Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6, 6023-6030 2024 Publisher: Learning Gate DOI: 10.55214/25768484.v8i6.3315 © 2024 by the authors; licensee Learning Gate © 2024 by the authors; licensee Learning Gate * Correspondence: eman.22dep13@student.uomosul.edu.iq A survey on the prevalence and risk indicators of dental erosion among 18- 22 years old students of Diyala university Eman D. Salman1*, Aisha A. Qasim2 1Diyala Health Directorate, Diyala, Iraq; eman.22dep13@student.uomosul.edu.iq (E.D.S.). 2College of Dentistry, University of Mosul, Iraq; dr.aisha6757@uomosul.edu.iq (A.A.Q.). Abstract: The aims of the study were to investigate prevalence and severity of dental erosion, and its related etiological risk factors and habits among students of university of Diyala. A cross-sectional survey of 404 university of Diyala undergraduate students, ages 18 to 22, was carried out. The participants were split into four groups: First Academic Stage (96), Second Academic Stage (133), Third Academic Stage (91), and Fourth Academic Stage (84). Before the exam began, general information and questions were captured in a unique form designed for data recording. Students also signed an informed permission form indicating their willingness to participate in research before the exam began. The prevalence and severity of dental erosion were classified for each tooth using the basic erosive wear examination (BEWE). The erosive wear criterion for each surface, tooth, and sexton ranges from 0 to 3. In this recent study females were higher percentage of dental erosion 56.9% than males 43.1% in score 0 of BEWE, also females were higher percentage of dental erosion in score 1, score 2 and score 3. Age 18 has a larger percentage of erosion (7.8%) in score 1 and no erosion in score 3, however age 19 has the highest score (18.2%) compared to the other age groups. Higher percentages in score 2 were 28.4% and 33.3%, respectively, for those aged 20 and 21. The percentage of degradation was higher in score 1 42.7% at age 22. Severe erosion was found in females than males, the enamel layer appears to be more impacted by tooth erosion as indicated by scores 1 and 2, which were determined by the BEWE index. Keywords: Dental erosion, Dental wear, Eroded, BEWE. 1. Introduction Erosive tooth wear, also known as dental erosion, is a disease of the hard tissues of the mouth that causes progressive loss of dental tissue as a result of chemo-physical or physical processes, with a focus on the involvement of chemical acid(1). The etiological factors of dental erosion can be divided to ‘external’ and ‘internal’ causes. External causes include circumstances relating to the workplace, certain drugs, and dietary consumption that can affect acidity. The primary exogenous causes of DE in today's children are lifestyle choices that include eating a diet richer in fruits and vegetables, drinking energy drinks during physical activity, but especially consuming more fruit juices and soft drinks. Both healthy and unhealthy lifestyle choices can increase a person's susceptibility to erosive wear (2,3). The first signs of dental erosive wear that patients typically report include pain and sensitivity issues, worsening aesthetic appearance indicated by tooth discoloration or shortening, loss of physiological contacts due to morphological changes in the teeth that may cause an unbalanced occlusion, and in severe cases effects on the temporomandibular joint's physiology(4,5). 2. Materials and Methods The study was carried out in the University of Diyala City Center/Baquba between 2023 and 2024 with approval from the relevant university authorities. It was consisted of a cross-sectional survey of undergraduate first, second, third and fourth academic stage students attending university of Diyala - Iraqi. The total sample size was (404 from both gender) students. Calculate the sample size of a survey 6024 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 6023-6030, 2024 DOI: 10.55214/25768484.v8i6.3315 © 2024 by the authors; licensee Learning Gate based on the population size (which is 20226 total number of students in university of Diyala), margin of error 5% and confidence level 95%. Before the exam, each student's name, gender, age, college, residence (rural or urban), mother's and father's educational backgrounds (illiterate, primary, secondary, senior secondary, graduation, post-graduation) and medical history were all recorded on a separate form. They were also asked about their medical history. The teeth were categorized according to the degree and kind of dental erosion using the basic erosive wear examination (BEWE) (6). The maximum value for any surface, tooth or sextant in the grading system is (3), and the total of the BEWE score, which ranges from 0 to 18. Scores and criteria for BEWE index (Table 1). Table 1. Basic erosive wear examination index by (6). Score Criteria 0 No erosive tooth wears. 