The Awareness of Dental Erosion and Its Causes and Protective Factors Among a General Adult Population of Trinidad and Tobago

Introduction

Tooth wear has been recognized as an emerging public health problem given the increasing prevalence of tooth wear in various geographic locations worldwide.^1–3 In considering tooth wear as a public health problem, strategies for population-based education and advice and preventive approaches by the clinical dental team can be developed and adopted.¹ Tooth wear is multi-factorial in etiology with up to 20% of cases showing clinical features of dental erosion, attrition, and abrasion.⁴ While abrasion and attrition result from complex tribological mechanical interactions; chemical erosion, or the loss of hard tissue that occurs when dissociated hydrogen ions interact with hydroxyapatite of enamel, has been shown in in-vitro studies to exacerbate the tissue loss associated with attrition and abrasion.⁵

Given the importance of dental erosion in the overall pathology of multifactorial tooth wear, an awareness of dental erosion, the common etiological causes of erosion, and factors or habits that could prevent dental erosion in the general population are necessary. Cross-sectional research among 20-25-year-old patients attending dental practices in The Netherlands revealed inconsistencies in this younger population’s knowledge about erosive tooth wear.⁶ Young adults sampled in this study preferred receiving information on erosive tooth wear from oral health care professionals.⁶

In a study of erosive tooth wear knowledge in a dental school in Brazil, dental students and faculty were aware of eating disorders and an acidic diet as the main etiological causes of erosive wear however patients erroneously identified poor oral hygiene and bacteria as etiological factors of erosive tooth surface loss.⁷ These findings were unchanged from an earlier study by the same authors where patients had the same misconceptions of the etiological factors of erosive tooth wear.⁸

This study aimed to investigate the awareness of dental erosion, its causes, and protective factors among a general adult population of Trinidad and Tobago. The null hypothesis stated there would be no difference between responses on causative or protective factors based on age, sex, or geographical location.

Methods

A 28-item anonymous de-novo questionnaire, developed using Google Forms (https://www.google.com/forms), was subjected to face validity to ensure the inclusion of content relevant to erosive tooth wear and clarity of items intended for a general population. The questionnaire was aligned with the CHERRIES framework for web-based surveys.⁹ Informed consent was incorporated into the electronic-based questionnaire. Three items collected demographic data of age range, sex, and geographic location. Four items enquired about previous diagnoses of any type of tooth wear, self-diagnosis of erosive wear, differentiation with dental caries, and assessed awareness of sensitivity associated with erosive wear. Twelve items presented common foods and beverages associated with an increased incidence of dental erosion. Three items assessed the knowledge of common habits or conditions that could influence the severity of dental erosion, and five items assessed the knowledge of protective factors that could prevent or stabilize dental erosion. All items were presented over three pages, with respondents having the ability to use the “back” function to review and change answers if required. All 24 research items related to awareness were presented on a single page. Respondents were asked to provide yes/no/don’t know responses to these items to ascertain the level of awareness regarding identifying erosive wear, differentiating dental erosive lesions from dental caries, the etiological causes of dental erosion, or protective factors.

Ethical approval was gained from the Campus Research and Ethics Committee of the St. Augustine Campus of The University of the West Indies (CREC 2402//11/2023) and the Ministry of Health of Trinidad and Tobago before deployment to nine community forums on social media platforms (Facebook and WhatsApp). Ethics approval was gained from the Ethics Committee of the University of the West Indies on the 16^th November 2023 while ethics approval was attained from the Ministry of Health on the 8^th February 2024.The social media groups were chosen since they included membership specific to specific geographical regions across Trinidad and Tobago. Individual administrators of each of the groups gave consent for the questionnaire to be posted in the social media groups. The questionnaire was deployed as an open survey where any participants of the identified groups could participate. Adults 18 years and older, who are members of these groups, were invited to participate in the study. The questionnaire’s preamble stated that dentists, dental auxiliaries, and dental students should not participate. Participation was voluntary and members of these groups could opt out of participating. No incentives were offered for participating in the research. The survey was deployed and accepted responses for 4 months. Following data collection, responses were downloaded and entered in SPSS (Social Sciences for Statistical Research, Version 29, IBM, Chicago). Demographic data and data on awareness of tooth wear, erosive wear, sensitivity, and differentiation with caries were presented descriptively.

Responses on causative and protective factors were cross-tabulated with demographic data and analyzed using Chi-squared test at an alpha level of 0.05. Responses of ‘don’t know’ and ‘no’ to assess knowledge on causative and protective factors were combined before statistical analysis. Significant cross-tabulations were further analyzed using a post-hoc Bonferroni adjustment at an alpha level of 0.05.

Results

Discussion

Foods and beverages with low pH are known to cause the loss of dental hard tissue through an erosive mechanism. Frequent and prolonged consumption of low-pH foods and beverages or exposure to gastric contents causes the loss of hydroxyapatite from the surface of the enamel, softening of the surface, and susceptibility of the eroded surface to further loss caused by the physical forces of attrition or abrasion.^5,10 Early erosive wear involves enamel and is unlikely to be self-diagnosed by persons. The finding that 43.1% of respondents felt they could self-diagnose erosive wear could indicate moderate or severe wear involving dentine in these respondents. This figure is in variance from the work of Rafeek et al who found 20% of a Trinidadian patient sample exhibited moderate and severe wear combined.¹¹

Tooth sensitivity is often the initial symptom of tooth wear.¹² With erosive wear, sensitivity may signal exposure of dentine, which may be the impetus for seeking professional dental care. With 62.9% of respondents recognizing sensitivity as a symptom of erosive tooth wear, this awareness can provide an opportunity for preventive approaches such as over-the-counter or in-office desensitizing agents.

