CODSJOD

Roopa K Thippanna, Vijayalakshmi C Ramu 10.5005/jp-journals-10063-0027 ORIGINAL ARTICLE

Prevalence of Dental Attrition and its Severity in Relation to Age and Gender: A Clinical Study 1Roopa K Thippanna, 2Vijayalakshmi C Ramu

Aim: The present study was conducted to evaluate the preva- INTRODUCTION lence and severity of dental attrition in different age groups in 1 both the gender among the population of Davangere district. Aging is a universal process. With the growing number Need for the study: Early diagnosis, treatment and preventive of seniors, the incidence of natural tooth retention is care of attrition has become an essential and important part increasing, and consequently, a greater prevalence of of daily practice.Hence, the present study was carried out to is observed in the aging population.2 evaluate the prevalence of dental attrition and its severity in different age groups in both the genders. Tooth wear is an inherent part of the aging process and therefore occurs continuously but slowly throughout Materials and methodology: The present study was con- 3 ducted randomly among the dentulous or partially edentulous life. Tooth wear over time alters the appearance of the individuals seeking dental treatment for various needs in teeth and smile in a way that is perceptible to dentists College of Dental Sciences, Davangere, Karnataka. A total and laypeople.4 of 570 subjects were divided into three groups according to Tooth wear is a general term describing the loss of different age i.e., young (18–34 years), middle (35–54 years) and old (55 years and above). dental hard tissues from the surfaces of the teeth caused Questionnaire and clinical examination was performed by factors other than dental caries, trauma, and devel- personally for each subject. Clinical examination involved the opmental disorders.5 This gradual wearing away of the evaluation of individual tooth for attrition and scoring was done tooth surface occurs in all individuals and can be classi- using attrition index modified by tooth wear index of Smith and fied as one of four types: attrition, , erosion, or Knight. a poorly characterized phenomenon called . Results: The study was carried out on 570 subjects divided into three groups. Subjects in the middle and old age group These surface loss modalities have distinct etiologies, showed 100% prevalence of attrition and subjects in younger characteristics and wear patterns. The wear of the teeth age group showed 91.5% prevalence. Mean attrition score in is irreversible and cumulative with age.6 subjects of young, middle and old age groups were 0.21, 0.82, Word attrition derived from the Latin verb “atter- 1.44 respectively. Mean attrition scores of males and females in all the age groups as 0.99, 0.67 respectively. ere," which is defined as the action of rubbing against 5 Conclusion: Highest prevalence of attrition was seen in both something. Dental attrition has a multifactor etiology, middle and old age compared to younger age. Younger age with age and the geometry of canine guidance having a showed least attrition score involving only enamel compared to significant influence, in addition to commonly accepted older age who showed attrition involving enamel and dentine. para function.7 As the age advances severity of attrition was also increased. Males showed higher attrition than females. Severity of attrition Tooth wear can progress to exposure of , was also more in males. resulting in dentinal hypersensitivity and consequently Keywords: Attrition, Prevalence of tooth wear, Severity of reduced chewing function. Severe tooth wear can result in attrition, Tooth wear. serious consequences such as pulpal pathology, occlusal How to cite this article: Thippanna RK, Ramu VC. Preva- disharmony, impaired function, and esthetic disfigure- lence of Dental Attrition and its Severity in Relation to Age ment. Sometimes complicated complete-mouth dental and Gender: A Clinical Study. CODS J Dent 2017;9(1):16-21. rehabilitations are necessary to treat severe tooth wear.8 Source of support: Nil Hence early diagnosis, treatment and preventive care of Conflict of interest: None these lesions become an essential and important part of daily practice. 1Professor, 2Senior Lecturer Hence, the present study was carried out to evaluate 1Department of Prosthodontics, College of Dental Sciences, the prevalence of dental attrition and its severity in dif- Davangere, Karnataka, India ferent age groups in both the genders. 2Department of Prosthodontics, Bangalore Institute of Dental Sciences, Bengaluru, Karnataka, India MATERIALS AND METHODOLOGY Corresponding Author: Vijayalakshmi C Ramu, Senior Lecturer, Department of Prosthodontics, Bengaluru Institute of Dental The materials and method followed in this study have Sciences, Bengaluru, Karnataka, India, e-mail: crviju1989@ been discussed under the following headings for the gmail.com convenience:

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Prevalence of Dental Attrition and its Severity in Relation to Age and Gender: A Clinical Study

• Armamentarium used in the study • Extensive restoration, cast restoration, cuspal cover- • Source of collection of data age. • Criteria for selection of subjects • Subjects who have undergone orthodontic treatment. • Study design • Presence of fixed or removable partial denture. • Flourosed teeth Armamentarium Study Design The instruments used in the study were: • Mouth mirrors Questionnaire and clinical examination were performed • Probe personally for each subject. A questionnaire was consisting • Explorer of closed-ended questions; questionnaire enquired the • William`s graduated periodontal probe socio-demographic data of subject that includes name, • Tweezer age, sex and occupation. • Kidney tray Every subject was asked to sit in the dental chair in an • Gauze sheets upright position. All the examinations were carried out by • Cotton holder and cotton the single operator, standing in front of the subjects. The • Examination gloves clinical oral examination was done under good illumina- tion using sterile diagnostic instruments (Fig. 1). Intraoral Source of Collection of Data examination proceeded in an orderly manner starting A cross-sectional study was conducted randomly among from upper right quadrant to lower right quadrant in a the dentulous or partially edentulous individuals seeking clockwise direction, to evaluate the attrition using attrition dental treatment for various needs in College of Dental index which is modified from the tooth wear index given Sciences, Davangere, Karnataka. by Smith and Knight in 1984 (Figs 2 to 5). A total of 570 subjects who were willing to participate Attrition: The degree of attrition was assessed by the in the study were selected and requested to fill in the following criteria: consent form. The subjects were divided into three groups Score Surface Criterion according to age, i.e., young (18–34 years), middle (35–54 0 O/I No loss of enamel surface characteristics years) and old (55 years and above). 1 O/I Loss of enamel surface characteristics 2 O Loss of enamel exposing dentin for less than one-third of the surface Criteria for Selection of Subjects I Loss of enamel just exposing dentin 3 O Loss of enamel exposing dentin for more than Inclusion Criteria for Selection of Subjects one-third of the surface I Loss of enamel and substantial loss of dentin, Presence of complete natural permanent dentition or but not exposing pulp or secondary dentin dentition with a single missing tooth in the posterior 4 O Complete loss of enamel, or pulp exposure, or and/or anterior region of the dental arch. exposure of secondary dentin I Pulp exposure or exposure of secondary Exclusion Criteria for Selection of Subjects dentin. • Two or more posterior and/or anterior teeth missing. O–Occlusal, I–Incisal

Fig. 1: Armamentarium Fig. 2: Maxillary arch showing no attrition of teeth

COD Journal of Dentistry, January-June 2017;9(1):16-21 17 Roopa K Thippanna, Vijayalakshmi C Ramu

Fig. 3: Mandibular arch showing no attrition of teeth Fig. 4: Maxillary arch showing attrition of teeth Table 3 shows mean attrition score in subjects of young, middle and old age groups as 0.21, 0.82, 1.44 respectively. Mean attrition score was found to be statistically sig- nificant (p < 0.05) when compared between different age groups. With the post –hoc Tukey’s analysis it was found that mean attrition scores were higher in old age groups when compared with middle and young age groups. Table 4 shows mean attrition scores of males and females in all the age groups as 0.99, 0.67 respectively. Statistically significant (p < 0.05) mean attrition scores were found between males and females in which males had higher scores when compares with females.