1 Initial loss of surface texture (Brightness loss, opaque surface or 'frosted glass' appearance). 2 Distinct defect, hard tissue loss, less than 50% of the surface area. Dentin could be involved. 3 Hard tissue loss in more than 50% of the surface area. Dentin could be involved. Note: Prior to a clinical examination, the teeth should ideally be cleaned. Six sextants, representing the oral cavity and dentition, were visually inspected. It was 17-14, 13-23, 24-27, 37-34, 33-43, 44-47(6). SPSS (version 19, USA) was used for data entry and analysis, descriptive statistics and chi square test. 3. Results The Prevalence of Dental Erosion: This research includes a total of 404 (174 males and 230 females) colleges students whose participate in this study from university of Diyala city center / Baquba which divided into four groups: First academic stage students (96), Second stage academic students (133), Third stage academic students (91) and Fourth stage academic students (84). A total of 11.312 teeth (33.936 tooth surfaces) were examined in this study. The prevalence of dental erosion about the survey of 404 subjects and minimum one tooth or one surface with dental erosion was (19.83%). The Severity of Dental Erosion, BEWE According to Gender: Females were higher percentage of dental erosion 56.9% than males 43.1% in score 0 of BEWE, also females were higher percentage of dental erosion in score 1, score 2 and score 3 (57.9%, 51.9% and 80.6%) respectively as showed in table (2). Table 2. The severity of dental erosion (Basic erosive wear examination index) score according to gender. Gender BEWE % Score 0 (%) Score 1 (%) Score 2 (%) Score 3 (%) Male % of studied sample 43.2% 42.6% 49.3% 20% Mean 1.56 5.1 10.53 16 Std. deviation 0.542 1.713 1.376 1.732 Erosion% 43.1% 42.1% 48.1% 19.4% Female % of studied sample 56.8% 57.4% 50.7% 80% Mean 1.57 5.21 11.03 16.58 Std. deviation 0.499 1.639 2.007 3.825 Erosion% 56.9% 57.9% 51.9% 80.6% Total % of studied sample 100% 100% 100% 100% Mean 1.57 5.16 10.78 16.47 Std. deviation 0.516 1.668 1.731 3.461 Erosion% 100% 100% 100% 100% The Severity of Dental Erosion, BEWE Score According to Age: In age 18 years the percent of erosion was higher in score 1 of BEWE index 7.8% and absent in score 3, while in age 19 years score 3 was highest 18.2% than other. In age 20 years and 21 years, higher percent in score 2 were 28.4% and 33.3% respectively. In age 22 years the percent of erosion was higher in score 1 42.7%, (Table 3). 6025 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 6023-6030, 2024 DOI: 10.55214/25768484.v8i6.3315 © 2024 by the authors; licensee Learning Gate Table 3. The severity of dental erosion, Basic Erosive Wear Examination Index score according to age. Age Years) ) BEWE % Score 0 (%) Score 1 (%) Score 2 (%) Score 3 (%) 18 % of studied sample 3.6% 8.6% 1.4% --- Mean 2 4.67 9 --- Std. deviation 0.0001 1.572 --- --- Erosion% 4.6% 7.8% 1.2% --- 19 % of studied sample 11.7% 12.0% 11.6% 20% Mean 1.54 4.56 11 15 Std. deviation 0.519 1.417 1.773 .00010 Erosion% 11.5% 10.6% 11.8% 18.2% 20 % of studied sample 27% 19.6% 27.5% 26.7% Mean 1.43 5.07 11.11 15.25 Std. deviation 0.504 1.649 1.487 1.258 Erosion% 24.7% 19.3% 28.4% 24.7% 21 % of studied sample 16.2% 17.7% 33.3% 20% Mean 1.61 5.73 10.78 19 Std. deviation 0.502 1.726 2.255 6.928 Erosion% 16.7% 19.6% 33.3% 23.1% 22 % of studied sample 41.4% 42.1% 26.1% 33.3% Mean 1.61 5.24 10.44 16.8 Std. deviation 0.537 1.682 1.149 2.95 Erosion% 42.5% 42.7% 25.3% 34% Total % of studied sample 100% 100% 100% 100% Mean 1.57 5.16 10.78 16.47 Std. deviation 0.516 1.668 1.731 3.461 Erosion% 100% 100% 100% 100% The Severity of Dental Erosion, BEWE Score According to Academic Stage: In first stage, the percent of erosion was higher in score 1 (27.7%) and lower percentage in score 3 (6.1%). In second stage, the percentage of erosion was higher in score 2 (48.3%). Score 3 was the higher percentage of dental erosion in third and fourth stage (33.2% and 23.9%) respectively, (Table 4). 