 Abstract | | |
Aims: In this study, we aimed at investigating the oral and dental health conditions of Lebanese and Syrian refugees living in proximity to Deir Kanoun Ras El Ain dump whereby its leachates influx into a canal used for irrigation and drinking purposes. Materials and Methods: This observational study involved oral and dental examinations of 589 Lebanese and Syrian Refugees participants living in the three villages: Deir Kanoun Ras El Ain, Klayleh, and Smaiyeh. Differences in oral and dental examination results were analyzed between different villages, sexes, nationalities, and age groups. Correlation tests were conducted between dental fluorosis, staining, papilla swelling, and several sociodemographic factors. Results: Dental fluorosis, staining, and papilla swelling were the most prominent problems among total participants. The highest percentages of individuals with the studied diseases were shown to be in Klayleh village, among females, and individuals aged between 21 and 40 years. Significant associations were observed between dental fluorosis and nationality; between dental staining and gender, nationality, age, and smoking; as well as between papilla swelling and age, smoking, and diabetes. Conclusions: Our study investigated and highlighted the prevalence of several oral and dental diseases among Lebanese and Syrian inhabitants that are related to environmental, social, and economic determinants and not just by individual behaviors. It also showed gaps of oral and dental health knowledge that recommend implementing health systems that focus on preventing oral diseases.
Keywords: Dump, fluorosis, papilla swelling, pollution, staining
How to cite this article:
Borjac J, Badr S, ElJoumaa M, Daas I, Kobeissi R. Oral and dental status of Lebanese and Syrian refugees living in proximity to Deir Kanoun Ras El Ain dump in Lebanon. J Int Soc Prevent Communit Dent 2019;9:409-16 |
How to cite this URL:
Borjac J, Badr S, ElJoumaa M, Daas I, Kobeissi R. Oral and dental status of Lebanese and Syrian refugees living in proximity to Deir Kanoun Ras El Ain dump in Lebanon. J Int Soc Prevent Communit Dent [serial online] 2019 [cited 2022 Oct 6];9:409-16. Available from: https://www.jispcd.org/text.asp?2019/9/4/409/264020 |
| Introduction | |  |
Globally, there is an increased burden of oral and dental diseases in spite of the immense enhancements in the oral health of many populations. The burden of these diseases is influenced by various sociobehavioral risk factors in both developing and developed countries.[1] Oral and dental diseases such as dental fluorosis, staining, pigmentation, erosion, and papilla swelling are common public health problems that have profound effects on the quality of life of individuals in most populations.[2],[3]
Dental fluorosis is a well-documented enamel defect that results from prolonged intake of fluoride during enamel formation.[4] The excessive uptake of fluoride hypomineralizes the tooth, decolorizes it into shades that vary from white to brownish opaque areas, and alters the structure of the tooth enamel, rendering it more susceptible to fracture and wear.[5] The prevalence of mild-to-moderate degrees of dental fluorosis is dependent on the amount of fluoride intake, duration, and age of the exposed individual.[6] Fluorosis occurs when fluoride is ingested in amounts that surpass the permissible level of 0.05–0.07mg/kg/day.[7] As drinking water is a major source of fluoride, the World Health Organization (WHO) recommended a permissible reference value of 1.5mg/L of fluoride in drinking water.[8]
Dental staining or discoloration is an abnormal change in tooth color due to the external accumulation of stains on its surface or to the internal absorption of pigments into its structure.[9] Extrinsic dental staining is commonly caused by dental plaque, foods and beverages, tobacco smoking, bacteria, metals, and some medications, whereas intrinsic dental staining is mainly caused by medications, genetics, diseases, trauma, dental caries, and aging.[10],[11]
Dental erosion is also a form of tooth wear defined as the irreversible loss of tooth substance rendering the enamel thin and giving a dull yellow color to the tooth. This chemical dissolution is caused by acids of nonbacterial sources.[12] The acid that leads to erosive wear could be of intrinsic sources such as stomach acid in gastroesophageal reflux disease, anorexia, and bulimia nervosa, or extrinsic sources such as the consumption of acidic foods and beverages and exposure to chlorinated swimming pool water or to acid fumes/droplets in the work place.[13],[14] Dental erosion is the most prevalent chronic disease that affects children aged between 5 and 17 years.[3]
