TOOTH WEAR INDICES

DR KASSIM ABDULAZEEZ
Department of periodontics
29/04/2019
 OUTLINE
• 1.INTRODUCTION
• 2.DEFINITION OF SOME TERMS
• 3.TOOTH WEAR
• 4.INDICES
• 5.TOOTH WEAR INDICES
• 6.CONCLUSION
• 7.REFERENCES
 INTRODUCTION
• Tooth wear means the loss of tooth substance by
means other than dental caries
• It is also called Non-carious tooth substance loss. It is
a very common condition that occurs in about 55.3%
of the population (Okeigbemen et al 2015).
• It is a normal physiological process that occurs
through out life majorly as a result of three
processes ; Attrition, Abrasion and Erosion. but it
becomes an oral concern when it occurs in an
accelerated rate.
 DEFINITION OF TERMS
• 1.FROTHING:
• This is the habit of holding carbonated drinks
in the mouth and sucking them in and out of
the teeth to make froth.it extends the contact
time of the drink to the teeth. thus,
predisposing the teeth to the resorptive and
demineralizing effect of the drink.
• 2.ABFRACTION:
• This is loss of tooth substance at the cervical
margins, as a result of minute flexure of teeth
under occlusal loading.The term is derived from
the latin words AB and FUNCTIO meaning
‘’away’’ and ‘’breaking’’ respectively.
• It present as triangular lesions along the
cervical margins of the buccal surfaces of teeth
were the enamel is thinner.
• 3.INDEX/INDICES:
• An index is an expression of clinical
observations in numerical values.it is used to
describe the status of the individual or group
with respect to a condition being
measured.indices are developed to compare
the extent and severity of disease
• 4.ORDINAL SCALE.
• The ordinal scale is a rank order scale in which
the numbers are assigned to the object to
determine the relative extent to which certain
characteristic is possessed.It helps in
identifiying that whether the object has more
or less of a characteristic as compared to
another object,but does not tell about how
much or less the characteristic is.
 TOOTH WEAR
• This means loss of tooth substance by means
other than dental caries.It is a very common
physiological condition that occurs through out
life and varies substantially in the population.
• Its is seen in 55.3% of the population.
• Attrition accounts for 29.6%,Abrasion
11.8%,Combination of Attrition and Abrasion
4.6% and Abfraction 2.0%.
• (Okeigbemen et al 2015)
FACTORS THAT DETERMINE WEAR OF TEETH

• These include:
• 1.Age
• 2.Occupation
• 3.Sensitivity or pain
• 4.Tooth cleaning aids
• 5.Brushing technique
• 6.Intake of carbonated beverages and method of
• intake ( e.g.Frothing )
• 7.Tooth brush texture
• 8.Sex
AETIOLOGY OF TOOTH WEAR

