Prevalence of dental erosion in Greek minority school children in Istanbul.
Abstract: AIM: To evaluate the prevalence and aetiology of dental erosion in Greek minority school children living in Istanbul (Turkey). METHODS: The present study was initiated in four Greek minority elementary schools in Istanbul where a total of 83 children (46 girls, 37 boys) between ages 7-14 years old were examined. Children were categorised into 7-11 and 12-14 ages groups. Data were obtained by clinical examination, questionnaire and standard data records. All tooth surfaces were examined, dental erosion was recorded per tooth and classified according to the index of Lussi et al. [1996] RESULTS: In the 7-11 yrs old group, 47.4% (n:18) of the children exhibited dental erosion while in 12-14 yrs old group, 52.6% (n:20) of the children exhibited dental erosion. There were no statitistical differences between age, gender groups and findings of dental erosion (p>0.05). However prevalence of dental erosion in 12-14 yrs old was twice that of the 7-11 years old children. In general, an unusual drinking pattern of slow swallowing of beverages significantly affected the prevalence of dental erosion (p=0.03). CONCLUSION: Multiple regression analysis revealed no relationship between dental erosion and related erosive sources such as medical conditions, brushing habits, swimming, and the consumption of acidic fruit juices and beverages (p>0.05). However it should be noted that the sample size in the current study was small.

Key words: dental erosion; epidemiology; Greek minority, Istanbul; orange juice; swimming
Article Type: Report
Subject: Dental caries (Care and treatment)
Dental caries (Research)
Elementary school students (Food and nutrition)
Elementary school students (Health aspects)
Elementary school students (Surveys)
Prevalence studies (Epidemiology) (Usage)
Authors: Caglar, E.
Sandalli, N.
Panagiotou, N.
Tonguc, K.
Kuscu, O.O.
Pub Date: 10/01/2011
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: Oct, 2011 Source Volume: 12 Source Issue: 5
Topic: Event Code: 310 Science & research
Product: Product Code: E197200 Students, Elementary
Geographic: Geographic Scope: Turkey Geographic Code: 7TURK Turkey
Accession Number: 277106783
Full Text: Introduction

Dental erosion is loss of tooth hard tissue due to a bacteria-free chemical process [Lussi, 1996]. While the intrinsic factors for dental erosion include vomiting, regurgitation, gastro-oesophageal reflux or rumination [Aine et al., 1990; Meurman and ten Cate, 1996], the extrinsic factors for dental erosion in childhood are related to acids of dietary or medicinal origins and also to behavioural factors [Zero, 1996]. Consuming soft drinks such as acidic fruit juices, fruit drinks, energy drinks and carbonated beverages have been detected as risk factors related to this dental hard tissue defect [Grenby, 1996 ; Scheutzel, 1996; Kunzel et al., 2000; Cavalcante et al., 2010].

Epidemiological studies in the last decade have shown that dental erosion in children and adolescents is an expected phenemon with a widespread prevalence [Al-Dlaigan et al., 2001; Ganss et al., 2001; Arnadottir et al., 2003; 2010; Dugmore and Rock 2004; Caglar et al., 2005; Jaeggi and Lussi, 2006; El Aidi et al., 2008; Bardolia et al., 2010]. Medical conditions were reported to be related at an increased risk of developing dental erosion [McDerra et al., 1998; Al-Dlaigan et al., 2002] while differences in lifestyle and behaviour must also be considered important in the aetiology of dental erosion. Istanbul is one of the oldest cities of Europe and has a Greek heritage minority tradition. However, in the dental literature there are no oral health data regarding Istanbulian Greek minority children. Therefore the aim of the present study was to assess the prevalence, and association with possible predictors, of dental erosion among Greek minority children in Istanbul.

Materials and methods

Subjects In January 2011 the study was initiated in four Istanbulian Greek minority elementary schools (Fener Rum Erkek Lisesi, Maraslyon Rum Ilkogretim Okulu, Zapion Rum Ilkogretim Okulu, Zografion Rum Ilkogretim Okulu) where a total of 83 children between ages 7-14 years old were examined. Seven children's parents refused to participate while three children were absent during the study period. The sample represents nearly all Greek minority children attending Greek schools on the basis of the application to the National Ministry of Education, Istanbul. The fluoride level in the drinking water of the district was <0.05 mg/l [Turkish Ministry of Health, 2003].

