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Year : 2019  |  Volume : 30  |  Issue : 2  |  Page : 200-206
The relationship between overweight/obesity and dental erosion among a group of Saudi children and adolescents

1 Department of Dental, Prince Sultan Military Medical City, Riyadh, KSA
2 Department of Pediatric Dentistry and Orthodontics, College of Dentistry, King Saud University, Riyadh, KSA
3 Department of Surgery, College of Medicine, King Saud University, Riyadh, KSA

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Date of Web Publication29-May-2019


Background: As childhood obesity is emerging in Saudi children and adolescents with high prevalence, it is considered as one of the major public health concerns. Therefore, it has been studied in relation to other diseases as a cause factor. Aim: The aim of this study is to investigate whether childhood obesity is a risk indicator for dental erosion and to obtain information on dietary habits that are related to dental erosion in overweight/obesity in a group of Saudi children and adolescents. Study Design: The study involved 370 children of both genders aged 4-18 years. The convenient sample included 190 overweight/obese children attending obesity clinic and 180 controls. Materials and Methods: Body mass index (BMI) (kg/m2) was calculated and BMI percentile obtained based on the age- and sex-specific according to the Centers for Disease Control chart (normal 5th to <85th percentile, overweight 85th to <95th percentile, and obese ≥95th percentile). Dental examination and questionnaire were carried out by one calibrated and trained examiner on these children using the UK Children's Dental Health Survey Classification for dental erosion. Results: The prevalence of dental erosion was more significant in the study group (8.42%) than the normal group (2.78%). Its severity was higher in the form of loss of enamel surface characterization in the study group (86.36%) compared to controls (13.64%). Carbonated drinks that were taken at night and drinks that were taken at night and drunk without a straw showed higher prevalence of dental erosion (33.3% and 10.3%) in overweight/obese participants. Conclusions: Dental erosion can be regarded as a risk indicator of childhood obesity in the form of loss of enamel surface characterization. Efforts should be taken to reduce carbonated drinks intake and to change the method of drinking erosive potential drinks among overweight/obese children.

Keywords: Adolescents, children, dental erosion, obesity, overweight

How to cite this article:
Jastaniyah N, Al-Majed I, Alqahtani A. The relationship between overweight/obesity and dental erosion among a group of Saudi children and adolescents. Indian J Dent Res 2019;30:200-6

How to cite this URL:
Jastaniyah N, Al-Majed I, Alqahtani A. The relationship between overweight/obesity and dental erosion among a group of Saudi children and adolescents. Indian J Dent Res [serial online] 2019 [cited 2023 Feb 3];30:200-6. Available from:

   Introduction Top

Childhood overweight and obesity are accurately defined by age- and gender-specific body mass index (BMI) ≥85th to <95th percentile and BMI ≥95th percentile, respectively.[1] The prevalence of overweight and obese children and adolescents is rapidly increasing in many countries around the world.[2] The American Academy of Pediatrics, Committee on Nutrition,[3] indicated that overweight and obesity are currently the most common medical conditions of childhood.

Recently, many developing countries have shown rapid economic developments and massive changes in dietary intake and habitual physical activity. Accordingly, these lifestyle-related changes contributed significantly to the increased prevalence of obesity[2] by influencing the quality and quantity of food intake and predisposing people to sedentary life.[4] One of these countries which have witnessed these massive changes during the last two decades is Saudi Arabia (SA).[5] Several studies on the prevalence of obesity among Saudi children and adolescents have been published and results revealed increasing ratios.[4],[5],[6] A nationwide study from SA included a sample of 12,701 children and adolescents 1–18 years of age (6281 boys and 6420 girls) concluded that the overall prevalence of overweight was 10.7% and 12.7% and that of obesity was about 6% and 6.8% in the boys and girls, respectively.[4]

Dental erosion has been defined as the irresolvable loss of dental hard tissue caused by chemical process that does not involve bacteria.[7] The associated factors that attribute to dental erosion have been divided into extrinsic, intrinsic, or idiopathic factors.[8] They include dietary factors[9],[10] salivary factors,[11] occupational environment,[12] systemic diseases,[13] medication,[11],[14] quality of dental hard tissue,[8] oral hygiene habits,[15] other factors as gender,[13],[16] and socioeconomic patterns.[9],[16]

At present, a single epidemiological study on dental erosion in SA was carried out by Al-Majed et al.[10] on 354 boys aged 5–6 years and 862 boys aged 12–14 years in Riyadh, in which pronounced dental erosion (into dentine or dentine and pulp) was observed in 34% of 5–6-year-olds and 26% of 12–14-year-olds. When the dental examination and questionnaire results were correlated, a statistically significant relationship was found between the number of primary maxillary incisors with the pronounced erosion of their palatal surfaces and the consumption of carbonated soft drinks at night. In addition, a significant relationship was also found between the number of permanent maxillary incisors with pronounced erosion on their palatal surfaces and the frequency of drinks at night, as well as the duration of drinks retained in the mouth. It was concluded that dental erosion is common in the primary and permanent dentitions of Saudi Arabian boys.

