Lin et al.

Asian Pac J Dent 2018; 18: 21-28

Erosive tooth wear and its related risk factors among Myanmar
residents in Japan
Wa Than Lin, BDS, PhD (1), Kaung Myat Thwin, BDS, PhD (2), Takashi Zaitsu, DDS,
PhD (2), Yuichi Kitasako, DDS, PhD (1,3), Junji Tagami, DDS, PhD (1), and Yoko
Kawaguchi, DDS, PhD (2)(1) Department of Cariology and Operative Dentistry, Graduate School of Medical and Dental Sciences,
Tokyo Medical and Dental University, (2) Department of Oral Health Promotion, Graduate School of
Medical and Dental Sciences, Tokyo Medical and Dental University, and (3) Dental Clinic, Ministry ofForeign Affairs, Tokyo, Japan
Purpose: The aim of this study was to assess oral health status and erosive tooth wear with related risk factors
among Myanmar residents in Japan.
Materials and Methods: One hundred and five Myanmar volunteers who aged 20-64-year-old participated inthis study. A cross-sectional epidemiological survey including a structured questionnaire and clinical oral
examination was conducted in Tokyo, Japan in 2018.
Results: The prevalence of dental caries and periodontal disease of all participants were 68.5% and 82.9%,
respectively. About two-third of participants (68.6%) had higher erosive scores (score 2-3). A significant
difference was observed in missing teeth (p = 0.049) and erosive score (p = 0.001) by length of stay in Japan.
Maxillary anterior teeth were most commonly affected by dental erosion, while the most severe erosive status
was found only in mandibular posterior teeth. The participants who took pickled foods (p = 0.048), lime (p =0.028), vinegar drinks (p < 0.001), and citrus juices (p = 0.003) almost every day were significantly higher
erosive scores. Frequent consumption of acidic drinks was significantly related with dental erosion (p = 0.004).
There were significant differences in heartburn (p = 0.024) and gastroesophageal reflux (p < 0.001) by erosivescore. The participants who brushed their teeth with soft texture of toothbrush showed a significant lower erosive
wear (p = 0.027).
Conclusion: Erosive tooth wear is a public health issue among Myanmar residents in Japan. Expansion ofawareness on erosive tooth wear and dietary counselling would be necessary to improve the condition.
(Asian Pac J Dent 2018; 18: 21-28.)
Key Words: erosion, Myanmar, risk factor, wear

Introduction
Oral health is an essential part for people’s general health and quality of life as it is considered to contributegeneral as well as social well-being and not merely absence of disease [1]. Dental erosion, recently recognized as
one of the common oral health problems, can be defined as the chronic, pathologic, irreversible loss of dental
hard tissue due to the exposure of intrinsic and extrinsic acids without any bacteria involvement [2]. It is often
widespread and may involve the entire dentition. This chemical wear process is almost always complicated byother forms of tooth wear such as attrition and/or abrasion [3]. Clinically, those dental hard tissue loss in
combined with mechanical wear can be referred to as erosive tooth wear (ETW) [4,5]. The etiology of erosive
tooth wear is multifactorial and complex with chemical, biological and behavior factors in its process. Its
prevalence seems to be trending higher in recent decades and became a globally growing concern due toincreased consumption of acidic soft drinks together with life style and behavioral changes [6,7].
Many studies concerned with dental erosion have been performed worldwide, showed as a high prevalence
especially in developed countries [8]. The reported prevalence of dental erosion varies greatly in the literature,
which can be partially explained as differences by age, gender, country, types of teeth and frequent consumptionof acidic drinks and foods [9-13]. Many studies were performed in European countries, but a few studies in
Asian countries were noted [14].

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Studies on oral health status and behaviors changes of foreign residents has become focus of attention as the
migrants or immigrants constitute substantial portion of population in many countries [15]. Myanmar, one of thedeveloping countries, which is in transition period and Myanmar people are trying to develop in each and every
sector. Nowadays, there are many Myanmar migrants who are working or studying abroad in other countries
especially in developed countries.
There was an increasing trend of Myanmar migrants in Japan, which accounts for nearly 15,000 people in2016 [16]. As studying or working aboard is quite difficult to settle in daily life, and the migrants may also beaffected by many stressful barriers. Therefore, they would change their life style and also eating behaviors.
Modernization associated with life style changes including dietary habits might result an impact on individual’s
oral health and also increased rate of erosive wear as their frequent consumption of acidic foods and drinks [9].
Therefore, to know the impacts for changing life style to oral health situation of migrant adults, the aim of thisstudy was to assess oral health status and erosive tooth wear with related risk factors among Myanmar residents
in Japan.

