1
Donia Abd El Lattif
V year, Group 14
Relationship between diet, lifestyle, health issues and dental
erosion development in children: A systematic review
Master’s thesis
Supervisor Sandra Petrauskiene
2
FINAL MASTER‘S THESIS IS CONDUCTED
3 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
MEDICAL ACADEMY FACULTY OF ODONTOLOGY
CLINIC FOR PREVENTIVE AND PEDIATRIC DENTISTRY
Relationship between diet, lifestyle, health issues and dental erosion development in children: A systematic review
Master’s thesis
The thesis was done
by student ……… Supervisor ………..
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(name, surname, year, group)(degree, name, surname)
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4 TABLE OF CONTENTS
SUMMARY: ...6
INTRODUCTION: ...7
1. SELECTION CRITERIA OF THE STUDIES. SEARCH METHODS AND STRATEGY ...9
1.1 LITERATURE SEARCH STRATEGY ... 9
1.2 INCLUSION AND EXCLUSION CRITERIA ... 9
2. SYSTEMISATION AND ANALYSIS OF DATA ...14
3. DISCUSSION ...19
4. CONCLUSIONS ...20
REFERENCES ...22
5 ABBREVIATIONS:
DE- Dental erosion ETW- Erosive tooth wear
GERD- Gastroesophageal reflux disease BEWE- Basic Erosive Wear Examination
WIMD- The Welsh Index of Multiple Deprivation TWI- Tooth Wear Index
CS- Cross-sectional study Gr- grade
SG- Study group CG- Control group
6 SUMMARY
Objective: To evaluate relationship between diet, lifestyle, health issues and DE development in children.
Materials and Methods: According to the PRISMA guidelines, publications of this systematic review were selected through PubMed and ResearchGate. The comprehensive search was restricted to English language articles, published from 2009 to 2019. Finally, 11 articles were selected in this systematic review.
Results:
The size of samples varied from 112 to 3812 subjects aged 3-18-year-old. Prevalence of DE varied from 3.9% to 98.1%. Grade 1 and 2 were the most prevalent of various indexes and while dental erosion were affected enamel structure, while dentine was not exposed in majority of subjects. Regular consumption of carbonated soft drinks, sport beverages or dietary acids were strongly associated with DE (OR: 3.42; 95% CI: 1.18-9.23; OR: 4.0; 95% CI: 2.1-7.6; OR: 3.99, 95% CI=1.37-11.59 (p=0.011)). Regular tooth brushing increases the risk for DE (OR = 1.7, CI 1.1–2.6). Visible dental plaque is a risk factor (OR: 2.0; 95 % CI: 1.2–3.4) of DE as well. Biological factors such as GERD, frequent vomiting and intake of certain medication are significantly related to DE development.
Conclusion
Improper dietary habits as daily consumption of carbonated drinks, sports drinks and sour sweets were the most commonly investigated and were significantly associated with DE development in children and adolescents. Moreover, biological and background related factors like GERD or asthma, lifestyle related factors (swimming in the pools) or background related factors such as gender, socioeconomic factors and parental education tend to increase the risk for DE development.
7
INTRODUCTION
Tooth erosion is a chronic irreversible loss of tooth structure such as enamel and dentine which can be distinguished depending on the type of acid involved and its´ origin [1].
The worldwide prevalence of dental erosion in children and adolescents remain unclear with rates ranging from 7.5% to 95%.Worldwide dental erosion is common in children and young people, and that, when present, it progresses rapidly [2]. The rates can be explained by various indices including age, type of examined tooth and geographic factors [3].
During the last decade there has been a significant increase in the prevalence and severity of erosive tooth wear, particularly in adolescents [4]. The increased morbidity that has been observed in recent years may be an indication that dental erosion has become an oral health problem that cannot be ignored in industrialized and developing countries [5]. From the clinical point of view, dental erosions can range from broad concavities in smooth tooth enamel or loss of enamel surface
anatomy, cupping out of occlusal surfaces with dentine exposure [6]. Consequently, dental erosions may result in sensitivity, pain or discomfort, functional problems, or deterioration of aesthetic appearance [7], thus the child may suffer from severe tooth surface loss, tooth sensitivity, over closure, poor aesthetics, or even dental abscesses in the affected teeth [8].
