sizewasdeemedtobeadequatelylarge.
In addition toscoring theseverity of dental erosionon the markerteeth,SimplifiedErosionPartialRecordingSystem(SEPRS) was calculated. This system presentsthe highest erosionscore fromthepalatalsurfacesofcentralmaxillaryincisors(accordingto Table 1) (tooth numbers 11and 21) and from cupping scores (accordingtoTable2)ofmandibularfirstpermanentmolars(tooth numbers36and46)(foursurfacesinall)[3].SEPRSthusprovides onescoreperindividualandisbasedonthehighestscorerecorded ononeofthesefoursurfaces.
The erosionscore assigned to each toothsurface on all the gradedanteriorteeth(buccalandpalatal)wascomparedbetween baselineandfollow-up,andregisteredasunchanged(0),onegrade ofprogression(+1)andtwogradesofprogression(+2).Themean progressionwascalculatedandthematerialwasdividedintothree groupsaccordingtothemeanchange:lowprogressiongroup0– 0.2scalesteps,middlegroup>0.2–0.5andhighprogressiongroup
>0.5steps.
Differencesbetweenthehighandlowprogressiongroupswere tested by theMann–WhitneyU-test regarding the variables of gender,consumptionofdrinks,dietaryhabits,oralhygienehabits,
physical activity, BodyMass Index (BMI), and oral and general health factors. Adjusted logistic regression analysis (forward conditionalmethod)wasperformedwithhighandlowprogres- sionoferosionasdependentvariableusingaselectionofreported variables that had theoretical relevance or differedstatistically significantly between the high and low progression groups accordingtotheMann–WhitneyU-test.Allindependentvariables weredichotomizedintotwocategoriesbeforebeingenteredinto thelogisticregression.Oddsratios(OR)withconfidenceinterval (95%)werecalculatedforeachindependentvariable.Allanalyses wereperformedusingIBM SPSSStatistics23 (IBMCorporation, 1NewOrchardRoad,Armonk,NewYork).P<0.05wereconsidered statisticallysignificant.
2.5.Ethicalconsiderations
Aninformedconsentwas signed bytheparticipantsor bya parent in cases of under-aged adolescents. Approval from the RegionalEthicalReviewBoardinUppsala,Sweden,wasobtained prior to the start of the study (no. 2009/031). If there was a diagnosis of dental erosion or some other oral pathology, the patientwasinformedabouttheconditionandpreventiveorother treatmentwerecarriedoutfreeofcharge(bothatthebaselineand follow-upexamination).
3.Results
Intra-examiner concordance between the two successive gradingsofdentalerosioninmaxillaryanteriorteethandcuppings on first molars in 13 individuals was 77.4%. Of the original 227patients,175(77%)completedtheexaminationatthefollow- up(meanage=17.9year,SD0.87,54%males).Themeanfollow-up timewas50.9months(fouryearsandthreemonths)witharange of 41–63 months. Of the 52 non-participants, 42 declined to participateorlivedelsewhereandtenfailedtoreturnthesigned Table2
Ordinalscaleusedforgradingcuppingsonocclusalsurfacesoffirstpermanentmolars[3].
Grade Criteria
0 Nocupping/intactcusptip
1 Roundedcusptip
2 Cupping1mm
3 Cupping>1mm
4 Fusedcuppings:atleasttwocuppingsarefusedtogetheronthesametooth
Table3
Combinederosionscalefromgradingofmaxillaryanteriorteeth(Table1)andmolarcuppings(Table2).
Grade Localization Criteria 0=Noerosion Anterior
teeth
Novisiblechanges,developmentalstructuresremain,macro-morphologyintact Molars Nocupping/intactcusptip
1=Milderosion Anterior teeth
Smoothenedenamel,developmentalstructureshavetotallyorpartiallyvanished.Enamelsurfaceisshiny,matt,irregular,”melted”, roundedorflat,macro-morphologygenerallyintact
Molars Roundedcusptip 2=Moderate
erosion
Anterior teeth
Enamelsurfaceasdescribedingrade1.Macro-morphologyclearlychanged,facettingorconcavityformationwithintheenamel,no dentinalexposure
Molars Cupping1mm 3=Severeerosion Anterior
teeth
Enamelsurfaceasdescribedingrades1and2.Macro-morphologygreatlychanged(closetodentinalexposureoflargesurfaces)or dentinsurfaceexposedby1/3
Molars Cupping>1mm 4=Verysevere
erosion
Anterior teeth
Enamelsurfaceasdescribedingrades1,2and3.Dentinsurfaceexposedby>1/3orpulpvisiblethroughthedentin Molars Fusedcuppings:atleasttwocuppingsarefusedtogetheronthesametooth
consentandwerethereforenotincludedinthefollow-upstudy.