Papilla swelling or lingual papillitis is the state of inflamed taste buds that line the tongue.[15] There are several causes of inflamed papilla including acid or gastroesophageal reflux, allergies and food sensitivities, mouth burns, bacterial or viral infections possibly due to the lack of oral hygiene, oral cancer, smoking, stress, and iron and vitamin B deficiencies.[15],[16]
These dental and oral problems may be related to the chemical quality of the water consumed by humans.[17] Water is one of the resources affected by human actions and environmental pollution that leave hazardous microorganisms and chemical elements in the body.[18] For example, the exposure to high amounts of iron or iodine can cause substantial black tooth. On the other hand, exposure to sulfide, silver nitrate, or manganese may be associated with gray-yellow or brown-black stains, copper or nickel can cause green stains, and cadmium can produce yellow-brown pigmentations.[17],[19]
The environmental, demographic, and epidemiological transitions that many countries, including Lebanon, have been going through impose an urgent need to search for oral and dental health aspect.[1],[20] In Lebanon, the epidemiological studies that refer to oral and dental health conditions are rare on the national level. According to the WHO, epidemiological, oral, and dental health studies aid in the determination of oral health preventive, curative, and restoring services as well as in treatments in relation to the demands. They also help in determining the needed resources for establishing, maintaining, expanding, or reducing dental care plans and policies.[21]
Lebanon is a Mediterranean country that has been suffering from environmental pollution, particularly water pollution in its many resources.[22],[23] Deir Kanoun harbors one of the worst country dumps of wastes. Leachates from this dump influx into a canal that is used for the irrigation of surrounding agricultural lands and for drinking purposes.[24] Therefore, this study aimed to investigate the oral and dental health conditions of Lebanese and Syrian refugees living in proximity to Deir Kanoun Ras El Ain dump in Lebanon.
| Materials and Methods | | |
Study area
This study area is located in south Lebanon along the Mediterranean coast, specifically in Deir Kanoun Ras El Ain (geographic coordinates 33.222°N, 35.246°E), Klayleh (geographic coordinates 33.198°N, 35.228°E) and Smaiyeh (geographic coordinates 33.221°N, 35.235°E) villages. Deir Kanoun Ras El Ain village has a total number of 3800 Lebanese inhabitants and 451 registered Syrian refugees. Klayleh has a total number of 6000 Lebanese inhabitants and 1300 registered Syrians. Smaiyeh, the smallest village, has a total number of 2000 Lebanese inhabitants and 70 registered Syrians (data obtained from the head of each municipality).
Ethical considerations
This retrospective observational study was conducted in three Lebanese Southern villages: Deir Kanoun Ras El Ain, Klayleh, and Smaiyeh. This study was approved by the institutional review board at Beirut Arab University (Code number 2017H-0026-S-R-0188).
Each subject involved in the study signed an informed consent about her/his approval for enrolling in the study, for undertaking any study-related activities, and for the publication of the results without specifically identifying the subject. Consent of guardians was taken for under-aged participants.
Study subjects
Healthy male and female candidates between 10 and 80 years of age were enrolled representing the three studied villages. The study involved Lebanese participants who were inhabitants of the villages as well as Syrian refugees. At enrolment, personal, demographic, medical history, and further required information were collected in a well-studied questionnaire (available in Supplementary Materials). In addition, each volunteer underwent oral and dental examinations under natural light by a dentist who was properly protected with complete personal protective equipment.[Additional file 1]
Potentially ineligible subjects were excluded if they (1) resided in one of these villages for less than a year and (2) were edentulous. From February 2016 to April 2016, 589 participants met the inclusion criteria and were identified for study enrolment and final analysis.
