Evaluation of the relationship between earthquake-induced post-traumatic stress disorder and tooth wear

doi:10.21203/rs.3.rs-4154322/v1

Background: This study aimed to was to evaluate the effects of earthquake-induced post traumatic stress disorder on tooth wear and oral hygiene of individuals.

Method: The study was conducted in a single centre and included 200 patients aged 18-70 years. The gender and age profile of the study participants was balanced. Voluntary consent forms were obtained from the participants and evaluated by a single operator. Post-traumatic Stress Disorder inventory (PTSD), Smith and Knight Tooth Wear Index and Simplified Oral Hygiene Index (OHI-S) were applied during the evaluation. Mann Whitney U test and Pearson Chi-Square Test were used to evaluate the data obtained. Bonferroni Corrected Z Test was applied for multiple comparisons.

Results: In general, tooth wear was observed in all participants. The most common tooth wear surfaces were occlusal and cervical surfaces. The PTSD scores of the group which had experienced an earthquake were higher than those of the group which had not experienced an earthquake. There was no significant correlation between PTSD scores and tooth wear scores (p>0.05). The group with higher PTSD scores and those which had experienced an earthquake had significantly higher OHI-S scores (p<0.001). In the evaluation made according to gender, women's OHI-S scores were higher in the groups which had experienced an earthquake and in the groups who did not experience an earthquake. Individuals over 35 years of age had higher tooth wear scores and OHI-S scores than individuals under 35 years of age (p<0.001).

Conclusion: Psychological stress in patients with post-traumatic stress symptoms was not found to cause direct non-caries wear on tooth surfaces. The high OHI-S scores obtained from the earthquake survivor group indicate that post-earthquake stress and changed lifestyle reduce oral care.

Post-traumatic stress disorder

tooth wear

oral hygiene index

anxiety

Trauma is defined as a situation that occurs as a result of a person being exposed to a threatening life event [1]. People may develop a chronic psychiatric disorder called Post-traumatic stress disorder (PTSD) after trauma. PTSD is defined as a mental illness that leads to deterioration in the social and occupational functionality of the person with symptoms such as re-experiencing for more than one month after the traumatic event, avoidance of stimuli that accompanied the trauma, alienation, and hyperarousal [2]. Major disasters such as war, earthquakes, and floods, which especially affect society, are among the first in the etiology of PTSD [2, 3]. It has been shown that 24-43% of people exposed to traumatic events, especially earthquakes, develop PTSD [4].

Tooth wear can occur as a result of chemical or mechanical causes without microorganisms [5]. Tooth wear can occur as a result of the natural aging process, but can also be exacerbated by the presence of various parafunctional habits such as bruxism, malocclusion, acidic beverage consumption, stress, and similar factors. The irreversible and multifaceted characteristics of the tooth wear process make it one of the most difficult conditions to manage, so early detection of wear is very important. Dentists have associated wear of the occlusal surface with bruxism and have referred to it as a pathological condition [6, 7]. However, it is stated that the wear areas formed due to intensive bruxism may also develop due to a combination of different factors [8]. In many studies, it is stated that the factors causing tooth wear are complex and it would be wrong to state that they are caused by a single mechanism [8, 9]. The clinician should consider all etiological and contributory factors before treatment. The process of tooth wear is irreversible and the multiple causes make it a challenging disease.

Mental and psychological factors may play a role in the causes of tooth wear. Especially in case of distress, stress, and depression, a person may involuntarily direct their attention to their own body [10-12]. Psychiatric disorders may affect eating and drinking habits, oral hygiene habits, and similar conditions along with the tooth wear process. In addition to facial pain in the temporomandibular joint (TMJ) in patients diagnosed with PTSD, intraoral findings such as abfraction, abrasion, tooth fractures, and cracks can be seen [13, 14]. Psychiatric disorders such as PTSD may give indirect or direct findings in the mouth [15]. The evaluation of PTSD symptoms that occur in individuals after major natural disasters such as earthquakes and the effects on teeth in this situation are of interest. In the present study, tooth wear in individuals was determined by using the Smith and Knight tooth wear index. The oral hygiene status of the patients was evaluated with the Simplified Oral Hygiene Index (OHI-S) to better understand the tooth wear and to evaluate the plaque accumulation on the teeth. This study aimed to evaluate the effects of earthquake-induced PTSD on tooth wear and oral hygiene of individuals.