This chemical–mechanical process may affect both the primary and the permanent dentitions [9]. The presence of dental erosion in the primary dentition may be a risk for erosive tooth wear in the permanent dentition [10]. Primary teeth are more susceptible to DE than permanent teeth due to the structural differences between both dentitions. Dentine involvement of DE may evolve more rapidly in primary dentition than permanent dentition due to the thinner enamel layer and higher content of water by volume [11]. In addition, the slower salivary sugar clearances and the lower salivary flow rates in children may contribute to increased susceptibility for erosion in children [12].
The causes of dental erosions are multifactorial and the subtle changes are present in the beginning stages, thus diagnosis of risk factors may be difficult [13]. Clinical appearance is the most important factor for diagnosing the condition, especially in the early stages [14].
There are different predisposing factors and etiologies of the erosive condition. The interplay of chemical, biological and behavioral factors is crucial and helps explain why some individuals exhibit more erosion than others, even if they are exposed to the same acid challenge in their diets [15].
Extrinsic factors include the consumption of acidic foods and carbonated beverages, citrus fruits, low pH medications and, to a lesser degree, occupational exposure to acidic environments
8 (occupation around acidic/chlorinated industrial environment), sports (swimming in heavily
chlorinated pools), lifestyle habits (swallowing and drinking habits, consumption of acidic beverage at bedtime). [16]. Most clinical research has focused on the impact of diet and lifestyle [17]. Sports drinks contain both free sugars and acids and have the ability to cause both dental caries and erosion [18].
The intrinsic factors include diseases that cause vomiting or regurgitation, such as
gastro-esophageal reflux, anorexia and bulimia nervosa, or illnesses that cause a reduction in saliva flow [19]. In GERD patients, gastric acids with low pH reach the oral cavity and leads to teeth wear [8]. Biological factors such as saliva and its contribution to pellicle formation are considered the most important. Unstimulated salivary flow rate and buffering capacity were proven that they were associated with dental erosion [12]. The buffering capacity of saliva is dependent on flow rates and is responsible for neutralizing and clearing acids that cause dental erosion. [20, 21]. A low pH has also been proven to be associated with DE. Thus, pH of 5.5 (below 7) was proven to be a potential cause of DE [22]. Moreover, dentine is more susceptible to erosion than enamel, and it can be eroded at a relatively high pH (∼6.0) [23].
In addition, behavioral factors such as eating and drinking habits, regular exercise with dehydration and decrease of salivary flow, excessive oral hygiene and, on the other side, an unhealthy lifestyle, e.g. chronic alcoholism, are predisposing factors for dental erosion.[15].
Child’s oral-health status is often related to social dimensions, such as parental income and
education, family structure and parenting quality. These factors have impact not only on oral health status, but also they influence psychological and psychosocial attributes in children. [24,25]
The fact that DE seems to be an increasing problem in children and adolescents and may cause extensive loss of tooth substance that require complicated and expensive restorative treatments, makes it essential for clinicians to pay attention to this condition [26].
Aim: To evaluate relationship between diet, lifestyle, health issues and dental erosion development in children.
Objectives:
1. To search and analyze which risk factors are related to dental erosion development in children and adolescents.
2. To assess the prevalence and most prevalent severity of dental erosion in this systematic review. 3. To evaluate associations between risk factors and dental erosions in this systematic review.
9 1.SELECTION CRITERIA OF THE ARTICLES. SEARCH METHODS AND STRATEGY 1.1 LITERATURE SEARCH STRATEGY
According to the PRISMA guidelines, publications of this systematic review were selected through PubMed and ResearchGate. The following key words and their combinations dental erosions, diet, GERD, soft drinks, acidic food, carbonated drinks and adolescents were used to search.
The comprehensive search was restricted to English language articles, published from 2009 to 2019. One investigator carried out the selection and evaluation of articles. The full coverage of studies is presented in the table of protocol. Searches were specific to literature published in English and in humans and were restricted to adolescents in the age of 3-18 and articles not older than 10 years ago. In the results it was shown 80 publications (abstracts). If full-content publications were not accessible without purchasing and duplicated articles, they were excluded. Later, 64 articles related to the topic were revised, of which 11 consistent with the subject of this review were qualified regarding to PICOS criteria. After all information’s having collected and exclusions that have been made, the gathering information was enough and efficient for the research project 1.2 INCLUSION AND EXCLUSION CRITERIA
1.2.1 Inclusion criteria for the selection were: Subjects-children.
Articles about dental erosions and its´ related risk factors Studies in vivo.