The52dropoutswerecomparedtotheparticipants(n=175)asto thevariablescollectedinthebaselinestudyatage13–14years.No significantdifferencesingenderorage(13or14years)werefound.
However,non-participantsreportedasignificantlylowerfrequen- cyofintakeof:carbonatedsoftdrinksotherthancola-typedrinks (P=0.008), ice cream (P=0.03), cheese (P=0.02), and a more frequentintake of:fruit drinks (P=0.046), juice(P=0.012) and carbonatedsoftdrinksbetweenmeals(P=0.018).Asregardsthe clinicalvariables,non-participantshadgreaterseverityoferosion accordingtoSEPRS(P=0.038)andlowerGBI(P=0.021)compared totheparticipants.
Frequencydistributionoferosionscoresinmaxillaryanterior teethand cuppingsinfirstmolarsatbaseline andfollow-upby genderareshowninFigs.1–4.FrequencydistributionofSEPRSare shownin Fig. 5 and thescores werenot significantlydifferent betweenboysandgirlsatbaseline(P=0.38)butwassoatfollow- up (P=0.001). The prevalence of severe/very severe erosion (Table 3)accordingtoSEPRSwas atbaselinefor boys9.5% and atfollow-up14.9%. Thecorrespondingfigures forgirlswerefor baselineandfollow–up,2.5%and6.3%respectively(Fig.5).
Dentalerosionwasgradedon1881buccalandlingualsurfaces ofmaxillaryanteriorteethand cuppingson685molarocclusal surfaces both at baseline and at follow-up (Table 4). Of the 2566surfacesgradedatfollow-up,theseverityoferosivewearwas scoredas improved in 93 surfaces (3.6%). These surfaces were recordedas unchangedinthestatisticalanalyses.In 30%ofthe participantstherewasadeteriorationinerosionbyoneseverity gradeononeormoresurfaces(n=51individuals)orbytwogrades (n=2individuals).830toothsurfaces(32.3%)hadchangedbyone severitygradeand67(2.6%)hadchangedbytwogrades,givinga totalof34.9%. 1.4%ofallrecordedsurfaceshadprogressedtosevere erosion(33surfacesin9individuals).234surfaceswerenotgraded onbothoccasionsdue touneruptedteeth(canines)atbaseline, orthodonticorextensiverestorativetreatmentbetweenbaseline and follow-up. Maxillary anterior teeth showed more erosive progression than first molars, 43.2% and 12.1% respectively.
Progression of erosion was most common in canines, 13/23 (56.4%), though only one of the canines had deteriorated into severeerosion(grade3)anditwasleastcommoninupperfirst molars16/26 (7.8%). Buccalsurfaces ofmaxillary anteriorteeth showedmore progressionthanpalatalsurfaces,48%and 38.2%, respectively.Nomorethan+2scalestepsofprogressionwasseen.
In total, 403 surfaces had deteriorated among the girls and
494 surfaces in boys, the difference being not statistically significant(datanotshown).
At baseline 59 individuals showed none/minimal signs of maxillaryanterior erosionand cupping onfirst molars (erosion score0or1).Ofthese,45individualswereassessedasgrade2or moreinatleastonetoothatfollow-up,whichgivesanincidenceof 76%.
Comparedtothelowerosiongroup,thehighprogressiongroup demonstratedatbaseline:significantlyhigherintakeofalldrinks (includingcoffee,tea,water,etc.)betweenmeals(P<0.05),lower intake of sour milk (P<0.05), more frequent medicine intake (P<0.05), tooth pain (P<0.05) and a “retaining” drinking technique(P<0.01),lowerVPIandGBI(P<0.05)andlowermean erosion scores on 13–23 (P<0.01). At follow-up, the high progressiongroupreportedmorefrequentintakeofsourcandy (P<0.05),drymouthduringthenight(P<0.05),lesserintakeof teaforbreakfast(P<0.05), milkforlunch (P<0.05)and sugar- containingnon-cola drinks (P<0.05). Nosignificant differences wereseenbetweenthetwogroupsasregardsdentalcaries,BMI, oral hygiene habits or variables associated with a sedentary lifestyle.
Forthewholesample,theyearlyconsumptionofcarbonated softdrinksincreasedfrom38to48L,andtheconsumptionofall acidic soft drinks from 119 to 132L. The reported yearly consumption of acidic alcoholic beverages (alcopop, wine and cider)was8L(range0–156L,SD20L)atfollow-up(notrecordedat baseline),andtherewas nodifferenceinconsumptionbetween HighandLowprogressiongroups.
