Knowledge, Awareness, and Attitudes towards Tooth Wear among Adult Patients who Visit the University of Ghana Dental School Clinic

1. INTRODUCTION

Tooth wear is an essential aspect of oral health that has become an area of concern [1]. It was described by Liu and colleagues [2] as a loss of hard tooth tissue with no occurrence of dental caries or trauma. Queensland Health also stated that tooth wear is an irreversible (irreparable) loss of tooth structure that often impairs effective tooth functioning [3]. This indicates that tooth wear promotes ineffective tooth functioning and introduces oral cavity restrictions, which, in turn, impact the quality of an individual's oral health. Chan and colleagues also asserted that tooth wear could become a problem, causing pain and affecting the functioning and aesthetics of the teeth [4]. Patients with tooth wear commonly have visible changes in the appearance of their teeth, pain, or sensitivity, which can also affect their masticatory function and lead to loss of occlusal vertical dimension [5], and in severe cases, it can have a range of effects on dentofacial morphology [6].

Tooth wear may be considered physiological or pathological [7], with a physiological process evident with aging, while a pathological process is described as “unacceptable levels of progressive wear” [7]. As a physiological process, tooth wear affects the enamel, dentin, and nerves as well as the blood vessels of the tooth [1]. Kaidonis also stated that physiologically, tooth wear is associated with friction between teeth in close contact, with this friction as a major cause [8].

Pathological tooth wear may result in a change in the appearance of the teeth, considered abnormal with respect to the age of the patient. That is, referring to the condition in which the teeth become severely worn such that their appearance is significantly damaged before they are lost, resulting in ineffective functioning of the teeth [9]. Pathological forms of tooth wear are often referred to as Abrasion, Attrition, Erosion, or Abfraction [9], and it is sometimes hard to determine the type of tooth wear present since the different types often occur together [3, 10]. Notably, Abrasion, Attrition, and Erosion are universally accepted, while Abfraction is not accepted by all [3]. According to Addy, Sellis, and colleagues, clinical and experimental studies demonstrate that individual tooth wear types rarely exist alone and often interact with each other [1, 11].

Contemporary discussions and attitudes towards tooth wear and its preventive measures are obviously attributed to contributing factors such as age, sex, education, and ethnicity. We have an aging population and a projection of an increase in life expectancy among those who remain dentate. On the other end of the dental spectrum, there is a large younger generation with a relatively high level of tooth wear due to lifestyle changes [12]. Epidemiologic studies by Lee reported an increase in the prevalence of tooth wear, while general dental practitioners also observed numerous dental patients with complications from worn teeth [13]. These cases indicate that tooth wear is common in dentistry. However, major attention has not been dedicated to this phenomenon until recent lifestyle changes highlighted its significance. The best treatment for tooth wear is prevention, which requires ensuring that the individual has a good level of knowledge and awareness of factors that promote and reduce tooth wear, as well as demonstrating a proper attitude towards reducing tooth wear. Abdullah stated that knowledge regarding tooth wear is essential for modifying oral health-related behaviours [14].

It is evident that numerous publications on dental management and the prevention of tooth wear exist regarding various etiologies; however, knowledge, aware-ness, and understanding of the pathogenesis of tooth wear are quite inadequate. In Ghana, to the best of the authors’ knowledge, no literature or detailed reports on tooth wear exist, resulting in an information gap. The rise in cases of tooth wear highlights the importance of undertaking this study to examine people’s knowledge, awareness, and certain practices that predispose them to early or extensive tooth wear. This study will create an avenue for educating the population and help in developing suitable preventive programs for patient safety.

2. METHODOLOGY

A non-probability sampling method was chosen for this study [15]. This involved using a quantitative research design [16], with a descriptive cross-sectional study approach [17]. The study population targeted the patients who visited the University of Ghana Dental School Clinic. A sample size of 100 was used to represent patients attending the University of Ghana Dental School Clinic. A consecutive sampling procedure was used to obtain participants for the study. Data were collected from participants primarily through closed-ended questionnaires. The questionnaire captured sociodemographic information, knowledge of tooth wear, awareness of tooth wear, and attitudes towards abrasion, attrition, and erosion. The recruitment period for this study was from when ethical approval was granted on 29th March 2023 to 29th June 2023. Data were accessed for research purposes from 30th June 2023 to 30th September 2023.

