CLINICAL AND LABORATORY STUDIES REGARDING CLINICAL ... · clinical and laboratory studies regarding clinical-biological indices related to dental ... chapter i. current data on enamel

“Grigore T. Popa” University of Medicine and Pharmacy - Iași

Faculty of Dentistry

SUMMARY

PH.D THESIS

CLINICAL AND LABORATORY STUDIES

REGARDING CLINICAL-BIOLOGICAL INDICES RELATED TO DENTAL

EROSIONS

Scientific coordinator

Prof. dr. Andrian Sorin

Ph.D student

Arnăuțeanu Cosmin George

i

CONTENT

STAGE OF KNOWLEDGE

Introduction

CHAPTER I. CURRENT DATA ON ENAMEL STRUCTURE AND COMPOSITION

I.1. General considerations

I.2. Physical properties

I.3. Chemical properties

I.4. Structural particularities

CHAPTER II. GENERAL ASPECTS REGARDING DENTAL EROSION.

II.1. Definitions

II.2. Clinical aspects

II.3. Histopatological aspects

II.4. Systems of classification

II.5. Data regarding prevalence and incidence of dental erosions

CHAPTER III. ETHIOPATOGENIC MECHANISMS IN THE INITIATION AND

EVOLUTION OF DENTAL EROSIONS

III.1. Extrinsic factors

III.2. Intrinsic factors

CHAPTER IV. PARACLINICAL METHODS USED IN THE QUANTITATIVE AND

QUALITATIVE OF DENTAL EROSIONS

IV.1. Aspects regarding the methodology of studies investigating dental erosion

processes

IV.2. Quantitative assessment methods

IV.3. Qualitative assessment methods

CHAPTER V. PREVENTION STRATEGIES IN THE TREATMENT OF DENTAL

EROSIONS

V.1.Strategies to prevent dental erosions

V.2. Restorative therapy of dental erosions

ii

PERSONAL SECTION

CAPITOL VI. REASONS FOR RESEARCH THEME CHOICE. THE RESEARCH

METHODOLOGY.

VI.1. The reason for research thema choice

VI.2. Objectives

VI.3. Research directions

CAPITOL VII. PREVALENCE AND DISTRIBUTION OF DENTAL EROSIONS:

EPIDEMIOLOGICAL STUDY

VII.1. The aim of study

VII.2. Materials and method

VII.3. Results and discussions

VII.4. Conclusions

CAPITOL VIII. STUDY IN VITRO REGARDING EROSION PROCESSES

INDUCED BY ACID AGENTS

VIII.1. The aim of study

VIII.2. Materials and method

VIII.3. Results and discussions

VIII.4. Conclusions

CAPITOL IX. THE EVALUATION OF THE EROSION EFFECT OF SOME

BEVERAGES FOR ATHLETES AND THE PROTECTIVE EFFECT OF SOME

REMINERALIZING PRODUCTS ON HARD DENTAL TISSUES

IX.1. The aim of study

IX.2. Materials and method

IX.3. Results and discussions

IX.4. Conclusions

CAPITOL X. STUDY REGARDING KNOWLEDGES AND ATTITUDES OF

DENTISTS ON DIAGNOSTIC AND TREATMENT OF DENTAL EROSIONS

X.1. The aim of study

X.2. Materials and method

X.3. Results and discussions

X.4. Conclusions

GENERAL CONCLUSIONS

REFERENCES

iii

Key words: dental erosions, prevalence, acid agents, demineralisation, remineralisation,

therapeutic management

PhD Thesis contains:

stage of knowledge organised in 5 chapters (44 pages);

personal studies organised in 5 chapters (176 pages);

163 tables and 131 figures;

326 references.

Note: the abstract presents selective references, tables and figures, respecting the content and

counting in pHD Thesis.

1

CHAPTER VI. REASONS FOR RESEARCH THEME CHOICE. THE RESEARCH METHODOLOGY

VI.1. Reasons for the choice of research theme

The quality of dental assistance and technological novelties depend on the

understanding of teeth properties, basic principles and mechanisms implied in the interaction

with surrounding environment.

Last decade the dental erosion and the associated erosion wear are considered high risk

factor for the integrity of hard dental tissues.

The initiation and evolution of dental erosion is influenced by structural characteristics

of teeth, saliva properties, acids sources, parafunctional habits.

A major role in the initiation and evolution of dental erosions is played by the

interaction between chemical factors (composition), biological factors (presence of

saliva/acquired pellicle, salivary rate) as well as behavioural factors (habits regarding the way of

beverages drinking, patterns of teeth abrasion after acid exposure).

Apart from visible clinical defects produced by dental erosion, the prolonged exposure

to acid produces the changes of hard dental tissues physical propertties. The demineralisation

produced by dental erosion reduces the tooth resistance and makes tooth surfaces susceptible to

erosion wear. The dental erosion is also linked by other forms of wear and increases the physical

wear.

The erosion manifests as dental wear, with increasing rate at global level.

Actually there is no accurate data regarding each category of dental wear due to various

indices systems that are not reflecting the ethiology as well as the epidemiological research

models performed on populations with diverse characteristics and age groups. The interpretation

and comparisons of epidemiological data studies is difficult due to the differences in terminology

as well as high number of indices systems used in diagnostic, classification and monitorisation of

erosive lesions categories.

Considering the increasing prevalence and incidence of dental erosion to childrens and

young adults, the early diagnosis of dental erosions for these age categories will allow the

approach for properly preventiv-therapeutical measures.

This approach is important considering the the negative impact of dental erosion on

definitive denture followed by damage of interocclusal and intermaxillary relations requesting

complex prosthetic therapeutical solutions with high financial and psychical costs for patients

with dental erosions.

The dental pratitioners must posess theoretical and practical knowledges regarding the

interaction between chemical, biological and behavioural factors, major feature of patients with

high risk.

Following the concern in current practice and during PhD preparation:

o the collecting of materials that integrate literature data regarding diverse forms of dental

erosions.

o the study of clinical, paraclinical and systemic aspects of patients with dental erosions

taken in research.

2

o the statistical studies, clinical studies, experimental studies, were performed using a

personal database recorded on patients diagnosed and treated in Clinical Base of Dental

Medicine Faculty, U.M.F. “Grigore T.Popa”.

VI.2. Objectives

For the performing of proposed aims, were specified the objectives as follows:

o the structuring of a complex assessment program including diagnostic correlated with

evolution stage and patients characteristics

o the statistical processing of clinical cases from a three years database

o the determination of ethiopathogenic factors

o the description of clinical elements and paraclinical examens used in the epidemiological

study (prevalence, distribution of dental erosion in relation to the investigated

parameters)

o the description of paraclinical examens used in in vitro studies regarding the

demineralization and remineralisation processes to the enamel and dentine surfaces of

teeth affected by dental erosions

o the description of questionnaire used to determine the opinions and therapeutical attitudes

of dental practitioners.

VI.3. Research directions

The study was oriented to the research directions as follows:

o Clinical study regarding the identification of clinical cases with dental erosions and

analysis of dental erosion distribution related to the researched factors (sex, age groups,

dental groups, dental surfaces, sextants)

o The impact of extrinsic and intrinsic factors on prevalence, distribution and severity of

dental erosions

o Chemical analysis of dental surfaces affected by dental erosion under action of chemical

erosive agents like beverages and sports drinks

o Chemical and profilometric analysis of dental enamel and dentine surfaces affected by

dental erosions and submitted to remineralisation processes by using CPP-ACP based

products

o Paraclinical assessment of physical-chemical properties of some beverages and sport

drinks with erosive potential

o The questionnaire-based study regarding the opinions and attitudes of dentists on

diagnostic possibilities, treatment techniques and materials, patients vindicate and

systemic factors analysis.

