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Canadian Journal of Applied Sciences; 2012; 2(1): 222-232, January, 2012 Intellectual Consortium of Drug Discovery & Technology Development Inc. ISSN 1925-7430 Available online http://www.canajas.com Original research article DENTAL EROSION; INFLUENCING FACTORS & PH ANALYSIS Muhammad Wasif Haq1, Batool M.2, Ahsan S.H.3, Lone M.A.4, Islam T5 (1) B.D.S. ,Demonstrator in Department of Periodontology ,Islamic International Dental Hospital,Islamabad, Pakistan. (2) B.D.S., Demonstrator in Department of Community Dentistry, Liaquat College of Medicine

& Dentistry, Karachi, Pakistan. (3) M.Sc, Assistant professor Oral Pathology, Liaquat College of Medicine & Dentistry,

Karachi, Pakistan. (4) Senior registrar in Department of Prosthodontics, Liaquat College of Medicine & Dentistry,

Karachi, Pakistan. (5) Lecturer, National Business School, National University of Science & Technology,

Islamabad, Pakistan. ABSTRACT: Aims: The primary aim of the study was to determine causative factors involved in dental erosion in patients coming for regular dental checkup at Liaquat college of medicine and dentistry, Karachi, Pakistan and to secondarily determine the initial pH of various solutions having potential for dental erosion (soft drinks, fruit based drinks and mouthwashes) and compare it with pH of

mineral water. Methods: A total of 100 participants completed a questionnaire that assessed patient age, gender, presence of extra oral symptoms (acidity, burning chest pain and vomiting), dental sensitivity, dry mouth, type of drink consumed, frequency of beverage intake, citrus fruit consumption and use of mouthwash. Dental examination was performed to assess dental erosion and the lesions graded according to Basic erosive wear examination (B.E.W.E.) index. For pH analysis, 2 samples from 14 different brands of soft drinks, fruit based drinks and mouthwashes were selected. The initial pH was recorded for a standard volume of 100 ml at 250 C by electronic pH meter at Husein Ebrahim Jamal (H.E.J.)labs, Karachi, Pakistan. The tests were repeated twice for every sample and the average pH was calculated and compared with the pH of commercially available mineral water

(control). 222

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Results: A total of 58 patients had erosion. Significant risk factors for dental erosion were increasing age, presence of extra oral symptoms, dry mouth, frequency of beverage intake and citrus fruits consumption (p0.05).The pH analysis revealed pH of all the tested samples within acidic range. Only two mouthwashes and mineral water had pH above 5.5.The tested samples on the basis of decreasing acidity were of the following order: soft

drinks< fruit based drinks< mouthwashes< mineral water. Conclusion: The results from this study indicated increasing age, presence extra oral symptoms, dry mouth, frequency of beverage intake and citrus fruit consumption to be strong risk factors for dental erosion. Soft drinks and fruit based drinks had sufficiently low pH that could cause tooth

dissolution while mouthwashes and mineral water (control) were found to be less acidic. Keywords: Dental erosion; influencing factors, pH analysis Correspondence: Dr.Muhammad Wasif Haq, Islamabad, Pakistan. Tel.: +923472000477, Email:

[email protected] INTRODUCTION: 1

Dental erosion is defined as loss of tooth substance by acid exposure not involving bacteria . Dental erosion is multifactorial in its etiology and is dependant on the interplay of various chemical, biological and behavioral factors. The chemical factors include pH of the acid, titrable acidity (amount of base needed to neutralize the acid) and the mineral content. The biological factors comprise of factors such as the presence of acquired pellicle (layer of salivary proteins deposited on the tooth surface which if not removed converts to dental plaque later), tooth structure and it’s relation to soft tissues, whereas the behavioral factors embrace eating and drinking habits, abnormal swallowing patterns such as swishing the drink in mouth and dehydration secondary to regular exercise and alcoholism. All these factors have been linked to play a role in the progression of dental erosion2. A variety of acids based on the source of their origin have been implicated in the etiology of dental erosion. These acids have been classified either as intrinsic/endogenous acids such as in acid regurgitation, Gastro esophageal reflux disease (G.E.R.D.) and vomiting or extrinsic/exogenous acids that are primarily obtained through dietary foodstuff such as cold drinks, citrus fruits, fruit juices and other acidic food substances. The recent data indicates that the consumption of acidic drinks such as cold drinks and fruit juices has risen particularly amongst the young with a subsequent increase in the dental erosion as well with major contribution by the extrinsic acid exposure3,4. Studies on the prevalence of dental erosion in children and adolescent from various countries such as U.S.A. 5, U.K. 5, Germany7, China8, Sudan, Saudi Arabia9 and Australia10 have

yielded dental erosion to be in a range of 31-74.1% 11. The acids either found in diet or derived from intrinsic sources can cause tooth dissolution if the pH of the acid is less than 5.5; the critical pH below which tooth starts to dissolve12. Generally the less the pH, the more mineral loss will occur from tooth surface13. Hence it has been asserted that the erosive potential of the acidic drinks is dependant on the pH and the buffering capacity of the

