Erosive tooth wear and BEWE Gum Health and Basic Periodontal … · 2020-06-14 · Erosive tooth wear can occur on all tooth surfaces; however, data confirms that key teeth to watch

Gum Health and Basic Periodontal Examination (BPE)

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Introduction

Section 1: Erosive tooth wear

Section 2: Identification of erosive tooth wear

Section 3: Prevalence and patient impact

Section 4: Risk factors for erosive tooth wear

Section 5: The Basic Erosive Wear Examination (BEWE)

Section 6: Patient advice and prevention

Section 7: Summary

References

Erosive tooth wear and BEWE

Introduction

Welcome to the distance learning module on the topic of erosive tooth wear and the use of the BEWE.

This module has been developed to help you understand

The patient impact of erosive tooth wear

The prevalence of the condition

Common risk factors

The importance of monitoring erosive tooth wear and how to use the BEWE

Patient advice for prevention


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Section 7: Summary

References


Why is erosive tooth wear important?

What is erosive tooth wear?

Erosive tooth wear is the 3rd most commonly observed oral condition, after dental caries and gum disease.1 Although the rate of progression for the condition can be slow, it can impact on patient quality of life in later years. Once a patient’s enamel is gone, it is gone for good.

Unlike other oral health conditions which may be monitored as part of an oral health assessment, the early stages of erosive tooth wear do not require chairside intervention.1 The role of the dental professional needs to focus on highlighting the condition and supporting patients in the management of risk factors.

It is important that patients at risk of developing the condition are identified early to prevent damage. The dental profession has a duty of care to record the condition in the clinical notes and to inform the patient. Like periodontal disease, it’s important that examination for erosive tooth wear is part of a routine oral health assessment and documented in the clinical records.

Remember: Erosive tooth wear can affect clean, plaque free teeth.

Erosive tooth wear is a multifactorial condition, resulting in the loss of tooth tissue through the combination of erosion (softening of the tooth surface caused by acids) with physical wear such as abrasion or attrition.2

When acids from the diet or intrinsic sources soften the tooth surface, it becomes more susceptible to mechanical wear. Erosive tooth wear includes abrasion and attrition, both of which can in theory work independently, but normally occur with erosion.2 We use the term erosive tooth wear to capture that erosion can be involved but not always.

Erosion

ErosiveToothWear

Abrasion Attrition


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Early identification is key to prevention

Erosive tooth wear can occur on all tooth surfaces; however, data confirms that key teeth to watch out for are the maxillary central incisors and mandibular first molars.3

The early stages of erosive tooth wear are difficult to distinguish with unworn teeth but as the condition progresses it is easier to diagnose however; the tooth may be compromised. The earlier you can diagnose the condition the better, so recording tooth wear in every patient helps to stop severe levels of wear.


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Signs of moderate tooth wear in anterior teeth

As enamel destruction becomes more pronounced it becomes easier to identify the condition clinically. Typical signs we can see are shown on the image below.

Loss of palatal tooth structure reduces support

along the incisal edge

Distinct buccal lesions can also occur and grow in size

The tooth becomes shorter

As the condition progresses the lack of

support leads to fracture of the enamel


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Prevalence of erosive tooth wearWith improvements in oral hygiene more people are keeping their teeth for life. This is resulting in the need for teeth to potentially function for 80 years or more.4 It is important to look for signs in patients of all ages – published data confirms that erosive tooth wear in the primary dentition is a risk factor for the permanent dentition.5

Modern lifestyles and an ageing population mean it is inevitable that erosive tooth wear will feature more in future patient populations. Tooth wear has been shown to be increasing in prevalence globally.6

https://youtu.be/8L0fgOf2SDQ


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Impacts of erosive tooth wearIn addition to the aesthetic impacts and functional limitations of moderate or severe erosive tooth wear, managing the consequences can be expensive and time consuming:7

Average cost £13,000Up to £30,000 for private treatment

(£4,500 for NHS)

Average treatment time – 18-24 Months


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Modern lifestyles are a risk factor

The importance of frequency of consumption occasions

Acidic diets and dietary habits are the key risk factors for erosive tooth wear. Globally, snacking, including healthy snacking, is on the rise.8 Snacking makes up a significant portion of consumption occasions throughout the day and fresh fruit is a leading snack.8

One third of mid-morning snacks and one quarter of mid-afternoon snacks are fruit.8

Research indicates that frequency of acidic challenge is one of the most important risk factors. In fact, the risk increases for each additional acid challenge people have.9,10

An odds ratio is a number used to describe the increased likelihood of having a condition if you have a certain risk behaviour compared to those who do not have the risk behaviour.

