GOOD

MORNING!
 IS TOOTHWEAR ASSOCIATED WITH
ORAL HEALTH RELATED QUALITY
OF LIFE IN ADULTS IN THE UK?
Patel J and Baker SR. Community Dent Health 2020; 37:174–179

Presentation by:
Dr. B. Aishwarya Lakshmi
Second year Postgraduate
Department of Public Health Dentistry
GDC&H
 INTRODUCTION
• ‘The loss of tooth substance by means other than caries or dental trauma’
Yule PL and Barclay SC. Dental Update 2015; 42:525-532.
DEFINITION OF TOOTH WEAR:
ORCA and Cariology Research Group of IADR
• The cumulative surface loss of mineralized tooth substance due to
physical or chemo-physical processes (dental erosion, attrition,
abrasion).
Schlueter N et al. Caries Res 2020; 54:2-6.
• Toothwear is increasing in prevalence
Kreulen et al. Caries research 2010; 44:151-159.

• Published literature - Toothwear and its management adopts the mechanistic

perspective of the biomedical model of health
Locker and Allen. Community Dent Oral Epidemiol 2007; 35:401-411.
Sischo L and Broder HL. J Dent Res 2011; 90:1264-1270.

• Available literature- concerns the prevention of toothwear and rehabilitation

following toothwear.
Kaidonis JA. Br Dent J 2012; 213:155-161.
Yule PL and Barclay SC. Dent Update 2015; 42:525-532.
Yim VKC. Dent Update 2011; 44:502.
• There have been several attempts to reorient the delivery of healthcare
into a more person-centered process based on the needs of the individual,
particularly with changes introduced following the WHO reclassification
of health.
WHO QoL Group. Soc Sci Med 1995; 41:1403-1409.

• It can be argued that further investigation of the patient experience of

toothwear is essential to improve our understanding of the impact of
toothwear on those affected.
Sischo L and Broder HL. J Dent Res 2011; 90:1264-1270.
WHO QoL Group. Soc Sci Med 1995; 41:1403-1409.
Al-Omiri MK et al. Int J Prosth 2006; 19:601-605.

Vargas-Ferreira F et al. Caries Res 2011; 44:531-539.

Rodriguez JM et al. The lancet 2013; 381:S94.

Andrade F et al. Public Health Nutr 2016; 19:1479-1485.

Abanto J et al. Spec Care Dentist 2014; 34:278-285.

• Few previous studies have provided any detail on statistical power,
and similarly, little detail on the sample’s demographic characteristics
have been given.
• Yet, we know from other oral health conditions that demographic
factors such as socioeconomic position, age and gender can have an
important impact on (oral health) quality of life

Guyatt GH and Cook DJ. JAMA 1994; 272:630-631.

 AIM OF THE STUDY
• To examine the association between different types of toothwear and
OHRQoL in a general population sample; namely the UK Adult Dental
Health Survey which is a representative sample of [6469] people across
England, Northern Ireland and Wales.
• A further aim was to examine whether key demographic factors (age,
gender, socioeconomic status) influenced the relationship between toothwear
and OHRQoL.
 RESEARCH QUESTIONS

(i) Is there an association between different types of

toothwear and OHRQoL?

(ii) Is this association influenced by demographic factors?

 MATERIALS AND METHODS

• Target population – Adults (16 years and older) living in UK

• Sample - Adult Dental Health Survey (ADHS) – 2009
• Sampling technique – Randomised cluster sampling
13,400 Households

13,509 Adults

11,380 (84%
response rate)
1,282
EXCLUDED
6,469 Adults (61%) due to Lack of
toothwear
or OHRQoL data
5,187 Adults

5,175 (ATW)
433 (ETW)
EROSIVE TOOTH WEAR

Bartlett D et al. Clin Oral investig 2008; 12:65-68.

ORAL HEALTH IMPACT PROFILE (OHIP-14)
INDEX OF MULTIPLE
DEPRIVATION

https://en.wikipedia.org/wiki/Multiple_deprivation_index
• Spearman’s Correlation – ATW, ETW and OHRQoL

• Adjusted linear regression model

• Power calculations were carried out using G*Power 3.1.9.2 (Universität

Kiel, Germany) with a specified alpha error of 0.05.