This study is a survey and clinical research study. It was conducted after two earthquakes of magnitude 7.8 and 7.6 occurred in Turkey on 6 February 2023. It was conducted between September and January at Inonu University Faculty of Dentistry.

Participants

A total of 200 people participated in the study. These people were divided into two groups: 100 people who had experienced the 6 February 2023 earthquake in Turkey and 100 people who did not experience an earthquake as a control group. Participants were assessed by a psychiatrist and a dentist. Individuals between the ages of 18-70 years, consisting of men and women, who could read and understand Turkish were included in the study. Patients with at least 20 intact and controllable teeth were included in the study [16]. Being younger than 18 years of age, having mental retardation or cognitive deficit, not having sufficient intellectual ability to read and understand the consent form and scales, having a disease due to a severe general medical condition, and having active psychotic symptoms were determined as exclusion criteria. All participants were informed in detail about the study protocol and their written informed consent was obtained. All examinations were performed by a single operator using air spray, a disposable mirror, and a World Health Organisation (WHO) periodontal probe.

Tests

Participants completed the following tests.

Post Traumatic Stress Disorder Inventory (PTSD)

It was developed to measure the symptoms and severity of PTSD. It was adapted into Turkish by Başoğlu et al. in 2001 [17]. The test consists of 23 items in total. The first 17 items fulfill the PTSD symptoms specified in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). A score of 25 and above on these 17 items indicates probable PTSD. Researchers have pointed out that the types that occur more than 6 months after the traumatic experience are important [18]. In the emergence of PTSD, the nature and severity of the trauma for that individual, the traumatic events he/she experienced before and the conditions he/she lived in after the trauma are the determining factors. The internal consistency coefficient calculated for the scale items aiming to measure post-traumatic stress reactions is 0.92 and the test-retest correlation coefficient of the scale items is 0.83. It was reported that the scale was able to discriminate people diagnosed with PTSD by another criterion at a level of 82% (sensitivity) and 76% (specificity) in undiagnosed people [19]. It has been reported that it has acceptable correlation coefficients with scale scores aiming to measure psychopathology and its criterion-related validity is high.

Smith & Knight Tooth Wear Index

The Tooth Wear Index is another index developed by Smith and Knight in 1984 and is still frequently used in epidemiological studies [20]. This index is the first index designed to measure and monitor multifactorial tooth wear. The index provides a general clinical perspective on the measurement of the amount of wear on all four surfaces of the teeth, regardless of the causative factor. The wears on the teeth were evaluated and recorded by following the protocols described by Smith and Knight (Table 1). In the study, any loss of enamel tissue was scored as 1. Buccal and cervical areas were evaluated separately.

Scores in which the dentin surface was exposed were categorized as 2, 3, and 4 according to severity.

Table 1 Smith and Knight Tooth Wear Index

Score

Surface

Criteria

0

B/L/O/I

C

No loss of enamel surface characteristics.

No loss of contour.

1

B/L/O/I

C

Loss of enamel surface characteristics.

No minimal loss of contour.

2

B/L/O

I

C

Loss of enamel exposing denitne for less than one third of surface.

Loss of enamel just exposing dentine.

Defect less than 1 mm deep.

3

B/L/O

I

C

Loss of enamel exposing denitne for more than one third of surface.

Loss of enamel and substantial loss of dentine.

Defect less than 1-2 mm deep.

4

B/L/O

I

C

Complete enamel loss - pulp exposure - secondary dentin exposure.

Pulp exposure or exposure of secondary dentine.

Defect more than 2 mm - pulp exposure - secondary dentin exposure.

Simplified Oral Hygiene Index (OHI-S)

This test is an index that measures a total of 6 teeth, 4 posterior and 2 anterior. Measurements are made from 4 buccal areas and 2 lingual areas, which are thought to give the best results of plaque and calculus accumulation. It is calculated by averaging the debris index and calculus index, which represent the amount of debris and calculus found on selected tooth surfaces. The scores obtained are categorized as good (0-1.2), moderate (1.3-3.0), and poor (3.1-6.0) [21).