Oral examination Written informed consent was obtained from the parents. Prior to the clinical avaluation, 1 week apart, two paediatric dentists were calibrated in the Dept. of Paediatric dentistry on 20 children with dental erosion (kappa:0.90). Oral examinations were carried out in a well-lit school operatory room using mirror and probe. Children were instructed to brush their teeth prior to examination for better oral examination. All tooth surfaces were examined.

Erosium index Dental erosion was recorded per tooth and was classified according to the classification of Lussi et al. [1996]: (i) tooth and (ii) severity, the erosion score for each tooth was that given for the most eroded surface. For the purpose of differential diagnosis, all detectable disorders of the dental hard tissue were recorded. These included developmental disturbances of dental hard tissue, such as coronal damage through injury, facets on incisal and occlusal surfaces of teeth due to attrition.

Questionnaire Following the clinical examination, the children and their parents completed at home an extensive questionnaire written in both Greek and Turkish. This standardised questionnaire, described earlier by Caglar et al. [2005], included the following information: personal demographic details, dental and medical history, frequency of brushing, habits concerning the timing and types of beverage consumption, fruits, ice cream, fruit yoghurt, and swimming habits (Table 1).

Data analysis The data were processed with the NCSS 2007[R] (Kaysville, UT, USA). Tests of the association between dental erosion and factors were carried out using Mann-Whitney-U, unpaired t test, Chi-square test. Besides the univariate analysis, multivariate regression analysis was carried out. Statistical significance was established at the 5% level.

Results

A total of 83 children (46 girls, 37 boys) were examined. Children were categorised into either 7-11 year age group (47 children), representing the mixed dentition, with a total of 1,037 teeth or 12-14 year age group (36 children), representing the permanent dentition, with a total of 996 teeth.

There was no significant difference between girls (52.6 %) and boys (47.4 %) regarding the prevalence of dental erosion (p>0.05). A total of 97 teeth (6 primary, 91 permanent) were scored as 1 according to the classification of Lussi et al. [1996] (Table 2). There were no scores coded as 2 or 3. In the 7-11 year old group 47.4% (n:18) of the children exhibited dental erosion, while in the 12-14 year old group 52.6% (n:20) of the children exhibited dental erosion. In the 7-11 year old group the children who had evidence of dental erosion consumed 1.1 [+ or -] 0.32 (mean [+ or -] SD) cups of acidic beverages per day and 2.5 [+ or -] 1.51 (mean [+ or -] SD) cups of fruit yoghurt per week, while the ones who did not show any signs of dental erosion consumed 1.27 [+ or -] 0.47 (mean [+ or -] SD) cups of acidic beverages per day and 4.0 [+ or -] 2.45 (mean [+ or -] SD) cups of fruit yoghurt per week. In the 12-14 year old group the children who had evidence of dental erosion consumed 1.43 [+ or -] 0.54 (mean [+ or -] SD) cups of acidic beverages per day and 3.33 [+ or -] 2.08 (mean [+ or -] SD) cups of fruit yoghurt/ per week, while the ones who did not show any signs of dental erosion consumed 1.17 [+ or -] 0.41 (mean [+ or -] SD) cups of acidic beverages per day and 2.6 [+ or -] 1.95 (mean [+ or -] SD) cups of fruit yoghurt per week.

Mann-Whitney-U test revealed no statistical differences between children having dental erosion and those who had no dental erosion. Furthermore there were no statistical differences between age, gender groups and findings of dental erosion using unpaired t test (p>0.05) (Tables 3 and 4).

The habit of holding the beverage in the mouth and possibly swishing it about before swallowing was described by both the children and their parents. This behaviour was determined as an unusual drinking pattern and significantly affected the prevalence of dental erosion (p=0.03).

Discussion

Dental erosion, as recently defined by Holbrook et al. [2003] 'is clearly a multifactorial disease, and the interaction of causative and protective factors is complex'. It is also important to note that the wide ranging prevalence of dental erosion may be related to variation in use of the different criteria for diagnosis [Muller, 2006]. A number of indices for the clinical diagnosis of erosive tooth wear have been proposed, which more or less are modifications or combinations of the indices published by Eccles [1979] and Smith and Knight [1984]. The most recent erosion index was introduced by O'Sullivan [2000] and may be considered to be complex. In this study, Lussi's [1996] erosion index was used as it was reproducable and easy to apply in children.