3

CHAPTER VII. PREVALENCE AND DISTRIBUTION OF DENTAL EROSIONS: EPIDEMIOLOGICAL STUDY

VII.1. AIM OF STUDY

The aim of study was to assess the prevalence, distribution and severity of dental

erosion related to different clinic-biological indices on young adult patients.

VII.2. MATERIALS AND METHOD

The study group included 1296 patients investigated in Clinical Base of Dental

Medicine Faculty U.M.F.”Grigore T.Popa” Iasi. Written consent was obtained for each

patient. The study group included 594 males and 702 females (fig.7.1) . 1074 patient were

age 18-25, 192 patients in age 26-35, 75 patients over 35 years(fig.7.2.). The mean age was

24,45 years. A total number of 72 patients and 396 teeth were diagnosed with dental erosions.

The severity of dental erosions was recorded using BEWE indices system (tabel 6).

Clinical aspects of dental erosions from study group are presented in figures 7.3.a-c.

Fig.7.3.a. M.A., age 25. Dental erosions-anterior maxillary teeth.

Frecvent consumption of sport drinks.

Fig.7.3.b.B.G., age 32. Dental erosions mandibular bicusps. Frecvent consumption of beverages.

4

Fig.7.3.c.M.N., age 35. Dental erosions mandibular bicusps. Frecvent consumption of soft drinks.

For each patient the examiner (PhD student) performed a clinical examen including

localisation, BEWE indices, nutritional habits, lifestyle, parafunctional habits. All teeth were

examined in same conditions of light and magnification. It were recorded data about consume

(frequency, quantity) of beverages, soft drinks, cola drinks, fruit juices, sport drinks, acid

aliments and medication with erosive potential.

Data were recorded as follows:

-presence/absence of dental erosions:

- related to study group;

- related to sex;

- related to age group;

- related to ethiological factor.

-distribution of dental erosion on dental groups/dental surfaces/sextants:

- related to sex

-related to age group;

- related to ethiological factor.

-severity of dental erosion (BEWE system):

-related to sex;

-related to age group;

-related to ethiological factor.

-distribution related to combination sextant/dental surface/ BEWE/sex/age group.

Table 7.I. BEWE system.

SCORE BEWE DESCRIPTION

0 No dental hard tissues loss

1 Low enamel loss

2 Distinct defect, hard dental tissue loss<50% surface area

3 Distinct defect, hard dental tissue loss>50% surface area

The database was created using Microsoft Office EXCEL 2007. The data statistical

processing was performed using software SPSS 17 (SPSS Inc, SUA). The statistical data were

presented as mean values and standard deviations. P<0.05 was considered as having

statistically significant result.

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VII.3. RESULTS AND DISCUSSIONS

The results regarding the prevalence of dental erosions and their distribution in

relation to sex, age groups, dental surfaces, dental groups, sextants, are presented in the next

graphs.

The prevalence for all study group was 6% (fig.7.4.).

A difference related to dental erosions prevalence was observed between males (7%)

and females (4%) (fig.7.5.a-b).

Fig.7.4. Prevalence of dental erosions

Fig.7.5.a-b.Prevalence of dental erosions related to patients sex

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Fig.7.6.a-c. Prevalence of dental erosions related to age group

Related to age groups, prevalence of dental erosions is 6% for age group 18-25, 4%

for age group 26-35 and 8% for patients over 35 years (fig.7.6.a-c).

75%

8%

8%8%

Factor eroziv

Bauturi Acidulate

Supliment Sportiv

Medicatie

Gastro intestinali

Fig.7.8.Distribution of ethiological factors in study group

Related to erosive ethiological factors, 75% of patients with dental erosions are

associated with consume of beverages and soft drinks. The consume of sport drinks is

observed for 8% patients with dental erosions, a similar value with patients under erosive

mediaction and patients with GERD (gastro-esophageal reflux disease) (fig.7.8.).

Related to dental surfaces, highest values of prevalence of dental erosions are 23%

for lateral buccal dental surfaces and 16% for buccal anterior maxillary teeth (fig.7.11.).

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Fig.7.12. Prevalence of dental erosions related to ethiological factors

Related to ethiological factors (fig.7.12.), 32% from total number of dental erosions

are observed to patients consuming sport drinks, 21% to patients frequent consume of

beverages, soft drinks and fruit juices, 19% to patients under erosive medication, and 14% to

patients with GERD.

The distribution of BEWE indices (severity of dental erosions) related to the

investigated factors is presented in the next graphs.

The BEWE mean value is higher for females (5,2) than males (4,7) (fig.7.13.).

Patients over 35 years are associated with highest BEWE mean value (8), followed by age 26-

35 (7) and age 18-25 (4,1) (fig.7.14.).

The sextants S4 and S6 present highest BEWE mean value (1.25) (fig.7.15.).

Fig.7.13. BEWE mean values (sex)

Fig.7.14. BEWE mean values (age groups)

Related to ethiological factors, patients associated with sport drink consume present

highest mean BEWE values (9), followed by medication (8), beverages (4,2) and GERD (4)

(fig.7.16).

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Fig.7.16. BEWE mean values (ehtiologic factors)

The statistical study aimed to confirm or deny the null hypothesis regarding the

absence of statistical differences regarding prevalence and severity of dental erosions

between different clinical-biological indices.

Statistical analysis regarding prevalence of dental erosions related to sex

(dental erosion study group)

Table 7.III. Mann-Witney, Wilcoxon tests. Grouping variable: Sex

Test Statisticsa

VAR00008

Mann-Whitney U 576.000

Wilcoxon W 1479.000

Z -.625

Asymp. Sig. (2-tailed) .532

a. Grouping Variable: Sex

Table 7.III. indicates Mann-Whitney test, with U value 576, and p = 0.532 > 0.05.

This result confirms the absence of statistically significant differences between mean values

BEWE for males and females.

Statistical analysis regarding prevalence of erosions related to age group

( dental erosion study group)

Non-parametric Kruskal Wallis test was applied for all age groups to confirm or deny

the existance of significant statistically differences between age groups.

Table 7.IV.a. Kruskal Wallis. Prevalence of dental erosions related to age groups

Test Statisticsa,b

VAR00008

Chi-Square 8.875

df 2

Asymp. Sig. .012

a. Kruskal Wallis Test

b. Grouping Variable: Age groups

Statistically significant differences were obtained for the three age groups (tabel

7.IV.a). Mann Whitney test was applied for each pair of age groups.

9


( dental erosion study group)

Table 7.b. Kruskall-Wallis test. Prevalence of dental erosions related to dental groups

Test Statisticsa,b

NrErosions

Chi-Square 81.614

df 5

Asymp. Sig. .000


b. Grouping Variable: Dental groups

The results of Mann-Whitney test show significant statistically differences between

the investigated dental groups (table 7.V.b.).


(dental erosions study group)

Table 7.VI.a. Mann-Whitney, Wilcoxon tests. Beverages vs. medication

Test Statisticsb

NrEroziuni


Wilcoxon W 183.000

Z .000

Asymp. Sig. (2-tailed) 1.000

Exact Sig. [2*(1-tailed Sig.)] 1.000a

a. Not corrected for ties.

b. Grouping Variable: Erosive factor

Table 7.VI.a indicates Mann-Whitney test, with U value 162.000, and p = 1.000 >

0.05. This result confirms the absence of statistically significant differences between mean

values BEWE for beverages and medication.

Table 7.VI.b. Mann-Whitney, Wilcoxon tests. Beverages vs. sports drinks

Test Statisticsb

NrEroziuni


Wilcoxon W 1521.000

Z -3.168


Exact Sig. [2*(1-tailed Sig.)] .001a


b. Grouping Variable: FactorEroziv

Table 7.VI.b. indicates Mann-Whitney test, with U value 36.000, and p=0.002< 0.05.

This result confirms the existance of statistically significant differences between mean values

BEWE for ethiological factors beverages and sport drinks. and females.