In the adjusted logistic regression analysis, gender and all variables (independent) that were found to be significantly differentbetweenthehighandlowprogressiongroups (depen- dent)wereenteredandtheconditionalforwardmethodapplied (Table 5). Among the variables predicting high progression measuredatfollowup,alowerseverityoferosivewearatbaseline hadthehighestOR(13.3),andfollowedinorderofdecreasingOR:
retainingdrinkingtechnique,morefrequentdrinkintakebetween meals,lowGBIandlessersourmilkintake,allwithreferencetothe baselinerecording.Usingtheabovefivevariables,sensitivityand specificity were 87% and 67%, respectively, and Nagelkerke R square0.53.
4.Discussion
The dropout of 23% (52/227 individuals) resulted in an attendance rate of 77% (175/227 individuals) which is deemed
Fig.1.Frequencydistributionofmaxillaryanteriortootherosionscoresingirlsatbaselineandfollow-up(ScaleaccordingtoTable1).
Fig.2.Frequencydistributionofmaxillaryanteriortootherosionscoresinboysatbaselineandfollow-up(ScaleaccordingtoTable1).
Fig.3.Frequencydistributionofcuppingscoresinfirstmolarsingirlsatbaselineandfollow-up(ScaleaccordingtoTable2).
Fig.4. Frequencydistributionofcuppingscoresinfirstmolarsinboysatbaselineandfollow-up(ScaleaccordingtoTable2).
good considering the relatively long follow-up period and acceptableaccording tothesample size estimation requiring a minimumof127individualsneededtodetecterosivechanges.It wasfeltthatthedrop-outwouldbetoonumerousifweofferedan appointment only for follow-up of dental erosion, so the examinationwasplannedinconjunctionwiththeordinaryrecall offered by the County Council/Public Dental Service, which explainstherelativelylongintervalof41–63monthsforfollow- up. The non-participants did in some respects differ from the participantsandseemedgenerallytoincludeamoreerosionprone groupofindividuals.Abiasedresultcannotthereforebeexcluded.
The scales for gradingerosionand cupping are designed to assesserosivewearwhileattemptingtoexcludewearcausedby attrition and abrasion as much as possible [3,14]. The incisal surfacesarethereforeomittedfromgradingandonlybuccaland palatalsurfacesonthemaxillaryanteriorteethareincludedwhich aretheteeththathavebeenshowntobemostcommonsitefor dentalerosion[1].Inaddition,cuppingsonthefirstmandibular molarwererecordedwhichareconsideredatypicalsignoferosive wear[42].Thescalesthatwereusedinthepresentstudyaremore sensitive for grading early stages of erosive wear than other commonly-used indices [25,43–46], and even early changes enamel morphology can be recorded. There are five grades in bothscalesandduetothenatureofanordinalscalethedifference betweenstepscanbesmall,whichmayexplainwhy3.6%ofthe surfacesweregradedasimprovedbetweenbaselineandfollow- up. These “improved” surfaces were therefore regarded as unchanged in the statistical analysis of the progression, since theprobabilityofdeteriorationislesslikelyandanimprovement notpossible.Theintra-examinerconcordanceof77.4%couldbe regardedasacceptable.
4.1.Incidenceandprogressionofdentalerosion
Inthisstudytheincidenceofdentalerosionwas76%.Thisfigure wascalculatedonthebasisofindividualswhohadamaximum score0or1atbaselineandscored2orhigheratthefollow-up.Ina 3-year longitudinal study in 11–15 year-olds, the incidence calculated on erosion-freechildren decreased with age,and at age14therewereonlyafewchildrenleftwhowereerosion-free [17].Alownumberoftotallyunworntoothsurfacesattheageof 13–14years was alsothecase in ourstudy, sothat togetany meaningful statistics we had to alsoinclude the children with lowestdegreeoferosion(score1)atbaselinefor theincidence calculation.
Progression of erosion at the toothsurface level was 34.9%
correspondingto30%attheindividuallevel.Wehavenotfound directlycomparablefigurestothepresentstudyandagegroupsin the literature, but 3-year progression for 11 and 12 year-old childrenwasreportedtobe56.3%and44.9%,respectively[17].The progressioninthisstudydifferedbetweenteethandsurfaceswith maxillary anterior teeth being most affected. This is not an unexpectedfindingsincetheseteetharewell-knownpredilection sites for developing erosive wear[1]. There was no significant genderdifferencebasedonthenumberofsurfacesthatprogressed during thefollow-up period;however, boys had a significantly higher prevalence of severe/very severe erosion at follow-up Fig.5. FrequencydistributionoferosionandcuppingscoresaccordingtoSEPRSinbothgendersatbaselineandfollow-up(ScaleaccordingtoTable3).
Table4
Progressionoferosionandcuppingscoresinallsixupperfrontteeth(1881surfaces) and all first molars (685 surfaces) between baseline and follow-up.
n=175individuals.Missingteeth=234.
