1. No category

B3 (14)
SELF-INDUCED VOMITING AND DENTAL EROSION – A
CLINICAL STUDY
&
ASSOCIATION BETWEEN HARMFUL ALCOHOL USE AND
PERIODONTAL STATUS ACCORDING TO GENDER AND
SMOKING
&
EARLY CHILDHOOD CARIES AND ITS RELATIONSHIP
WITH PERINATAL, SOCIOECONOMIC AND NUTRITIONAL
RISKS
Approved for 2 Continuing Educational Units.
Uhlen et al. BMC Oral Health 2014, 14:92
http://www.biomedcentral.com/1472-6831/14/92
RESEARCH ARTICLE
Open Access
Self-induced vomiting and dental erosion – a
clinical study
Marte-Mari Uhlen*, Anne Bjørg Tveit, Kjersti Refsholt Stenhagen and Aida Mulic
Abstract
Background: In individuals suffering from eating disorders (ED) characterized by vomiting (e.g. bulimia nervosa),
the gastric juice regularly reaches the oral cavity, causing a possible risk of dental erosion. This study aimed to
assess the occurrence, distribution and severity of dental erosions in a group of Norwegian patients experiencing
self-induced vomiting (SIV).
Methods: The individuals included in the study were all undergoing treatment at clinics for eating disorders and
were referred to a university dental clinic for examinations. One calibrated clinician registered erosions using the
Visual Erosion Dental Examination (VEDE) system.
Results: Of 72 referred patients, 66 (63 females and three males, mean age 27.7 years) were or had been
experiencing SIV (mean duration 10.6 years; range: 3 – 32 years), and were therefore included in the study. Dental
erosions were found in 46 individuals (69.7%), 19 had enamel lesions only, while 27 had both enamel and dentine
lesions. Ten or more teeth were affected in 26.1% of those with erosions, and 9% had ≥10 teeth with dentine
lesions. Of the erosions, 41.6% were found on palatal/lingual surfaces, 36.6% on occlusal surfaces and 21.8% on
buccal surfaces. Dentine lesions were most often found on lower first molars, while upper central incisors showed
enamel lesions most frequently. The majority of the erosive lesions (48.6%) were found in those with the longest
illness period, and 71.7% of the lesions extending into dentine were also found in this group. However, despite
suffering from SIV for up to 32 years, 30.3% of the individuals showed no lesions.
Conclusions: Dental erosion commonly affects individuals with ED experiencing SIV, and is more often found on
the palatal/lingual surfaces than on the buccal in these individuals, confirming a common clinical assumption.
Keywords: Dental erosion, Eating disorders, Vomiting
Background
Eating disorders (ED) are conditions characterized by
restricted food intake or binge eating, and often by selfinduced vomiting (SIV). In addition to having the potential to impair both physical health and psychosocial
functioning [1], these disorders could also have an impact on oral health. Among oral complications is dental
erosion, an irreversible loss of tooth substance as a consequence of exposure to acids that do not involve bacteria [2]. Such acids may enter the oral cavity from
extrinsic (e.g. acidic foodstuff ), as well as from intrinsic
sources (gastric acid).
* Correspondence: [email protected]
Department of Cariology, Institute of Clinical Dentistry, Faculty of Dentistry,
University of Oslo, PO Box 1109, Oslo N-0317, Norway
The prevalence of ED has been studied in different countries. A nationally representative survey from the U.S. estimated that the lifetime prevalence of ED ranged from
0.6 – 4.5% among adults [3] and from 0.3 – 0.9% among
adolescents [4]. According to questionnaire-based, epidemiological studies in Norway, the lifetime prevalence of
any ED among adolescents was found to be 12.5% [5], and
of anorexia nervosa (AN) and bulimia nervosa (BN)
among adult females 0.4% and 1.6%, respectively [6]. A recent study in Finland reported that the lifetime prevalence
of AN among young adults was 1.3% and of BN 1.1% [7],
whereas a large German study found the prevalence of AN
and BN among children and adolescents to be 0.14% and
0.11%, respectively [8].
Significant higher values of erosive tooth wear have
been found in patients suffering from ED compared to
© 2014 Uhlen et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Uhlen et al. BMC Oral Health 2014, 14:92
http://www.biomedcentral.com/1472-6831/14/92
control groups [9-15]. Johansson et al. [15] found that
patients with ED had an 8.5-times increased risk of having dental erosion compared to healthy controls, and
that individuals with a longer history of ED had lesions
more frequently.
An obvious risk factor considering dental health in
individuals suffering from BN, certain forms of AN or
other EDs, is repeated vomiting. The stomach content,
which can have a pH close to 1 [16,17], repeatedly reach
the mouth and may be destructive to the tooth substance [11]. Recent studies have shown more dental erosive wear among adolescents reporting vomiting [15,18],
and that these individuals have a 5.5-times higher risk of
dental erosions than those without such behaviour [15].
As emphasized by Hellstrom [19], eating disorders are
serious and potentially fatal conditions, where the implications on dental health are reasonably not considered
among the most important. However, although many of
the physical manifestations of these disorders are reversible, those affecting the teeth’s hard tissue are not [20,21].
Dentists play a significant role in identifying, preventing
and treating dental erosion, and it is therefore important
to be aware of risk indicators associated with this condition. A common apprehension among clinicians is that
dental erosions are typically localized on the palatal surfaces of the upper front teeth in patients with vomiting or
regurgitation, while erosions on the buccal or facial surfaces may be a result from high consumption of highly
acidic foods and drinks. Although there is some support
for this in the literature, [9,10,17,19,22-25], several of these
studies have limitations. Three of the studies have a low
number of participants included [19,22,24], and calibration
of examiners prior to onset of the studies was performed
in only one study [23]. In addition, two of the studies
did not distinguish between enamel and dentine lesions,
making the severity assessment of the erosions difficult
[10,25]. This complicates the examiners’ ability to monitor the progression of the lesions.
It is often assumed by clinicians and researchers that
ED patients have an increased risk of developing dental
erosion. However, more information about dental erosions in this risk group is required in order to adequately
prevent and treat them. Therefore, the aim of this study
was to assess the occurrence, distribution and severity of
dental erosions in patients suffering from eating disorders characterized by self-induced vomiting, and the
possible association between dental erosions and the
duration of the eating disorder.
Methods
Participants
The individuals included in the study were all undergoing psychiatric and/or medical outpatient treatment at
clinics for eating disorders during 2005 – 2013. Because
Page 2 of 7
of the assumed relation between eating disorders and
dental problems, all patients at these clinics were offered
a referral for a dental examination. The patients who
were interested were then offered a dental examination
at a university dental clinic (University of Oslo, Norway).
The eating disorder diagnoses were made by the professional team at the eating disorder clinics. Of 72 referred
patients examined at the university dental clinic, 62 had
been diagnosed with BN, eight with AN, one with bingeeating disorder (BED) and one with an unspecific eating
disorder. Self-induced vomiting was, or had been, a part
of the eating disorder for 67 patients, and only these individuals were further studied. After the examination,
one additional individual was excluded from the study
because of crowns and onlays on all lower molars and
upper front teeth.
Interview
Prior to the dental examination, each patient was interviewed by one examiner. The standardized interview was
based on questions from a previously tested questionnaire [26,27], and discussed the patient’s present medical
condition, other diseases/diagnoses and medical history.
In addition, the examiner asked each patient about their
dietary habits, such as consumption of acidic beverages
and foods. This consumption was assessed by frequency
questions with five possible responses: several times
daily, once daily, 3–5 times weekly, 1–2 times weekly
and less than once weekly. The participants were also
asked if they vomited after eating, and if so, how often
(daily, several times weekly, monthly and occasionally)
and how long time since the last episode of vomiting.
The duration of self-induced vomiting was recorded
during the interview, with three possible responses: 3–7
years, 8–10 years and more than 10 years duration of
self-induced vomiting. Only a few participants specified
the time of last episode of vomiting, and because this
ranged from weeks to years, it was therefore not further
considered in the study. The frequency of SIV was registered as times of vomiting per week, and ranged from
two to 210 times per week.
Calibration and clinical examination
The intra-oral clinical examination was performed by one
previously calibrated clinician (AM). The examiner was
calibrated with four other clinicians (intra- and interexaminer agreement values of mean κw = 0.95 and mean
κw = 0.73; range 0.71 – 0.76, respectively). For more details
see Mulic et al. [28].
The clinical examination was performed in a dental
clinic with standard lighting, using mirrors and probes.