Statistical analysis
Data analysis was performed with the Statistical Package for Social Sciences (SPSS, version 23.0, SPSS Inc., Chicago, IL) and Microsoft Excel 2010. Study sample characteristics were summarized using simple descriptive statistics (i.e., mean, standard deviation, and percentages). Bivariate correlation test using the Pearson correlation coefficient was performed with P < 0.05 considered significant.
| Results | | |
Demographic data
Five hundred eighty-nine participants were enrolled in this study. [Table 1] shows their distribution according to village, sex, nationality, and age group distribution. | Table 1: Distribution of subjects according to village, sex, nationality, and age group
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Dental health status of all participants
The percentage of total participants with dental fluorosis, staining, pigmentation, papilla swelling, and erosion were 27.85%, 44.15%, 6.5%, 24.8%, and 5.1% respectively [Figure 1]. | Figure 1: Percentage of individuals with dental fluorosis, staining, pigmentation, papilla swelling, and erosion among total individuals involved in the study
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Village-related findings
According to village distribution, the highest percentages of individuals with dental fluorosis, staining, pigmentation, papilla swelling, and erosion were shown to be in Klayleh village followed by Deir Kanoun whereas the least were in Smaiyeh [Figure 2]A. As shown in [Figure 2A], 39.6% of all cases of fluorosis, 42% of all cases of staining, 63.1% of all cases of pigmentation, 37% of all cases of papilla swelling, and 50% of all cases of erosion were shown to be among Klayleh inhabitants. Deir Kanoun village had 39.6% of all cases of fluorosis, 29.6% of all cases of staining, 18.4% of all cases of pigmentation, 34.2% of all cases of papilla swelling, and 50% of all cases of erosion. Smaiyeh village had 20.7% of all cases of fluorosis, 28.4% of all cases of staining, 18.4% of all cases of pigmentation, and 28.7% of all cases of papilla swelling whereas no cases of erosion were recorded. | Figure 2: Percentage of individuals with dental fluorosis, staining, pigmentation, papilla swelling, and erosion in accordance of village (A), sex (B), nationality (C), and different age groups (D)
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Gender-related findings
The highest percentages of cases with dental fluorosis, staining, pigmentation, papilla swelling, and erosion were shown to be among females compared to males. Results indicated that 59.8% of all cases of fluorosis, 52.7% of all cases of staining, 57.9% of all cases of pigmentation, 52.7% of all cases of papilla swelling, and 73.3% of all cases of erosion were females. In contrast, 40.2% of all cases of fluorosis, 47.3% of all cases of staining, 42.1% of all cases of pigmentation, 47.3% of all cases of papilla swelling, and 26.7% of all cases of erosion were males [Figure 2B].
Nationality-related findings
The highest percentages of cases with dental fluorosis, staining, and pigmentation were shown to be among Syrian participants, whereas the highest percentages of cases with papilla swelling and erosion were shown to be among Lebanese participants. Findings revealed that Syrian participants comprised 64.6% of all cases of fluorosis, 56.2% of all cases of staining, and 63.2% of all cases of pigmentation. On the other hand, Lebanese participants comprised 57.5% of all cases of papilla swelling and 66.6% of all cases of erosion [Figure 2C].
Age-related findings
[Figure 2D] shows the percentages of individuals with dental fluorosis, staining, pigmentation, papilla swelling, and erosion among different age groups. It is shown that the highest percentages of cases with dental fluorosis (44%), staining (41.5%), and pigmentation (60.5%) were shown to be among individuals aged between 21 and 40 years. Moreover, the highest percentages of cases with papilla swelling (39%) and erosion (63.3%) were shown to be among individuals aged between 41 and 60 years.
