Abu Dhabi Education Council - Research Office

BOSTON UNIVERSITY

INSTITUTE FOR DENTAL RESEARCH AND EDUCATION

THESIS

PREVALENCE OF ATTRITION IN MIXED DENTITION IN

SCHOOL CHILDREN OF ABU-DHABI, UAE

DR. AFRA ALI ABDULLA FADHEL AL MEMARI

Submitted in partial fulfillment of the requirements for the degree of

MASTER OF SICENCE IN PEDIATRIC DENTISTRY

2012

ii

ACKNOWLEDGMENT

First, I would like to express my appreciation and thankfulness for Allah, the Most

Gracious, and the Most Merciful, for all the strength and blessings to successfully complete

my thesis and crossing my faith with the dedicated people who supported me.

Many thanks to my parents for their continuous support which is extended from my

childhood till my Master Degree. My deepest appreciation goes to my bother Eng. Saoud

Al-Maamari and my sister Amna Al-Maamari for their considerable support, and wide

knowledge who did not hesitate to participate directly to my thesis, and my other siblings for

their positive attitudes.

My deep gratitude and admiration is expressed to my direct mentor Dr. Abeer

Basunbul (program director), and my indirect mentors Dr. Harold Goodis, and Dr. Sami

Chogle and Dr. Maria Orellana, for exposing me to their knowledge and experience and to

Dr. Manal Al Halabi.

My deepest gratefulness to Abu Dhabi Education Council for granting me the

opportunity to complete my thesis.

I would also extend my appreciation to those people who helped and supported me

during the completion of my research.

Lastly, my genuine appreciation is dedicated to Dr. shaimaa Al Kayoumi, this thesis

could have not been completed without her care, assistance, and encouragement.

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DEDICATION

To my blessed parents, who have taught me how to appreciate, possess and apply

knowledge I have learnt.

To my source of inspiration, Dr. Abeer Basumbul.

To my supportive coachs Dr. Harold Goodis and Dr. Sami Chogle, and Mariya Orellana for

the superior knowledge gained.

To my brother Eng. Saoud Al-Maamari and my sister Amna for their support.

To my closest friend Dr. Shaimaa Al Kayoumi for her assistance and care.

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ABSTRACT

Objective: To measure the prevalence and severity of dental attrition and evaluate the

difference between private and government schools, boys and girls, in mixed dentition

school children of UAE.

Methods: An epidemiological cross-sectional survey was conducted by trained, calibrated

examiners using the smith and knight scale. The cluster sample consisted of 371 children

(168 boys, 203 girls) attending 4 schools (2 private, 2 governments) selected in different

regions of Abu Dhabi. Data was collected by clinical examinations performed outdoors

under natural light, and using a dental mirror and probe. The data analysis consisted of

Multi-linear regression analysis, ANOVA, Kppa and Kindall’s Tau-b.

Results: school children attrition prevalence was 50.7%, attrition severity was 26.24% and

DFT scores were 30.09%.

Conclusion: Attrition prevalence and severity is significantly higher in the government than

in private schools, while there was no difference in the attrition prevalence between girls and

boys. A statistically significant relation found between attrition prevalence and severity in

type of school, right canine classification, and number of siblings.

v

Table of Contents

ACKNOWLEDGMENT.......................................................................................................... ii

DEDICATION ........................................................................................................................ iii

ABSTRACT ............................................................................................................................ iv

List of tables .......................................................................................................................... viii

List of figures .......................................................................................................................... ix

I. INTRODUCTION ............................................................................................................ 1

II. REVIEW OF LITERATURE ........................................................................................... 3

Etiology .................................................................................................................................... 3

Bruxism .................................................................................................................................... 4

Tempromandibular Joint Disorder ........................................................................................... 6

Occlusion ................................................................................................................................. 8

Diet ........................................................................................................................................... 8

Salivary flow rate ................................................................................................................... 10

Medical conditions ................................................................................................................. 11

Tooth brush and tooth paste Oral Hygiene products ............................................................. 12

Management ........................................................................................................................... 13

III AIMs ........................................................................................................................... 15

IV MATERIALS AND METHODS ................................................................................ 16

IRB Approval and Sample Collection ................................................................................... 16

Inclusion and Exclusion Criteria ............................................................................................ 18

vi

Inter-examiner Calibration and Preparation for School Visit ................................................ 20

DFT scores ............................................................................................................................. 21

V. DATA ANALYSIS ........................................................................................................ 22

VI. RESULTS ................................................................................................................... 25

Responses to the Questionnaire ............................................................................................. 25

Parents related information .................................................................................................... 25

Education ............................................................................................................................... 25

Employment ........................................................................................................................... 27

Childs related information ..................................................................................................... 28

Variables on children habits: ................................................................................................. 29

Dietary habits ......................................................................................................................... 31

Oral Hygiene Practices .......................................................................................................... 32

Prevalence of attrition in private versus government schools ............................................... 34

Significant variables............................................................................................................... 37

Attrition prevalence ............................................................................................................... 37

Attrition severity .................................................................................................................... 38

Primary canine attrition severity and classifications ............................................................. 42

DFT% ..................................................................................................................................... 43

Other variables ....................................................................................................................... 45

Attrition variables .................................................................................................................. 45

DFT% variables ..................................................................................................................... 46

vii

VII. DISCUSSION ............................................................................................................. 48

VIII. CONCLUSION ........................................................................................................... 55

LIMITATIONS AND FUTURE RRECOMMENDATIONS ............................................... 57

REFERENCES ...................................................................................................................... 58

APPENDEX ........................................................................................................................... 70

A- School consent form ................................................................................................ 70

B- Participant consent form.......................................................................................... 71

C- Questionnair form ................................................................................................... 74

D- Examination form ....................................................................................................... 77

viii

List of tables

Table 1: Drug groups which are related to salivary hyposecretion ....................................... 11

Table 2: Groups of patients at risk of developing excessive tooth wear. .............................. 12

Table 3: Tooth Criteria classification with accordance to smith and knight scale ................ 17

Table 4: Inclusion and Exclusion Criteria for participants .................................................... 18

Table 5: Questionnaire general layout ................................................................................... 19

Table 6: Intra-examiner calibration of examiner A ............................................................... 22

Table 7: Intra-examiner calibration of examiner B ................................................................ 23

Table 8: Inter-examiner calibration first examination by A followed by B .......................... 23

Table 9: Inter-examiner calibration first examination by B followed by A .......................... 24

Table 10: Demonstrative data for the relationship between prevalence and type of school,

for models (Regression) and (Residual) ................................................................................ 37

Table 11: Dependent Variable: attrition Prevalence .............................................................. 37

Table 12: Predictors: (Constant), Rcan, Rmol, school, Number ........................................... 41

Table 13: Dependent Variable: attrition severity ................................................................... 42

Table 14: Mean, Median, and Standard deviation values of the attrition prevalence and

severity. .................................................................................................................................. 42

Table 15: DFT% significant variables ................................................................................... 44

Table 16: Mean, median and standard deviation values of DFT% ........................................ 45

Table 17: Attrition excluded variables ................................................................................... 46

Table 18: DFT% excluded variables...................................................................................... 47

ix

List of figures

Figure 1: Demonstration of tooth criteria classification as specified in Table 3 ................... 17

Figure 2: Sample size layout .................................................................................................. 20

Figure 3: Father’s educational level ....................................................................................... 26

Figure 4: Mother’s educational level ..................................................................................... 26

Figure 5: Father’s professional level...................................................................................... 27

Figure 6: Mothers’ professional level .................................................................................... 28

Figure 7: children related variables........................................................................................ 29

Figure 8: Overall comparison between private and Governmental schools .......................... 29

Figure 9: Comparison between Habits adapted by participants in both private and

governmental schools............................................................................................................. 30

Figure 10: Frequency of video games played ........................................................................ 30

Figure 11: Consumption of Carbonated drinks per week ...................................................... 31

Figure 12: Consumption of fruit based drinks per week........................................................ 32

Figure 13: Consumption of fresh fruit cuts per week ............................................................ 32

Figure 14: Teeth brushing frequency on daily basis .............................................................. 33

Figure 15: Tooth brush type ................................................................................................... 33

Figure 16: Tooth paste type ................................................................................................... 34

Figure 17: attrition prevalence according to school category ................................................ 35

Figure 18: attrition prevalence scores according to school category ..................................... 35

Figure 19: attrition severity score according to school category ........................................... 36

Figure 20: attrition prevalence according to gender .............................................................. 36

Figure 21: attrition prevalence according to teeth ................................................................. 38

Figure 22: Attrition scores frequency .................................................................................... 39

x

Figure 23: Upper dental arch ................................................................................................. 39

Figure 24: Lower dental arch ................................................................................................. 40

Figure 25: Attrition prevalence according to segments ......................................................... 40

Figure 26: Attrition severity according to segments .............................................................. 41

Figure 27: DFT% according to school category .................................................................... 43

Figure 28: DFT% according to brushing frequency .............................................................. 44

Figure 29: DFT% according to mother’s educational level ................................................... 44

1

I. INTRODUCTION

Attrition is defined as loss of the tooth structure or restoration and it can be induced by the

masicatory forces or the contact of the teeth against each other and the interproximal

surfaces. It mostly affects occlusal and incisal surfaces, also slightly at the contact points [1].