• The required power was 0.80.

• SPSS® version 23 (International Business Machines Corp.)

RESULTS
ENGLAND WALES NORTHERN
IRELAND

• 7.2% • 9% • 5.4%
• Most deprived • Less deprived

Mean IMD = 3.8 to 5%

Age and gender were normally distributed
 Research question 1:
Is there an association between different types of
toothwear and OHRQoL?

• There was a significant positive correlation between ATW and total

OHIP-14 score (r = 0.059, p <0.05) but no significant relationship
between ETW and total OHIP-14 score (r = –0.081, p = 0.091).
• Post-hoc power tests for ATW-OHRQoL and ETW-OHRQoL returned
a power (1-β err prob) of 1.00 and 0.99 respectively.
 Research Question 2:
Is the association between toothwear and OHRQoL
influenced by sociodemographics?
• The incorporation of the demographic variables age, gender and IMD
decile resulted in greater variance in OHIP-14 scores attributable to
ATW and ETW: 0.02% for ATW and ETW (F=14.15, p<0.05).
• Gender, age, and deprivation were all influenced the regression model
(p<0.05), accounting for between 1.2% (age) and 7.0% (gender) of
variation in OHIP-14 scores.
• The post-hoc power test for ATW returned a power (1-β err prob)

of 1.00 and is thus interpreted to achieve the desired statistical

power (within the limits of this post-hoc test), whilst that for ETW

was 0.52, indicating it did not achieve sufficient power.

 DISCUSSION
• A significant positive correlation - linear regression model adjusted
for age, gender and deprivation.
• No significant relationship between ETW and total OHIP14 scores in
bivariate analysis.
• The regression model - relationship between moderate and severe
erosive toothwear and total OHIP14 scores.
• ADHS - Cross-sectional data
• Regression analysis using an adjusted model - severe toothwear only.
• The confidence interval at this point does not cross zero but is wide
(0.76-6.60) suggesting a wide variation in OHIP-14 total scores within
each group.
• Given that statistical power was achieved, this may be an indication that
either mild and moderate ATW did not have a significant relationship
with OHRQoL, or that the measure used (total OHIP-14 score) was not
sufficiently sensitive to differences in OHRQoL associated with ATW.
• Many oral health conditions OHRQoL

• Published literature report varying impacts of oral health conditions, such as

periodontal disease, on OHIP-14 total scores

• Due to variations in methods, it is not possible to compare the difference in

impact between oral health conditions on OHIP-14 total scores directly,

however, these results suggest that tooth loss and periodontal disease may

have greater impacts than tooth wear.

• Toothwear may result in functional limitations in addition to changing
the appearance of teeth.
• In some cases, also result in pain
• The risk of pain may be increased if the severity of wear increases.
Al-Omiri MK et al. Int J Prosth 2006; 19:601-605.
Papagianni CE et al. J Oral Rehab 2013; 40:185-190.

• Furthermore, functional limitations or changes in appearance may

become more noticeable with greater severity.
• This may explain the differences found with different severities of

ATW. It is not clear how and in what way individuals perceive these

differences and in turn, how they translate into self-reported impacts

on oral health-related quality of life.

• Qualitative interviews to explore the dimensions of quality of life
influenced by different severities of toothwear may be appropriate.
Guyatt GH and Cook DJ. JAMA 1994; 272:630-631.

• There was a small significant relationship between moderate and

severe ETW and total OHIP-14 score, but in the opposite direction
to that for ATW.
• The study does not have sufficient power to detect a difference at this
level (i.e. to assess the difference between toothwear severity and total
OHIP-14 score), and this finding may, therefore, be at risk of type 2
error.
• It is not clear why there was a negative relationship between ETW and
total OHIP-14 score. Erosive toothwear may be associated with lower
total OHIP-14 scores (i.e. better OHRQoL).
• One would have expected a positive relationship due to the likelihood

of pain and sensitivity, or due to other factors already described (i.e.

more severe toothwear would result in a higher impact on OHRQoL).