Across the entire sample, more than half the respondents knew the various etiological agents and medical conditions that could result in erosive tooth wear, including, gastro-esophageal reflux, eating disorders (GERD), conditions that cause excessive vomiting, apple cider ingestion, excessive soda consumption, and citrus consumption. GERD and other conditions that bring gastric contents into contact with the oral cavity are known causes of erosive tooth wear.¹³ Sodas, citrus, and fruit juices with low pH frequently consumed over long periods can also cause erosive tooth wear.¹⁴ Surprisingly 53.8% of respondents did not know excessive wine consumption could cause dental erosion while 50% of respondents did not know excessive pickled fruits and vegetables could cause dental erosion. The lack of awareness of the erosive potential of wine could be cultural since wine drinking is not widespread in Trinidad and Tobago. Interestingly 50% of respondents answered a combined no/don’t know when addressing the item on consumption of lemon water.

Most respondents had the misconception that sugary foods and beverages could cause erosive tooth wear. This aligns with the findings of Hermont et al where 74.9% of Brazilian respondents believe sugar consumption was an etiological cause of tooth erosion.⁷ While there is cause for concern for this misconception from an educational standpoint, many sugared soda drinks are a risk factor for dental erosion.¹⁵ Respondents correctly identified excessive soda consumption as an etiological factor in dental erosion. A holistic approach when giving dietary advice to optimize oral health can be used, advising patients on the oral health benefits of reduced consumption of sodas in terms of reduction of dental caries and dental erosion.

Apple cider vinegar has gained popularity as a homeopathic remedy for several medical conditions; however, it has been shown to have the effect of accelerated erosion of dental hard tissue in clinical studies despite not affecting resting salivary pH.¹⁶ Approximately 40% of respondents either did not know or answered negatively that apple cider vinegar did not cause erosion. Given that apple cider vinegar has been shown in in-vitro studies to be several times more likely to cause dental erosion than soda, targeted education in the Trinidadian population, across all ages, on its erosive potential is required. Conversely, age-specific education, particularly in the 18-30-year age group is required for questionnaire items that had significant Chi-squared tests when cross-tabulated with age.

More than 50% of respondents did not know or answered negatively on the other factors that may influence the erosive potential of foods and beverages. These included consumption habits, consumption temperature, and alterations in saliva. Nuanced consumption habits of erosive beverages such as “swish and swallow” or holding the beverage in the mouth to feel the bubbles associated with carbonated beverages have been postulated to have an even greater erosive potential.^17,18 The temperature at which beverages are consumed may also affect their erosive potential with researchers showing variations in pH and titratable acidity because of temperature changes.^17,19 Alterations in the quality or quantity of saliva due to medical conditions or medication use could also influence the normal buffering capacity when acidic food and beverages are consumed.²⁰

The authors intentionally replaced the term “GERD” with “Heartburn”, in a duplicate item, believing some respondents would be confused by the medical term and used a term familiar to laypersons, despite “Heartburn” being a symptom of “GERD”. The authors expected similar responses to both items. Surprisingly, 64.8% of respondents did not know heartburn could cause erosive wear compared to 46.2% of respondents who were unaware GERD could cause erosive wear. Some authors have claimed erosive wear is directly proportional to contact of teeth with stomach contents and concluded that dental professionals should be part of multi-disciplinary teams that can provide information on the severity of GERD.^13,21 In this population, dental professionals may have a role to play in the education and referral of patients to medical professionals when patients complain of heartburn where there is clinical evidence of dental erosion.

The concentration of calcium, phosphate, and fluoride ions in foods or beverages is an important modulating factor in the erosive mechanism.²² The erosive potential of beverages can be influenced by the degree of saturation of calcium and phosphate ions at the tooth-beverage interface.²³ Knowledge was poor, related to these protective factors, across all age groups, except for the item on increasing fluoride as a preventive approach in stabilizing or reducing dental erosion. There was a misconception across all age groups that brushing immediately following an erosive challenge could prevent erosion. These results align with research completed in a UK population but are of concern since research has demonstrated immediate brushing after an erosive challenge can exacerbate hydroxyapatite loss from the surface of softened enamel.^24,25

The study relied on the participation of members from various social media groups and may not be representative of the broader population. Data on prior diagnosis of tooth wear, identification of erosive wear, and differentiation from dental caries were self-reported by respondents. This introduces potential biases such as recall bias or social desirability bias, where respondents may provide responses, they perceive as favourable. The study’s findings may not be generalizable beyond Trinidad and Tobago. Cultural and socioeconomic factors not represented in the sample could influence awareness and knowledge levels differently. Further research would include re-examining the Tobago population using a different methodology for sampling respondents and an awareness of the socio-economic factors that could influence the awareness and knowledge of erosive tooth loss.

Conclusion

The null hypothesis was rejected since it was determined there were significant differences in the knowledge of causative and protective factors of dental erosion among respondents in the various age categories and geographical locations. When it came to the awareness of medical conditions that cause dental erosion, there were significant associations with age. Of concern was the lack of knowledge concerning many common causative and protective factors associated with dental erosion, specifically the types of foods and beverages that could cause erosion or factors that could worsen or mitigate dental erosion. Oral health care knowledge, as it pertains to the causative and protective factors associated with dental erosion, needs to be improved as it can form the basis for prevention in the general population and in dental care settings in Trinidad and Tobago.