Knowledge and Awareness of Dental Erosion among Croatian Certified Wine Assessors

Abstract

Objectives

The aim of this study was to evaluate the knowledge and awareness of dental erosion, its etiology and preventive practices among certified Croatian wine assessors.

Participants and Methods

An anonymous questionnaire structured in two sections was completed by 90 certified Croatian wine assessors, representing more than 80% of active certified assessors in Croatia. The first section covered demographic and professional data, including age, years of professional experience, frequency of wine tasting and habits related to tasting. The second section evaluated participants’ knowledge regarding etiology, prevention and therapy pertaining to dental erosion. Data were analysed using descriptive statistics and standard statistical tests commonly applied in questionnaire-based studies.

Results

Although the majority of participants visited the dentist regularly, only two-thirds noted that their dentist knew their occupation. Wine assessors’ knowledge of dental erosion was not typically associated with dentists’ awareness of their occupation. While merely 23% of participants learned about dental erosion from their dentists, 45% acquired this knowledge from other sources. Although 67% of respondents had heard of dental erosion, their factual knowledge was limited. A total of 69% of participants reported no specific oral care practices before or after wine tasting; observable habits were not related to their professional experience.

Conclusion

Awareness of dental erosion among Croatian wine assessors proved insufficient. An appropriate form of education, especially one provided by dentists, is required to emphasize the risks and outline the potential for prevention and treatment of dental erosion.

Introduction

Wine consumption is deeply embedded in Western culture. As a component of the Mediterranean diet, wine has also become an important topic in public health discussions in which its potential health benefits and adverse effects continue to be debated (1). Although wine production is often perceived as an agreeable profession due to tasting as an integral part of quality control, it actually entails several occupational hazards, including significant risks to oral health. Frequent exposure of oral tissues to the chemically aggressive constituents of wine places professional wine assessors at an increased risk of developing dental erosion, dentin hypersensitivity and xerostomia, while associated complications often exacerbate the problem (2, 3). Numerous studies have identified dental erosion as the predominant oral pathology among professional wine assessors, whose work involves not only drinking wine but also the act of swirling and retaining it in the mouth for extended periods, thereby increasing the erosive effects of the wine acids (3–11). Saliva, which normally acts as a natural buffering system in the oral cavity, becomes diluted and washed away during repeated wine tasting; this results in a decrease in oral pH towards the acidic range of wine (12). As reported by Wiktorsson et al., the high frequency of tasting among Swedish wine tasters indicated that between twenty and fifty wines were sampled per day, which supports the premise that dental erosion is a genuine occupational hazard in wine production and professional tasting (4, 7).

Dental erosion is defined as the chronic, pathological loss of dental hard tissues caused by extrinsic or intrinsic acids in the absence of bacterial involvement (13, 14). Although intrinsic factors, such as gastric acid, may lead to severe erosive tooth wear, their effect on dental erosion is far less pronounced than acids introduced into the oral cavity from external sources (15, 16). It stands to reason that, among professional wine tasters, dental erosion is predominantly associated with exposure to extrinsic acids. Wine typically has a pH of approximately 3.0 to 3.8 and contains mainly tartaric, malic, lactic, and citric acids; succinic and acetic acids are also present, albeit in smaller amounts. Hydrogen ions released during the dissociation of these acids together with calcium-binding anions (chelating agents) contribute to the demineralization of dental hard tissues. Demineralization may be followed by or occur simultaneously with remineralization, which may partially repair the demineralized tissues. These processes alternate only while the pH value remains above the critical threshold; once the pH falls below this level, demineralization predominates, resulting in an accelerated loss of dental hard tissues, which clinically manifests as dental erosion. The extent of demineralization depends on several factors: tooth structure, genetic determinants of enamel quality, salivary flow and composition, type of acid involved, duration of exposure (as well as the pattern of acid contact with the tooth surface) and oral hygiene practices (17, 18). The development of dental erosion is therefore multifactorial; some factors promote its onset, whereas others help to prevent or mitigate the demineralization of dental hard tissues. Frequent exposure to wine acids is unavoidable for professional wine assessors and industry personnel. Consequently, they should be aware of this occupational hazard associated with this vulnerability and cognizant of preventive measures that mitigate risks to their oral health. Dentists should therefore be familiar with their patients’ professional activities to provide timely advice and preventive guidance before advanced stages of dental erosion require clinical treatment. Numerous studies have identified dental erosion as a consequence of wine consumption (7, 8, 11, 19), while considerably more have focused on acidic non-alcoholic beverages as etiological factors in the development of erosive tooth wear (20–23). However, few studies have assessed the levels of knowledge and awareness of this condition (5, 24, 25). This type of investigation, particularly among individuals at increased risk of dental erosion, is crucial for raising awareness as well as for the future development of effective educational programmes and preventive guidelines. Despite the risk of dental erosion in viniculture having been repeatedly recognised as a genuine occupational hazard that requires a multidisciplinary approach (5, 7, 26–29), studies investigating knowledge and awareness of this condition among wine professionals remain scarce (30). While recognised at several international levels through ISO standards (31), various international professional associations (32) and European Union legislation (33), wine assessors have yet to be considered as a specific group of accredited professionals within the wine industry. The need for targeted research and inclusion of dental science in this specific segment of enology is further supported by the fact that wine assessors encounter a significant risk of dental erosion.