The affected teeth are characterized as flat, round or sharply angled with polished surfaces

on the occlusal or incisal areas of the teeth and may be the result of excessive attrition of one

tooth against the other [2]. Erosion is a very important contributing factor to the loss of tooth

substance by attrition.

Dental attrition is an increasing dilemma that has been noticed by dentists, in which

grinding is the possible cause. The grinding process is an oral sign of bruxism and bruxism

is a Greek word meanings “vrigmos o’dodon” that includes grinding and clenching [3] The

American Academy of Orofacial Pain defines bruxism as “ a diurnal or nocturnal

parafunctional activity including clenching, bracing, gnashing and grinding of the teeth”

while the American Sleep Disorders Association defines it as “ tooth grinding or clenching

during sleep plus one of the following: tooth wear, sounds or jaw muscle discomfort in the

absence of a medical disorder”.

Local/mechanical factors, systemic/ neurological factors and psychological factors

like sleep confusion associated with dreams at night, day time emotional expression,

concern induced responses or the anticipation of worrying situations (anxiety and stress)

appear to be the contributors of bruxism and affects 15% to 100% of the population.4 7% to

15.1% is the prevalence range of bruxism in children 5-7 with a few studies confirming

higher rates in girls than boys [8].Consequences of bruxism includes: loss of tooth structure

that can range from mild to severe either localized or generalized [14], thermal

2

hypersensitivity, tooth hypermobility, hypercementosis, fractured cusps, pulpitis, pulp

necrosis [15], muscular pain, degenerative tempromandibular joint disease, muscular

hypertrophy, headache and periodontal tissue injury [4].

Management of bruxism includes: occlusal adjustment of dentition, use of

interocclusal appliances [9], behaviour modification [10], and pharmaceuticals [11].

According to Hachmann and McDonald and others [12], patients suffering from bruxism

may use a bite plate covering the occlusal surfaces of all teeth to prevent the continuous

attrition [13]. Allergic diseases are considered as systemic contributors to the bruxism.

Patients should be referred to a specialist to treat the problem when seen [13].

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II. REVIEW OF LITERATURE

Etiology

Multiple factors causes’ dental attrition, parafunction is one of the most common

factors. Clinical observations and data from previous literature indicates that malocclusion,

iatrogenic factors, and increased psycho emotional stress are the predisposers to functional

disorder of the masticatory system, especially Temporo Mandibular Joint (TMJ)

dysfunctions and bruxism. There are different studies in previous literatures, which have

related the various intrinsic, and extrinsic factors for bruxism and dental attrition including

psychological factors, occupation, diet etc [16]. In younger populations greater awareness is

needed to control attrition as diets increase in acidity, and snacking frequency on both acidic

and sugary foods continues to increase [17]. The higher susceptibility of the deciduous

dentition to tooth wear has rather been attributed to the reduced thickness and softness of the

enamel to its greater solubility in acid [27, 28]. Deciduous teeth are smaller than permanent

teeth, enamel is softer, and there are morphological differences compared to permanent

teeth, therefore, the erosive process reaches the dentine earlier and leads to an advanced

lesion after a shorter exposure to acids, compared with permanent teeth. Common sites for

dental erosion in primary teeth are the occlusal aspects of the molars and the palatal surfaces

of the upper incisors. [37] Several studies have investigated that malocclusion and

orthodontic treatment have been variably associated with this condition. Tooth wear is

influenced by the way the mandibular teeth contact the maxillary teeth [21].

4

Bruxism

Bruxism is defined as the habitual nonfunctional mandibular movement with forceful

contact between occlusal tooth surfaces, which is uncontrolled. Excessive grinding,

clenching or friction of teeth that can lead to several dental, oral, and facial complications

[18, 20]. Bruxism is defined by the American Academy of Orofacial Pain as: “A diurnal or

nocturnal parafunctional activity including clenching, bracing, gnashing and grinding of the

teeth” [4]. The American Academy of Sleep Medicine defines bruxism as a stereotyped oral

motor disorder characterized by sleep related grinding and/or clenching of the teeth, whereas

the American Academy of Orofacial Pain extends the definition to the same movements that

occur during wakefulness. There is a considerable amount of literatures suggesting that sleep

and a wake bruxism are 2 different disorders with a different etiopathogenesis. Sleep

bruxism is characterized by both a grinding type and a clenching type activity and is

associated with complex micro arousal phenomena occurring during sleep, the

pathophysiology of which is yet to be clarified, whereas awake bruxism is characterized by a

clenching type activity and is associated with psychosocial factors and a number of

psychopathological symptoms [23], its etiology is still controversial but the multifactorial

cause has been recognized, including pathophysiologic, psychologic and morphologic

factors. Moreover, masticatory neuromuscular system immaturity can lead to bruxism in

younger children [18]. Bruxism may also be caused by allergic processes such as asthma and

respiratory airway infection and is also linked to diseases such as basal ganglia infarction,

cerebral palsy, Down syndrome, epilepsy, Leigh disease, meningococcal septicemia,

multiple system atrophy, gastro esophageal reflux, and Rett syndrome. In addition to

5

hyperactivity, which is associated with bruxism due to the effect of the am, pheta mines

which are used for the management of attention deficit hyperactivity disorder [33]. Oral

habits such as thumb sucking, onicofagy, object biting etc can be usual and happen

temporarily. However, when they surpass a physical tolerance, the system may collapse and

harm the person’s health. According to Cheifetz et al, the fact that children without any oral

habits present a higher prevalence of bruxism suggests that this parafunction can also be an

alternative method to relieve stress [39].

Wear of the teeth is the most commonly mentioned sign of bruxism although there is

considerable argument about the correlation between bruxism and tooth wear. Investigators

have different suggestions on bruxism and its association with attrition. Schneider and

Peterson reported 15% of children demonstrate tooth wear due to bruxism. Marbach et al

reported that only 34.4% of the self reported bruxers in their study showed evidence of tooth

wear. The authors noted that evidence of tooth wear did not essentially indicate bruxing.

According the American Sleep Disorders Association the diagnosis of sleep bruxism is

based on the report of tooth grinding or clenching in combination with at least one of the

following signs: abnormal tooth wear, sounds associated with bruxism, and jaw muscle

discomfort they also consider the presence of tooth injury as one of the criteria for severe

bruxism, the association between severity of bruxism and tooth damage is not yet

established. Sleep bruxism has prevalence in the general adult population from 10- 20%.

Reported prevalence in children ranges from 7-15.1%, with girls apparently more frequently

affected. It is also reported in up to 20% of children younger than 11 years of age. This is

probably an underestimate and may indicate only clinically significant bruxism. The

prevalence decreases with age. Obstructive sleep apneas resulting in frequent arousals in

6

children have been correlated with problems in behavior regulation, attention, and executive

functioning [19, 20, 22, 24].

The specificity and clinical validity of tooth wear as an indicator of bruxism has been

questioned. The observation of tooth wear is subjective, and no correlation has been

demonstrated between degree of tooth wear and level of electromyography (EMG) bruxism

activity. In addition, several studies imply that tooth wear is a natural observable fact

associated with aging. In summary, the multifactorial cause of tooth wear, the difficulties of

measuring tooth wear, and the natural complex activity pattern of bruxism all complicate the

correlation of tooth wear and bruxism [19].

Tempromandibular Joint Disorder

Temporomandibular joint (TMJ) pain is an uncommon complaint in children.