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Our study shows reduced values of dental erosions prevalence (6%) comparing with

literature data related to adolescents and young adults: Arnadottir&col. (23.2% în Islanda),

Bardsley&col.(27.1% în Marea Britanie), van Rijkom&col. (16% în Olanda), Vargas-

Fereira&col.(7.2% în Brazilia), Kumar&col.(8.9% în Brazilia), Wang&col.(23.2% în China),

Okunseri&col.(39% în SUA), Margaritis&col.(50% în Grecia) /10, 30, 169, 229, 287, 290,

299/.

Related to ethiological factors, 75% patients consume frequently beverages and soft

drinks, result sustained by the literature data.

Al-Dlaigan&col.(2001) show that 80% adolescents consume beverages with 23%

high and frequent consumers (>22/săptămână) /2/. Chrysanthakopoulos NA(2012) assessed

the prevalence and the associated ethiological factors in Greece on adolescents /52/. The

results show a high rate of dental erosions (33.8%) associated with high frequency of

beverages and fruit juices and with rinsing habits before to swallow. Curcă&Danilă(2010)

investigated prevalence and severity of noncariogenic lesions using Smith&Knight indices on

614 pacienţi with age over 18 years /58/. 2.9% from noncariogenic lesions with indice 1 are

dental erosions, percent that increases to 7.9% for noncariogenic lesions with indice 2. 20%

noncariogenic lesions with indice 3 Smith&Knight are dental erosions. From patients that

consume alchohol, 87% are affected by dental erosions with high rate of indice 3, comparing

with only 50% in control group. Micu Magdalena-Ioana (2010) repports a 7.6% frequency of

pure dental erosions related to all noncariogenic lesions found in patients over 18 /206/.

Ganns C&col.(2001) found a prevalence of 11.6% in Germany, while O’Brian (1993) found

30% in Great Britain/95/.

Kunzel&col.(2000) found specific localisation of dental erosions to buccal surfaces

of lateral and central incisive of dental erosions in study group of childrens that consume high

quantities of orange juices /171/. Also O’Brien(1993) found frequent localisation of dental

erosions to buccal and oral dental surfaces to adolescents and young adults that consume

beverages and fruit juices /225/. Vered Y&col.(2014) performed an epidemiological BEWE-

based study regarding prevalence and distribution of dental erosions in 500 adolescents and

young adults /291/. The results show the presence of dental erosions on over 50% subjects

with 10% having dental erosions more than half of dental surfaces. Mean value of BEWE

increased with age and erosive diet. Holbrook WP.&col.(2014) found 30.7% prevalence of

dental erosions for age group 15 ani (38.3% males, 22.7% females) and BEWE mean values

1.00 for males and 0.42 for females (p<0.001) /132/. Valorile BEWE au prezentat diferenţe

semnificative statistic comparativ cu vârsta 12 ani (19.9% băieţi, 11% fete) cu scoruri medii

BEWE de 0.22 pentru băieţi şi 0.079 pentru fete.

The correlation between beverage consume and prevalence of dental erosions are

explained by superior content of phosphoric acid compared to citric acid, malic acid, lactic

acid pphosphoric acid in cola drinks, with higher erosive potential /303/. The consume of

energy drinks, especially during physical exercises is also associated to increased prevalence

and severity of dental erosions/136/.

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VII.4. CONCLUSIONS

The prevalence of dental erosions is reduced in Romania (6%) with higher values for

males (8%) and lower values for females (4%).

Related to age group, highest values of dental erosions frequency are associated to

patients over 35 years (8%) and lowest values for patients in age group 26-35 (4 %).

Related to localisation, most affected are sextants S4 and S6, buccal surfaces of lateral

teeth and buccal surfaces of anterior maxillary teeth, and mandibular molars and

bicusps.

Related to ethiological factors, most affected by dental erosions are patients with high

consume frequency of beverages and soft drinks.

Related to severity, the distribution is balanced with 33% for mild dental erosions,

33% for moderate dental erosions and 33% for severe dental erosions.

Higher BEWE mean values BEWE are associated to patients high consumers of sport

drinks (BEWE 9), while patients high consumers of beverages have 4,5. Highest

BEWE values are encountered to females (5.2), patients over 35 years (8.00), sextants

S4 and S6 (BEWE 1.25) and erosive medication (BEWE 8.00).

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CHAPTER VIII. STUDY IN VITRO REGARDING EROSION PROCESSES INDUCED BY ACID AGENTS

VIII.1. AIM OF STUDY

The aim of study was to investigate the topography and to analyse chemically the

enamel submitted to the action of various acid agents in the presence and absence of acquired

salivary pellicle.

VIII.2. MATERIALS AND METHOD

The study group included 15 unaffected teeth extracted from orthodontic or

periodontal reasons extraşi din motive ortodontice sau parodontale (Fig. 8.1.). The teeth were

sectioned in three slices using diamond discs (Komet Dental, Brasseler GmbH&Co,

Germania), under water cooling (Fig.8.2.). The samples were immersed for 7 days in artificial

saliva AFNOR, changed at every 24 hours. For each tooth one sample was maintained as

control: 1 minute in distilled water, followed by 4 hours immersion in artificial. Another

sample was immersed for 12 hours in acid agents: Red Bull, green tea Lipton, apple juice

Auchan, mineral water Borsec, lemon juice (Fig. 8.3.). The last sample was submitted to a

cycle demineralisation-remineralisation three times: demineralisation by immersion in acid

solution for 1 minute, followed by remineralisation in artificial saliva for 4 hours. These

protocols were selected to simulate the real conditions acid beverages consume in oral cavity.

After each demineralisation the samples were washed in distilled water.

The solutions pH: 3,4 for Red Bull, 3,0 for Lipton –green tea, 3,4 for apple juice, 3,2

for mineral water, 2,4 for lemon juice.

Fig. 8.3 Acid solutions used in study

Fig. 8.1. Teeth in study group

Fig. 8.2. Slices of teeth after sectioning

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After samples preparation, these were analysed to investigate surface topography,

using electronic microscope VEGA II LSH, TESCAN Cehia; the chemical analysis was

performed using EDX detector QUANTAX QX2, BRUKER/ROENTEC Germany (Fig. 8.4.).

VIII.3. RESULTS AND DISCUSSIONS

The figures 8.5., 8.6., 8.7. present aspects of enamel for control samples, samples

under continuous immersion and alternative immersion in apple juice as erosive agent.

For samples immersed in apple juice the erosion was moderate as observed in figures

8.6. and 8.7.


under continuous immersion and alternative immersion in green tea as erosive agent.

Fig. 8.5. Control

group enamel sample- apple

juice as acid agent (SEM X 500)

Fig. 8.6. Study group

enamel sample-apple juice as

acid agent (SEM X 1000)


enamel sample- acid juice as

demineralising agent and

artificial saliva as remineralising

agent (SEM X 1000)

Fig. 8.4. Electronic microscope and EDX

detector

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For samples immersed in apple juice the erosion was moderate, similar with apple

juice study group, as observed in figures 8.9. and 8.10.


under continuous immersion and alternative immersion in apple juice as erosive agent.

For samples immersed in apple juice the areas of erosion alternated with unaffected

enamel, as observed in figures 8.12. and 8.13.


under continuous immersion and alternative immersion in lemon juice as erosive agent.


enamel sample- mineral water as



agent (SEM X 1000)



erosive agent (SEM X 1000)

Fig. 8.11. Control

group enamel sample- mineral

water as erosive agent (SEM X

1000


enamel sample- green tea as



agent (SEM X 1000)


enamel sample- green tea as


Fig. 8.8. Control

group enamel sample- green tea

as erosive agent (SEM X 1000)

15

In the study group with continuous immersion in lemon juice, a pronounced

dissolution of enamel prisms was observed with the exposure of interprismatic enamel areas

(Fig.8.15.); this aspect is different from study group with alternative immersion (Fig.8.16.)

with more reduced demineralisation areas.


under continuous immersion and alternative immersion in Red Bull as erosive agent.

