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Risk indicators for the severity of erosive wear in deciduous dentition of Mexican schoolchildren aged 5 to 7 years
1Master and Doctoral Program in Medical, Dental and Health Sciences at the School of Dentistry, National Autonomous University of México, 04510 Mexico City, Mexico
2Dental Public Health Department, Graduate and Research Division at the School of Dentistry, National Autonomous University of México, 04510 Mexico City, Mexico
3Department of Operative Dentistry and Periodontology, University Medical Centre, 79106 Freiburg, BW, Germany
4Faculty of Higher Studies (FES) Iztacala, National Autonomous University of Mexico, 54090 Tlalnepantla, MX, Mexico
*Corresponding Author(s):alvaroedgar@unam.mx (Álvaro E. González-Aragón Pineda)
| History | Submitted: 01 September 2023 | Accepted: 10 October 2023 | Published: 03 May 2024 |
| Copyright: | ©2024 The Author(s). Published by MRE Press. |
The objective of this work was to estimate the prevalence and severity of erosive tooth wear (ETW), and to identify risk indicators of deciduous dentition of a group of schoolchildren from public schools in Tlalnepantla de Baz, State of Mexico. A cross-sectional study was carried out in 352 schoolchildren from 5 to 7 years old. The severity of the ETW was evaluated using the Basic Erosive Wear Examination (BEWE). Risk indicators were evaluated through a survey which included food and beverage consumption, consumption habits, vitamin C consumption, gastroesophageal reflux, heartburn, belching, xerostomia, vomiting and teeth grinding. Multinomial logistic regression models were fitted. The prevalence of ETW was 99.7% (n = 351). Regarding severity, 46.6% were at a null/mild level, 27.3% moderate, and 26.1% severe. Males were more likely to present severe ETW (odds ratio (OR) = 2.23, 95% confidence interval (CI), 1.27–3.93; p = 0.005). The risk indicators for the severity of ETW were the frequent consumption of citrus fruits (OR = 2.09, 95% CI, 1.12–3.89; p = 0.021), fruit juice (OR = 1.99, 95% CI, 1.06–3.75; p = 0.033), processed beverages (OR = 2.15, 95% CI, 1.23–3.78; p = 0.008) and hot sauce (OR = 1.82, 95% CI, 1.03–3.20; p = 0.036). The prevalence of ETW in the deciduous dentition was very high (99.7%) and ~1/3 for severe ETW. The dietary factors associated with severe ETW are part of the regular consumption of Mexican school-age children, which impact their oral health condition. It is important to establish intervention strategies from the infant stage, focused on both children and their caregivers.
Cite this article
María Fernanda Vázquez-Ortíz, Socorro Aída Borges-Yáñez, Adrian Lussi, Álvaro E. González-Aragón Pineda. Risk indicators for the severity of erosive wear in deciduous dentition of Mexican schoolchildren aged 5 to 7 years.Journal of Clinical Pediatric Dentistry,2024,48(3):146-155 DOI:10.22514/jocpd.2024.068
1. Introduction
The term erosive tooth wear (ETW) refers to dental wear where tooth erosion is the main etiological factor, and is defined as the chemical (dental erosion) and mechanical (attrition and abrasion) process, that results in the cumulative loss of dental hard tissue not caused by bacteria [1].
Deciduous dentition presents anatomical and histological characteristics that increase the risk of presenting lesions because of ETW. Deciduous teeth have thinner and more porous enamel compared to permanent teeth [2]. Therefore, the tissue loss includes dentin, resulting in more severe lesions compare to permanent teeth [3].
In general, the enamel of deciduous teeth is considerably less mineralized than permanent teeth [4], and has less hardness [5]. Also, it has been shown that, under acid attack, the enamel of deciduous teeth is lost faster than permanent teeth [6]. These differences mean that deciduous teeth have a disadvantage against dissolution compared to permanent teeth [2].
Although there are only few reports on the prevalence of ETW in deciduous teeth, it has been estimated that it is between 30–50% worldwide, having higher ranges than those reported in permanent dentition (20–41%) [7]. This can also be observed in the severity of the wear, since a higher frequency of ETW has been detected in deciduous dentition than in permanent dentition, with 21–48% and 2–30%, respectively [8, 9, 10].