Etiologic factors suggested as contributing to the development of tempromandibular disease

(TMD) include congenital abnormalities, temporomandibular disorders, infections,

connective tissue disease (CTD), trauma, occlusal factors, parafunctional habits such as

bruxism, nail biting, and non nutritional sucking, head posture and others. Three main

TMDs appear to be more common in chidren: opening limitation, mandibular deviation and

movement difficulty. The incidence of TMD symptoms is increasing from the primary

dentition to the mixed dentition and is often due to great changes in occlusion and TMJ. The

prevalence of TMD is 16% in children with primary dentition and 90% in children with

mixed dentition. One study of the primary dentition reported 34% of patients with signs

and/or symptoms of TMD. An epidemiological study of 4724 children aged 5-17 years

reported 25% with symptoms. Clicking was seen in 2.7% of children in the primary

dentition and 10.1% in late mixed dentition and further increased to 16.6% in patients with

7

permanent dentition. A similar study in pre-school children found clicking affects girls more

than boys. For Bonjardim et al. the majority of the symptoms in adolescents were mild, and

girls were more affected, probably due to the result of biologic variables (e.g., hormonal

characteristics), as maturation in girls typically occurs earlier than in boys. In general, the

prevalence of signs and symptoms of TMD is lower in children compared to adults and is

even less in younger child but increases with increasing age. There is variation in the

literature about relationship between TMD and Bruxism in children and adolescence.

Bruxism was not considered related to signs and symptoms of TMD in young children in

some surveys on the other hand a number of studies showed that there is significant

relationship between attrition, symptoms of TMD and deviation on opening and there was

also a significant association between bruxism and most of the TMD signs and symptoms in

children. Controversy also found in the association between tooth wear and TMD in young

children. A variety of psychological and behavioral characteristics are exhibited by TMD

patients such as increased somatization, stress, anxiety and depression. It has been

mentioned that TMD and bruxism are more likely to grow in populations with high anxiety

level, which is one of the main factors in bruxism development. The cause and relationship

between TMD and bruxism has not been established yet. According to the literature, tooth

wear is more likely to be associated with bruxism, clenching and grinding than with TMD

[23].

Malocclusions like skeletal anterior open bite, overjet greater than 6 to 7 mm, long

face, centric relation to centric occlusion slides greater than 4 mm, unilateral lingual cross

bite, 5 or more missing posterior teeth, Class II and III malocclusions are known to be

associated with TMD, however subjects with normal occlusion have lower odds for

symptoms and signs of TMD [10, 18, 19, 24-26].

8

Occlusion

Erosion, abrasion, and attrition are frequently combined; differentiation between

them is not always possible. However, the most visible sign of functional wear probably is

related to attrition if occlusal factors involved in causing dental wear. Malocclusion and

masticatory forces are indicated by some studies as primary etiologic factors for non carious

lesion development, although other authors did not find this correlation. Due to the

controversies in the literature and the high prevalence of malocclusions in children, therefore

it is necessary to help professionals to differentiate between physiologic and pathologic

processes to verify the pattern of tooth wear of various occlusal relationships. Different

tooth wear patterns found in subjects with normal occlusion and those with malocclusions.

Angle’s Class II malocclusion has been associated with increased wear in posterior teeth, In

contrast, class II division II malocclusion is associated with increased wear in the anterior

teeth, on the other hand the absence of teeth contacts may prevent tooth wear, and the

presence of an open bite or crossbite may decrease the risk of wear. Among children, class II

malocclusion and absence of open bite was associated with increased tooth wear as well as

younger age and male gender [21]. Tooth wear on the malocclusion subjects is a

consequence of a different interocclusal arrangement and should not be considered

pathologic [2, 29].

Diet

Tooth wear can be induced by erosion, attrition and abrasion. Interaction between

erosive and mechanical wear is considered to be important. In Australia, the prevalence of

erosion in the deciduous dentition was recently found to be as high as 68%. Several studies

9

indicate a relation between dental erosion and a high consumption of cola-type and other

acid containing soft drinks. In vitro, exposure of human enamel to citric acid solutions

results in a considerable reduction in enamel hardness [27]. The critical pH of enamel is 5.5

and therefore any drink or food with a lower pH may cause erosion. This dietary pattern had

been shown to contribute in tooth wear, especially dental erosion [31]. The erosive potential

of erosive agents depends on the chemical factors, e.g. pH, titratable acidity, mineral

content, clearance on tooth surface and on its calcium chelating properties. Biological

factors such as saliva, acquired pellicle, tooth structure, tooth position and its relation to the

soft tissue and tongue are related to the pathogenesis of erosive wear. Behavioral factors,

which include excessive consumption of acidic foods and beverages like citric acid,

phosphoric acid, ascorbic acid, malic acid, tartaric acid and carbonic acids found in fruits

and fruit juices, soft drinks both carbonated and still, some herbal teas, dry wines and

vinegar-containing foods [34] readymade packaged or canned foods and bottled drinks,

drinking habits like swishing or holding drinks in the mouth, food stuffs, medications and

extreme oral hygiene, can play a role in the etiology of erosive wear. A relation was found

by the researchers between patients diagnosed with dental erosion and the cumulative

consumption of citrus fruits more than twice daily, consumption of soft drinks daily, and

consumption of apple vinegar or sports drinks once a week or more. Another study by

Stafne and Lovestedt reported that consumption of lemon juice daily for therapeutic reasons

showed a marked degree of erosion after only three months of use, when compared to

subjects with less consumption of lemon juice who experienced less erosion after more than

a year of use. Eccles and Jenkins described 26 cases of erosion, which they associated with

the consumption of excessive quantities of fruit, fruit juices and other acidic beverages. An

increased risk has also been implicated in consumption of acidic beverage at bedtime

10

because of the nocturnal absence of salivary flow. Dental wear is also influenced by the

abrasiveness of the individual food, such as that seen in case reports involving patients who

are lacto vegetarians and constantly eat healthful but rough foods. Persons developed

obvious occlusal wear, with cupping of the exposed dentine which was similar to the

mediaeval population due to the raw-food diet, which was both fibrous and with a high acid

content. This suggested that an erosive diet makes the occlusal surfaces vulnerable to wear

even by weakly abrasive materials by softening them, such as raw vegetables, which would

not have an effect on sound dentine [36, 37].

Salivary flow rate

Saliva plays a major protective role against tooth wear. It functions as a lubricant, is

able to dilute and to buffer acidic drinks. Salivary proteins are also involved in building a

protective pellicle layer on the enamel surface; therefore, a reduction in salivary flow rate

may potentiate tooth wear by erosion and attrition. A clear relationship was found between

reduced salivary flow rate and the ability to clear dietary acids from the mouth [36]. In

addition, the bicarbonate level in saliva is positively correlated with salivary flow rate;

therefore, saliva produced at a low flow rate has a lower pH and a lower buffering capacity.

In addition, the salivary calcium concentration is lower in children than adults, which means

that children have a higher risk of demineralization [27]. Gambonand et al. and others

concluded that computer gaming may reduce the salivary flow rate as well. Autoimmune

diseases like Sjögren’s syndrome cause progressive destruction of the salivary glands, while

others lead to reversible effect on the saliva rate, as in hypertension, depression,

malnutrition, dehydration, diabetes, etc. Wide range of drugs as used worldwide, induce

11

salivary gland hypofunction. Table 1 shows the drug groups that have been most directly

linked to salivary hyposecretion [35]

Table 1: Drug groups which are related to salivary hyposecretion

Medicine group Examples

Anorectic Fenfluramine

Anxiolytics Lorazepam, diazepam

Anticonvulsants Gabapentin

Antidepressants - Tricyclic Amitriptyline, imipramine

Antidepressants - SSRI Sertraline, fluoxetine

Antiemetics Meclizine

Antihistaminics Loratadine

Antiparkinsonian Biperidene, selegiline

Antipsychotics Clozapine, chlorpromazine

Bronchodilators Ipratropium, albuterol

Decongestants Pseudoephedrine

Diuretics Spironolactone, furosemide

Muscle relaxants Baclofen

Narcotic analgesics Meperidine, morphine

Sedatives Flurazepam

Antihyperptensive Prazosin hydrocloride

Antiarthritic Piroxicam

Medical conditions

Cerebral palsy, Down syndrome, asthma, diabetes, cardiovascular diseases, GORD

are known to be directly and indirectly associated with dental attrition. Table 2 illustrates

patient at risk of developing attrition according to the analyses of the patients’ lifestyles in

southeast Queensland [32].

12

Table 2: Groups of patients at risk of developing excessive tooth wear.

Group 1 Healthy, active people whose sports or workplace dehydration reduces salivary protection of

the teeth against acids in sports or other soft drinks. Addiction to caffeine in cola beverages.

Group 2 Patients with anxiety states, depression, anorexia or bulimia nervosa on tranquillising or

antidepressant medications associated with xerostomia and reversible sialadenosis. The

medication results in loss of salivary protection against both acid soft drinks and intrinsic

acid vomiting.

Group 3 Patients with oesophagitis from GOR sometimes associated with alcoholism. Alcohol is a

dehydrating drug that has long-term effects on salivary glands. Erosion is produced both by

extrinsic acids in wines and spirits with mixes and by intrinsic acid from GOR.

