al-majed [2002] risk factors for dental erosion in 5-6-year old and 12-14 year old boys in saudi...

Community Dent Oral Epidemiol 2002; 30: 3846 Copyright C Munksgaard 2002Printed in Denmark . All rights reserved

ISSN 0301-5661

Ibrahim Al-Majed, Anne Maguire andRisk factors for dental erosion inJohn J. MurrayDepartment of Child Dental Health, DentalSchool, Framlington Place, Newcastle upon56 year old and 1214 year old Tyne, NE2 4BW, United Kingdom

boys in Saudi ArabiaAl-Majed I, Maguire A, Murray JJ. Prevalence and risk factors for dental erosionin 56 year-old and 1214-year-old boys in Saudi Arabia. Community Dent OralEpidemiol 2002; 30: 3846. C Munksgaard, 2002

Abstract Material and methods: Dental examinations were carried out on 354boys aged 56 years, and 862 boys aged 1214 years, attending 40 schools in Riy-adh. The prevalence of dental erosion was assessed using diagnostic criteria sim-ilar to those employed in the 1993 UK National Survey of Child Dental Health.Results: Pronounced dental erosion (into dentine or dentine and pulp) was ob-served in 34% of 56 year olds and 26% of 1214 year olds. Information on foodand drink consumed and dietary habits was obtained by means of a question-naire. Parents reported that 65% of 56 year old boys took a drink to bed. Waterwas the commonest drink consumed (37%) followed by carbonated soft drinks(21%). One third of parents reported that their son had something to eat in bed orduring the night and 60% of this was sweet food or confectionery. Seventy percent of 1214 year old boys reported consuming drinks at night; these were mainlywater (30%), carbonated soft drinks (27%) and tea or coffee, with sugar (18%).Forty-six per cent of the 1214 year olds reported that they ate in bed at least oncea week and 54% of this was sweet food or confectionery. When the dental exami-nation and questionnaire results were correlated, a statistically significant relation-ship was found between the number of primary maxillary incisors with pro-nounced erosion of their palatal surfaces and the consumption of carbonated soft Key words: Dental Erosion; risk factors;drinks at night (P0.015). A significant relationship was also found between the Saudi Arabia; Prevalence; boys (children)number of permanent maxillary incisors with pronounced erosion on their palatal J. J. Murray, Dean, Dental School,surfaces and the frequency of drinks at night (P0.020), as well as the duration Framlington Place, Newcastle upon Tyne,

NE2 4BW, UKof drinks retained in the mouth (P0.038). Conclusion: It is concluded that dentalerosion is more common in the primary and permanent dentitions of Saudi Ara- Submitted 15 September 2000;bian boys compared with results for similar age groups from the United Kingdom. accepted 6 April 2001

Dental erosion can be defined as the progressiveloss of hard dental tissues by a chemical processnot involving bacterial action (1, 2). Such tissueloss is insidious in nature and may not be ap-parent until the patient reports symptoms of sen-sitivity or the fracture of thinned incisal edges(3). Millward and co-workers (4) considered toothwear in young children to be dental erosion ex-cept when it occurred on the incisal edges of an-terior teeth and occlusal surfaces of posteriorteeth. Although tooth surface abrasion in childrenis uncommon, attrition of incisal edges in the pri-mary dentition is very common at the time of

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exfoliation, and it is extremely difficult to sepa-rate erosion from attrition in the late stages of theprimary dentition (4, 5).

Dental erosion was included in UKs 1993 Na-tional Survey of Child Dental Health (6). A total of17061 children aged 515 years were examinedusing a modification of the Smith & Knight index(7). The survey results showed 52% of five and six-year-old children were found to have one or moreeroded primary incisors and in 24% of children ofthese ages, erosion had progressed into dentine orpulp. In the permanent dentition, 25% of the chil-dren over eleven years of age were found to have

Risk factors for dental erosion in boys in Saudi Arabia

dental erosion on the palatal surfaces of maxillaryincisors and approximately 12% of children aged1215 years had erosion on the buccal surfaces. Inonly 2% of children aged over 13 years had the ero-sion progressed into dentine or pulp.

