Knowledge, Attitude and Practice Survey on Awareness of the Association between Diet and Dental Erosion

Keywords

Dental Erosion; Carbonated Drinks; Milk; Fruits; Juice; Diet.

Introduction

Erosive tooth wear is the chemico mechanical removal of dental hard tissues which can result in reduced aesthetics, compromised tooth structure, and loss of quality of life, possibly resulting in the need of costly restorative intervention [1, 2]. The prevalence and severity of erosive tooth wear is increasing, particularly in the younger population [3, 4]. Causal association between diet and dental erosive tooth wear progression have been established and an acidic diet is believed to be a significant aetiological agent in this increase in prevalence. It is hypothesized that frequent daily dietary acid intakes are needed for severe erosive tooth wear to occur [5, 6]. Extrinsic causes include demineralizing acidic beverages and some medicines such as vitamin supplements. Intrinsic causes include recurring vomiting, low salivary flow which naturally results in inadequate rinsing and buffering of demineralizing acids on tooth surfaces. It is important to be able to identify the range of food, drinks and medications that have erosive potential [7, 8]. The addition of fruit or fruit flavourings to drinks has also increased which can also have equivalent erosive potential to that of carbonated drinks [9-11]. It is reasonably safe to assume that any dietary food or drink with added fruit or fruit flavouring will be acidic. While the erosive potential of specific dietary acids is important, it is essential to look at the overall pattern of consumption [12-14]. The frequency of dietary acid intake has been recognized as one of the primary risk factors for erosive tooth wear. The aim of this survey was to assess the knowledge, attitude and practice of the awareness of the association between diet and dental erosion among the general public.

Materials and Methods

An online survey was done with the structured questionnaire based on knowledge, attitude, practice among the general public regarding dental erosion and its correlation with the diet. The questionnaire had 15 questions in which 5 questions based on knowledge, 5 based on attitude, 5 questions based on practice were created. The participants were general public aged between 18-50 years. A snowball sampling method was followed for this study. The questionnaires were distributed via electronic media and responses were collected. All the participants were allowed to choose one of the given three to four choices for each item in the questionnaire. 302 responses were assessed. The advantages of online surveys are easy collection of data, cost effective and the disadvantage is repeated answers and incomplete answers. Then, it was assessed whether knowledge, attitude, practice were sufficient for dental erosion and its association with diet. Later it was compared to improve the needs of the same.

Ethical Approval

Ethical permission and approval for the project was obtained from the Institutional Review Board of Saveetha Institute of Medical and Technical Sciences, Chennai, India. (SBA/2019/23/03.)

Eligibility Criteria

General public aged between 18-50 years, Tamilnadu, India

Data Collection

This cross sectional survey was conducted among the general public from August to October of 2019. A self structured questionnaire of having 15 questions was shared online and 302 responses were obtained.

Sample Size

Total number of distributed questionnaires was 315. Out of which 10 were incomplete forms, 3 did not answer and that were excluded from the study. Hence, 302 responses were analysed.

Statistical Analysis

After data entry in the excel sheet, SPSS software was used to analyze the data. The descriptive statistics were used to determine the frequencies and percentage of the responses given by the participants. Correlation analysis was performed to find the association between diet and dental erosion. Chi Square test was performed to determine the association between the knowledge about dental erosion and its correlation with diet.

Results and Discussion

Majority of the general public consume highly acidic beverages causing erosive tooth wear. Lack of awareness of the association between diet and dental erosion was found among the general public. Since, the p-value is significant there is an association between most of the groups and variables in this study.

Majority of the percentage of respondents (45.36%) consume carbonated drinks twice/thrice in a week as represented in graph 1. There is a growing evidence of a considerable increase in consumption of potentially erosive drinks among the youth population. Soft drinks - carbonated and non carbonated drinks could cause damage to the teeth for two reasons such as low pH and high titratable acidity [15, 16].

In this study, 30.6% of the respondents did not experience the sour taste in the mouth as represented in graph 2. Majority of the respondents (42.5%) have experienced regurgitation as represented in graph 3 and 34.7% of the respondents consuming acidic beverages have experienced heartburn frequently as represented in graph 4. Approximately 34.5% of the respondents reported that they have heard about dental erosion and 32.1% of the respondents do not know the causes of dental erosion as represented in graph 5,6. This indicates the inadequate knowledge and awareness among the general public regarding the association between diet and dental erosion.

