The prevalence, etiology and management of tooth wear in the

United Kingdom
Bernard G. N. Smith, BDS, PhD, MS, MRD, a David W. Bartlett, BDS, PhD,
MRD, ~ and Nigel D. Robb, BDS, PhD c
UMDS, Guy's Hospital, London, United Kingdom
Statement o f p r o b l e m . Recent epidemiologic evidence suggests that tooth wear is now a significant
problem in both children and adults. There is growing evidence that a major cause of the severe wear in
patients is regurgitation erosion due to a variety of factors including gastroesophageal reflux disease.
P u r p o s e . The purpose of this article is to discuss the prevalence of tooth wear in the United Kingdom.
Emphasis in management should be on accurate diagnosis, and in some patients, long-term monitoring
before embarking on any irreversible, intervenfive treatment. Even when treatment is necessary, a period of
monitoring is helpful to assess the rate of progress of the wear, the effectiveness of preventive measures,
and therefore the extent of the treatment necessary.(J Prosthet Dent 1997;78:367-72.)

I t is not always possible to differentiate between
erosion, attrition, and abrasion, as these conditions fre-
quently occur in combination. It is therefore necessary
to have a term for the condition in which teeth become
worn and tooth wear is a convenient, simple term readily
understood by patients. This is important because the
management o f tooth wear relies on the patient under-
standing the nature o f the condition, so that the patient
can provide sufficient information (sometimes sensitive
or embarrassing) to the clinician to allow for a differen-
tial diagnosis and to prevent further progression.
An alternative term, tooth surface loss (TSL), has been
proposed. 1 However, this term has two significant dis-
advantages. First, it understates the severity o f the con-
dition by implying that only the surface o f the tooth is
lost, whereas in some situations, the wear can be very
extensive. The second disadvantage o f the term is its
subtlety that escapes most patients and some dentists.
The term was originally proposed to differentiate tooth
surface loss from tooth subsurface loss, the latter being
a way o f describing early enamel caries. This distinction
is i m p o r t a n t because early e n a m e l caries can be
remineralized, whereas once the surface o f the enamel
is lost, there is no matrix in which remineralization can
take place. This distinction is important to scientists and
clinicians but is less useful in communicating with pa-
tients.
DEFINITION OF TERMS
The terms erosion, attrition, and abrasion should only
be applied clinically when there is strong evidence that
the differential diagnosis is clearly one o f the three con-
Presented at the Academy of Prosthodontics, Newport Beach, Calif.,
May 1996.
~Professor, Department of Conservative Dentistry.
bLecturer, Department of Conservative Dentistry.
CLecturer, Department of Restorative Dentistry, The Dental School,
Newcastle upon Tyne, U.K.
ditions. When there is inadequate evidence or when a
combination o f causes is present, then the term tooth
wear is preferred. Erosion is the result o f chemical dam-
age (acids) excluding chemicals produced by bacteria.
Attrition is defined as the physical wear o f one tooth
against another, which means that only tooth surfaces
that make contact with each other can be described as
having attrition. Abrasion is the physical wear o f the tooth
surface by something other than another tooth.
PREVALENCE OF TOOTH WEAR IN THE
UNITED KINGDOM
There have been two major surveys in recent years,
one o f adult patients in the South East o f England 2 and
the other a national survey o f children conducted by a
government agency. 3 The adult survey used the T o o t h
Wear Index (TWI). 4 This index was designed to record
levels o f tooth wear regardless o f the cause. It has been
used in a number o f studies, 5-7 the largest being 1007
patients in the South East o f England. 2 Briefly, each vis-
ible tooth surface (facial, lingual, and occlusal/incisal)
is recorded together with a separate score for the facial
cervical region, which sometimes suffers a different pat-
tern o f wear. Scores from 0 to 4 are given, according to
the severity o f wear (TWI manual2.~). A problem in re-
cording tooth wear is some wear is natural and progresses
throughout life in contrast to caries and periodontal dis-
ease, which should not occur at all. The TWI therefore
incorporates threshold values for each tooth surface for
each decade o f age, and a computer program calculates
unacceptable levels o f wear (above these thresholds). For
example, Figure 1, A shows a mandibular molar with
cupped out wear defects through to dentin in a 17-year-
old patient. This amount o f wear is unacceptable or
pathologic for this age. Figure l , B shows a much more
extensive pattern o f wear, with dentin exposed across
most o f the molar occlusal surface in a 75-year-old pa-
tient. Assuming that this wear had been progressive

OCTOBER 1997 THE JOURNAL OF PROSTHETIC DENTISTRY 367

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. A, Cupped out wear defects on occlusal surface of 17-
year-old patient. B, Dentin exposed by wear across almost all
occlusal surface in 75-year-old patient.