The enamel samples immersed in acid solution in the absence of acquired salivary

pellicle were associated with severe dissolution of enamel areas with chipped aspect (Fig.

8.18.). The enamel samples immersed in acid solution in the presence of acquired salivary

pellicle (obtained by previous immersion in artificial saliva) were associated with intact

enamel areas with mild erosion in the adjacent areas (Fig. 8.19.).


enamel sample- Red Bull as



agent tul eroziv Red Bull și

remineralizare în salivă artificală

(SEM X 1000)


enamel sample- Red Bull as


Fig. 8.17. Control

group enamel sample- Red Bull

as erosive agent (SEM X 1000)



demineralising agent and lemon

juice as remineralising agent

(SEM X 1000)


enamel sample- lemon juice as


Fig. 8.14. Control

group enamel sample- lemon

juice as erosive agent (SEM X

1000)

16

The mean values of Ca and P (wt%) in enamel surfaces for all study groups are

presented in table 8.XVI.

Table 8.XVI. Mean values of Ca and P ions (wt%) for study groups

Apple juice Green tea Mineral

water

Lemon juice Red Bull

Ions concentration (wt%) C

Ca

P

P

C

Ca P

P

C

Ca

P

P

C

Ca

P

P

C

Ca

P

P

Control 3

2.65

1

2.67

3

1.84

1

3.56

3

2.65

1

3.58

2

9.09

1

2.67

3

2.09

1

3.20

Continuous

immersion in acid solution

3

0.13

1

2.20

3

0.39

1

2.24

2

9.58

1

2.82

1

8.67

9

.90

2

3.13

1

0.25

Alternative

immersion in acid solution

and saliva

3

1.25

1

2.51

3

1.69

1

2.83

3

1.07

1

2.20

2

8.91

1

1.14

3

1.69

1

2.76

It was observed a tendencty for the decrease of Ca and P ions levels following

immersion in acid solutions.

For all five acid solutions, the values of Ca and P ions concentrations were closer to

control group for alternative immersion study group comparing with continous immersion

study group (Figurile 8.20-8.25).

0

10

20

30

40

Calciu smalt Fosfor smalt

Suc de meremartor

Suc de meresolutie

Suc de meretest

0

5

10

15

20

25

30

35


Ceai verdemartor

Ceai verdesolutie

Ceai verdetest

0

5

10

15

20

25

30

35


Apa mineralamartor

Apa mineralasolutie

Apa mineralatest

0

5

10

15

20

25

30

35


Suc de lamaiemartor

Suc de lamaiesolutie

Suc de lamaietest

0

5

10

15

20

25

30

35


Red Bullmartor

Red Bullsolutie

Red Bulltest

Fig.8.21. Ca and P variation in enamel for

control, solution, test. Green tea as acid solution. Fig.8.20. Ca and P variation in enamel for

control, solution, test. Apple juice as acid

solution.


control, solution, test. Lemon juice as acid

solution.


control, solution, test. Mineral water as acid

solution.


control, solution, test. Red Bull as acid solution.

17

Values were statistically analysed using Mann-Whitney, Anova and Bonferoni tests.

Tables 8.XX.a-b present the results of Mann-Whitney test for comparison of calcium

ions concentration in solution study group and test study group immersed in RedBull.

Tables 8.XX.a-b.Mann-Whitney test.Comparison of Ca levels between solution study group and test study group

Ranks

lot N Mean Rank Sum of Ranks

Enamel/Ca solution 5 3.00 15.00

test 5 8.00 40.00

Total 10

Test Statisticsb

Enamel/Ca

Mann-Whitney U .000

Wilcoxon W 15.000

Z -2.611




b. Grouping Variable: lot

Statistically significant results were obtained when comparing the concentration of

calcium ions in solution study group and test study group (p=0,009 < 0.05).

Tables 8.XXIII.a-b present the result of Mann-Whitney test used to compare the P

ions concentration between solution study group and test study group immersed in RedBull.

Tables 8.XXIV.a-b. Mann-Whitney test.Comparison of Ca levels between solution study group and test study

group Ranks

lot N Mean Rank Sum of Ranks

Enamel/P solution 5 3.00 15.00

test 5 8.00 40.00

Total 10

Test Statisticsb

Enamel/P

Mann-Whitney U .000

Wilcoxon W 15.000

Z -2.611




b. Grouping Variable: lot

Statistically significant results were obtained when comparing the concentration of P

ions in solution study group and test study group (p=0,009 < 0.05).

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Tables 8.XXVI.a-b present the result of Anova test used to compare the P ions

concentration between solution study group and test study group immersed .in lemon juice.

Table 8.XXVI. Anova test. Comparison of Ca and P levels between control, solution study group and test study

group. Acid agent- juice lemon

ANOVA

Sum of Squares df Mean Square F Sig.

Ca enamel Between Groups 355.777 2 177.889 88944.333 .000

Within Groups .024 12 .002

Total 355.801 14

enamel P

Between Groups 21.619 2 10.809 4567.394 .000


Total 21.647 14

Total 27.803 14

With p<0,05 the statistical test demonstrates the existance of statistically significant

differences between the study groups.

Table 8.XXIX presents the results of Anova test for comparison between Ca and P

ions concentration in control group, solution study group and test study group immersed in

mineral water.

Table 8.XXIX. Anova test. Comparison of Ca and P levels between control, solution study group and test study

group. Acid agent- mineral water

ANOVA


enamel Ca

Between Groups 23.569 2 11.784 6148.435 .000


Total 23.592 14

enamel P

Between Groups 8.577 2 4.289 4765.185 .000


Total 8.588 14

Total 2.398 14



Table 8.XXXII presents the results of Anova test for comparison between Ca and P


green tea.

19

Table 8.XXXII. Anova test. Comparison of Ca and P levels between control, solution study group and test study

group. Acid agent- green tea

ANOVA


enamel Ca

Between Groups 8.967 2 4.483 2861.809 .000


Total 8.986 14

enamel P

Between Groups 4.372 2 2.186 2676.939 .000


Total 4.382 14

Total 24.886 14



Table 8.XXXV presents the results of Anova test for comparison between Ca and P


apple juice.

Table 8.XXXV. Anova test. Comparison of Ca and P levels between control, solution study group and test study

group. Acid agent- apple juice

ANOVA


enamel Ca

Between Groups 1.325 2 .663 17.500 .000


Total 1.779 14

enamel P

Between Groups .277 2 .139 168.510 .000


Total .287 14

Total 36.051 14



Numerous in vitro and in vivo researches assessed the erosive potential of different

drinks and foods.

The chelating properties of citric acid can increase the erosive process in vivo by the

interaction with saliva, apart from direct demineralisation and mineral dissolution from hard

dental tissues /202/. Some experimental in vitro studies demonstrated more powerful action of

citric acid comparing with phosphoric acid for similar titratable acidity /302/.

The content of Ca and P of drinks is an important factor that influences concentration

gradient in local environment from tooth surface. The adding of Ca and P salts in acid drinks

conducted to promising results regarding the prevention of dental erosions /16, 26, 174/.

The sport drinks have powerful erosive activity especially when consumed during

physical training sessions and associated with dehydration their erosive activity is more

prononunced /136/.

20

Regarding topographic changes, the results obtained by our study, following

immersion of enamel samples unprotected by acquired salivary pellicle in acid solutions, are

similar with literature data /202/

Drinks pH has a direct influence on the dissolution rate of enamel. The phosphoric

acid, citric acid and Na citrate are frequently found in beverages and sport drinks /51/. The

acids with chelating properties can produce dissolutions even at high levels of pH /289/.

The content of Ca and P in foods and drinks influences local environment but despite

the effect of reducing progresssion, not always the minerals addition can completely prevent

the initiation of dental erosions /186/.