Procedure

Before the study, the volunteer candidates were taken to the waiting room and preliminary information about the study was given. The informed consent form was presented to those who agreed to participate in the study for signature. After the preparations were completed, the volunteer was taken to the examination room and an intraoral examination was performed. The form was filled out by making the necessary markings by the index criteria determined in the Tooth Wear Index. Then, the teeth were examined according to the criteria specified in the Simplified Oral Hygiene Index and the forms were filled in the same way. The Informed Consent Form, PTSD Inventory, Tooth Wear Index, and OHI-S forms were kept in the study file until statistical evaluation.

Demographics

A total of 216 participants were approached for participation in the study. All of them agreed to participate in the study and fill out the forms. 17 participants were excluded from the study because the number of teeth was not sufficient and 9 participants filled out the forms incompletely. The remaining 200 participants consisted of 100 people who had experienced an earthquake and 100 people who did not experience an earthquake.

Statistical Analysis

Data are analysis with IBM SPSS V23. Compliance with normal distribution are analysis by the Kolmogorov-Smirnov Test. Mann Whitney U Test was used to compare variables that did not conform to normal distribution according to binary groups. Pearson Chi-Square Test was used for the comparison of categorical data and multiple comparisons were made with Bonferroni Corrected Z Test. The results of the analyses were presented as frequency (percentage) for categorical variables, mean±standard deviation, and median (minimum-maximum) for quantitative variables. The significance level was taken as p<0.050.

A total of 200 participants were included in the study between September 2023 and January 2024. When the distribution of the participants according to age, gender, and PTSD scores is analysis, it is seen that there is a balanced distribution (Table 2).

Table 2 Age and gender distribution of participants according to groups

Category		Groups		Total Test Statistics p*
		Experienced	Non- experienced	Total Test Statistics p*
Gender	Men	49 (49)	46 (46)	95 (47,5)	0,180	0,671
Gender	Women	51 (51)	54 (54)	105 (52,5)
Age	Under 35 years	52 (52)	51 (51)	103 (51,5)	0,020	0,887
	35 years and over	48 (48)	49 (49)	97 (48,5)
PTSD	<25	57 (57)	65 (65)	122 (61)	1,345	0,245
	25 and over	43 (43)	35 (35)	78 (39)

*Pearson Chi-Square Test

Table 3 Comparison of age, OHI-S, and PTSD values of the groups which had experienced and did not experience an earthquake

	Grup				Total		Test Statistics	p*
	Experienced		Non-experienced		Total
	Mean ± S.deviation	Median (min-max)	Mean ± S.deviation	Median (min-max)	Mean ± S.deviation	Median (min-max)
Age	37,26 ± 14,61	33,5 (18 - 71)	35,55 ± 11,4	34 (18 - 65)	36,41 ± 13,1	34 (18 - 71)	4813,5	0,648
OHI-S	2,38 ± 1,1	2,16 (0,66 - 5,6)	1,4 ± 1,07	1 (0 - 6)	1,89 ± 1,19	1,66 (0 - 6)	2415,0	<0,001
PTSD	21,95 ± 14,95	21,5 (0 - 66)	18,45 ± 13,25	17 (0 - 44)	20,2 ± 14,2	19,5 (0 - 66)	4406	0,146

*Mann Whitney U Test

When the age distributions are analysis, it was seen that the mean age distributions of both groups were balanced (p=0,648). When the OHI-S scores are analysis, the values of the group that experienced an earthquake were higher than the group that did not experience an earthquake and were statistically significant (p<0.001). The mean PTSD score of the group which had experienced an earthquake was higher than the group which did not experience an earthquake and there was no statistically significant difference (p=0,146).

