PREVALENCE AND SEVERITY OFTOOTH SURFACE LOSS IN

ADULTS.

INVESTIGATOR

Juliet Owuor- V28/2218/0S

Level 3 U.O.N

SCHOOL OF DENTAL SCIENCES

SUPERVISORS

Internal: Dr.L.W. GATHECE. BDS, MPH (NBI)

Lecturer, Department of Periodontology, community andpreventive dentistry.

School of Dental Sciences, U.O.N.

External: PROF.W.R. LESAN. BDS, MSc(Rest.Dent)FADI.

Lecturer, department of conservative and prostheticdentistry.

School of Dental Sciences, U.O.N.

A COMMUNITY DENTISTRY RESEARCH PROJECT SUBMITTED IN PARTIALFULFILMENT OF THE REQUIREMENT FOR THE DEGREE OF BACHELOR OFDENTAL SURGERY, UNIVERSITY OF NAIROBI, 2008.

DECLARATION

I Juliet A. Owuor BDSIII, do solemnly declare that this is my original work andthat it has not been submitted for any other purpose to any other institution orplace.

r/}Signature. .. .. .Date ~ .;. )J../v.'. .

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APPROVAL

This research project has been submitted for examination with our approval asUniversity supervisors.

Dr. L.W. Gathece BDS, MPH(NBI). Department of Periodontology, Communityand Preventive dentistry, University of Nairobi.

Signature Date .

Prof. W.R. Lesan BDS,MSc(Rest.Dent)F AD!. Department of Conservative andProsthetic dentistry. School of Dental Sciences, University of Nairobi.

Signature Date .

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DEDICATION

To the Almighty God who has helped me overcome all the challenges that I facedon the road to making this research project a reality. To my mother for theconstant encouragement.

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ACKNOWLEDGEMENTS

I would like to apprecicate the help offer by the following people who aided mein completing this research project.

My supervisors: Dr Gathece and Prof. Lesan for the valid advice.Ben Muchoki who assisted me to analyse the data.My classmate [yoti Bahra who assisted me in data collection and analysis.My roommate, Consolata Kinuthia whose computer was used to type out theproject.My parents for the financial support.

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TABLE OF CONTENTS

TITLE PAGE .iDECLARATION .iiAPPROVAL .iiiDEDICATION .ivACKNOWLEDGEMENTS vTABLE OF CONTENTS viABBREVIATIONS viiLIST OF TABLES AND FIGURES viiABSTRACT 1INTRODUCTION 3LITERATURE REVIEW 5PROBLEM STATEMENT 8JUSTIFICATION OF THE STUDY 8OBJECTIVES 9HyPOTHESIS 9VARIABLES 9

Independent Variables 9Dependent Variables 9

MATERIALS AND METHODS 10Study Design 10Study Area 10Study Population 10Sample Size Determination 10Sampling Methods 11Inclusion Criteria 12Exclusion Criteria 12Data Collection Instruments and Techniques 12Data analysis and Presentation 12

VI

Ethical Consideration 13Perceived Benefits 13

RESULTS 14DISCUSSION 17CONCLUSION 18RECOMMENDATIONS 18REFERNCES 19APPENDIX 22CONSCENT FORM 22CLINICAL EXAMINATION FORM 23APPROVAL FROM ETHICAL COMMITTEE 24

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ABBREVIA TIONS

UoNNCCLBDSKshsDrTSLProfUSAUKKNHFDI

University of NairobiNon-carious cervical lesionsBachelor of Dental SurgeryKenya shillingsDoctorTooth surface lossProfessorUnited States of AmericaUnited KingdomKenyatta National HospitalFederation dentaire intanationale

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LIST OF TABLES AND FIGURES

Figure 1: Age and gender distribution of tooth surface loss 14Figure2: Geographic distribution of TSL. 15Figure3: Occupational distribution of participants 15

Table 1: Simplified scoring criteria for tooth wear index 7Table 2: Classification of mean degree of TSL. 12Table 3: Mean total distribution ofTSL. 16Table 4: Mean degree ofTSL 16

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ABSTRACT

BACKGROUND

Tooth wear is the loss of tooth surface, which is not caused by decay or injury. Itis also referred to as tooth surface loss. Tooth surface loss falls under three maincategories; attrition, erosion and abrasion. There have been few studies carriedout in Kenya with regard to identifying the prevalence and severity of toothsurface loss.

OBJECTIVE

The study set out to determine the prevalence and severity of TSL in adultpatients.

STUDY DESIGN

The study is a descriptive cross-sectional study using hospital based studygroups.

SETIING

The study was conducted in the University of Nairobi Dental Hospital oraldiagnosis clinic.

MATERIALS AND METHODOLOGY

A sample size of 90 patients was chosen through simple random sampling.Consent was obtained from the dean of the Dental school hospital and from thesubjects themselves before any data collection begins. Data was collected by useof a clinical examination data form and examination under artificial light. Toothsurface loss will be scored using the simplified tooth surface loss index byBardsley et al (1984).