t h r o u g h o u t life, the chances are this t o o t h will remain
symptomless and functional. Therefore this a m o u n t o f
wear, at this age, could be regarded as acceptable.
PREVALENCE IN ADULTS
The results of the survey of 1007 patients 2 showed that,
for the 15- to 26-year-age group, 5.73% o f tooth surfaces
were worn to an unacceptable degree. In the 56- to 65-
year-age group, the wear was 8.19% and wear in the over
65-year-age group was 8.84%. The figures for the three
intermediate decades were lower, between 3.37% and
368
SMITH, BARTLETT, AND ROBB
0 5 10 15 20
M e a n T o o t h W e a r Score
Fig. 2. Mean tooth wear scores for four groups of patients
particularly vulnerable to dental erosion compared with equal
numbers of age- and sex-matched controls. Patients in first
three groups were categorized by psychiatrists treating them.
Abstaining anorexics and bulimic patients had classic symp-
toms of their conditions. Vomiting anorexics had episodes of
vomiting in addition. Chronic alcoholics were attending cen-
ter for treatment of alcoholism.
4.62%. The explanation for the decrease from the first
age group to the middle age groups is that the threshold
levels, although increasing with age, assume a steady in-
crease in wear throughout life. This appears not to be the
case and there is evidence that some young people under
the age o f 26 years have accelerated rates o f wear and
those over the age of 55 years also have a greater propor-
tion o f their tooth surfaces unacceptably worn.
The absolute figures are troubling. In particular, the
older age groups who retain their natural teeth longer
are likely to need a substantial amount o f treatment if
more than 8% o f their t o o t h surfaces are worn to an
unacceptable degree. However, not all o f these worn
surfaces may need treatment.
W h i c h patients are m o r e at risk?
It is n o w firmly established T M that anorexia nervosa
and bulimia nervosa are strongly related to dental ero-
sion, particularly the palatal surfaces o f the maxillary
incisor teeth. Erosion later spreads to other teeth begin-
ning with the occlusal and facial surfaces o f the man-
dibular molar and premolar teeth. Chronic alcoholism
produces a similar pattern o f erosion, although usually
more generalized, n-14 Figure 2 illustrates the differences
in mean T o o t h Wear Score between four study groups
and age- and sex-matched controls from the survey pre-
viously described. 4
D o e s loss o f p o s t e r i o r s u p p o r t increase t h e w e a r o f
a n t e r i o r teeth?
It has often been assumed that there must bc a rela-
tionship between loss o f posterior support and increased
wear o f the occluding surfaces o f anterior teeth. This
assumption, although appearing to be c o m m o n sense,
VOLUME 78 NUMBER 4
SMITH, BARTLETT, AND ROBB
is not logical when the physiology of the masticatory
system is considered. The mechanical assumption is that
there is a certain amount of chewing to bc done and, if
the posterior occlusal table is reduced, then this func-
tion will be transferred to the anterior teeth. In fact, the
amount of force applied to any tooth is limited by its
proprioceptive feedback mechanism triggered by the
mechanoreceptors in the periodontal membrane. The
physiologic view is therefore that each tooth will sustain
a certain amount of force regardless how many other
teeth are involved in mastication. In the study of 1007
patients, correlation coefficients were calculated for the
TWI score For the relevant anterior tooth surfaces and
the number of missing posterior teeth (Fig. 3). It can be
seen that, although all positive, nearly all the correla-
tion coefficients were less than 0.3, with the exception
of the maxillary incisal surface, for the over 65-year-age
group. This was 0.51 and was just statistically signifi-
cant. However, if the wear on the maxillary incisal edges
had been due entirely to attrition, the wear on the man-
dibular incisal edges would have been similar. The im-
plication is that a secondary factor, presumably erosion,
influenced the maxillary incisal edges in at least some of
the patients. This evidence, although by no means con-
clusive, suggests that posterior tooth loss does not sig-
nificantly affect anterior tooth wear.