Table 4 Comparison of tooth wear scores on all tooth surfaces of the groups

Groups

0

1

2

3

4

R

E

Test Statistics

p*

Experienced- Occlusal

Non-experienced

Occlusal

0 (0)

1730 (61,8)

1754 (62,6)

635 (22,7)^a

498 (17,8)^b

109 (3,9)^a

186 (6,6)^b

11 (0,4)^a

50 (1,8)^b

168 (6)

173 (6,2)

147 (5,3)

139 (5)

62,061 <0,001

Experienced- Cervical

Non-experienced

Cervical

0 (0)

1982 (70,8)

2077 (74,2)

507 (18,1)

451 (16,1)

92 (3,3)

73 (2,6)

6 (0,2)

2 (0,1)

66 (2,4)

56 (2)

147 (5,3)

139 (5)

10,728 0,057

Experienced- Palatinal

Non-experienced

Palatinal

5 (0,1)

3 (0,1)

2478 (88,5)

2487 (88,8)

128 (4,6)

132 (4,7)

23 (0,8)

28 (1)

2 (0,1)

0 (0)

22 (0,8)

14 (0,5)

147 (5,3)

139 (5)

4,570 0,471

Experienced-

Buccal

Non-experienced

Buccal

1 (0,1)

2 (0,1)

2349 (83,9)

2360 (84,2)

236 (8,4)

35 (1,3)

35 (1,2)

0 (0)

33 (1,2)

147 (5,3)

139 (5)

0,248 0,993

*Pearson Chi-Square Test; a-b: No difference between groups with the same letter in each row

R: Restored tooth

E: Extracted tooth

Among the study groups, 5.3% and 5% of the teeth of those which had experienced an earthquake and those who did not, respectively, were extracted. Restored surfaces were in different proportions according to the restoration on each surface. When tooth wear on the occlusal surface is analysis, score-2 was significantly higher in the group that experienced an earthquake (p<0.001), while score-3 and score-4 were higher in the group that did not experience an earthquake (p<0.001). There was no significant difference between the groups on the cervical, palatinal, and buccal surfaces (p>0.05). The surface with the highest rate of 88.8% (score-1) of wear within the enamel boundaries was the palatinal surface of the non-experienced group. The lowest score-1 rate was 61.8% on the occlusal surface of the experienced group. Score-2, in which dentin was exposed, was the highest with 22.7% on the occlusal surface of the group that experienced an earthquake. Score-3 was highest on the occlusal surface of the non-experienced group with 6%. Finally, score-4 was on the occlusal surface of the non-experienced group with a rate of 1.8%. As a result, it is seen that the occlusal surface has the highest wear rate among the participants. The surface with the least wear was the palatinal surface.

The occlusal and cervical surfaces had the highest tooth wear depths. The distribution and analyses of the wears on these surfaces, OHI-S, and PTSD scores are presented in Tables 5, 6, and 7.

Table 5 Comparison of occlusal wear, cervical wear, OHI-S, and PTSD scores according to gender

	Experienced				Non-experienced
	Gender		Test Statistics	p	Gender		Test Statistics	p
	Men (n=1262)	Women (n=1325)	Test Statistics	p	Men (n=1197)	Women (n=1406)	Test Statistics	p
OHI-S	2,31 ± 1,22 2 (0,66 - 5,6)	2,45 ± 0,95 2,33 (0,83 - 4,33)	868249,5	<0,001**	1,14 ± 0,91 1 (0 - 4)	1,62 ± 1,13 1,17 (0,33 - 6)	1000078,5	<0,001**
PTSD	21,89 ± 15,99 21 (0-66)	22 ± 13,85 22 (0 - 49)	1453,5	0,143**	19,32 ± 12,83 19 (0-43)	17,7 ± 13,65 16(0 - 44)	1129	0,434**
O0 O1 O2 O3 O4	0(0)	0(0) 872 (69) 361 (28,6)^b 29 (2,3)^b 2 (0,2)^b	39,618	<0,001*	0(0)	0(0) 940 (71,2) 240 (18,2)^b 118 (8,9)^b 23 (1,7)	13,984	0,003*
	858 (70,3)				814 (69,8)
	274 (22,4)^a				258 (22,1)^a
	80 (6,6)^a				68 (5,8)^a
	9 (0,7)^a				27 (2,3)
S0	0(0)	0(0)	11,390	0,010*	0(0)	0(0)	13,133	0,004*
S1	993 (78,7)^a	989 (74,6)^b			986 (82,4)^a	1091 (77,6)^b
S2	224 (17,7)^a	283 (21,4)^b			184 (15,4)^a	267 (19)^b
S3	45 (3,6)	47 (3,5)			25 (2,1)^a	48 (3,4)^b
S4	0 (0)^a	6 (0,5)^b			2 (0,2)	0 (0)