And also the sugars in the drinks are metabolized by plaque microorganisms to generate organic acids that cause demineralization [17, 18]. Erosion is due to the loss of the outermost surface of enamel and occurs when the surface pH falls below 5.5. For instance, the mean pH of soft drinks samples was 2.30, while the mean calcium and fluoride ion concentration were 0.58 and 0.066 respectively [19, 20]. The low pH as well as the low calcium and fluoride ion concentration indicate the high erosive potential. Not only soft drinks but also the citrus fruits play a major risk factor in dental erosive tooth wear [21, 22].

Chewing vitamin C tablets were significantly associated with the development of tooth wear. Vitamin C (Ascorbic acid) has low pH and high titratable capacity which serves as a risk factor in erosive tooth wear [23, 24]. Based on the origin of the erosion causing acids, a distinction between endogenous and exogenous erosion is made [25]. Intrinsic erosion most commonly affects the palatal and occlusal tooth surfaces, While extrinsic erosion is initially localized on the labial surfaces of anterior teeth [26, 27].

Erosion in the initial stage appears as a smooth silky shiny surface, resulting in the concavities of smooth surfaces or cupping of the cusps. The acid exposure leads to the dissolution of inorganic dental hard tissue, which results in a rough surface similar to an etching pattern in conservative and endodontic procedures [28- 46]. As a result, the microhardness of the superficial layer and thus the mechanical resistance is reduced [47, 48]. With the further progression, the extensive loss of the tooth substance occurs. Dentin demineralization leads to the exposure of organic matrix that acts as a diffusion barrier and is capable of further erosion progression [49, 50]. In addition to the type and frequency of acid exposure, modifying host factors determine the extent and progression of erosive defects. These factors include in particular, saliva properties such as flow rate, buffering capacity, pH and composition. Extrinsic acid exposures include the consumption of acidic foods such as soft drinks, citrus fruits, vinegar, wine and acidic drugs such as acetyl salicylic acid, Iron tablets and vitamin supplements [51, 52]. Occupational acid exposures might affect the industrial workers, professional swimmers and wine tasters. The extent of dental hard tissue erosion is determined by the erosivity of erosion causing solution and also the frequency and type of consumption [53, 54]. Certain drinking habits (drinking in sips, use of straws in direct tooth contact, and intensive rinsing) leads to the prolonged pH drop in the oral cavity compared to the short consumption. Jarvinen et al, 2015 have shown the intake of citrus fruits more than twice daily, the daily drinking of soft drinks and the weekly consumption of vinegar or sport drinks is capable of increasing dental erosive tooth wear significantly [55].

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Figure 1:

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Graph 1. Bar chart showing association between respondents and responses, X axis represents the frequency of consumption of carbonated drinks among the respondents and Y axis the age group of respondents. Majority of the percentage of respondents consume carbonated drinks twice/thrice in a week(Blue color). Chi square test (2.214) was done and association was found to be not statistically significant. Pearson's Chi square P value of 0.21 > 0.05.

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Figure 2:

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Graph 2. Bar chart showing association between respondents and responses, X axis represents the experience of sour taste in the mouth among the respondents and Y axis the age group of respondents. Majority of the respondents do not experience the sour taste in the mouth (blue color). Chi square test (1.014) was done and association was found to be statistically significant. Pearson's Chi square P value of 0.01 < 0.05.

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Figure 3:

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Graph 3. Bar chart showing association between respondents and responses, X axis represents the experience of regurgitation in the mouth among the respondents and Y axis the age group of respondents. Majority of the respondents have experienced regurgitation (blue color). Chi square test (2.017) was done and association was found to be statistically significant. Pearson's Chi square P value of 0.02 < 0.05.

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Figure 4:

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Graph 4. Bar chart showing association between respondents and responses, X axis represents the experience of heartburn among the respondents and Y axis the age group of respondents. Majority of the respondents have experienced heartburn (blue color). Chi square test (3.014) was done and association was found to be statistically significant. Pearson's Chi square P value of 0.03 < 0.05.

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Figure 5:

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Graph 5. Bar chart showing association between respondents and responses, X axis represents the knowledge regarding dental erosion among the respondents and Y axis the age group of respondents. Majority of the respondents have heard the term dental erosion (blue color). Chi square test (2.024) was done and association was found to be statistically significant. Pearson's Chi square P value of 0.02 < 0.05.

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Graph 6. Bar chart showing association between respondents and responses, X axis represents the knowledge regarding the causes of dental erosion among the respondents and Y axis the age group of respondents. Majority of the respondents do not have adequate knowledge regarding the causes of dental erosion (blue color). Chi square test (1.018) was done and association was found to be statistically significant. Pearson's Chi square P value of 0.01 < 0.05.