6026 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 6023-6030, 2024 DOI: 10.55214/25768484.v8i6.3315 © 2024 by the authors; licensee Learning Gate Table 4. The severity of dental erosion basic erosive wear examination index score according to academic stage. Score 0 (%) Score 1 (%) Score 2 (%) Score 3 (%) First % of studied sample 27% 28.7% 10.1% 6.7% Mean 1.6 4.98 10.71 15 Std. deviation 0.498 1.682 1.704 ---- Erosion% 27.6% 27.7% 10.1% 6.1% % of studied sample 41.4% 33.5% 49.3% 40.0% Second Mean 1.59 5.13 10.56 15.17 Std. deviation 0.541 1.623 1.307 0.983 Erosion% 42% 33.3% 48.3% 36.8% % of studied sample 17.1% 22% 30.4% 33.3% Third Mean 1.42 5.43 11.14 16.4 Std. deviation 0.507 1.695 2.308 3.05 Erosion% 15.5% 23.2% 31.5% 33.2% % of studied sample 14.4% 15.8% 10.1% 20% Fourth Mean 1.62 5.18 10.86 19.67 Std. deviation 0.500 1.722 1.773 6.429 Erosion% 14.9% 15.8% 10.2% 23.9% % of studied sample 100% 100% 100% 100% Total Mean 1.57 5.16 10.78 16.47 Std. deviation 0.516 1.668 1.731 3.461 Erosion% 100% 100% 100% 100% Answers to BEWE Index Questioner Items: There were insignificant difference in answers of first question about teeth sensitivity, but there were a significant difference in question nine about vomiting at (p ≤0.05) and in question 21 about drink water before going to sleep at (p ≤0.01), (Table 5). Table 5. Descriptive analysis of YES-answers to BEWE index questioner items by colleges of Diyala university. Questions No. Erosion% Hypersensitivity of teeth 262 65.1% Energy drinks consumption 167 40% Eat fresh fruit regularly 382 95% Consumption of natural fruit juice 313 74.4% Consumption of artificial fruit juice 307 75.4% Eat spicy foods 291 74% Eat Pickles frequently 225 56.8% Eat Ketchup frequently 129 30.9% Vomit (At least once a week) 75 15.1% Brush your teeth after vomiting 241 57.1% Ice coffee consumption 174 60.3% Frequent coffee consumption 151 35.7% Soft drink consumption 340 84.1% Beverage consumed with straw 277 69.9% Keep/rinse sweet carbonated drinks in mouth 184 46.3% Brush your teeth after consumption of 126 28.7% 6027 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 6023-6030, 2024 DOI: 10.55214/25768484.v8i6.3315 © 2024 by the authors; licensee Learning Gate soft drink Frequent milk consumption 237 61.1% Yogurt consumption 278 70.6% Vitamin C supplement consumption 149 35.7% Chew chewing gum 329 80.3% Drink water before going to sleep 324 84% Drink soft drink before sleeping 176 41.3% Used whitening toothpaste 178 46% Self-assessed gastric reflux 122 29.7% Sour taste in your mouth 144 33.9% Heartburn (Acid indigestion) 192 46.8% Medical diseases 93 22.1% Use Fluoride rinse or gel 63 17.1% Note: * significant difference at (p ≤ 0.05). **Highly significant difference at (p ≤0.01). 4. Discussion There were 404 young adult male and female college undergraduate students in the study sample. Young college students are essential to the spread of preventative knowledge and health promotion among families and their community (7). Therefore, general health and dental health are interconnected and are critical to each other (8). There is much more to oral health than just having beautiful, white teeth. It affects each person's well-being and quality of life and is crucial to overall health (9). Oral health is closely linked to overall health and quality of life, as well as social connections and oral functions (10). It was discovered that dental erosion was greater in undergraduate students in previous studies (11,12) Conversely, the percentage was lower than the value found by other studies, 28%, 38.9%, and 26% (13–17). Variations in sample size, differences in the indices used to measure tooth erosion and the tooth surfaces examined caused variation in prevalence of tooth erosion with the above studies. Moreover, socioeconomic, cultural, regional and lifestyle variables may have an impact on the results of the prevalence data (18). In addition, variations in individual oral hygiene practices and the fluoride concentration of drinking water or dental fluoridation likely have a significant impact (19). Furthermore, prior research has demonstrated that the BEWE index has good accuracy (6). Direct oral examination, dental photos, traditional dental models or digital dental models can all be used to assess the BEWE index. The BEWE index demonstrated sufficient intra- and inter-examiner repeatability in our study utilizing the direct oral examination(20). According to the result of current study females were higher percentage of dental erosion 56.9% than males 43.1% in score 0 of Basic Erosive Wear Examination index (BEWE), also females were higher percentage of dental erosion in score 1, score 2 and score 3. The difference between males and females in tooth erosion may be connected to variations in dietary choices and lifestyle/behavioral patterns. Score 1 and score 2 involved only the enamel, confirming findings in (15,21–25), also were observed in some studies (11,26,27). According to score 3, there was a low incidence of