*Pearson Chi-Square Test; **Mann Whitney U Test; a-b: No difference between groups with the same letter; mean ± standard deviation; median (minimum-maximum)

Men and women were compared in both groups. The OHI-S scores of women were higher in both groups and were statistically significant (p<0.001). When PTSD scores are analysis, no significant difference was found between men and women (p<0.05). When occlusal tooth wear scores are analysis, score-2 was higher in women, while score-3 and score-4 were higher in men in the group that experienced an earthquake. (p<0.001). In the non-experienced group, score-2 and score-4 were higher in men, while score-3 was significantly higher in women (p<0.001). When cervical tooth wear scores are analysis, score-1 was higher in the group that experienced an earthquake, while score-2 and score-4 were higher in women (p<0,001). In the group that did not experience an earthquake, score-1 was higher in men, while score-2 and score-3 were higher in women and statistically significant (p<0,001).

Table 6 Comparison of occlusal, cervical, OHI-S, and PTSD scores according to age categories

	Experienced				Non-experienced
	Age Categories		Test Statistics	p	Age Categories		Test Statistics	p
	18-35 years (n=1373)	35-70 years (n=1214)	Test Statistics	p	18-35 years (n=1335)	35-70 years (n=1268)	Test Statistics	p
OHI-S	2,26 ± 1,12 2,16 (0,66 - 5,6)	2,51 ± 1,06 2,33 (0,66 - 5,33)	872914,5	<0,001**	1,26 ± 0,82 1 (0,17 - 4)	1,54 ± 1,25 1,16 (0 - 6)	847459,5	<0,001**
PTSD	22,59 ± 14,69 20 (0-66)	21,25 ± 15,34 21 (0-56)	1217,5	0,865**	18,05 ± 13,44 17,5 (0-43)	18,85 ± 13,15 17 (0-44)	1389	0,309**
O0	0(0)	0(0)	367,147	<0,001*	0(0)	0(0)	309,069	<0,001*
O1	1137 (85,9)^a	593 (51,1)^b			1097 (86,2)^a	657 (54,1)^b
O2	175 (13,2)^a	460 (39,6)^b			113 (8,9)^a	385 (31,7)^b
O3	12 (0,9)^a	97 (8,4)^b			49 (3,8)^a	137 (11,3)^b
O4	0 (0)^a	11 (0,9)^b			14 (1,1)^a	36 (3)^b
S0	0(0)	0(0)	232,933	<0,001*	0(0)	0(0)	341,191	<0,001*
S1	1214 (88,4)^a	768 (63,3)^b			1254 (93,9)^a	823 (64,9)^b
S2	143 (10,4)^a	364 (30)^b			74 (5,5)^a	377 (29,7)^b
S3	16 (1,2)^a	76 (6,3)^b			7 (0,5)^a	66 (5,2)^b
S4	0 (0)^a	6 (0,5)^b			0 (0)	2 (0,2)

*Pearson Chi-Square Test; **Mann Whitney U Test; a-b: No difference between groups with the same letter; mean ± standard deviation; median (minimum-maximum)

Age distribution was performed as under and over the mean age of 35 years. When the OHI-S scores are analysis, the scores of the group aged 35 years and over were higher and statistically significant in both groups (p<0.001). When PTSD scores are analysis, no significant difference was found in both groups (p>0.05). When occlusal tooth wear scores are analysis, score-1 was higher in the group under 35 years of age in the group that experienced an earthquake (p<0.001). Score-2, score-3, and score-4, which were deeper lesions, were higher in the group aged 35 years and over and were statistically significant (p<0.001). Similarly, while score-1 was higher in the group under 35 years of age, score-2, score-3, and score-4, which were deeper lesions, were higher in the group aged 35 years and over (p<0.001). When cervical tooth wear scores are analysis, they were similar to occlusal scores. In other words, in both groups, score-1 was higher in the group under 35 years of age, while score-2, score-3, and score-4, which were deeper lesions, were higher in the group aged 35 years and over (p<0.001).