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DATA ANALYSIS

Data was analysed using the SPSS computer software programme with the helpof a biostatistician. Results were presented in the form of pie charts, frequencytables and charts.

RESULTS

There was a high prevalence of TSL, at 32.1%.Male patients36(59%) were moreaffected than female 25(41%)patients. The age groups most affected by TSL werethose aged between 31-40 years 17( 27.9%). Majority of the patients were fromurban areas 33(54.1%). The mean degree of TSL on each tooth was less than 1;hence the severity if TSL was mild. Mandibular teeth were more as affected byTSL than maxillary teeth.

CONCLUSION

The hypothesis was proved. The severity of TSL was related to occupation,geographical type and age. There were no adults who presented with severe TSL.TSL is a growing concern in this country. Early preventative measures canreverse the progression to TSL.

PERCIEVEDBENEFITS

The study aims to generate knowledge on the causes of tooth surface loss and thepreventative measures that can be undertaken.

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INTRODUCTION

Tooth surface loss is the loss of tooth surface, which is not caused by decay orinjury. Tooth surface loss is the term used to cover non-carious tooth surface lossby attrition, abrasion and erosion (1). Attrition occurs in conditions where thereis prolonged tooth to tooth contact and pathologically in abnormal occlusion forexample in crowding of teeth and malposed teeth. Other causes includeabnormal chewing habits for example bruxism due to stress (of modern life) orstructural defects in teeth like amelogenisis imperfecta. Abrasion is mechanicalwearing away of teeth due to contact with external agents, leading to artifactswhich occurs frequently on incisal and occlusal surfaces. Erosion is the chemicalwearing away of tooth surface to form shallow, smooth highly polishedexcavations. It is a pathological process (2).

Abfraction is caused by biomechanicalloading forces due to flexure and fatigueof tooth tissues that occur away from the point of loading, mainly affecting thecervical areas. Other causes of cervical lesions include toothbrush abrasion anderosion. (3).Erosion is the wearing away of tooth surface through decalcificationby acid. Erosion is dependent on the origin of the acid. Intrinsic sources of acidproduce palatal and lingual erosive lesions while extrinsic acid causes buccal andfacial erosive lesions. Erosion is predominantly on the occlusal surfacesespecially mandibular first molars, followed by facial surfaces of anteriormaxillary teeth. Oral erosion is frequently found on maxillary incisors andcanines. (4).The mandible exhibits more tooth wear than the maxilla. (5).Erosionof enamel and dentine is due to direct demineralizing action of acids and differsin clinical and microscopic appearance from dental caries. Gastric acids mayreach the oral cavity in persons who vomit or regurgitate regularly as in patientswith some form of intestinal obstruction like hiatus hernia or people who sufferfrom anorexia nervosa. Erosion of tooth surfaces leads to disfigurement, loss offunction and occasionally, loss of teeth. This condition is initially painless whenthe erosive process is still on the enamel surface, however, as erosion progressesinto dentine, the tooth may become sensitive and pulp eventually dies. (6).

Tooth surface loss is a common problem affecting a large proportion of people inthe world. In a study done on the pattern of tooth wear amongst 12-18year oldstudents in a Nigerian population 86% had tooth wear (7). While in a study

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conducted in Trinidad, 62.2% of patients aged 16 to 73 year had at least one TSLlesion (8). In another study by Johansson AK in Saudi Arabia, in young men witha mean age of 20.9years, 29% of them had erosive TSL. (9). While in a study doneby Dugmore in the United Kingdom, 59.7% of 12 year olds had TSL (10). In astudy done by Smith and Robb in the 97% of all ages had TSL. (11)

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LITERA TURE REVIEW

Tooth surface loss causes loss of enamel and can lead to exposure ofdentine.(12).The causes of tooth surface loss are either intrinsic or extrinsic andare usually chemical (acidic) or mechanical (frictional) in nature (13).

In Kenya, a microscopic study done by Lesan to determine the effects of acommercial beverage on the effects of a commercial beverage on the enamelsurface of a human tooth revealed that the tooth surfaces exposed to the testsolution were observed to have been etched to various degrees. Hence, it wasconcluded that commercial beverages causes etching or erosion of human teethin vitro.(14).

In a study by Levitch in the United Kingdom, 5% to 85% of adults examined hadTSL (15). In a study done by Kumar on the prevalence and severity of TSL inNigeria, 56.52% of the 15-55year olds had tooth surface loss on the mandibularteeth compared to 46.71% in maxillary teeth. (16). In another study done byOginni in Nigeria, 64.1%of the adult patients had attrition, 15.8% had abrasionwhile 7% had erosion. The frequency of TSL increased with age. (17). In Sweden,a study done to establish the prevalence of TSLby Hugoson, the correspondingTSL figures for the 30-80 year age groups were 20%, 32%, 18%, 14%, 26% and23% respectively. Men presented more TSL than women. In the same study, 49%of 15year olds and 65%of 20 year olds had either incisal or occlusal wear (18).

