GMJ GULF MEDICAL JOURNAL ORAL PROCEEDINGS PREVALENCE AND FACTORS ASSOCIATED WITH TOOTH Omar Barakat 1 *, Ardeshir Amirhosseini 1, Mohammad Ahmad 1, Sara Al-Fallahi 1, Talal Atassi 1, Walid El-Sayed 2 1Final year students, College of Dentistry, 2 Assistant Professor of Oral Biology, Department of Oral Biology, Gulf Medical University, Ajman, UAE *Presenting Author ABSTRACT Objective: The study had two objectives: to determine the prevalence and the most common causes of tooth discoloration among students of Gulf Medical University (GMU); and investigate any association between tooth discoloration and students habits, socio-demographic factors, and dental and medical history. Materials & Methods: This was a cross-sectional questionnaire-based study carried out among GMU students. Students perception about the color of their teeth was assessed by asking related questions in this regard. Information on socio-demographic characteristics of the population was gathered. Data was coded and entered into SPSS software. Descriptive statistics were used to determine the prevalence and the most common causes of tooth discoloration, and associations (mentioned under Objectives), if any. Results: The study covered 250 subjects. More than half the participants (57%) considered the shade of their teeth to be normal, while 42.8% (nearly 43%) believed they had some sort of tooth discoloration. The most common color was brownish-yellow, with habits and dental treatment perceived to be largely responsible for discoloration. The study also proved the association between tooth discoloration and gender as well as history of dental treatment (p value < 0.05). Conclusion: Less than half (42.8%) the participants of GMU believed their teeth were discolored. Findings suggested that extrinsic stains, mainly a result of habits or dental treatment, are the most common cause of tooth discoloration. Keywords: Tooth discoloration, extrinsic discoloration, intrinsic discoloration, internalized discoloration Citation: Barakat O, Amirhosseini A, Ahmad M, Al-Fallahi S, Atassi T, El-Sayed W. Prevalence and factors associated with tooth discoloration among UAE university students. Gulf Medical Journal. 2016;5(S1):S131 S135. INTRODUCTION Tooth discoloration is considered one of the most important reasons prompting patients to visit dental clinics. Discoloration of teeth has a great impact on the psychology of patients and could even lead to psychological trauma 1. Therefore, it is important for dental Correspondence: Walid El-Sayed (BDS, MDS, PhD of Oral Biology), Assistant Professor of Oral Biology, Oral Biology Department, College of Dentistry, Gulf Medical University, Ajman, UAE. Email: waleed150eg@yahoo.com practitioners to have the right knowledge about the causes of tooth discoloration to be able to explain the exact nature of the condition to their patients, to make the correct diagnosis and provide proper treatment. Development of the mammalian teeth is a complex process resulting from the sequential and reciprocal interaction between oral ectodermal and the underlying mesenchymal tissues of the first branchial arch 2. Macroscopically, each tooth is divided into a crown, which erupts into the mouth, and a root that is anchored within the alveolar bone in 131
OMAR BARAKAT, ET AL health 3. Microscopically, the coronal part of the tooth crown consists of three dental hard tissues: enamel, dentine and cementum with a central pulp that includes vessels and nerves 3. Any change in these structures is likely to cause an alteration in the outer appearance of the tooth, referred to as tooth discoloration 4. Tooth discoloration is not an uncommon condition presented in dental clinics. Several factors lead to tooth discoloration with different degrees of severity. In general, the causes can be classified under two broad groups: physiological and pathological 1 4. Physiological changes in tooth structure occur with age due to factors such as formation of secondary dentine, development of extrinsic stains and gradual wear of enamel, significantly influencing the color of the underlying dentine 4. Furthermore, the color of a tooth is not the same across the entire crown morphology. Normally, the shade varies, with the gingival margin often having a darker appearance due to the close approximation of the underlying dentine, and the crown at the cusp of the posterior teeth or the incisal ridges of anterior teeth being whiter. Also, color varies from one tooth to another; for instance, the permanent canine tooth is darker than permanent incisors 4. Pathological factors, however, are the most common causes of tooth discoloration. Basically, there are three types of pathological tooth discoloration. The first is extrinsic discoloration, where the change in color takes place outside the tooth substance (enamel, dentine and pulp) and stains are formed on the tooth surface. It is caused by extrinsic factors that can be either direct or indirect 4, 5. The second is intrinsic discoloration caused by internal change in the structural composition of the dental hard tissues (enamel and/or dentine). It can be attributed to a number of metabolic diseases and systemic factors that affect the developing dentition and cause discoloration 4, 6. The third is internalized discoloration, where extrinsic stains develop in the tooth substance (enamel and/or dentine) due to certain conditions such as tooth wear and gingival recession, formation of dental caries and usage of restorative materials 4, 