Correlation between dental fluorosis and some sociodemographic factors
The correlations between dental staining and some sociodemographic factors were assessed in a correlation matrix using the Pearson correlation coefficient. The correlation matrix that assesses the variance of dental staining, village, sex, nationality, and age is illustrated in [Table 2]. Results show a significant positive correlation between dental fluorosis and nationality (r = 0.269, P < 0.01) only. | Table 2: Correlation matrix between dental fluorosis and some sociodemographic factors
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Correlation between dental staining and some sociodemographic factors
The correlations between dental staining and some sociodemographic factors were assessed in a correlation matrix using the Pearson correlation coefficient. [Table 3] shows the correlation matrix that evaluates the variance of dental staining, village, sex, nationality, age, pregnancy, and smoking in relationship with each others. The association between dental staining and sociodemographic factors such as sex (r = 0.121, P < 0.01), nationality (r = 0.23, P < 0.01), age (r = 0.212, P < 0.01), and smoking (r = 0.087, P < 0.05) indicates a significant positive correlation between these factors. | Table 3: Correlation matrix between dental staining and some sociodemographic factors
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Correlation between papilla swelling and some sociodemographic factors
The associations between papilla swelling and some sociodemographic factors were evaluated a correlation matrix as shown in [Table 4]. This correlation matrix showed a significant positive correlation between papilla swelling and sociodemographic factors including age (r = 0.252, P < 0.01), smoking (r = 0.139, P < 0.01), and diabetes (r = 0.106, P < 0.05). | Table 4: Correlation matrix between papilla swelling and some sociodemographic factors
Click here to view |
| Discussion | | |
This study provided knowledge of the oral and dental health profiles among Lebanese inhabitants and Syrian refugees residing in Deir Kanoun Ras El Ain, Klayleh, and Smaiyeh villages. To the best of our knowledge, this is the first study in Lebanon that uses a randomized sample of subjects with different nationalities, age groups, and sexes. In fact, randomized samples represent an important contribution for the comprehension of the oral health–disease process among populations rather than other national studies that focus on specific groups and restrict to convenience samples such as health center and institutionalized subjects.[25] In Lebanon, very few regional studies were held using convenience samples: Diab et al.[26] assessed the oral health status of institutionalized individuals with intellectual disabilities living in Mount Lebanon, whereas Doumit et al.[27] assessed the prevalence of dental caries and fluorosis among Lebanese children in 18 towns.
This study focused on few oral and dental problems namely dental fluorosis, staining, pigmentation, papilla swelling, and erosion. Results showed that dental fluorosis, staining, and papilla swelling were the most prominent problems among total participants. However, few participants showed dental pigmentation and erosion. According to village distribution, Klayleh village had the highest percentages of individuals with dental fluorosis, staining, pigmentation, papilla swelling, and erosion.
Dental fluorosis, staining, pigmentation, papilla swelling, and erosion are well-documented oral problems that occur in different populations. Fluorosis is caused by excess intake of fluoride that could be from different sources including drinking water,[28] vegetables and fruits grown in soils irrigated with fluorinated water or supplied with fertilizer and pesticides, fish, and dental products.[29],[30] Our findings are consistent with several studies where human populations in countries such as China,[31] India,[32] Iran,[33] Libya,[34] Turkey,[35] Saudi Arabia,[36] Algeria,[37] and Jordan[38] have been reported to be suffering from dental fluorosis due to the consumption of fluoride-enriched water and food.
In addition, a study that could be considered similar in relation to the prevalence of extrinsic stains was conducted by Rebelo de Sousa et al.[17] in Brazil. This study showed that there was low prevalence of extrinsic stains, being found mainly in children and adolescents.[17] Another study by Alkhatib et al.[39] assessing the prevalence of tooth discoloration in the United Kingdom showed that half the population had mild tooth discoloration whereas only 6% had severe discoloration.[39] Similarly, a study by Xiao et al.[40] assessed the prevalence of tooth discoloration among a Chinese urban population. Their results showed that tooth discoloration is common among the Chinese where 48.9% of the enrolled individuals with some tooth discoloration.[40]
Moreover, our erosion-related findings are consistent with other population-based studies in countries such as Norway,[41] Brazil,[42] Switzerland,[43] Finland,[44] United Kingdom,[45] Saudi Arabia,[46],[47] and Turkey[48], which have been afflicted with erosion mainly due to the consumption of acidic beverages and foods.
