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189]
Original Article
Dental erosion in schoolchildren and associated
factors: A cross‑sectional study
Juliana Beckman Frazão, Letícia Gonçalves Machado, Meire Coelho Ferreira
Department of Dentistry, Ceuma University, São Luís 65075120, Maranhão, Brazil
ABSTRACT
Context: Throughout life, the teeth are exposed
to different types of wear, including dental
erosion, which is characterized by the loss of
surface‑mineralized tissue due to a chemical
process without bacterial involvement and strongly
influenced by eating habits. Aim: The aim of
this study to evaluate the prevalence of dental
erosion in schoolchildren and associated factors.
Setting and Design: This is a cross‑sectional study.
Material and Methods: The study was conducted
at a public and private school in the city of São
Luís (MA), Brazil, involving a sample of 239 children
aged 6–10 years. Data were collected through a
questionnaire and clinical examination. Dental
erosion was evaluated using the Basic Erosive Wear
Examination. Statistical Analysis: Data analysis
involved descriptive statistics, Pearson’s Chi‑square
test, the linear trend Chi‑square test, and Fisher’s
exact test, with the level of significance set to 5%.
Results: The male sex accounted for 50.2% of the
sample and the female sex accounted for 49.8%;
62.8% attended the public school and 37.2% attended
the private school. The prevalence of dental erosion
was 11.7%, with the highest prevalence among
9‑year‑olds (46.4%). Dental erosion was significantly
associated with age (P = 0.009) and type of
school (P < 0.001). Conclusion: The present findings
underscore the need for strategies to prevent or
arrest the erosive process through local actions
involving schoolchildren, parents/caregivers, and
teachers.
KEYWORDS: Child, dental erosion, prevalence,
tooth wear
Introduction
Dental erosion is characterized by the progressive,
irreversible loss of dental tissue stemming from a
chemical process without bacterial involvement.[1]
The etiology of this condition is associated with acids
of an extrinsic origin, such as food, beverages or the
© 2018 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
Address for correspondence:
Prof. Meire Coelho Ferreira,
Josué Montello, Nº 1, Renascença II, São Luís,
MA, 65075120, Brazil.
E‑mail: meirecofe@hotmail.com
Access this article online
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www.jisppd.com
DOI:
10.4103/JISPPD.JISPPD_1041_17
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workplace, as well as an intrinsic origin, namely the
stomach, the acid of which comes into contact with
the oral cavity through the process of involuntary
regurgitation or voluntary regurgitation in the case of
individuals with bulimia nervosa.[2‑5]
According to a systematic review of the literature
addressing dental erosion in the primary dentition,
this condition should be considered a disease just as
dental caries.[6] The prevalence in children ranges from
15.1% to 59.7%.[7‑12] The occurrence of dental erosion
is associated with socioeconomic factors, age, eating
habits, and the practice of sports.[13,14] Most studies
show that more than 60% of erosion is limited to the
enamel.[9,8,13,15‑17]
An early diagnosis of dental erosion on primary teeth
is important to the prevention of future harm to the
This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
non‑commercially, as long as appropriate credit is given and the new
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For reprints contact: reprints@medknow.com
How to cite this article: Frazão JB, Machado LG, Ferreira MC.
Dental erosion in schoolchildren and associated factors: A cross-
sectional study. J Indian Soc Pedod Prev Dent 2018;36:113-9.
113
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Frazão, et al.: Prevalence of dental erosion in schoolchildren
permanent dentition and contributes to the success of
treatment. An understanding of the prevalence of this
condition can assess in planning the most adequate
treatment. The current increase in the consumption
of highly processed foods and beverages by children
from both high‑income and low‑income families has
led to a consequent increase in the number of cases of
dental erosion. Thus, the hypothesis tested herein is
that there is no difference in the prevalence of dental
erosion between children at public and private schools.
Thus, the aim of the present study was to evaluate the
prevalence of dental erosion in schoolchildren aged
6–10 years and associated factors.
Material and Methods
A cross‑sectional study was conducted with a sample
of 239 children enrolled at a public school (Monsenhor
Frederico Chaves Elementary School) and private
school (Upaon Educacional Ltd.) in the city of São