dentin lesions, which is consistent with earlier research (23,28). According to the report, there was no pulp involvement (25). Lesion depth depend in many factors as prolong still of carbonated beverages in the oral cavity has been demonstrated to cause a PH decline (29,30). The degree to which dental erosion affects the surface of the mouth is also influenced by the amount of acidic beverages that are ingested(31), the effect becomes much more pronounced when temperature of acid becomes higher as a result of temperature of oral cavity, the frequency and timing of food intake was the frequent consumption of acidic fruits and the timing of fruit intake is also crucial(32). In the result of present study in age 18 years the percent of erosion was higher in score 1 of BEWE index 7.8% and absent in score 3, while in age 19 years score 3 was highest 18.2% than other. In age 20 years and 21 years, higher percent in score 2 were 28.4% and 33.3% respectively. In age 22 years the percent of erosion was higher in score 1 42.7%. Hasselkvist et al., (2016) discovered that the 6028 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 6023-6030, 2024 DOI: 10.55214/25768484.v8i6.3315 © 2024 by the authors; licensee Learning Gate development of erosive lesions was prevalent and correlated with lifestyle characteristics in Swedish teenagers between the ages of 17 and 18 (33). In Skalsky Jarkander et al. (2018) dental erosion was more common in 17-year-olds (34.3%). Teenagers aged 17 have a higher prevalence of severe erosive wear (grades 3) was 20.7%(2). Where the comparable percentage was 22.3% for those who were 18 and 19 years old. The variations in prevalence between these studies can be explain by different age ranges, study populations and/or grading schemes. Erosion value of the stages was (19.5%, 39.3%, 26.4% and 14.8%) respectively, thus, result showed that second stage has higher value of dental erosion when compared with other stages. Thus, in first stage, the percent of erosion was higher in score 1 and lower percentage in score 3. In second stage, the percentage of erosion was higher in score 2. Score 3 was the higher in third and fourth stage. This different may be due to changes in lifestyle, dietary and personal hygiene habits of the student (34). There was insignificant difference in answers of third question about eat fresh fruit. Fresh fruits are among the healthiest foods for teeth because of their nutritional value and positive effects on oral hygiene but excessive consumption of citrus fruits such as lemons, grapefruit and oranges (35), apples, bananas and grapes showed positive association with dental erosion (36). Previously Abdul Manaf et al., (2012) concluded the presence of dental erosion was not related to amount of acidic fruits (37). Fruit consumption and tooth degradation are only associated when consumption is considerable. Therefore, eating citrus fruits more than twice a day (four to five times a day) has been linked to a significant risk of erosion. Question two excessive energy drink use during physical activity combined with xerostomia from dehydration, which causes tooth erosive damage(38). The same results were found by Kumar et al. (12). About question four and five were insignificant difference in answers, frequent consumption of “unhealthy acidic beverages” soft drinks, for example, are thought to be more dangerous when it comes to the development of erosive wear since they are consumed more frequently and for longer periods of time than "healthy acidic beverages," like fruit juices (39). Using a straw in question fourteen would decrease the amount of time that an acidic beverage is in contact with the hard teeth tissue; hence, acidic drinks will be less harmful (40). In question twenty three was agree with Binaljadm et al., toothbrush and toothpaste abrasive properties will soften dental hard tissue and increase (40). Additionally, brushing your teeth before eating has been linked to an increased risk of erosion. Previous research has indicated that this association may be due to the dental biofilm's protective role, which decrease the mineralized tissues exposed to acidic environments by loss of ions (41–43). 5. Conclusion The findings of this study showed a high prevalence of dental erosion in this group of students, especially among females, with the presence of many risk factors. Then young adults need to be aware about their dietary habits and oral hygiene, and also a proper dental health program needs to be applied. Copyright: © 2024 by the authors. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). 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