The acids that cause ETW come from two sources: extrinsic if it comes from the diet and medications with low pH [11, 12], or intrinsic when it comes from the gastric juice that travels through the esophagus and comes into contact with the dental tissues in the oral cavity [1]. Some risk indicators for ETW in deciduous dentition are frequent consumption of chewable vitamin C tablets [13], and suffering from gastroesophageal reflux [14]. However, frequent consumption of an acidic diet has been the most reported risk indicator, specifically the consumption of acidic beverages [15, 16, 17].
Acid beverages such as fruit juices (natural and artificial) and soft drinks are highly consumed by Mexican children [18]. In the 2022 National Health Survey (in Spanish, ENSANUT), it was shown that between 82.6% and 93.6% of Mexican children consume sweetened beverages, where this type of acidic beverages is classified [19].
Considering this important risk indicator for the development of ETW and that there are high prevalence data in permanent dentition (62.5%) and mixed dentition (62.0%) [20, 21], the objective of this study was to estimate the prevalence and severity of ETW, and to identify risk indicators in deciduous dentition of a group of schoolchildren from public schools in Tlalnepantla de Baz, State of Mexico. The hypothesis is that food and beverage consumption, vitamin C consumption, gastroesophageal reflux, heartburn, headache, xerostomia, vomiting and teeth grinding will be risk indicators of the presence of severe ETW.
2. Materials and methods
This is a cross-sectional study conducted in first grade schoolchildren from public elementary schools in the municipality of Tlalnepantla de Baz, State of Mexico, and it was carried out between October 2021 and June 2022. The study was carried out under the guidelines established in the Strengthening Reporting of Observational Studies in Epidemiology.
2.1 Participants
The municipality of Tlalnepantla de Baz has a population of 672,202 of which 3% are between 5–9 years old. It has a population of 148,924 people aged 5 and over, who attend school. On average, the population has 10.9 years of schooling, 30.1% of the population has a university education, an average of 3.3 people live in a household, and 71.1% of the population is a beneficiary of some health service. According to the National Population Council (in Spanish, CONAPO), the marginalization index of the Municipality is “very low”. The municipality has 196 public elementary schools with a first-grade students’ group each. Each first grade group has 15 students on average [22, 23].
The sample size was estimated based on a known prevalence of 32% obtained from a previous study with an age-matched population [24]. Considering an error of 5 percentual points of the real value and a 95% confidence level, the result was n = 323 participants. Considering a non-response rate of 20%, a total of 391 schoolchildren were invited. A probabilistic sampling by conglomerates was carried out, considering each first-grade students’ group of public elementary schools of Tlalnepantla de Baz, a conglomerate. Twenty-six first-grade students’ groups were selected to reach the necessary sample size. The selection was carried out randomly through the statistical program Stata v. 17 (StataCorp, College Station, TX, USA).
Schoolchildren who presented a health condition that prevented dental evaluation or who wore fixed orthodontic appliances that prevented the student’s oral examination were excluded (n = 2).
2.2 Variables
The dependent variable was defined based on the Basic Examination for Erosive Wear (BEWE) criteria. To obtain the BEWE scores, each dental sextant was evaluated, and the total sum was obtained [25, 26]. BEWE scores were categorized as: none/mild (0–8), moderate (9–13) and severe (≥14) [27]. The independent variables (risk indicators) were: food and beverage consumption (citrus fruits, non-citrus fruits, fruit juices, milk, yogurt, processed beverages, sweets, hot sauce and ketchup), consumption habits (lemon sucking, consumption of acidic drinks while doing sports, consumption of acidic drinks before sleeping, keeping or swirling drinks in the mouth), vitamin C consumption, gastroesophageal reflux, heartburn, belching, suffering from xerostomia, vomiting and teeth grinding. During the application of the survey, the answer was considered as “Yes”, if it was experienced it at least once a week. The following variables were also included: age, sex, frequency of teeth brushing (1 time/2 times/3 times or more) and the simplified oral hygiene index (OHI-S Acceptable/Deficient) [28].
2.3 Data collection
2.3.1 Survey
Information about diet and health was collected from an adapted survey, from the one used in a previous study [29], and which was validated for this study. Content and construct validity was evaluated in 26 schoolchildren (different from the study sample), obtaining a correlation (Spearman’s rho) of 0.799 (p < 0.001), and an area under the receiver operating characteristic (ROC) curve of 0.96. Internal consistency and test-retest reliability were evaluated, obtaining a Cronbach’s alpha coefficient of 0.80 and an agreement percentage of 80%, between applications.