Luís, Maranhão, Brazil, between January 2015 and
April 2015. The schools were selected by convenience.
Classes were randomly selected from a list of those
with children aged 6–10 years and children were
randomly selected from the selected classes.
The inclusion criteria were age 6–10 years and no
physical or mental impediment to cooperation
during the clinical examination. Children whose
parents/guardians did not provide a signed statement
of informed consent authorizing participation,
refusals to participate on the part of children, a lack
of cooperation during the clinical examination, and
absence from school on the day scheduled for data
collection were recorded as dropouts.
The sample size was calculated considering a 75%
prevalence rate of dental erosion,[18] 5% estimated
error rate, and 95% confidence interval (CI). The initial
“n” was determined to be 288 children. Adjustment
to finite population was performed (535 children
in the age range at the public school and 400 at the
private school), leading to a final sample size of 354
children (187 from the public school and 167 from the
private school).
Data collection involved the administration of a
questionnaire to parents/caregivers and clinical
examinations of the children. The questionnaire
addressed demographic characteristics (sex, age,
and ethnicity), socioeconomic characteristics (type of
school, mother’s schooling, and monthly household
income), aspects related to dental erosion (ingestion
and frequency of acidic foods and beverages, manner
of ingesting acidic beverages, use of medications,
therapeutic class of medications, and purpose of
medications), and dental wear due to bruxism or
harmful habits (grinding the teeth during sleep,
nail biting, biting objects, biting inner cheeks, or
biting lips).
114 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 2 | April-June 2018
The children brushed their teeth before the clinical
examination, which was performed in the school
setting by a single trained examiner in face‑to‑face
position with the child. A headlamp (Petzl, Tikka XP,
Crolles, France), mouth mirror (Prisma, São Paulo, SP,
Brazil), and gauze (removal of bacterial biofilm not
removed by brushing) were used. Individual protective
equipment was used during the examination.
All primary teeth were evaluated for dental erosion,
except those with carious lesions and extensive
restorations. Dental erosion was evaluated using the
Basic Erosive Wear Examination (BEWE),[19] which is
scored as follows: 0 = No loss of tooth enamel; 1 = initial
loss of enamel surface texture; 2 = Loss of hard tissue
(dentin) on <50% of the surface area; and 3 = loss of
hard tissue (dentin) on more than 50% of the surface
area. The vestibular, occlusal, and lingual/palatal
surfaces of the teeth were examined. The highest score
was recorded and the tooth with the highest score was
recorded for the sextant. The sum of the highest scores
for each sextant was calculated. The total ranged from 0
to 18, with a score of 0 indicative of an absence of dental
erosion and a score equal to or higher than 1 indicative
of the presence of dental erosion.
To perform the differential diagnosis of dental erosion,
dental attrition was assessed using the tooth wear
index.[20] Wear was classified as no wear on dentin (0),
dentin just visible (including concavity) or exposed
on <1/3 of the surface (1), dentin exposed on more
than 1/3 of the surface (2), and secondary dentin or
pulp exposure (3). Wear stemming from bruxism or
harmful oral habits (nail biting, biting object, cheek
biting, or lip biting) was recorded in the presence of
at least two antagonist teeth with facets of wear with
sharp margins that adjust to excursive mandibular
movements.
A pilot study was conducted with 10 children to test
the methods and determine intra‑examiner agreement.
For such, two examinations were performed with a
7‑day interval. Kappa coefficients for the conditions
evaluated ranged from 0.72 to 1.0.
The data were analyzed using the Statistical Package
for the Social Sciences (SPSS, version 21.0, IBM
Corporation, Armonk, New York, USA). Descriptive
and inferential statistics were conducted (Pearson’s
Chi‑square test, linear trend Chi‑square test, and
Fisher’s exact test), with the level of significance set to
5% (P < 0.05).
This study received approval from the Research Ethics
Committee of University Ceuma (#978.551/2014).
The statement of informed consent was sent to
parents/caregivers together with the questionnaire. At
the end of the study, a lecture was given to the children
and the parents were informed with regard to their
children’s oral status.
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Frazão, et al.: Prevalence of dental erosion in schoolchildren