Available full text articles.
Articles published in English language. Articles not older than 10 years.
1.2.2 Exclusion criteria were:
Adult participants (older than 18 years old). Studies carried out on animals or in vitro. Systematic review or literature review. Non-full texts article available;
Articles published not in English. Articles published before 2009. 1.2.3 PICOS (eligibility criteria)
10 In this systematic review 3-18 years old children and adolescents were subjects. Studies were
conducted to assess the development of dental erosions and its´ association with the potential DE risk factors.
The following indices were used to evaluate the grade and degree of severity of dental erosions: BEWE index, Lussi index, TWI, O´Sullivan index and Aine Tooth Wear Erosion index.
Table 1. Indexes to assess severity of dental erosion in the systematic review.
Index Scores
Lussi index
Facial surfaces:
0- No erosion.
1- Loss of surface enamel.
2- Involvement of dentin for <1/2 of the attacked area of the tooth surface. 3- Involvement of the dentin for >1/2 of the attacked area of the tooth surface.
Occlusal/lingual surface:
0- No erosion.
1- Slight erosion. Loss of surface enamel. Dentin is not involved. 2- Severe erosion. Enamel and dentin are involved.
Aine tooth wear erosion index
0- No erosion,
1- Mild opacities or white spots/etched appearance
2- Occlusal surface filled with small holes, incisal edges thinned and flattening of cusps. 3- Dentin exposure at the bottom of the holes on occlusal surfaces or other surfaces
O’Sullivan index
0- Normal enamel
1-Matte appearance of enamel surface without any contour loss 2- Loss of only enamel
3-Loss of enamel with exposure of dentin 4-Loss of enamel and dentin
5-Loss of enamel and dentin with pulp exposure
Basic Erosive Wear
Examination(BE WE)
0- No surface loss
1- Initial loss of surface texture
2- Distinct defect, hard tissue loss of less than 50% of the surface area 3- Distinct defect, hard tissue loss of more than 50% of the surface area
Tooth Wear Index (TWI)
0- No loss of enamel surface characteristics. 1- Loss of enamel surface characteristics.
2- Loss of enamel exposing dentine for less than one third of surface. 3- Loss of enamel exposing dentine for more than one third of surface. 4- Complete enamel loss - pulp exposure - secondary dentin exposure.
NDNS (National Diet and Nutrition Surveys) index
0- No erosion
1-Loss of enamel only
2- Enamel and dentine are involved
11 DE risk factors analyzed in this systematic review are presented in Table 2.
Table 2. Risk factors of dental erosion analyzed in the systematic review. Risk factors
Behavioral
Dietary habits [27, 28] Daily eating of sour sweets (≥2/day)
Carbonated drinks such as lemonades and cola(≥2/day) Fruits such as lemons, oranges and apples(≥2/day)
Natural and diluted fruit juices such as apple and orange juices(≥2/day) Sport drinks(≥2/day)
Eating pattern [29] Chewing habits
Drinking habits such as consumption of acidic beverage before bedtime
Related to oral hygiene [29] Brushing teeth less than 2 times/day
Brushing teeth in less than 1 hour after eating or drinking Duration of tooth brushing- (2 minutes of brushing)
Biological
Health issues [30, 31] GERD
Asthma/Corticosteroid inhalersusers
Regular bouts of heart burn, indigestion, and acid taste in mouth Frequent vomiting
Oral cavity [32] Saliva
Acquired dental pellicle
Tooth structure and positioning in relation to tongue and soft tissues
Lifestyle related [32] Sports such as swimming (gas-chlorinated water)
Background related
Gender Study [33] Girls tend to brush their teeth more frequently.
Girls hold their drinks more often in their mouth than boys Socioeconomic factors [34] Ethnical background
Low socioeconomic status
Parental education [27] Lower caregivers’ educational level is less likely to have erosive tooth wear
12 The bias evaluation is based on assessment of study’s sample size, clearly presented risk factors of dental erosion and statistical analysis. Risk of bias is found as low (Table 3).