The survey was answered by the main caregiver of each child through an interview. The interviewers were trained and standardized for the application of the survey, so that they did not influence the answers of the interviewees. Table 1 presents the questions comprising the survey.
| Variable | Question | Answer |
| Lemon sucking | Does your child like to suck lemon? | No/Yes |
| Consumption of acidic beverages while playing sports | Does your child consume acidic drinks (e.g., soft drinks, sports drinks) during or after sports activities? | No/Yes |
| Consumption of acidic drinks before sleeping | Does your child drink any acidic drinks just before sleeping? | No/Yes |
| Keeping or swirling drinks in the mouth | When your child consumes any kind of drink, does he/she keep or swirl in his or her mouth before swallowing? | No/Yes |
| Food and beverage consumption | How often does your child consume the following foods and beverages: citrus, non-citrus fruits, fruit juices, milk, flavored milk, plain yogurt, fruit yogurt, soft drinks, sports drinks, and artificial juices? | Never/One day/Some days (2–4 days)/Most days (5–7 days)/Several times a day |
| Vitamin C consumption | How often does your child consume vitamin C effervescent tablets/chewable tablets? | Never/One day/Some days (2–4 days)/Most days (5–7 days)/Several times a day |
| Gastroesophageal reflux | Has a doctor or health professional diagnosed your child with gastroesophageal reflux? | No/Yes |
| Heartburn | Have you ever noticed that your child has heartburn? | No/Yes |
| Belching | Have you ever noticed that your child belches a lot? | No/Yes |
| Xerostomia | Has your child ever told you that he has a dry mouth? | No/Yes |
| Vomiting | Have you noticed that your child vomits frequently? | No/Yes |
| Frequency of teeth brushing | How many times a day does your child brush his/her teeth? | 1 time/2 times/3 times or more |
| Teeth grinding | Does your child grind his teeth while sleeping or while awake? | No/Yes |
2.3.2 Dental evaluation
Dental evaluation was performed by a standardized examiner (MAVO) to detect ETW lesions using the BEWE index (the risk level category), and oral hygiene using the OHI-S. Standardization consisted of theoretical and practical sessions with models, photographs and participants different from the study sample, but of similar age. Subsequently, inter-rater reliability against the gold standard (AEGAP) and intra-rater reliability were evaluated in 18 participants. Kappa coefficients >0.8 were obtained.
For the dental evaluation, the participant laid down on a school table and a portable artificial light was used to illuminate the oral cavity. First, oral hygiene was evaluated and then the presence and severity of ETW. For the examination, a PCP11 probe (Hu-Friedy, Chicago, Ill., USA), a dental mirror (Arain, Sialkot, Punjab, Pakistan) and gauze were used.
According to the OHI-S for oral hygiene, the buccal surfaces of teeth 55, 51, 65 and 71 and the lingual surfaces of 75 and 85 were evaluated. If any were absent, a contiguous tooth was evaluated [28].
For the ETW, the examiner evaluated all deciduous teeth present from the buccal, palatal/lingual and occlusal/incisal surfaces. The examiner identified the ETW according to the following codes: 0: when there was no evidence of erosion, 1: initial loss of enamel, 2: distinctive defect less than 50% of the surface, and 3: distinctive defect greater than 50% of the surface. In case of doubt between two criteria, the examiner chose the lower criterion. If the tooth surface presented any extensive restoration (>1/3), the surface was excluded.
2.4 Data analysis
The data was recorded in the EpiData Entry 3.1 program (EpiData Association, Odense, Denmark) and analyzed with the Stata v. 17 software.
The severity of ETW and the distribution of risk indicators were obtained. Subsequently, a bivariate analysis was performed between the ETW severity and the independent variables (risk indicators). For the bivariate analysis, the Chi-square test was used and a value of p < 0.05 was considered statistically significant.
Multiple models for ETW severity were fitted using multinomial logistic regression. The value of p ≤ 0.35 was established to include the variable in the model and the biological plausibility (all adjusted according to the number of examined deciduous teeth). Odds ratios (OR) and 95% confidence intervals (CI) were calculated. A statistically significant result was considered if the 95% confidence interval did not include one and a value of p < 0.05. Finally, possible interactions between the associated variables were sought.