The present study population had some obvious limitations as the number of Istanbulian Greek minority children was small in proportion to the child population of the city. However, the sample includes all Greek minority children in Istanbul who attended Greek elementary schools. A recent study [Caglar et al., 2005] undertaken on Istanbulian children aged 11 years (and using a different erosion index) showed that 28% (n=43) of the children exhibited dental erosion while analysis found no relationship between dental erosion and related erosive sources. The present study supports these findings. This is not entirely surprising as the dietary habits of the Greek minority population has its roots in Istanbul cuisine and therefore the dietary habits of the Greek and Turkish children living in Istanbul are probably the same. However this data may not be comparable as a different recording method was applied.

This study has not found any relationship between medical and dietary sources and dental erosion. However, swallowing beverages slowly (possibly together with swishing the drink) had a significant relationship where age groups were not categorised. Unusual drinking, eating and swallowing habits would be underlined as they were reported to increase the direct contact time of acidic foods and beverages with the teeth, and were considered to be behavioral factors that increase the risk of dental erosion [Lussi and Hellwig, 2001, Caglar et al., 2005].

It is important to learn more about the aetiology of dental erosive lesions before they can be accurately diagnosed, confidently treated and more importantly, prevented [Caglar et al., 2005]. Early diagnosis of the process and adequate preventive measures are therefore important. Personal interviews could give better information about dietary habits. Preventive advice to children, teenagers, parents and health officers should include a warning about the dangers of erosive sources to the teeth.

Conclusions

In this study, multiple regression analysis revealed no relationship between dental erosion and related erosive sources such as medical conditions, brushing habits, swimming, consumption of acidic fruit juices and beverages. However, it should be noted that the sample size in this study was small.

Acknowledgements

We would like to thank Dr Roland Blankenstein (UK) for revising the English text, Ms Evangelia Kanari and Mr Yani Demirgioglu; students and parents of Fener Rum Erkek Lisesi, Maraslyon Rum Ilkogretim Okulu, Zapion Rum Ilkogretim Okulu, Zografion Rum Ilkogretim Okulu schools, and Ms Rana Konyalioglu for statistical expertise.

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E. Caglar, N. Sandalli, Panagiotou N, Tonguc K, O.O. Kuscu

Dept. of Paediatric Dentistry, Dental School, Yeditepe University, Istanbul, Turkey

Postal address: Asist. Prof. Dr. Esber Caglar Dept. of Pediatric Dentistry, School of Dentistry, Yeditepe University Bagdat cad 238, Goztepe 34728 Istanbul, Turkey

Email: caglares@yahoo.com
Table 1. Questionnaire concerning background
information concerning dental erosion (Original in
Greek /Turkish)

A. Medical history (Asthma, gastric diseases),
drugs used

B. Dental history (caries, orthodontic treatments)

C. Frequency of brushing habit

D. Consumed beverages per day indicated by number
of glasses

Water                Buttermilk   Fruit      Iced tea    Nesquik[R]
                                  juice

Fresh orange juice   Tea          Coke       Pop soda    Milk

Tang[R]               Cappy[R]    Fanta[R]   Sprite[R]   Seven up[R]

Other

E. Time of consuming the
beverages indicated above

At meal               Between meals Before bed    Irregular

F. Consumed fruit per day

Orange                Melon         Grapefruit    Pear

Strawberry            Lemon         Banana        Peach

Grapes                Kiwi          Apple         Other

G Consumed fruit yoghurt per week by cups.

H. Type of consumption

Oral        Oral
                        Unusual drinking   Straw   Other
Slowly      Quickly

I. Swimming in a swimming pool

Regularly

Professionally-summer   Professionally-all   Irregularly
school                  year period          (only in summer holiday,
                                             less than a month)
Since last year       More than a year

Table 2. Distribution of primary and permanent
teeth showing dental erosion in a population of
Greek minority children (n=97)

Age in years      Tooth no    N of teeth showing
                                dental erosion
                     54                1
                     53                3
                     51                1
                     61                1
7-11 age group       12               11
                     11               11
                     21               10
                     22                8
                     31                1
                     41                1
                     11               19
                     21               19
12-14 age group      22                7
                     31                2
                     41                2