A study done by Ganss, in Germany, 70.6%of children with a mean age of 11+/-3.3 years, had TSL in the primary dentition. (19). In Switzerland, Geneva, a studycarried out by Lussi, 29.9% of 26-30 year olds had occlusal TSL compared to42.6% of 46 year olds. Data from interviews revealed that acidic beverages aresignificantly associated with presence of erosion. (20). While in another studydone by Jaeggi 6-50% of 2-5 year old children showed erosion on deciduousdentition. Young school children aged between 5-9 years already had erosivelesions on permanent teeth in 14% of the cases. 11-100%of adolescents between9and 17 years showed signs of erosion. In adults aged between 18-88 years,prevalence data ranged between 4 and 82%. (21).

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In a study done in Nigeria by Taiwo, 92.8%of the elderly patients examined hadTSL. (22).In Croatia, a study carried out by Brocic 16.6%of teeth in patients agedbetween 10-65years had NCCL (23). In Trindad, a study done by Pegoraro onthe prevalence and severity of non-carious cervical lesions, 17.23% of patientswith a mean age of 40.6 years had TSL (24). In a study conducted by Arowolojuon the erosion of tooth enamel surfaces among 11-68 year old automobilemechanics and battery technicians in Nigeria, 3.2% of automobile mechanics hadTSL,compared to 41% of the battery mechanics. (25).

In Brazil, a study done by Rios to evaluate the prevalence and aetiologicaJ factorsinvolved with wear of deciduous dentition, wear on the incisors was diagnosedin 34.8%of children aged 6 years old; 78.1%presented wear in canines and 40.7%in molars. (26). In a study done by Tomasik in Poland to investigate theaetiological factors involved in non-carious cervical lesions in 15-75 year oldpatients, TSL on all surfaces of the tooth, including cervical, was related to ageand the ranges were 25-60%.Older patients were more likely to exhibit NCCL.NCCL was more common in premolars with a mean of 85.1%.(27).A study doneby Piotrowski in Indianapolis USA to determine the prevalence andcharacteristics of abfraction-like cervical lesions in US war veterans, 78.1percentreported using a brushing technique that is known to cause toothbrush abrasionin the affected area. (28). Although different indices have been used, it isapparent from the literature review that TSL is prevalent in many countries andaffects both males and females. It also manifests in children and adults.

Review of the literature reveals the fact that many different tooth surface lossindices have been developed for clinical and laboratory use all over the world.The earliest indices shared common, arbitrary criteria, relying on descriptiveterms such as slight, mild, moderate, severe and extensive. Bardsley et al. (29)pioneered a new, simplified version of TWI (30) when carrying outepidemiological studies on large numbers of adolescents in North West England.Subjects were then grouped together to produce three classifications: no or mildwear-no score less than I, moderate wear-a score of 2. Severe tooth wear- 3.(Table 1). This index will be used in the study.

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Table1: Simplified scoring criteria for TWI (30)

IScoreI,.., • .

I!GlNowear into dentine

- -- ... -. -.--- - -.. - - -- ,=---- ~

1Dentine just visible (including cupping) or dentine exposed for lessIthan1/3 of surface

2 ntine exposure greater than 1/3 of surface

113 Exposure of pulp or secondary dentine

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PROBLEM STATEMENT

Tooth surface loss is a growing concern in these modern times especially erosionwhich is somewhat related to eating habits. A large majority of tooth surface lossis preventable. Tooth surface loss manifests in different ways and can progress, ifnot intercepted early, to destroy the tooth structure. Like dental caries it shouldbe given the much needed awareness. It is important to prevent anydevelopment of tooth wear; if there is any tooth wear that has began to takeplace, efforts should be made by both the dentist and the patient to arrest theprocess as soon as it is noted. This is especially in children and adults so as toprevent premature tooth loss. Tooth surface loss is also reversible in the earlystages.

JUSTIFICA TION OF THE STUDY

Few studies done previously in Kenya clearly show the prevalence and severityof tooth surface loss in adults, yet it is one of the reasons for patient presentationto the dentist and early tooth loss due to sensitivity as a result of dentineexposure. World wide, few studies have been conducted, as well and there is nodefinite method of quantifying the degree of tooth wear. There is a need togenerate knowledge in this area.

Due to the scarcity of information on the epidemiology of tooth surface lossstudies, it is necessary to carry out studies, which will enable both the dentistand patient to promote better diet control, to take note of abnormal habits andillnesses that may negatively affect the status of the dentition. The data collectedwill aid in formulation of awareness, treatment and management plans that areaimed at prevention, control and treatment of tooth surface loss.

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