The research showed that if acidic fruit was consumed with meals – there was no additional risk.9,10 However if more than 3 dietary acid hits were consumed each day, outside of meals, the risk of developing erosive tooth wear increases by up to 13 times.9,10

• Fruit with meals every day = no increased chances

• 1/day between meals = double the chances

• 2/day between meals = over five times the chances of having erosive tooth wear

With meals:• 1/day = Just under double the chances• 2/day = Over 6 times the chancesBetween meals:• 1/day = 2.5 times the chances• 2/day = Over 11 times greater chance

of having erosive tooth wear

FRUIT & TOOTH WEAR ACIDIC DRINKS & TOOTH WEAR


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Strength of acidThis table highlights the erosive potential of some common drinks. Remember all fruit consumed with meals is safe. Acidic drinks with meals are safe as long as you are not having them every day.11

PRODUCT EROSIVE POTENTIAL

Sparkling water Low

Beer Low

Cola drinks Medium

White wine Medium

Orange juice Medium

Apple juice High

Grapefruit juice High

https://youtu.be/EWxa9R8be-g


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Medical conditions relevant to erosive tooth wearIn addition to food and drink, intrinsic acids also have a part to play in erosive tooth wear. Symptoms of gastro-oesophagel reflux disease (GORD) are very common and up to 65% of the population experience intermittent reflux symptoms.11 GORD is traditionally considered a disease of middle aged or older people, a younger patient with severe tooth wear might have an eating disorder.12


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Support for the BEWE use in general practiceThe BEWE was designed specifically for clinicians working within the general practice environment as a quick and efficient means to record the ETW severity in the clinical notes. It was designed to mirror the BPE, so that both indices can be used at the same time as they are both conducted in a similar manner, with both recording the most severe surface or site in each sextant.

In 2018 a working group of key dental associations met to discuss the need to screen for erosive tooth wear. This meeting included representatives from the Erosive Tooth Wear Foundation, Kings College London, FGDP(UK), BSDHT, Dental Protection and representatives from the BDA Scientific Affairs Committee. As part of this meeting a consensus was reached that the BEWE is the most convenient way to record the severity of erosive tooth wear and should be used routinely at each oral health assessment.

FACULTY OF GENERAL DENTAL PRACTICE


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How to undertake the BEWE examinationSimilar to the BPE, the BEWE divides the patient’s dentition into sextants and a score is assigned based on the most severely affected tooth area within that sextant.

For both grades 2 and 3 dentine is commonly involved. Grade 0 would normally be expected to be seen in newly erupted teeth found in adolescents but is unlikely in adults, particularly over the age of 25.

CODE 1Initial loss of enamel

tooth surface texture

CODE 2Distinct defect,

hard tissue loss <50%

CODE 3Hard tissue loss

≥50%

CODE 0No

ETW

≤2 3-8 ≥149-13

Cumulative Sextant Score


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Once you have assigned a score to each of the sextants, this is totalled up cumulatively and can be compared with the management advice that forms part of the BEWE.

Most importantly you need to remember that if a patient scores a 3 in any sextant then they should be considered a high risk.

It is only at this point that restorative intervention may be indicated – for all other scores this should be avoided where possible.

The following video presented by Professor David Bartlett and Dr Saoirse O’Toole demonstrates the process of the BEWE examination.

Score (cumulative score of all sextants)

Management

Low: 6 or lower* • Oral hygiene, dietary assessment• Routine maintenance and

observation• Repeat at 2-year intervals

Medium: 7-12* • Oral hygiene, dietary assessment• Routine maintenance• Fluoride measures• Avoid restorations• Repeat at 3-6 month intervals

High: 13 or over* • As above with the exception of the following:

• Consider restorations

https://youtu.be/t4yJVtRVUn8


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The BEWE is designed to use the same sextant-based examination process as the BPE. It is therefore recommended that both indices can be undertaken as part of one examination. This video featuring Dianne Rochford, President Elect of the BSDHT demonstrates the process for using the BPE and the BEWE together.