3. Results
Of the 391 children who were invited to participate, 352 accepted. The non-response rate was 10% (n = 39) where the main cause of refusal was fear of contagion by Sars-Cov-2 (COVID-19).
The ages of the 352 children ranged from 5 to 7 years, with a mean of 6.17 ± 0.45 years. The mean number of deciduous teeth present was 17.49 ± 2.06, with a median of 18 and a minimum of 12 teeth.
3.1 Erosive tooth wear
The prevalence of ETW was 99.7% (n = 351). The mean BEWE score was 9.80 ± 4.80 (Minimum: 0–Maximum: 18) for all children. Regarding severity, 46.6% were at a null/mild level (BEWE score: 0–8), 27.3% moderate (BEWE score: 9–13) and 26.1% severe (BEWE score ≥14).
All 5-year-old children (n = 11) presented null or mild severity, 23.8% of 6-year-old schoolchildren presented severe ETW, compared to 38.8% of 7-year-old schoolchildren (p < 0.001). Regarding sex, 32.1% of males presented severe ETW, compared to 20.6% in females (p = 0.050). Table 2 shows the severity of ETW according to age and sex.
| Variable | Total (%) | Null/mild (%) | Moderate (%) | Severe (%) | p* | |
| Age | ||||||
| 5-year-old | 11 (100) | 11 (100.0) | 0 (0.0) | 0 (0.0) | <0.001 | |
| 6-year-old | 269 (100) | 131 (48.7) | 74 (27.5) | 64 (23.8) | ||
| 7-year-old | 72 (100) | 22 (30.6) | 22 (30.6) | 28 (38.8) | ||
| Sex | ||||||
| Male | 168 (100) | 72 (42.9) | 42 (25.0) | 54 (32.1) | 0.050 | |
| Female | 184 (100) | 92 (50.0) | 54 (29.4) | 38 (20.6) | ||
| Total (%) | 352 (100) | 164 (46.6) | 96 (27.3) | 92 (26.1) | ||
| *Chi-square test. |
3.2 Risk indicators
The prevalence of severe ETW was higher in schoolchildren with frequent consumption of citrus fruits (30.4% vs. 18.4%), fruit juices (36.4% vs. 22.7%), and processed drinks (34.8% vs. 20.9%) (p < 0.05). No differences were found in the prevalence of severe ETW regarding the consumption of non-citrus fruits, natural milk, flavored milk, natural yogurt, fruit yogurt, sweets and ketchup (p > 0.05) (Table 3).
| Variable | Total (%) | Null/mild (%) | Moderate (%) | Severe (%) | p** | |
| Citrus fruitsš | ||||||
| No | 125 (100) | 64 (51.2) | 38 (30.4) | 23 (18.4) | 0.049 | |
| Yes | 227 (100) | 100 (44.0) | 58 (25.6) | 69 (30.4) | ||
| Non-citrus fruits† | ||||||
| No | 285 (100) | 127 (44.6) | 80 (28.0) | 78 (27.4) | 0.280 | |
| Yes | 67 (100) | 37 (55.2) | 16 (23.9) | 14 (20.9) | ||
| Fruit juices | ||||||
| No | 264 (100) | 135 (51.2) | 69 (26.1) | 60 (22.7) | 0.007 | |
| Yes | 88 (100) | 29 (32.9) | 27 (30.7) | 32 (36.4) | ||
| Milk | ||||||
| No | 97 (100) | 47 (48.4) | 22 (22.7) | 28 (28.9) | 0.468 | |
| Yes | 255 (100) | 117 (45.9) | 74 (29.0) | 64 (25.1) | ||
| Flavored milk | ||||||
| No | 179 (100) | 81 (45.3) | 45 (25.1) | 53 (29.6) | 0.297 | |
| Yes | 173 (100) | 83 (48.0) | 51 (29.5) | 39 (22.5) | ||
| Natural yogurt | ||||||
| No | 318 (100) | 149 (46.9) | 85 (26.7) | 84 (26.4) | 0.777 | |
| Yes | 34 (100) | 15 (44.1) | 11 (32.4) | 8 (23.5) | ||
| Fruit yogurt | ||||||
| No | 298 (100) | 136 (45.6) | 80 (26.9) | 82 (27.5) | 0.382 | |
| Yes | 54 (100) | 28 (51.9) | 16 (29.6) | 10 (18.5) | ||
| Processed drinks§ | ||||||
| No | 220 (100) | 110 (50.0) | 64 (29.1) | 46 (20.9) | 0.016 | |
| Yes | 132 (100) | 54 (41.0) | 32 (24.2) | 46 (34.8) | ||
| Sweets | ||||||
| No | 95 (100) | 52 (54.7) | 23 (24.2) | 20 (21.1) | 0.166 | |