Childhood obesity has been associated with the frequent servings of energy-dense foods[17] and sweetened drinks ingested each day.[18] Although many studies[9],[10] have investigated the relationship between dietary history and dental erosion, up-to-date, only one study has been published evaluating the relationship between erosive tooth wear and childhood obesity,[19] the authors found that there was no significant relationship between the “at risk for overweight” and the “overweight” groups and they were considered almost similar to the “healthy weight” group.

As childhood obesity is emerging in Saudi children and adolescents with high prevalence, it is considered as one of the major public health concerns. Therefore, it has been studied in relation to other diseases as a cause factor.[20] However, up-to-date; there is no previous study in SA that evaluated the correlation between childhood obesity and dental erosion. For this reason, the current study aimed:

  1. To investigate whether childhood overweight/obesity is a risk indicator of dental erosion among a group of Saudi children and adolescents in Riyadh, SA
  2. To obtain information on dietary habits and its relation to dental erosion in overweight/obese group of Saudi children and adolescents.

   Materials and Methods Top

Ethical approval

Ethical approval was obtained before the commencement of the study from King Saud University, College of Dentistry Research Center (CDRC) Riyadh, SA, with NF 2193.

Sample selection and distribution

The study involved 370 children of both gender aged (4–18 years). The sample of these children was a convenience sample where the children were selected from these two groups as follows:

  1. Control group – 180 randomly selected, Saudi children with no history of significant medical problems such as gastrointestinal diseases (gastroesophageal reflux) attending national campaigns at shopping malls and summer camps organized by the Obesity Research Chair, King Khalid University Hospital, Riyadh, SA
  2. Overweight/obesity group – 190 Saudi children attended the pediatric obesity clinics at King Khalid University Hospital, Riyadh, SA.

Inclusion and exclusion criteria

The study included the following:

  • Boys or girls aged 4–18 years
  • Children who were citizens of SA
  • Children with BMI percentile ≥5th percentile.

The study excluded the entire participants who do not fulfill the above criteria.

Sample size and study power

The estimated sample size was based on specific criteria:

  • The power of the study was set at 80%, alpha was set at 5%
  • From the literature review, the percentage of dental erosion in the Saudi children was about 30%
  • It was assumed that the difference in percentage of dental diseases between normal group and overweight/obese group is 15% which means that the percentage of the dental problems in overweight/obesity group is 45%
  • According to these calculations, the sample size was estimated to be 176 for each group by STATA® software version-10, STATA Software, (Texas, USA).

Data collection

  • Ethical approval was obtained before the commencement of the study from CDRC with NF 2193
  • In addition, a written informed consent was obtained from the parents or guardians who accompany the children explaining the aim, importance, and methods of the study and requesting their consent to the children's participation
  • General information was recorded including: name, age, and gender, the age been considered in years by subtraction of the date of birth from the date of examination.
  • Following that, the child weight and height were taken and BMI (weight/height in kg/m2) was calculated. The child's accurate height was taken to the nearest “0.5 mm” and weight to the nearest “0.1 kg” with the participant in light cloth and without shoes. The weighing scale used was an electronic digital scale “Seca® 703 column scale” (made in Germany) which was placed on a hard, level uncarpeted floor. The scale was calibrated daily before weighing any participant. Both height and weight were measured by a well-trained assistant. The BMI percentile was obtained based on the age- and sex-specific Centers for Disease Control and Prevention chart. The participant was considered as normal when the observed BMI for gender and age percentile is 5th to <85th percent, overweight when the percentile is 85th to <95th and obese when >95th percentile.[1]
  • After that, the child was guided for dental assessment. While doing dental examination which included (dental caries decayed-extracted-filled teeth [deft/DMFT]), dental trauma (UK Children's Dental Health Survey Classification of dental trauma), dental erosion (UK Children's Dental Health Survey Classification for dental erosion), and oral hygiene (modified Massler and Schour rate dental cleanliness), one of the parents was filling the questionnaire regarding dental erosion and diet pertinent to dental erosion.