Access saliva was removed from the teeth with compressed air and cotton rolls. The lingual/palatal and buccal surfaces of all teeth, and the occlusal surface of
Uhlen et al. BMC Oral Health 2014, 14:92
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Page 3 of 7
premolars and molars, were examined. For severity grading of dental erosion, a well established scoring system
with the ability to diagnose early stages, as well as more
advanced stages of erosion, was required. Scoring of dental
erosion was therefore performed according to the Visual
Erosion Dental Examination (VEDE) system [27-29]: Score
0: No erosion; score 1: Initial loss of enamel, no dentine
exposed; score 2: Pronounced loss of enamel, no dentine
exposed; score 3: Exposure of dentine, < 1/3 of the surface
involved; score 4: 1/3-2/3 of the dentine exposed; score
5: > 2/3 of dentine exposed. The number and distribution
of affected teeth and surfaces were also registered. When
surfaces were either filled, repaired with a crown or a veneer, affected by attrition or abrasion, or the tooth had been
extracted, the surfaces and teeth were recorded as missing
and excluded.
Ethical considerations
The study was approved by the local Regional Committee for Medical Research Ethics and The Norwegian Social Science Data Services. Written, informed consent
was obtained from all participants.
Statistical analysis
The statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS, Chicago, IL,
USA, version 20). Presence of dental erosive wear was
used as the dependent variable. Frequency distributions,
descriptive and bivariate analyses (Chi-square test) were
conducted to provide summary statistics and preliminary
assessment of the associations between independent variables and the outcome.
The level of significance was set at 5%.
Results
Participants
Of the 66 individuals included, 63 were female and
three were male, with a mean age of 27.7 years (range:
20 – 48). Two participants did not answer the question
regarding the duration of their eating disorder, but for
the remaining 64 participants, the mean duration of the
disorder was 10.6 years (range: 3 – 32 years).
Prevalence, severity and distribution of dental erosions
Of the 66 individuals included in the study, 20 (30.3%)
showed no signs of dental erosions. The mean age of
these individuals was 27.7 years (range: 20 – 48) and the
duration of ED ranged from 3 to 32 years (mean: 10.6).
Of the 46 individuals with dental erosion, only 43 answered the question of the duration of SIV.
Dental erosions were found in 46 individuals (69.7%), 43
women and three men. Of these, 19 individuals had enamel lesions only, while 27 had both enamel and dentine
lesions. Of the individuals with erosions, 35 participants
(76.1%) had five or more teeth affected, while 12 (26.1%)
had 10 or more teeth with erosive lesions. Four individuals
(9%) had ≥10 teeth with dentine lesions. Erosions grade 4
or 5 (severe erosion) were found in only six of the individuals, three of these had been suffering from ED for 16, 21
and 28 years, while two had been diagnosed six and nine
years ago.
Dentine lesions appeared most frequently on occlusal
surfaces (n = 66, 58.4%), followed by palatal surfaces on
front teeth (n = 22, 19.5%). Of the 66 surfaces with
dentine erosions on occlusal surfaces (Table 1), lower
first molars had most often dentine involvement (n = 28),
while enamel lesions were most frequently found on upper
central incisors (n = 58).
Duration of SIV and dental erosions
The group of individuals (n = 16) with the longest duration of SIV (>10 years) had 71.7% of the dentine lesions
and 40.4% of the enamel lesions (Table 1).
Of the individuals included in the study, eight (17.4%)
had five or more teeth with dentine lesions. Only seven of
these individuals answered the question of the duration
of SIV, and for those who did, the mean duration was
17.1 years (range: 6 – 28). Ten participants (21.7%) had
Table 1 Distribution and severity of affected tooth surfaces according to duration of SIV
Affected tooth surfaces
Duration of SIV 3–7 years
(n = 14)
Duration of SIV 8–10 years
(n = 14)
Duration of SIV >10 years
(n = 16)
All individuals
(n = 44)
E
D
E+D
E
D
E+D
E
D
E+D
E
D
E+D
Front B (n = 79)
21
0
21
26
2
28
Front P (n = 147)
47
2
49
31
4
35
30
0
30
77
2
79
47
16
63
125
22
147
Lateral segments B (n = 15)
0
0
0
0
0
0
11
4
15
11
4
15
Lateral segments P (n = 33)
0
0
0
8
0
8
6
19
25
14
19
33
Lateral segments O (n = 158)
23
15
38
34
9
43
35
42
77
92
66
158
All surfaces
91
17
108
99
15
114
129
81
210
319
113
432
E = Enamel; D = Dentine; Front B = Buccal surfaces of canines and incisors in both upper and lower jaw; Front P = Palatal surfaces of canines and incisors in upper
jaw; Lateral segments B = Buccal surfaces of premolars and molars in both upper and lower jaw; Lateral segments P = Palatal surfaces of premolars and molars in
upper jaw; Lateral segments O = Occlusal surfaces of premolars and molars in both upper and lower jaw.
Uhlen et al. BMC Oral Health 2014, 14:92
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five or less surfaces with erosions (Figure 1). Seven of the
individuals had lesions on occlusal surfaces only. Eight of
those with five or less involved tooth surfaces had been
suffering from ED for 5 – 10 years, while two patients reported duration of 26 and 28 years, respectively.
The distribution of the total number of surfaces with
erosive lesions (n = 432) according to the duration of SIV
is presented in Table 1. The palatal surfaces were most
frequently affected (41.6%), followed by occlusal surfaces
(36.6%), regardless of the duration of SIV (Table 1). However, the longer the duration of SIV, the more lesions were
recorded on the palatal surfaces of the front teeth and in
the lateral segments (Table 1). The same was found on the
buccal surfaces; though the prevalence was lower (Table 1).
The individuals who had been suffering from ED for
more than 10 years had significantly more buccal lesions
in the lateral segments than those with a shorter duration of the disorder (p = 0.02). This group did also have
significantly more palatal lesions in the lateral segments
than those who had been suffering from ED for 3 –
7 years (p < 0.01) and 8 – 10 years (p = 0.04). Nine individuals who had induced vomiting for more than
10 years showed no signs of dental erosions, and in two
individuals less than five teeth were affected.
Consumption of acidic beverages
Of the 54 individuals who answered the questionnaire,
24 reported a high daily intake of acidic beverages (≥0.5
liters per day), 30 participants reported a low consumption (<0.5 liters per day), and of these 17 (70.8%) and 23
persons (76.7%) showed dental erosions, respectively.
The mean age in these groups was 28.4 (range: 21 – 48)
Page 4 of 7
and 27.5 years (range 20 – 43), and the mean duration
of SIV was 12.0 (range: 3 – 28) and 9.9 years (range: 3 –
21). The mean number of teeth with erosions was 4.3 in
the high consumption group and 5.8 in the low consumption group. Only one person in the high consumption group showed erosions grade 4 and 5, and no more
than 9 teeth were affected, while in the low consumption
group 3 individuals showed erosions grade 4 or 5, and
six participants had 10 or more teeth affected with dental erosions.
Discussion
In this study, dental erosions were found in 69.7% of the
individuals having a history of self-induced vomiting
(SIV). This is in the lower range of previously reported
prevalence (47 – 93%) among bulimic patients [11,12,30].
Although all the individuals included in the current study
had a history of SIV, and thereby were at risk of developing dental erosions, 30.3% of the participants did not display any signs of erosion lesions. Previous studies have
reported different findings. All patients with ED in the
study by Robb et al. [10] had significantly more abnormal
tooth wear (erosion) than the healthy control group, this
finding being most prominent in the SIV group. None of
the 23 women with AN in the study by Shaughnessy et al.
[31] showed dental erosions, even though 26% of the participants reported a history of binge-eating/purging activity. Rytomaa et al. [11] found that 13 of 35 bulimics did
not suffer from dental erosions. The observation that not
all bulimic patients show a pathological level of tooth wear
has also been reported by Milosevic and Slade [9] and
Touyz et al. [30]. Although vomiting has been related to
Figure 1 Number of affected surfaces with erosive lesions in relation to duration of SIV.
Uhlen et al. BMC Oral Health 2014, 14:92
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the occurrence of erosive wear, the study by Robb et al.
[10] showed that those who suffered from AN, but did not
vomit, also showed more erosions than the control
population.