| Yes | 257 (100) | 112 (43.6) | 73 (28.4) | 72 (28.0) | ||
| Hot sauce | ||||||
| No | 213 (100) | 104 (48.8) | 62 (29.1) | 47 (22.1) | 0.097 | |
| Yes | 139 (100) | 60 (43.2) | 34 (24.4) | 45 (32.4) | ||
| Ketchup | ||||||
| No | 313 (100) | 148 (47.3) | 84 (26.8) | 81 (25.9) | 0.756 | |
| Yes | 39 (100) | 16 (41.0) | 12 (30.8) | 11 (28.2) | ||
| Total (%) | 352 (100) | 164 (46.6) | 96 (27.3) | 92 (26.1) | ||
| *Greater than or equal to 5 days of consumption, **Chi-square test. šLemon, orange, tangerine and grapefruit, †Pineapple, Grape, Strawberry, and Tamarind, §Soft drinks, sports drinks and artificial juices. |
No significant differences were observed according to consumption habits, vitamin C consumption, gastroesophageal reflux, suffering from heartburn, belching, xerostomia, vomiting, grinding teeth, brushing frequency and the simplified oral hygiene index regarding ETW severity (p > 0.05) (Table 4).
| Variable* | Total (%) | Null/mild (%) | Moderate (%) | Severe (%) | p** | |
| Lemon sucking | ||||||
| No | 207 (100) | 96 (46.4) | 56 (27.0) | 55 (26.6) | 0.975 | |
| Yes | 145 (100) | 68 (46.9) | 40 (27.6) | 37 (25.5) | ||
| Acidic drinks while doing sports | ||||||
| No | 309 (100) | 148 (47.9) | 79 (25.6) | 82 (26.5) | 0.151 | |
| Yes | 43 (100) | 16 (37.2) | 17 (39.5) | 10 (23.3) | ||
| Acidic drinks before sleeping | ||||||
| No | 290 (100) | 130 (44.8) | 79 (27.3) | 81 (27.9) | 0.209 | |
| Yes | 62 (100) | 34 (54.8) | 17 (27.4) | 11 (17.8) | ||
| Keeping or swirling drinks in the mouth | ||||||
| No | 235 (100) | 107 (45.5) | 69 (29.4) | 59 (25.1) | 0.452 | |
| Yes | 117 (100) | 57 (48.8) | 27 (23.0) | 33 (28.2) | ||
| Effervescent Vitamin C | ||||||
| No | 295 (100) | 136 (46.1) | 8 (27.8) | 77 (26.1) | 0.870 | |
| Yes | 57 (100) | 28 (49.1) | 14 (24.6) | 15 (26.3) | ||
| Chewable Vitamin C | ||||||
| No | 264 (100) | 125 (47.4) | 70 (26.5) | 69 (26.1) | 0.838 | |
| Yes | 88 (100) | 39 (44.3) | 26 (29.6) | 23 (26.1) | ||
| Gastroesophageal reflux | ||||||
| No | 321 (100) | 150 (46.7) | 90 (28.1) | 81 (25.2) | 0.380 | |
| Yes | 31 (100) | 14 (45.2) | 6 (19.3) | 11 (35.5) | ||
| Heartburn | ||||||
| No | 307 (100) | 140 (45.6) | 89 (29.0) | 78 (25.4) | 0.166 | |
| Yes | 45 (100) | 24 (53.3) | 7 (15.6) | 14 (31.1) | ||
| Belching | ||||||
| No | 313 (100) | 144 (46.0) | 87 (27.8) | 82 (26.2) | 0.781 | |
| Yes | 39 (100) | 20 (51.2) | 9 (23.1) | 10 (26.6) | ||
| Xerostomia | ||||||
| No | 266 (100) | 125 (47.1) | 72 (27.0) | 69 (25.9) | 0.965 | |
| Yes | 86 (100) | 39 (45.4) | 24 (27.9) | 23 (26.7) | ||
| Vomiting | ||||||
| No | 341 (100) | 160 (46.9) | 94 (27.6) | 87 (25.5) | 0.332 | |
| Yes | 11 (100) | 4 (36.4) | 2 (18.2) | 5 (45.4) | ||
| Teeth grinding | ||||||
| No | 214 (100) | 99 (46.3) | 58 (27.1) | 57 (26.6) | 0.965 | |
| Yes | 138 (100) | 65 (47.1) | 38 (27.5) | 35 (25.4) | ||
| Frequency of teeth brushing | ||||||
| 1 time | 89 (100) | 43 (48.3) | 21 (23.6) | 25 (28.1) | 0.925 | |
| 2 times | 157 (100) | 73 (46.5) | 44 (28.0) | 40 (25.5) | ||
| 3 times or more | 106 (100) | 48 (45.3) | 31 (29.2) | 92 (25.5) | ||
| OHI-Sš | ||||||
| Acceptable | 246 (100) | 117 (47.6) | 66 (26.8) | 63 (25.6) | 0.856 | |
| Deficient | 106 (100) | 47 (44.3) | 30 (28.3) | 29 (27.4) | ||