Results Table 1: Demographic and socioeconomic

characteristics of sample (n=239), São Luís,
The response rate was 80% for the public school and Maranhão, Brazil, 2015
53% for the private school. The dropouts at the public Variables n (%)
and private schools were due to a lack of parental School
authorization (15% and 37%) and the misplacing Public 150 (62.8)
of documents (5% and 10%). Table 1 displays the Private 89 (37.2)
socioeconomic and demographic characteristics Sex
of the sample. The majority of children (62.8%) Male 120 (50.2)
attended the public school. Monthly household income Female 119 (49.8)
was less than two times the Brazilian minimum wage Age (years)
among 43.9% of the sample. 6 6 (2.5)
7 43 (18.0)
Table 2 displays the data on the consumption of acidic 8 72 (30.1)
foods and beverages. The frequency was two to three 9 69 (28.9)
times a day among 37.7% of the children who ingested 10 48 (20.1)
acidic beverages, and the majority (72.8%) reported Skin color
drinking directly from a glass. White 79 (33.1)
Black 19 (7.9)
Among the participants in the study, 8.8% used some Mixed 124 (51.9)
type of medication for varied purposes [Table 3]. Yellow 2 (0.8)
Mother’s schooling (years)
Among the children examined, 28 (11.7%) exhibited ≤8 35 (14.6)
dental erosion and 5.4% had a score of 1 on the >8 203 (84.9)
BEWE [Table 4]. Not reported 1 (0.4)
Household income
Dental erosion was significantly associated with age <2 times BMMW 105 (43.9)
(P = 0.009) and type of school (P < 0.001). The highest 2‑<5 times BMMW 41 (17.2)
prevalence was found among 9‑year‑olds (46.4%),
5‑<10 times BMMW 32 (13.4)
followed by 8‑year‑olds (35.7%) [Table 5].
≥10 times BMMW 19 (7.9)
Does not know 42 (17.6)
Discussion BMMW=Brazilian monthly minimum wage

In the present study, the prevalence of dental erosion Table 2: Frequency distribution of consumption
was 11.7%, and both age and type of school were of acidic foods and beverages (n=239), São Luís,
significantly associated with the outcome. The strong Maranhão, Brazil, 2015
point of this study was the choice of schools in socially
Variables n (%)
distinct areas, which enabled the investigation of the
Acidic foods*
influence of socioeconomic status on the occurrence
of dental erosion. The major limitation of the study is No 1 (0.4)
related to the cross‑sectional design, which impedes the Yes 70 (29.3)
establishment of a cause‑and‑effect relationship. Thus, Frequency of intake of acidic foods*
the associations identified only suggest explanations 1×/day 45 (18.8)
for the outcome. 2‑3×/day 90 (37.7)
4‑7×/day 29 (12.1)
The prevalence of dental erosion in the present Acidic beverages*
sample was lower than rates reported for 5‑year‑old No 2 (0.8)
children in two previous studies (42% and 58%)[11,12] Yes 161 (67.4)
but similar to the rate reported in a study involving Frequency of intake of acidic beverages*
a similar age group (15.1%).[7] The divergences 1×/day 46 (19.2)
in prevalence rates may be explained by the use 2‑3×/day 90 (37.7)
of different indices for the diagnosis of dental 4‑7×/day 28 (11.7)
erosion as well as the target public investigated. Mode of ingesting acidic beverages*
The BEWE index used in the present study is a Directly from glass 174 (72.8)
simple, easy‑to‑use assessment tool.[19] Besides being With straw 13 (5.4)
adequate for epidemiological studies, it provides *Missing data
greater internal validity to the study since the
diagnostic criteria determined by the index are easy The significant difference in dental erosion among
to understand and measure. the different age groups is in agreement with data

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Frazão, et al.: Prevalence of dental erosion in schoolchildren