Table 3. Bias evaluation of studies included to this systematic review.
Authors, year Sufficient sample size, its calculation
Proper explanation of statistical analysis
Clearly presented dental erosion risk factors Statistically significant results (p<0.05) Buczkowska-Radlinska et al. (2012)[32] + + + -Farahmand et al. (2013) [30] + - + -Massignan et al. (2019) [27] + + + -Struzycka et al. (2017) [35] + + + +
Muller -Bolla et al. (2015) [34] + + + + Li et al. (2018) [38] + + + + Chrysanthakopoulos (2012) [36] + + + -Hamasha (2013) [31] + + + -Simangwa et al. (2019) [28] + + + + El Aidi et al. (2011) [37] + + + + Wang et al. (2010) [33] + + +
-13 PRISMA flow chart diagram
Figure 1: Illustrates by a flow chart the process of filtering (PRISMA flow diagram Ide
nti fic ati
on Records identified through database searching (n = 234) Records after duplicates removed (n =80) Records screened (n = 154 ) Records excluded (n = 90) Full-text articles assessed for eligibility (n = 64)
Full-text articles excluded, with reasons (n = 53)
Studies included in qualitative synthesis (n = 11)
14 2. SYSTEMIZATION AND ANALYSIS OF DATA:
The main findings of this systematic review are presented in Table 4. Overall, 11 articles were analyzed, including 10 cross-sectional studies and 1 longitudinal study. Subsequently, this systematic review covers studies conducted in countries such as Poland, France, Jordan, China, Greece, Iran, Netherlands, Tanzania and Brazil.
The size of samples varied from 112 to 3812 subjects from age of 3 years old to18 year-old. Two studies enrolled patients with both dentitions primary and permanent [27] [30], while other articles presented results related to dental erosion development in permanent dentitions [28] [29] [31] [32] [33] [34] [35] [36] [37].
In addition, two studies compared results between control and study groups (such as different types of swimmers and patients with GERD) [30] [32].
Prevalence of DE was assessed in 10 studies and varied from 3.9% [34] to 98.1% [30].
In this systematic review three studies employed BEWE index [29] [34] [35], two studies used Lussi index [32] [37] and O´Sullivan index [27] [33] and one study assessed severity of dental erosion with Aine index [30], NDNS [36] and TWI [31], while one study [28] did not specify the in used index. Moreover, scores of DE severity indices were presented in 6 studies [28] [30] [32] [33] [34] [35]. Finding of studies showed that the most common extend of dental erosion covered enamel structure, while dentine was not exposed.
Considering the risk factors of dental erosions, majority of studies focused on only dietary habits (behavioral factor) [27] [28] [31] [33] [34] [36] [37]. Meanwhile, three studies investigated behavioral and biological factors impact on DE development [27] [32] [35] ; one study analyzed behavioral and background related risk factors’ [29] and one study assessed only biological risk factor [30] relationship to dental erosion development.
Numerous studies confirmed that regular or frequent consumption of carbonated soft drinks, sport beverages or dietary acids are strongly associated with dental erosions [28] [29] [34] [35] (for example: OR: 3.42; 95% CI: 1.18-9.23 [27]; OR: 4.0; 95% CI: 2.1-7.6 [5]; OR: 3.99, 95% CI=1.37-11.59 (p=0.011) [36]. Moreover, habit of drinking when drinks are held in the mouth before
swallowing is related to dental erosion development (OR: 2.85, 95% CI+1.45-5.58 (p=0.002)) [31] [33] [36]. Finally, time (like bedtime) of acidic beverages consumption can be associated with dental erosion progression (OR=0.24, 95% CI=0.11-0.53] (p<0.001)) [36]. Controversially, some
15 dietary products like milk and yoghurt product were found negatively associated with dental erosion development [37].
Oral hygiene can also be another factor that contributes to the presence of DE. For instance, regular tooth brushing can increase the risk for dental erosion development (OR = 1.7, CI 1.1–2.6) [28], while results of another research claimed that poor oral hygiene or visible dental plaque is a risk factor (OR: 2.0; 95 % CI: 1.2–3.4) as well [34].
This systematic review revealed that biological factors such as GERD, frequent vomiting and intake of certain medication are significantly related to dental erosion development [30] [31]. In addition, some lifestyle related risk factors such as competitive swimming can increase the risk for dental erosion development [32].