| Total (%) | 352 (100) | 164 (46.6) | 96 (27.3) | 92 (26.1) | ||
| *Yes = at least once a week, **Chi-square test for all variables and Fisher’s exact test for vomiting, šSimplified oral hygiene index. |
3.3 Multiple analysis
In the multinomial logistic regression model, the variables age, sex, citrus fruits, non-citrus fruits, fruit juice, flavored milk, processed drinks, sweets, hot sauce, consumption of erosive drinks while doing sports, consumption of erosive drinks before bedtime, heartburn, vomiting, reflux, hygiene and teeth grinding were included.
The final model showed that for each year in the children’s age, the odds of presenting moderate ETW increased by more than twice (OR = 2.46, 95% CI, 1.32–4.57; p = 0.004) and the odds increased four times for severe ETW (OR = 4.04, 95% CI, 2.10–7.79; p < 0.001). Males had twice the odds of presenting severe ETW compared to females (OR = 2.23, 95% CI, 1.27–3.93; p = 0.005).
Schoolchildren who had frequent consumption of citrus fruits (OR = 2.09, 95% CI, 1.12–3.89; p = 0.021) and processed beverages (OR = 2.15, 95% CI, 1.23–3.78; p = 0.008) were twice as likely to suffer from severe ETW.
Those who frequently consumed natural fruit juice (OR = 1.99, 95% CI, 1.05–3.75; p = 0.033) and hot sauce (OR = 1.82, 95% CI, 1.03–3.20; p = 0.036) had 99% and 82% higher odds of presenting severe ETW, respectively (Table 5).
| MODERATE ETW* | ||||
| Variable | Crude | Adjusted** | ||
| OR (95% CI) | p | OR (95% CI) | p | |
| Age (Years old) | 2.40 (1.32–4.37) | 0.004 | 2.46 (1.32–4.57) | 0.004 |
| Sex (Reference = female) | 0.99 (0.60–1.65) | 0.981 | 1.07 (0.63–1.81) | 0.804 |
| Citrus fruits*** (Reference = no) | 0.98 (0.58–1.63) | 0.929 | 0.99 (0.57–1.70) | 0.962 |
| Fruit juices (Reference = no) | 1.82 (1.00–3.32) | 0.050 | 1.75 (0.94–3.26) | 0.080 |
| Processed drinksš (Reference = no) | 1.02 (0.60–1.74) | 0.946 | 0.99 (0.57–1.71) | 0.971 |
| Hot sauce (Reference = no) | 0.95 (0.56–1.61) | 0.850 | 0.94 (0.54–1.61) | 0.820 |
| Gastroesophageal reflux (Reference = no) | 0.71 (0.26–1.92) | 0.506 | 0.62 (0.22–1.72) | 0.362 |
| OHI-S† (reference = acceptable) | 1.13 (0.65–1.96) | 0.659 | 0.96 (0.54–1.70) | 0.902 |
| Teeth grinding (Reference = no) | 1.00 (0.60–1.68) | 0.994 | 1.02 (0.60–1.73) | 0.943 |
| SEVERE ETW* | ||||
| Variable | Crude | Adjusted** | ||
| OR (95% CI) | p | OR (95% CI) | p | |
| Age (Years old) | 3.36 (1.85–6.10) | <0.001 | 4.04 (2.10–7.79) | <0.001 |
| Sex (Reference = female) | 1.82 (1.08–3.04) | 0.024 | 2.23 (1.27–3.93) | 0.005 |
| Citrus fruits*** (Reference = no) | 1.92 (1.09–3.38) | 0.024 | 2.09 (1.12–3.89) | 0.021 |
| Fruit juices (Reference = no) | 2.48 (1.38–4.47) | 0.002 | 1.99 (1.05–3.75) | 0.033 |
| Processed drinksš (Reference = no) | 2.03 (1.21–3.43) | 0.008 | 2.15 (1.23–3.78) | 0.008 |
| Hot sauce (Reference = no) | 1.66 (0.99–2.79) | 0.055 | 1.82 (1.03–3.20) | 0.036 |
| Gastroesophageal reflux (Reference = no) | 1.45 (0.63–3.35) | 0.379 | 1.26 (0.51–3.12) | 0.613 |
| IHO-S† (Reference = acceptable) | 1.14 (0.65–1.99) | 0.631 | 0.98 (0.53–1.83) | 0.972 |
| Teeth grinding (Reference = no) | 0.93 (0.55–1.59) | 0.802 | 0.97 (0.55–1.72) | 0.933 |