Dental erosions can be caused by acids from extrinsic
(e.g. acidic foodstuff ) as well as from intrinsic sources
(gastric acid). In the present study, one of the inclusion
criteria was self-induced vomiting, a challenge to the enamel due to exposure to gastric acid. Nearly half (n = 24)
of the participants who completed the questionnaire
also reported a high daily intake of acidic beverages. It is
likely that individuals who induce vomiting up to several
times per day have a higher risk of developing dental
erosion than those who never, or more seldom, practice
this behaviour. It is reasonable to assume that individuals who, in addition to exposing their teeth to gastric
acids several times per day, often consume acidic beverages, have a greater risk of developing dental erosion
than those who do not. However, in the present study,
there were more erosions and more severe lesions in the
group with low consumption of acidic beverages than in
the group with high consumption. Bartlett and Coward
[16] compared the erosive potential of gastric juice and a
carbonated beverage in vitro and found that gastric juice
had greater potential to cause dental erosions in enamel
and dentine than a carbonated drink. The authors
pointed out that the result reflects the lower pH and titratable acidity of gastric juice. This could be a reason
why more lesions were not found in those individuals
who consumed large amounts of acidic beverages in
addition to SIV.
For patients with ED it is difficult to evaluate the risk
of various dietary factors, vomiting and/or unfavourable
saliva factors. Information about the frequency and duration of SIV is associated with uncertainties, because ED
often are associated with shame and denial. It is often a
general finding that these individuals are well-educated
and well-informed about the condition. Many of them
normally choose healthy diets devoid of sweets and sugary soft drinks. In contrast, when they have episodes of
binge-eating they select “junk food”, which is high in fat,
sugar, salt and calories [12].
The results from the present study showed that the
participants who had been practicing SIV for more than
10 years showed more erosions and more severe lesions
(with exposed dentine). Frequent acid exposures may
have a detrimental effect on the teeth’s hard tissue, and
particularly if the exposures continue over a long period
of time. This finding is in accordance with results from
Johansson et al. [15] and Altshuler et al. [25], who found
a significant association between the duration of the ED
and the prevalence of dental erosions. In addition, Dynesen et al. [14] showed that the duration of the ED had a
significant influence on the severity grade of the erosive
Page 5 of 7
lesions. However, other studies did not find any association between frequency, duration of vomiting and dental erosion [9,10]. In the present study nine individuals
who had induced vomiting for more than 10 years
showed surprisingly no signs of dental erosions, and in
two individuals less than five teeth were affected.
The different results from the studies mentioned, and
the fact that one third of the individuals in the present
study did not show any erosive lesions despite regular
vomiting, might be explained by individual differences in
the susceptibility to erosion. It is still not clear what factors are relevant for the development and progression of
erosion in these patients. Saliva factors, salivary flow
rate, the pellicle and the composition of the enamel may
be as important as the frequency of acid exposures [10].
It has often been speculated that differences in the
composition of saliva could be responsible for the rapidly progressing erosive substance loss in patients with
vomiting-associated ED [32]. A lower salivary pH in ED
patients than in healthy controls has been documented
by Touyz et al. [30], but in contrast Milosevic et al. [33]
did not find any differences between BN patients and
controls. Schlueter et al. [34] suggested that enhanced
proteolytic activity in the saliva of bulimic patients might
contribute to an altered buffering capacity of the saliva,
as well as development and progression of dental erosion through degradation of dentine and the pellicle.
Levels of amylase, immunoglobulin and electrolytes have
also been investigated, but the findings differ substantially [32]. Several studies have shown a significantly
lower unstimulated salivary flow in bulimic patients than
in controls [11,14,19]. Many ED patients are prescribed
antidepressants or other psychopharmaceutical medication, that are known to reduce salivary flow, and Dynesen
et al. [14] showed that xerogenic medication significantly
lowered unstimulated flow rate in this patient group.
The assumption that dental erosions caused by vomiting or regurgitations are typically localized on the palatal
surfaces of the upper front teeth, and that erosions
caused by high consumption of acidic foods and drinks
are found on buccal surfaces, has led to efforts to relate
the location of erosive lesions to the etiology of the condition [17,22,23]. From a clinical point of view, it is
important to investigate whether it is possible to differentiate between erosions caused by SIV and erosions
caused by consumption of acidic foodstuff. Hellstrom
[19] reported that while lingual erosions were a frequent
finding in individuals experiencing SIV, such lesions did
not appear in individuals without this behaviour. Lussi
et al. [23] found that chronic vomiting appeared to be
the variable most indicative for lingual erosions. The
present results showed that the majority of the lesions
were found on the palatal surfaces and that the individuals with the longest duration of SIV had significantly
Uhlen et al. BMC Oral Health 2014, 14:92
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more buccal and palatal lesions in the lateral segments
than those with a shorter duration of the disorder. The
more severe lesions (with exposed dentine) appeared
most frequently on the occlusal surfaces of the lower
first molars, followed by the palatal surfaces on the
upper incisors. These results were consistent with work
previously reported by Mulic et al. [18] in a study of
healthy adolescents, and can partly be explained by the
position of these teeth in the mouth and partly by their
early time of eruption. The lower first molars are the
first permanent teeth to erupt, they have an important
function concerning occlusion and chewing, and acidic
liquids naturally gravitate towards the floor of the
mouth. The upper incisors also erupt at an early age, and
as the rough surface of the tongue serves as a short-time
reservoir for acids from foodstuff and liquids, the movements of the tongue have the potential to cause both an
abrasive and an erosive effect (perimylolysis) on the palatal
surface of the upper front teeth [35]. The rinsing effect of
saliva is weaker on the upper teeth than on the lower, and
the saliva clearance and buffer capacity are even lower in
individuals with reduced saliva secretion [17].
Vigorously and frequent tooth brushing is a common
habit in ED patients, and in combination with the repeated
exposure to stomach acid, this could also contribute to the
increased erosive tooth wear in this group [15,19]. However, a study concerning oral hygiene habits did not ascertain why some of the vomiting bulimic patients suffered
from severe erosions and others did not [36].
As expected, the prevalence of dental erosion in the
individuals experiencing SIV was high. In addition, the
duration of SIV seemed to influence the number of palatal and buccal lesions.
However, the present study does have some limitations: The proportion of male participants versus females was small. This, however, reflects the gender
distribution shown in the study by Jaite et al. [8], where
as much as 92.7% of individuals with bulimia nervosa
were female, and seems to reflect the population prevalence of ED. Information on e.g. the exact duration of disease, frequency of SIV, oral hygiene habits and eating habits
is unfortunately difficult to obtain, as it is based exclusively
on the participants’ subjective memory and their willingness
to share. One might consider using standardized questionnaires instead of interviews, but these have approximately
the same limitations in this matter. Another possible limitation of this study is that the participants were all undergoing treatment at clinics for eating disorders. Thus, the study
does not include individuals who do not receive treatment
for their disease, and the results might have been different
if corresponding information from such individuals was
obtained. Saliva secretion was not measured in this study.
Considering that one third of the participants with EDs in a
study by Rytomaa et al. [11] had decreased unstimulated
Page 6 of 7
saliva secretion, and hence decreased protection against
dental erosion, this might have been an interesting
addition to the study. However, Dynesen et al. [14] found
that although individuals with vomiting had a significantly
lower unstimulated salivary flow rate compared to a control group, this did not significantly influence dental
erosion.
Conclusion
In the present study, dental erosions frequently affected
individuals with ED experiencing SIV, and erosions were
more often found on the palatal than on the buccal surfaces in these individuals, supporting a common clinical
assumption. However, an interesting finding was that
nearly one third of the individuals who had been experiencing SIV presented no visual signs of dental erosion.
This emphasizes the necessity of further investigation
concerning the etiology of the condition, and of communicating the increasing knowledge of ED and dental erosion to clinical practitioners. Since dentists often are the
first health care professionals to whom persons with previously undiagnosed ED may present [32], and as dental
care is an important part of the overall treatment for
these patients, it is of imperative importance that dentists have an adequate knowledge regarding such disorders and how to prevent and treat the resulting oral
consequences.
Competing interests
The authors declare that they have no competing interest. The authors alone
are responsible for the content and writing of the paper.
Authors’ contributions
MMU and AM carried out the data collection; MMU did the data analysis and
writing of the article. ABT initiated the idea and along with KRS and AM
supervised the project and assisted in writing/editing of the article.
All authors have read and approved the final manuscript.
Acknowledgements
The authors would like to thank the participants for cooperation during the
date collection.
Received: 1 April 2014 Accepted: 21 July 2014
Published: 29 July 2014
References
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders. Arlington, VA: American Psychiatric Association; 2013:329–354.