The UK National Diet and Nutrition Survey (8)of children aged 11/2 to 41/2 years was conductedusing the same diagnostic criteria for dental ero-sion as the 1993 National Survey of Child DentalHealth. The results showed 19% of children haderosion affecting the palatal surfaces and 10% ofchildren had erosion of the buccal surfaces of theirmaxillary incisors. Erosion involved dentine or thepulp palatally in 8% and buccally in 2%. The sur-vey showed a weak relationship between the fre-quent consumption of sweetened drinks and car-bonated soft drinks and dental erosion, with thetiming of consumption (bedtime) of these drinksmore closely associated with the frequency of den-tal erosion.

Sales of soft drinks in the temperate climate ofthe UK have increased dramatically over the past40 years to 178 litres per capita in 1996 with adoles-cents accounting for up to 65% of these purchases(9). Since the consumption of soft drinks has beenwidely implicated as a major factor in the aetiologyof dental erosion (10), in the hotter climates of de-veloping countries there is increasing concern forthe dental health of consumers since daily fluidconsumption is high and soft drinks, particularlycarbonated soft drinks, are increasingly available atreasonable cost.

Saudi Arabia is fast developing country with apopulation of approximately 19 million (11). Thenations economy increased almost 40 fold from1960 to the late 1980s (12). Changes to the diet haveincluded substantial increases in the consumptionof carbonated beverages and acidic drinks (13). Ahigh prevalence of tooth wear among Saudi Arabi-an adults has been reported (14, 15), but no epide-miological study of dental erosion in Saudi Arabi-an children has so far been carried out.

Objectives

O To carry out an epidemiological study to deter-mine the prevalence of dental erosion in the pri-mary dentition of 56 year old boys and the per-manent dentition of 1214 year old boys inRiyadh City.

O By means of a questionnaire, to obtain informa-tion on dietary habits in 56 year old and 1214year old boys.

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O To investigate whether there are any specific riskfactors for dental erosion that can be identifiedin the Saudi Arabian population, by correlatingthe results of the clinical examination and ques-tionnaire data.

Material and methods

Riyadh City is a very good example of a Saudi Ara-bian urban area with a complex structure of popu-lation of different origins. As such it was an appro-priate site to study the prevalence, aetiology,predisposing factors and treatment needs for den-tal erosion in children in Saudi Arabia. The systemof schooling in the Kingdom of Saudi Arabia pro-vides females with their own schools and entire fe-male staff. During school hours males are not al-lowed to enter the female schools. Due to theschool rules in Saudi Arabia, which separate gen-ders in all levels of education, boys only were in-cluded in this school-based study.

At the time of the study the total number ofschoolboys aged 515 years in Riyadh City was148 625. These boys were studying at 341 elementa-ry schools and 146 intermediate schools. A table ofrandom allocation (16) was used to produce a listof 40 schools. It was planned that approximately30 boys would be examined in each school, givinga predicted sample of 1200 boys.

Clinical methodPreparation for the study took place in the UKfrom October 1996 until December 1996. Duringthis stage the study protocol was produced, thefirst author was trained and the examinationform and questionnaire were designed. In SaudiArabia the official permissions were sought andmaterials needed for the study implementationwere prepared in January 1997. The fieldwork forthe study was carried out from February 1997 toJuly 1997.

Children were examined in a room usually adja-cent to the classroom, with the student lying ona semi-reclined preadjusted mattress chair with aheadrest. A portable source of light (halogen 40wlamp) was used for dental examination togetherwith individually wrapped and sterilised mouthmirrors and gloves. Once cotton rolls had beenused to dry the tooth surfaces, dental mirrors wereused to visually inspect the teeth and dental ero-sion was recorded, for the labial and palatal sur-faces of all primary maxillary incisors and the oc-clusal surfaces of first primary molars in 56 year

Al-Majed et al.

olds. In the 1214 year olds, dental erosion was re-corded for the labial and palatal surfaces of all per-manent maxillary incisors and the occlusal surfacesof first permanent molars. These surfaces were ex-amined for loss of surface enamel characteristics,and/or exposure of dentine or pulp without in-volving the incisal edge, and the depth of loss oftooth tissue for each surface was examined accord-ing to the following criteria:

Code 0 NormalCode 1 Enamel only -loss of surface characterisa-

tionCode 2 Enamel and dentineloss of enamel,

exposing dentineCode 3 Enamel, dentine and pulploss of enamel

and dentine resulting in pulpal exposureCode 9 Assessment could not be made; when the

tooth was either missing or had a large res-toration.