Materials and Methods
Subjects
A cross-sectional study was performed in Tokyo, Japan in April, 2018. The subjects were Myanmar people whocame to charity dental consultation of Myanmar Family Clinic & Garden (MFCG) group. A total of 105
volunteer participants who aged 20-64-year-old (male 59, female 46) were included after a sign on writtenconsent form. Data was collected with two parts; a structured questionnaire and a clinical oral examination.
Questionnaire survey
The participants were asked to answer a structured questionnaire, inquiring about socio-demographic
characteristics (gender, age, occupation, educational level, length of stay in Japan and health insurance status),
consumption of acidic foods (grape fruit, orange, apple, pickled foods, lime, tamarind) and acidic drinks(carbonated soft drinks, sport drinks, vinegar drinks, fermented dairy juices, citrus juice, wine), drinking habitsof acidic drinks (frequency of acidic drinks, drinking habits before sleep), symptoms of gastric disease(heartburn, gastroesophageal reflux, repeated vomiting), and oral hygiene behaviors (texture of tooth brush,
brushing pressure). The participants answered frequency for consumption of acidic drinks and foods by selecting
one choice; ‘almost every day: 5 or more days per week’, ‘sometimes: 1 to 4 days per week’ or ‘never’.
Clinical oral examination
All trained examiners were calibrated with a principal investigator before the study. The inter-examiner
reliability was performed using Kappa statistics > 0.79. A clinical oral examination was performed with aregistered dentist and a recorder by using a dental mirror, a WHO-CPI probe and a handheld light. Dentition
status was assessed with DMFT index score based on WHO criteria for dental caries. Periodontal status wasevaluated using a WHO-CPI probe with the Community Periodontal Index (CPI) score [17]. The six index teeth
were probed and the highest score was recorded.
The ETW was examined with the Basic Erosive Wear Examination (BEWE) index [18], which has fourscores; score 0: no surface loss, score 1: initial loss of enamel surface texture, score 2*: distinct defect, hardtissue loss < 50% of the surface area, and score 3*: hard tissue loss ≥ 50% of the surface (*dentine can involve).
The buccal/labial, lingual/palatal, and occlusal/incisal surfaces of each tooth except third molars were examined

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and the surface with highest score was noted. Then BEWE sum score was calculated by adding scores of all
sextants for risk level assessment (sum score 0-2: no risk, sum score 3-8: low risk, sum score 9-13: medium risk,
and sum score14-18: high risk).
Statistical analysis
Descriptive statistics were computed mean or percentages of variables. Chi-square test for categorical data and
ANOVA test for continuous data were used for analysis of the associations between variables. The statisticalanalysis was performed by using the Statistical Package for Social Sciences (SPSS 18.0, IBM, Chicago, IL,
USA). The level of statistical significance for all tests were set at p < 0.05.
Ethical approval
This study was approved by the Ethical Committee of Human Research of Tokyo Medical and Dental University(Approval No. D2016-097) and also permitted by the Embassy of Republic of the Union of Myanmar, Tokyo,
Japan.

Results
A total of 105 participants were included with mean age of 29.4 ± 8.4 years (minimum age 20 years, maximum
age 64 years). Nearly half of participants (46.7%) came to Japan for work (25.7% for part-time and 21.0% for
full-time), 43.8% came to Japan for study, and 9.5% had no work or were dependent. About 89.5% ofparticipants were university education level, only 10.5% were high school education level. More than half ofparticipants (53.3%) stayed in Japan for 2 years or less while 46.7% were more than 2 years. Most participants(80.0%) were covered by Japanese public health insurance.
Table 1 shows oral health status including erosive tooth wear in mean BEWE score of Myanmar people bylength of stay in Japan. Overall caries prevalence of all participants was 68.5% with mean DMFT of 2.40 ± 2.60.
Decay teeth (1.30 ± 1.83) was the major component of DMFT, followed by filled teeth (0.86 ± 1.79) and missing
teeth (0.25 ± 0.58). The prevalence of periodontal disease (CPI code ≥ 1) was 82.9% in the present study. About
two-third of participants (68.6%) had higher BEWE scores (score 2 and score 3), but 31.4% of participants had
ETW with initial loss of surface texture on their teeth (score 1). A significant difference was observed in missing
teeth (p = 0.049) and mean BEWE score (p = 0.001) by length of stay in Japan. There were no significant
differences in dentition status, periodontal disease and mean BEWE score by age or gender.
Table 1 Oral health status of Myanmar residents in Japan