Whilst the BEWE is not optimally designed for use with children, it can be used as a simple tool for recording the presence of wear. The key element of this is to monitor and document and to inform the patient or their carer.

Remember that primary dentition wears at a faster rate than the permanent dentition.13

The BEWE and BPE

The use of the BEWE with children

https://youtu.be/rc_ElSnDtcw


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It is still important to ensure that you follow a healthy diet and get your “5 a day” - Eat as much fruit as you like but with meals

Try not to have fizzy drinks or fruit juices every day – when you do have them, have them with meals

Try to consume acidic food or drinks quickly. Do not sip slowly, swish or swill drinks around your mouth or graze on acidic foods

Watch out for a combination of acids e.g. orange juice for breakfast and fizzy drinks for lunch

Key advice for patients may include:

Water, plain sparkling water, milk and regular tea/coffee are safe

Acidic sugar-free drinks are just as erosive as their sugar sweetened counterparts

Be aware of hidden dietary acids: e.g. fruit cordial, fruit teas, pickles, addition of lemon or fruit water/tea, fruit flavoured or acidic sweets

Useful dietary facts

1. How many dietary acids are consumed daily; fruits, anything with a fruit flavouring / teas, acidic drinks, acidic sweets and medications?

2. How many of these are between meals?

3. Do you spend more than 10 minutes consuming any dietary acid at a single sitting?

4. Do you sip, swish, hold or rinse acidic drinks before swallowing?

Key questions to ask patients about their diet


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The following advice forms part of the Delivering Better Oral Health toolkit for patients at risk of erosive tooth wear:

Avoid frequent intake of acidic food or drinks

Keep acidic drinks to mealtimes and limit the number of fruit drinks

Do not brush immediately after vomiting

Advise patients to seek medical assistance for gastro-oesophageal reflux disease (GORD) and eating disorders

Ensure regular medication is acid free and be aware of medications that reduce saliva flow and thus impact on clearance

Use toothpaste containing at least 1450ppm fluoride twice daily

Fluoride toothpaste protects enamel

Choose a less abrasive toothpaste

Do not brush immediately after eating or drinking acidic food or drinks

Preventative advice

Oral hygiene advice from the same publication includes:


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The current understanding on progression of erosive tooth wear is that continued and repetitive acid challenges cause the enamel surface to soften, releasing calcium and phosphate ions (i.e. demineralisation). This surface is now more susceptible to physical wear from attrition and or abrasion.

If the enamel surface is exposed to fluoride at this stage e.g. from a toothpaste or mouthwash, minerals are taken up on the surface (i.e. remineralisation) resulting in the formation of fluorapatite which is more resistant to further mild acidic challenges than the original enamel).15

It’s important to remember the multifactorial nature of erosive tooth wear; if the softened enamel surface is not exposed to mechanical forces from abrasion or attrition, it can remain intact.

The role of fluoride in prevention

During mild acid challenges

F- Ca2+ Ca2+ Po4

This leaves behind a softened surface which is more at risk to

physical forces e.g brushing.Acid causes outflow of minerals

Fluoride and calcium ions can be incorporated back into the tooth

structure, rehardening it and making it less susceptible to

future acid challenges


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The Relative Dentine Abrasivity or RDA scale was developed by academics, industry members and government agencies to establish a standardised scale of the abrasivity of toothpaste.16 The scale assigns toothpastes with an abrasivity value, relative to a standard reference abrasive which is given the arbitrary value of 100.16

The role of RDA and abrasivity in toothpaste

Toothpaste RDA levels


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Pronamel Intensive Enamel Repair toothpaste is uniquely formulated for patients with early signs of erosive tooth wear:

Actively repairs acid weakened enamel caused by dietary acids17,18

Helps lock in vital minerals into enamel17,18

Low abrasion formulation

The unique formulation of Pronamel Intensive Enamel Repair includes:

Sodium fluoride (1450ppm)

Lactate and controlled pH – to promote fluoride uptake

Co-polymer – to enhance acid resistance19

Pronamel is proven to drive minerals deep into the enamel surface to repair weak areas17

Pronamel Intensive Enamel Repair Toothpaste

Adapted from GSK data on file, 18005. In-vitro cross-sectional DSIMS images of enamel surfaces to compare penetration of fluoride. *vs two competing toothpastes. **Regenerate Original Advanced Enamel Science (1450 ppm fluoride as sodium monofluorophosphate). Sourced in March 2018. ***Oral B Pro-Expert Gum & Enamel Repair (1100 ppm F as stannous fluoride, 350 ppm F as sodium fluoride). Sourced in March 2018.