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Figure 7:

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Graph 7. Bar chart showing association between respondents and responses, X axis represents the wear changes noted by the respondents and Y axis the age group of respondents. Majority of the respondents have not noticed the wear changes in their teeth (blue color). Chi square test (2.029) was done and association was found to be statistically significant. Pearson's Chi square P value of 0.012< 0.05.

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Intrinsic erosion is caused by the acidic gastric fluid coming into contact with the oral cavity. In patients with bulimia nervosa, gastrointestinal reflux disease or alcohol abuse. The prevalence of dental erosion in reflux patients amounts to 17 percent to 68 percent. Conversely, 25 percentage to 83 percentage of all patients with erosion suffer from reflux [25, 56].

Furthermore, patients with eating disorders often show a low salivary flow rate as a result of general dehydration or as a side effect of psychotropic drugs, which might further increase the risk of developing erosive lesions [10]. When dietary related erosion is diagnosed, patients should be advised to restrict the consumption of acidic foods and drinks to the meals [5]. Acidic beverages should be consumed, cooled and as fast as possible in order to reduce their erosivity [57, 58].

It was shown that the addition of calcium effervescent tablets to orange juice reduced the erosivity, but did not have a negative impact on the taste [10]. Yoghurt contains quite high concentrations of calcium and phosphate and is therefore non erosive despite its low pH [2]. Staufenbiel et al, 2015 found that erosive lesions are more prevalent in patients with a vegetarian diet than in non-vegetarians [55]. A comparison of erosivity of different acid sources is difficult because not only chemical parameters but also the adhesion to the tooth structure as well as dietary habits such as frequency, quantity, and temperature must be considered. [59, 60].

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Table 1:

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Table 1. Showing distribution of respondents which were included for the study based on age, gender. Maximum number of respondents were reported in the age group of 20-30 years. Out of 302 responses , 36.4 % were female and 63.5 % were male.

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Table 2:

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Table 2. Showing Questionnaire and the Responses.

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Table 3:

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Table 3. KAP scores towards the association of dental erosion with the diet.

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Table 4:

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Table 4. Correlation analysis of KAP toward the association of dental erosion with the diet.

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So, intervention measures should be taken to reduce or prevent dental erosive tooth wear from diet factors. Dental professionals should educate patients about the consequences of frequent soft drink consumption and provide positive suggestions to minimize the risk. Public health professionals should guide the people especially youth and children to limit the intake of acidic beverages. Oral health educators should reinforce the association between dietary factors and associated erosive tooth wear among the general public to create and establish awareness concerning dental erosive tooth wear.

Conclusion

This cross sectional descriptive study shows a majority of the general public are associated with the consumption of potentially erosive drinks. They do not have adequate knowledge about dental erosion and its correlation with diet factors. Hence, establishing awareness among the general public regarding dental erosion and its correlation with diet is mandatory.

Clinical Significancen

The prevalence of dental erosion seems to be increasing and dietary components contribute to many enamel defects. Modern diet appears to contain more acidic content which can demineralise enamel, alters the buffering capacity of saliva and plays an aetiological role in many oral disorders.

Limitations

This study was confined among a smaller number of populations and have not focused on the occupation of the respondents.

Future Scope

This study can be conducted in a larger number of populations, The questions can be focused on the occupation of respondents.

Acknowledgement

With Sincere gratitude, we acknowledge the staff members of the department of Conservative Dentistry and Endodontics and Saveetha Dental College and study participants for their extended support towards the completion of research.

