Identifying erosive tooth wear

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How to diagnose erosive tooth wear

Although the rate of progression for erosive tooth wear is slow, it can impact upon quality of life in later years. Dental Professionals have a duty of care to record signs of the condition in the clinical notes and inform the patient. The Basic Erosive Wear Examination or BEWE is a simple screening tool to use alongside the BPE to help alert the professional and the patient to erosive tooth wear. Explore the tools that can help you identify erosive tooth wear.

Identification of erosive tooth wear

Common enamel wear features

Common features of erosive tooth wear2,3

These include:

  • Yellowing (advanced sign)
  • Thinning and translucency
  • Surface changes (smoothing)
  • Loss of structural features (rounding)
Other signs of enamel wear

Other signs of tooth erosion2,3

These include:

  • Palatal erosive tooth wear
  • Occlusal cupping

Raising awareness of the need to screen for erosive tooth wear and the role of the BEWE

In 2018 a group of experts including members of the Erosive Tooth Wear Foundation and representatives from the FGDP(UK), BSDHT, Dental Protection and others met to discuss the need to raise the profile of erosive tooth wear as a threat to oral health. Erosive tooth wear is the 3rd most commonly observed oral condition.Global trends of increased snacking throughout the day, often on fruit between meals, are factors which may increase risk. There was agreement that the BEWE index offered a simple way to screen for and record signs of erosive tooth wear and to act as a prompt to protect both the patient and the dental professional.

Find out more about the meeting from the write up in the British Dental Journal.

The Basic Erosive Wear Examination (BEWE)

The BEWE is a quick, effective, validated tool for assessing enamel wear.It is recommended in the latest UK Department of Health oral healthcare guidelines,5,6 and was a key tool in the ESCARCEL study; the first pan-European epidemiology study on non-carious cervical lesions (NCCL) and associated risk factors, and the largest and most comprehensive study of its kind.

Find out more about this GSK-supported study here.

Dr. Saoirse O'Toole discusses the BEWE tool

Learn how to use the BEWE tool in practice from Dr. Saoirse O'Toole at King's College London Dental Institute.

The need to record erosive tooth wear and provide preventative advice

There is still a lot that remains unknown about the natural history and progression risks of erosive tooth wear. Managing the consequences can be expensive and time consuming for patients. As with periodontal disease, it's therefore important that examination of erosive tooth wear be part of the routine oral health assessment and documented in the clinical records.

Tips for minimising your risk as a dental professional

  1. To avoid a potential delay in diagnosis ensure examination for erosive tooth wear forms part of every routine oral health assessment.
  2. Ensure patients are fully informed about 
    • the extent of the condition in order to be able to provide valid treatment options (preventative and restorative)
    • any early areas of ETW that are being monitored
  3. Routinely record ETW using BEWE and document the fact that the patient has been notified along with any preventative lifestyle advice given
  4. Ensure patients understand the importance of looking after their own oral health and managing their risk factors

The BEWE in practice

  • Step 1 – Talk to your patient

    Female Dentist icon

    How to diagnose tooth erosion

    Your patient’s diet or dietary habits may increase their risk of erosive tooth wear.3,7 Ask them the following questions to help determine their risk:

    1. How many different dietary acids are consumed daily; fruits, anything with a fruit flavouring, acidic drinks, acidic sweets and medications?
    2. How many of these are between meals?
    3. Do you spend more than 10 minutes consuming any acidic food or drink at a single sitting?
    4. Do you sip, swish, hold or rinse acidic drinks before swallowing?
    5. Do you consume dietary acids at an increased temperature e.g. hot water with lemon, stewed fruits, fruit teas?
  • Step 2 – Assign BEWE scores

    Dentition divided into sextants

    BEWE scores describe how severly each sextant of your patient’s dentition is affected by enamel wear. Each sextant should be assigned a score of 0 to 3:

    0. No erosive wear 1. Initial loss of enamel surface texture 2. Distinct defect, hard issue loss extending over less than 50%* of the surface area 3. Hard tissue loss extending over 50%* or more of the surface area

    Once assigned, the scores from each sextant can be used to calculate a cumulative BEWE score.

    *In scores 2 and 3, dentine is often involved

  • Step 3 – Make your recommendations

    Based on your patient’s cumulative BEWE score, plan an appropriate management strategy. The table below gives recommendations for each cumulative score bracket.5

    Score (cumulative score of all sextants) Management
    None: 0–2*
    • Routine maintenance and observation
    • Repeat at 2-year intervals
    Low: 3–8*
    • Oral hygiene, dietary assessment
    • Routine maintenance and observation
    • Repeat at 2-year intervals
    Medium: 9–13
    • Oral hygiene, dietary assessment
    • Routine maintenance
    • Fluoride measures
    • Avoid restorations
    • Repeat at 3–6 months intervals
    High: 14 or over*
    • As above, with the exception of the following:
    • Consider restorations

    Table adapted from Bartlett et al. 20084

    *Cut-off values are based on experience

Sensodyne Pronamel – helping protect your patients against enamel wear

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