2. Pindborg J: Pathology of the Dental Hard Tissues. Copenhagen: Munksgaard;
1970:445.
3. Hudson JI, Hiripi E, Pope HG, Kessler RC: The prevalence and correlates of
eating disorders in the National Comorbidity Survey Replication. Biol
Psychiatry 2007, 61(3):348–358.
4. Swanson SA, Crow SJ, Daniel LG, Swendsen J, Merikangas KR: Prevalence
and correlates of eating disorders in adolescents. Results from the
national comorbidity survey replication adolescent supplement. Arch Gen
Psychiatry 2011, 68(7):714–723.
5. Kjelsas E, Bjornstrom C, Gotestam KG: Prevalence of eating disorders in
female and male adolescents (14–15 years). Eat Behav 2004, 5(1):13–25.
6. Gotestam KG, Agras WS: General population-based epidemiological study
of eating disorders in Norway. Int J Eat Disord 1995, 18(2):119–126.
BMC Oral Health
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Association between harmful alcohol use and periodontal status according to
gender and smoking
BMC Oral Health 2014, 14:73
doi:10.1186/1472-6831-14-73
Hyang-Sun Kim ([email protected])
Ji-Hyun Son ([email protected])
Hee-Yong Yi ([email protected])
Hae-Kyoung Hong ([email protected])
Hyoun-Jun Seo ([email protected])
Kwang-Hak Bae ([email protected])
ISSN
Article type
1472-6831
Research article
Submission date
16 April 2014
Acceptance date
17 June 2014
Publication date
20 June 2014
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Association between harmful alcohol use and
periodontal status according to gender and smoking
Hyang-Sun Kim1,†
Email: [email protected]
Ji-Hyun Son2,†
Email: [email protected]
Hee-Yong Yi3
Email: [email protected]
Hae-Kyoung Hong4
Email: [email protected]
Hyoun-Jun Seo5
Email: [email protected]
Kwang-Hak Bae3,6,*
Email: [email protected]
1
Department of Physiology, College of Medicine, Seoul National University,
Seoul, Korea
2
Korean Minjok Leadership Academy, Hoengseong-gun, Wonju, Gangwon-do,
Korea
3
Department of Preventive and Public Health Dentistry, School of Dentistry,
Seoul National University, 28, Yeongeuon-dong, Jongno-gu, 110-749 Seoul,
Republic of Korea
4
Department of Dental Hygiene, Kyungdong University, Wonju, Gangwon-do,
Korea
5
Kyoung-ki Academy, Seoul, Korea
6
Dental Research Institute, School of Dentistry, Seoul National University,
Seoul, Korea
†
Equal contributors.
Abstract
Background
The aim of this study is to assess the association of harmful alcohol use based on the alcohol
use disorders identification test (AUDIT) score with periodontal status according to gender
and smoking in a representative sample of Korean adults.
Methods
This study analyzed 5,291 participants older than 19 years whose data of harmful alcohol use
and periodontal status were available. Harmful alcohol use was defined by the WHO
guidelines for the administration of AUDIT. The periodontal status was assessed by the
Community Periodontal Index (CPI). Multivariate logistic regression analysis was performed
with adjustment for socio-demographic variables, oral and general health behavior, oral
health status and systemic conditions. All analyses considered a complex sampling design,
and multivariate analysis was also performed in the subgroups.
Results
Multivariate logistic regression analysis revealed a marginal association between harmful
alcohol use and higher CPI in the total sample. The adjusted odds ratio (OR) of harmful
alcohol use was 1.16 (0.97 to 1.38) for higher CPI. Higher CPI was significantly associated
with harmful alcohol use in men (OR: 1.28; 95% CI: 1.03-1.60) and non-smokers (OR: 1.29;
95% CI: 1.06-1.57).
Conclusion
Periodontal status is significantly associated with harmful alcohol use in men and nonsmokers in a representative sample of Korean adults.
Keywords
Harmful Alcohol use, Periodontal status, Association, Gender, Smoking
Background
Periodontitis is a chronic and long-lasting low-grade inflammatory disease that leads to a
break-down of the connective tissue and bone that anchors the teeth to the jaws [1,2]. It is a
highly prevalent disease worldwide contributing to the global burden of chronic diseases and
represents a major public health problem in many countries [3,4]. In Korea, the prevalence of
periodontitis is 29.4% among adults [5]. Periodontitis is also related to systemic alterations
such as atherosclerotic vascular disease and metabolic syndrome [6,7].
Long-term and excessive alcohol consumption can influence host defenses causing toxic
damage, which is implicated in a wide variety of diseases, disorders, and injuries such as oropharyngeal cancer, liver cirrhosis, pancreatitis, hypertension, gastritis, diabetes, some forms
of stroke, and mental disorders such as depression [8-10].
As chronic and even acute, moderate alcohol use can increase host susceptibility to infections
caused by bacterial pathogens and impaired host defense after alcohol exposure appears to be
linked to a combination of decreased inflammatory response, altered cytokine production,
and abnormal reactive oxygen intermediate generation [11], it may be related to periodontitis
independently of other potential confounders.
However, a recent systematic review reported that, among 14 studies, only 3 studies showed
clear association, and 6 studies showed marginal or weak association of alcohol consumption
or dependence with periodontitis, while the other 5 studies did not find significant association
[10]. Moreover, there was much diversity in the way of measuring alcohol consumption, and
most studies considered limited potential confounders or examined non-representative small
samples [10,12,13]. Hence, further studies are needed to elucidate whether or not alcohol
consumption is a risk factor for periodontitis.
The Alcohol use disorders identification test (AUDIT) was developed by the World Health
Organization (WHO) and validated by lots of studies as a simple method of screening for
excessive drinking as the cause of the presenting illness, which is the only screening test
specifically designed for international use, and in comparison to other screening tests, the
AUDIT has been found to perform equally well or at a higher degree of accuracy across a
wide variety of criterion measures [14].
When investigating the periodontitis-associated factors, effect modification needs to be
considered in an appropriate manner in epidemiological studies because multivariate models
with a single estimate require homogeneity of the effect across different levels of extraneous
variables such as gender and smoking [15].
However, there are few studies on the association between alcohol consumption based on
AUDIT score and periodontitis in a nationally representative sample considering effect
modification.
Therefore, the aim of this study is to assess the association of harmful alcohol use based on
AUDIT score with periodontal status according to gender and smoking in a representative
sample of Korean adults.
Methods
Study design and subject selection
The data included a subset of the Fourth Korea National Health and Nutrition Examination
Survey (KNHANES) conducted in 2009 by the Korea Center for Disease Control and
Prevention (KCDC). The sampling protocol for the KNHANES was designed to involve a
complex, stratified, multistage, probability-cluster survey of a representative sample of the
non-institutionalized civilian population in Korea. The survey was performed by the Korean
Ministry of Health and Welfare. The target population of the survey was all noninstitutionalized civilian Korean individuals aged 1 year or older. The survey employed
stratified multistage probability sampling units based on geographic area, gender, and age,
which were determined based on the household registries of the 2005 National Census
Registry, the most recent 5-year national census in Korea. Using the 2005 census data, 200
primary sampling units (PSU) were selected across Korea. The final sample set for
KNHANES included 4,600 households. Among 12,722 sampled individuals, the number of
participants was 10,533. The response rate was 82.8%. A total of 7,893 individuals aged over
19 participated in KNHANES, but 5,291 of the participants, who received a periodontal
examination, were examined for AUDIT. A detailed description of the sampling was
described in the KNHANES report [5].
Clinical variables
Periodontal status
The WHO community periodontal index (CPI) was used to assess periodontal status. Higher
CPI was defined as a CPI greater than or equal to ‘code 3’, which indicates that at least one
site had a > 3.5 mm (code 4 > 5.5 mm) – probing pocket depth. The index tooth numbers
were 11, 16, 17, 26, 27, 31, 36, 37, 46 and 47.
A CPI probe that met the WHO guidelines was used [16]. The mouth was divided into
sextants. An approximately 20 g probing force was used. In 2009 KNHANES, 27 trained
dentists examined the periodontal status of the subjects. The inter-examiner mean of kappa
value was 0.77 (0.53 to 0.94) [17].