3. RESULTS

Table 1 below indicates the demographic characteristics of the participants. There were an equal number of males and females (50% each). The age distribution of the participants was grouped into five categories: 18 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, and 61 years and above. The study’s findings indicated that three-fifths of the participants were between the ages of 31 and 60 years. The highest age distribution was between 31 and 40 years, with a percentage of 26% (n = 26), implying that the majority of the participants were in this age group. The least age distribution of the participants was 61 years and above (n = 11). The majority of the participants were Ghanaians and had blue-collar jobs, with just a few foreigners. Nearly half of the participants had tertiary education, followed by secondary/technical education, which accounted for about a third, and then primary education, which constituted 17%.

3.4. Attitude towards Erosion

In Table 5, the majority of the participants (43%) took carbonated or alcoholic drinks occasionally, a few of the participants (13%) rarely took carbonated or alcoholic drinks, while a small number (7%) took these drinks daily. A few participants (4%) consumed citrus fruits daily, while most of the participants took citrus fruits either weekly or occasionally. More than half of the participants (56%) consumed acidic bedtime drinks and foods after tooth brushing whenever they felt hungry.

Table 5.

Variable	Frequency	Percentage (100%)
1. How frequently participants drank carbonated or alcoholic drinks
a. Daily	7	7
b. Weekly	35	35
c. Occasionally	43	43
d. Rarely	13	13
e. Never	2	2
2. How many times did participants consume citrus fruits	-	-
a. Daily	4	4
b. Weekly	47	47
c. Occasionally	46	46
d. Rarely	6	6
e. Never	0	0
3. How frequently participants took acidic bedtime drinks and foods after tooth brushing
a. Daily	0	0
b. Weekly	41	41
c. Whenever I feel hungry	56	56
d. Never	3	3
4. How frequently participants vomited	-	-
a. Not Often	10	10
b. Sometimes after taking in meals.	23	23
c. Only when Sick	67	67
d. Never	0	0
5. Participants who experienced heartburn or indigestion
a. Yes, I normally do	45	45
b. No, I don’t	15	15
c. Sometimes I do	40	40
6. How often do participants who experienced heartburn or indigestion
a. Always after eating	22	22
b. Sometimes after eating certain foods	25	25
c. Occasionally	23	38
d. Whenever I am sick	15	15
e. Rarely	0	0

In terms of how frequently participants vomited, a few of them (10%) indicated that they do not vomit often, while the majority of the participants (67%) indicated that they vomited only when sick. Finally, as it is established that heartburn and indigestion cause tooth wear, many of the participants (45%) normally experienced it, while 40% experienced it sometimes. About a quarter (25%) experienced it after eating certain foods, 23% experienced it occasionally, and 15% experienced it whenever they were sick.

Table 6 compared the level of knowledge, awareness, and attitudes towards tooth wear across various age groups, genders, and education levels. For respondents between the ages of 18–30, 31–40, and 41–50, the majority (76.5%, 84.6%, and 50%) had low knowledge of tooth wear, while those between 51–60 had a larger proportion of participants (37.5%) with moderate knowledge. Those aged 61 and above were evenly split, with 36.4% having both high and low levels of knowledge of tooth wear. Regarding the level of awareness of tooth wear, respondents between ages 18–30, 31–40, 41–50, 51–60, and 61+ (64.7%, 69.2%, 72.8%, 70.3%, and 72.7%) had a high level of awareness of tooth wear, respectively. An overwhelming majority of respondents aged 18–30, 31–40, 41–50, 51–60, and 61+ (70.6%, 92.3%, 90.9%, 95.8%, and 81.8%) had a high level of attitude towards tooth wear, respectively.

Table 6.