Table 7 Comparison of tooth wear and OHI-S scores according to PTSD score distribution

	Experienced				Non-experienced
	PTSD		Test Statistics	p	PTSD		Test Statistics	p
	<25 (n=1417)	25 and over (n=1068)			<25 (n=1608)	25 and over (n=880)
OHI-S	2,2 ± 0,96 2 (0,66 - 4,16)	2,61 ± 1,21 2,66 (0,66 - 5,6)	899360	<0,001**	1,5 ± 1,02 1,17 (0 - 4,34)	1,21 ± 1,1 1 (0,17 - 6)	551057	<0,001**
O0 O1	0(0)	0(0) 727 (68,1) 285 (26,7) 56 (5,2) 0 (0)^b	13,011	0,005*	0(0)	0(0) 526 (59,8)^b 229 (26)^b 92 (10,5)^b 33 (3,8)^b	83,443	<0,001*
	1003 (70,8)				1228 (76,4)^a
O2	350 (24,7)				269 (16,7)^a
O3	53 (3,7)				94 (5,8)^a
O4	11 (0,8)^a				17 (1,1)^a
S0	0(0)	0(0) 879 (79)^b 198 (17,8)^b 35 (3,1) 0 (0)^b	10,143	0,017*	0(0)	0(0) 708 (76,7)^b 173 (18,7) 40 (4,3)^b 2 (0,2)	18,93	<0,001*
S1	1103 (74,8)^a				1369 (81,5)^a
S2	309 (20,9)^a				278 (16,5)
S3	57 (3,9)				33 (2)^a
S4	6 (0,4)^a				0 (0)

*Pearson Chi-Square Test; **Mann Whitney U Test; a-b: No difference between groups with the same letter; mean ± standard deviation; median (minimum-maximum)

The groups were divided into two according to the scores obtained from the first 17 questions of the PTSD test. When the OHI-S scores are analysis, the scores of those who scored 25 and over were significantly higher in the group which had experienced an earthquake (p<0.001). In the non-experienced group, the OHI-S scores of those who scored less than 25 were higher (p<0.001). When occlusal tooth wear scores are analysis, score-4 was higher in the group with a score lower than 25 in the group that experienced an earthquake (p<0.001). In the non-experienced group, score-1 was higher in the group with a score lower than 25 (p<0,001). Score-2, score-3, and score-4 were higher in the group with a score of 25 and over and were statistically significant (p<0,001). When the cervical tooth wear scores are analysis, score-2 and score-4 were higher in the non-experienced group with a score less than 25 (p<0,001). Cervical score-1 was higher in the group with a score of 25 and over and was statistically significant (p<0,001). In the group which had not experienced an earthquake, score-1 was higher in the group with a score lower than 25, while score-3 was higher in the group with a score of 25 and over (p<0.001).

This study is a cohort study and consists of 200 people in total. The groups consisted of 100 who had experienced an earthquake and 100 non-experienced people. The study groups were divided into subgroups according to gender, age, and PTSD scores and compared according to earthquake status. In general, tooth wear was present in all participants of the study. The fact that the number of teeth with no wear was low can be explained by the fact that these teeth had been in the mouth for at least 10 years. In the controls, score-2, score-3, and score-4, in which dentin was exposed, were higher on the occlusal and cervical surfaces than on the palatal and buccal surfaces (Table 4). Etiology was not questioned during the scoring of tooth wears and all evaluations were performed by a single operator. The fact that lesions with greater depth were more common on the occlusal and cervical surfaces may be related to the causes of tooth wear. It is expected that tooth wear is more prominent on the occlusal and cervical surfaces than on other surfaces. Bartlett et al. and Wazani et al. have mentioned many reasons for the wear of the occlusal and cervical surfaces. The most common of these causes are bruxism, horizontal tooth brushing, and acid attacks [22, 23]. There was no significant correlation between the depth of the wears in the occlusal and cervical surfaces and earthquake experience (Table 4). When PTSD scores are analysis, higher scores were found in the group which had experienced an earthquake compared to the group which had not experienced an earthquake (Table 3). While 43% of the group which had experienced an earthquake showed PTSD symptoms, this rate was 35% in the group which had not experienced an earthquake (Table 2). In previous studies, the most common orofacial disorders in patients with PTSD symptoms were reported as temporomandibular joint dysfunctions, periodontitis, and bruxism [23, 24]. In our study, no significant correlation was found between tooth wear scores and PTSD scores. While score-3 and score-4 in the occlusal surfaces were higher in the non-experienced group, score-3 and score-4 in the cervical surfaces were higher in the experienced group (Table 4). There is no evidence that disorders such as bruxism, which causes traumatic occlusal forces, cause non-caries tooth wear on the teeth [25]. Researchers explain the causes of wear as multifactorial [26]. Stress on the teeth can be effective in the wear of the teeth. In addition, acid attacks can also cause the enamel surface to dissolve and the underlying dentin to emerge over time [9]. When the OHI-S scores are analysis, they were significantly higher in the group which had experienced an earthquake compared to the group which had not experienced an earthquake (Table 3). PTSD and OHI-S scores had a significant relationship between the groups. This may be related to the disruption of daily routines and consequently decreased oral care in individuals affected by trauma. Solis et al. and Kildahl et al. reported that individuals with post-traumatic stress symptoms had decreased oral care and high oral hygiene index scores [27, 28]. High OHI-S scores may indicate possible plaque accumulation and acid attacks on tooth surfaces. High OHI-S scores may be important in explaining the multifactorial causes of tooth surface abrasion [9]. In our study, the tooth wear scores of the experienced group, which had high PTSD and OHI-S scores, did not differ significantly compared to the other group.

