Prevalence of Dental Erosion in Children from Schools and Dental Clinics: A Cross-Sectional StudyABSTRACT
Objective: To investigate the prevalence of erosion in permanent teeth and associated factors.
Material and Methods: A cross-sectional study was conducted with 208 children aged 8 to 11 years old, from public schools and dental clinics (both private and public). Data collection included a demographic and socioeconomic questionnaire, and questions related to dental erosion, as well as an oral clinical examination. Dental erosion (DE) in permanent teeth was assessed using the Tooth Wear Evaluation System (TWES). Chi-square test, and univariate and hierarchical multivariate Poisson regression were performed.
Results: The overall prevalence of DE was 26%, being more prevalent in children from dental clinics (61.1%; p=0.003), those who consumed soft drinks (62%; p=0.016), and with attrition (51.9%; p=0.049). The sample of children from dental clinics, soft drink consumption, and the frequency of consuming acidic foods and beverages 2 to 3 times a day were suggestive factors for explaining DE (PRadjust=1.864; CI95% =1.072-3.242; PRadjust=2.027; CI95%=1.040-3.951; PRadjust=1.803; CI95%=1.171-2.775). The age of 11 years was revealed as a protective factor against DE (PRadjust=0.420; CI95%=0.196-0.899).
Conclusion: Dental erosion was associated with dental clinic samples, consumption of soft drinks, and the frequency of consuming acidic foods and beverages.
Keywords:
Child; Adolescent; Tooth Erosion; Schools; Dental Clinics.
Introduction
Dental erosion (DE) refers to the demineralization of hard dental tissues due to chemical exposure to non-bacterial acids [1], whose main sources are diet and gastric acid. This type of dental structure loss can be associated with dental attrition and abrasion [2] and is therefore often referred to as erosive tooth wear [3].
When an acid with a critical hydrogen ion potential (pH) for demineralization, i.e., less than 5.5 for enamel and 6.5 for dentin [4], comes into contact with mineralized dental tissue, preferably superficial demineralization occurs. This results in a decrease of mineral ions from the organic matrix of enamel [5], making the dental enamel softened and vulnerable to mechanical forces [6]. In this perspective, there is a loss of dental tissue resulting from the interaction between repeated acid challenges and mechanical forces [5].
Dentin, on the other hand, is a less mineralized tissue than enamel, which makes it more soluble and susceptible to physical wear. Acids dissolve the periand intertubular mineral component while the organic part (collagen matrix, proteins) remains undissolved, maintaining a sponge-like structure. Collagen fibers are degraded by collagenases and other proteolytic enzymes in the oral cavity [7].
The etiological factors involved in DE are categorized into nutritional factors, which depend on the erosive potential of foods and beverages, the ability of the erosive substance to adhere, elevated temperature, agitation of the erosive agent on the tooth, and patient-related factors such as saliva, acquired pellicle, tooth shape and position, medication use, gastroesophageal reflux disease (GERD), vomiting, lifestyle, dietary habits, and excessive oral hygiene [5]. When the causative source of DE cannot be identified, it is classified as an idiopathic origin [8].
Clinically, the initial involvement of enamel by erosion presents a dull appearance. As the process progresses, the enamel begins to appear glossy. In a more advanced stage, only the enamel along the gingival margin of the vestibular and palatal surfaces remains intact. With the loss of enamel, the remaining dental structure shows a yellowish color characteristic of dentin. On the occlusal surfaces of posterior teeth, cusps become rounded and a local defect described as a pit, groove, or crater develops. These excavations become deeper, and the occlusal morphology disappears [1,3] (Figures 1a-c).
a - First permanent molar with a dull appearance indicative of initial DE; Deciduous molars with a dull appearance; worn cusps; excavations in pits and fissures indicating loss of occlusal morphology; and yellowish discoloration (dentin exposure); b - Permanent molar with a glossy appearance, indicating progression of DE; deciduous molars with craters on occlusal surfaces, indicating loss of occlusal morphology; yellowish discoloration (dentin exposure); c - Permanent molar with rounded and worn cusps, characteristic of advanced stage DE; deciduous molars with absent cusp anatomy, wear in the central part of occlusal surface, and yellowish discoloration (dentin exposure).
Children and adolescents are at risk populations for DE, mainly due to the consumption of acidic processed foods and beverages [3]. The worldwide prevalence of DE in these populations varies from 7.2% to 74%, with a global average prevalence of 30% [9]. In some countries like Uruguay and China, DE in children and adolescents is already considered a public health issue, with a prevalence of 52.9% and 75%, respectively [10,11]. In Brazil, population-based cross-sectional studies with schoolchildren have shown a prevalence of DE ranging from 15% to 25.1% [12,13].