References

1. Lussi A, Ganss C, editors. Erosive tooth wear: from diagnosis to therapy. Karger Medical and Scientific Publishers; 2014 Jun 24.
2. Lussi A, Jaeggi T. Dental erosion: diagnosis, risk assessment, prevention, treatment. Quintessence; 2011.
3. Meurman JH, Murtomaa H. Effect of effervescent vitamin C preparations on bovine teeth and on some clinical and salivary parameters in man. Scand J Dent Res. 1986 Dec;94(6):491-9.Pubmed PMID: 3468598.
4. Ganss C. Definition of erosion and links to tooth wear. Monogr Oral Sci. 2006;20:9-16.Pubmed PMID: 16687881.
5. Zohoori FV, Duckworth RM, editors. The Impact of Nutrition and Diet on Oral Health. Karger Medical and Scientific Publishers; 2019 Nov 7.
6. Kreulen CM, Van’t Spijker A, Rodriguez JM, Bronkhorst EM, Creugers NH, Bartlett DW. Systematic review of the prevalence of tooth wear in children and adolescents. Caries Res. 2010;44(2):151-9.
7. Piangprach T, Hengtrakool C, Kukiattrakoon B, Kedjarune-Leggat U. The effect of salivary factors on dental erosion in various age groups and tooth surfaces. J Am Dent Assoc. 2009 Sep;140(9):1137-43.Pubmed PMID: 19723947.
8. Al-Ashtal A, Johansson A, Omar R, Johansson AK. Dental erosion in groups of Yemeni children and adolescents and the modification of an erosion partial recording system. Int J Paediatr Dent. 2017 Jul;27(4):283-292.Pubmed PMID: 27545983.
9. Dugmore CR, Rock WP. A multifactorial analysis of factors associated with dental erosion. Br Dent J. 2004 Mar 13;196(5):283-6.Pubmed PMID: 15017418.
10. Waterhouse PJ, Auad SM, Nunn JH, Steen IN, Moynihan PJ. Diet and dental erosion in young people in south-east Brazil. Int J Paediatr Dent. 2008 Sep;18(5):353-60.Pubmed PMID: 18445002.
11. Addy M, Edgar WM, Embery G, Orchardson R. Tooth wear and sensitivity: Clinical advances in restorative dentistry. Thieme; 2000 Apr 17.
12. Chadwick RG, Mitchell HL, Manton SL, Ward S, Ogston S, Brown R. Maxillary incisor palatal erosion: no correlation with dietary variables? J Clin Pediatr Dent. 2005 Winter;29(2):157-63.Pubmed PMID: 15719922.
13. Bartlett DW, Coward PY, Nikkah C, Wilson RF. The prevalence of tooth wear in a cluster sample of adolescent schoolchildren and its relationship with potential explanatory factors. Br Dent J. 1998 Feb 14;184(3):125-9. Pubmed PMID: 9524373.
14. Williams D, Croucher R, Marcenes W, O'Farrell M. The prevalence of dental erosion in the maxillary incisors of 14-year-old schoolchildren living in Tower Hamlets and Hackney, London, UK. Int Dent J. 1999 Aug;49(4):211-6. Pubmed PMID: 10858756.
15. Luo Y, Zeng XJ, Du MQ, Bedi R. The prevalence of dental erosion in preschool children in China. J Dent. 2005 Feb;33(2):115-21.Pubmed PMID: 15683892.
16. Batra M, Vesna A, Stevanovic M, Jankulovska M, Shah AF. Dental Caries experience among 12 year old school children from Macedonia and India. J Dent Probl Solut 2 (3): 044. 2015;47:1-91.
17. . Aparna M, Sreekumar S, Thomas T, Hedge V. Assessment of dental caries experience among 5-16 year old school going children of Mangalore, Karnataka, India: a cross-sectional study. Ann Essences Dent. 2018 Nov 25;10(1):12-7.
18. Nahás Pires Corrêa MS, Nahás Pires Corrêa F, Nahás Pires Corrêa JP, Murakami C, Mendes FM. Prevalence and associated factors of dental erosion in children and adolescents of a private dental practice. Int J Paediatr Dent. 2011 Nov;21(6):451-8.Pubmed PMID: 21793955.
19. Aidi HE, Bronkhorst EM, Huysmans MC, Truin GJ. Factors associated with the incidence of erosive wear in upper incisors and lower first molars: a multifactorial approach. J Dent. 2011 Aug;39(8):558-63.Pubmed PMID: 21704669.
20. Ratnayake N, Ekanayake L. Risk indicators for tooth wear in Sri Lankan adolescents. Caries Res. 2010;44(1):14-9.Pubmed PMID: 20068303.
21. Chen YG, Li X, Hu DY, Shen H, Li KZ, Zhao Y, et al. Prevalence of tooth erosion of 5-year-old and 12-year-old children in Xuzhou city]. Hua Xi Kou Qiang Yi Xue Za Zhi. 2009 Oct;27(5):565-7.Pubmed PMID: 19927735.