Regarding gender, our results revealed that females had higher percentages of dental fluorosis, staining, pigmentation, papilla swelling, and erosion compared to males. Although some studies showed that females act more positively toward oral health than males,[49],[50] many other studies have shown that the rates of oral and dental problems are higher in females than in males due to several factors that could explain our findings.[51],[52] These factors mainly include hormonal fluctuations during events such as puberty and menstruation, diets, genetic variations, and saliva composition.[51] For example, systemic diseases associated with caries have been shown to be associated with the female gender.[53] Other female-related factors such as earlier eruption of teeth and hence longer exposure to foods and beverages, easier access to foods and frequent eating during food preparation, and pregnancy contribute to poorer oral health than males.[52]
As for nationality, the highest percentages of cases with dental fluorosis, staining, and pigmentation were shown to be among Syrian participants, whereas the highest percentages of cases with papilla swelling and erosion were shown to be among Lebanese participants. These findings could be explained by a wide range of personal, socioeconomic, and environmental factors. It should be noted that Syrian refugees enrolled in this study were of poor income, lower education, and low occupational status as most of them were living in refugee camps that lack basic hygiene. Furthermore, some of the Syrian refugees live near to a canal that runs along Deir Kanoun Ras El Ain dump of wastes and drink from its polluted water, which could be considered as a risk factor for their oral diseases. The correlation between dental health and demographic factors such as age, gender, place of residence, or unfavorable oral health care, as well as unhealthy lifestyles, are well-documented in literature.[54],[55],[56],[57]
On the basis of age groups, our findings revealed that the highest percentages of cases with dental fluorosis, staining, and pigmentation were among individuals aged between 21 and 40 years. Our results are consistent with a study by Johansson et al.,[58] which showed that oral diseases are very common in children and young adults. On the other hand, our results indicated that the highest percentages of cases with erosion were shown to be among individuals aged between 41 and 60 years. Similar findings were obtained by Jaeggi and Lussi[43] who showed that erosion was observed in 29.9% of the young (26–30 years) and 42.6% of the old (46–50 years) participants.
We went further to investigate the correlations between dental fluorosis and sociodemographic factors where results showed a significant positive correlation between dental fluorosis and nationality. Similarly, results indicated that there were significant associations between dental staining and sociodemographic factors such as gender, nationality, age, and smoking. On the basis of the literature, extensive research has been conducted to correlate sociodemographic factors and smoking with dental diseases including staining.[59],[60],[61] Similarly, results showed that there were significant associations between papilla swelling and some sociodemographic factors such as age, smoking, and diabetes. Cigarettes were shown to contain chemicals that cause irritation to the taste buds and thus inflammation and swelling. Also, diabetes has been considered as a risk factor for inflamed and swollen taste buds.[61],[62]
| Conclusion | | |
All in all, health and oral health are affected by environmental, social, and economic determinants, and not just by individual behavior, genetics, and a well-functioning service.[45] Although oral and dental diseases are not life threatening, they are considered as important public health problems due to their high incidence and remarkable effects on general health and high cost of treatment.[63] Our study highlighted the prevalence of several oral and dental diseases among Lebanese and Syrian inhabitants that are related to environmental, social, and economic determinants and not just by individual behaviors.[45] It also showed gaps of oral and dental health knowledge that recommend implementing health systems that focus on preventing oral diseases.
Financial support and sponsorship
US National Academy of Science PEER cycle 5 program [grant number 5-56/AID-OAA-A-11-00012].