Abanto J et al. Spec Care Dentist 2014; 34:278-285.

• Severe ETW may result in chipping of teeth with marked changes to

the appearance of the visible surface of teeth.

• The differences in the relationship with OHRQoL for ATW and ETW
are interesting and unexpected.
• Possible explanations may be a relative insensitivity of OHIP-14 to
toothwear, or different types of toothwear may have different impacts
on OHRQoL, perhaps due to the pattern and appearance of wear.
• For example, erosive toothwear typically presents as smooth wear
lesions on the palatal surfaces (i.e. be less visible to patients),
whereas in ATW the wear may be more apparent to patients, with an
aesthetic impact.
• It is not possible to ascertain the cause of this difference from these
data, suggesting that qualitative research is necessary to explore
individual experiences of toothwear.
• The present findings indicate that women may experience more
impacts on OHRQoL as a result of toothwear than men.
• Toothwear has anecdotally been reported to be more prevalent in
females.
Cunha-Cruz et al. Community Dent Oral Epidemiol 2010; 38:228-234.
• In this study, greater deprivation was associated with less impact from
toothwear.
• Other studies have reported similar findings for other oral conditions
(such as caries and periodontal disease), and the mechanisms, in this
case, may be similar.
Watt R. Community Dent Oral Epidemiol 2007; 35:1-11.
• Possible mechanisms for this may relate to similar upstream
determinants of health which can influence diet, stress and
occupational amongst other things.
• These can influence both the prevalence of a disease in a population,
but also the impact of the disease on individuals by changing
environmental pressures, access to healthcare, and perceived
availability of service.
• Older participants experienced less severe OHRQoL impacts than
younger groups.
• Toothwear in older individuals may have progressed more slowly and
the effect on OHRQoL may, therefore, be less, given the potential for a
slower progression of toothwear in these groups.
• Toothwear of similar severity in a younger patient may have
progressed more rapidly, and thus may have a greater influence on
OHRQoL.
• Furthermore, the changes experienced here may be different than those
in older individuals due to differences in perceptions related to oral
health between age groups.
Masood M et al. J Dent 2017; 56:78-83.

• Some reports suggest that toothwear may progress more rapidly in

younger individuals due to changes in lifestyle, such as diet
Bartlett D et al. J Dent 2013; 41:1007-1013.
 LIMITATIONS
• The findings - population settings > individuals.
• There was a slight skew towards older age in the sample.
• OHIP-14 total scores appear to have a negative skew (45% had an OHIP-14 total score
of 0).
• This study does not account for other variables that may influence OHRQoL (such as
caries and tooth loss).
• Furthermore, OHIP-14 data has been used to indicate OHRQoL as the most suitable
measure in the ADHS 2009 dataset.
• Whilst this measure has been validated in several studies to measure OHRQoL in different

populations, these studies largely focus on other oral conditions, which may have differing

impacts on daily functioning and experience.

• The use of OHIP14 may fail to identify a relationship between OHRQoL and toothwear

when one exists.

• Generic OHRQoL measures may lack sensitivity to impacts associated with toothwear and

thus a condition-specific measure may be useful to investigate this association further.

Li MHM and Bernabe E. J Dent 2016; 55:48-53.

 CONCLUSION
• Association between toothwear and oral health impacts in daily life.
• At a population level, this association appears small and significant
only for moderate and severe toothwear.
• Further exploration of individual experiences of toothwear is
recommended alongside a more detailed examination of the types of
impacts toothwear has on quality of life.
 MERITS
• Title is meaningful and precise
• Abstract was structured and had an informative and balance summary
• Key words are mentioned
• Article followed IMRAD format
• Introduction followed seminaristic approach
• Background, aim and objectives of the study were mentioned
• Research question was clearly stated
• Study design was mentioned
• Sampling strategy was clearly defined
• Limitations and bias of the study were mentioned
 DEMERITS
• Null hypothesis was not mentioned
• Basis of classification of IMD index was not mentioned
• Coding criteria of ETW were wrong
• 34-44 years age group in table 1 and table 2
• Correlation analysis was not mentioned in a tabulated form
• Results were not clear
• Ethical clearance ???
CROSS-
REFERENCE
S
1. Anterior tooth wear and quality of life in a nursing home population
Al-Allaq T et al. Spec Care Dentist 2018; 38(4):1-4