Due to the irreversible nature of DE and its consequences, such as hypersensitivity, pulpal involvement, occlusal problems, and aesthetic issues, and considering changes in dietary habits over different decades, it is crucial to explore DE in various populations. Investigating whether different spaces of care for children bring differences in the prevalence of DE allows us to define whether different approaches are necessary. This exploration helps in planning oral health actions and establishing public policies aimed at promoting a healthy and less acidic foods. Thus, the objective of this study was to investigate the prevalence of DE and associated factors in children from schools and dental clinics.
Material and Methods
The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [14].
Ethical Clearance and Study Design
This study was approved by the Research Ethics Committee of CEUMA University (Opinion no. 4,579.418). Informed consent and assent forms were signed by the students and their guardians.
A cross-sectional study was conducted with children aged 8 to 11 years old, from public schools, a private dental office, and a public dental clinic at the Center for Dental Specialties in São Luís, Maranhão, Brazil.
Sample
To participate in the research, children had to be aged between 8 and 11 years old, have mixed dentition with erupted first permanent molars, not have dentin carious lesions, and not have genetic syndromes, neurological disorders, heart conditions, or immunodeficiencies.
A sample calculation was conducted to estimate the difference between two proportions (sample from schools and dental clinics) regarding DE (outcome). The proportional mean was considered for the prevalence parameter of outcome (20.2%) and based on15% of DE for the school sample [12], and 25.4% for DE in the dental clinics sample [2]. A difference to be detected between the groups of 10 and an alpha of 5%. The initial sample size was 123 per group. An adjustment was made for finite population considering patient visits at private and public clinics in the 2nd semester of 2019 (total "N" of 528 children; source of this data: clinical administration), resulting in a final sample size of 100 for each group (school and dental clinics samples). The sample size calculation was performed on the website: http://calculoamostral.bauru.usp.br.
The school sample was obtained through three-stage cluster probability sampling (random selection of schools, classes, and students), with the sample proportionate to 4 health districts (Bequimão, Centro, Cohab, Itaqui-Bacanga). For the dental clinics sample, convenience non-probability sampling was used, forming as children attended for initial dental evaluation.
Data Collection
Data collection was conducted by two researchers (D.M. and D.V.) from June 2019 to June 2021. The research instruments included a demographic and socioeconomic questionnaire (child's gender, age, and race; maternal education and family monthly income); general health, dietary habits, and vomiting episodes (health issues; medication use; consumption, frequency, and manner of acidic food and beverage intake; vomiting episodes; GERD, bulimia, and anorexia); and a clinical record containing the Tooth Wear Evaluation System (TWES) [15].
The questionnaires were answered by the children's guardians, either sent home (school sample) or completed in the clinical setting (dental clinics sample). Subsequently, the children underwent clinical oral examination for the diagnosis of DE in permanent teeth using the TWES [15].
The TWES considers dental wear as a multifactorial condition, with its Qualification Index module assessing clinical signs of DE, attrition, and abrasion. In this study, only the clinical signs for DE were considered: Occlusal "cupping," incisal "grooving," "pitting," rounding of cusps and grooves; Non-occlusal surface wear; Restorations above the wear plane; Wide concavities within the smooth enamel surface limit, flattened convex areas, or concavities become present, width exceeds depth; Increased incisal translucency; Glossy appearance of amalgam restorations; Preservation of enamel "collar" near the gingival margin; Absence of biofilm, discoloration, or tartar; Hypersensitivity; or Smooth glossy appearance, sometimes dulled [15]. Any child showing one of these signs on any tooth was considered to have DE.
The clinical examination of children from schools was conducted in a school classroom, with the examiner seated facing the child and using a headlamp (Petzl Zoom Headlamp, Petzl America, Clearfield, UT, USA). Gauze was used for drying the teeth, a WHO-621 probe (Trinity, Campo Mourão, PA, Brazil) was used for removing food debris and residual dental plaque, and a mouth mirror (Duflex, SS White, Rio de Janeiro, RJ, Brazil) was used for tooth examination. For the dental clinics sample, children were examined under similar conditions as in schools, except they were seated in a dental chair under the light of a dental reflector. Personal protective equipment was used. Children from schools and dental clinics with visible dental plaque underwent tooth brushing before the clinical examination, respectively, in school washrooms and dental clinic facilities.
The researchers were trained and calibrated for TWES, and intraand inter-examiner agreement was analyzed using the Kappa statistic (K=0.85). A pilot study was conducted with 10 children who were not included in the main study.