In this context the results obtained by personal study have important clinical

implications for dental pratitioners.

VIII.4. CONCLUSIONS

1. The concentrations of Ca and P ions decreased after immersion in the tested acid

solutions;

2. Highest decrease of Ca and P ions from enamel surfaces was recorded for

immersion in lemon juice, followed by Red Bull, mineral water, apple juice and

green tea;

3. The presence of acquired salivary pellicle offered protection to enamel surfaces, as

Ca and P concentrations were less diminished comparing with the enamel surfaces

immersed in acid solutions in the absence of acquired salivary pellicle.

21

CAPITOL IX. THE EVALUATION OF THE EROSION EFFECT OF SOME BEVERAGES FOR ATHLETES AND THE PROTECTIVE EFFECT OF SOME REMINERALIZING PRODUCTS ON HARD DENTAL TISSUES

IX.1. THE AIM OF STUDY:

I. To determine pH and viscosity of three drink sports used to sustain physical

training

II. To assess and compare the effects of these sport drinks on surface hardness of

enamel and dentine

III. To assess and compare the effects of the three sport drinks on enamel and dentine

after remineralisation cycles with fluor-based products.

IX.2. MATERIALS AND METHOD

The three sport drinks used in study are as follows : Gatorade liquid (Pepsico),

energising tablets Isostar lemon (Isostar) CytoMax orange powder (CytoSport). The sport

drink Isostar was obtained by dissolving a tablet in 250 mL pure water (Borsec, Romaqua

Group), and sport drink CytoMax was obtained by dissolving one powder measure (25 mg) in

250 mL pure water (Borsec, Romaqua Group).

The sport drinks pH was determined using electronic pH-meter (Hanna pH 210). 10

measurement were performed for each sport drink repporting mean value.

The reological study was performed using Anton Paar, Physica MCR 501 with

Peltier system of temperature regulating (figure 9.1.). The temperature was regulated in a

range -40 -200oC. The measurement were performed using a geometry with cilinders.

Fig.9.1. Reometer Anton Paar Physica MCR 501

The flow curves were performed using a shear rate between 0.001-100 1/s, at

a temperature 37 oC and a time 5 minutes.

The study group used 33 unaffected teeth extracted for orthodontic reasons.

The teeth were maintained in distilled water. The teeth were sectioned using diamond discs

(Komet Dental, Brasseler GmbH&Co, Germania), under water cooling, aiming to obtain 2

horisontal slices (2 mm thickness). These slices were cut buccal-oral in two halves, obtaining

four slices for every tooth. The dental sections were divided randomly in two groups : study

group I included 40 samples, study group II included 90 samples. In study group I 10 samples

22

were maintained continuously in artificial saliva, as control group (control group 1), 10

samples were submitted to the erosive action of sport drink Isostar (Isostar): 5 series of 3

minutes immersion in sport drinks on 2 hours daily, for 14 days (study group 2). Another 10

samples were submitted to the erosive action of sport drink CytoMax (CytoSport): 5 series of

3 minutes immersion in sport drink on 2 hours daily, for 14 days (study group grup 3) ;

another 10 samples were submitted to the erosive action of sport drink Gatorade (Pepsico): 5

series of 3 minutes immersion 2 hours daily, for 14 days (study group 4).

Between erosive action of sport drinks, slices were maintained in artificial saliva.

Artificial saliva for this study was AFNOR standard S90-701, with pH 8,67 and next

composition: NaCl 0,7g/L; KCl 1,2 g/L; Na2HPO4 0,26 g/L; NaHCO3 1,5g/L; KSCN 0,33

g/L; uree 1,35 g/L. The times of immersion in sport drinks were chosen to simulate the

administration conditions during daily sport training. Each sample was immersed in same

quantity (15 mL) of tested drink, and these were changed after each immersion. The artificial

saliva was changed daily. In study group II, 30 samples were submitted to the previous

immersion protocole in Gatorade (study group 2), 30 samples were submitted in CytoMax

(study group 3), 30 samples were submitted to the previous immersion protocole in Isostar

(grup 4), but for 10 samples in each study group, previous to first immersion, was applied

toothpaste Colgate Total® for 3 minutes (Colgate Company) (subgrup a), to 10 samples fluor

gel Densell Company for 1 minute (subgrup b), and to 10 samples MI Paste Plus for 3

minutes (GC Company) (subgrup c).

The prepared samples were submitted to the analysis of surface microhardness for

enamel and dentine using digital devices CV 400 DAT (Namicon) (figure 9.2.).

Fig.9.2. Digital device CV 400 DAT (Namicon) for microhardness test

The microhardness was tested using Vickers method to compare variation of

mechanical properties of anisotrop materials /259/.

The measuring were performed using a testing device with diamond head at 136º

angle and 2,5 mm diameter. Indentation were performed with 50 g force with a minimal

distance between two consecutive indentation 1 mm. The number of indentaion for each

sample was 3, with mean value recorded after 3 measurings. The criteria for an indentation

were as follows : sharp on diagonal edges, uniform, without unregular areas in tested areas

(figura 9.3.). The microhardness was calculated after formula: D=1854,4·F/d2 (N/mm2)

(D=Vickers microhardness, F= test force, d= lenght of diagonal edge).

Fig 9.3. Proper indentation

23

IX.3. RESULTS AND DISCUSSIONS

The pH values of the three tested drinks were: 4.01 for Isostar, 4.74 for CytoMax,

3.23 for Gatorade.

The flow curves for all tested sport drinks are presented in graph 9.4.

Fig.9.4. Flow curves for the tested beverages

The mean values of viscosity for all sport drinks are presented in table 9.III.

Table 9.III. Viscosity mean values

Sample Gatorade Isostar Cytomax

Shear Rate(s-1) Viscosity

(mPa·s)

Viscosity

(mPa·s)

Viscosity

(mPa·s)

0.0681 6.66 4.64 64.6

0.1 2.58 0.239 58.2

0.147 2.82 0.618 52.7

0.215 2.21 1.56 44.6

0.316 1.18 1.24 33.8

0.464 1.1 1.09 25.7

0.681 1.16 1.11 19

1 0.778 0.648 14

1.47 0.948 0.773 10.4

2.15 0.901 0.808 8.6

3.16 0.915 0.827 6.91

4.64 0.892 0.785 5.91

6.81 0.906 0.795 5.15

10 0.902 0.798 4.57

14.7 0.915 0.821 4.05

21.5 0.94 0.847 3.67

31.6 0.953 0.86 3.36

46.4 0.984 0.891 3.14

68.1 1.04 0.943 2.99

100 1.08 1.05 2.84

0.1

1

10

100

mPa·s

0.01 0.1 1 10 1001/s

Shear Rate .

Gatorade

Viscosity

Isostar

Viscosity

Cytomax

Viscosity

24

Highest viscosity value was recorded for sport drink CytoMax, followed by Gatorade

and Isostar.

The mean values and standard deviations of microhardness values are specified in

table 9.V. Table 9.V. Mean values and standard deviations of hardness values in study group I (MPa)

Descriptive Statistics

N Minimum Maximum Mean Std. Deviation

Statistic Statistic Statistic Statistic Std. Error Statistic

Ctrlsalivadentine 10 55.40 59.10 57.2300 .27731 .87693

Ctrlsalivaenamel 10 186.80 219.80 203.0500 3.25833 10.30375

IsostarIdedentine 10 35.80 37.20 36.5600 .11944 .37771

IsostarIsenamel 10 113.00 114.70 113.8000 .15986 .50553

CytoMaxIdentine 10 22.00 23.60 37.1300 .15420 .48762

CytoMaxIenamel 10 109.40 110.90 110.3000 .17826 .56372

GatoradeIdentine 10 36.00 38.70 22.9000 .25300 .80007

GatoradeIenamel 10 103.90 107.50 105.6600 .38361 1.21308

Valid N (listwise) 10

The mean values of enamel microhardness after immersion in sport drinks were

lower than control group (mean value 113.8 after immersion in Isostar, 110.3 after immersion

in CytoMax and 105.6 after immersion in Gatorade). The same tendency was recorded for

dentine microhardness(mean value 36.56 after immersion in Isostar, 37.13 after immersion in

CytoMax and 22.90 after immersion in Gatorade). The highest values of microhardness were

recorded for Isostar and lowest values were recorded for Gatorade both for enamel and

dentine.