Caries prevalence (%)
DT (mean ± SD)
MT (mean ± SD)
FT (mean ± SD)
DMFT (mean ± SD)
Periodontal disease (%) (CPI code ≥ 1)
Mean BEWE score (%)
Score 0Score 1
Score 2
Score 3Total
(n = 105)68.5
1.30 ± 1.83
0.25 ± 0.58
0.86 ± 1.79
2.40 ± 2.60
82.9

Length of stay in Japan≤2 years (n = 56)>2 years (n = 49)
62.5
75.5
1.29 ± 2.04
1.31 ± 1.58
0.14 ± 0.40
0.37 ± 0.73
0.62 ± 1.56
1.12 ± 2.01
2.05 ± 2.65
2.80 ± 2.53
85.7
79.6

0.0
31.4
67.6
1.0

0.0
46.4
51.8
1.8

23

0.0
14.3
85.7
0.0

p-value
0.152
0.955
0.049
0.157
0.146
0.406
0.001

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Fig. 1 Distribution of erosive tooth wear by teeth sextants
Table 2 Erosive tooth wear and types of acidic foods and drinks
Total
Erosive tooth wear, n (%)(n = 105)
mean BEWE score 0-1 (n = 33)
mean BEWE score 2-3 (n = 72)
Grape fruit
Almost everyday
10 (9.5)
3 (9.1)7 (9.7)
Sometimes
72 (68.6)
22 (66.7)
50 (69.4)
Never
23 (21.9)
8 (24.2)
15 (20.8)
OrangeAlmost everyday
5 (4.8)2 (6.1)3 (4.2)
Sometimes
83 (79.0)
25 (75.8)
58 (80.6)
Never
17 (16.2)
6 (18.2)
11 (15.3)
Apple
Almost everyday
6 (5.7)
1 (3.0)5 (6.9)Sometimes
85 (81.0)
29 (87.9)
56 (77.8)
Never
14 (13.3)
3 (9.1)
11 (15.3)
Pickled foods
Almost everyday
21 (20.0)
3 (9.1)18 (25.0)
Sometimes
62 (59.0)
24 (72.7)
38 (52.8)
Never
22 (21.0)
6 (18.2)
16 (22.2)
Lime
Almost everyday
25 (23.8)
3 (9.1)22 (30.6)
Sometimes
66 (62.9)
22 (66.7)
44 (61.1)
Never
14 (13.3)
8 (24.2)
6 (8.3)
Tamarind
Almost everyday
5 (4.8)1 (3.0)4 (5.6)
Sometimes
63 (60.0)
18 (54.6)
45 (62.5)
Never
37 (35.2)
14 (42.4)
23 (31.9)
Carbonated soft drinks
Almost everyday
24 (22.9)
7 (21.2)
17 (23.6)
Sometimes
64 (61.0)
22 (66.7)
42 (58.3)
Never
17 (16.2)
4 (12.1)
13 (18.1)
Sport drinks
Almost everyday
12 (11.4)
3 (9.1)9 (12.5)
Sometimes
62 (59.0)
18 (54.5)
44 (61.1)
Never
31 (29.5)
12 (36.4)
19 (26.4)
Vinegar drinks
Almost everyday
23 (21.9)
2 (6.1)21 (29.2)
Sometimes
56 (53.3)
6 (18.1)
50 (69.4)
Never
26 (24.8)
25 (75.8)
1 (1.4)
Fermented dairy juices
Almost everyday
11 (10.5)
3 (9.1)8 (11.1)
Sometimes
78 (74.3)
24 (72.7)
54 (75.0)
Never
16 (15.2)
6 (18.2)
10 (13.9)
Citrus juices
Almost everyday
21 (20.0)
4 (12.1)
17 (23.6)
Sometimes
76 (72.4)
23 (69.7)
53 (73.6)
Never
8 (7.6)6 (18.2)2 (2.8)Wine
Almost everyday
5 (4.8)2 (6.1)3 (4.2)
Sometimes
45 (42.9)
12 (36.4)
33 (45.8)
Never
55 (52.4)
19 (57.6)
36 (5.0)24

p-value

0.925

0.838

0.463

0.048

0.028

0.536

0.668

0.56

<0.001

0.828

0.003

0.64

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Table 3 Erosive tooth wear and related risk factors
Total(n = 105)
Acidic drinks per day
Three times and above
1-2 times
Never
Drinking habits before sleep
Almost everyday
Sometimes
Never
Heartburn≥ once a week
≥ twice a month
Never
Gastroesophageal reflux≥ once a week
≥ twice a month
Never
Repeated vomiting≥ once a week
≥ twice a month
Never
Texture of tooth brush
Hard
MediumSoft
Brushing pressure
Hard
MediumSoft