On the other hand, background related factors such as a low economic status [34], gender (girls and males drinking habits) can be associated with dental erosion development [33] [35]. Meanwhile, findings of one study showed that a low parental education level is adversely related to dental erosion development (OR 0.39; 95% CI: 0.17–0.88) [27].
16 Table 4. Characteristics of studies included in the systematic review.
Authors Study type
Participants Risk factors Indices/clinical examination Outcomes
Number Age (year) Prevalence of DE Severity Location/Pattern 1 Buczkow ska-Radlinsk a et al. 2012 [32] CS 131 (62-SG; 69- CG) 14-16 Chlorinated water Dietary habits Acidic medicines 26 %-competitive swimmers (SG); 10 %-recreational swimmers (CG); (p=0.02) Lussi Index- Gr 1 Labial surfaces of central incisors affected:10%- SG;0%- CG;
It was found more affected labial sufaces (SG) than palatal surfaces ( CG) (p=0.008); CG consumed more frequently dietary acids than SG (p=0.001); More frequent consumption of dietary acids among 15-16year old than among 14-15year old (SG) (p<0.001); 2 Farahma nd et al. 2013 [30] CS 112 (54-SG; 58-CG) 3-12 GERD 98.1%-SG;19.0%-CG (p<0.0001)
Aine tooth wear erosion index: Gr 1- SG-63.0%; CG-13.8%; Gr 2-SG-25.9%; CG- 5.2%; Gr 3- SG- 9.2%; CG- 0.0% ; (p=0.88) Localized erosion: SG-33.3%; CG-8.6%; Generalized erosion: SG- 63.0%; CG- 10.3%; Both types: SG- 1.9%; CG- 0.0%; (p=0.59) Occlusal surfaces of primary molars were affected more frequently in GERD patients (p<0.0001).
There is a positive correlation between GERD and dental erosion. 3 Massigna n et al. 2019 [27] CS 1085 8-10 Dietary habits, vomitting
15.67% O’Sullivan index - High consumption of sports drinks is positively associated with erosive tooth wear. (OR 3.42; 95% CI: 1.18–9.23). Lower parental educational level was less likely to have erosive tooth wear (OR 0.39; 95% CI: 0.17–0.88). 4 Struzyck a et al. 2017 [35] CS 1869 18 Acidic diet, hygienic habits, medical conditions 42.3% 45.7% -males. 39.0% -females. BEWE index Gr 1- 28.9% Gr 2- 12% Gr 3- 1.4% Anterior region- 35.3% Lateral region- 19.8% (p<0.0001)
Acidic dishes and beverages in the examined population constituted a strong risk factor for progression .
17 5 Muller -Bolla et al. 2015 [34] CS 331 14 Dietary habits 3.9%-56.8% 39 % (BEWE score≥3) BEWE index Gr 0- 13% Gr 1- 26% Gr 2- 27.3% Gr 3- 7.2% Gr 4- 8.9% Gr 5- 21% BEWE≥ 1 3.9%- maxillary incisors; 55%- Incisors and first molars; 56.8%- All teeth (all surfaces)
The risk factors for DE (BEWE score ≥ 3) were daily
consumption of acidic beverages (OR: 4.0; 95 % CI: 2.1–7.6) and acidic sweets (OR: 3.2; 95 % CI: 1.2– 8.0), low socio economic category (OR: 2.4; 95 % CI: 1.1–5.0) and visible dental biofilm (OR: 2.0; 95 % CI: 1.2– 3.4). 6 Li et al. 2018 [38] CS 720 12-15 Dietary factors, demographics, socioeconomic status
56.1% BEWE index Canines had the highest mean BEWE scores followed by incisors and first molars
The risk of ETW was significantly associated with age, gender, having gastro‐ oesopha‐geal reflux, having gastritis/gastric ulcer, daily
consumption of acidic foods/soft drinks/fruit juices and taking acidic foods/drinks before sleep. 7 Chrysant hakopoul os 2012 [36] CS 770 13-16 Dietary habits 33.8% 33.1 %- boys 34.3%- girls
NDNS The habit of holding drinks in the mouth before swallowing [OR=2.85, 95% CI=1.45-5.58] (p=0.002), the ingestion of acidic drinks at bedtime [OR=0.24, 95% CI=0.11-0.53] (p<0.001), the consumption of carbonated drinks [OR=3.99, 95% CI=1.37-11.59] (p=0.011) and fruit juices [OR=0.12, 95% CI=0.04-0.38] (p<0.001) were the most important associated factors of dental erosion.