Group 4 Asthma sufferers at risk either from the acidity of medications or from reduction in salivary

flow induced by medications. Asthmatics’ lifestyles and diet may include the risk factors of

Groups 1 and 2.

Group 5 Diabetics and patients with other cardiovascular diseases suffer reduced salivary protection

of the teeth as a result of their condition or from antihypertensive or diuretic medication.

Group 6 Patients with syndromes which may be genetic, epigenetic or iatrogenic which place them at

risk of dental erosion by affecting salivation.

Australian Dental Journal 2001;46:4. (32)

Tooth brush and tooth paste Oral Hygiene products

Oral hygiene practices alone have long been implicated in tooth wear. Tooth

brushing wear is time-dependent and appears to be influenced by many factors, including

the frequency, duration and force of brushing. Many oral care products such as toothpastes

and fluoride-rinsing solutions exhibit a low pH. This, on one hand, enhances the chemical

stability of some fluoride compounds and, on the other, favors the incorporation of fluoride

ions in the lattice of hydroxyapatite forming fluoridated hydroxyapatite. Many studies have

found that tooth brushing after exposure to citrus fruit juice accelerates teeth structure loss.

13

The clinical suggestion of this is that tooth brushing may do more harm than good by

accelerating tooth structure loss when performed immediately after ingestion of acidic foods

or beverages. Saliva reverses the transient demineralization of a tooth surface in early stages.

However, tooth brushing immediately after an acid challenge result in irreversible loss of

tooth structure by removing the partially demineralized tooth surface before saliva can repair

it. Individuals who are susceptible to dental erosion may not receive the benefit of enhanced

enamel remineralization through fluoride if their toothpaste also contains pyrophosphate.

Lussi and Jaeggi suggested that after topical application of acidic oral hygiene products with

a high fluoride content some mineral is dissolved from the enamel surface, thereby

increasing the local pH and leading to reprecipitation of fluoridated hydroxyapatite.

Moreover, the buffer capacity of saliva and the organic pellicle led to an additional

protective effect. It seems that highly concentrated slightly acidic fluoride applications are

able to increase abrasion resistance and decrease the development of erosions of enamel and

dentin. Wiegand et al. showed that toothbrush and abrasion of eroded dentin might be

influenced by the fluoride content, by the RDA value and particularly by the buffer capacity

of the applied dentifrice or gel [36-38].

Management

Clinicians play an important role in determining possible etiological factors in the

treatment of the parafunctional habits. Where it is the dentist’s responsibility to caution

parents and establish a multidisciplinary treatment [40] The available literature does not

provide sufficient support to treat bruxism in children. The most common treatment for

bruxism is patient/ parent education, rigid occlusal splint to protect the teeth and masticatory

system, which has not been proven effective in the primary dentition, stainless steel crowns,

14

psychological techniques, medications to relieve anxiety and improve sleeping, stress

reduction and change in lifestyle. Treatment is not always recommended because children

generally outgrow the condition. Children should be referred to a specialist when they have

upper airway obstruction or severe psychological problems. While children or adolescents

who are taking medications for conditions that may cause bruxism, other options should be

discussed with the patients’ primary care provider [41, 42].

In vitro softening of human molar enamel can be inhibited by the topical treatment

with NaF 12,000 ppm and concentrated fluoride varnish (22,600 ppm). Fluoride

mouthwashes are used in the treatment of dental erosion due to the fact that both saliva and

fluoride are important in the remineralization process whereby enamel erosion is repaired.

Some resistance to excessive tooth wear from acid erosion in adulthood, can be conferred by

prior exposure to fluoride in the first 12 years of life as it also does for resistance to

demineralization by dental caries. However, treatment with fluoride varnish (2.26%) for 24

h and high concentration F rinses (1.2%) for 48 h applied prior to acidic challenge have been

shown to offer in vitro protection against erosion [37, 38].

15

III AIMs

The aim of this study was to measure the prevalence and severity of dental attrition

and evaluate the difference between tooth attrition in private and government schools, boys

and girls, in mixed dentition period using Smith and Knight scale, and to measure the DFT

scores, molar and canine classifications, posterior cross bites, orthodontic appliance, space

maintainers, previous Trauma, tooth malformation, and Stainless steel crowns.

16

IV MATERIALS AND METHODS

IRB Approval and Sample Collection

As an ethical practice, an IRB approval been granted prior to carrying out the

research. After granting the permission to do so, representative schools were approached.

Further step was taken which is providing explanations to visited schools with the

importance and criticality of such a study. As a reward for volunteered families, tooth brush,

tooth paste, dental advices and free dental consultation were given for each child. A sample

size of four schools addressing approximately more than 400 students was selected. Details

are provided below.

Four schools selected (two private and two governmental), after which Informed

consents were given to children ranging from second grade to sixth grade. Selection of this

age is critical, the reason behind selection of this age frame is to target the mixed dentition

period. 1050 informed consents were distributed in the four schools with questionnaires. In

two weeks, 524 out of the 1050 were received back. The informed consents had details of

the research, the procedure of examination of the children who will be enrolled, together

with a questionnaire form to be filled by the parents. The parents were requested to sign the

informed consent and send it back to school (see appendix A-C).

The epidemiological surveys were conducted by two examiners under regular light in

an indoor setting, using a mirror, dental probe, gauze and torch light. The schoolchildren

were given one-to-one interaction by the examiners were attrition score data collected with

accordance to Smith and Knight Scale, (Table 3 and Fig. 1). In addition to that, other data

17

were taken in consideration such as the molar and primary canine relationship, complete

examination of both jaws, teeth malformation (hypomineralization, hypocalcification,

amelognesis imperfecta, dentinogenesis imperfect), space maintainers or orthodontic

appliances, and recording in case of present previous trauma (fractured teeth). Two dental

assistants assigned to record the findings on the examination form (see appendix D).

Table 3: Tooth Criteria classification with accordance to smith and knight scale

Score Tooth Criteria

0 No wear or negligible wear of enamel

1 Obvious wear of enamel, or wear through the enamel to the dentin in single spots

2 Wear of the dentin up to one-third of the crown height

3 Wear of the dentin more than one-third of the crown height

Figure 1: Demonstration of tooth criteria classification as specified in Table 3

18

Inclusion and Exclusion Criteria

In the following table (Table 4), further explanations were given for the selection of

participants and reasons of exclusion.

Table 4: Inclusion and Exclusion Criteria for participants

INCLUSION CRITERIA EXCLUSION CRITERIA

1. UAE nationals

2. Signed informed consent

3. Good general health as provided

through the medical history.

4. Mixed dentition (male and

females)

5. Availability during the screening.

6. Presence of the involved teeth

(primary canines, first and second

primary molars and permanent first

molars) in full occlusion.

1. Expatriates.

2. Complete permanent or complete primary dentition.

3. Diseases such as basal ganglia infarction, cerebral

palsy, Down syndrome, epilepsy, Leigh disease,

meningococcal septicemia, multiple system atrophy,

gastroesophageal reflux, Rett syndrome. , heart disease,

asthma or diabetes.

4. Badly decayed teeth, fractured teeth, large restorations

or crowns.

5. Congenital malformations like Ameliogenesis

imperfect, dentiongenesis inperfecta, enamel hypoplasia

and hypomineralization.

6. Fixed ortho appliance that prevent proper examination.

General information been asked in the questionnaire provided, questioinnair general

layout is provided below (Table 5):

19

Table 5: Questionnaire general layout

Par

ent’

s re

late

d i

nfo

rmat

ion

parents educational level:

1. Primary

2. Secondary

3. College and post graduate

Parents occupation:

1. Employed

2. Unemployed

Ch

ild

’s r

elat

ed i

nfo

rmat

ion

Total siblings number

order between siblings

Medical History status

Medications taken if any

Is your child overly emotional? Yes/No/Sometimes

Is your child hyperactive? Yes/No/Sometimes

Does your child have a normal sleep cycle? Yes/No/Sometimes

Does your child grind his/ her teeth at night? Yes/No/Sometimes

Does your child grind or clench his teeth in stressful or fearful situations? Yes/No/Sometimes

Does your child complain of pain in the jaw or headache early in the morning? Yes/No/Sometimes

How many times does your child brush his/ her teeth per day? 0 /1 /2 /3/more than 3

What type of tooth brush does your child use? Soft /Medium/Hard

What type of tooth paste does your child use?

Does your child suffer from any gastroesophegeal reflux problems? Yes/No

Did your child get any dental trauma or jaw fracture? Yes/No

Does your child suffer any jaw problem? Yes/No

Ch

ild

’s r

elat

ed i

nfo

rmat

ion

Does your child have any oral

habits such as:

a) Putting things in their

mouths

b) Biting on their finger nails

or other objects

c) Sucking their fingers

d) Sucking a pacifier

e) Other (please specify)?