Association between Age and Knowledge of Tooth Wear
Variable	Level of Knowledge			X2	p-value
Age(years)	High N (%)	Moderate N (%)	Low N (%)
18-30	3(17.6)	1(5.9)	13(76.5)	21.597	0.006 *P ≤ 0.05
31-40	2(7.7)	2(7.7)	22(84.6)
41-50	6(27.3)	5(22.7)	11(50)
51-60	8(33.3)	9(37.5)	7(29.2)
61+	4(36.4)	3(27.2)	4(36.4)
Association between age and awareness of tooth wear
-	Level of awareness			-	-
18-30	11(64.7)	3(17.6)	3(17.6)	2.657	0.954 *P ≤ 0.05
31-40	18(69.2)	3(11.5)	5(19.2)
41-50	16(72.7)	4(18.2)	2(9)
51-60	17(70.8)	5(20.8)	2(8.3)
61+	8(72.7)	2(18.2)	1(9)
Association between age and attitude towards tooth wear
-	Level of Attitude			-	-
	Positive N (%)	Negative N (%)
18-30	12(70.6)	5(29.4)		7.306	0.121 *P ≤ 0.05
31-40	24(92.3)	2(7.7)
41-50	20(90.9)	2(9.1)
51-60	23(95.8)	1(4.2)
61+	9(81.8)	2(18.2)
Association between gender and knowledge of tooth wear
Variable	Level of knowledge			X2	p-value
Gender	High N (%)	Moderate N (%)	Low N (%)
Male	10(20)	9(18)	31(62)	1.030	0.598 *P ≤ 0.05
Female	13(26)	11(22)	26(52)
Association between gender and awareness of tooth wear
-	Level of awareness			-	-
Male	33(66)	8(16)	9(18)	2.210	0.331 *P ≤ 0.05
Female	37(74)	9(18)	4(8)
Association between gender and attitude towards tooth wear
-	Level of Attitude			-	-
	Positive N (%)	Negative N (%)
Male	42(84)	8(16)		1.515	0.218 *P ≤ 0.05
Female	46(92)	4(8)
Association between level of education and knowledge of tooth wear
Variable	Level of knowledge			-	-
Education Level	High N (%)	Moderate N (%)	Low N (%)	-	-
Primary	0	2(11.8)	15(88.2)	12.741	0.012 *P ≤ 0.05
Secondary	6(17.6)	7(20.6)	21(61.8)
Tertiary	17(34.7)	11(22.4)	21(42.8)
Association between level of education and awareness of tooth wear
-	Level of awareness			-	-
Primary	10(58.8)	4(23.5)	3(17.6)	3.215	0.523 *P ≤ 0.05
Secondary	22(64.7)	6(17.6)	6(17.7)
Tertiary	38(77.6)	7(14.3)	4(8.2)
Association between level of education and attitude towards tooth wear
-	Level of Attitude			-	-
	Positive N (%)	Negative N (%)
Primary	11(64.7)	6(35.3)		10.663	0.05 *P ≤ 0.05
Secondary	31(91.2)	3(8.8)
Tertiary	46(93.9)	3(6.1)

The outcome of gender and tooth wear revealed that, out of the 50 participants, each for males and females, more than half (62% and 52%) had poor knowledge of tooth wear. Also, the highest number of participants for males and females had a high level of awareness of tooth wear (66% and 74%). Almost all males and females (84% and 92%) showed positive attitudes towards tooth wear.

The majority of participants had poor knowledge of tooth wear across all educational levels (42.8%, 61.7%, and 88% for tertiary, secondary, and primary education, respectively). Additionally, none of the participants with primary education had a high level of knowledge of tooth wear. Furthermore, numerous participants from the various educational levels had a relatively high level of awareness (58.8%, 64.7%, and 77.6% for primary, secondary, and tertiary education, respectively). For primary, secondary, and tertiary education, almost all the participants (64.7%, 91.2%, and 93.9%) had positive attitudes towards tooth wear.

4. DISCUSSION

Apart from a few, most of the patients who visited the University of Ghana Dental School admitted that they had not heard of tooth wear and lacked knowledge about it. This is consistent with Richards and Al-Ashtal [19, 20], who were of the view that the average individual may not be knowledgeable about tooth wear and its causes. Additionally, they shared sentiments that, including laypersons, there was evidence of a lack of knowledge of dental tooth wear (especially erosion) even among some dentists and dental students. Adequate knowledge about tooth wear is paramount to promote oral health literacy, overall dental health, and the general well-being of the individual [21].