All coded readings were dictated to a scribe duringthe dental examination for entry onto an examina-tion sheet. All collected data were checked for ac-curate coding and correct data entry onto examina-tion sheets.

The collected data were entered into computerdata file and then verified by the Data PreparationService at the University of Newcastle upon Tyne.Once the data had been entered into a data set anSPSS statistical programme (version 8.0) was usedfor statistical analysis.

QuestionnaireA questionnaire was designed, similar to that usedin the National Diet and Nutrition Survey (8). Itwas then translated to Arabic and then processed,printed and copied according to the expectednumber of students to be examined in each of theselected schools.

At a preparatory visit, one week prior to thedental examination, each students school recordwas reviewed to obtain basic information abouteach expected participant. For the 56 year oldboys, questionnaires were distributed for comple-tion by parents to determine their knowledge oforal hygiene and dietary habits of the child andthe family. Boys aged 1214 years of age were al-lowed to complete the questionnaires themselvesin their classrooms under supervision. Com-pleted questionnaires were collected on the dayof the examination. In the case of non-returnedquestionnaires, that particular school was re-visited after requesting further co-operation from

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the school administration in questionnaire collec-tion.

Reproducibility of diagnosisTo assess the reproducibility of the application ofdiagnostic criteria, approximately 10% of the sub-jects were re-examined. In each dental examinationsession the scribe selected 35 students for re-ex-amination, without informing the examiner, and afurther clinical examination was undertaken for theselected students at that same school visit. Thescribe was instructed to allow a time difference(not very specific but usually near the end of theexamination session) between the first and secondexamination.

Statistical analysisTo enable a correlation between the examinationstudy and the questionnaire survey to be under-taken, the dental examination data file was mergedwith the questionnaire data file for each of the twoage groups to produce two merged data files. Onlythose subjects who attended the examination ses-sion and returned a completed questionnaire wereincluded in the correlation analysis. Pearsonscorrelation co-efficient and linear regression anal-ysis were used to analyse the degree of associationbetween the erosion variables and the erosion-re-lated questionnaire variables. A linear regressionanalysis model was formulated with each statis-tically significant erosion-related questionnairevariable (independent) and a grouped erosion vari-able e.g. erosion of all palatal surfaces of incisors(dependent). Following this, the other clinical inde-pendent variables were adjusted to the model andtested for statistical significance.

Results

Clinical dataprimary dentitionThree hundred and fifty four boys, aged 56 years,from 15 elementary schools in Riyadh, were exam-ined. Of these boys, 95% exhibited evidence of den-tal erosion in one or more maxillary primary inci-sors or first primary molars, 34% exhibitedpronounced dental erosion of clinical significance(erosion into dentine or erosion into pulp). (Table1) The prevalence of dental erosion in one or moremaxillary primary incisors was 82%; 16% exhibitedpronounced dental erosion (erosion into dentine orerosion into pulp) in one or more maxillary pri-mary incisors. The severity of erosion is given inTable 1. Overall, 1026 palatal surfaces of maxillary


Table 1. Prevalence and severity of dental erosion on the palatal and labial surfaces of primary maxillary incisors in 354 boysaged 56 years

Right Right Left Left All primarylateral central central lateral maxillary incisors

(52) (51) (61) (62)No. (%) No. (%) No. (%) No. (%) No. (%)a

Labial SurfacesNo. of surfaces assessed 338 313 322 332 1305b

No. of eroded surfaces 278 (82) 221 (71) 231 (72) 273 (82) 1003 (77)Enamel only 276 (99) 217 (98) 227 (98) 271 (99) 991 (99)Enamel and dentine 2 (1) 3 (2) 3 (2) 2 (1) 10 (1)Enamel, dentine and pulp 0 (0) 1 (1) 1 (1) 0 (0) 2 (0)

Palatal SurfacesNo. of surfaces assessed 339 315 323 332 1309c


Upper Upper Lower Lower All occlusalright left left right Surfaces(54) (64) (74) (84)