Fig. 5: Mandibular arch showing attrition of teeth DISCUSSION The global population is increasing at an annual rate of After scoring the individual teeth, the sum score of 1.2%, while the population of those 65 years or older is all teeth examined was divided by the number of teeth. increasing at a rate of 2.3%.9 The proportion of the elderly The value obtained was considered as the attrition score. to the total population of India rose from 7.5% in 2001 to 8.2% in 2011.10 RESULTS Tooth wear is perceived internationally as an ever- Data were subjected to statistical analysis. increasing problem, especially in the elderly, as it is more 11 Table 1 shows the prevalence of attrition in the study common in this age group. Tooth wear is physiologic, 12 group. Subjects in the middle and old age group showed occurring as a normal aging process. Tooth surface loss is a macroscopically irreversible process that accumulates 100% prevalence of attrition and subjects in younger age with age.5 Lambrechts estimated the normal vertical loss group showed a 91.5% prevalence. of enamel from physiological wear to be approximately Table 2 shows the frequency distribution of attrition 20 to 38 μm per annum.11 This process is accelerated by score in 570 subjects. Total 41% of the subject showed several endogenous and exogenous factors termed as that attrition score between 1.0 and 2.0 and in 41% of the pathologic.12 subject's score of less than 0.5 was seen. Table 2: Prevalence of severity attrition in 570 subjects Attrition score Frequency Percent Table 1: Prevalence of attrition < 0.5 239 41.29% Age groups Sample size Attrition present 0.51–1 91 15.96% Young age N = 190 174 (91.5%) 1–1.5 152 26.66% Middle age N = 190 190 (100%) 1.51–2 84 14.73% Old age N = 190 190 (100%) 2.1–2.5 4 0.70% Total 570 554 (97.28%) > 2.5 0 0

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Prevalence of Dental Attrition and its Severity in Relation to Age and Gender: A Clinical Study

Table 3: Attrition score in different age groups Table 4: Attrition score in males and females of all the age groups Attrition Sl. Sample Attrition score score Tukey`s no Gender size (mean ± SD) T-test Sl. Sample (mean ± post hoc 1 Male (1) N = 267 0.99±0.59 t = 0.5 No Age groups size SD) analysis 2 Female(2) N=303 0.67±0.56 p <0.001 1 Young age1 0.21 ± 0.20 3 > 2 > 1 (HS) (18–34 yrs) N = 570 p < 0.001 2 Middle age2 0.82 ± 0.41 (HS) also affect an individual’s quality of life. It should be (35–54 yrs) emphasized that most often a combination of factors are 3 Old age3 (55 yrs 1.44 ± 0.32 responsible for the wear. and above) ANOVA F = 669.22 p < 0.001 (HS) Hence, it is important to find the causative factors which will help in the management of attrition. So, the Attrition is the loss of tooth substance occurring as a study was carried out to find the causative factors of result of mechanical wear between the opposing surfaces dental attrition, severity, and prevalence of dental attri- of teeth during masticatory and parafunctional move- tion. ments. Wear facets are characterized as flat, round or In the present study, attrition index modified by sharply angled and polished surfaces, most often seen on tooth wear index of Smith and Knight was chosen as it is the occlusal surfaces of posterior teeth, the incisal edges user-friendly, easily, comparable and widely used. Clini- of anterior teeth.13 cal examination was conducted to score the individual Factors causing excessive or pathological occlusal teeth, after that the sum score of all teeth examined was wear are: congenital anomalies, psychological factors, and divided by the number of teeth. The value obtained was , iatrogenic like occlusalpre maturities, coarse considered as the attrition score. This attrition score porcelain restorations, deleterious habits like betel nut showed the severity of attrition in the subject. chewing/tobacco pan chewing, nail-biting and coarse In the present study prevalence rate of the attrition diet class III incisal relationship and lack of posterior among the population studied was 97.2 %, where younger support also lead to attrition.5 age group subjects showed the prevalence rate of 91.5 % When the process of tooth wear is excessive, it leads to and middle, old age group subjects showed the prevalence tooth shortening, exposed dentin, tooth hypersensitivity, of 100% (Graph 1). Similar results were seen in a study by or, more seriously, exposure of the canal, , pulp Seligman et al. where 91.5% of the young adult population necrosis, loss in occlusal vertical dimension, mechanical showed similar tooth wear.14 This showed that a minimal failure of teeth or restorations and an unsightly appear- amount of tooth wear in enamel is universal. This could ance.11 be due to age, habits and functional activity. Dental attrition is one of the main causes of non- Tooth wear is seen in the subjects of all the age groups, carious lesions which results in deterioration of natural but the severity of attrition was varied. Least attrition dentition and consequent degradation of .12 score of less than 0.5 was seen in 41.2% of the study The challenges faced during the clinical management population (Graph 2). This is incongruent with the study of patients with tooth wear has raised considerable pro- conducted by Sangeeta Yadav where 88% of the study fessional interest as its impact could be severe and may population had one or more tooth with significant attri-