| *Reference: Null/mild ETW, **Adjusted according to number of examined deciduous teeth, ***Lemon, orange, tangerine, and grapefruit, šSoft drinks, sports drinks and artificial juices, †Simplified oral hygiene index. ETW: erosive tooth wear; OR: odds ratios; CI: confidence intervals. |
4. Discussion
According to the present study, in a representative sample from the State of Mexico, almost all children with deciduous dentition (99.7%) had ETW, with a 26.1% presenting severe ETW. In Mexico, there are a few studies that report the prevalence of ETW in deciduous dentition. In children from 6 to 12 years in Mexico City, a prevalence of 62% in mixed dentition was reported [21].
Worldwide, ETW has been detected, for example, in five-year-old children from Norway a prevalence of ETW in the deciduous dentition of 80% was reported [30], also, in Colombian children from two to five years of age, a prevalence of 100% was reported in the deciduous dentition [31] and in six-year-old children from Greece, a prevalence of 78.8% using the BEWE index was found [32]. Similar results were found in the present study.
The variation in the prevalence of ETW in deciduous dentition could be explained by different criteria for its diagnosis and the impact of different risk indicators between populations [14, 33].
Likewise, in the present study, several factors were related to the prevalence of severe ETW in children in deciduous dentition, including age, sex, consumption of citrus fruits, fruit juices and hot sauce. It has been observed that as age increases, the severity of ETW increases. It was observed that for each year of increase in age, the probability of presenting moderate ETW increased more than two times (OR = 2.46) and four times (OR = 4.04) for severe ETW in deciduous dentition. The results observed in the present study confirm previous findings showing that the severity of dental wear is proportionally related to the increase in age and is related to a longer exposure to acids [31, 34].
Another variable found to be associated with the severity of ETW in the deciduous dentition was sex (OR = 2.23). Regarding sex, several studies carried out on permanent dentition have reported a greater presence of ETW in males, which is consistent with the present study [14, 15]. Bite force, which has been proven to be greater in males than in females [35], may account for these variations.
Erosive tooth wear is highly variable, some people experience total tooth destruction and others maintain most of their dental structure throughout their lives, it is likely that other factors are related to ETW which could help to explain some of the variability in the results. One of them is the frequent and excessive consumption of citrus fruits in the form of lemon and orange juice and soft drinks and citrus drinks. In the present study, children who had a frequent consumption of citrus fruits (OR = 2.09) and processed drinks (OR = 2.15) were twice as likely to present severe ETW, similarly, those children who consumed natural fruit juice (OR = 1.99) and hot sauce (OR = 1.82). This can be explained by the fact that the ingredients of the hot sauce include vinegar, which has been demonstrated to have erosive potential on dental tissue [36]. The findings of the current study are consistent with prior research, which have linked ETW to the frequent consumption of fruit juices and soft drinks [14].