The aim of this study was to assess the knowledge of certified Croatian wine assessors with regard to dental erosion, its etiology and prevention and the potential oral health risks associated with the wine sector. These findings should provide a baseline for educational strategies pertaining to dental erosion and its prevention among wine industry employees, with a particular emphasis on professional wine assessors.

Participants and Methods

The study was conducted at the Laboratory for Sensory Testing of the Croatian Agency for Agriculture and Food. The laboratory is responsible for conducting sensory analyses of wines, fruit wines, aromatized wine-based products and spirits, and is accredited in accordance with the HRN EN ISO/IEC 17025:2017 standard. Due to its distinctive nature and complexity, sensory analysis was performed by certified assessors whose qualifications are defined and accredited through the Croatian Wine Act (34); the procedures for verifying sensory abilities and professional competence are established by the Implementing Regulation (35).

The study included certified assessors listed in the official register, which is periodically updated in accordance with legal provisions and publicly available through the institution’s official documentation portal. The study sample comprised 108 certified ‘wine assessors’, the term being defined as trained professionals authorized to perform the sensory evaluation of wines. Participation in the study was voluntary and anonymous.

A descriptive questionnaire-based cross-sectional study was designed to assess awareness, factual knowledge and preventive behaviours related to dental erosion among certified wine assessors. The study was conducted using an online questionnaire created on Google Forms. The questionnaire consisted of two sections: (1) demographic and professional information (including age, professional experience in the wine sector and wine tasting, oral health habits and wine tasting practices); and (2) awareness and factual knowledge of dental erosion. Awareness was assessed through questions addressing participants' recognition of dental erosion as a potential occupational health issue and their perception of its relevance to wine tasting. Factual knowledge was defined as participants' ability to correctly identify evidence-based information regarding the etiology, clinical manifestations, reversibility and prevention of dental erosion. Each questionnaire item was analysed separately according to its objective and response format. Therefore, no composite knowledge score was calculated. The questionnaire was developed within the laboratory, and subsequently underwent expert review by a specialist in preventive and restorative dentistry to confirm the scientific accuracy and clinical relevance of items. Prior to distribution, a pilot test was conducted at the laboratory with three certified assessors to evaluate the clarity of the questions and the response format.

The response rate was 83% of the initial sample; 98% of the returned questionnaires were included in the analysis. Participants’ professional experience in the wine sector and their years of experience in professional wine tasting are presented in Figure 1.

Figure 1.

Participants’ professional experience in the wine industry and years of experience in professional wine tasting.

Statistical Analysis

Data were analysed using descriptive statistics and statistical methods commonly applied in survey-based research to test the differences among variables. Frequencies of qualitative variables were presented graphically. As the Kolmogorov–Smirnov test indicated that the data did not follow a normal distribution, comparisons among categorical variables were performed using the non-parametric χ² test for independence. A contingency table was constructed for each response option. Given the presence of multiple comparisons, the χ² test for independence was performed separately for each response option. Effect sizes for the χ² analyses were quantified using Cramer's V, and Cohen’s criteria were used for interpretation of V or r < 0.3 small, 0.3 – 0.5 medium, > 0.5 large.

To control for alpha inflation resulting from multiple testing, the Bonferroni correction was applied in both sets of analyses. The significance threshold was therefore set at α = 0.01 (0.05/5) for the symptom variable and α = 0.008 (0.05/6) for the treatment variable. A statistical analysis of the distribution of responses across the targeted groups was performed to evaluate the influence of the dentist–patient relationship as it pertained to the knowledge and behaviour of certified assessors, as well as to examine the influence of tasting intensity and overall professional experience. The null hypothesis (H₀) was used to test whether dentists’ awareness of the respondents’ profession (i.e., certified enologists engaged in intensive tasting) is associated with their knowledge of the symptoms of dental erosion and with oral hygiene practices aimed at preventing its occurrence. Data processing and statistical analyses were performed using Microsoft Excel and Statistica (version 12.0; TIBCO/StatSoft, Tulsa, OK, USA).