PREVALENCE OF DENTAL EROSION IN
CHILDREN
A national survey of over 2,000 children conducted in
the United Kingdom in 1993 examined all aspects of oral
health, s One measurement was dental erosion of the max-
illary anterior teeth. The results for permanent incisor teeth
in children betwecn 7 and 15 years of age are illustrated
in Figure 4 and are distressingly high. Some evidence of
palatal enamel erosion was seen in more than a quarter of
the subjects over 11 years of age and was sufficiently se-
vere in 13- to 15-year-old subjects to have penetrated to
dentin in between 2% and 3% ofthc subjects. The Survey
Report s suggests that this may be due to an increase in
the consumption of soft drinks, which contain acid, but
offers no evidence to support this assumption.
ETIOLOGY OF EROSION
In addition to this survey of children, there is grow-
ing evidence that erosion rather than attrition or abra-
sion is the major cause of tooth wear. ~6-19Certainly, the
extent of the wear, particularly in young age groups, is
much greater when the causc is erosion compared with
other causes.
Dental erosion is now recognized as being caused by
one or more of the following factors, and perhaps some
other factors as yet unknown: regurgitation occurring
in the eating disorders, gastroesophageal reflux disease
(GERD), morning sickness, chronic alcoholism, hiatus
hernia, and voluntary rumination. 2
OCTOBER 1997
THE JOURNAL OF PROSTHETIC DENTISTRY
Corl
Coe
0.6
0.5
0.4
0.3
0.2
0.1
Fig. 3. Correlation between tooth wear score and number of
missing posterior teeth for four age groups. Number of miss-
ing teeth potentially ranged from nil (all molar and premolar
teeth present) to 20 (N = 776).
% o f Children
with Erosion
35
jJ
30
o
15
J
7 8 9 10
Fig. 4. The proportion of children with erosion affecting the
permanent incisor teeth.
The Following dietary items, taken to excess, are
thought to produce dental erosion: Fruit juice and car-
bonated drinks, citrus Fruit, picldes, spicy Food, and vin-
egar. Some industrial processes producing acid fumes
and droplets cause dental erosion, although this is now
less common with improved industrial practices. Also,
some medications are acid. A common example is chew-
able vitamin C tablets that have a p H of about 2.
The coFactors that affect the extent of erosion include
the flow rate and buffering capacity of saliva and the
effect on saliva of some common drugs such as the di-
uretics and many of the antidepressants. The e n a m e l /
dentin susceptibility to erosion may be influenced by
the fluoride content.
Recent studies 212s have shown that regurgitation ero-
sion in patients with GERD is closely related to dental
erosion, particularly palatal erosion of the maxillary inci-
sor teeth. By using the standard internationally accepted
tests for GERD, including 24-hour monitoring of esoph-
ageal pH together with oral pH, this study related these
measurements to dental erosion. Figure 5 illustrates the
369
THE JOURNAL OF PROSTHETIC DENTISTRY
GERD +
Symptoms +
GERD +
Symptoms-
GERD-
Symptoms + ~ 6
GERD
Symptoms
5 10 15 20
N u m b e r of Patients
Fig. 5. Number of patients with and without gastroesophageal
reflux disease and with and without symptoms. All 40 patients
had well-established palatal erosion exposing large areas of
dentin.