No. (%) No. (%) No. (%) No. (%) No. (%)a

Occlusal SurfacesNo. of surfaces assessed 295 307 258 258 1118d,e


a Percentages rounded to nearest whole number.b 47 surfaces excluded because of exfoliation, extractions or large restorations.c 43 surfaces excluded because of exfoliation, extraction or large restorations.d 73 teeth excluded because of exfoliation or extraction.e 225 teeth excluded because of large restorations or cariously involved surfaces.

primary incisors (78%) had evidence of erosion,mainly erosion of enamel. Palatal erosion into den-tine occurred on 71 central incisors, and 56 lateralincisors with 20 central incisors and 10 lateral inci-sors showing erosion into the pulp. Of the 1305 la-bial surfaces assessed, 99% of the surfaces with ero-sion involved enamel only. Erosion into dentinewas twice as prevalent in mandibular first primarymolars (22%) compared with maxillary first pri-mary molars (11%).

Clinical datapermanent dentitionOf the 862 boys aged 1214 years examined, 95%exhibited some dental erosion in one or moremaxillary permanent incisors or first permanentmolars; with 26% exhibiting pronounced dental er-osion (erosion into dentine or erosion into pulp).

Restricting the analysis only to the 3420 perma-nent maxillary incisors assessed, 72% had evidence

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of some dental erosion; 12% were found to havepronounced dental erosion (erosion into dentine orerosion into pulp).

The prevalence of dental erosion on palatal sur-faces of maxillary incisors was 66% (Table 2), with317 palatal surfaces showing erosion into dentine(14% of affected teeth). Ten teeth (0.3% of the 3420teeth assessed) had suffered erosion into the pulp.

The frequency of dental erosion on labial sur-faces was evenly distributed among the maxillarypermanent incisors, being found in 59% of the labi-al surfaces of 3420 teeth assessed. Erosion into den-tine affected only 0.1% of the 3420 labial surfacesassessed; only two maxillary incisors were pulpallyinvolved due to labial erosion. Virtually all occlusalsurfaces of first permanent molars showed someevidence of erosion. Erosion into dentine occurredmore frequently in mandibular molars, (18%) thanmaxillary molars, (6%) (Table 2).

Al-Majed et al.

Table 2 Prevalence and severity of dental erosion on the palatal and labial surfaces of permanent maxillary incisors in 862boys aged 1214 years

right right left left all permanentlateral central central lateral maxillary incisors

(12) (11) (21) (22)No. (%) No. (%) No. (%) No. (%) No. (%)a

Labial SurfacesNo. of surfaces assessed 859 851 854 856 3420b

No. of surfaces eroded 511 (59) 497 (58) 501 (59) 507 (59) 2016 (59)Enamel only 505 (99) 491 (99) 494 (99) 500 (99) 1990 (99)Enamel and dentine 6 (1) 6 (1) 6 (1) 6 (1) 24 (1)Enamel, dentine and pulp 0 (0) 0 (0) 1 (0) 1 (0) 2 (0)

Palatal SurfacesNo. of surfaces assessed 859 851 854 856 3420b

No. of surfaces eroded 556 (65) 567 (67) 571 (67) 557 (65) 2251 (66)Enamel only 482 (87) 482 (85) 482 (84) 478 (86) 1924 (85)Enamel and dentine 71 (13) 82 (15) 86 (15) 78 (14) 317 (14)Enamel, dentine and pulp 3 (0) 3 (0) 3 (0) 1 (0) 10 (0)

Upper Upper Lower Lower All occlusalright left left right surfaces(16) (26) (96) (46)

No. (%) No. (%) No. (%) No. (%) No. (%)a

Occlusal SurfacesNo. of surfaces assessed 731 758 651 638 2778c,d


a Percentages rounded to nearest whole number.b 28 teeth excluded because of extraction, avulsion or large restoration.c 150 teeth excluded because of extraction.d 520 teeth excluded because of large restorations.

Reproducibility of diagnosisDuplicate examinations were carried out on 49 56year old boys. Diagnostic reproducibility was as-sessed by considering the palatal surfaces of pri-mary incisors. Cohens Kappa was calculated at0.913 representing good agreement for reproduci-bility of erosion.

Duplicate examinations were also carried out on100 1214 year old boys. Variation in diagnosis onthe palatal surfaces of maxillary permanent inci-sors was used as a marker of diagnostic reproduci-bility. Cohens Kappa was calculated at 0.889. Thehigh Kappa values should be considered withsome caution because of the very high prevalenceof erosion into enamel.