Table 3: Frequency distribution of use of medications, partially resulted from the loss of primary anterior
therapeutic class, and purpose of medications (n=239), teeth.
São Luís, Maranhão, Brazil, 2015
Variables n (%)
A significant association was found between type
Current use of medications*
of school and dental erosion, with this condition
more prevalent in the public school (96.4%). A likely
No 203 (84.9)
explanation for the higher prevalence in the public
Yes 21 (8.8)
school is the socioeconomic status of the children.
Therapeutic class*
Due to the lower cost of acidic foods and beverages,
Anti‑allergic 1 (0.4)
children with a lower income may have greater access
Vitamins 1 (0.4)
to such products. Moreover, the parents/caregivers
Corticosteroids 4 (1.7)
of public schoolchildren may have less information
Anticonvulsant 2 (0.8)
on the harmful effects of acidic foods and beverages
Antibiotic 1 (0.4) than those with a more privileged socioeconomic
Antiasthma/bronchodilator 2 (0.8) status. A study evaluating children aged 3 to 6 years
Anti‑inflammatory 2 (0.8) found that the prevalence of dental erosion was
Psychostimulant 1 (0.4) significantly higher among children at schools in lower
Phytotherapeutic agents 1 (0.4) income areas, which the authors attributed to greater
Purpose of medication (treatment)* awareness regarding healthy eating habits among
Adenoids 4 (1.7) families in higher income areas.[7]
Allergy 2 (0.8)
Neck contusion 1 (0.4) The frequency of acidic beverages was not significantly
Precocious puberty 1 (0.4) associated with dental erosion. This is in agreement
Memory loss 1 (0.4) with data described in a previous study involving
ADHD 1 (0.4) Brazilian schoolchildren aged 11–14 years, in which
Sinusitis 3 (1.3) the high consumption of acidic beverages was
Sore throat 2 (0.8) unable to explain dental erosion.[13] However, a
*Missing data. ADHD=Attention deficit hyperactivity disorder moderate‑to‑high frequency of acidic beverage intake
is known to be capable of leading to dental erosion.[21]
A previous study found a higher prevalence of dental
Table 4: Occurrence of dental erosion on primary
teeth and frequency of scores on Basic Erosive erosion among 5‑year‑old children who consumed
Wear Examination (n=239), São Luís, Maranhão, carbonated beverages and acidic fruit juices at least
Brazil, 2015 three times a day. In this study, children who consumed
carbonated beverages had a 2.3‑fold greater chance
Variables n (%)
of exhibiting dental erosion on the dentin level.[11] A
Occurrence of erosion§ higher prevalence rate was also found among children
Absent 190 (79.5) aged 5 to 12 years who consumed soft drinks and
Present 28 (11.7) industrialized beverages (Prevalence ratio (PR) = 3.5;
BEWE (total score)§,* RP = 2.58, respectively; 95% CI not presented in the
0 190 (79.5) study).[22] The divergence in the results of different
1 13 (5.4) studies is due to differences in the sample size, age
2 8 (3.3) group, and indices used to measure dental erosion.
3 4 (1.7)
4 1 (0.4) Excessive acids from one’s diet can dissolve the
5 1 (0.4) acquired glycoprotein film covering the teeth and come
8 1 (0.4) into direct contact with the dental surface, leading
Missing data, *Sum of sextant scores (highest score of each sextant).
§
to the rapid demineralization of the enamel.[23] This
BEWE=Basic Erosive Wear Examination
glycoprotein film is fundamental to the integrity of the
dental surface and is involved in the remineralization
from a previous study involving children aged 6 to process of tooth enamel.[24] Parents/caregivers need to
12 years.[8] In the study cited, primary and permanent be made aware of acidic foods and beverages and how
anterior teeth were examined and the children most such substances should be ingested. Dental erosion in
affected by dental erosion were aged 6 and 7 years. the primary dentition may be a predisposing factor
In contrast, 6‑year‑olds and 7‑year‑olds in the present for erosion in the permanent dentition as eating habits
investigation either had no dental erosion or had caries and health conditions established during the primary
on all their teeth. This difference may be explained dentition phase can be perpetuated in the permanent
by the fact that Mangueira et al.[8] evaluated primary dentition phase.
and permanent anterior teeth, whereas only primary
teeth were examined in the present study. Thus, the A total of 8.8% of the children evaluated took
findings for 6‑year‑olds and 7‑year‑olds may have medications. Some medications with an acid pH

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Frazão, et al.: Prevalence of dental erosion in schoolchildren

Table 5: Dental erosion according to sociodemographic variables and frequency of ingestion of acidic foods
and beverages (n=239), São Luís, Maranhão, Brazil, 2015
Dental erosion P*
Absent, n (%) Present, n (%)
Age (years)
6 6 (3.2) 0 0.009**
7 43 (22.8) 0
8 61 (32.3) 10 (35.7)
9 52 (27.5) 13 (46.4)
10 27 (14.3) 5 (17.9)
Sex
Male 98 (51.6) 13 (46.4) 0.611
Female 92 (48.4) 15 (53.6)
Type of school
Public 108 (56.8) 27 (96.4) <0.001
Private 82 (43.2) 1 (3.6)
Mother’s schooling (years)
≤8 28 (14.7) 4 (14.3) 1.000***
>8 162 (85.3) 24 (85.7)
£
Frequency of acidic foods (×/day)
1 33 (25.2) 4 (23.5) 0.314**
2‑3 79 (60.3) 8 (47.1)
4‑7 19 (14.5) 5 (29.4)
£
Frequency of acidic beverages (×/day)
1 34 (26.0) 4 (23.5) 0.270**
2‑3 79 (60.3) 8 (47.1)
4‑7 18 (13.7) 5 (29.4)
£
Mode of ingesting acidic beverages
Directly from glass 137 (92.6) 20 (90.9) 0.677***
With straw 11 (7.4) 2 (9.1)
*Pearson’s Chi‑square test, **Linear trend Chi‑square test, ***Fisher’s exact test, £Missing data (dependent and/or independent variable)