Delivers more fluoride deep into acid-weakened enamel surface vs. two competing toothpastes

Pronamel Intensive Enamel Repair

Comparator 1** Comparator 2***

Dynamic secondary ion mass spectroscopy images of fluoride uptake to enamel surfaces in vitro


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Also available from Pronamel

Pronamel Extra Freshness Toothpaste, New Pronamel Intensive Enamel Repair, Pronamel Daily Mouthwash, Pronamel for Children age 6-12, Pronamel toothbrush*caused by dietary acids


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Section 7: Summary

Erosive tooth wear and the BEWE

Key advice for minimising professional risk

Erosive tooth wear is the 3rd most commonly observed oral condition, however it is not a condition that is routinely screened or monitored as part of the standard dental examination.1 Modern lifestyles and dietary habits and the fact that people are retaining their teeth for longer means the condition is likely to remain prevalent into the future.

The increased expectations of patients and the public with regards to dentistry standards mean an increased risk of dissatisfaction and potentially litigation if erosive tooth wear is not monitored, recorded or prevented.1 The fact that the condition impacts plaque free surfaces means it may affect patients who are traditionally considered as ‘low risk’.1

Ensure that erosive tooth wear forms part of every routine oral health assessment to avoid a missed diagnosis

Routinely record erosive tooth wear using the BEWE and document the fact that preventative advice is given

Ensure that patients are fully informed about:

The extent of the condition in order to be able to provide valid consent for treatment options (preventative and restorative)

Any areas of erosive tooth wear that are being monitored

Ensure that patients understand where possible the importance of looking after their own oral health and managing their risk factors


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References

1. Bartlett DW et al. Monitoring erosive tooth wear: BEWE, a simple tool to protect patients and the profession

2. Bartlett D. Personal perspective and update on erosive tooth wear – 10 years on. Part 1: Diagnosis. BDJ Vol 221. No.3. August 2016

3. Erosive tooth wear foundation. https://www.erosivetoothwear.com/health-professionals/

4. Adult Dental Health Survey. 2009. National Statistics

5. Harding et al. Community Dental Health. 2010: 27; 41-45

6. Schlueter et al. Br Dent J. 2018; 9(22): 364-370

7. O’Toole et al. 2018

8. Kantar World Panel. Eat, Drink & Be Healthy. How at-home consumption is changing. Feb 2019

9. O’Toole et al. Timing of dietary acid intake and erosive tooth wear: a case-control study. J Dent 2017; 56: 99-104

10. Lussi & Schaffner 1999

11. GERD & chronic heartburn: counselling patients. Pharmacy Times. Jan 2014. https://www.pharmacytimes.com/publications/issue/2014/january2014/gerd-and-chronic-heartburn-counseling-patients.

12. Yamasaki et al. J Neurogastroenterol Motil, 2018; 24(4): 559-569

13. Johansson AK et al. Journal of Dentistry 2001; 29(5): 333-340 https://www.researchgate.net/publication/11869451_Dental_erosion_in_deciduous_teeth-An_in_vivo_and_in_vitro_study

14. Erosive tooth wear foundation. https://www.erosivetoothwear.com/health-professionals/

15. Erosive tooth wear foundation https://www.erosivetoothwear.com/patients/what-does-fluoride-actually-do-in-erosive-tooth-wear/

16. Oral Health Topics Toothpastes. Relative Dentin Abrasivity. American Dental Association. Available online at https://www.ada.org/en/member-center/oral-health-topics/toothpastes. Accessed 17/10/19

17. GSK data on file. Study number 18005

18. GSK data on file. Study number 208166

19. ESR 17-258

Erosive tooth wear and BEWE Gum Health and Basic Periodontal … · 2020-06-14 · Erosive tooth wear can occur on all tooth surfaces; however, data confirms that key teeth to watch

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