Table 3. Presence of erosive sources in 7-11 years
old Greek minorty children and their relationship
with dental erosion

Related erosive source                    Erosion (-)    Erosion (+)

                               Present    n      %       n      %

Asthma                            -      28     96.6    17     94.4
                                  +       1     3.4      1     5.6
Gastric Reflux                    -      26     89.7    18    100.0
                                  +       3     10.3     0     0.0
Swallowing slowly                 -      19     65.5    15     83.3
                                  +      10     34.5     3     16.7
Using straws                      -      27     93.1    16     88.9
                                  +       2     6.9      2     11.1
Irregular timing of drinking      -       7     24.1     5     27.8
                                  +      22     75.9    13     72.2
Using medicaments                 -      29    100.0    18    100.0
Orthodontic therapy               -      26     89.7    15     83.3
                                  +       3     10.3     3     16.7
Swimming professionally           -      25     86.2    18    100.0
                                  +       4     13.8     0     0.0
Acidic drinks                     -      18     62.1     8     44.4
                                  +      11     37.9    10     55.6
Fruit yoghurt                     -      20     69.0    10     55.6
                                  +       9     31.0     8     44.4
Orange juice                      -      16     55.2     8     47.1
                                  +      13     44.8     9     52.9
Brushing                          -       5     17.9     2     11.1
                                  +      23     82.1    16     88.9

Related erosive source

                                       P

Asthma                         [chi square]:0.12
                                      0.73
Gastric Reflux                 [chi square]:1.99
                                      0.16
Swallowing slowly              [chi square]:1.76
                                      0.18
Using straws                   [chi square]:0.25
                                      0.62
Irregular timing of drinking   [chi square]:0.08
                                      0.78
Using medicaments                     1.00
Orthodontic therapy            [chi square]:0.40
                                      0.53
Swimming professionally        [chi square]:2.71
                                      0.10
Acidic drinks                  [chi square]:1.40
                                      0.24
Fruit yoghurt                  [chi square]:0.86
                                      0.35
Orange juice                   [chi square]:0.28
                                      0.60
Brushing                       [chi square]:0.39
                                      0.53

Table 4. Presence of erosive sources in 12-14
years old Greek minority children and their
relationship with dental erosion

Related erosive source                    Erosion (-)   Erosion (+)

                               Present    n      %      n      %

Asthma                            -       15    93.8    18    90.0
                                  +       1     6.3     2     10.0
Gastric Reflux                    -       15    93.8    19    95.0
                                  +       1     6.3     1     5.0
Swallowing slowly                 -       11    68.8    18    90.0
                                  +       5     31.3    2     10.0
Using straws                      -       16   100.0    18    90.0
                                  +       0     0.0     2     10.0
Irregular timing of drinking      -       12    75.0    14    70.0
                                  +       4     25.0    6     30.0
Using medicaments                 -       15    93.8    20   100.0
                                  +       1     6.3     0     0.0
Orthodontic therapy               -       15    93.8    18    90.0
                                  +       1     6.3     2     10.0
Swimming professionally           -       16   100.0    17    85.0
                                  +       0     0.0     3     15.0
Acidic drinks                     -       10    62.5    13    65.0
                                  +       6     37.5    7     35.0
Fruit yoghurt                     -       11    68.8    17    85.0
                                  +       5     31.3    3     15.0
Orange juice                      -       9     56.3    13    65.0
                                  +       7     43.8    7     35.0
Brushing                          -       8     50.0    8     40.0
                                  +       8     50.0    12    60.0

Related erosive source

                                       P

Asthma                         [chi square]:0.16
                                      0.69
Gastric Reflux                 [chi square]:0.03
                                      0.87
Swallowing slowly              [chi square]:2.56
                                      0.11
Using straws                   [chi square]:1.69
                                      0.19
Irregular timing of drinking   [chi square]:0.11
                                      0.74
Using medicaments              [chi square]:1.29
                                      0.26
Orthodontic therapy            [chi square]:0.16
                                      0.69
Swimming professionally        [chi square]:2.62
                                      0.11
Acidic drinks                  [chi square]:0.02
                                      0.88
Fruit yoghurt                  [chi square]:1.36
                                      0.24
Orange juice                   [chi square]:0.29
                                      0.93
Brushing                       [chi square]:0.36
                                      0.55
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