Graph 1: Prevalence of attrition Graph 2: Prevalence of severity attrition in 570 subjects

COD Journal of Dentistry, January-June 2017;9(1):16-21 19 Roopa K Thippanna, Vijayalakshmi C Ramu

Graph 3: Attrition score in different age groups Graph 4: Attrition score in males and females of all the age groups tion with grades of 2 or more on a 0–4 scale of a standard showed more adverse habits than females which might attrition index.15 have resulted in attrition.15 In the present study, it was observed that the attrition Initial management of tooth surface loss depends on rate was increased with the increase in age (Graph 3). As accurate diagnosis of the condition, the identification of the age increased mean attrition score was also increased the etiology and frequent monitoring of the successive in the study population. This was incongruent with the changes; hence to prevent further damage. Treatment earlier studies conducted by Hugosan et al., Pergamalian planning is sometimes very challenging, and it is very- et al., which showed that attrition increases with the necessary that accurate analysis of the tooth surface loss 16,17 increase in age. This showed that as the age advances, is made at an early stage and that satisfactory preven- attrition becomes more severe. It has been reported that tive measures are carried out. In patients who exhibit tooth wear is an age-dependent process. This increase only physiological wear with no esthetic or functional in attrition with the increased age was due to increased complaints and associated symptoms of discomfort, the functional activities, the accumulative effect of duration management strategies should be primarily limited to of etiological factors. preventive measures and monitoring. In those patients Least attrition score of 0.5 was seen in 94.2% of exhibiting pathological tooth wear, there is a need for younger subjects and 91.05% older age subjects showed the attrition score of 1 to 2. None of the subjects showed active restorative involvement along with the preventive 5 attrition score of more than 2.5. A study conducted by strategies and regimes. Hugosan et al. showed the attrition score of 2 in 6%, 10% Some limitations of the present study were it is a and 31% of subjects aged 20, 30 and 70 years respectively.16 cross-sectional study, and the methodology included This showed that younger subjects had minimal wear only clinical examination using the index. For evalua- involving only enamel and older subjects showed wear tion and management of attrition follow up studies will involving both enamel and dentine. This was attributed to be more helpful. The methodology could have included functional wear and increase in duration of habits. Older one more method of verifying the scoring like intraoral people are exposed to the risk factors of tooth wear over photographs and high-density casts. a longer, and they also tend to indulge in deleterious oral health practices that result into tooth wear. CONCLUSION It was found that male subjects in the present study Within the limitations of this study, the following conclu- showed more attrition than female subjects. Male subjects sions can be drawn: of all the age groups showed higher attrition than female • The highest prevalence of attrition was seen in both subjects of all the age groups (Graph 4). Similar results middle and old age compared to younger age. were seen in earlier studies of Hugosan et al., Seligman • Younger age showed the least attrition score involv- et al. and Donachie et al.14,16,18 ing only enamel compared to older age who showed The higher attrition score in men may be probably due attrition involving enamel and dentine. to strong masseter function, greater muscle fiber mass, • As the age advances severity of attrition was also stronger ligaments resulting in higher biting force. Males increased. 20 CODSJOD

Prevalence of Dental Attrition and its Severity in Relation to Age and Gender: A Clinical Study