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drink3. However several studies have failed to demonstrate any significant association between the 14

consumption of low pH substances and dental erosion . Therefore the primary aim of the study was to determine causative factors for dental erosion in patients attending dental O.P.D. in Liaquat College of Medicine and Dentistry, Karachi, Pakistan and secondarily to determine the initial pH of various soft drinks, fruit juices, and mouthwashes

and compare it with the mineral water used as a control. MATERIALS AND METHODS: The study design was observational. This study was conducted in Liaquat College of Medicine and Dentistry, Karachi, Pakistan from the months of July to August 2011. Patients with permanent dentition and having all teeth present except 3rd molars in four quadrants of the mouth were selected and asked to fill the questionnaire (See Appendix 1). Patients with acute dental pain or

infection were excluded. A total of 100 participants aged 17- 70 years (subcategorized into three clusters; 17-30 years, 3150 years and 51-70 years of age) completed the questionnaire after which their dental examination was performed using sterilized mirror and dental probe. Reviews on the validity of indices designed to measure dental erosion have not only indicated variation amongst different indices but also pointed out that majority of clinicians underestimated the prevalence of erosion15,16 . In this study the Basic Erosive Wear Examination (B.E.W.E.) index was selected to calibrate grades for erosive lesions. This index has the advantage of not only being simple but it can also be used in conjunction with the diagnostic criteria of all the previous indices. B.E.W.E. index records the most severely affected tooth surface amongst different groups of teeth and categorizes patient in

different levels of erosion; none (if the score is less than or equal to 2), low (if score ranges from 38), medium (if the score ranges from 9-13) and high (if the score ranges from 14 and above). Statistical package for social sciences (S.P.S.S.) version 17 was used for statistical analysis and Chi-Square test was employed to determine association between various factors and dental erosion. The p value of equal to or less than 0.05 was considered significant. For pH testing, a total of fourteen samples of different brands of soft drinks, fruit based drinks, mouthwashes and mineral water were randomly collected (non-probability sampling) from the local stores of Karachi, Pakistan. Two samples were collected for each of the fourteen brands. The soft drinks chosen were Pepsi, Coke, Fanta, Mountain Dew, Sprite, Pepsi (diet) and 7 Up (diet). Following mouthwashes were selected; Listerine, Enziclor, Protect, Aqua Fresh and Ni-Flam whereas amongst the fruit based drinks Pakola apple sidra and Nestle orange juice were taken. As a control, Nestle mineral water was selected. After taking a standard volume of 100 ml of every sample, the initial pH upon immediately opening the bottle was determined. An electronic pH meter (Jenway model 3505) was used to determine the pH at room temperature of 250 C at the laboratories of Husein Ebrahim Jamal (H.E.J.) Karachi, Pakistan. The electrode of the pH meter was dipped in the solution till a constant value of pH was obtained for every sample. The tests were repeated twice for every sample and the mean pH value of different solutions tested was calculated. 224

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Figure 1. Association of various factors with Dental Erosion.

Figure 2. pH values of carbonated beverages, citrus fruits, mouthwashes & mineral water (control). 225

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Figure 3. Association of increasing age with increasing levels of dental erosion. RESULTS The mean age of the participants of this study was 35.48 years (SD 13.37 years). Amongst the 100 people, 62 were male patients and 38 were female patients. The frequency of dental erosion was 58. A total of 42 people were at none risk level , 30 people were at low risk level, 21 people were at medium risk level while 7 people were at high risk level for erosion as calculated by B.E.W.E.

index. DISCUSSION The results from the current study indicate statistically significant association of erosion with increasing age (p0.05). This finding is in accordance to other studies that did not demonstrate any increased risk between males and females in relevance

to dental erosion except one study that indicated erosion to be more common in males 19, 20,21. The presence of extra oral symptoms such as acidity, burning chest pain and vomiting on a chronic basis were found to be significantly associated with dental erosion (p0.05). Many participants in the study reported to experience dental sensitivity yet intra-orally no signs of dental erosion were present. It has been suggested that if dental erosion progresses at a rapid rate the patient may complain of sensitivity, however if the rate of progression is slow then the symptoms may not arise which may explain that not all the patients suffering from dental erosion experience dental sensitivity 23

especially if erosive attack is confined to enamel only

A highly statistically significant association was observed between dry mouth and dental erosion (p0.05). One possible explanation could be that the drinks evaluated had pH well below 5.5 and had sufficient potential to cause dental erosion. A strong determinant for dental erosion was frequency of intake of drinks(p