Results

Results showed that, among certified wine assessors, visitation to different dental services was evenly distributed: public dental services (30%), private dentists (35%) and both types of services (35%). Most assessors reported visiting a dentist at least occasionally, regardless of the presence of specific symptoms. In approximately two-thirds of cases, dentists were aware of the participants’ profession as well as the fact that their activities involve intensive wine tasting (Figure 2). With regard to tasting intensity, one third of participants reported tasting up to 20 samples per week; thirty percent of participants tasted between 20 and 49 samples per week, while the remaining third tasted 50 or more samples per week; in some cases, up to 200 wines were sampled. Across groups defined by tasting intensity, the range of professional experience varied from only a few years to more than 35 years.

Figure 2.

Participants’ relation to their dentists and dental services.

A total of 69% of participants reported no specific dental care practices before and/or after tasting. Oral care habits before or after tasting did not vary with increasing years of professional tasting experience (χ² = 1.915, df = 2, p = 0.384). The observed association was weak (Cramer's V = 0.147), indicating a small effect size. Among the participants who practiced some form of dental care, the most frequently mentioned practices included brushing with commercially available toothpaste for sensitive teeth, using commercial mouth rinses for sensitive teeth and brushing of teeth after tasting. Only four participants reported using a specialised toothpaste or protective dental coating. A total of 66% of participants reported frequently rinsing their mouth with water during tasting, whereas 5% did not rinse at all and 29% did so only occasionally. The χ² test indicated no significant difference in mouth-rinsing behaviour between groups defined by whether their dentist was aware of their professional activities (Table 1).

Table 1. Results of the χ² test and Cramer's V for the variables ‘dentist’s awareness of the patient’s profession’, ‘recognized symptoms of dental erosion’ and ‘treatments for reducing the potential for dental erosion’.

		Dentist aware of profession (n=59)	Dentist possibly unaware (n=15)	Dentist not aware of profession (n=15)	χ2	df	p	Cramer's V
Symptoms of DE	Tooth discoloration	29 (49.2%)	9 (60.0%)	5 (33.3%)	2.18	2	0.335	0.157
	Sensitivity to cold/heat	42 (71.2%)	10 (66.7%)	8 (53.3%)	1.74	2	0.419	0.140
	Thinning of tooth edges	27 (45.8%)	5 (33.3%)	8 (53.3%)	1.26	2	0.533	0.119
	Shinier, smoother surfaces	4 (6.8%)	0 (0%)	0 (0%)	2.13	2	0.345	0.155
	Fractures of the edges of the tooth	14 (23.7%)	6 (40.0%)	5 (33.3%)	1.81	2	0.404	0.143
Treatments reducing the potential of DE	Teeth brushing immediately after tasting	37 (62.7%)	10 (66.7%)	7 (46.7%)	1.56	2	0.457	0.132
	Using a harder toothbrush	3 (5%)	1 (6.7%)	0	0.92	2	0.632	0.102
	More intensive brushing	14 (23.7%)	5 (33.3%)	2 (13.3%)	1.67	2	0.435	0.137
	Avoiding fluoride toothpaste	2 (3.4%)	1 (6.7%)	0	1.02	2	0.599	0.107
	None of the above	6 (7%)	2 (13.3%)	0	1.93	2	0.381	0.147
	Not sure	14 (23.7%)	3 (20%)	9 (60%)	8.35	2	0.015*	0.306**

* Trend observed; however, statistical significance was not confirmed after the Bonferroni correction.

** Moderate effect

One third of respondents indicated that they were not familiar with the term ‘dental erosion’. This group included professionals of various ages with tasting experience ranging from 5 to 45 years. Participants who were familiar with the concept of dental erosion (67%) identified the following as sources of information: 23% cited their dentist; 24% referred to their workplace or other professional environment; the largest proportion (53%) reported obtaining information through the media or similar sources. To determine if awareness of dental erosion corresponded to factual knowledge, responses to several knowledge-based questions were analysed. The results are presented in Figures 3–6.

Figure 3.

Distribution of responses to the question ‘What is dental erosion?’

Figure 4.

