Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2018  |  Volume : 36  |  Issue : 2  |  Page : 113--119

Dental erosion in schoolchildren and associated factors: A cross-sectional study

Juliana Beckman Frazao, Leticia Goncalves Machado, Meire Coelho Ferreira 
 Department of Dentistry, Ceuma University, São Luís 65075120, Maranhão, Brazil

Correspondence Address:
Meire Coelho Ferreira
Josué Montello, N° 1, Renascença II, São Luís, MA, 65075120


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.

How to cite this article:
Frazao JB, Machado LG, Ferreira MC. Dental erosion in schoolchildren and associated factors: A cross-sectional study.J Indian Soc Pedod Prev Dent 2018;36:113-119

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Frazao JB, Machado LG, Ferreira MC. Dental erosion in schoolchildren and associated factors: A cross-sectional study. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2022 Jan 24 ];36:113-119
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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 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],[3],[4],[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],[8],[9],[10],[11],[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],[16],[17]

An early diagnosis of dental erosion on primary teeth is important to the prevention of future harm to the 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).

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.


The response rate was 80% for the public school and 53% for the private school. The dropouts at the public and private schools were due to a lack of parental authorization (15% and 37%) and the misplacing of documents (5% and 10%). [Table 1] displays the socioeconomic and demographic characteristics of the sample. The majority of children (62.8%) attended the public school. Monthly household income was less than two times the Brazilian minimum wage among 43.9% of the sample.{Table 1}

[Table 2] displays the data on the consumption of acidic foods and beverages. The frequency was two to three times a day among 37.7% of the children who ingested acidic beverages, and the majority (72.8%) reported drinking directly from a glass.{Table 2}

Among the participants in the study, 8.8% used some type of medication for varied purposes [Table 3].{Table 3}

Among the children examined, 28 (11.7%) exhibited dental erosion and 5.4% had a score of 1 on the BEWE [Table 4].{Table 4}

Dental erosion was significantly associated with age (P = 0.009) and type of school (P < 0.001). The highest prevalence was found among 9-year-olds (46.4%), followed by 8-year-olds (35.7%) [Table 5].{Table 5}


In the present study, the prevalence of dental erosion was 11.7%, and both age and type of school were significantly associated with the outcome. The strong point of this study was the choice of schools in socially distinct areas, which enabled the investigation of the influence of socioeconomic status on the occurrence of dental erosion. The major limitation of the study is related to the cross-sectional design, which impedes the establishment of a cause-and-effect relationship. Thus, the associations identified only suggest explanations for the outcome.

The prevalence of dental erosion in the present sample was lower than rates reported for 5-year-old children in two previous studies (42% and 58%)[11],[12] but similar to the rate reported in a study involving a similar age group (15.1%).[7] The divergences in prevalence rates may be explained by the use of different indices for the diagnosis of dental erosion as well as the target public investigated. The BEWE index used in the present study is a simple, easy-to-use assessment tool.[19] Besides being adequate for epidemiological studies, it provides greater internal validity to the study since the diagnostic criteria determined by the index are easy to understand and measure.

The significant difference in dental erosion among the different age groups is in agreement with data from a previous study involving children aged 6 to 12 years.[8] In the study cited, primary and permanent anterior teeth were examined and the children most affected by dental erosion were aged 6 and 7 years. In contrast, 6-year-olds and 7-year-olds in the present investigation either had no dental erosion or had caries on all their teeth. This difference may be explained by the fact that Mangueira et al.[8] evaluated primary and permanent anterior teeth, whereas only primary teeth were examined in the present study. Thus, the findings for 6-year-olds and 7-year-olds may have partially resulted from the loss of primary anterior teeth.

A significant association was found between type of school and dental erosion, with this condition more prevalent in the public school (96.4%). A likely explanation for the higher prevalence in the public school is the socioeconomic status of the children. Due to the lower cost of acidic foods and beverages, children with a lower income may have greater access to such products. Moreover, the parents/caregivers of public schoolchildren may have less information on the harmful effects of acidic foods and beverages than those with a more privileged socioeconomic status. A study evaluating children aged 3 to 6 years found that the prevalence of dental erosion was significantly higher among children at schools in lower income areas, which the authors attributed to greater awareness regarding healthy eating habits among families in higher income areas.[7]

The frequency of acidic beverages was not significantly associated with dental erosion. This is in agreement with data described in a previous study involving Brazilian schoolchildren aged 11–14 years, in which the high consumption of acidic beverages was unable to explain dental erosion.[13] However, a 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 erosion among 5-year-old children who consumed carbonated beverages and acidic fruit juices at least three times a day. In this study, children who consumed carbonated beverages had a 2.3-fold greater chance of exhibiting dental erosion on the dentin level.[11] A higher prevalence rate was also found among children aged 5 to 12 years who consumed soft drinks and industrialized beverages (Prevalence ratio (PR) = 3.5; RP = 2.58, respectively; 95% CI not presented in the study).[22] The divergence in the results of different studies is due to differences in the sample size, age group, and indices used to measure dental erosion.

Excessive acids from one's diet can dissolve the acquired glycoprotein film covering the teeth and come into direct contact with the dental surface, leading to the rapid demineralization of the enamel.[23] This glycoprotein film is fundamental to the integrity of the dental surface and is involved in the remineralization process of tooth enamel.[24] Parents/caregivers need to be made aware of acidic foods and beverages and how such substances should be ingested. Dental erosion in the primary dentition may be a predisposing factor for erosion in the permanent dentition as eating habits and health conditions established during the primary dentition phase can be perpetuated in the permanent dentition phase.

A total of 8.8% of the children evaluated took medications. Some medications with an acid pH have erosive potential, such as antiallergic agents,[25] corticosteroids, antibiotics,[26] bronchodilators,[26],[27],[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]

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.


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


Conflicts of interest

There are no conflicts of interest.


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