• Males showed higher attrition than females. The 10. Thomas S. The need for geriatric dental education in India: the severity of attrition was also more in males. geriatric health challenges of the millennium. International dental journal. 2013 Jun 1;63(3):130-136. 11. Liu B, Zhang M, Chen Y, Yao Y. Tooth wear in aging people: REFERENCES an investigation of the prevalence and the influential factors 1. Desai VD, Priyadarshini SR. Oral manifestations in geriatric of incisal/occlusal tooth wear in northwest China. BMC oral patients. Indian Journal of Medicine and Healthcare. 2012 Oct health. 2014 Jun 5;14(1):1. 1;1(7):195-200. 12. Jain R, Hegde MN. Dental Attrition-Aetiology, Diagnosis and 2. Hattab FN, Yassin OM. Etiology and diagnosis of tooth wear: Treatment Planning: AReview. IOSR Journal of Dental and a literature review and presentation of selected cases. Int J Medical Sciences (IOSR-JDMS);1(14):60-66. Prosthodont. 2000 Mar-Apr;13(2):101-107 13. Cunha‐Cruz J, Pashova H, Packard JD, Zhou L, Hilton TJ. 3. Ibiyemi O, Taiwo JO. Some socio-demographic attributes Tooth wear: prevalence and associated factors in general as covariates in tooth wear among males in a rural com- practice patients. Community dentistry and oral epidemiol- munity in Nigeria. Ethiop J Health Sci. 2012 Nov;22(3):189- ogy. 2010 Jun 1;38(3):228-234. 195 14. Seligman DA, Pullinger AG, Solberg WK. The prevalence of 4. Morley J. The role of cosmetic dentistry in restoring a youthful dental attrition and its association with factors of age, gender, appearance. J Am Dent Assoc. 1999;130(8):1166-1172. occlusion, and TMJ symptomatology. Journal of Dental 5. Hanif A, Rashid H, Nasim M. Tooth surface loss revisited: Research. 1988 Oct 1;67(10):1323-1333. Classification, etiology, and management. Journal of Restor- 15. Yadav S. A Study on Prevalence of Dental Attrition and its ative Dentistry. 2015 May 1;3(2):37. Relation to Factors of Age, Gender and to the Signs of TMJ 6. Casanova-Rosado JF, Medina-Solís CE, Vallejos-Sánchez AA, Dysfunction. The Journal of Indian Prosthodontic Society. Casanova-Rosado AJ, Maupomé G, Avila-Burgos L. Dental attrition and associated factors in adolescents 14 to 19 years of 2011 Jun 1;11(2):98-105. age: a pilot study. Int J Prosthodont. 2005 Nov-Dec;18(6):516- 16. Hugoson A, Bergendal T, Ekfeldt A, Helkimo M. Prevalence 519 and severity of incisal and occlusal tooth wear in an adult 7. Kaushik SK, Madan R, Gambhir A, Prasanth T. Aviation stress Swedish population. ActaOdontologicaScandinavica. 1988 and dental attrition. Ind J Aerospace Med. 2009;53(1):6-10. Jan 1;46(5):255-265. 8. Pigno MA, Hatch JP, Rodrigues-Garcia RC, Sakai S, Rugh JD. 17. Pergamalian A, Rudy TE, Zaki HS, Greco CM. The association Severity, distribution, and correlates of occlusal tooth wear between wear facets, bruxism, and severity of facial pain in in a sample of Mexican-American and European-American patients with temporomandibular disorders. The Journal of adults. Int J Prosthodont. 2001 Jan-Feb;14(1):65-70 prosthetic dentistry. 2003 Aug 31;90(2):194-200. 9. Kandelman D, Petersen PE, Ueda H. Oral health, general 18. Donachie MA, Walls AW. Assessment of tooth wear in an health, and quality of life in older people. Special care in ageing population. Journal of dentistry. 1995 Jun 30;23(3):157- dentistry. 2008 Nov 1;28(6):224-236 164.

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