The statistical analysis was performed using Kruskal Wallis test for dentine

microhardness. The statistical results show statistically significant differences between the

four study groups with p = 0.0001 < 0.05 (tables 9.VII.a-b.).

Tables.9.VII.a-b. Kruskal Wallis test. Comparison of dentine hardness values

Ranks

Study group N Mean Rank

Demineralisation Control saliva dentine 10 35.50

Isostar I dentine 10 18.00

CytoMax I dentine 10 5.50

Gatorade I dentine 10 23.00

Total 40

Test Statisticsa,b

Demineralisation

Chi-Square 33.908

df 3

Asymp. Sig. .000


b. Grouping Variable: Lot

25

The mean values and standard deviations of microhardness values are specified in

table 9.V. Table 9.XXV.Mean values and standard deviations of hardness values (MPa) in study groupII

Descriptive Statistics

N Minimum Maximum Mean Std. Deviation

Statistic Statistic Statistic Statistic Std. Error Statistic

IsostarIIpastad dentine

10 25.50 26.70 26.1300 .13085 .41379

IsostarIIpastad enamel 10 34.90 36.40 35.7000 .17575 .55578

IsostarIIfluor dentine

10 45.10 46.90 45.0000 .18148 .57388

IsostarIIfluor enamel

10 203.10 205.50 158.3000 .22657 .71647

IsostarIIMiPaste dentine

10 44.00 46.60 46.0600 .29740 .94045

IsostarIIMiPaste enamel

10 154.80 162.60 204.0000 .80567 2.54777

CytomaxIIPastad dentine

10 55.00 57.90 41.2600 .29061 .91900

CytomaxIIPastad enamel

10 185.00 188.30 186.9600 .33106 1.04690

CytomaxIIfluor dentine

10 64.90 67.90 56.5300 .32457 1.02637

CytomaxIIfluor enamel

10 224.30 244.70 202.1600 1.73917 5.49974

CytomaxIIMiPastedentine 10 39.80 42.40 66.1300 .27536 .87076

CytomaxIIMiPasteenamel 10 187.70 219.00 234.6600 3.60753 11.40801

GatoradeIIPastaddentine 10 38.70 40.30 33.7000 .21554 .68158

GatoradeIIPastad enamel

10 129.80 131.90 130.7600 .24459 .77345

GatoradeIIfluor dentine

10 33.10 34.20 38.8300 .11832 .37417

GatoradeIIfluor enamel

10 145.90 146.70 138.9600 .09452 .29889

GatoradeIIMiPastedentine 10 38.50 39.10 39.5300 .06333 .20028

GatoradeIIMiPasteenamel 10 138.30 139.50 146.2600 .13013 .41150

Valid N (listwise) 10

The use of MI Paste and fluoride gel previous to immersion in Isostar conducted to

higher microhardness values of enamel and dentine (204.00 Mpa and 46.06 MPa, respectively

158.30 Mpa and 45.00 Mpa, comparing to values associated to use of toothpaste before

immersion in sport drinks (35.70 Mpa şi 26.13 MPa). Highest enamel and dentine

microhardness values were recorded for the use of MI Paste before immersion in sport drinks

(234.66 MPa and 66.13 Mpa), followed by the use of fluoride gel (202.16 MPa şi 56.53 Mpa)

and toothpaste (186.96 and 41.26 Mpa).

The results of Anova test for dentine microhardness values showed statistically

significant differences with p = 0.0001 < 0.05 (table 9.XXVII).

26

Table 9.XXVII. Anova test. Comparison between dentine hardness values ANOVA

Remineralisation dentine


Between Groups 11307.358 8 1413.420 2714.699 .000

Within Groups 42.173 81 .521

Total 11349.531 89

Statistically significant differences were recorded between the all

remineralisation products with two exceptions: between the use of toothpaste and the use of

MI Paste before immersion in Gatorade and between the use of fluoride gel and the use of MI

Paste before immersion in Isostar.

The microhardness values for enamel were analysed with Anova test. The results

showed statistically significant differences with p = 0.0001 < 0.05 (tables 9.XXIX.a-b.).

Tables 9.XXIX.a-b. Anova test. Comparison of enamel hardness values

ANOVA

Remineralisation enamel


Between Groups 269536.921 8 33692.115 1787.317 .000

Within Groups 1526.904 81 18.851

Total 271063.825 89

Statistically significant differences were recorded for all remineralisation products

with exception of the use of fluoride gel before immersion in Isostar and Cytomax.

The epidemiological studies repports direct relation between excesive consume of

soft drinks and the increase of dental erosions prevalence /212,160/. The erosive properties of

beverages, fruite juices, sport drinks are associated significantly with pH values, acidity,

content of fluor and phosphorus ions and enamel surface microhardness /195/. The erosive

properties of liquids are also associated to titratable acidity, acid quantity temperature and

buffering properties /142, 257, /.

The in vitro studies demonstrate that low pH beverages produce erosion to the level

of hard dental tissues /104,174,176 /. Also all tested sport drinks in personal research showed

erosive potential on enamel and dentine, sustaining the literature data/151/.

In personal study the sport drinks with lowest pH had the highest erosive potential

while drinks with high pH, reduced titratable acidity and higher concentrations of calcium,

phosphat and fluore ions present reduced erosive potential /210/.

The samples analysed by flow curves present inverse relation between viscosity and

shear rate due to high water quantity /166/. In personal study the sport drink with highest

viscosity (Gatorade) is not associated with highest erosive potential on enamel and dentine.

This result demonstrates that clearance rate does not influence the erosive properties of

beverages.

The citric acid and phosphoric acid present pronounced erosive effect on hard dental

tissues due to chelating properties on calcium ions/203,259,260/. The erosive potential of

sport drinks tested in personal study is also explained by the content of citric acid.

MI Paste plus combines milk phosphoproteins with calcium phosphate. The agent

CPP stabilises calcium ions and phosphat ions forming complexes with fast adsorbtion. The

same concept is associated to Recaldent product.

27

The classification of erosive potential of various beverages and foods accordingly to

their pH, titratable acidity, calcium, phosphat and fluor ions is complicated, if not impossible.

Also it must be considered behavioural factors and biological factors (eat and drinking habits,

diet content of fruits and vegetables, oral hygiene practices) and biological factors (salivary

rate, buffering ability, acquired pellicle, teeth anatomy).

IX.4. CONCLUSIONS

1. Highest pH value was found for sport drink CytoMax, followed by Isostar and

Gatorade.

2. Highest viscosity value was recorded for sport drink CytoMax, followed by

Gatorade and Isostar.

3. All three tested sport drinks determined the significant decrease of enamel and

dentine microhardness, as effect of their erosive potential on enamel and dentine.

4. Gatorade was associated with highest erosive effect on enamel and dentine,

followed by CytoMax and Isostar.

5. The use of fluor toothpaste, fluor gel MI Paste (caseine, calcium phosphate, fluor)

previous to immersion in sport drinks, reduced the erosive effects of sport drinks both for

enamel and dentine.

6. The most protective effect on enamel and dentine was recorded for MI Paste Plus,

followed by fluoride gel (fluoride gel Densell) and tooth paste (Colgate total).

7. Enamel microhardness associated to the previous use of remineralisation products

was significantly higher than dentine microhardness.