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Righolt AJ, Jevdjevic M, Marcenes W, Listl S Global-, regional-, and country-level economic impacts of dental diseases in 2015. J Dent Res 2018;97:501-7.  |
| 2. | Zuo H, Chen L, Kong M, Qiu L, Lü P, Wu P, et al. Toxic effects of fluoride on organisms. Life Sci 2018;198:18-24. |
| 3. | Mulic A, Tveit AB, Hove LH Dental erosion. Arch Oral Biol 2018;96:137-145. |
| 4. | Aimée NR, van Wijk AJ, Maltz M, Varjão MM, Mestrinho HD, Carvalho JC Dental caries, fluorosis, oral health determinants, and quality of life in adolescents. Clin Oral Investig 2017;21:1811-20. |
| 5. | Molina-Frechero N, Nevarez-Rascón M, Nevarez-Rascón A, González-González R, Irigoyen-Camacho M, Sánchez-Pérez L, et al. Impact of dental fluorosis, socioeconomic status and self-perception in adolescents exposed to a high level of fluoride in water. Int J Environ Res Public Health 2017;14:73. |
| 6. | Wiener RC, Shen C, Findley P, Tan X, Sambamoorthi U Dental fluorosis over time: A comparison of national health and nutrition examination survey data from 2001-2002 and 2011-2012. J Dent Hyg 2018;92:23-9. |
| 7. | Burt BA The changing patterns of systemic fluoride intake. J Dent Res 1992;71:1228-37. |
| 8. | World Health Organization. Guidelines for Drinking-Water Quality: Fourth Edition Incorporating the First Addendum. Geneva, Switzerland: WHO; 2017. |
| 9. | Nasreddine S, Sayah F, Kassir F, Doumit M Tooth staining and discoloration: A review of literature. Part I: etiology and classification. Dental News 2015:XXII (IV). |
| 10. | Kapadia Y, Jain V Tooth staining: A review of etiology and treatment modalities. Acta Sci Dent Sci 2018;2:67-70. |
| 11. | Sulieman M An overview of tooth discoloration: Extrinsic, intrinsic and internalized stains. Den Update 2005;32:463-4, 466-8, 471. |
| 12. | Ganss C, Schlueter N Diagnosis of dental erosion. Clin Dent Rev 2017;1:12. |
| 13. | Marshall TA Dietary assessment and counseling for dental erosion. J Am Dent Assoc 2018;149:148-52. |
| 14. | Paryag A, Rafeek R Dental erosion and medical conditions: An overview of aetiology, diagnosis and management. West Indian Med J 2014;63:499-502. |
| 15. | Wang H, Zhou M, Brand J, Huang L Inflammation and taste disorders: Mechanisms in taste buds. Ann N Y Acad Sci 2009;1170:596-603. |
| 16. | Järvinen J, Mikkonen JJ, Kullaa AM Fissured tongue: A sign of tongue edema? Med Hypotheses 2014;82:709-12. |
| 17. | Rebelo de Sousa K, Batista MJ, Rocha Goncalves J, de Sousa Mda L Extrinsic tooth enamel color changes and their relationship with the quality of water consumed. Int J Env Res Public Health 2012;9:3530-9. |
| 18. | Coleman DC, O’Donnell MJ, Shore AC, Russell RJ Biofilm problems in dental unit water systems and its practical control. J Appl Microbiol 2009;106:1424-37. |
| 19. | Schemel-Suárez M, López-López J, Chimenos-Küstner E Dental pigmentation and hemochromatosis: A case report. Quintessence Int 2017;48:155-159. |
| 20. | Paula JS, Meneghim MC, Pereira AC, Mialhe FL Oral health, socio-economic and home environmental factors associated with general and oral-health related quality of life and convergent validity of two instruments. BMC Oral Health 2015;15:26. |
| 21. | Nithila A, Bourgeois D, Barmes DE, Murtomaa H WHO global oral data bank, 1986-96: An overview of oral health surveys at 12 years of age. Bull World Health Organ 1998;76:237-44. |
| 22. | Houri A, El Jeblawi SW Water quality assessment of Lebanese coastal rivers during dry season and pollution load into the Mediterranean sea. J Water Health 2007;5:615-23. |