Does your child consume carbonated drinks? Daily/1/2/3- weekly/1/2/3-monthly/1/2/3-No

Does your child consume fruit based drinks? Daily/1/2/3- weekly/1/2/3-monthly/1/2/3-No

Does your child eat citric fruits? Daily/1/2/3- weekly/1/2/3-monthly/1/2/3-No

All children who matched the criteria submitted the consent, and the questionnaire forms

added up to (371) child of a mixed dentition period between second grade and sixth grade

(Figure 2). While (153) were excluded from the study, from which 27 (7M-20F) were absent

in the day of examination, 27 (12M-15F) were on the permanent dentition, 27 (18M-9F)

were asthmatic, 2 (males) were diabetic (type 1 diabetes), 3 (2M-1F) were suffering seizures

attach, 1 male with congenital heart problem, 1 female with cemented orthodontic appliance,

4 due to missing data on the examination forms, and 61 (22M-39F) were expatriates. The

20

expatriates who participated were examined and appreciation letters were given to each

along with tooth brush and tooth paste as an appreciation to their support.

Figure 2: Sample size layout

Inter-examiner Calibration and Preparation for School Visit

Two examiners were trained regarding the attrition scores using clinical pictures.

Then they were calibrated on 10% of the sample number and the calibration values were

calculated by Kappa statistics. The calibration was done with the same disposable kits that

were planned for the school visit.

The disposable kits contained a mouth mirror, probe and tweezer. Examinations were

planned at school in a non dental set up, and thereby torches were used for lighting. All

personal protective equipment like gloves and masks were carried to school, along with

disposable bags for non medical and medical wastes.

371 subject

private schools

184 subject

94 boy

90 girl

Government schools

187 subjects

74 boy

113 girl

21

The children were examined in their respective schools on the day of examination

and the scores were filled by the recorders in the Patient Examination Forms. The

examinations at both the venues were conducted during the whole day before they leave

school. Each school needed two days for the examinations. Each child after examination was

given an appreciation letter for their parents demonstrating briefly on the child's oral status

and the necessity of dental treatment with free consultation at our dental clinic and all

children were briefly educated about the importance of oral hygiene

DFT scores

All participants had full dental examination, all carious, filled, crowned, fractured

teeth recorded and data were collected on the presence of any orthodontic appliances or

space maintainers.

22

V. DATA ANALYSIS

The data analysis consisted of Multi-linear regression analysis, ANOVA, Kppa and

Kindall’s Tau-b. Tooth coded 5, 7, 8, 9 and the teeth on the unilateral cross bite side were

excluded from the statistical analysis as they were with tooth malformation, not fully

erupted or not in full occlusion, had extensive caries or large restorations, and missed

respectively. The general agreement percentage and Kappa values were measured for intra-

examiner and inter-examiner, in the cases were the Kappa statistics cannot be computed

Kendall's tau-b statistics was measured.

The intra-examiner and inter-examiner agreement percentage ranged from excellent

to absolute agreement as bellow (Tables 6- 9):

Table 6: Intra-examiner calibration of examiner A

Kappa value

Asymp. Std.

Error Approx. T

Approx.

Sig. Agreement

attrition 0.895 0.021 29.475 <0.001 Excellent

Molar classification 0.899 0.069 8.326 <0.001 Excellent

Canine classification 1 0 7.357 <0.001 Absolute

Posterior crossbite 0.721 0.187 4.442 <0.001 Very good

upper arch findings 0.968 0.01 33.34 <0.001 Excellent

Lower arch findings Kendall's/ .985 0.007 73.489 <0.001 Excellent

Previous Trauma 1 0 4.359 <0.001 Absolute

Tooth Malformation 1 0 4.359 <0.001 Absolute

Cross Tabulation

Ortho appliance All agree

space maintainer All agree

23

Table 7: Intra-examiner calibration of examiner B

Kappa value Asymp. Std. Error Approx. T Approx. Sig. Agreement

attrition 0.731 0.033 21.683 <0.001 Very good

Molar classification Kendall's/ .936 0.06 5.026 <0.001 Excellent

Canine classification 0.886 0.078 7.21 <0.001 Excellent

upper arch findings Kendall's/ .972 0.008 70.712 <0.001 Excellent

Lower arch findings Kendall's/ .979 0.008 72.515 <0.001 Excellent

Tooth Malformation 1 0 4 <0.001 Absolute

Table 8: Inter-examiner calibration first examination by A followed by B

Kappa value Asymp. Std. Error Approx. T Approx. Sig. Agreement

attrition 0.753 0.046 16.13 <0.001 good

Molar classification 0.756 0.164 4.879 <0.001 good

Canine classification 0.743 0.13 4.686 <0.001 Very good

Posterior crossbite 0.642 0.326 2.995 0.003 Very good

upper arch findings 0.975 0.011 27.782 <0.001 Excellent

Lower arch findings 0.95 0.015 26.866 <0.001 Excellent

Cross Tabulation

Previous Trauma All agree

Ortho appliance All agree

Tooth

Malformation All agree

space maintainer All agree

Cross Tabulation

Previous Trauma All agree

Ortho appliance All agree

Posterior crossbite All agree

space maintainer All agree

24

Table 9: Inter-examiner calibration first examination by B followed by A

Kappa value Asymp. Std. Error Approx. T Approx. Sig. Agreement

attrition Kendall's/0.846 0.027 29.999 <0.001 Excellent

Molar classification 0.677 0.109 5.994 <0.001 Very good

Canine classification 0.668 0.103 6.865 <0.001 Very good

Posterior crossbite 1 0 6.164 <0.001 Absolute

upper arch findings 0.938 0.013 35.882 <0.001 Excellent

Lower arch findings 0.944 0.012 36.752 <0.001 Excellent

Cross Tabulation

Previous Trauma All agree

Ortho appliance All agree

Tooth Malformation All agree

space maintainer All agree

25

VI. RESULTS

A total of (4822) teeth were evaluated. Among these teeth, (1944) presented with no

dental wear, (1016) scored 1, (1100) scored 2 and (8) scored 3, (53) teeth were excluded due

to tooth malformations, (49) permanent molar were not fully erupted or not in full occlusion

and (652) were not included due to large caries lesions or restoration or SSCs.

Responses to the Questionnaire

Among the 371 children examined, 184 were from private schools (90 girls, 94 boys) and

187 were from the government schools (113 girls, 74 boys), totaling 203 girls and 168 were

boys.

Parents related information

Education

Among the 371 children father’s reported as 2 were not educated (0.5%), 33 had

their primary education (8.9%), 157 had secondary or high school certificate (42.3%), 177

had Bachelors or postgraduate studies (47.7%), and 2 didn’t answer (0.5%). Mother’s

education were reported as 14 not educated (3.8%), 56 had primary education (15.1%), 178

had secondary or high school certificates (48%), 119 had Bachelor or postgraduate studies

(32.1%), and 4 didn’t answer (1.1%). Marital status was reported as 2.7% divorced and

18.3% with no answer. Father’s and mother’s education in private versus government

schools is seen in the following charts (Figures 3 and 4).

26

Figure 3: Father’s educational level

Figure 4: Mother’s educational level

0 2.2

25

72.9

1.1

15.5

59.4

23

not educated primary secondary or high school

bachelor or postgraduate

Father's educational level

private government

0.5 3.8

42.9

52.7

0

7

26.2

52.9

11.8

2.1

not educated primary secondary or high school

bachelor or postgraduate

no answer

Mother's educational level

private government

27

Employment

In the employment category, 51 fathers reported as being unemployed (13.7%), 319

employed (86%), and one didn’t answer (0.3%). Mothers reported as 298 unemployed

(80.3%), 72 were employed (19.4%), and one didn’t answer (0.3%). In the entire sample, 3

fathers passed away (0.8%), and 2 mothers as well (0.5%).

Father’s and mother’s employment in private versus government schools in the following

(Figures 5 and 6).

Figure 5: Father’s professional level.

6

94

0

21.4

78

0.5

not employed employed no answer

Father's employement

private government

28

Figure 6: Mothers’ professional level

Childs related information

Of the 371 subjects, answers showed that children 40.2% were emotional, 60.4%

hyperactive, ubnormal sleep cycle 4.9%, grind at night 4%, grind under stressful situations

4.3%, suffered morning headache or jaw pain3.8% , gastro-esophageal reflux 3.2%, and

dental trauma or jaw fracture 6.2% are as below (Figure 7).