28

CHAPTER X. STUDY REGARDING KNOWLEDGES AND ATTITUDES OF DENTISTS ON DIAGNOSTIC AND TREATMENT OF DENTAL EROSIONS

X.1. AIM OF STUY

The aim of study was to assess the knowledges and attitudes of dentists from Iassy

regarding diagnostic and therapeutical management of dental erosions.

X.2. MATERIALS AND METHOD

A questionaire was send to 79 dentists working to private dental practices in Iassy.

The informations regarding sex, age, experience were collected.

The questionaire included, in first part, 15 questions regarding attitudes in diagnostic

of dental erosions, experience about prevalence, ethiological factors, preventive and

therapeutical means used, options regarding treatment techniques and materials.

Second part included a dental erosions clinical case with photos and anamnesis data

and questions regarding their preventive-therapeutical options and restoration type.

The dentists were classified in three classes of experience: 64 dentists with 0-5 years

experience, 6 dentists with 6-10 years experience and 9 dentists with over 10 years experience

(fig 10.1.). The age range was 25-58 years, and the sex distribution was 23 males, 56 females

(fig 10.2.).

The collected data were recorded, analysed and expressed using Microsoft Excel.

10.3. RESULTS AND DISCUSSIONS

The distribution of dentists opinions in entire study group and related to the

experience category (1-5 years; 6-10 years; over 10 years) is presented in the next graphs.

QUESTIONS I- DIAGNOSTIC ATTITUDE AND EXPERIENCE REGARDING PREVALENCE< DISTRIBUTION AND ETHIOLOGICAL FACTORS.

I.1. Do you record dental erosions in clinical papers?

85% dentists record dental erosions, 100% for 6-10 years experience, 88% for 0-5

years experience and only 56% for dentists over 10 years experience (fig.10.3.a-b).

29

Fig 10.3.a. Dental erosions recording (study group)

Fig 10.3.b.Dental erosion recording (experience)

I.2. What system do you use to record and assess dental erosions?

81% dentists use a simple system to assess dental erosions; 13% do not use any

system, only 6% use a complex system for the recording of dental erosions (Smith&Knight,

BEWE etc) (fig.10.4.a).

85%

15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Da Nu

1.1

Da88%

Da100%

Da56%

Nu13%

Nu0%

Nu44%

0%

20%

40%

60%

80%

100%

120%

0-5 6-10 10+

1.1

30

Fig 10.4.a. Assessment systems of dental erosion (study group)

Simple assessing systems are used by 88% for 1-5 years experience, 67% for 6-10

years experience and only 44% for dentists over 10 years experience. Complex assessing

systems are used by 66% 6-10 years experience and over 10 years experience, 67% for 6-10

years experience and only 44% for dentists over 10 years experience (fig.10.4.b).

Fig 10.4.b. Assessment systems of dental erosions (experience)

I.8. From your experience, do you consider that actually prevalence of dental

erosions increased comparing with 5-10 years ago?

44% dentists consider that prevalence of dental erosions increased if repported

to 5-10 years ago, 56% can’t appreciate and only 3% consider that prevalence of dental

erosions remained at same level (fig.10.10.a).

81%

6%13%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Simplu Complex Niciunul

1.2

Simplu88%

Simplu67%

Simplu44%

Complex3%

Complex0%

Complex33%

Niciunul9%

Niciunul33%

Niciunul0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-5 6-10 10+

1.2

31

Fig 10.10.a. Prevalence dynamics of dental erosion (study group)

The opinion that prevalence of dental erosions increased was accounted for 38%

dentists with 0-5 years experience, 33% dentists with 6-10 years experience, 78% dentists

over 10 years; it can’t be appreciated for 59% dentists with 0-5 years experience, 67% dentists

with 6-10 years experience, 22% dentists with over 10 years experience (fig.10.10.b).

Fig 10.10.b. Prevalence dynamics of dental erosions (experience)

I.9. From your experience, what dental group do you consider as most affected

by dental erosions?

67% dentists consider that mandibular molars are most affected by occlusal

dental erosions, while 44% dentists consider that maxillary anterior teeth are most affected by

cervical erosions (fig.10.11.a).

42%

3%

56%

0%

10%

20%

30%

40%

50%

60%

Da Nu Nu am putut aprecia

1.8

Da38%

Da33%

Da78%

Nu3%

Nu0%

Nu0%

Nu am putut aprecia

59%

Nu am putut aprecia

67%

Nu am putut aprecia

22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0-5 6-10 10+

1.8

32

Fig.10.11.a. Relation dental erosions- dental group (study group)

Fig 10.11.b. Relation dental erosions –dental group (experience)

I.11. Did you identified most probable ethiological factor of dental erosions?

59% dentists could not identify in most cases the ethiological factor of dental erosions

after anamnesis and clinical examen, 33% dentists identify only occasionally, 8% identify

rarely the ethiological factor (fig.10.13.a).

10%15%

67%

8%

0%

15%

44%

8%3%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

MMX PMMX MMD PMMD MMX PMMX FMX MMD PMMD FMD

Eroziuni dentare ocluzale Eroziuni dentare cervicale

1.9

MMX9%

MMX0%

MMX22%

MMX0%

MMX0%

MMX0%

PMMX13%

PMMX33%

PMMX22%

PMMX13%

PMMX33%

PMMX22%

MMD69%

MMD67%

MMD56%

MMD6%

MMD0% MMD

22%

PMMD9%

PMMD0%

PMMD0%

PMMD0%

PMMD0%

PMMD22%

FMX44%

FMX67%

FMX33%

FMD38%

FMD0%

FMD0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-5 6-10 10+ 0-5 6-10 10+

Eroziuni dentare ocluzale Eroziuni dentare cervicale

1.9

33

Fig.10.13.a.Identification of ethiological factors (study group)

Related to dentists with 0-5 years experience, 59% dentists can identify usually the

probable ethiological factor, 34% identify ocasionally, 6% identify rarely. Related to dentists

with over 10 years experience, 78% dentists can identify usually the probable ethiological

factor, while 22% identify rarely. (fig.10.13.b).

Fig 10.13.b.Identification of ethiological factors (experience)

QUESTIONS II- THERAPEUTICAL ATTITUDE, TECHNIQUES AND

MATERIALS USED FOR THERAPY OF DENTAL EROSIONS

II.1. Do you treat always, sometimes, never dental erosions?

42% dentists treat always the diagnosed dental erosions, 33% dentists treat some of

the diagnosed dental erosions, and 25% send patients to specialists if diagnose complex

pathology of dental erosions (fig.10.18.a).

59%

33%

8%

0%

10%

20%

30%

40%

50%

60%

70%

De obicei Ocazional Rar

1.11

De obicei59%

De obicei33%

De obicei78%

Ocazional34%

Ocazional67%

Ocazional0%

Foarte rar6% Foarte rar

0%

Foarte rar22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0-5 6-10 10+

1.11

34

Fig.10.18.a. Treatment decision in dental erosions (study group)

The dental erosions are treated always by 47% from dentists with 0-5 years

experience, 33% from dentists with over 10 years experience; the diagnosed dental erosions

are treated but not all by 25% dentists with 0-5 years experience and by 44% dentists with

over 10 years experience (fig.10.18.b).

Fig.10.18.b. Treatment decision in dental erosions (experience)

II.4. For patients with dental erosions what type of preventive/therapeutical

measures do you used?(scale from 1 to 8): A.Advices about oral hygiene; B.Advices

about diet; C.Correction of salivary rate; D. Fluoride mouthwashes; E. Fluoride gels; F.

CPP-ACP products (Recaldent, Tooth Mooth); G. Clorhexidine mouthwashes/gels;

H.Correction of systemic factors implied in dental erosions ethiology.