Harmful alcohol use
The AUDIT was administered as a self-report questionnaire composed of 10 questions
including frequency of drinking, typical quantity, frequency of heavy drinking, impaired
control over drinking, increased salience of drinking, morning drinking, guilt after drinking,
blackouts, alcohol-related injuries, and others concerned about drinking (see Additional file
1: Table S1). Each of the questions has a response with a score ranging from 0 to 4. The
participants with a total AUDIT score of 8 or higher were assessed as harmful alcohol use
according to the WHO guidelines for the administration of AUDIT [14].
Covariates
The socio-demographic variables included gender, age, household income, and educational
level. Household income was the family income adjusting for the number of family members.
The educational level was assessed by highest diploma.
The oral health behaviors included daily frequency of toothbrushing and use of dental floss or
interdental brush. As general health behavior, current smoking status was included.
According to the current smoking status, the participants were divided to 3 groups (Nonsmokers: those who had never smoked or had smoked fewer than 100 cigarettes in their life,
current smokers: those who were currently smoking and had smoked 100 cigarettes or more
in their whole life, past smokers: those who had smoked in the past but they stopped smoking
at that time).
The oral health status included the number of decayed permanent teeth (DT), which was
examined and summarized according to WHO criteria [18]. The systemic conditions included
diabetes and obesity.
Statistical analysis
The individual weighted factors were used and the complex sampling design of the survey
was considered to obtain the variances. Multivariate logistic regression analyses were applied
to examine the relationships between harmful alcohol use and periodontal status. The odds
ratios of harmful alcohol use for higher CPI were adjusted for above-mentioned covariates in
logistic model. Because the interaction terms of periodontal status with gender and smoking
was significant, subgroup analyses were performed to gain estimates stratified according to
gender and smoking. Statistical analyses were performed using SPSS version 19.0 software
(SPSS, Chicago, IL, USA).
Results
The prevalence of higher CPI defined as a CPI code ≥ 3 was 30.9% (code 4 was 5.9%). The
mean age of the participants was 39.13 (38.35 to 39.90) in the participants with lower CPI
and 50.30 (49.24 to 51.36) in those with higher CPI. The mean number of DT of the
participants was 0.79 (0.71 to 0.86) in the participants with lower CPI and 0.90 (0.79 to 1.01)
in those with higher CPI. Table 1 list the characteristics of the study participants categorized
by the periodontal status.
Table 1 Bivariate comparisons of the characteristics between the participants with
lower and higher CPI
n
Gender (n = 5291)
Male
Female
Highest diploma (n = 5283)
Primary school
Middle school
High school
≥ University or College
Household income† (n = 5247)
< 25%
25 - 50%
50 - 75%
> 75%
Diabetes (n = 5291)
No
Yes
Obesity‡ (n = 5251)
Underweight
Normal
Obesity
Oral health behaviors
Daily frequency of toothbrushing (n = 5291)
Once or less
Twice
Three times or more
Use of floss or interdental brush (n = 5291)
No
Yes
General health behaviors
Harmful alcohol use§ (n = 5291)
No
Yes
Present smoking status (n = 5282)
Past smoker
Current smoker
Non-smoker
Lower CPI
%* (95% CI)
n
Higher CPI
%* (95% CI)
1444 63.2 (60.5-65.8)
2176 77.6 (75.3-79.7)
965
706
36.8 (34.2-39.5)
22.4 (20.3-24.7)
666
362
1452
1134
52.0 (47.4-56.5)
58.9 (53.8-63.9)
73.5 (70.7-76.2)
76.4 (73.7-78.9)
497
260
559
353
48.0 (43.5-52.6)
41.1 (36.1-46.2)
26.5 (23.8-29.3)
23.8 (21.1-26.3)
581
786
1036
1182
63.1 (58.5-67.4)
66.6 (63.4-69.7)
69.0 (65.6-72.2)
75.1 (72.4-77.6)
366
424
467
405
36.9 (32.6-41.5)
33.4 (30.3-36.6)
31.0 (27.8-34.4)
24.9 (22.4-27.6)
3450 71.2 (69.1-73.2) 1483 28.8 (26.8-30.9)
170 45.6 (39.4-52.0) 188 54.4 (48.0-60.6)
179 77.8 (71.4-83.1) 55 22.2 (16.9-28.6)
2337 71.6 (69.3-73.8) 1024 28.4 (26.2-30.7)
1068 64.5 (61.4-67.4) 588 35.5 (32.6-38.6)
401 63.2 (58.7-67.6)
1381 66.8 (63.7-69.7)
1838 73.7 (71.3-76.1)
249
738
684
36.8 (32.4-41.3)
33.2 (30.3.-36.3)
26.3 (23.9-28.7)
2653 68.8 (66.4-71.2) 1316 31.2 (28.8-33.6)
967 72.7 (69.5-75.7) 355 27.3 (24.3-30.5)
2519 72.4 (70.0-74.6) 1048 27.6 (25.4-30.0)
1101 65.7 (62.8-68.5) 623 34.3 (31.5-37.2)
662 62.0 (58.5-65.5)
776 61.8 (58.1-65.4)
2213 78.0 (75.7-80.0)
450
515
719
38.0 (34.5-41.5)
38.2 (34.6-41.9)
22.0 (20.0-24.3)
*
Weighted percent and 95% confidence interval.
Household income: monthly average family equivalent income.
(=monthly average household income/√(the number of household members)).
‡
Underweight (<18.5 kg/m2); Normal (18.5 to 24.9 kg/m2); obese (≥25 kg/m2).
§
AUDIT score ≥ 8.
†
Table 2 showed the marginal association between harmful alcohol use and higher CPI in the
multivariate logistic regression model in a total sample. Harmful alcohol use might be
associated with higher CPI, but the strength of the association was marginal. The results of
the subgroup analyses are also presented in Table 4. The association was different according
to the strata of gender and smoking. While harmful alcohol use showed moderate association
with higher CPI in males (OR: 1.28; 95% CI: 1.03-1.60) and non-smokers (OR: 1.29; 95%
CI: 1.06-1.57), the significant association between harmful alcohol use and higher CPI was
not found in females and current smokers.
Table 2 Adjusted odds ratios (OR) and 95% confidence intervals (CI) of harmful
alcohol use (AUDIT score ≥ 8) for higher CPI in total sample and each subgroup
Total
Gender
Male
Female
Current smoker
No
Yes
OR
1.158
95% CI
0.969-1.383
1.284
0.803
1.028-1.604
0.565-1.139
1.291
1.003
1.058-1.575
0.717-1.403
The multivariate logistic regression model was adjusted for socio-demographic variables
(age, gender, household income, educational level), oral health behaviors (daily frequency of
toothbrushing, use of floss or interdental brush), general health behaviors (present smoking
status), oral health status (active caries) and general health status (diabetes mellitus and
obesity).
In the subgroup, each effect modifier was excluded from its multivariate model.
Discussion
In this study, an association was found between harmful alcohol use and periodontal status
after adjusting for the socio-demographic variables, oral and general health behaviors, and
oral health status, especially in men and non-smokers.
While alcohol consumption has been widely perceived as a risk factor of periodontitis due to
the biological plausibility based on the relationship between alcohol use and impaired
systemic conditions such as reduced resistance to infection and liver damage [19-21], several
studies reported a negative correlation between alcohol consumption and periodontitis based
on longitudinal and cross-sectional researches.
For example, Jansson [22] conducted a longitudinal investigation of 513 individuals from the
County of Stockholm in 1970 and 1990. He did not find any significant association between
alcohol consumption and periodontitis. Even though the subjects with higher alcohol
consumption had calculus more frequently than those with lower alcohol consumption,
alcohol consumption was not associated with periodontitis. Torrungruang et al. [23]
performed a cross-sectional survey targeting 2,005 people aged 50 to 73 years in Thailand,
and also reported that alcohol consumption had no significant effect on the severity of
periodontal disease severity in the multivariate model.
This disparity might be due to differences in the potential confounders, assessment of alcohol
consumption, criteria of periodontitis, and ethnical backgrounds. In addition, effect
modification could be another reason for the variation. Most previous studies on the
association between alcohol consumption and periodontitis did not consider effect modifiers.
Ylöstalo et al. [15] reported that effect modification was not always treated in an appropriate
manner in epidemiological studies although it was a basic concept in quantitative research.
Based on the analysis of simulation data, they concluded that effect modification might
explain the variation in the results of studies on the association between periodontitis and
systemic disease. In this study, as we found significant interaction terms, subgroup analysis
was performed with subgroups stratified by the levels of effect modifiers. The results of this
study did not support the association between harmful alcohol use and periodontal status in
the total sample. However, subgroup analysis showed that harmful alcohol use was
significantly associated with higher CPI in men and non-smokers.