22. . Amaechi BT, editor. Dental erosion and its clinical management. Springer; 2015 Sep 28.
23. . Paschos E. Tooth wear in the deciduous dentition of 5-to 7-year-old children: risk factors. J Orofac Orthop. 2013;2(74):96-7.
24. Gatou T, Mamai-Homata E. Tooth wear in the deciduous dentition of 5-7-year-old children: risk factors. Clin Oral Investig. 2012 Jun;16(3):923- 33.Pubmed PMID: 21732089.
25. Bartlett D. Intrinsic causes of erosion. Dental Erosion. 2006;20:119-39.
26. Milosevic A, Lennon MA, Fear SC. Risk factors associated with tooth wear in teenagers: a case control study. Community Dent. Health. 1997 Sep 1;14(3):143-7.
27. Khan F, Young WG(2011). Toothwear: The ABC of the Worn Dentition. John Wiley & Sons,.
28. Mohanty S, Ramesh S, Priya VV, Gayathri R. Inhibition of purE Gene Using Herbal Compounds to Treat Oral Diseases Caused by Oral Pathogens– An in silico Study. J. Pharm. Sci. Res. 2017 Jul 1;9(7):1246.
29. Auswin MK, Ramesh S. Knowledge, attitude, and practice survey on the use of dental operating microscope in endodontics: A cross-sectional survey. Pharm. Educ. Res. 2017.
30. Teja KV, Ramesh S. Shape optimal and clean more. Saudi Endod. J. 2019 Sep 1;9(3):235.
31. Ramarao S, Sathyanarayanan U. CRA Grid - A preliminary development and calibration of a paper-based objectivization of caries risk assessment in undergraduate dental education. J Conserv Dent. 2019 Mar-Apr;22(2):185-190. Pubmed PMID: 31142991.
32. Poorni S, Srinivasan MR, Nivedhitha MS. Probiotic Streptococcus strains in caries prevention: A systematic review. J Conserv Dent. 2019 Mar;22(2):123- 128.
33. Manohar MP, Sharma S. A survey of the knowledge, attitude, and awareness about the principal choice of intracanal medicaments among the general dental practitioners and nonendodontic specialists. Indian J Dent Res. 2018 Nov-Dec;29(6):716-720.Pubmed PMID: 30588997.
34. Azeem RA, Sureshbabu NM. Clinical performance of direct versus indirect composite restorations in posterior teeth: A systematic review. J Conserv Dent. 2018 Jan-Feb;21(1):2-9.Pubmed PMID: 29628639.
35. Jenarthanan S, Subbarao C. Comparative evaluation of the efficacy of diclofenac sodium administered using different delivery routes in the management of endodontic pain: A randomized controlled clinical trial. J Conserv Dent. 2018 May-Jun;21(3):297-301.Pubmed PMID: 29899633.
36. Nandakumar M, Nasim I. Comparative evaluation of grape seed and cranberry extracts in preventing enamel erosion: An optical emission spectrometric analysis. J Conserv Dent. 2018 Sep-Oct;21(5):516-520.Pubmed PMID: 30294113.
37. Malli Sureshbabu N, Selvarasu K, V JK, Nandakumar M, Selvam D. Concentrated Growth Factors as an Ingenious Biomaterial in Regeneration of Bony Defects after Periapical Surgery: A Report of Two Cases. Case Rep Dent. 2019 Jan 22;2019:7046203.Pubmed PMID: 30805222.
38. . Siddique R, Nivedhitha MS, Jacob B. Quantitative analysis for detection of toxic elements in various irrigants, their combination (precipitate), and para-chloroaniline: An inductively coupled plasma mass spectrometry study. J Conserv Dent. 2019 Jul-Aug;22(4):344-350.Pubmed PMID: 31802817.
39. Teja KV, Ramesh S, Priya V. Regulation of matrix metalloproteinase-3 gene expression in inflammation: A molecular study. J. Conserv. Dent. 2018 Nov;21(6):592-596.
40. Rajakeerthi R, Nivedhitha MS. Natural Product as the Storage medium for an avulsed tooth–A Systematic Review. Cumhuriyet Dent J. 2019;22(2):249- 56.
41. Siddique R, Nivedhitha MS. Effectiveness of rotary and reciprocating systems on microbial reduction: A systematic review. J Conserv Dent. 2019 Mar-Apr;22(2):114-122.Pubmed PMID: 31142978.
42. Janani K, Sandhya R. A survey on skills for cone beam computed tomography interpretation among endodontists for endodontic treatment procedure. Indian J Dent Res. 2019 Nov-Dec;30(6):834-838.Pubmed PMID: 31939356.