74.5

25.5

0

86.1

13.4

0.5

not employed employed no answer

Mother's employment

private government

29

Figure 7: children related variables

The results in private versus government schools as seen in figure 8.

Figure 8: Overall comparison between private and Governmental schools

Variables on children habits:

15.1% of the participating children were putting things in their mouth, 25.1% biting

on their finger nails or lip, 1.9% sucking their fingers, and children playing videos games as

0

20

40

60

80

100

120

No

Yes

Sometimes

No answer

0

20

40

60

80

100

120

%

Private schools government schools

private vs government

emotional

hyperactive

normal sleep cycle

grind at night

gring under stress

morning headach or jaw pain

gastroesophegeal reflux

dental trauma or jaw fracture

30

7.5% while those not playing, the following percentages record the time spent playing video

games 17.8% as daily, 23.5% as 3-5/week, 28% 1-2/week or weekends only, 4.9% reported

playing only on summer and winter vacations, and 18.3% with no answer. (Figures 9 and

10).

Figure 9: Comparison between Habits adapted by participants in both private and

governmental schools

Figure 10: Frequency of video games played

83.7

16.3

86.1

13.9

73.9

26.1

75.9

24.1

98.4

1.6

97.9

2.1

No Yes No Yes

Private Gover.

Habits

Putting things in the mouths Biting on the finger nails or lip

Sucking the fingers

5.4

16.3

25

32.6

3.8

16.8

9.6

19.3 21.9 23.5

5.9

19.8

playing video games

Priv. Gov.

31

Dietary habits

Dietary habits of the 371 child reported that consumption of carbonated drinks

ranged from once a month to 21 times a week, the fruit based drinks ranging from none to

56 times a week and eating citrus fruits ranging from none to 35 times a week. The figures

below illustrate the difference in these variables in private versus government schools.

(figure 11, 12 and 13)

Figure 11: Consumption of Carbonated drinks per week

0

5

10

15

20

25

Carbonated drinks/week

Priv. Govr.

32

Figure 12: Consumption of fruit based drinks per week

Figure 13: Consumption of fresh fruit cuts per week

Oral Hygiene Practices

Most of the children reported brushing twice a day (54.4%) while, 33.7% brushing

once a day, 5.9% brushing 3 times a day, 4% brushing more than 3 times a day, 1.6%

reported not brushing and 0.3% no answer. Tooth brush type reported the majority (54.4%)

0 5

10 15 20 25 30 35 40 45

Fruit based drinks/week

Priv. Govr.

0

5

10

15

20

25

30

Eating citrus fruits/week

Priv. Govr.

33

used a medium tooth brush, while 43.3% used a soft brush, 1.3% used hard brush, and 0.8%

didn’t answer. Toothpaste type reported 38% used children’s toothpaste, while 20.7% used

adult toothpaste, 30.7% didn’t specify, and 0.5% didn’t answer. These three variables are

listed in the figures below for the combined numbers of private and government schools.

(Figures 14-16).

Figure 14: Teeth brushing frequency on daily basis

Figure 15: Tooth brush type

1.1

29.9

64.1

4.3 0.5 0 2.1

37.4

44.9

7.5 7.5

0.5

0 1 2 3 4 no answer

Teeth brushing/day

Priv. Govr.

43.5

55.4

0.5 0.5

43.3

53.5

2.1 1.1

soft medium hard no answer

Toothbrush type

Priv. Govr.

34

Figure 16: Tooth paste type

Prevalence of attrition in private versus government schools

The statistical analysis showed that attrition is significantly higher in the government

than in private schools and there was no difference in the attrition rates between girls and

boys. (Figures 17-20).

41.8

20.1

37.5

0.5

34.2

41.2

24.1

0.5

kids adult not specified no answer

Toothpaste type

Priv. Govr.

35

Figure 17: attrition prevalence according to school category

Figure 18: attrition prevalence scores according to school category

0.45383

0.56026

Private school Government school

Attrition prevalence

Mean

36

Figure 19: attrition severity score according to school category

Figure 20: attrition prevalence according to gender

0.23568

0.28868

Private school Government school

Attrition severity

Mean

37

Significant variables

Attrition prevalence

The analysis for attrition prevalence and the variables demonstrated a statistically

significant relationship between attrition prevalence and type of school (P=<0.001), right

canine classification (P=.001), number of siblings (P=0.004), and sucking fingers (p=0.023).

The prevalence of attrition in the examined teeth showed that as canines had the highest

rates followed by the second primary molars, first primary molars and the permanent first

molars respectively (P=<0.001) (Figure 21).

Table 10: Demonstrative data for the relationship between prevalence and type of

school, for models (Regression) and (Residual)

ANOVAe

Model Sum of Squares df Mean Square F Sig.

4 Regression 1.209 4 .302 12.708 <0.001

Residual .785 33 .024

Total 1.994 37

d. Predictors: (Constant), school, Rcan, Number, Sucking the fingers

e. Dependent Variable: attrition Prevalence

Table 11: Dependent Variable: attrition Prevalence

38

Figure 21: attrition prevalence according to teeth

Attrition severity

The analysis for attrition severity and the variables demonstrated a statistically

significant relationship between attrition severity and type of school (P=0.002), right canine

classification (P=0.000), right molar classification (P= 0.019), number of siblings (P=0.007),

and sucking the finger (p=0.023).

Of the 2124 teeth which were scored by 1, 2, and 3, most scored by 2 (51.78%), followed by

score 1 (47.8%) and 3 (0.3%). The prevalence of attrition was higher on the canines

followed by the second primary molars, first primary molars and first permanent molars

respectively while the severity of attrition scores were found to be highest on the canines

followed by first primary molars, second primary molars, and first permanent molars

respectively. On the segments the results were as follow, attrition prevalence reported

highest on the upper canines, upper primary molars, lower primary molars, lower canines,

upper permanent molars and lower permanent molars respectively while the attrition

0

5

10

15

20

25

canine 1st primary molar

2nd primary molar

1st permanent molar

prevalence of attrition

Series1

39

severity reported with highest attrition scores with the upper canines followed by the lower

canines, lower primary molars, upper primary molars and least by the permanent molars. On

the comparison between upper and lower jaws the results showed that the upper jaw attrition

is higher when compared with the lower jaw (p<0.001) (Figures 22-26).

Figure 22: Attrition scores frequency

Figure 23: Upper dental arch

47.8 51.78

0.3 0

10

20

30

40

50

60

1 2 3

Attrition scores freguency

%

0

10

20

30

40

50

60

70

16 55 54 53 63 64 65 26

upper dental arch

1

2

3

40

Figure 24: Lower dental arch

Figure 25: Attrition prevalence according to segments

0

5

10

15

20

25

30

35

40

45

36 75 74 73 83 84 85 46

lower dental arch

1

2

3

41

Figure 26: Attrition severity according to segments

Table 12: Predictors: (Constant), Rcan, Rmol, school, Number

ANOVAe

Model Sum of Squares df Mean Square F Sig.

4 Regression .364 4 .091 11.427 .000d

Residual .262 33 .008

Total .626 37

e. Dependent Variable: attrition Severity

42

Table 13: Dependent Variable: attrition severity

Coefficientsa

Model

Unstandardized Coefficients

Standardized

Coefficients

t Sig. B Std. Error Beta

4 (Constant) .150 .061 2.452 .020

Rcan -.017 .004 -.462 -3.925 .000

Rmol .027 .011 .283 2.457 .019

school .123 .036 .454 3.424 .002

Number -.011 .004 -.380 -2.900 .007

Primary canine attrition severity and classifications

The linear regression analysis showed that there is a significant relationship between

the canine attrition severity and the classification on the same side, right canines were

statistically significant with the right canine classification (P=<0.001) and left canines were

also statistically significant with the left canine classification (P=<0.001).

Table 14: Mean, Median, and Standard deviation values of the attrition prevalence and

severity.

Statistics

attrition

Prevalence

attrition

Severity

age

N Valid 371 371 38

Missing 0 0 333

Mean .50747 .26240 9.21

Median .55600 .26700 9.10

Std. Deviation .226337 .135590 1.059

Minimum .000 .000 7

Maximum 1.000 .889 12

43

DFT%

The analysis for DFT% score and other variables have shown a statistically significant

relationship, DFT score and type of school (P=.000), tooth brushing/day (P=.000), and

Mothers educational level (P=0.009). The mean value of the DFT% is 30.1%. DFT score

was higher in the government than the private schools; on the other hand teeth brushing

proved that increasing its frequency decreases the DFT score, while mother’s educational

level found to have interestingly the lowest DFT in the not educated mothers and the highest

in the mothers with primary education and bachelor or postgraduated mothers had DFT

scores higher than the mothers with secondary or high school education. (Figures 27-29).