| 23. | Kouzayha A, Al Ashi A, Al Akoum R, Al Iskandarani M, Budzinski H, Jaber F Occurrence of pesticide residues in Lebanon’s water resources. Bull Environ Contam Toxicol 2013;91:503-9. |
| 24. | Geoflint. Environmental and Social Impact Assessment. Plot Number/765/ Ain Baal, Tyre South Lebanon. Beirut, Lebanon: Geoflint; 2017. Available from www.cdr.gov.lb/study/ESIAAinbaalFinal.pdf |
| 25. | Lamster IB, Myers-Wright N Oral health care in the future: Expansion of the scope of dental practice to improve health. J Dent Educ 2017;81:e83-90. |
| 26. | Diab HA, Salameh Z, Hamadeh GN, Younes G, Ayoub F Oral health status of institutionalized individuals with intellectual disabilities in Lebanon. J Oral Maxillofac Res 2017;8:e4. |
| 27. | Doumit M, Doughan B Dental caries and fluorosis among children in Lebanon. Indian J Dent Res 2018;29:317-22. |
| 28. | Neurath C, Limeback H, Osmunson B, Connett M, Kanter V, Wells CR Dental fluorosis trends in US Oral Health Surveys: 1986 to 2012. JDR Clin Trans Res 2019;2380084419830957:1-11. |
| 29. | Kumar S, Chauhan A, Kumar A, Kumar S, Gupta A, Roy S, et alDental fluorosis and associated risk factors in early adolescents in India. Int J Adolesc Med Health 2018;20170200:1-7. |
| 30. | Martínez-Mier EA, Soto-Rojas AE, Ureña-Cirett JL, Stookey GK, Dunipace AJ Fluoride intake from foods, beverages and dentifrice by children in Mexico. Community Dent Oral Epidemiol 2003;31:221-30. |
| 31. | Wang B, Zheng B, Zhai C, Yu G, Liu X Relationship between fluorine in drinking water and dental health of residents in some large cities in China. Environ Int 2004;30:1067-73. |
| 32. | Plaka K, Ravindra K, Mor S, Gauba K Risk factors and prevalence of dental fluorosis and dental caries in school children of north India. Environ Monit Assess 2017;189:40. |
| 33. | Abtahi M, Dobaradaran S, Jorfi S, Koolivand A, Mohebbi MR, Montazeri A, et al. Age-sex specific and sequela-specific disability-adjusted life years (DALYS) due to dental caries preventable through water fluoridation: An assessment at the national and subnational levels in Iran, 2016. Environ Res 2018;167:372-85. |
| 34. | Suneel-Tejaswi KL, Shetty S, Annapoorna BM, Pujari SC, Sarveshwar-Reddy R, Nandlal B A pioneering study of dental fluorosis in the Libyan population. J Int Oral Health 2013;5:67-72. |
| 35. | Oruc N Occurrence and problems of high fluoride waters in turkey: An overview. Environ Geochem Health 2008;30:315-23. |
| 36. | Siddiqui AA, Al Hobeira H, Mirza AJ, Alshammari AK, Alshammari BA, Alsalwah NH Dental fluorosis in Saudi Arabia: A review of current literature. Ann Int Med Dent Res 2017;3:44. |
| 37. | Messaïtfa A Fluoride contents in groundwaters and the main consumed foods (dates and tea) in Southern Algeria region. Environ Geo 2008;55:377-83. |
| 38. | Hamdan MA The prevalence and severity of dental fluorosis among 12-year-old schoolchildren in Jordan. Int J Paediatr Dent 2003;13:85-92. |
| 39. | Alkhatib MN, Holt R, Bedi R Prevalence of self-assessed tooth discolouration in the United Kingdom. J Dent 2004;32:561-6. |
| 40. | Xiao J, Zhou XD, Zhu WC, Zhang B, Li JY, Xu X The prevalence of tooth discolouration and the self-satisfaction with tooth colour in a Chinese urban population. J Oral Rehabil 2007;34:351-60. |
| 41. | Asmyhr Ø, Grytten J, Holst D Occurrence of risk factors for dental erosion in the population of young adults in Norway. Community Dent Oral Epidemiol 2012;40:425-31. |
| 42. | Luciano LCO, Ferreira MC, Paschoal MA Prevalence and factors associated with dental erosion in individuals aged 12-30 years in a northeastern Brazilian city. Clin Cosmet Investig Dent 2017;9:85-91. |