Distribution of responses to the question ‘What are the symptoms of dental erosion?’

Figure 5.

Distribution of responses to the question ‘Which factors increase the risk of dental erosion?’

Figure 6.

Distribution of responses to the question ‘Which treatments may reduce the potential for dental erosion?’

A total of 90% of participants indicated that dental erosion (‘DE’) represents the loss of enamel and dentin due to the action of acids. However, 24% of respondents in this group also indicated that DE represents enamel loss caused by microbiological activity, specifically bacterial; these responses are regarded as inaccurate. The response options related to treatments aimed at reducing erosion potential were designed to assess factual knowledge. As all proposed answers describing specific treatments or behaviours were incorrect, the results indicate an unsatisfactory level of knowledge among most participants (Figure 6). No statistically significant correlation was found between dentists’ awareness of their patients’ profession and the level of knowledge professional wine assessors had acquired regarding dental erosion, including recognition of symptoms and an understanding of preventive strategies (Table 1). Cramer's V indicated small effect sizes for all comparisons except for the response "Not sure" regarding preventive strategies, which showed a moderate effect (V = 0.306). These findings suggest that the observed differences between groups were of limited practical significance.

Discussion

To the best of our knowledge, this is the first study examining oral health habits and knowledge regarding dental erosion among Croatian enologists who are certified wine assessors. The high participation rate (83%) contributes to the strength of this investigation. Numerous studies on dental erosion in professional winemaking have primarily focused on risk factors and clinical case reports. In these studies, dental erosion was diagnosed in individuals who were otherwise in excellent general health and had healthy lifestyle habits, with the possible exception of their continuous exposure to wine tasting (6, 8, 14, 36, 37). Several authors have reported that white and sparkling wines, which typically predominate in professional tastings, are generally more erosive than red wines (37–40). However, red wines may represent a comparable risk, despite the potentially protective effects of the polyphenols present in reds (36, 40).

The results in this study indicate that Croatian wine assessors whose work involves frequent sensory evaluation are insufficiently informed about dental erosion. Although these individuals are educated in their area of expertise and generally attentive to oral health, and despite visiting dentists regularly even in the absence of symptoms, limitations in the dentist–patient relationship appear to exist. It was determined that despite the participants having demonstrated a general awareness of oral health, this awareness was not complemented by an adequate knowledge of the risks associated with dental erosion or the appropriate oral hygiene practices. Notwithstanding the fact that a high percentage of the participants were familiar with the term ‘dental erosion’ (67%), their responses to questions pertaining to definition and symptoms suggest that their factual knowledge of the subject appears to be deficient.

As multiple responses were allowed for several questions, participants may have selected more than one option based on partial knowledge, uncertainty, or guessing, making it difficult to distinguish true knowledge from response strategy. This may have resulted in an overestimation of participants' actual knowledge. For example, although many participants correctly identified dental erosion as the loss of enamel and dentin caused by acid exposure, 22% of those who selected the correct answer also chose the incorrect statement that dental erosion is "a process of enamel loss caused by the action of specific bacteria", indicating uncertainty despite recognizing the correct concept.

A similar limitation applies to the question addressing the symptoms of dental erosion, where all listed symptoms were correct. Participants frequently selected two symptoms, possibly reflecting personal experience or assumptions rather than knowledge of the chronological clinical presentation of dental erosion. In contrast, the question addressing the reversibility of symptoms allowed only a single response option, thereby minimizing response ambiguity. The consistency of findings obtained from the single-response question supports the interpretation that questions allowing multiple responses may be more susceptible to response ambiguity.

These findings are not unexpected: even within the dental profession, and despite increasing awareness and understanding of dental erosion, challenges remain in its diagnosis, classification and management in everyday clinical practice (40, 41). A study conducted in Australia reported that after only 5–10 years of professional practice, approximately 50% of wine tasters already experience increased tooth sensitivity. Tasting more than 50 wines per week might therefore be considered a high-risk activity (42).