Figure 27: DFT% according to school category

27.7001433

32.4435936

Private school Government school

DFT%

Mean

44

Figure 28: DFT% according to brushing frequency

Figure 29: DFT% according to mother’s educational level

Table 15: DFT% significant variables

0

5

10

15

20

25

30

35

0 1 2 3 more than 3

Teeth brushing/day

DFT%

27.6939429

32.4658852

29.4768797 29.8507691

not educated primary secondary or highschool

bachelor or postgraduate

Mothers education and DFT %

DFT%

45

Table 16: Mean, median and standard deviation values of DFT%

Statistics

DFT%

N Valid 371

Missing 0

Mean 30.0910468

Median 30.4347000

Std. Deviation 14.43571498

Minimum .00000

Maximum 73.91300

Other variables

Attrition variables

All other variables were not statistically significant (Table 17). One variable showed a

trend towards, the hyperactive children (P=0.091) which may be due to the sample size

being so large. If the samples with highest attrition scores were compared to subjects with

no attrition, other significant relations may be shown.

46

Table 17: Attrition excluded variables

Excluded Variablese

Model

Beta In t Sig.

Partial

Correlation

Collinearity

Statistics

Tolerance

4 Left molar classification -.143d -.742 .463 -.130 .345

Left canine classification -.093d -.591 .559 -.104 .527

Right posterior cross bite -.035d -.277 .783 -.049 .833

Left posterior cross bite -.016d -.137 .892 -.024 .982

DFT% -.122d -.907 .371 -.158 .705

age .070d .517 .609 .091 .708

Father’s education -.147d -1.269 .213 -.219 .926

Mother’s education -.048d -.411 .684 -.072 .962

Father’s employment .054d .418 .679 .074 .767

Mother’s employment .041d .349 .729 .062 .943

Divorced parents .089d .762 .451 .134 .944

Order between siblings -.001d -.007 .994 -.001 .940

Medical condition .117d .995 .327 .173 .924

medication .036d .302 .765 .053 .923

emotional .181d 1.607 .118 .273 .956

hyperactive .194d 1.744 .091 .295 .967

normal sleep cycle .101d .865 .393 .151 .937

grind at night -.102d -.791 .435 -.139 .772

grind under stress .007d .050 .960 .009 .741

morning headache or jaw pain .185d 1.512 .140 .258 .816

teeth brushing/day -.155d -1.316 .197 -.227 .899

tooth brush type .015d .125 .902 .022 .945

tooth paste type -.066d -.562 .578 -.099 .940

Gastro-esophageal reflux .148d 1.064 .295 .185 .651

dental trauma or jaw fracture .154d 1.341 .189 .231 .937

jaw problem -.026d -.217 .830 -.038 .923

Putting things in the mouths .069d .597 .555 .105 .973

Biting on the finger nails or lip .000d .001 .999 .000 .728

Sucking the fingers .227d 1.612 .117 .274 .613

Videos gaming .037d .320 .751 .056 .974

carbonated drinks/week .055d .475 .638 .084 .955

fruit based drinks/week -.059d -.472 .640 -.083 .836

eat citric fruits/week -.005d -.041 .968 -.007 .844

a. Predictors in the Model: (Constant), Rcan

b. Predictors in the Model: (Constant), Rcan, Rmol

c. Predictors in the Model: (Constant), Rcan, Rmol, school

d. Predictors in the Model: (Constant), Rcan, Rmol, school, Number

e. Dependent Variable: attrtition Severity

DFT% variables

All other variables were excluded from the DFT% because they were not statistically

significant (Table 18).

47

Table 18: DFT% excluded variables

Excluded Variablesd

Model

Beta In t Sig.

Partial

Correlation

Collinearity

Statistics

Tolerance

3 Father’s education -.005c -.077 .939 -.004 .700

Father’s employment .027c .523 .602 .027 .974

Mother’s employment .037c .662 .508 .035 .831

divorced .055c 1.070 .285 .056 .962

Father died -.018c -.346 .729 -.018 .989

Mother died -.035c -.699 .485 -.037 .992

Number of siblings .019c .340 .734 .018 .785

Order between siblings -.014c -.274 .784 -.014 .925

tooth brush type .022c .434 .664 .023 .982

tooth paste type -.029c -.560 .576 -.029 .952

Videos gaming .061c 1.185 .237 .062 .963

carbonated drinks/week .053c 1.010 .313 .053 .938

fruit based drinks/week .008c .149 .882 .008 .906

eat citric fruits/week .024c .452 .652 .024 .920

c. Predictors in the Model: (Constant), school, teeth brushing/day, Mother

d. Dependent Variable: DMFT %

48

VII. DISCUSSION

As a successful approach in tooth wear management, it is highly crucial to identify

the etiological factors. In many cases, the diagnosis might be complex due to multiple

etiologic factors that may confuse the clinical appearance of tooth wear [44]. Early

prediction of tooth wear can easily aid individuals whom are at risk of developing wear.

“The prevalence of tooth wear has been reported in several studies that have used many

indexes for analysis "[45-47]. In such a study, besides using indices for examinations,

different teeth and surfaces have been examined and surprisingly, results appeared in various

ways, which as a result made it more complex to compare the results. In this paper, the

Smith and Knight scale for epidemiological surveys was used, which demonstrated fair

accuracy and validity. It is highly important to mention that I would recommend other

working groups to conduct studies in order to validate the diagnostic criteria and grading.

The differences in the prevalence data among many studies [46-48] may be partly

explained by the differences in diagnostic criteria and indexes used, as well as varying

socioeconomic, cultural and geographical factors which could influence the outcome of

prevalence data. In this paper it was proven that the attrition prevalence was higher in the

government than the private schools, which is similar to an outcome of a study conducted by

Duze et al [49].

With accordance to study performed by Peres et al. [50], Gender was not

significantly correlated with tooth wear, this result came in sync with most studies assessing

tooth wear in deciduous dentition which have not found any differences between different

genders such as [52-61] On the other hand, a remarkable higher prevalence of exposed

dentine was found in UK boys than in girls and more boys had buccal/labial and

49

lingual/palatal tooth surface erosion than girls [62, 63]. Van Rijkom et al. [64] suggested

that the one possible reason for the difference in prevalence of erosive tooth wear between

boys and girls could be the difference of bite force and Pigno et al found that males among

children and adults had an increased prevalence of tooth wear, probably reflecting the higher

bite force of males compared to females [65]. In his study, mechanical tooth wear

assessment carried out, and none of the individuals correlated with tooth wear. Bruxism,

which is a strong risk factor for occlusal tooth wear, failed to demonstrate a significant

correlation as well. This result is similar to those of previous studies [66, 68]. This is

possibly due to parents' negligence of the presence of this condition and underestimating it

[67]. Marbach et al. found that only 34.4% of the patients with self reported bruxing in their

study showed evidence of tooth wear; the authors noted that evidence of tooth wear does not

necessarily indicate bruxing of the teeth [69]. Detmar et al. found no relationship between

degree of tooth wear and the level of bruxism activity as measured by EMCs [70]. There

was no association found between tooth wear and the socioeconomic status of children

estimated by their parents' education and occupation. In previous studies, tooth wear in

deciduous dentition has been uncertainly correlated with socioeconomic class. Harding et al.

and Kazoulis et al. found higher tooth wear rates in families with low socioeconomic status

[52, 55], on the other hand, Luo et al. and Mangueira et al. found higher tooth wear rates in

families with high educational level and in children who attended private schools [54, 74].

Where in this paper, attrition is found to be higher in the government than the private

schools and no association found with parents educational level. The occurrence of erosive

tooth wear can be influenced by the socioeconomic status of a population due to different

eating and drinking habits. Another possible interpolation can be also correlated to hygiene

habit of these groups. Millward et al. carried out a study examining the prevalence of

50

erosion of 178 4-year-old children and concluded that there is more erosion in the higher

socioeconomic groups [59]. In China, A remarkably higher prevalence of erosion was found

in children whom consumed fruit drinks in their childhood, and whose parents had higher

educational level [54]. The reasons expected for the increased erosion in the higher social

class was possibly due to the Western style diet, such as consumption of fruit juices,

carbonated soft- and other lifestyle-drinks; while the children from a more moderate or

lower educational background were more likely restricted to traditional drinks. In contrast to

these findings, Harding et al. found a correlation between low socioeconomic status,

frequent consumption of fruit squash and carbonated drinks and the occurrence of dental

erosion [55]. In this paper, it was not assessed if the children from the low socioeconomic

background had more plaque, which would be a diffusion barrier for erosion.