Most patients knew that oral health is as important as general health and that tooth wear may lead to pain and sensitivity. This confirms Gopi Chander and Venkat’s studies, which indicated that patients suffering from tooth wear usually experience changes in the appearance of their teeth, pain or sensitivity, which can also affect their masticatory function and lead to the loss of occlusal vertical dimension [5]. However, about 42% of the patients thought that tooth wear was a form of cavity or tooth decay and did not know that it was an irreversible disease. This means that the patients who visited the University of Ghana Dental School Clinic had misconceptions and inadequate knowledge about tooth wear. This finding is contrary to the definition of tooth wear by Toufique [22] and Mehta [23], who emphasized that tooth wear is an irreversible, non-carious dental problem that leads to the loss of dental hard tissue. Furthermore, Lussi [24] also expressed that tooth wear is one of the most serious dental conditions, increasing the risk of irreversible loss of normal tooth tissue, resulting in reduced oral health and causing certain restrictions in the mouth.

Additionally, the majority of the patients who visited the Dental School Clinic thought that tooth wear was caused by bacteria instead of frequent consumption of acidic foods such as oranges, lemons, carbonated drinks, and alcohol. Only a few of the patients knew that grinding of teeth causes tooth wear; most thought otherwise. Aseri [25] opined that, among other factors, tooth wear is caused by a variety of intrinsic factors such as grinding, excessive vomiting, and gastric reflux, and extrinsic factors such as acidic drinks, fumes, and foods. In Oginni’s study [10], it was revealed that participants who consumed between 6 and 10 oranges per day during the season had erosion, particularly on the anterior surfaces, while Sun [26] expressed that acidic beverages, xerostomia, and inappropriate brushing habits were also identified as risk factors for tooth wear. This is in contrast with a study carried out by Cheng [27], who concluded that excessive intake of soft drinks could cause dental consequences, including dental erosion. The majority also admitted that they vomited only when they were sick and experienced indigestion and heartburn either after eating certain foods, occasionally, or whenever they were sick.

Furthermore, most of the patients knew that holding pins and threads between teeth is also a major cause of tooth wear. This result is consistent with Schlossman [28], whose study revealed that certain habits such as smoking, holding a nail or needle between the teeth, nail biting, tearing of tooth threads, using tooth sticks, and even the use of an ill-fitting clasp or removable denture prosthesis can cause tooth wear, particularly dental abrasion. On the contrary, most of the patients did not know that brushing with a hard-bristle toothbrush, as well as brushing immediately after consuming acidic foods, may worsen tooth wear. The patients assumed it was a good habit to brush after eating food since it is well known that individuals should brush before bed. Oginni [10] investigated certain habits that predispose one to tooth wear and found that brushing technique and toothbrush design were more relevant in causing tooth wear, especially dental abrasion. Litonjua [29] also established that the kind of tooth wear known as cervical abrasion is caused by toothbrushes, toothpastes, and brushing techniques. According to Bartlett and Smith [30], tooth brushing involves hard bristles, the amount of force, frequency of brushing, and the abrasiveness of the toothpaste; hence, an individual could control tooth wear if knowledgeable. It is therefore recommended that patients and individuals be educated about their lifestyle, especially regarding the moderate consumption of acidic foods and proper brushing habits, to promote knowledge and reduce the prevalence of tooth wear. Few of the patients brushed their teeth twice daily; however, the majority of the patients either brushed once a day or occasionally twice a day. The attitude of brushing once a day or occasionally twice a day has opposite effects. Too much brushing, while preventing the development of caries, serves as a risk factor for abrasion. Even though very few of the patients used a combination of toothbrush, paste, and either chewing sticks or sponges, most of the patients used only a toothbrush and fluoride-containing toothpaste. Furthermore, it was encouraging to note that many of the patients used medium or soft-bristled toothbrushes for brushing. Soft-bristle toothbrushes reduce dental abrasion and are recommended to maintain good oral hygiene. Most of the patients brushed within 3 to 5 minutes, while a few brushed for more than 5 minutes. Only 15% of them brushed for the recommended time. This demonstrates that many patients thought brushing their teeth for more than 3 minutes kept the teeth clean; however, this actually promotes dental abrasion. This is consistent with a study by Attin [31], who suggested that more brushing may protect the teeth against dental caries but, at the same time, may cause tooth surface loss. The majority of these participants also either regularly or sometimes bit their nails in an attempt to reduce nail length. Biting the nails with the teeth tends to cause friction between the nails and the teeth, which can cause abrasion. This is consistent with a study carried out by Vyas and Juneja [32, 33], who revealed that nail biting is a habit practiced by many but carries numerous health risks, including attrition of the incisors. It is therefore recommended that people be educated about the adverse effects of biting nails with their teeth and also on the proper techniques for brushing to avoid dental abrasion and promote overall oral health. Additionally, most of the patients sometimes ground or clenched their teeth, whether knowingly or unknowingly. This attitude is a negative behavior that tends to promote attrition.