Although professional experience may be expected to influence knowledge and awareness of the risks associated with intensive wine tasting, as well as personal approaches to oral care, no such correlation was observed in the present study. The distribution of oral care habits before or after tasting did not differ significantly across categories of professional wine tasting experience (<10, 10–20, and >20 years) (χ² = 2.550, df = 2, p = 0.279). The observed association was weak (Cramer's V = 0.169), indicating a small effect size. The potential influence of the dentist–patient relationship was also examined. It might be expected that dentists who are aware of their patients' profession would be more actively engaged in providing advice on occupation-related oral health risks. However, the present findings suggest that dentists' awareness of their patients' profession was not associated with better factual knowledge of dental erosion. Instead, participants' knowledge appeared to depend more on intuitive judgement and personal experience than on professional counselling. For example, recognizing symptoms such as tooth discoloration and sensitivity may reflect subjective perception or previous personal experience, whereas identifying smoother, shinier tooth surfaces or structural damage requires more specific clinical knowledge. These findings suggest that communication between dentists and patients exposed to occupational acid challenges is not sufficiently targeted. Simply knowing that a patient is professionally involved in wine tasting does not necessarily mean that specific information about dental erosion and its clinical manifestations is provided. In contrast, dentists' awareness of participants' professional wine tasting activity showed a trend towards an association with preventive oral health behaviour, although statistical significance was not retained after Bonferroni correction. Participants whose dentists were aware of their occupational exposure reported oral care before or after wine tasting more frequently than those whose dentists were unaware (χ² = 9.370, df = 2, p = 0.009). Although causality cannot be inferred from this cross-sectional study, the moderate effect size (Cramer's V = 0.324) suggests that effective communication between dentists and professionally exposed patients may contribute to the adoption of preventive oral health behaviors, even if it does not necessarily improve factual knowledge of dental erosion. Despite the observed association between dentists' awareness of occupational exposure and preventive oral health behaviour, no differences were found between public and private dental care services. The type of dental care was not associated with either factual knowledge of dental erosion or oral care practices. Although participants demonstrated general awareness of oral health, these findings suggest that communication regarding the occupational risk of dental erosion could be further improved, particularly among certified wine assessors. Similar findings indicating insufficient knowledge and awareness of acid erosion among wine tasters have also been reported in Brazilian and Australian studies (5, 30). The studies showed that, although the majority of participants had heard of dental erosion, their understanding of this issue was relatively poor. Another study reported that seven of the nine Norwegian wine tasters who had recently visited a dentist had not been informed about dental erosion, although in five participants the lesions had already progressed to involve dentine (29).

As a general observation, it should be noted that wine assessors do not regularly rinse their mouth during tasting sessions; overall, assessors are neither adequately informed about nor are consistent in applying more advanced preventive practices. The most frequent responses regarding oral care before or after tasting detail incorrect procedures, the brushing of teeth immediately after tasting being particularly pronounced. Significantly, this common practice is clinically discouraged because it interferes with the natural remineralization process.

Recommendations for the prevention of dental erosion among wine assessors exist and are available (42, 43). Preventive approaches before, during and after tasting include the use of fluoride-containing toothpaste and the application of protective agents containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) (44). Nevertheless, the present study indicates that, in the main, participants are unfamiliar with the abovementioned preventive measures. On balance, the results of this study indicate insufficient education and unsatisfactory oral care practices among certified wine assessors.

Because the study population consisted of a relatively homogeneous occupational group, the variability of demographic and professional characteristics was limited, reducing the suitability of multivariable analyses aimed at identifying predictors of knowledge. Although no clinical examination was performed and it was therefore not possible to relate participants' knowledge and preventive behaviors to clinically observed dental erosion, previous studies have demonstrated the presence of dental erosion in this population (6, 26, 29, 45). Future clinical studies may further strengthen these findings by examining the relationship between knowledge, preventive behaviours, and clinically assessed dental erosion.

Conclusion

Wine professionals and certified wine assessors whose work involves intensive wine tasting are exposed to an increased risk of dental erosion. Consequently, they have a greater need to apply appropriate dental care and protective strategies in addition to standard oral hygiene. Although participants in this study were educated professionals in viniculture, their knowledge of this oral pathology and their behavior regarding preventive practices was inadequate. Although most wine assessors reported regular dental visits as part of their routine oral health care, in a considerable number of cases, their dentists were unfamiliar with their specific professional activities. Dentists' awareness of their patients' occupation was not associated with better factual knowledge of dental erosion, but it was associated with a trend towards more favorable oral care practices before and after wine tasting. These findings suggest that communication regarding occupation-related oral health risks may contribute to preventive behavior, although there remains considerable scope to improve the delivery of targeted information on dental erosion.

The findings of the present study highlight the need for greater attention to occupation-specific oral health counselling in routine dental practice, as well as for the development of educational materials on dental erosion and its prevention. In addition, educational programmes for future certified wine assessors should be supplemented with information on occupational exposure to erosive challenges to increase awareness of this professional risk and promote the adoption of evidence-based preventive practices among certified wine assessors.