number o f patients with and without GERD and with
and without symptoms in 40 patients with well-estab-
lished palatal erosion, exposing large areas o f dentin in all
patients. The relationship between symptoms and GERD
in 16 of the patients is to be expected, but the finding
that 9 of this sample of 40 patients (36%) had no symp-
toms and yet were diagnosed as having GERD is surpris-
ing. These are patients lmown by gastroenterologists as
"silent refluxers." GERD is a cyclical condition and not
all patients who suffer from it are diagnosed during a single
24-hour p H monitoring period. It is therefore possible
that some o f the nine other patients who were not diag-
nosed with GERD and also who did not have symptoms
may have produced evidence o f GERD if the measure-
ments had been taken at another time.
MANAGEMENT AND TREATMENT
Tooth wear is a condition that affects the patients'
dentitions for the remainder o f their lives. A lifelong
approach to management should therefore be taken
rather than short-term expedient treatment measures.
The emphasis should be on persistent efforts to identify
the cause o f the wear and appropriate prevention insti-
tuted with the same enthusiasm that dietary control and
oral hygiene are emphasized in the prevention o f caries
and in the management o f progressive periodontal dis-
ease, respectively. Long-term monitoring is necessary to
assess the effectiveness o f preventive measures and any
further progression o f the wear before deciding whether
interventive treatment is necessary.
Restorative treatment is only necessary when one o f
the following criteria is met. Active treatment is prema-
ture unless one of these indications is present: The pa-
tient is presently concerned about his or her appearance;
tooth sensitivity or pain that cannot be controlled con-
servatively; or progressive, uncontrollable wear that is
altering the occlusal vertical dimension or will make res-
370
SMITH, BARTLETT, AND ROBB
Fig. 6. Casts of occlusal surface of maxillary occlusal splint
taken 3 months apart. Cast on left shows wear facet develop-
ing, due to attrition. Cast on right shows further development
of wear facets.
toration difficult if allowed to continue. Currently, it is
believed that active treatment is provided too early in
many patients. 26
PREVENTION
It is not possible to describe herein the details o f the
methods o f prevention of the eating disorders, chronic
alcoholism, or GERD that are mainly medical in nature
but to which the dentist can make a significant contri-
bution. Ira dietary cause is clearly identified, the dentist
has a major role in preventing erosion.
Preventing attrition caused by nocturnal bruxism is
difficult, but hard acrylic resin occlusal splints can be
effective. Figure 6 shows casts o f the occlusal surface of
a maxillary occlusal splint taken 3 months apart. Wear
facets can be seen developing in the occlusal surface in
the cast on the left and these have progressed signifi-
cantly in the cast on the right This technique is valuable
in establishing that nocturnal bruxism is the cause o f
attrition. Continuing to wear an acrylic resin occlusal
splint at night absorbs the wear on the splint rather than
further damaging the teeth. In severe, long-term situa-
tions, a cobalt chromium skeleton base can be used with
occlusal surfaces in acrylic resin, which can be replaced
as necessary.
MONITORING
Monitoring by periodic clinical examination is sub-
jective, and objective records should be kept. These may
be photographic records or study casts. Figure 7, A and
B, shows the maxillary incisor teeth o f a 15-year-old boy
who has palatal erosion that has exposed wide areas o f
dentin. This has become stained, showing that the ero-
sion is no longer active Active erosion leaves a clean,
unstained surface. The teeth were not sensitive, the la-
bial appearance was not affected (Fig. 7, B) and the in-
cisal edges have not been shortened There was there-
fore no need to treat this condition, but there was a
long-term need for continual monitoring in the event
that the cause o f the erosion (which had not been reli-
ably identified) returned
Figures 8 and 9 show sets of study casts taken several
VOLUME 78 NUMBER 4
SMITH, BARTLETT, AND ROBB
Fig. 7. A, Stain on eroded palatal surfaces of incisor teeth of
15-year-old boy. B, Labial surfaces showing no stain and no
loss of incisal length.