Harding et al. found higher odds ratios of erosive tooth wear in the group of frequent

consumers of carbonated and fruit drinks after conducting a study which is carried out

covering 202 5-year-old Irish children [55]. In a case–control study covering 103 British

aged between 2–7-year olds, significant finding correlated the prevalence of erosive tooth

wear with the frequency of consumption of acidic beverages, the habits of swishing and

holding the fluid in the mouth. Murakami et al. in a sample of 967 Brazilian children with

ages varied between 3–4 years, found higher odds ratios of erosive tooth wear in the group

that consumed soft drinks twice or more per day [75]. Al Majed et al. In a study conducted

with a sample of 46 children aged between 5–6-year-old boys in Saudi Arabia with

pronounced tooth wear (involving dentine and pulp) on the palatal surfaces of maxillary

incisors, found a remarkable relation between consumption of carbonated drinks in bedtime

and the number of affected surfaces [71]. Millward et al. in a group of 101 children aged 4–

16 years, assessing both deciduous and permanent dentition, found significant association of

51

tooth wear severity (no/mild–moderate– severe) with the frequency of consuming

carbonated drinks, fruit drinks, and fruit-based drinks at bedtime [59]. Surprisingly, the

present study and other investigators have not found any relationship between erosive

dietary factors and tooth wear [48, 53, 57, 76]. The sample size was enough to reveal the

effect of dietary factors on tooth wear. Yet, a larger sample could have helped to reveal the

correlations with more unlikely exposures, such as acidic medicine, gastric acids, and habits

related to physical wear.

Most commonly dental erosion, non-carious-lesions, have been investigated by

Walker et al, [48, 79]. In primary dentition, erosive tooth wear was identified in dentine [48,

79] and the most affected teeth were the molars [79, 80], incisors [48] or canines [55]. In

permanent dentition, tooth erosion was more frequently found in enamel [51, 77-79] and the

teeth most affected by wear were the molars [80] and canines [77]. The present study

analyzed a non-specific tooth wear cases inclusive of any type of wear. The results

demonstrated that canines presented higher tooth wear frequency and severity than the other

groups of teeth. This in accordance with Tartsitsa et al. who found that the most frequently

affected teeth were the canines and tooth wear involving dentine was mainly observed in

canines [28]. The prevalence and severity of tooth wear in canines found to be associated

with type of canine classification, however, additional research is necessary to support the

correlation between malocclusion and tooth wear described in the scientific literature.

According to previous studies class II malocclusion and absence of posterior or anterior

open bite was associated with tooth wear in children, but not in adults [66, 81, 82]. Many

etiological factors emerge to influence tooth wear, and it was found that there was an

association between the different lesions evaluated and gender. A logical approach can be

taken, that could explain the anomaly, through further investigation considering the

52

difference in enamel formation between primary and permanent teeth combined with other

variables such as bite force. A decent predictor of increased risk of erosion and general

tooth wear in permanent dentition is dental erosion in primary dentition. According to

Harding et al. children identified with erosive tooth wear extending to dentine or pulp at age

5 were five times as likely to have tooth wear on the occlusal surfaces of the first permanent

molar teeth at age 12 [17], Ganss et al. using orthodontic study models reported a similar

finding. So precise preventive and therapeutic measures are necessary required to avoid

increasingly the clinical problems [83]. In the present study no association found between

teeth wear and the frequency of teeth brushing which conflicts with [17] who found that

children brushing twice a day or more had less tooth wear on their incisors that those

brushing less frequently. In the present paper no correlation found between caries experience

and severity of tooth wear this confirms the results of [38]. There was no association

between children oral habits (putting things in their mouth, biting on their finger nail or lip)

with attrition prevalence or severity except for sucking the finger which showed a significant

relationship with attrition prevalence (p=0.023), in the present paper the association between

these habits and bruxism wasn’t studied, while in a study conducted by Shinkai et al. no

relation was found between bruxism and oral habits [84]. Other studies found a relationship

between bruxism and oral habits. Cheifetz et al reported that children with thumb sucking

habits had a smaller chance of showing bruxism (p = 0.06) [43, 85].

A systematic review of previous literature reviews demonstrated a fairly strong

indication for an inverse relationship between socioeconomic status and the prevalence of

caries among children [86, 89-92] A study on 13 to 14 year olds concluded that dental caries

experience and oral hygiene status of children were strongly correlated to socioeconomic

status [87, 88]. Another study done in the UAE Mohammed Mustahsen [93] found an

53

inverse relationship between socioeconomic status & DMFT in children which is consistent

with the results in this paper where we found that DFT% in government school is higher

(Mean value 32.4%), in comparison with private school students (Mean value 27.7%)

although private tend to greatly use the kids tooth paste (42.8%) when compared to

government school children (43.2%). And the majority of government school children tend

to use the adult tooth paste (41.2%) when compared to private school children (20.1%)

which confirm the findings of Martins et al. that children with a high socioeconomic status

tend to use a children's toothpaste [94]. Most of the children (54.4%) reported brushing

twice a day. No statistically significant difference found in the DFT% between girls and

boys in the present paper which conflicts the results of Arbabzadeh Zavareh who found that

girls have higher level of DMFT index [95]. Brushing frequency as found here is statistically

significantly associated with the DFT% greater brushing frequency resulted in less DFT%

and this is consistent with Costa el al who concluded that children who brushed their teeth

twice a day had less caries [99] similar finding was recorded by Whelton et al, at age 15 in

the Irish national survey [98]. According to Baccush et al. children whose mothers had low

education exhibited a higher total DMFT score than those whose mothers had high

education [96] where the present study interestingly found that children whose mothers were

not educated had the lowest DFT% (27.7), and the greatest DFT% found in children whose

mothers had their primary education (32.4%) followed by the children whose mothers had

their bachelor or postgraduate study (29.8%), and then by the children whose mothers had

their secondary or high school study (29.47%). This could be due to the fact that doing

further studies after the high school would decreases the mother’s attention on the child oral

health, or due to the mother being employed. Fathers education and occupation where not

54

statistically related with the DFT% in the present paper while Mehdi et al. found significant

differences between the DMFT index with father’s education and occupation [97].

55

VIII. CONCLUSION

1. Attrition prevalence is significantly higher in the government (Mean value 0.56) than

in private schools (Mean value 0.45) while there was no difference in the attrition

prevalence between girls and boys.

2. Attrition severity is significantly higher in the government (Mean value 0.28) than in

private schools (Mean value 0.23)

3. A statistically significant relation found between attrition prevalence and type of

school (P=<0.001), right canine classification (P=.001), Number of siblings

(P=0.004), and sucking the finger (p=0.023).

4. A statistically significant relation found between attrition severity and type of school

(P=0.002), right canine classification (P=0.000), right molar classification (P=

0.019), number of siblings (P=0.007), and sucking the finger (p=0.023).

5. The severity of attrition scores found to be highest on the canines followed by

second primary molar, first primary molars, and first permanent molars respectively.

6. According to segments attrition severity reported with highest attrition scores with

the upper canines followed by the lower canines, lower primary molars, upper

primary molars and least by the permanent molars.

7. Attrition of the upper jaw was significantly higher than the lower jaw (p<0.001).

8. A significant relationship between the canine attrition severity and the classification

on the same side, right canines were statistically significant with the right canine

classification (P=<0.001) and left canines were also statistically significant with the

left canine classification (P=<0.001).

56

9. A significant relationship found between the canine attrition severity and canine

classification, Class I canine and cusp to cusp occlusion associated with higher

attrition scores on canines when compared to class II and III (p <0.001).

10. Primary canine class I on the right side of the jaw associated with higher attrition

prevalence and severity when compared to C.II and III (P= 0.000).

11. Molar Class I on the right side of the jaw associated with lower attrition scores when

compared to Class II and III (P= 0.019).

12. All other variables were not statistically significant with attrition but one variable

showed a trend in hyperactive children with (P=0.091).

13. The mean value of the DFT% is 30.1%. DFT score was higher in the government

(32.44%) than the private schools (27.7%) with no difference between boys and

girls.

14. A statistically significant relation found between, DFT score and type of school

(P=.000), teeth brushing/day (P=.000), and Mothers educational level (P=0.009).

57

LIMITATIONS AND FUTURE RRECOMMENDATIONS

1. The questionnaire variables filled by the parents in terms of accuracy the information

will be more accurate if collected by one to one interaction with the parents.

2. The variables of attrition like bruxism, dietary habits and Oral Hygiene habits might

show significant correlation if done as control versus sever attrition groups.

3. Additional research is necessary to support the correlation between malocclusion and

tooth wear.

58

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APPENDEX

A- School consent form

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B- Participant consent form

72

73

74

C- Questionnair form

75

76

77

D- Examination form