Data Analysis
The Statistical Package for the Social Sciences (SPSS) (IBM SPSS, version 23.0, IBM Corporation, Armonk, New York, USA) was used for data analysis. Descriptive analysis, bivariate analysis (chi-square test), and multivariate analysis (Poisson regression) were performed. The chi-square test was employed to investigate the association of DE with sample origin; sex; age; maternal education level; family income; health issues; medication use; gastroesophageal reflux; consumption, frequency, and manner of acidic food and beverage intake; and dental attrition. To estimate the strength of association, univariate and hierarchical multivariate Poisson regression models, adjusted with robust variance, were applied. Independent variables were introduced into the adjusted model based on their statistical significance (p < 0.20). Confounding variables (age, sex, and sample origin) for DE were controlled in the model. A significance level of 5% was adopted.
Results
The total sample consisted of 208 children, with 56.3% from public schools and 43.8% from dental clinics. For the total sample, the prevalence of DE was 26%. DE was more prevalent in children from dental clinics (61.1%) and significantly associated with sample origin (p=0.003) (Table 1).
Distribution of sample frequency and prevalence of DE according to sample origin, demographic, and socioeconomic characteristics.
DE was significantly associated with soft drink consumption (p=0.016) and dental attrition (p=0.049) (Table 2).
Distribution of sample frequency and prevalence of DE according to aspects related to general health, acidic foods and beverages, and dental attrition.
Table 3 presents the data from Poisson regression, showing that the sample from dental offices, soft drink consumption, and the frequency of consuming acidic foods and beverages 2 to 3 times per day were suggestive explanatory factors for DE (PRadjust=1.864; p=0.027; PRadjust=2.027; p=0.038; PRadjust=1.803; p=0.007). The age of 11 years was revealed as a protective factor against DE (PRadjust=0.420; p=0.026).
Univariate and hierarchical multivariate Poisson regression assessing the association between DE and independent variables.
Discussion
This study evaluated the prevalence of erosion in permanent teeth and associated factors. DE was significantly more prevalent in children originating from dental clinics (61.1%) and those who consumed soft drinks (62%). The dental clinic sample, soft drinks consumption, and consuming acidic foods and beverages 2 to 3 times a day were suggestive factors of explaining DE. The age of 11 years was a protective factor against DE.
The total prevalence of DE (26%) found in the present study corroborates the prevalence findings (25.1%) of a population-based cross-sectional study conducted by Salas et al. [13]. Other cross-sectional studies have found a prevalence of DE ranging from 15.0% to 52.9% [11,12,16]. In the present study, the consumption of soft drinks in relation to the occurrence of DE explains the significant prevalence observed.
Regarding the prevalence of DE in the studied groups, the prevalence was significantly higher in the dental office sample (61.1%). Among the offices, children treated in public offices were more affected (40.7%). In a clinical sample study conducted by Corrêa et al. [2], the prevalence was much lower (25.4%) than in the present study. Factors such as age group, the index used for the diagnosis of DE, type of tooth, sample size, and factors involved in the etiology of DE may account for the differences found.
According to data from literature, the prevalence of DE increases with age [17]. However, in the present study, age was not associated with DE. Similarly, there was no difference between genders, unlike findings from population-based studies where males were significantly more affected by DE [11,12]. In those studies [11,12], male sex was a predictor of DE. Differences between sexes are attributed to physical, behavioral, and lifestyle characteristics. Stronger masticatory muscles and greater bite force exhibited by boys [18] may be related to a higher prevalence of DE on occlusal surfaces. Additionally, boys are more engaged in physical activities, which can affect the quantity and consequently the quality of their saliva [19].
DE is a complex, multifactorial process [7,20], where biological factors (chronic diseases, GERD, tooth mineral composition), chemical factors (saliva flow and buffering capacity, pH of foods and medications), and behavioral factors (eating disorders, dietary habits, and lifestyle) may be present and contribute to exacerbation. Therefore, assessing individual risk and severity of DE is necessary [1,21].
The overall prevalence of consuming acidic foods and beverages (88%), specifically soft drinks (62%), citrus fruits and natural juices (62%), and artificial juices (40.4%) was significant. Besides pH and the adherence capacity of acidic foods and beverages to teeth, other factors influence the erosive potential of foods, such as calcium and phosphate content. If an acidic solution contains calcium and phosphate, it alters the saturation degree, becoming supersaturated relative to tooth mineral, preventing the tooth from losing minerals to the oral environment and thus preventing DE, even in an acidic oral environment. An example of food under these conditions is yogurt, which, despite its low pH, typically contains sufficient calcium and phosphate to cause supersaturation and prevent tooth mineral dissolution [10].