| 43. | Jaeggi T, Lussi A Prevalence, incidence and distribution of erosion. Monogr Oral Sci 2014;25:55-73. doi:10.1159/000360973. |
| 44. | Järvinen V, Rytömaa I, Meurman JH Location of dental erosion in a referred population. Caries Res 1992;26:391-6. |
| 45. | Daly B, Newton JT, Fares J, Chiu K, Ahmad N, Shirodaria S, et al Dental tooth surface loss and quality of life in university students. Prim Dent Care 2011;18:31-5. |
| 46. | Al-Majed I, Maguire A, Murray JJ Risk factors for dental erosion in 5-6 year old and 12-14 year old boys in Saudi Arabia. Community Dent Oral Epidemiol 2002;30:38-46. |
| 47. | Al-Dlaigan YH, Al-Meedania LA, Anil S The influence of frequently consumed beverages and snacks on dental erosion among preschool children in Saudi Arabia. Nutr J 2017;16:80. |
| 48. | Caglar E, Kargul B, Tanboga I, Lussi A Dental erosion among children in an Istanbul public school. J Dent Child (Chic) 2005;72:5-9. |
| 49. | Hamasha AA, Alshehri A, Alshubaiki A, Alssafi F, Alamam H, Alshunaiber R Gender-specific oral health beliefs and behaviors among adult patients attending King Abdulaziz Medical City in Riyadh. Saudi Dent J 2018;30:226-31. |
| 50. | Al-Ansari JM, Honkala S Gender differences in oral health knowledge and behavior of the health science college students in Kuwait. J Allied Health 2007;36:41-6. |
| 51. | Ferraro M, Vieira AR Explaining gender differences in caries: A multifactorial approach to a multifactorial disease. Int J Dent 2010;2010:649643. |
| 52. | Lukacs JR, Largaespada LL Explaining sex differences in dental caries prevalence: Saliva, hormones, and “life-history” etiologies. Am J Hum Biol 2006;18:540-55. |
| 53. | Errico G, Hunt G, Hunt D Closing the gap: Examining sex differences in oral health. Am J Phy Anthropol 2019; 168:70. |
| 54. | Bahannan S, Eltelety S, Hassan M, Ibrahim S, Amer H, El Meligy O, et al. Oral and dental health status among adolescents with limited access to dental care services in Jeddah. Dentistry J 2018;6:15. |
| 55. | Khandare AL, Gourineni SR, Validandi V Dental fluorosis, nutritional status, kidney damage, and thyroid function along with bone metabolic indicators in school-going children living in fluoride-affected hilly areas of Doda district, Jammu and Kashmir, India. Environ Monit Assess 2017;189:579. |
| 56. | Paulander J, Axelsson P, Lindhe J Association between level of education and oral health status in 35-, 50-, 65- and 75-year-olds. J Clin Periodontol 2003;30:697-704. |
| 57. | Damyanov ND, Witter DJ, Bronkhorst EM, Creugers NH Dental status and associated factors in a dentate adult population in Bulgaria: A cross-sectional survey. Int J Dent 2012;2012:578401. |
| 58. | Johansson AK, Omar R, Carlsson GE, Johansson A Dental erosion and its growing importance in clinical practice: From past to present. Int J Dent 2012;2012:632907. |
| 59. | Ozturk O, Fidanci I, Mustafa UN Effects of smoking on oral cavity. J Exp Clin Med 2017;34:3-7. |
| 60. | Javed F, ALHarthi SS, BinShabaib MS, Gajendra S, Romanos GE, Rahman I Toxicological impact of waterpipe smoking and flavorings in the oral cavity and respiratory system. Inhal Toxicol 2017;29:389-96. |
| 61. | Verhulst M, Loos B, Gerdes V, Teeuw W Evaluating all potential oral complications of diabetes mellitus. Front Endocrinol 2019;10. |
| 62. | Bhandare NN, Keny MS, Nevrekar RP, Bhandare PN Diabetic tongue—could it be a diagnostic criterion? J Family Med Prim Care 2014;3:290-1. |
| 63. | Monajem S Integration of oral health into primary health care: The role of dental hygienists and the WHO stewardship. Int J Dent Hyg 2006;4:47-51. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4] |
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