42%

33%

25%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Tratati intotdeuna toateeroziunile dentare

Tratati partialeorziuniledentare

Uneori trimiteti pacientiicu patologie complexa la

alti specialisti

2.1

47%

0%

33%25%

100%

44%28%

0%22%

0%

50%

100%

150%

0-5 6-10 10+

2.1

Tratati intotdeuna toate eroziunile dentare

Tratati partial eroziunile dentare

Uneori trimiteti pacientii cu patologie complexa la alti specialisti

35

Fig.10.21.a. Preventive/therapeutical measures (study group)

Fig.10.21.b. Preventive/therapeutical measures (experience)

The advices about oral hygiene (17%) and diet(16%) and fluoride mouthwashes

(13%) with are the most used preventive/therapeutical measures for patients with dental

erosions. There is no significant differences between dentists related to experience regarding

the investigated preventive and therapeutical measures (fig.10.21.a-b).

17%

16%

12%13%

11% 10%10%

11%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

A B C D E F G H

2.4

18% 17% 15%

16% 14% 13%

11%12% 21%

13% 14%14%

11% 11%7%

10% 10%13%

9% 10%9%

11% 11% 8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-5 6-10 10+

2.4Corectarea factorilorsistemici implicaţi înetiologia eroziunii dentareAdministrare de ape de gura și geluri ce conțin clorhexidinăAdministrare de geluri pebază de CPP-ACP

Administrare de geluri cufluor

Administrare de ape de gurăcu fluor

Corectarea ratei fluxuluisalivar

36

II. Do you treat cervical erosive lesions always, sometimes, never ?

Fig.10.23.a. Treatment of cervical dental erosion (study group)

67% dentists treat always and 33% treat sometimes cervical dental erosions

(fig.10.23.a).

Fig.10.23.b. Treatment of cervical erosive lesions (experience)

Regarding cervical erosive lesions and related to experience, 72% dentists with

0-5 years experience treat always, 28% sometimes; 56% dentists with over 10 years

experience treat always, 44% sometimes (fig.10.23.b).

67%

33%

0%0%

10%

20%

30%

40%

50%

60%

70%

80%

Intotdeuna Uneori NU

2.6

Intotdeauna72%

Intotdeauna33%

Intotdeauna56%

Uneori28%

Uneori67%

Uneori44%

Niciodata0%

Niciodata0%

Niciodata0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

0-5 6-10 10+

2.6

37

II.7. What kind of materials do you use in treatment of dental erosions? (scale

from 1 to 7): A. Amalgam; B. Hibrid composite resins; C. Compomers; D.Glassionomer

cements; E. Ceramic veneers; F. Metal or ceramo-metal crowns.

Fig.10.24.a. Materials used in restorative therapy of dental erosions

(study group)

Fig.10.24.b Materials in restorative therapy of dental erosions (experience)

In the treatment of dental erosions, amalgam is most used by 17% dentists, followed

by composite resins (16%), compomers (16%) s glassionomer cements (15%). Dentists with

0-5 years experience used most frequently glassionomer cements (18%), dentists with 6-10

years experience used most frequently composite resins(19%), and dentists with over 10 years

experience used most frequently composites flow (19%) (fig.10.24.a-b).

Despite increasing focus of researchers on dental erosions, Dugmore&Rock (2003)

proved that most dentists motivate ocasionally or rarely patients to treat this pathology /68/.

17%16% 16%

15%

17%

8%

10%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

A B C D E F G

2.7

18%12%

16%

17%

19% 7%

16%

11%19%

14%

17%21%

07%

12%

11%

9%16%

12%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-5 6-10 10+

2.7Coroane de înveliș

Fațete ceramică

Cimenturi glassionomere tradiționale

Compomeri

Compozite fluide

Rășini compozite

CGI mr

38

Mulic A&col. (2010; 2012) identified an improper level of informations regarding dental

erosions and erosive wear from dentists to patients included in risk categories /214, 215, 216/.

The personal study proved that actually the dentists working in private practices in

rare aware on the importance of dental erosion pathology, diagnostic possibilities and

treatment. However most dentists do not use a specific indices system to record dental

erosion. Also there are no uniform opinions regarding distribution of dental erosions in

relation to parameters like sex and age. However most dentists are aware that dental erosions

predominate to males patients age 15-25, associated with high consume of beverages and soft

drink, result similar with literature data /93, 189/.

The result of personal study sustain the results of Sabahipour L.&Bartlett D(2009)

which found that most dentists in Great Britain use composite resins as materials for the

therapy of dental erosions, while in Europe this percent reduces to 33%, 50% decide not to

treat teeth affected by dental erosions, and 10% treat with ceramo-metal crowns /261/.

10.4. CONCLUSIONS

Most dentists in private dental cabinet in Iassy are aware of the importance to

diagnose and treat dental erosions.

The ethiological factors is detected most by dentists with experience over 10 years

(78%).

Dentists consider that most affected teeth are mandibular molars (occlusal erosions)

and anterior maxillary teeth (cervical erosions).

The preventive-therapeutical measures related to oral hygiene advices, diet advices,

fluoride mouthwashes are largely used both by dentists under 5 years experience and

dentists over 10 years experience.

In therapy of dental erosions, amalgam is most used by 17% dentists, followed by

composite resins (16%), compomers (16%) glassionomer cements (15%).

39

GENERAL CONCLUSIONS

o The dental erosion prevalence is low (6%) with higher values (8%) in the male

population and smaller values (4%) in the female population.

o In relation to the age group, the highest values of dental erosion prevalence (8%) are

found at patients older than 35 years; the lowest values of dental erosion prevalence

are found at patients betweenthe ages of 18 to 25 years (4%).

o In relation to etiological factors, the highest values of dental erosion prevalence were

found at patients associated with consume of beverages and soft drinks; 75% of the

patients sample with dental erosion patients frequent consume beverages, soft drinks

and fruit juices.

o The highest mean BEWE values were found at patients consuming sport drinks

(BEWE 9); patients associated with consume of beverages and soft drinks have mean

BEWE 4.5. The BEWE mean value is higher for females (BEWE 5,2), patients over

35 years (BEWE 8.00), the sextants S4 and S6 (BEWE 1.25) and patients under

erosive mediacation (BEWE 8.00).

o Highest decrease of Ca and P ions from enamel surfaces was recorded for immersion

in lemon juice, followed by Red Bull, mineral water, apple juice and green tea;

o The presence of acquired salivary pellicle offered protection to enamel surfaces, as Ca

and P concentrations were less diminished comparing with the enamel surfaces

immersed in acid solutions in the absence of acquired salivary pellicle.

o Highest pH value was found for sport drink CytoMax, followed by Isostar and

Gatorade.

o Gatorade was associated with highest erosive effect on enamel and dentine, followed

by CytoMax and Isostar

o The use of fluor toothpaste, fluor gel MI Paste (caseine, calcium phosphate, fluor)

previous to immersion in sport drinks, reduced the erosive effects of sport drinks both

for enamel and dentine.

o The most protective effect on enamel and dentine was recorded for MI Paste Plus,

followed by fluoride gel (fluoride gel Densell) and tooth paste (Colgate total).

o Most of the private dental practitioners in Iași are well aware of the importance of

diagnosing and treatment of the tooth erosion.

o Preventive measures (advice on oral hygene, diet, and the use of mouth wash that

contain fluoride) are widely used by all three groups (0-5, 6-10, 10+ experience).

o In the dental erosion therapy, the amalgam material is the most used by 17% of the

people questioned, followed by composite resins (16%), compomer material (16%)

40

and CGI (15%). Dentists with 0-5 years of experience use most of the time CGI

(18%), the ones with 6-10 years of experience use composite resins (19%) and the

ones with over 10 years of experience use composite flow (19%).

41

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CLINICAL AND LABORATORY STUDIES REGARDING CLINICAL ... · clinical and laboratory studies regarding clinical-biological indices related to dental ... chapter i. current data on enamel