Questionnaire dataprimary dentitionThe 271 responses from parents of 56 year oldboys represented a response rate of 75.7%. Of theparents responding, 65% reported that their childtook a drink to bed for consumption before sleep

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or during the night (Table 3) with 41% reportinguse of drinks 13 nights per week, and 16% havingdrinks every night. Water was the most commondrink consumed (37%), followed by carbonatedsoft drinks (21%) and then milk (19%). Fruit juiceand tea were equally selected (8%). Of the 186parents who answered the question regarding

Table 3. Frequency of night drinks intake in 271 56 year oldboys and 851 1214 year old boys.

Drinks intake 56-year-olds 1214-year-olds

Number % Number %

Never 93 35 249 3013 nights per week 106 41 307 3746 nights per week 20 8 88 11Every night 42 16 188 22

Total 263a 832b

a 8 parents did not answer this questionb 19 boys did not answer this question


Table 4. Foods eaten at night by 110 boys aged 56 years and386 boys aged 1214 years

Drinks intake 56-year-olds 1214-year-olds

Number % Number %

Fruit 15 14 118 19Crisps or savoury snacks 19 17 110 18Confectionery and sweet 21 19 93 15

snacksCakes 12 11 83 14Toast/sweet sandwiches 9 8 70 12Cerealsweetened 12 11 49 8Cerealsunsweetened 3 3 14 2Biscuitssweetened 12 11 28 5Biscuitsunsweetened 3 3 27 4Other 5 5 16 3

Total 111a 608b

a Parents of one 56 year old boy selected more than onekind of food taken at night.

b 222 boys aged 1214 years selected more than one kind offood taken at night.

sugars content of night drinks, 140 parents (75%)responded that their son had added sugar in hisdrinks or consumed drinks containing sugars atnight.

One third of parents reported that their son hadsomething to eat in bed or during the night (otherthan the evening meal); 17% of boys ate in bed orduring the night less than once a week, 10% atefrom one to three nights per week, and 6% ate

Table 5. Linear regression analysis model for pronounced dental erosion of palatal surfaces of primary maxillary incisors in46 56 year old boys (Significance; *P,0.05)

Model Unstandardised coefficients

B SE P value

Kinds of drinks taken at night 0.271 0.094 0.015*(0none or non carbonated, 1carbonated drinks)Frequency of food intakes at night 0.274 0.306 0.390(0never, 1One to 3 nights/ week,246 nights/week, and 3every night/week)Erosive potential of food taken at nighta 0.338 0.427 0.445(1low, 2moderate, 3high)Frequency of brushing 0.284 0.545 0.612(1,1/day, 21/day, 32/day,43/day, 5.3/day)Frequency of drinks taken at night 0.361 0.984 0.720(0never, 11- 3 nights/ week,246 nights/week, and 3every night)Frequency of drinks taken at night 0.140 1.977 0.945(0never, 1one night/week)

aLowunsweetened cereals or unsweetened biscuits, crisps or savoury snacks.Mediumsweetened cereals, sweetened biscuits, cakes, toast and sweet sandwiches.Highconfectionery, fruit (e.g. lemons).

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every night. A total of 111 selections of differentkinds of foods were made by 110 parents of theboys who ate at night. Of these selections, 60% wassweet food, 14% fruit, and 17% crisps or a savourysnack (Table 4).

Questionnaire datapermanent dentitionThe 851 completed questionnaires from 1214 yearolds represented a response rate of 97.9%. Overtwo thirds (70%) of boys aged 1214 years reportedhaving night drinks: 37% had drinks 13 nights perweek, 22% had drinks every night. (Table 3) A totalof 696 selections of different kinds of drinks takenat night were made by 636 boys aged 1214 years.These were mainly water (30%), carbonated softdrinks (27%), and tea or coffee (18%). Sixty per centof the boys were taking night drinks to which theyhad added sugars or which contained sugars.

Forty six per cent of the 1214 year old boys re-ported that they ate in bed, at least once a week; 9per cent ate in bed every night. A total of 608 selec-tions of different kinds of food were made by the386 boys who ate at night. Fruit was the most se-lected food (19%) followed by crisps or savourysnacks (18%), with sweet ford and confectioneryconstituting 54% of foods eaten at night (Table 4).