  • Questions that correlated to dental erosion were adopted from Al-Majed[21] who designed the National Diet and Nutrition Survey[22]
  • All the questions were multiple choices and they were in Arabic language
  • After filling the questionnaire, the parent was interviewed to validate the data by dental researchers.

Dental examination

All the participants were examined by the same researcher who was undergoing extensive training and exercise in using of the indices and the data were recorded by a well-trained assistant. The child was examined lying on a semi-reclined preadjusted mattress chair with a headrest together with a headlight source (Rayovac SPHLTLED-B Sportsman LED Headlight®) using a sterilized disposable mouth mirror, dental probe, gloves, and cotton wool rolls.

Dental erosion

The dental erosion was assessed for the labial and palatal surfaces of the maxillary incisors as well as the occlusal surfaces of first molars. These surfaces were examined for loss of surface enamel characteristics and/or exposure of dentin or pulp without involving the incisal edge using the modified Smith and Knight index by O'Brien[23] according to the following criteria shown in [Table 1].
Table 1: UK Children's Dental Health Survey classification of dental erosion

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Reproducibility of the diagnosis

To assess the reproducibility of the diagnostic criteria, 18 participants were reexamined. The clinical examination was undertaken without informing the examiner at the end of the examination session.

Statistical analysis

This study was comparing between two groups: Overweight and obese children as one group and the control as the other group. Using SPSS® (Statistical Package for the Social Sciences) version-17, descriptive statistics were first performed to all demographic and outcome variables. Pearson Chi-Square and Fisher's exact tests were used. They were two-sided and the significance level was set at 0.05. In addition, proportional t-test in MINITAB® statistical program version-14 was used to test proportional response variables and the significance level was set at 0.05. Intra-examiner reliability was measured using Cronbach's alpha test in continuous responses, while Cohen's kappa test was used in noncontinuous responses.

   Results Top

Sample characteristics

All the participants (370) who participated were examined and filled the questionnaire. The sample demographics are demonstrated in [Table 2] and [Table 3]. The participants fell within 4 to 18 age ranges. The mean age was 11.09 standard deviation [SD] ±3.29 in the overweight/obese group and 9.63 SD ± 3.74 in the controls with similar gender distribution between the two groups.
Table 2: Characteristics of participants included in the study (continuous variables)

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Table 3: Characteristics of participants included in the study (categorical variables)

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Reproducibility of the diagnosis

Intra-examiner agreements were carried out on 18 participants, nine of them were overweight/obese children and the other nine were controls. Diagnostic reproducibility was assessed for height by Cronbach's alpha test and was found to be 0.98. In addition, Cohen's kappa was used to assess the diagnostic reproducibility of dental erosion and was calculated at 1.00.

Relationship between childhood obesity and dental erosion

It was found that the overall overweight/obese children had dental erosion more than controls (P = 0.019). The data showed more dental erosion in mixed dentition than primary or permanent dentition even though there was no statistical significance. When it comes to gender, it was found that the overweight/obese males were higher than normal males (P = 0.034). Regarding the parents' education and socioeconomic status, no difference had been shown [Table 4].
Table 4: Relationship between childhood obesity and dental erosion through type of dentation, gender, and socioeconomic status

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Using the questionnaire with the dental examination, various confounding factors that may attribute to the dental erosion showed significant differences. Starting with the dietary factors, carbonated drinks taken at night and drinks taken at night and drunk without a straw showed higher prevalence of dental erosion in overweight/obese participants (P = 0.013 and 0.013, respectively). On the other hand, drinks taken at night and drunk straight away showed high significance in the study group (P = 0.042) [Table 5]. Furthermore, the overweight/obese group who had dental erosion was not drinking low-calorie soft drinks (P = 0.004).
Table 5: Relationship between childhood obesity and dental erosion through erosive potential of drinks taken at night

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In contrast to the potentially erosive drinks, potentially erosive food taken at night had no erosive effect in the study sample. Likewise, no relation had been found between both groups in dental erosion through some of its related diseases as (asthma, prolonged colds, prolonged sore throats, frequent bouts of heartburn, indigestion, or an acid taste in the mouth, frequent bouts of vomiting). In addition, frequency of teeth brushing with fluoridated toothpaste showed no difference.