18
8 Hamasha 2013 [31]
CS 3812 12-14 Dietary habits 32.2% TWI Regular bouts of heart burn, indigestion, and acid taste in the mouths; medical conditions (asthma); chewable vitamin C, iron tonics, and antacid drugs, prolonged retention of drinks in the mouth; frequent vomiting are significantly associated (P < 0.001). 9 Simangw aet al. 2019 [28] CS 906 12-17 Dietary habits Gr 0–2- 98.1%; Gr 3–4 (extending into dentine) 1.9%; Regular intake of carbonated soft drinks (OR = 1.6, CI 1.1–2.5) and regular tooth cleaning (OR = 1.7, CI 1.1–2.6) are associated with DE.
1 0 El Aidi et al. 2011 [37] Longi tudina l study 565 10-12 Dietary habits 26.7% 42% (after 3 year follow-up)
Lussi-index Lesions in molars were mainly located on occlusal surface; DE were situated on palatal surface in upper anterior teeth. DE in lower first molars was positively associated with alcoholic mixed drink (OR = 1.45) and tooth grinding (OR=4.00) and was negatively associated with milk (OR=0.96) and yoghurt products (OR = 0.84). 1 1 Wang et al. 2010 [33] CS 1499 12-13 Dietary habits 27.3% 25.5% (12y) 29.0% (13y) O´Sullivanindex Gr 1: 44% Gr2: 54.6% Gr 3: 1.4% The most frequently affected teeth were the central incisors
Girls had a higher frequency of consumption of fruits and succade than boys (P < 0.001 and P = 0.014), while boys drank more sport drinks than girls (P < 0.001).
Girls liked to suck or hold drinks in their mouths (P = 0.045); boys consumed a greater amount of acidic drinks than girls (P < 0.001).
19 3. DISCUSSION:
This systematic review revealed that the most common risk factors of dental erosion development among children and adolescents were related to dietary habits such as frequent consumption of carbonated drinks, sports drinks, sour sweets and fruit juices [27, 29, 34- 36] and drinking habits like holding the drink in the mouth for a prolonged time or drinking before bedtime[29]. However, biological factors associated to health issues, for example, GERD and asthma should not be
underestimated [30, 31]. Last, but not least risk factors covering the following background related indicators are gender (girl) and lower socioeconomic status of the patient may increase the risk for dental erosion development, while lower caregivers´ educational level can decrease it [27, 33, 34]. A variety of indices used to assess severity level of dental erosion indicates that there is no one the most suitable index. Although number of grades varied from 0 to 5 and the extent of dental tissues loss could be defined as no loss, loss of enamel, loss of dentin without or with pulp exposure in the selected indexes. In this systematic review, the most prevalent extent of dental erosion severity was affected enamel structure, while dentine was not exposed.
This systematic review showed that children and adolescents consume beverages containing acids daily such as sports drinks and carbonated drinks [27, 29, 34- 36] and it was related to dental erosion development. In contrary, the other meta-analysis did not find association among the consumption of acid juice, sports drinks, and milk and yoghurt products with tooth erosion [38]. It might be explained that milk and yogurt are an important source of calcium, phosphate and casein and they protect enamel against low pH [39]. In addition, a frequent consumption of milk could be considered as a substitute way in diet behavior to prevent dental erosion. [38].
It is essential to know the target group with the highest scores of DE experience and the causes which contribute to the probability of developing DE in order to implement adequate educative and preventive programs. Adolescence has been recognized as an important period of life in terms of food-related behaviors. During this period, adolescents spend more time with their friends and also make many food choices independently [40]. Adolescents tend to have an unhealthy beverage intake pattern [41]. This shows that education and preventive programs are important and should be given from young age in schools. If education programs focus on showing the schoolchildren the importance of tooth brushing and consequences of improper dental care, it will help the child establish an early background on how to prevent further dental problems [42].