To the best of our knowledge, this is the first study to report gender and smoking as effect
modifying factors of the association between alcohol consumption and periodontal status.
Some studies reported that smoking and alcohol consumption are associated with increased
risk of systemic diseases such as fatty liver disease and metabolic syndrome, especially when
these two exposures occur together [24,25]. The result of this study is opposite to those
previous results. However, considering that smoking is one of the strongest risk factors for
periodontitis [26], it could be inferred that smoking may mask the effect of alcohol
consumption on periodontal health in smokers.
Briasoulis et al. [27] found that the association between light to moderate alcohol intake and
the risk of developing hypertension differed between women and men. They explained that
differences in the pattern of drinking, beverage choices, and smoking habits may contribute
to the observed sex differences because the health effects of drinking may depend on drinking
pattern, and failure to differentiate episodic from regular drinkers may obscure the real
associations. It is consistent with the gender difference found in this study.
Further studies will be needed to elucidate the association between alcohol consumption and
periodontal status according to gender and smoking.
The difference in the assessment of alcohol consumption is also suggested to be one of the
explanations for the variation in the results of the studies on the association between alcohol
consumption and periodontal status. Amaral Cda et al. [10] reported that alcohol consumption
was assessed by various unvalidated questionnaires with different criteria varied according to
researchers in lots of studies. Therefore, this study used the AUDIT to determine harmful
alcohol use.
The AUDIT was developed by the WHO and validated by lots of studies as a screening tool
for excessive drinking [14]. Epidemiologic studies have used the AUDIT [28,29]. In order to
evaluate the AUDIT against other common screening measures, Allen et al. [30] reviewed the
studies in which the sensitivity and specificity of the AUDIT were contrasted with those of
the alternative measures. They found that the AUDIT performed at a level at least
comparable with and generally exceeding that of the alternate measures. However, there have
been few studies on the association between periodontitis and alcohol consumption based on
AUDIT [31].
This study had several limitations. The periodontal status was assessed by CPI. Although CPI
is an easier way to assess the prevalence of periodontitis in a population survey and has been
adopted as an index for periodontitis in epidemiologic studies on the association between
systemic health and periodontal disease [32], the limitation of CPI should be deliberately
considered since it can overestimate or underestimate the prevalence of periodontitis due to
the use of representative teeth and pseudo pockets [33]. Therefore, the term of higher CPI
was used instead of periodontitis to classify periodontal status. Another important limitation
of this study is its cross-sectional design, which makes it impossible to determine the
direction of the causal relationship of harmful alcohol use with periodontal status. As the
association of subgroups found in this study was so weak, further studies will be needed to
confirm the association between harmful alcohol use and periodontal status in men and nonsmokers.
Nevertheless, this is the first epidemiologic study to report an effect modification of the
association between harmful alcohol use and periodontal status by gender and smoking in a
nationally representative sample of adults.
Conclusion
Periodontal status is significantly associated with harmful alcohol use defined using the
AUDIT in men and non-smokers. The underlying mechanisms showing an effect
modification of the association between harmful alcohol use and periodontal status by gender
and smoking remain to be determined through prospective cohort studies.
Human subjects approval statement
The study was conducted in compliance with the principles of the Helsinki Declaration.
Ethical clearance of the study was approved by the Institutional Review Board (IRB) of
Korea Centers for Disease Control and Prevention (IRB number. 2009-01CON-03-2C).
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
BK designed the study and, YH and HH performed the statistical analysis. KH, SJ, and SH
interpreted the findings and drafted the manuscript. BK read and approved the final
manuscript. All authors read and approve the final manuscript.
Acknowledgements
The study was self-supported, but the Korea Center for Disease Control and Prevention
provided the data of the Fourth Korea National Health and Nutrition Examination Survey to
be used in the study.
References
1. Li P, He L, Sha YQ, Luan QX: Relationship of metabolic syndrome to chronic
periodontitis. J Periodontol 2009, 80:541–549.
2. Williams RC: Periodontal disease. N Engl J Med 1990, 323:373–382.
dos Santos Junior et al. BMC Oral Health 2014, 14:47
http://www.biomedcentral.com/1472-6831/14/47
RESEARCH ARTICLE
Open Access
Early childhood caries and its relationship with
perinatal, socioeconomic and nutritional risks: a
cross-sectional study
Valdeci Elias dos Santos Junior1,2*, Rebeca Maria Brasileiro de Sousa1, Maria Cecília Oliveira1,
Arnaldo França de Caldas Junior1 and Aronita Rosenblatt1
Abstract
Background: Socioeconomic, perinatal and other life cycle events can be important determinants of the health status
of the individual and populations. This study aimed to assess the prevalence of early childhood caries (ECC), perinatal
factors (gestational age, teenage pregnancy and birth weight), family income and nutritional risk in children.
Methods: A cross-sectional study in which 320 children were examined according to the criteria established by the
World Health Organization. A previously validated questionnaire was used to obtain information from parents and
guardians about family income, gestational age and birth weight. To check the nutritional risk, we used the criteria
provided by the CDC (Center for Disease Control). For Statistics, Pearson’s, chi-square and the multivariate Poisson
analyses were used to determine the association among variables.
Results: Approximately 20% of children had ECC, and the Poisson multivariate analyses indicated that family income
(p = 0.009), birth weight (p < 0.001) and infant obesity (p < 0.001) were related to the increase of ECC, and gestational
age was not significantly associated with ECC (p = 0.149). Pregnancy in adolescence was not included in the regression
analyses model because it was not statistically significant in the chi-square test (p > 0.05).
Conclusion: The prevalence of ECC was related to low family income, premature birth and infant obesity.
Keywords: Dental caries, Child, Obesity, Teenage pregnancy, Birth weight, Prematurity
Background
Early childhood caries is a common public health problem
in developing countries, where malnutrition is still an issue.
This pattern of decay develops very rapidly in preschoolers,
affecting tooth surfaces that are naturally caries-prone
[1,2]. Whereas the disease is influenced by social context,
this discussion goes beyond the boundaries of oral health
issues to social equality [3].
Adverse perinatal factors result in poor oral health
conditions, considering that low birth weight children tend
to develop enamel and dentine defects, which facilitates
the adhesion and colonization of cariogenic bacteria in
poorly calcified dental tissue [2,4]. The current literature
[3-5] indicates that there is a strong association between
enamel defects, prematurity and low birth weight [6].
According to The World Health Organization [7],
adolescent pregnancy is a health risk that affects
mothers and newborns that also increases disadvantageous
social and biological life events [7]. Prematurity and low
birth weight is closely related to infant mortality, perinatal
infections and the poor growth and development of
children [8].
Therefore, this study aimed to assess the prevalence of
early childhood caries and its association with perinatal
factors, such as gestational age, pregnancy and birth
weight, along with family income and nutritional risk, to
produce incremental evidence-based knowledge to update
the state of care in a fast-growing society.
* Correspondence: [email protected]
1
Department of Paediatric Dentistry, Faculty of Dentistry, University of
Pernambuco, Recife, Brazil
2
Rua São Sebastião, 417 #101 CEP 54410500, Jaboatão dos Guararapes, PE,
Brazil
© 2014 dos Santos Junior et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
dos Santos Junior et al. BMC Oral Health 2014, 14:47
http://www.biomedcentral.com/1472-6831/14/47
Methods
This is an epidemiological study conducted in Cabo de
Santo Agostinho, in the southeastern part of Pernambuco,
Brazil, which has a population of approximately 185,123
inhabitants [9]. The sample was comprised of 320 preschoolers aged from three to four years who were attending municipal kindergarten.
The calculation of sample size considered that a previous
pilot study on ECC indicated a prevalence of 22.3%,
with a 95% confidence interval and a 5% standard
error. This resulted in a sample of 266 children, and
after adding 20% to avoid data loss, a sample size of
320 children was established.
The pilot study was conducted with 10% of the sample
in the yards of the schools, in a knee-to-knee position,
with natural light and using a dental mirror and wooden
spatula. Children received oral hygiene instruction and
supervised tooth brushing before the exam. The children
who took part in this trial were included in the final
sampling.
This study was approved by the Ethics Committee of
the University of Pernambuco. (Protocol No. 119/12).
Consent for undertaking the research was obtained
from the school principals, and consent to perform
the examinations came from the parents or guardians.
Only the children of those parents or guardians who
returned the signed permission forms were included
in the study.