Correlation and regression analysisThe total number of 56 year old subjects includedin the merged data file was 268; of these 43 had

Al-Majed et al.

Table 6. Linear regression analysis model for erosion into dentine/dentine and pulp of the palatal surfaces of maxillarypermanent incisors in 95 1214-year-old boys. (Significance, *P,0.05)

Un-standardised Coefficients

Model B SE P Value

Frequency of drinks taken at night(0never, 1 1 night/week) 1.656 0.659 0.020*Duration of drinks in mouth (0drinks straight away, 1makes it last) 0.566 0.255 0.038*Erosive potential of food taken at nighta

(1low, 2moderate, 3high) 0.870 0.306 0.010*Frequency of foods taken at night(0never, 1 1 nights/week) 1.233 0.449 0.012*Frequency of vomiting in case of illness (1other, 2once a month,3once a week and more than once a week) 0.834 0.343 0.024*Illnesses related to dental erosion (1low, 2moderate, 3high) 0.329 0.267 0.232Family income (1low, 2moderate, 3high) 0.354 0.319 0.280Fathers education (1lowest 6highest) 0.164 0.185 0.383Frequency of brushing(,1/day, 1/day, 2/day, 3/day, . 3/day) 0.132 0.166 0.435

a Lowunsweetened cereals or unsweetened biscuits, crisps or savoury snack.Mediumsweetened cereals, sweetened biscuits, cakes, toast and sweet sandwiches.Highconfectionery, fruit (e.g. lemons).

pronounced dental erosion of palatal surfaces ofprimary maxillary incisors and were included inthe analysis. The Pearson correlation coefficient forthe relationship between dental erosion of the pala-tal surfaces of all maxillary incisors of the primarydentition and the erosion-related questionnairevariables showed no statistical significance. How-ever, when the correlation was performed for pro-nounced (i.e. into dentine and/or pulp) erosion ofthe palatal surfaces of the maxillary lateral incisors,there was a significant relationship (P0.049) forthe kinds of foods taken at night. As Table 5 de-scribes, linear regression analysis showed a statis-tically significant relationship between the numberof palatal surfaces of primary maxillary incisorswith pronounced erosion and carbonated drinkstaken at night (P0.015). with the risk of develop-ing pronounced dental erosion on the palatal sur-face of one or more primary maxillary incisor being1.29 times more likely (95% CI: 0.59, 2.87) when thechild drank one or more carbonated soft drinks atnight. However, the other independent erosion re-lated questionnaire variables were found not to bestatistically significant when adjusted to the linearregression model.

The merged data file for 1214 year olds resultedin a total of 824 subjects. Ninety five boys had pro-nounced dental erosion of the palatal surfaces ofpermanent maxillary incisors and were included inthe analysis. Using pronounced palatal erosion asthe dependent variable, linear regression analysis

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showed a statistically significant relationship be-tween the number of permanent maxillary incisorswith pronounced dental erosion of their palatalsurfaces and two erosion-related questionnairevariables (Table 6); frequency of drinks at night(P0.020) and the duration of drinks in the mouth(P0.038).

The study showed a negative regression coeffi-cient and significant relationship (P0.024) be-tween frequency of vomiting in case of illnessand pronounced dental erosion. However, it wasdecided that the reliability of the respondents inreporting their medical history was questionableand this association was not considered further.

Discussion

In the UK Childrens Dental Health Survey report(6), dentists found it difficult to agree on the diag-nosis of the presence of erosion in enamel only. Itwas decided that the UKs 1993 Childrens DentalHealth Survey approach of highlighting the clinicalimportance of pronounced dental erosion (erosioninto dentine, erosion into dentine and pulp) shouldbe followed.

Although the dental erosion of one or moremaxillary primary incisors in 56 years Saudi boysin this study was high (82%), pronounced dentalerosion was 16%. This percentage is very close tothe UKs levels of erosion into dentine or pulp (1215%) of children aged 56 years, which was found


in Northern Ireland in 1993. The UK National Dietand Nutrition Survey (8) showed erosion into den-tine or pulp in 13% of children aged 31/2 to 41/2,slightly lower than that found in the present study.