6. The objective of our study was to determine the prevalence and the most common causes of tooth discoloration among students of GMU, and investigate any association between tooth discoloration and students habits, socio-demographic characteristics, and dental and medical history. MATERIALS & METHODS This was a cross-sectional questionnaire-based study carried out among students of GMU, Ajman. The population included clinical and pre-clinical students. The inclusion criteria were students should be above 17 years of age and must sign the consent form. Naturally, those below 17 years or not willing to give consent were excluded from the survey. The number of participants was 250. Duration of the study was almost 6 8 months. The questionnaire was prepared after extensive review of literature and validated by two subject matter experts (a prosthodontics specialist, and a community doctor). The questionnaire was divided into three parts: (i) socio-demographic profile section (age, gender, course and level of study, and nationality of the participant); (ii) section on essential direct questions relevant to both, those with tooth discoloration and without; and (iii) section containing relevant questions about the most likely causative factors for tooth discoloration. Approval was obtained from GMU s Research Committee and Ethics Committee. Data was analyzed using the SPSS program, and presented in the form of percentages, tables and graphs; the Chi square test was used to determine associations. RESULTS Participants in the study aged mainly between 17 and 25 years (98%); only 2% were 26 30 years old. Females accounted for more than 66% (two-thirds) of the group, while males accounted for 34% (one-third). Furthermore, participants were from diverse ethnic backgrounds, with Arabic ethnicity predominant at almost 48%. Students of Far 132
No. of participants PREVALENCE AND FACTORS ASSOCIATED WITH TOOTH Eastern ethnicity (included Indians, Chinese, and Pakistanis) constituted 9.6%, while those of African and mixed (from the rest of the world) nationalities represented 13% and 13.2%, respectively. Analysis of the answers (to the questionnaires) established clearly that drinking coffee and tea was the most common habit among the participants (63.5%), followed by drinking soft drinks (48.5%) and smoking (41.4%); refer to Figure 1 for details. The medical history of the participants showed that most were healthy (98%), while just 2% showed systemic problems, such as cardiovascular diseases, pregnancy or respiratory problems, requiring medication. The dental history of the respondents showed that minor dental treatments were the most common, such as simple filling and periodontal treatment (25%). Interestingly, a relatively large number of the participants had undergone surgical and nonsurgical dental extraction (16.4%) and root canal treatment (14.3%), while a smaller number admitted receiving other dental treatments such as home bleaching (5.7%), crown (3.6%) and bridge (0.7%) restorations. Figure 1. Distribution of participants by personal habit 180 160 140 120 100 80 60 40 20 0 2.8% 3.6% 16.4% 48.4% 63.2% Nicotine Alcohol Smoking Soft drinkscoffee and tea Of the respondents, 42.8% (nearly 43%) believed that they had tooth discoloration, while 57% believed the shade of their teeth was normal (as shown in Figure 2). Out of the 42.8%, 18% pointed out that they had brownish-yellow stains. Another 10.4% said that they had white patches in one or more teeth. The proportion of those with greyishblue to brownish-yellow discoloration was the lowest at less than 1%. Figure 2. Self-assessment of study participants on their tooth color 57.20% 42.80% Tooth discoloration Normal tooth color With regard to the common causes of tooth discoloration (from the perspective of the participants), drinking coffee and tea was the strongest etiological reason, with 11.6% respondents (of the 42.8% admitting tooth discoloration) citing it. Interestingly, 14% were neither able to identify the cause nor did they know when discoloration had set in. Another 2.4% stated that a combination of habits led to discoloration. Only 0.8% cited trauma as the reason behind their tooth discoloration. A comparison of the habits of participants showed that the most common personal habits were drinking coffee and tea, soft drinks, smoking and consumption of alcohol and nicotine. Figure 3 shows that participants with discoloration in the anterior region constituted the largest section (74%). Only 15% of 42.8% had tooth discoloration in the posterior segment. Moreover, just 11% reported discoloration in different locations. On the other hand, 31.2% participants (of the 42.8%) reported discoloration in the anterior region (upper or lower), whereas 6.4% reported discoloration in the posterior segment. 133