Conventional methods of dental erosion prevention include dietary analysis; restrict contact with erosive foods and drinks, parental and child´s education and optimization of the protective
20 mechanisms of saliva. However, the success of preventive methods very highly relies on the
acceptance and cooperation of the patient [43].
Studies revealed that several materials can be used to reduce dental erosion development. For instance, Tooth Mousse has a tendency on reducing dental erosion caused by citric acid [44] and an acidic sports drink [43, 45]. The effectiveness of Tooth Mousse may be due to the lubricating potential of its component ingredients such as glycerol, as well as its remineralizing potential. [44]. Other agents which have potential for prevention of dental erosion contain high levels of
bioavailable fluoride together with potassium nitrate [44]. The preventive effects of fluoride and its associated compounds have been attributed to the formation of precipitates on the tooth surface, which act as a protective barrier against acid impact [46, 47].
Fluoride applications are recommended to prevent further development of DE. Main preventive strategies include dietary habits controlling, stimulation of salivary flow, optimization of fluoride regimens, modification of erosive beverages and adequate oral hygiene measures [46].
Preventive measures are crucial to avoid a pathological status, when the teeth are so worn that their functionality is impaired. Moreover, dental erosion may also be perceived by patients and dentists when the appearance of the teeth is affected [48].
4. CONCLUSIONS
1. This systematic review revealed that various risk indicators of DE play an important role in DE development during childhood and adolescence period. The main risk indicators such as behavioral, biological or background related indicators were shown to have a high impact on the development of DE.
2. Prevalence of dental erosion varied from 3.9% to 98.1%. Considering the severity of dental erosions, grade 1 and 2 were the most prevalent of various indexes and while dental erosion were affected enamel structure, while dentine was not exposed in majority of subjects.
3. Improper dietary habits as daily consumption of carbonated drinks, sports drinks and sour sweets were the most commonly investigated and were significantly associated with dental erosion
development in children and adolescents. Moreover, biological and background related factors like GERD or asthma, lifestyle related factors (swimming in the pools) or background related factors such as gender, socioeconomic factors and parental education tend to increase the risk for dental erosion development.
21 PRATICAL RECOMMENDATIONS.
There are some management guidelines that can be followed to prevent the development of DE or treat DE in children as early as possible. It is crucial to make a diagnosis on the oral and general child´s health status, in case of diseases that can cause DE such as GERD.
Dietary control is a very important step since the food/drinks that contain acids are the main source and causative factor of DE. The child and parents, should be advised to decrease their intake of any carbonated drinks, sports drinks, sour sweets, fruits or fruit juices and to take care of their oral hygiene and understand the importance of timing and frequency of brushing.
Food which is rich in calcium such as milk or yogurt can be beneficial against DE development. Last but not least, toothbrushing should not be performed after eating/drinking.
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26 Aim: To evaluate relationship between diet, lifestyle, health issues and dental erosion development in
children
Objectives: 1.To search and analyze which risk factors are related to dental erosion development in children
and adolescents.
2. To assess the prevalence and most prevalent severity of dental erosion in this systematic review.
3. To evaluate associations between risk factors and dental erosions in this systematic review.
Methods: Eligibility criteria PICOS P-Participants : children I-Interventions: - Clinical examination
- Severity (BEWE index, Lussi index, TWI, O´Sullivan index and Aine Tooth Wear index)
C- Comparators-Indicators (to revise)
1)Biological: GERD, saliva, life style related factors (e.g. swimming)
2)Behavioral: dietary habits, eating pattern, carbonated drinks, sugar consumption, oral hygiene, consumption of fruit juice, fruit, daily eating of sour sweets
3) Backgroundrelated: gender, socioeconomic factors, parental education.
O- Outcomes:
Prevalence of dental erosion, DE index.
S-Study design: Cross-sectional studies, clinical studies -Inclusion criteria:
1)Study subjects- children.
2) Articles about dental erosions and its´ related risk factors 3)Available full-text articles
4) Articles in English language
-Exclusion criteria:
1) studies in vitro; studies performed on animals 2) Adult participants
3)Non-full texts 4) Non-English articles
5)Published articles before 2009
Publication type Information sources
Electronic databases: PubMed, NCBI, research gate.
Keywords: dental erosions, tooth wear, diet, GERD, soft drinks, acidic food, carbonated drinks, adolescents
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