Fig. 8. Cast on left was taken when patient was in his early
sixties. He had just had mandibular right first molar extracted.
Cast on right was taken 10 years later and there has been
insignificant progression of wear, which had been largely due
to erosion. Until time that first cast was taken, he was eating
spicy, Asian diet, producing regurgitation. Later when his wife
died, he dramatically changed to bland diet and regurgitation
ceased.
years apart. Figure 8 shows that wear had not continued
and Figure 9 shows casts where it had, although treat-
ment was still not indicated.
TREATMENT
When treatment is indicated for one of the above rea-
sons, the minimum treatment necessary to solve the prob-
lem should be used. This will range from simple desensi-
tizing procedures through conventional restorations to
multiple crowns. With regurgitation erosion that has pro-
gressed to the point where the incisal edges are signifi-
cantly reduced or the labial surfaces are affected, it is of-
ten necessary to crown at least the six maxillary anterior
teeth. In some situations, there is sufficient dentin re-
OCTOBER 1997
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 9. These casts taken 9 years apart show some progres-
sion in wear of mandibular incisor teeth, but little further wear
of posterior teeth. It would have been difficult to restore teeth
in 1981 and there was no indication to do so because patient
had no significant complaints of appearance or sensitivity.
Leaving teeth unrestored for these 9 years has done no signifi-
cant harm and has avoided possible complications of difficult
restorations. Incidentally result of further wear has produced
more uniform occlusal plane.
Fig. 10. Casts on left show eroded maxillary incisor teeth and
overerupted mandibular incisor teeth, Casts on right show
result of orthodontic treatment to depress mandibular incisor
teeth, thereby creating space for crown preparations on max-
illary incisors without reducing eroded palatal surfaces any
more. This approach produced more esthetic appearance and
is less destructive than crown lengthening and conventional
crown preparations.
maining to produce retentive preparations, but in others,
the wear has progressed to the point where further prepa-
ration o f the worn surfaces would be unwise. In these
situations, the occlusion is usually disrupted and some
localized orthodontic treatment to intrude the teeth,
which have supraerupted as a result o f wear, is preferable
to crown lengthening. This can be achieved by conven-
tional orthodontic treatment (Fig. 10) or by the use o f a
fixed Dahl appliance (Fig. l l , A, B, and C). 27,28
SUMMARY
The prevalence o f unacceptable levels o f tooth wear
in the United Kingdom is high, particularly in older age
groups where substantial treatment may be necessary.
371
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 11. A, Maxillary teeth have been eroded both palatally
and labially by regurgitation. B, Fixed Dahl appliance bonded
to maxillary anterior teeth acting as simple orthodontic ap-
pliance to depress mandibular incisors. C, After wearing DaN
appliance for 3 months, clearance between maxillary and
mandibular incisor teeth is achieved so crown preparations
can be made with minimum further palatal tooth reduction.
There is also a high amount o f erosion in children, at
least in the United Kingdom. Patients specifically at risk
include those with eating disorders (anorexia or bulimia
nervosa), chronic alcoholics, and patients with diagnosed
and undiagnosed GERD. Posterior tooth loss is prob-
ably not significantly related to anterior tooth wear.
Long-term management of tooth wear should start with
a sound differential diagnosis, strenuous efforts at pre-
vention, long-term monitoring, and proceed to active
treatment only when indicated. When treatment is indi-
cated, it should be limited to solving specific problems,
although this may well indicate extensive reconstruc-
tion in s o m e s i t u a t i o n s .
Figures 6, 7a, 8, 9, and 10 were borrowed with permission from
Smith BGN, Some Facets of Tooth Wear (Ann R Austr Coil Dent Surg
1991 ;11:37-51 ).
372
SMITH, BARTLETT, AND ROBB
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Reprint requests to:
DR, B. G. N. SMITH
GUY'S HOSPITALDENTALSCHOOL
LONDONSE1 9RT
UNITED KINGDOM
Copyright 1997 by The Editorial Council of The Journal of Prosthetic Den-
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VOLUME 78 NUMBER4