Al-Allaq T et al assessed the extent to which a relationship may exist between the wear of the
anterior teeth and quality of life among 100 nursing home residents (mean age 75.7 years) in
Ronchester, New York. Inclusion criteria was participants must have at least 4 upper and 4
lower anterior teeth. Data regarding level of tooth wear of each subject according to the Tooth
Wear Index (TWI) of Donachie and Walls (Adapted) and then verbally administered Geriatric
Oral Health Assessment Index (GOHAI) of Atchison and Dolan were obtained. The results
showed that the mean tooth wear score was 2.1 ± 0.9 and the mean GOHAI score was 27.4 ±
7.1. Regression analyses revealed that tooth wear was positively related to age and inversely
related to quality of life. GOHAI score increased with TWI (P-value = 0.0003). Females
tended to have higher GOHAI score than males (P-value = 0.02). The effect of age on the
GOHAI score was not significant (P-value = 0.31). Therefore, the authors suggested that the
tooth wear is negatively related to quality of life.
2. Quality of life and other psychological factors in patients with tooth wear.
Kalsi H et al. Br Dent J 2021:1-5.

Kalsi H et al investigated the relationship between generic and condition-specific (CS) quality of life,
general psychological wellbeing and personality among 102 patients with tooth wear aged 18–70 years in
London. Data was obtained by administering the Oral Impact on Daily Performance (OIDP) quality of life
questionnaire, the NEO-FFI Personality questionnaire and the General Health Questionnaire-12 (GHQ).
Tooth wear was measured with the Basic Erosive Wear Examination (BEWE). Results showed that the
increased BEWE scores were correlated with older age and worse generic and CS-related quality of life.
Mean BEWE score was 12. No significant gender differences were found. Increased GHQ scores were
positively correlated with increased: generic and CS OIDP scores (p <0.05). Multivariable regression
analyses showed that neuroticism score had a statistically significant effect on quality of life when
adjusted for tooth wear severity. Positive correlations were observed between increasing BEWE scores
and generic and CS OIDP scores (p = 0.017 and p = 0.031, respectively), indicating that as tooth wear
severity increased, generic and CS quality of life decreased. . Hence, authors of this study concluded that
the patients with tooth wear had reduced levels of general psychological wellbeing and increased
neuroticism scores which had an independent effect on quality of life, independent of tooth wear severity.
These findings may help explain why different individuals with the same levels of tooth wear experience
differing impacts upon their quality of life.
 REFERENCES
1. Schlueter N, Amaechi BT, Bartlett D, Buzalaf MAR, Carvalho TS, Ganss C et al. Terminology
of Erosive Tooth wear: Consensus report of a workshop organized by the ORCA and the
Cariology Research Group of the IADR. Caries Res 2020; 54:2-6.
2. Kalsi H, Khan A, Bomfim D, Tsakos G, McDonald AV, Rodriguez JM. Quality of life and
other psychological factors in patients with tooth wear. Br Dent J 2021:1-5.
3. Al-Allaq T, Feng C, Saunders RH. Anterior tooth wear and quality of life in a nursing home
population. Spec Care Dentist 2018; 38(4):187-190.
4. https://en.wikipedia.org/wiki/Multiple_deprivation_index
5. http://
doc.ukdataservice.ac.uk/doc/6884/mrdoc/pdf/6884foundation_report_and_technical_informati
on.pdf
6. https://files.digital.nhs.uk/publicationimport/pub09xxx/pub09300/hse2011-all-chapters.pdf
7. Sischo L, Broder HL. Oral health-related quality of life: what, why, how, and future
implications. J Dent Res 2011; 90(11):1264-1270.
8. https://applications.emro.who.int/emhj/1206/12_6_2006_894_901.pdf?ua=1
THANK
YOU!