The importance of screening for erosive tooth wear
David Bartlett presents two case studies to demonstrate why dental professionals should screen for erosive tooth wear.
Erosive tooth wear is the third most common dental condition, after caries and periodontal disease. Typically, it affects up to 30% of European adults aged 18 to 30 years old. Of which about 3% have severe levels that could justify restorative intervention.
The severity increases with age and some estimates suggest up to 10% of 80-year-olds have levels of tooth wear that could justify care.
For a condition that affects so many patients, and is increasing in prevalence, it is important that we screen all patients to reduce the risk of missing a diagnosis. However, in a busy practice and without a routine, it is easy to miss a diagnosis.
If the basic erosive wear examination (BEWE) is part of every clinical exam, the clinician can make a record in the notes and inform the patient of their risk. From a dentolegal point of view, the records should also indicate the preventive advice offered. Along with the patient’s compliance with that advice.
The BEWE was devised in 2008 for general dentists as a screening tool. It mirrors the basic periodontal examination (BPE) and uses the same protocol; clinicians record the tooth surface with the most severe score in each sextant. And the total mouth score added to give a risk assessment.
The BEWE uses a four-point scale:
0 – no wear
1 – early signs of wear, such as flattening of cingula and perikymata
2 – involving changes less than 50% of the surface
3 – involving changes greater than 50% of the surface.
Both scores 2 and 3 may include exposure of dentine.
The cumulative score can help assess the need for intervention (Tables 1 and 2). Experience of the BEWE has developed. So we would recommend a score of three in any sextant as high risk.
A meeting of minds
Supported by GSK, a group of experts representing the Faculty of General Dental Practitioners (UK), British Society of Dental Hygienists and Therapists, the Faculty of Dentistry, Oral and Craniofacial Sciences at King’s College London, Dental Protection, and the Erosive Tooth Wear Foundation met to consider the need for erosive tooth wear to be a part of every clinical examination.
The experts agreed that regular and routine screening of erosive tooth wear should occur at every dental examination. As routine, it would become embedded into clinical practice and less likely a diagnosis was missed.
This recommendation was launched as their joint consensus in July 2019 at the dental school of King’s College London.
The group concluded that as the BPE is part of every clinical examination, and used the same protocol as the BEWE, they could be done at the same time to reduce the burden for busy dental practitioners.
When done at the same time, the BEWE should take less than a minute more to complete than the BPE. Clinicians can write the outcome in the notes using the same table style as the BPE. Or electronically using a software patch at www.erosivetoothwear.com.
What’s the problem with erosive tooth wear?
Although severe tooth wear is relatively rare, 3% remains an important group of patients in practice.
The cost of care to restore erosive tooth wear is more expensive than caries or periodontal disease because of the complexity and cost of materials, and expertise needed by the dentist.
A study at King’s showed costs could reach £13,000 for private treatment (£4,500 for NHS treatment) and take up to 24 months.
The distribution and pattern of tooth wear often means it involves multiple teeth. So the complexity can beyond the confidence of many practitioners.
Erosive tooth wear is a progressive condition, but relatively slow, meaning the mouth adapts to change. As teeth wear and become shorter, the occlusion adapts, resulting in short clinical crowns without space for conventional restorations.
Techniques involving changing the occlusion often mean dentists are not confident and may refer for advice or care.
There is a limit on the capacity from specialists or university/NHS consultants to provide care. So, ideally, early identification of risk reduces the impact.
Therefore, it is essential to regularly screen for tooth wear at every dental examination to reduce the risk that progression results in restorative intervention.
The profession has increasingly adopted the term erosive tooth wear. It includes all forms of wear, but recognises that erosion is often implicated.
The term includes bruxism or attrition and abrasion, even when they are the dominant cause of wear.
Erosive tooth wear has received international recognition and is the most commonly accepted term. It is important for dentists to understand it has a broad meaning. And that it includes all forms of chemical and mechanical wear.
A 30-year-old healthy male (Figures 1 and 2) presented complaining of a change to the appearance of his anterior teeth.
He had recently changed dentists, and was concerned about the appearance of his front teeth and the impact on their longevity.
The BEWE on the anterior teeth revealed a score of three as the wear covered more than 50% of the surface.
From a management perspective, the incisal edge of the central incisors is worn and dentine is exposed on the palatal surfaces. The severity of wear justifies intervention to improve the appearance and probably with composites. Crowns are overly destructive.
Composites bonded to the enamel and dentine with an appropriate adhesive and used to restore the tooth shape will increase the occlusal vertical dimension. But, over a few months, the occlusion adapts. Contacts on the posterior teeth redevelop as the overeruption occurs.
This ‘Dahl’ effect is reliable and normally takes between six weeks and six months. Normally quicker in younger adults.
While composites create a natural appearance, they often need refurbishment or replacement after major or minor fractures. Consequently, it is sensible to warn patients of this possibility.
If a BEWE had identified progression earlier, then preventive advice might have stopped the loss of the incisal edge.
This advice should be to keep consumption of acidic foods and drinks, including fruits, to meal times, which eliminates the risk.
Regular snacking, swilling or holding acidic foods or drinks in the mouth prior to swallowing increases the risk of progression.
In addition, a formulated toothpaste developed to prevent erosive tooth wear will supply fluoride to assist in the prevention.
A 20-year-old (Figure 3) presented for a routine dental appointment without any concerns. The clinician took a BEWE at the examination. This showed a score two on the buccal/facial surface of the upper anterior teeth and a score three along the incisal edge.
On the upper left central incisor there is evidence of erosive wear on the buccal/facial surface, with a localised lesion, circular in shape and possibly exposing dentine. There was no dentine sensitivity.
The incisal edge of both central incisors was worn and there was a class III incisal relationship.
Prevention is key to the management of this case. Dietary control and fluoride would address the erosive lesions on the buccal/facial surface. While a full coverage splint worn either in the mandible or maxilla would manage the attrition along the incisal edge.
Composite restorations would not be successful on the incisal edge as they need bulk for success. Thin layers often do not bond or under load will fracture. Successful dietary control and fluoride will halt the progress.
For both cases, it is essential to document the level of wear. Today’s patients use the internet to discover more about their condition. The website www.erosivetoothwear.com and gsk.dentistry.co.uk provides advice for patients and dentists.
Successful management will prolong tooth survival and reduce the impact of erosive tooth wear.