have erosive potential, such as antiallergic agents,[25]
corticosteroids, antibiotics,[26] bronchodilators,[26‑28]
and anticonvulsants.[26] Among those who made use
of medications, 4 (1.7%) took corticosteroids, 2 (0.8%)
used bronchodilators, 2 (0.8%) took anticonvulsants,
and 1 (0.4%) took an antiallergic agent. A study
evaluating the pH of 23 pediatric medications,
including antihistamines and bronchodilators, found
that 86.9% of the medications had acid pH below the
critical threshold,[27] which is in agreement with data
from a study that analyzed pediatric syrups (cough
medicines, expectorants, antihistamines, and
bronchodilators), in which all medications evaluated
had acid pH.[28] As such medications are often
prescribed for children, the effect on primary and
permanent teeth is worrisome. Parents/caregivers
and physicians should, therefore, be made aware of
the pH of medications and instructions with regard to
drinking water after taking such medications should
be given to parents/caregivers as such behavior assists
in removing acids from tooth surfaces.
Some factors can exert an influence on the erosive
potential of extrinsic and intrinsic etiological factors,
such as salivary flow, characteristics of the teeth,
food/beverage intake habits, the times at which
acidic foods/beverages are ingested, and oral hygiene
habits.[1,21,29] Moreover, the manner of swallowing can
affect the pH of the dental surface and increase the
risk of erosion. Johansson et al.[30] evaluated different
swallowing methods (maintaining a beverage in the
mouth for a short period of time, drinking for a long
period of time, and sipping the beverage) and found that
maintaining the liquid in the mouth before swallowing
led to a greater drop in the pH of the dental surface.
In the present study, 90.9% of the children with
dental erosion drank acidic beverages directly from
the glass. However, this form of ingestion was not
significantly associated with the outcome. A literature
review evaluating the prevalence of erosion based on
studies conducted in Brazil states that drinking acidic
beverages directly from the glass increases the risk of
greater erosion severity as the beverage comes into
contact with a greater number of teeth.[31]
The amount of saliva produced is a factor that can exert
an influence on the development of dental erosion.
Low saliva production reduces the capacity to wash
away and neutralize acids stemming from the diet that
contributes to dental erosion.[29] Individuals with low
salivary flow are at greater risk of developing erosion
than those with a greater amount of saliva.[29]

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Frazão, et al.: Prevalence of dental erosion in schoolchildren
Saliva plays an important role in arresting the erosive
process by removing acid from dental surfaces, thereby
impeding the aggravation of surface mineral loss and
assisting in the process of remineralization. Based on
this salivary function, toothbrushing should ideally be
postponed for a time after the teeth come into contact
with acidic foods or beverages. However, although
additional mineral loss from enamel exposed to
acidic foods/beverages can be minimized if brushing
is delayed, an in situ study evaluating the abrasive
potential of nonfluoridated dentifrices containing
calcium carbonate and silicon dioxide on eroded
enamel blocks found that waiting 1 h before brushing
did not offer a protective effect against additional
mineral loss.[21]
Dental erosion can also be influenced by the position
of the teeth in the dental arch. Maxillary incisors are
more prone to dental erosion than mandibular incisors
because mandibular incisors are more protected by
saliva and the tongue during the ingestion of acidic
foods and beverages. The positioning of soft tissues can
also exert an influence on the erosive process as eroded
enamel can undergo further wear when coming into
contact with soft tissues.[32] Thus, counseling patients
only with regard to the origin of acids that are directly
involved in the occurrence of dental erosion is not
enough, and guidance should also be offered with
regard to factors that modulate the erosive process.
Conclusion
In the present study, dental erosion was associated
with age and type of school, which demonstrates the
need to make the target population aware of this oral
problem as well as the etiological factors involved and
ways to prevent or arrest the ongoing erosive process
through local actions involving schoolchildren,
parents/caregivers, and teachers.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 2 | April-June 2018 119
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