In Mexico, the consumption of hot sauces is usually accompanied by food and snacks with lemon. A recent study conducted in Mexican schoolchildren reports that the consumption of food and snacks accompanied with chili and lemon is associated with the prevalence of ETW (OR = 1.59; 95% CI: 1.07–2.38; p = 0.023) [21].
The relationship found between processed beverages and ETW could be due to unusual eating, drinking, or swallowing habits, since during feeding, children could hold the acidic beverage in the oral cavity before swallowing it, increasing the exposure time of the acid substance on the teeth and therefore, increasing the risk of erosion [37]. Previous studies have shown that the pH and buffering capacity of soft drinks determine their erosive potential, which in turn contributes to erosive tooth wear [13].
Even though in the present study, no association was found between the consumption of acidic beverages before bedtime and the severity of ETW (p = 0.209). Studies have reported that increased consumption of acidic fruit juices, fruit drinks, and carbonated beverages may be causing an increase in the prevalence of ETW, especially in children and teenagers [14, 20, 38].
Few studies have found an association between ETW and teeth grinding, gastric reflux and/or vomiting. In children with special needs, an association was found between gastric reflux (OR = 2.24) and the presence of ETW [38], likewise vomiting (OR = 3.27) in children from six to 16 years old, and gastric reflux (OR = 3.21) were shown to be associated with ETW [39]. In the present study, no association was found between the presence of reflux and ETW. The reason for not finding an association could be due to the fact that previous studies focus on adolescents and adults with permanent dentition [40].
One of the limitations of this study is its cross-sectional design since it is not possible to determine the cause-effect relationship of the independent variables with the ETW. Another limitation is that various studies have used different criteria for the diagnosis of ETW and this makes it difficult to compare its prevalence and severity [14]. Finally, future studies should consider measuring bite force.
An advantage of the present study was that the evaluation of the ETW was carried out through the BEWE index, which is an easy-to-use index and is currently used in various studies, making the present study comparable with similar studies worldwide. The BEWE is easy to use and has good acceptance for epidemiological studies. The required levels of validity, reliability, sensitivity, and specificity provided by the BEWE have been demonstrated [25, 26].
In a 5-year follow-up, Ganss et al. [41], reported that subjects with ETW in their deciduous dentition had an increased risk (relative risk of 3.9) of ETW in their permanent teeth. This highlights the need to provide children with comprehensive dental care, early diagnosis by general dentists and specialists, identifying the main etiological factors involved and implementing relevant preventive measures.
Future studies should focus on designing strategies to educate children and their parents and/or caregivers about the care and preservation of teeth in the face of possible acid attacks that may occur throughout their lives.
5. Conclusions
The prevalence of ETW in deciduous dentition was very high (99.7%) and ~1/3 was severe. The dietary factors associated with severe ETW are part of the regular consumption of Mexican school-age children, which impact their oral health condition.
Given that children who present ETW in the deciduous dentition have a high risk of presenting it in their permanent dentition, it is important to establish intervention strategies from the infant stage, focused on both children and their caregivers.
Abbreviations
ETW, erosive tooth wear; BEWE, Basic Erosive Wear Examination; OHI-S, simplified oral hygiene index; OR, odds ratios; CI, confidence intervals.
Availability of data and materials
The data is available upon request. Please write to the corresponding author.
Author contributions
MFVO, SABY and AEGAP—designed the research study. MFVO and AEGAP—performed the research; analyzed the data; wrote the manuscript. SABY and AL—reviewed the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The research protocol was submitted to the Ethics and Research Committee of the Faculty of Dentistry, of the National Autonomous University of Mexico, who approved the study protocol (CIE/0505/11/2021), and to the Ethics Committee of the Faculty of Higher Education Iztacala, of the National Autonomous University of Mexico (CE/FESI/052020/135). The parents or guardians who agreed to participate signed an informed consent form, and the students were asked for their assent.
Acknowledgment
The authors thank the master’s and doctoral program in Medical, Dental, and Health Sciences at the Mexican National Autonomous University (Universidad Nacional Autónoma de México), and the National Council of Science and Technology (Consejo Nacional de Ciencia y Tecnología, CONACYT).
Funding
This work was supported by UNAM-PAPIIT IA202823.
Conflict of interest
The authors declare no conflict of interest.