Grading—atbaseline Gradingatfollow-up Totalatbaseline
0 1 2 3 4
NoErosion(grade0) 232 443 63 738
Milderosion(grade1) 964 357 3 1324
Moderateerosion(grade2) 446 30 1 477
Severeerosion(grade3) 23 0 23
Verysevereerosion(grade4) 4 4
Totalatfollow-up 232 1407 866 56 5 2566
Table5
Adjustedlogisticregressionanalysis(Forwardconditionalmethod).Dependent variable:low(n=48)andhigh(n=58)progressiongroup.Includeddichotomized independentvariablesfrombaselinedata:Alldrinksbetweenmeals(<2L/weekvs.
>2L/week),sourmilk(never/seldomvs.>1time/month),toothpain(never/seldom vs.1time/month),medicineintake(novs.yes),retainingdrinkingtechnique(no vs.yes),VPI(<10%vs.>10%),GBI(nobleedingvs.bleeding1surface),mean erosionindex(<1vs.>1).Dichotomizedindependentvariablesfromfollow-up:
sugarednon-colacarbonatedsoftdrinks(1time/monthorlessvs.>1time/week), sourcandy(never/seldomvs.>1time/month), Milkforlunch(<0.3L/weekvs.
0.3L/week),Teaforbreakfast(Noteavs.1time/week),drymouthatnight (never/seldomvs.1time/month).Genderwasalsoincludedasanindependent variable.
Variablessignificantlycorrelated tothehighprogressiongroup
Sig. OR 95%CIforEXP(B) Lower Upper Erosionindex—baseline(mean<1) 0.001 13.3 2.92 62.50 Retainingdrinkingtechnique—baseline(yes) 0.044 6.03 1.05 34.72 GBI—baseline(nobleeding) 0.008 6.02 1.59 22.72 Drinksbetweenmeals—baseline(>2L/week) 0.015 5.96 1.41 24.27 Sourmilk—baseline(never/seldom) 0.024 4.81 1.22 18.87 CI=Confidenceinterval;NagelkerkeRsquare0.53
comparedtogirls,althoughtherewasnosignificantdifferenceat baseline.Aninterestingfindingwas that,in manycases, severe erosiondevelopedearlyinlife,attheageof13–14years,showinga riskofsevereerosionofpermanentteethevenbeforeadolescence, andindicatingthatdentalhealthworkersshouldpayattentionto dental erosion even in young permanent teeth. In summary, progressionoferosionlesionsiscommonandboysseemtobeat greaterrisk thangirlsfor developingmore pronouncederosion between13–14to17–19yearsofage.
4.2.Highandlowprogressiongroupsvs.associatedfactors
Inthebivariateanalyses,thehighprogressiongroupdiffered significantlyfromthelow progression groupasregardsseveral tentativeerosion-pronecausativefactorsreported/recordedboth atbaselineandatfollow-up.Dietaryfactorsincludedwerehigher consumption of drinks and sour candy, as well all drinks as betweenmeals,andlowerintakeofordinaryandsourmilk,allof whichfactorshavebeenshowntohavearelationshipwithdental erosioninpreviousstudies[27,47].Anotherfactor,self-reportedin thequestionnaire,was a “retaining”drinking technique,whose correlation with the development of erosive wear has been reportedonpreviously[37,38].Thehighprogressiongroupalso presentedmoretoothpain,probablyduetothehypersensitivity causedbytheerosionlesions,reportedmorefrequentdrymouth andmedicineintakeaswell ashaving lowerVPIand GBI,allof whicharecommonlyreportedfindingsinerosionsubjects[48–51].
Adjusted logistic regression revealed that individuals with lowerseverityoferosivewearatbaselinehadthehighestOR(13.3) for developing more erosion during follow-up, which was an expected finding. Other significant factors, albeit of lesser predictivestrength,indecreasingorderwere:“retaining”drinking technique,lowerGBI,morefrequentdrinksbetweenmealsand lessfrequent sourmilkintake.These fivevariables gavea high sensitivity(87%)butarelativelylowspecificity(67%)forpredicting erosivewear.NagelkerkeRSquarewas>0.5whichindicatesagood fitofthemodel.
5.Conclusion
Boththeincidenceandprogressionofdentalerosionarehigh between 13–14 and 17–19 years of age. The hypothesis that progression was associated with certain lifestyle factors was fulfilled;thatitwashigherinboyswasnotconfirmed,although boysdevelopedmoresevereerosionthangirlsduringthefollow- upperiod.
Acknowledgements
Thisstudy was supported bygrants from the Public Dental Service,RegionÖrebroCountyCouncil,SwedenandtheSwedish DentalSociety.Wewould liketoexpress oursincerethanksto BeatriceReber-Holmqvist,ÖrebroCounty Council,forherassis- tanceandcontributiontothisstudy.
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