The mouth prevalence of dental erosion of maxil-lary permanent incisors or permanent first molarsin the present study was 95% in 1214 year oldSaudi boys; pronounced dental erosion was 26%.The high percentage (91%) of dental erosion on theocclusal surfaces of the 1214 year old Saudi boys,found in the present study, is consistent with thehigh level of tooth wear found by Fareed and co-workers (14, 15) in adults aged 1925 years.

The prevalence of pronounced dental erosion ofpermanent maxillary incisors in 1214 year oldSaudi boys was 12%, far higher than the findingsof the UKs 1993 study of 2% for children aged 13years using the same diagnostic criteria. Thefindings of the 1996 National Diet and NutritionSurvey of children aged 418 years in the UnitedKingdom have been presented recently (17). A sim-ilar pattern for erosion on the various surfaces ex-amined was evident from both countries, but theprevalence and severity for every surface washigher in Saudi Arabia than in the UK.

The dietary dimension of dental erosion in thispresent study was evaluated using a questionnairedirected to parents of 56 year old boys. The mainobjectives of the questionnaire were to allow therespondent to recall as much information relatedto dental erosion as possible, including night drinkfrequencies, types of night drinks, night food fre-quencies, and types of night foods. Almost 23% ofthe 56 year old Saudi boys had high frequency ofnight drinks intakes (every night and 46 nightsper week). In the present study 21.4% of the con-sumed night drinks was carbonated soft drinks,usually the cola type. Another acidic drink, fruitjuice, constituted 7.5% of the night drinks of thesechildren. This finding is important especially whenit is known that fruit juices are served to childrenwith no dilution in Saudi Arabia.

The questionnaire results showed a high con-sumption of carbonated soft drinks in Saudi boysaged 1214 years; 60% reported adding sugars totea or milk drinks. These dietary related factors inthis study are in accordance with findings of Khan(18) and Johansson et al. (13) who reported that thehigh consumption of carbonated soft drinks andthe frequent drinking of tea (with a lot of addedsugar) were common practices among children andyoung adults in Saudi Arabia.

A significant relationship was found between the

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number of primary maxillary incisors with pro-nounced erosion of their palatal surfaces and theuse of carbonated soft drinks taken at night (P0.015). A significant relationship was also foundbetween the number of permanent incisors withpronounced erosion of their palatal surfaces andthe frequency of drinks at night (P0.020), as wellas the duration of drinks retained in the mouth (P0.038). Johansson et al. (19) showed a strong corre-lation between the presence of dental erosion anda high level of cola-type soft drinks in a group ofyoung male Saudi military inductees aged 1925years. However the present study is the first toshow a relationship between dental erosion andcarbonated soft drink consumption in Saudi chil-dren.

A recent report showed that the production ofsoft drinks by industrial plants in Saudi Arabia hadincreased; in 1999 1.2 billion litres of soft drinkswere produced (20). In view of this, the recent co-operation between the Ministry of Health and theMinistry of Education to apply a ban on the saleand consumption of carbonated soft drinks atschools and the replacement of these drinks withmilk and juices is welcomed (21). This campaign isa step forward towards a healthier lifestyle, but itneeds to be in conjunction with health awarenessvisits to schools in order to explain to the school-children the risk of food habits such as the frequentconsumption of carbonated soft drinks to health ingeneral, and oral health in particular.

Conclusions

O Thirty four per cent of 56 year old boys fromRiyadh City, Saudi Arabia showed evidence ofpronounced dental erosion of clinical signifi-cance (erosion into dentine or erosion into den-tine and pulp) in one or more maxillary primaryincisors or first primary molars.

O Twenty six per cent of 1214 year old boys fromRiyadh City showed evidence of pronounceddental erosion in one or more permanent maxil-lary incisors or permanent first molars.

O Twenty one per cent of 56 year old boys weresaid by their parents to consume carbonated softdrinks at night; 75% of parents reported thattheir children had added sugar in his drinks orconsumed drinks containing sugar at night.;

O Sixty per cent of 1214 year old boys reportedtaking night drinks to which they had addedsugar or which contained sugar; 27 per cent re-ported consuming carbonated drinks at night

Al-Majed et al.

O The following risk factors for dental erosionwere identified:- consumption of acidic drinks at night- consumption of drinks on one night or more

per week- extended duration of drinks at night.

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al-majed [2002] risk factors for dental erosion in 5-6-year old and 12-14 year old boys in saudi...

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