The depth of tooth wear on the occlusal and cervical surfaces was more pronounced than on the other surfaces. Among the total participants, tooth surfaces with score-2, score-3, and score-4 in the occlusal surfaces were 27% in the experienced group and 26.2% in the non-experienced group. In the cervical surface, score-2, score-3, and score-4 were 21.6% in the experienced group and 18.8% in the non-experienced group. These scores were much lower on the palatinal and buccal surfaces (Table 4). There are many studies explaining the concentration of tooth wear in the occlusal and cervical surfaces [16, 23].

In our study, the wears occurring on these surfaces are analysis in Tables 5, 6, and 7 considering gender, age and PTSD scores.

In the evaluation made according to the gender of the participants, women had worse oral hygiene in both groups. In studies where oral hygiene status was evaluated on gender, it was observed that women generally had better values and paid more attention to their oral hygiene [29, 30]. In contrast to other studies, the high tooth wear scores in women in this study may be due to socio-demographic reasons and oral hygiene education. When PTSD scores are analysis, women had higher scores in the group which had experienced an earthquake, while women had lower scores in the group which had not (Table 5). Yehuda et al. and Ahmed et al. reported that stress symptoms after traumatic events were higher in women [31, 32]. The higher OHI-S scores in women may be related to the effect of post-traumatic psychological stress on oral care [33]. In addition, the role of women in society and social factors may be effective in this situation. When tooth wear scores are analysis, no clear distinction was observed between men and women. While occlusal score-3 and score-4 were higher in men who had had experienced an earthquake, cervical score-2 and score-4 were higher in women (Table 5).

When the participants are analysis according to age groups, both tooth wear scores and OHI-S scores of individuals aged 35-70 years were higher than those of individuals aged 18-35 years in both groups. When similar studies in the literature were are analysis, tooth wear scores increasing with age were obtained as expected [34, 35]. The prolonged use of the teeth with increasing age leads to tooth wear as a natural process [23]. High OHI-S scores may mean increased acid attacks and tooth wear due to possible plaque accumulation [24]. PTSD and OHI-S scores of individuals aged 18-35 years who had experienced an earthquake were higher than those of individuals in the same age group which had not experienced an earthquake. When tooth wear scores are analysis, occlusal score-2 and cervical score-2, score-3 were higher in the 18-35 age group which had not experienced an earthquake. This may give an idea about the effects of post-traumatic psychological stress on oral hygiene values and tooth wear scores.