On the other hand, the severity of dental erosion was measured and found that the erosion into enamel (loss of surface characterization) was highly significant (P = 0.000) in the study group, erosion into enamel and dentin was similar between the two groups and no erosion into the pulp had been found [Table 6].
Table 6: Severity of dental erosion in relation to childhood obesity

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   Discussion Top

SA has undergone huge changes in lifestyle, including dietary habits and physical activity patterns, resulting in increased prevalence of obesity. Multiple studies worldwide have documented the relationship of obesity and several aspects of oral health as periodontitis, xerostomia, dental caries, and many more. However, these studies are lacking in SA, necessitating the conduct of the current study.

In the present study, although there was a significant difference in the mean age between the study group and the controls, this did not translate to oral health condition difference as the mean age for both groups fell within one type of dentation (mixed dentition).

Furthermore, there was a difference between males and females within each group, but no difference was found between the study group and the controls, and this was not considered significant factor as the comparison was between groups and not within the group. The possible reason of the data shift toward the female gender in the study group, could be because more overweight/obese female children came to the clinic seeking treatment than male children.[4]

All the 370 participants who participated filled the questionnaire and had been examined. They were interested in having such dental examination and having some advices about their dental health.

To provide a measure of reliability, a portion (5%) of the participants were reexamined. The outcome of the reproducibility calculations for the height using Cronbach's alpha test was excellent (.98), and for dental erosion, diagnosis was excellent (1.0) using Cohen's kappa test.

The dental erosion prevalence in the current study was (8.4%) which is lower than that found by Al-Majed et al.[10] (30%). Although the same index was used (UK National Survey of Children's Dental Health Index), this huge difference may be referred to the large sample size that had been studied previously (1216 children) or due to the misdiagnosis of dental erosion with dental caries.[24] From the literature review of dental caries experience in SA, it was found that, in the last decade in a national study carried out by Al-Shammery,[25] the mean DMFT (decayed, missing, and filled scores) was approximately 2.69 in Riyadh children aged 12–13 years, while Al-Dosari et al.[26] found that the mean DMFT at the same age group in Riyadh region had been increased to 5.06. Thus, the increased DMFT may explain the conflict in the diagnosis of dental erosion. In our study, no significant difference was found in deft/DMFT between overweight/obese children and controls. The caries experience was more prevalent with a significant difference in the normal group (96.1%) compared to the overweight/obese group (88.9%).

In this study, it was found that dental erosion prevalence was significantly higher in the study group. When relating dental erosion to BMI, McGuire et al.[19] found in a part of the National Health and Nutrition Examination Survey (NHANES 2003-2004) that the overweight and obese children had increased odds of having erosive tooth wear compared to healthy weight children, although this relation was not significant. They also found that 46% of (1962) children aged 13–19 years had some evidence of dental erosion. Regardless the sample size and the different methodology, these dissimilar results could be due to regional variation. Compared to normal males, overweight/obese males were significantly found to have dental erosion which is similar to many studies that found male children had greater dental erosion than female children.[19],[22] The type of dentition, parents' education, and socioeconomic status did not show any difference between both groups as such relation was inconsistent in many previous studies.[9],[13],[16],[21]

Although the dental erosion in relation to diet and other confounding factors in relation to childhood obesity had not been studied yet, the current study findings showed that dental erosion was more significant in overweight/obese children who drank carbonated soft drinks at night and without using a straw. These finding are supported by many studies which had related dental erosion to the diet.[10],[27],[28],[29],[30],[31] In contrast, dental erosion was more in the study group who drank night drinks straight away which disagreed with Al-Majed et al.[10] and Edwards et al.[27] Regarding, the potential erosive foods that are taken at night, illnesses that are related to dental erosion and frequency of teeth brushing, no significant difference was found which is in agreement with Al-Majed et al.[10] The limitations of the study was that it was carried on a convenience sample from an obesity clinic. The questionnaire and dietary data were self-reporting and could have participant recall bias. The causal relationships cannot be established and the observed association could be as a result of other unexplored factors.

   Conclusions Top

It was clear that dental erosion can be regarded as a risk indicator of childhood obesity in the form of loss of enamel surface characterization. Efforts should be taken to reduce carbonated drinks intake and to change the method of drinking potentially erosive drinks among overweight/obese children. Further investigations are needed to consider other factors that may play a role in dental erosion as this is a multifactorial disease. There is also the need to conduct a longitudinal countrywide study to identify the particular relationship between childhood obesity and dental erosion.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Correspondence Address:
Dr. Nahla Jastaniyah
Department of Dental, Prince Sultan Military Medical City, Riyadh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_774_17

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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