The examinations were performed by a calibrated
examiner for visual exam following criteria established by
the World Health Organization [10]. Kappa coefficients
for intra-examiner agreement was K = 0.90.
Cavitated carious lesions in children younger than
71 months were classified as ECC, according by Drury et al.
[11]. The individuals with syndromes that impact the
oral cavity were excluded from the sample to avoid
confounding factors.
In addition to the oral examination, children were
measured and weighed to assess nutritional risk as
proposed by the CDC (Center for Disease Control) [12],
which analyses the BMI (Body Mass Index) curve by age
and sex from 2–19 years of age. The child was considered
to be underweight when the value was below the 5th
percentile, normal weight when between the 5th (inclusive)
and below the 85th, overweight when between the 85th
(inclusive) and 95th and obese when above the 95th
percentile. The measurement of body weight was recorded
by the researcher, with the child standing with minimal
clothing without shoes on a portable calibrated scale with
a precision of 100 g, and the height was measured with a
tape strip scale.
The examiners administered a questionnaire, which
was previously validated in a pilot study, to parents
and guardians at the pick-up time at school in order
Page 2 of 5
to obtain information on family income. To determine the
gestational age and birth weight, we accessed the vaccination and the local maternity hospital records that followed
the WHO criteria [13], indicating preterm to be less than
37 weeks. The WHO criteria [8] for adolescent pregnancy
included girls from 10 to 19 years of age. The classification
for birth weight included very low birth weight (less than
1500 g), low birth weight (less than 2500 g) and normal
birth weight (equal to or greater than 2500 g).
After data collection and the categorization of variables,
we created a database for statistical analysis using SPSS
(Statistical Package for Social Sciences) version 17. To test
the association between two categorical variables, the chisquared test was used. To explain the prevalence of early
childhood caries and its association with the other risk
factors, we chose the Poisson regression test, which is
similar to logistic regression, with the advantage that the
prevalence ratio (PR) is more stable and the value for OR
varies in a smaller range. The margin of error was 5%.
Results
Three hundred and twenty preschoolers were evaluated.
There were no losses or drop-outs because the schools
were not very far from each other and we could always
return to see those that failed to attend school regularly.
The mean age was 43.2 months. The presence of ECC
was registered as yes/no and results showed that 20% of
children had this type of dental disease.
The prevalence of ECC was shown to be related to low
family income, low birth weight, infant obesity and
shorter gestational age (p < 0.05). There was a higher
prevalence of ECC among children with low birth weight
(80.4%) than those born with a normal weight (9.9%) and
those born preterm (82.8%) compared with those born at
term (13.7%) (Table 1). Twenty-five percent (80 cases)
involved adolescent pregnancy. Table 2 shows the results
for the multivariate Poisson regression analysis to explain
the association of early childhood caries with the following
variables: family income, birth weight, gestational age and
nutritional risk. For significant variables, the probability of
the presence of early childhood caries increased if the
child was underweight at birth (p < 0.001), demonstrated
infant obesity (p < 0.001) or exhibited a family income less
than or equal to $ 282.00 (p = 0.009).
Pregnancy in adolescence was not included in the
statistical regression model because it did not show a
statistically significant difference in the person's chi-squared
test (p > 0.05).
Discussion
The present study is in accordance with previous reports
[14-16] that describe the strength of the relationship
between decreases in family income, the risk of children developing ECC and the impact of this social
dos Santos Junior et al. BMC Oral Health 2014, 14:47
http://www.biomedcentral.com/1472-6831/14/47
Page 3 of 5
Table 1 Early childhood caries, family income, adolescent pregnancy, birth weight, gestational age and nutritional risk
Evaluation ECC
Variable
YES
NO
TOTAL
P value
PR (IC a 95%)
p(1) = 0.01*
3.34 (1.71 to 6.51)
N
%
n
%
N
%
64
20.0
256
80.0
320
100.0
No Income
14
34.1
27
65.9
41
100.0
Less than or equal to minimum wage ($ 282.00)
37
24.3
115
75.7
152
100.0
2.38 (1.32 to 4.27)
More than one minimum wage
13
10.2
114
89.8
127
100.0
1,00
Yes
15
18.7
65
81.3
80
100,0
No
38
16
204
84
240
100,0
Low
37
80.4
9
19.6
46
100.0
Normal
27
9.9
247
90.1
274
100,0
Premature
24
82.8
5
17.2
29
100.0
Term
40
13.7
251
86.3
291
100.0
Underweight
2
100,0
-
-
2
10,0
Normal weight
57
18.4
253
81.6
310
100.0
Obesity
5
62.5
3
37.5
8
100.0
TOTAL
• Family income
• Adolescent pregnancy
p(1) >0.18
1.16 (0,63 to 2,01)
1,00
• Birth weight
p(1) < 0.01*
8.16 (5,55 to 12.00)
1.00
• Gestacional age
p(1) < 0.01*
6.02 (4.32 to 8.39)
1.00
• Nutritional Risk
p(1) = 0.01*
**
(*)Significant association at 5.0%.
(**)Unable to determine due to the occurrence of null frequencies.
(1) By chi-square test.
determinant of health. Lagreca [17] conducted a survey that reported the incidence of dental caries in relation to the socioeconomic status that indicated that
in Brazil, children whose family income was in the
range of the minimum wage, caries incidence was
57% higher than those whose family income was
above four times the minimum wage. Then, with the
speed of the production and the diffusion of new and
advanced science, it would be anachronistic to continue to
refer to the aetiology of dental caries exclusively by the
Table 2 Results of multivariate poisson regression to the prevalence of early childhood caries
PR and IC 95,0%
Variables
Univariate
Adjusted
P value
No
3.58 (1.80 a 7.12)
2.42 (1.20 a 4.88)
p = 0.009*
Less than or equal to minimum wage ($ 282.00)
2.50 (1.36 a 4.61)
2.15 (1,30 a 3.54)
1,00
1,00
8.40 (5.66 a 12.46)
7.09 (3.91 a 12.86)
1,00
1,00
6.11 (4.35 a 8.58)
1.39 (0.89 a 2.19)
1.00
1.00
• Family income
More than one minimum wage
• Birth weight
Low
Normal
p < 0.001*
• Gestational age
Premature
Term
p = 0.149
• Risk nutritional
Normal weight
Obesity
(*):Significant at 5.0%.
1.00
1.00
3,40 (1.89 a 6.11)
6,24 (3.06 a 12.72)
p < 0.001*
dos Santos Junior et al. BMC Oral Health 2014, 14:47
http://www.biomedcentral.com/1472-6831/14/47
intersection of primary factors, such as microbiota and
host substrate.
According to the Brazilian Institute of Geography and
Statistics-IBGE [9], 53.9 million Brazilians live in extreme
poverty, which accounts for 31.7% of the population. In
the northeastern part of the country, 76.5% of the families
earn less than the minimum wage, which is approximately
that found in the present study: 60.3% of families living
in poverty.
From the perspective of health inequality, Marmot,
Bell and Goldblatt [18] conceptualized that there is a
convergence between unfavourable socioeconomic conditions and the presence of diseases. Corroborating this
concept, the present study indicated that children
from families that earn less than $ 282 are at a higher risk
for ECC.
It has been suggested that human life events can alter
stable biological mechanisms and turn them into a
genetic legacy process called incorporation of biologic
features [19]. From this perspective, the traditional
etiological factor for caries, which involves the association
of high sugar intake [20,21], poor oral hygiene [22-24],
lack of exposure to fluoride and perinatal disturbances
related to enamel defects [21,24], which could influence
genetic legacy.
Currently, reports [25,26] show that prematurely born
individuals have poor mineralization of the teeth and
poorer oral health indicators, supporting the evidence of
the role played by enamel defects in the development of
ECC. Moreover, in a 7-year cohort study, Targino et al.
(2011) [24] revealed that enamel defects constitute a risk
factor for the development of early childhood caries. Thus,
perinatal factors such as low birth weight and gestational
prematurity are risk factors for the development of early
childhood caries.
Due to the worldwide increase in childhood obesity
across populations and the polarization of dental caries,
several studies [27,28] reported on the associations of
obesity and infant caries; however, the results of these
studies are still controversial. In 2006, a systematic review
[29] found only one study that consistently showed a
direct association between obesity and dental caries with a
high level of evidence. The findings of this work show an
association between childhood obesity and dental caries,
as in some previous epidemiological and cohort studies
[27,28]. The results of this study indicate that it is possible
that the conflicting results could be related to variations
in the way data were collected, the socioeconomic status
of the sample, the parameters used to analyse nutritional
status and caries diagnosis [29].