In a population-based study conducted by Loureiro et al. [11] with 12-year-old adolescents, consuming yogurt 3 times or more per day was significantly associated with DE (OR=3.98, 95% CI=1.18-13.47). Although only 3.9% of the sample consumed yogurt 3 times or more daily, the authors emphasize that due to the high frequency of consumption, the low pH of yogurt products could pose a considerable challenge to the protective effect attributed to the calcium present in the food.
The consumption of acidic foods or beverages was not associated with DE, consistent with the findings of Salas et al. [13] in a study involving children and/or adolescents. In the present study, it is believed that the lack of association is due to the small number of children, preventing a true result from being observed.
Regarding soft drinks, cola-based ones, conventional or sugar-free, have a higher erosive potential due to their low pH (around 2.30), low concentration of calcium and fluoride, and stronger adherence to dental enamel compared to saliva, preventing their displacement from the enamel surface by saliva [6].
In the present study, children who consumed soft drinks exhibited a higher prevalence of DE, with the consumption of these drinks being a significant predictor of DE (RP = 2.037). Similar findings were reported by Corrêa et al. [2] and Alves et al. [12], and subsequently consolidated in a systematic review by Li et al. [22]. In the clinical sample study, children who consumed soft drinks frequently had 2.43 times higher odds of DE [2]. A similar finding was observed in a population-based cross-sectional study with 12-year-old schoolchildren. In this study, schoolchildren who reported soft drinks consumption were more likely to have at least one tooth with DE (OR=5.04; 95% CI=1.17-21.71) [12].
In this study, GERD was reported in 5 children, of whom 3 had DE. GERD can be present without symptoms, known as "silent reflux," and should be suspected in the presence of erosive lesions of idiopathic cause [18], although non-acid reflux is more common in children compared to adults. Therefore, a diagnosis of GERD in a child with DE may not necessarily indicate it as the source of dental wear, suggesting that extrinsic factors may be responsible for the erosive process [23,24].
Of the 52 children with DE, only five had health problems, and only two were using medications, which explains the lack of association between these variables and DE. Liquid medications for children, used continuously to treat chronic disorders, often have low pH, high titratable acidity, and high viscosity, which have erosive effects on dental structure [25,26]. Therefore, due to the use of medications with these characteristics, a significant association between asthma and DE has been observed [27]. The acids present in these medications have a dual erosive action, either through the action of hydrogen ions or the action of acidic anions (such as citrates) that can form complexes with calcium, reducing saliva supersaturation and leading to the dissolution of enamel crystal surfaces [28]. It is worth noting that asthmatic patients who use medication may not have erosive lesions, just as asthmatic patients who do not use medication. This indicates that the cause of DE is not always the asthma medication.
In addition to factors related to foods that modulate the erosive process, saliva also influences this process. Although saliva has a remineralizing effect on demineralized dental tissue, its ability to repair mineral losses becomes limited if acid challenges are frequent. As surface alterations increase with frequent acid challenges, saliva's ability to reverse them diminishes because it becomes undersaturated with respect to hydroxyapatite and fluorapatite [12,13].
This study has limitations that should be acknowledged, such as its cross-sectional design, which does not establish a cause-and-effect relationship. Although the clinical examination of children from the dental office and school samples was conducted in different settings (under reflector light in offices and headlamp light in schools), other conditions were standardized, including drying teeth with gauze, using a mouth mirror, and a WHO probe. The study's strengths included the probabilistic cluster sampling process for selecting schools in the researched districts, which allows for generalizing findings to the target population and validating the establishment of educational and preventive measures for this population.
Since erosive challenge causes irreversible superficial tissue loss, educational and preventive actions to control the process are necessary. Therefore, the role of professionals in private and public healthcare networks, as well as school teachers, is essential in educating patients and students about the consequences of frequent consumption of acidic foods and beverages, especially acidic liquids, on tooth structure.
Conclusion
Dental erosion was associated with dental clinic sample, soft drinks consumption, and frequency of consuming acidic foods and beverages.
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Financial Support
None.
Acknowledgments
The authors would like to thank the children and their guardians for agreeing to participate in this research.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Alidianne Fábia Cabral Cavalcanti
Publication Dates
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Publication in this collection
08 Dec 2025 -
Date of issue
2026
History
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Received
26 July 2024 -
Reviewed
30 Jan 2025 -
Accepted
20 Mar 2025