Almost all of the patients (over 90%) admitted that prevention of tooth wear was better than curing it. They also knew that every individual needed to visit the dentist and attend regular checkups every 6 months. This is in line with Sancheti’s [34] study on the need to visit the dentist. According to Dr. Sancheti, every individual should visit the dentist every six months to prevent not only tooth wear but also other dental issues that may arise. Patients who visited the Dental School Clinic preferred toothpaste that contained fluoride. This indicates that patients knew that using fluoride toothpaste was beneficial to the oral cavity. However, patients did not know that saliva also helps protect the teeth. This is contrary to Holbrook [35], whose study emphasized that saliva plays an important role in the prevention of tooth wear and advised that patients should chew sugar-free gum to encourage saliva flow, especially in patients with xerostomia without any underlying condition [35]. Schneider [36] also asserted that chewing sugar-free gum after eating or drinking stimulates saliva production, which neutralizes acid in the mouth and minimizes the possibility of teeth being decayed or worn away.

There was a significant association between the age of respondents and the level of knowledge of tooth wear. The elderly respondents demonstrated both high and low levels of knowledge of tooth wear. This was contrary to Abdullah’s [14] study, which mentioned that there is no significant association between age and knowledge of tooth wear.

It was established that females had higher knowledge and awareness of tooth wear and positive attitudes towards tooth wear; however, there was no significant association between gender and knowledge, awareness, and attitudes towards tooth wear. This is in contrast with the study carried out by Abdullah [14], who found significant differences in the association between knowledge and practice with the gender of his subjects. This could be due to the limited sample size used compared to the study by Abdullah et al., which included 349 participants.

In this study, all the participants had some level of education. The majority of the participants had either completed secondary or tertiary education, with very few having only primary education. There was a significant association with knowledge and attitude of tooth wear, but no significant relationship with awareness, which is similar to Ibiyemi [37]. This could be because those with higher educational backgrounds were more likely to practice good oral health.

5. LIMITATION

The study was limited to adult patients who visited the university’s clinic; hence, it may not be a true representation of the general population. This limits the generalization of the findings, which may be biased. Recruiting participants, particularly adults, can be difficult. A larger sample size could have been used.

CONCLUSION

Generally, participants’ level of knowledge of tooth wear was quite low. The attitudes towards tooth wear were generally positive, with a significant association between age and the level of knowledge of tooth wear. There was no significant association between gender and knowledge, awareness, or attitudes towards tooth wear. The level of education was seen to have a significant association with knowledge and attitudes towards tooth wear. The study also found that the majority of the participants used the term ‘dental caries’ instead of ‘tooth wear’.

RECOMMENDATION

Overall, these findings highlight the urgent need for mass education on tooth wear in local dialects and, if appropriate, official translations and graphics to be made available to individuals in order to promote their knowledge formally and informally. Dentists should take time to explain to patients what tooth wear is, how it differs from dental caries, and how it can be prevented or its onset delayed. There should be regular tooth wear screenings for adult patients visiting the dental clinic, with follow-up appointments to monitor tooth wear progression and ensure timely interventions, promoting better oral health outcomes.

REFERENCES