Although the present research indicated no significant
association between adolescent pregnancy and ECC,
perinatal complications arising from the lack of biological
development of teenagers are themselves risk factors for
Page 4 of 5
preterm and low birth weight children [25], which were
identified as risk factors for ECC [29].
Conclusion
The prevalence of ECC was shown to be related to low
family income, premature birth and infant obesity. Thus,
this study showed that socio-economic factors and perinatal
events are important determinants for the status of oral
health in children.
Bullet points
It is essential to monitor the prevalence of early
childhood caries and its risk factors.
Low family income, premature birth and infant
obesity should be considered as risk factors for the
development of ECC.
Competing interest
This study was funded by the Ministry of Education of Brazil. Thus, there is
no conflict of interest, nor any such interference with the results of this
article.
Authors’ contributions
VSJ participated in the study design and epidemiological data analysis and
drafted the manuscript. CMC facilitated the field work and data collection.
RMB was the main dentist who examined and diagnosed all of the children.
AR and AFCJ were the main supervisors, and they guided the study design,
performed statistical analysis and drafted the manuscript. All authors read
and approved the final manuscript.
Acknowledgements
The authors would like to express their gratitude to the teachers, school staff
and parents who participated in the survey. This study was supported by a
grant from the Brazilian Ministry of Education (CAPES).
Received: 2 January 2014 Accepted: 1 May 2014
Published: 6 May 2014
References
1. Suckling GW: Development defects of enamel – historical and present
day perspectives of their pathogenesis. Adv Dent Res 1989, 3:87–94.
2. Horowitz HS: Research issues in early childhood caries. Community Dent
Oral Epidemiol 1998, 26(Suppl 1):67–81.
3. Fearne JM, Bryan EM, Elliman AM, Brook AH, Wlliams DM: Enamel defects
in the primary dentition of children born weighing less than 2000 g.
Br Dent J 1990, 168:433–437.
4. Goodman AH, Martinez C, Chavez A: Nutritional supplementation and the
development of linear enamel hypoplasias in children from
Tezonteopan. Am J Clin Nutr 1991, 53:773–781.
5. Tesch C, Oliveira BH, Leão A: Measuring the impact of oral health
problems on children’s quality of life: conceptual and methodological
issues. Cad Saude Publica 2007, 23:2555–2564.
6. Lai PY, Seow WK, Tudehope DI, Rogers Y: Enamel hypoplasia and dental
caries in very-low birthweight children: a case-controlled, longitudinal
study. Pediatr Dent 1997, 19:42–49.
7. WHO: World Health Organization Health needs of adolescents. Report of a
Committee of Experts from WHO. Geneva: WHO; 1997:55p.
8. Guimarães AAG, Velásquez-Meléndez G: Low birth weight determinants
from the Born Alive National Surveillance System in Itaúna, Minas Gerais.
Rev Bras Saúde Matern Infant 2002, 2:283–290.
9. IBGE: Brazilian Institute of Geography and Statistics. Census 2010; 2013.
http://www.censo2010.ibge.gov.br/resultados.
10. WHO: World Health Organization Basic Epidemiological survey of oral health.
Manual. 4th edition. Geneva: World Health Organization; 1997.
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QUESTIONNAIRE
B3 (14)
SELF-INDUCED VOMITING(SIV) AND DENTAL EROSION – A CLINICAL STUDY
Question 1: Which of the following are TRUE with regard to dental
erosion?
A It is a reversible loss of tooth substance
B It occurs as a consequence of exposure to acids that do
not involve bacteria
C It is an irreversible loss of tooth substance
D It occurs as a consequence of exposure to acids that
involve bacteria
E The acids may enter the oral cavity from extrinsic as well
as from intrinsic sources
Question 2: Is it TRUE or FALSE that significant higher values of
erosive tooth wear have been found in patients suffering from
eating disorders (ED) compared to control groups?
A TRUE
B FALSE
Question 3: According to recent studies, adolescents reporting
vomiting have a how many times higher risk of dental erosions than
those without such behavior?
A 2 times
B 3.5 times
C 4 times
D 5.5 times
E 7 times
Question 4: According to this study, what percentage of the
individuals having a history of self-induced vomiting was found to
have dental erosion?
A 47.7%
B 53.6%
C 69.7%
D 93%
Question 5: In this study, which group had more erosions and more
severe lesions?
A In the group with high consumption of acidic beverages
B In the group with low consumption of acidic beverages
Question 6: Which of the following are characteristic of patients
with ED?
A ED is often associated with shame and denial
B Information about the frequency and duration of SIV is
accurate
C Patients with ED are generally not well educated and
poorly informed about the condition
D Many patients with ED choose healthy diets devoid of
sweets and sugary soft drinks
E When patients with ED have episodes of binge-eating
they select “junk food”, which is high in fat, sugar, salt
and calories
Question 7: Is it TRUE that in all the studies it was found that there
was an association between frequency, duration of vomiting and
dental erosion?
A YES
B NO
Question 8: Has it been established in several studies that there is
a significantly lower unstimulated salivary flow in bulimic patients
than in healthy controls?
A YES
B NO
1
Question 9: The tongue, as a short-time reservoir for acids from
foodstuff and liquids, has the potential to cause which of the
following on the palatal surface of the upper front teeth?
A An abrasive effect
B An erosive effect
C Both an abrasive and an erosive effect
Question 10: Is it TRUE or FALSE that according to Dynesen et al.
individuals with vomiting had a significantly lower salivary flow rate
compared to a control group and this had a significant influence on
dental erosion?
A TRUE
B FALSE
Question 11: Erosions of individuals with ED experiencing SIV, were
more often found on which surface?
A The palatal surface
B Buccal surface
C Both the palatal and buccal surfaces had equal erosion
ASSOCIATION BETWEEN HARMFUL ALCOHOL USE AND PERIODONTAL STATUS ACCORDING TO GENDER AND
SMOKING
Question 12: Impaired host defense after alcohol exposure may be
linked to which of the following?
A Altered cytokine production only
B Abnormal reactive oxygen intermediate regeneration
C Decreased inflammatory response only
D A combination of altered cytokine production,
decreased inflammatory response and abnormal
reactive oxygen intermediate generation
E Periodontitis independently of other potential
confounders
Question 13: Is it TRUE or FALSE that all the studies, but one, found
an association between alcohol use and periodontitis?
Question 14: According to some studies smoking and alcohol
consumption are associated with increased risk of which of the
following systemic diseases?
A Fatty liver disease only
B Metabolic syndrome only
C Fatty liver disease and metabolic syndrome, especially
when these two exposures occur together
Question 15: Is the AUDIT a validated screening measure to
determine harmful alcohol use?
A YES
B NO
A TRUE
B FALSE
2
EARLY CHILDHOOD CARIES (ECC) AND ITS RELATIONSHIP WITH PERINATAL, SOCIOECONOMIC AND NUTRITIONAL
RISKS
Question 16: To which of the following is prematurity and low
birth weight closely related?
A Poor growth of children
B Perinatal infections
C Infant mortality
D Poor development of children
E All of the above
Question 17: Is it TRUE or FALSE that low birth weight children
tend to develop enamel and dentine defects, which facilitates the
adhesion and colonization of cariogenic bacteria in poorly calcified
tissue?
A TRUE
B FALSE
Question 18: According to the results of the study which of the
following was shown to be related to prevalence of ECC?
A High income
B Low birth weight
C Infant obesity
D Low family income
E Shorter gestational age
Question 19: In Brazil, children whose family income was in the
range of the minimum wage, caries incidence was what percentage
higher than those whose family income was above four times the
minimum wage?
A 75%
B 5%
C 70%
D 57%
E 50%
Question 20: Is it TRUE that the results of several studies reporting
on the association of obesity and infant caries are still
controversial, and the findings of this study confirm this with no
association between childhood obesity and dental caries?
A YES
B NO
3
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B3 (14)
SELF-INDUCED VOMITING AND DENTAL EROSION – A CLINICAL STUDY
ASSOCIATION BETWEEN HARMFUL ALCOHOL USE AND PERIODONTAL STATUS ACCORDING TO GENDER AND SMOKING
EARLY CHILDHOOD CARIES AND ITS RELATIONSHIP WITH PERINATAL, SOCIOECONOMIC AND NUTRITIONAL RISKS
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