OMAR BARAKAT, ET AL Figure 3. Distribution of discoloration position in dentition 15% 11% Analysis of data indicated an association between tooth discoloration and gender it was predominant in females (p value < 0.05). In addition, data revealed a correlation between tooth discoloration and dental treatment, as tooth discoloration was significant among participants who had received dental treatment (p value < 0.05). DISCUSSION 74% Anterior segment Posterior segment Variable locations The color of the tooth is very important for a visually appealing smile an aesthetically pleasant smile plays a key role in a person s interactive communication skills. There are several designing treatments to make a smile more attractive, such as correction of dental proportions and the arrangement of different elements: teeth, gingiva, lips and face. The findings of the study suggest that less than half the respondents (42.8%) believed they suffered from some kind of tooth discoloration. In addition, the study showed that from the perspective of the participants, their habits (such as drinking coffee, tea, different soft drinks and smoking) were the most common cause of tooth discoloration. The results affirm what has been cited in literature: (i) external discoloration is the major variable that controls and affects the color of the tooth; and (ii) individuals habits are the most common factor behind this type of discoloration 1, 4, 6. In our survey, the low percentage of tooth staining/discoloration (42.8%) can be directly attributed to the regular and meticulous oral hygiene habits of most participants (94% of the respondents brushed their teeth not less than once per day). The inverse relationship between good oral hygiene and low percentile of tooth discoloration highlights the importance of home tooth brushing (in terms of quality and frequency) as an important measure to minimize tooth discoloration 7. In our study, we did not find any case of amelogenesis imperfecta or dentinogenesis imperfecta as a cause of intrinsic or even internalized tooth discoloration. The prevalence of amelogenesis imperfecta ranges from 1 14,000 to 1 7,000 8 ; therefore, it is very clear that we did not find any case as our sample size was very small at 250 (which is considered one of the major pitfalls in our work). However, in our study, we found that the most common cause of internalized tooth discoloration was the dental material used in dental procedures by dentists. Our results affirm what is there in literature: tooth discoloration can follow dental treatment 8. Of the 107 participants that confirmed tooth discoloration, 18% (the highest proportion) stated the presence of a brownishyellow stain, which may be due to their habits and diet preferences such as consumption of soft drinks 1, 4. The second type was white patches observed by 10.4% participants in one or more teeth. White patches/ spots are caused by several etiological factors. One of these could be associated with initial caries, defined as the initiation of a cavity by the demineralization of the tooth structure 9. Our study revealed that a major section of participants who admitted tooth discoloration did not suffer from any kind of pain. Usually most people refrain from visiting the dentist until a symptom emerges such as pain or a strong feeling of uneasiness. This may explain why most participants did not go for a treatment for tooth discoloration. However, the two most relevant treatments (going by the percentage of respondents), as observed in our study, were office bleaching (7.9%) and home 134
PREVALENCE AND FACTORS ASSOCIATED WITH TOOTH bleaching (5.7%). Clearly, the desire to enhance their tooth/teeth appearance had driven the participants for these treatments. Our study did not indicate any clear association between different variables and tooth discoloration; the only correlations that emerged were those with gender and with dental treatments. We believe this could be due to the small size of the sample to establish several strong associations, the sample should be large in size 10. CONCLUSION In summary, the aim of this study was to determine the prevalence and the most common causes of tooth discoloration among students of GMU, and investigate any association between tooth discoloration and different variables such as students habits, socio-demographic characteristics or dental and medical history. More than half the participants (57%) considered their tooth color to be normal, while 42.8% believed they had some sort of tooth discoloration. Students habits and dental treatment emerged as the most common causes of tooth discoloration (external discoloration). The most common color was brownish-yellow. The study also proved the correlation between tooth discoloration and gender as well as history of dental treatment (p value < 0.05). REFERENCES 1. Manuel ST, Abhishek P, Kundabala M. Etiology of tooth discoloration- a review. Nigerian Dental Journal. 2010 Dec;18(2):56 63. 2. Balic A, Thesleff I. Tissue Interactions Regulating Tooth Development and Renewal. Curr Top Dev Biol. 2015;115:157 86. 3. Nanci A. Ten Cate s oral histology: development, structure, and function. 7th ed. St. Louis: Mosby Elsevier; 2008. 4. Watts A, Addy M. Tooth discolouration and staining: a review of the literature. Br Dent J. 2001;190(6):309 16. 5. Eriksen HM, Nordbø H. Extrinsic discoloration of teeth. J Clin Periodontol. 1978;5(4):229 36. 6. Sulieman M. An overview of tooth discoloration: extrinsic, intrinsic and internalized stains. Dent Update. 2005;32(8):463 4, 466 8, 471. 7. Ghassemi A, Hooper W, Vorwerk L, Patel V, Sheth J. Clinical Study to Assess the Stain Removal Effectiveness of a Tooth Whitening Regimen with Added Whitening Booster. J Clin Dent. 2015;26(3):76 9. 8. Bäckman B, Holm AK. Amelogenesis imperfecta: prevalence and incidence in a northern Swedish county. Community Dent Oral Epidemiol. 1986;14(1):43 7. 9. Żyła T, Kawala B, Antoszewska-Smith J, Kawala M. Black stain and dental caries: a review of the literature. Biomed Res Int. 2015;2015:469392. 10. Hong EP, Park JW. Sample size and statistical power calculation in genetic association studies. Genomics Inform. 2012;10(2):117 22. 135