Erosive tooth wear, n (%)
mean BEWE score 0-1 (n = 33) mean BEWE score 2-3 (n = 72)

p-value29 (27.6)
70 (66.7)
6 (5.7)8 (24.2)
20 (60.6)
5 (15.2)

21 (29.2)
50 (69.4)
1 (1.4)0.004

7 (6.7)25 (23.8)
73 (69.5)

2 (6.1)9 (27.3)
22 (66.6)

5 (6.9)16 (22.2)
51 (70.9)

0.85

2 (1.9)13 (12.4)
90 (85.7)

0 (0.0)1 (3.0)32 (97.0)

2 (2.8)12 (16.7)
58 (80.5)

0.024

15 (14.3)
36 (34.3)
54 (51.4)

2 (6.1)24 (72.7)
7 (21.2)

13 (18.1)
12 (16.7)
47 (65.2)<0.0010 (0.0)5 (4.8)100 (95.2)

0 (0.0)3 (9.1)30 (90.9)

0 (0.0)2 (2.8)70 (97.2)

0.281

10 (9.5)
83 (79.1)
12 (11.4)

2 (6.1)24 (72.7)
7 (21.2)

8 (11.2)
59 (81.9)
5 (6.9)0.027

12 (11.4)
87 (82.9)5 (4.7)3 (9.1)27 (81.8)
3 (9.1)9 (12.5)
61 (84.7)
2 (2.8)0.342

Maxillary anterior teeth were most commonly affected by dental erosion, followed by mandibular anterior
teeth, while maxillary posterior teeth were least affected. BEWE score 1 was highest prevalence in all sextants
but the most severe erosive status (BEWE score 3) was found only in mandibular posterior teeth (Fig. 1).
According to BEWE guideline, 76 participants (72.4%) were low risk of ETW (BEWE sum score 3-8), and21.0% of them (n = 22) were medium risk (BEWE sum score 9-13). Only seven participants (6.7%) were no risk
(BEWE sum score 0-2), while no participant was high risk (BEWE sum score 14-18).
There were significant differences in association between consumption of some acidic foods and drinks withrespect to ETW (Table 2). The participants who took pickled foods (p = 0.048), lime (p = 0.028), vinegar drinks(p < 0.001), and citrus juices (p = 0.003) almost every day showed significantly higher mean BEWE scores(score 2-3) in this study.
Table 3 shows the ETW with related risk factors by mean BEWE score. About two-thirds of participants(66.7%) took acidic drinks 1-2 times per day. The participants with frequent consumption of acidic drinks per
day had a significantly higher ETW than those without (p = 0.004). Most participants had never experience on
symptoms of heartburn (85.7%), gastroesophageal reflux (51.4%), and repeated vomiting (95.2%). There weresignificant differences in heartburn (p = 0.024) and gastroesophageal reflux (p < 0.001), but no significant
difference was found in repeated vomiting by mean BEWE score. Most participants used medium texture of
tooth brush (79.1%) with medium brushing pressure (82.9%). The participants who brushed their teeth with soft
texture of toothbrush showed a significant lower mean BEWE score in the present study (p = 0.027).

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Asian Pac J Dent 2018; 18: 21-28