43. Siddique R, Sureshbabu NM, Somasundaram J, Jacob B, Selvam D. Qualitative and quantitative analysis of precipitate formation following interaction of chlorhexidine with sodium hypochlorite, neem, and tulsi. J Conserv Dent. 2019 Jan-Feb;22(1):40-47.Pubmed PMID: 30820081.
44. Rajendran R, Kunjusankaran RN, Sandhya R, Anilkumar A, Santhosh R, Patil SR. Comparative evaluation of remineralizing potential of a paste containing bioactive glass and a topical cream containing casein phosphopeptide- amorphous calcium phosphate: An in vitro study. Pesqui. Bras. Odontopediatria Clín. Integr. 2019;19:1-10.
45. Govindaraju L, Neelakantan P, Gutmann JL. Effect of root canal irrigating solutions on the compressive strength of tricalcium silicate cements. Clin Oral Investig. 2017 Mar;21(2):567-571.Pubmed PMID: 27469101.
46. Khandelwal A, Palanivelu A. Correlation between dental caries and salivary albumin in adult population in Chennai: An in vivo study. Braz. Dent. Sci. 2019 Apr 30;22(2):228-33.
47. Zero DT. Etiology of dental erosion--extrinsic factors. Eur J Oral Sci. 1996 Apr;104(2 ( Pt 2)):162-77.Pubmed PMID: 8804884.
48. Jager DH, Vieira AM, Ruben JL, Huysmans MC. Estimated erosive potential depends on exposure time. J Dent. 2012 Dec;40(12):1103-8.Pubmed PMID: 23000470.
49. O'Toole S, Bernabé E, Moazzez R, Bartlett D. Timing of dietary acid intake and erosive tooth wear: A case-control study. J Dent. 2017 Jan;56:99-104. Pubmed PMID: 27856311.
50. Lussi A, Schaffner M. Progression of and risk factors for dental erosion and wedge-shaped defects over a 6-year period. Caries Res. 2000 Mar- Apr;34(2):182-7.Pubmed PMID: 10773637.
51. Jensdottir T, Arnadottir IB, Thorsdottir I, Bardow A, Gudmundsson K, Theodors A, et al. Relationship between dental erosion, soft drink consumption, and gastroesophageal reflux among Icelanders. Clin Oral Investig. 2004 Jun;8(2):91-6.Pubmed PMID: 14745590.
52. Hasselkvist A, Johansson A, Johansson AK. Association between soft drink consumption, oral health and some lifestyle factors in Swedish adolescents. Acta Odontol Scand. 2014 Nov;72(8):1039-46.Pubmed PMID: 25183250.
53. Johansson AK, Lingström P, Birkhed D. Comparison of factors potentially related to the occurrence of dental erosion in high- and low-erosion groups. Eur J Oral Sci. 2002 Jun;110(3):204-11.Pubmed PMID: 12120705.
54. Ganss C, Schlechtriemen M, Klimek J. Dental erosions in subjects living on a raw food diet. Caries Res. 1999;33(1):74-80.Pubmed PMID: 9831783.
55. Staufenbiel I, Adam K, Deac A, Geurtsen W, Günay H. Influence of fruit consumption and fluoride application on the prevalence of caries and erosion in vegetarians--a controlled clinical trial. Eur J Clin Nutr. 2015 Oct;69(10):1156-60.Pubmed PMID: 25782429.
56. Scheutzel P. Etiology of dental erosion--intrinsic factors. Eur J Oral Sci. 1996 Apr;104(2 ( Pt 2)):178-90.Pubmed PMID: 8804885.
57. Søvik JB, Skudutyte-Rysstad R, Tveit AB, Sandvik L, Mulic A. Sour sweets and acidic beverage consumption are risk indicators for dental erosion. Caries Res. 2015;49(3):243-50.Pubmed PMID: 25765077.
58. Caneppele TM, Jeronymo RD, Di Nicoló R, de Araújo MA, Soares LE. In Vitro assessment of dentin erosion after immersion in acidic beverages: surface profile analysis and energy-dispersive X-ray fluorescence spectrometry study. Braz Dent J. 2012;23(4):373-8.Pubmed PMID: 23207852.
59. Zimmer S, Kirchner G, Bizhang M, Benedix M. Influence of various acidic beverages on tooth erosion. Evaluation by a new method. PLoS One. 2015 Jun 2;10(6):e0129462.Pubmed PMID: 26035729.
60. Manton DJ, Cai F, Yuan Y, Walker GD, Cochrane NJ, Reynolds C, et al. Effect of casein phosphopeptide-amorphous calcium phosphate added to acidic beverages on enamel erosion in vitro. Aust Dent J. 2010 Sep;55(3):275-9. Pubmed PMID: 20887514.