The PTSD inventory was translated into Turkish in 2001 by Başoğlu et al. [17]. The first 17 items are used to assess post-traumatic violence. Individuals scoring 25 and over indicate possible PTSD symptoms. In the study, PTSD scores of the experienced and non-experienced people were evaluated. The rate of those with a score of 25 and over was higher in the group which had experienced an earthquake (Table 2). This group also had higher scores in the OHI-S. The fact that both scores were high may provide information about the decrease in oral care with the psychological stress experienced. Green et al. evaluated the effects of PTSD on oral care. The results showed a high prevalence of periodontitis [13]. Similar to this study, oral care deteriorated in the patient group with PTSD. When the tooth wear values of the group showing PTSD symptoms and the group experienced the earthquake are analysis, occlusal score-4, and cervical score-2, score-3, and score-4 were lower than the group not showing PTSD symptoms. This shows that there is no significant relationship between the psychological stress experienced after the earthquake and tooth wear findings. Similarly, Wörner et al. evaluated the relationship between PTSD and tooth wear and showed that there was no significant relationship with tooth wear [24]. Bruxism is a condition in which many factors play a role in its etiology and the relationship with tooth wear has not been established [36, 37]. Psychological stress after a traumatic event causes clenching of teeth and temporomandibular joint disorders [24, 38].

One of the limitations of this study is that the tooth wear index used in the study cannot classify the tooth wear in the enamel tissue in detail. In future studies, there is a need for a tooth wear index that can also classify the abrasions occurring in the enamel [16]. Another limitation is that tooth abrasions were recorded without questioning the etiology. In future studies, a questionnaire questioning the etiology should be included in the study. Similarly, whether the participants had any psychiatric illnesses before the earthquake and whether they received any treatment for these illnesses were not included in the study. The sample size in the study can also be expanded in future studies.

In our study, it could not be determined that the psychological stress experienced in patients with post-traumatic stress disorder symptoms directly caused non-carious wears on tooth surfaces. The high OHI-S scores obtained from the group which had experienced an earthquake indicate that post-earthquake stress and changing lifestyles reduce oral care. Decreased oral care and increased clenching may have a negative effect on teeth. Post-traumatic stress disorder is a disorder that closely concerns the oral health of individuals. Poor oral care may cause TMJ dysfunctions, tooth loss, and tooth wear in people with this disease [13, 24, 38]. Tooth wear is a complex condition that requires a multidimensional approach to diagnosis and treatment. Emotional stress, which can also occur due to reasons such as PTSD, can increase bruxism and thus increase occlusal forces, increasing the possibility of abfraction defects on the teeth [15]. It has been stated by researchers that it is wrong to associate non-caries tooth wear with a single factor, that it increases with age and is closely related to socio-economic status [9, 39].

PTSD: Post-traumatic stress disoerder; OHI-S: Simplified Oral Hygiene İndex; TMJ: Temporomandibular Joint; WHO: World Health Organisation; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders-IV;B: Buccal; L: Lingual; O: Occlusal; I: Incisal; C: Cervical; R: Restored tooth; E: Extracted tooth.

Acknowledgements

The authors thank all of the parents for joining the study and for their support for completing questionnaires.

Authors’ contributions

All authors have actively participated in the scoping review and have made a substantial contribution to (1) either conception and design, or acquisition of data, or analysis and interpretation of data; as well as (2) the drafting of the article or its revision; and (3) to the fnal approval of the version to be published. All authors read and approved the final manuscript.

Funding

This scoping review has not been funded by any external body

Ethics approval and consent to participate

The present study was carried out with the approval of the Inonu University Faculty of Medicine Malatya Clinical Research Ethics Committee (Protocol number: 2023/71).

Consent for publication

Not applicable.

Competing interests

The authors of this article declare that they have no competing interests.

Availability of data and materials

All data generated or analyzed during this study are included in this published article. Details of all studies analysed in this scoping review are included in Table 2, 3, 4, 5, 6 and 7 in this article.

Author details

¹Assistant Professor, Inonu University, Faculty of Dentistry, Department of Restorative Dentistry, Malatya, Turkey. ²Assistant Professor, Yuzuncu Yıl University, Faculty of Dentistry, Department of Oral Diagnosis and Radiology, Van, Turkey. ³Assistant Professor, Inonu University, Faculty of Medicine, Department of Psychiatry.

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No competing interests reported.

Evaluation of the relationship between earthquake-induced post-traumatic stress disorder and tooth wear

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Version 1

Abstract

Background

Materials and Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1