Discussion
A pervious study reported oral health status and oral health care barriers for Myanmar residents in Japan [15],but available data regarding erosive wear is still lacking. This is the first study to investigate ETW with its
related factors and risk levels for Myanmar residents in Japan. Although there are many indices to investigate,
there is no universal method to access erosive tooth wear [19]. In this study, BEWE index was used as it wasdeveloped with simple system for scoring not only to access the severity but also to guide for management of thelesions [18]. The prevalence of erosive wear with BEWE score 2 and 3 of Myanmar residents in Japan was 69%,
which apparently higher than that of Japanese people (26%) [10]. Further, hard tissue loss by erosive wear (score
2 and 3) were significantly predominant in participants who stayed in Japan more than 2 years. These might bedue to changing food culture and eating habits after migration [20], with adoption of some specific food items
like vinegar drinks which has high potential to develop erosive wear [12], and increased consumption of acidic
soft drinks accompanying with their stressful lives.
The present study approved the previous reports, which frequent consumption of acidic drinks per day wasstrongly related to develop ETW and increase wear progression [11,12,21,22]. This could be due to mineral loss
from enamel surface increased with continuous acidic attack and subsequent softening of enamel which prone topredispose erosive tooth wear [23]. Pickled foods, lime, vinegar drinks and citrus juices were significantly
associated with high ETW scores. Pickled foods and lime in the form of juice are widely used in cuisine andsalad in Myanmar, but not popular in Japan. On the other hand, vinegar drinks are rarely used in Myanmar
though increasingly use in Japan [10]. Some participants might be changed their food culture after migration, orothers seem to be already experienced erosive wear before coming to Japan and these wear process became
progression as food culture changes after they arrived at Japan.
Participants with symptoms of heartburn and gastroesophageal reflux are significantly related with higher
tooth wear scores in the present study. Regurgitation of gastric contents are main intrinsic source of acids, also a
causative factor of ETW [21]. Gastric juice consists mainly of hydrochloric acid, produced by the parietal cells
in the stomach. The presence of the highly acidic gastric juice (pH 1.0-3.0) in the oral cavity may lead to dental
erosion [22]. Frequent gastric regurgitation in patients with symptoms of gastroesophageal reflux and heartburnwere increased risk indicators for dental erosive wear [12].
Regular oral hygiene care is important for removal of dental plaque and control of plaque related oral diseases[24]. On the other hand, texture of tooth brush is considered to be predisposing factor for tooth wear process[22,25]. Tooth brush with texture of hard or medium bristles was a significant risk factor in the present study,
which was similar with a previous report [26]. Therefore, mechanical wear together with chemical wear process
could be proved to produce more progression of ETW.
The distribution of erosive lesions showed a highest prevalence in maxillary anterior teeth which was in linewith previous findings [9,13,27]. The possible reason is that these teeth have exposed to oral environment for
longer period than other teeth, thus being more susceptible to negative effects of the acid challenges. Moreover,those teeth were poorly bathed in saliva whereas limited saliva flow tends to inadequate buffering [13]. BEWE
score 3 was found only in mandibular posterior teeth in the present study. It could be explained that increased
occlusal force in molars in addition with acidic attack might lead to severe ETW in these regions. Over one-fifthof participants was in medium risk level according to BEWE guideline which indicates that the specific

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etiological factors (intrinsic or extrinsic origin or combination of both) were needed to identify in addition todietary advice with close monitoring.
In the present study, caries prevalence of participants was 69% with mean DMFT of 2.40, and the prevalenceof periodontal disease was 83%. Since caries experience and periodontal status were high, these findings
revealed that Myanmar residents in Japan can’t access adequate oral care even though most participants involved
in health insurance system, which was similar to previous report [15]. Several reasons for limited access to oral
care of Myanmar residents in Japan are considered. First, language barrier could be a significant limitation foraccessing adequate oral care. Second, lack of familiarity with seeking oral care and health care system of thecountry would be a considerable barrier. Third, time arrangement to get necessary oral health services would be
difficult as more than 90% of participants were engaged in work or study in this study.
There were some limitations in the present study. First, we collected a small convenient sample in Tokyo thus
the sample could not be generalized to all Myanmar residents in Japan. Second, we didn’t record the distributionof erosive wear in each tooth level and tooth surface level in this study. Therefore, further cross-sectional andlongitudinal studies should be needed with more details ETW status in future. Third, we have no information
about their oral health status before coming to Japan. So, we could not compare oral health status including
ETW of participants before and after coming to Japan. Nevertheless, this cross-sectional study could provide theuseful information about erosive wear and could aid in conducting further epidemiological studies. It was foundas a public health issue among Myanmar residents in Japan. Therefore, it is important to provide expansion ofawareness on erosive tooth wear and dietary counselling in particular with avoidance of frequent consumption ofacidic foods and drinks.
Acknowledgments
The authors acknowledge to Myanmar Family Clinic & Garden (MFCG) voluntary group and Myanmar dentists in Japan for
their contribution and support for this study. We are also grateful to Myanmar Embassy, Japan for allowing andrecommending perform this study in Myanmar people.

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Correspondence to:Dr. Kaung Myat Thwin
Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences,
Tokyo Medical and Dental University
1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8549, Japan
Fax: +81-3-5803-0194 E-mail: neko1189@gmail.com
Accepted October 31, 2018.
Copyright ©2018 by the Asian Pacific Journal of Dentistry.
Online ISSN 2185-3487, Print ISSN 2185-3479

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