• 1.Abrasion
• 2.Attrition
• 3.Erosion
• 4.Gastroesophageal reflux disease(GERD)
• 5.Abfraction
• 6.Vomiting e.g. bulimia,alcoholism
• 7.Eructation
• 8.Low PH Diet/Fluids
• 9.Frothing
CLASSIFICATION OF TOOTH WEAR
• Grippo et al 1991 put forward a classification
of hard tissue lesions of teeth.He defined four
categories of tooth wear:
• 1.Attrition
• 2.Abrasion
• 3.Erosion
• 4.Abfraction
• Other authors include Kornfeld , Blacks, Lee
and Eakle also classified tooth wear lesions.
• ATTRITION:
• This is the loss of tooth substance as a result of
physical tooth to tooth contact during normal
or parafunctional masticatory activities
(bruxism).
• Attrition mostly causes wear of the incisal and
occlusal surfaces of the teeth. A degree of
attrition is normal/physiologic.it can become
noticeable with age.
• The following factors can affect the degree of
tooth destruction
• 1.Poor quality or absent of enamel seen in
• -fluorosis
• -environmental/hereditary enamel hypoplasia
• -premature contact
• 2.Intraoral abrasives
• 3.Pringing habits
• CLINICALY FEATURES
• 1.Occurs both in deciduous and permanent teeth
• 2.most frequently in
• Incisal and occlusal surfaces,
• Lingual surfaces of anterior maxillary teeth and
• Labial surface of anterior mandibular teeth
• 3.Cupping of occlusal surfaces
• ABRASION:
• This is the pathological wear of tooth
substance through bio-mechanical frictional
processes other than the teeth or mastication
e.g. Tooth brushing, Tooth picks, Dental floss,
Pipe smoking, using tooth paste with high RDA
value, nail biting,horizontal tooth brushing
stroke.
• CLINICAL FEATURES
• 1.It tend to present as round, concave or
wedge shape ditching around the cervical
margins of teeth
• 2.It has sharply defined margins
• 3.It Can present as a notches in the incisal
edge of anterior teeth
• 4.The degree of lost is greatest on prominent
teeth (Cuspids and Bicuspid) and teeth
adjacent to edentulous area
• 5.occasionally it is more advanced on the side
of the arch opposite the dominant hand
• EROSION:
• This is the loss of tooth substance by
Chemical/acid dissolution of the teeth either of
intrinsic or extrinsic origin that is unrelated to
acid produced by bacteria in dental plaque.
• It is a wear of non occluding tooth surfaces
(buccal and lingual surfaces) with sharply
defined wedge shape depression in the cervical
area.
• AETIOLOGY
• 1.Vomiting associated with eating disorders like
anorexia nervosa, bulimia nervosa and
rumination
• 2.Reflux or chronic regurgitation associated with
gastrointestinal problems.
• 3.Regular intake of acid medications (chewable
acetylsalicyclate acid tablet)
• 4.Regular intake of chewable vitamin c tablet.
• 5.High consumption of acid drinks and food
• 6.professional wine testing
• 7.field of occupation-acid battery workers
• 8.pregnancy
• ACTIVE AND PASSIVE EROTION
• Smooth clean surfaces and presence of
dentine hypersensitivity suggest an active
erosion
• Stained teeth and absence of dentine
hypersensitivity suggest an inactive erosion
• CLINICAL FEATURES
• 1.It is usually seen on the palatal (inside)
surfaces of upper anterior teeth and the
occluding (top) surfaces of the molar teeth.
• 2.It is rarely seen in archaelogical record
suggesting it is mostly as a result of dietary
changes, habits or diseases.
 Prevention of erosion
• 1.decrease the frequency of consumption of
acidic drinks and food especially at bedtimes
• 2.if soft drinks are consume;it should be
chilled and consumed in one sitting at meal
times.
• 3.avoid sipping the drink or swishing it around
the mouth before swallowing.
• 4.Consumption of neutralizing foods such as
cheese after the intake of an acidic drink of
food
• 5.Encourage the consumption of water and
nutritious beverages.
• ABFRACTION:
• This is the loss of tooth substance at the
cervical margin caused by bio-mechanical
tensile stress that present as triangular
lesions.it was postulated that these lesions
were caused by fatigue of the enamel and
dentine as a result of funtional stress. Its
existence is debated.
• CLINICAL FEATURES
• 1.Wedge defects limited to the cervical area of
• the teeth
• 2.Deep,narrow plus V-Shaped grooves
• 3.Predominantly affects
• bicuspids and molars (Facial surfaces)
• 4.There is greater prevalence in those with
• brusixim
 INDICES
• An Index is a numerical value describing the
relative status of a population on a graduated
scale with definite upper and lower limits,
which is designed to permit and facilitate
comparism with other population classified by
the same criteria and methods. RUSSEL A .L
 CLASSIFICATION OF INDEX
• Indices are classified based on
• 1.Direction in which their score can fluctuate
• 2.The extent to which the oral cavity is
• measured
• 3.The entity they measured
• 4.General index
 Based on the direction in which their score
can fluctuate
• Based on the above an indices can further be
classified into
• 1.Reversible index:
• Measures condition that can be changed
• e.g.periodontal index
• 2.Irreversible index:
• Index that measures conditions that will not
change e.g. Tooth wear indices
 Depending upon the extent to which areas
of oral cavity are measured
• 1.Full mouth indices:
• Patients entire dentition or periodontium is
measured.e.g. Oral hygiene index
• 2.Simplified indices:
• Measures only a representative sample of the
dental apparatus e.g. Simplified oral hygiene
index
According to the entity which they measure:

• 1.Disease index:
• ‘’D’’ decay portion of the DMF index is the best
example of disease index
• 2.Symptom index:
• Measuring gingival or sulcular bleeding are
essentially example of symtom indices
• 3.Treatment indices:
‘’F’’Filled portion of DMFT index is the best example for
treatment index
 General indices
• 1.Simple index:
• Index that measures the presence or absent of
a condition e.g. plaque index, Tooth wear
index.
• 2.Cumulative index:
• Index that measures all the evidence of a
contition,past and present e.g. DMF index
 ideal Requisites of an index
• 1.Clarity and Simplicity:
• Should be easy to apply so that there is no undue
time lost during field examination
• 2.Objectivity:
• Criteria for the index should be clear and
unambiguous, with mutually exclusive categories
• 3.Validity:The index must measure what it is
intend to measure, so it should correspond with
clinical stages of the disease under study
• 4.Reliability:
• It should measure consistently at different
times and under a variety of conditions
• i.e
• (a) inter examiner reliability:different
examiner record the same result
• (b) Intra examiner reliability:same examiner
records the same result at repeated attempts
• 5.Precision:
• Ability to distinguish between small
increments.
• 6.Acceptability:
• Safe and not demeaning to the subject
• 7.Quantifiability:
• The index should be amenable to statistical
analysis and interpretable
 TOOTH WEAR INDICES
• There is a need for the measurement of tooth
wear,and the literature abound with many
methods which are quantitative and
qualitative .
• The quantitative methods tend to rely on
objective physical measurements,such as
depth of groove,area of facet or height of
crown
• Why the Qualitative methods,which rely on
clinical descriptions,can be more subjective if
appropriate training and caliberation are not
carried out but which ,with correct technique
can be a valuable epidermiological tool.
• Examples include:
 EXAMPLES
• 1.Index for dental erosion of non-industrial
origin( by Eccles)
• 2.Tooth wear index ( by Smith and Knight)
• 3.Basic erosive wear examination-BEWE
• (by Barlett,Ganss and Lussi)
• 4.Erosion index(by Lussi)
• 5.Simplified scoring criteria for tooth wear
indices( by Bardsley)
 INDEX FOR DENTAL EROTION OF NON-
INDUSTRIAL ORIGIN
(by Eccles J.D 1979 )
• Eccles originally classified lesions broadly as
early,small and advanced,with no strict criteria
definitions,thus allowing wide interpretation.
• Later,the index was refined and expanded,with
greater emphasis on the descriptive criteria.It
was then presented as a comprehensive
qualitative index,grading both severity and site
of erotion due to non industrial causes.
• Eccles index can be considered as having four
separate 3-point ordinal scale,namely
• A.facial surfaces
• B.lingual and palatal surfaces
• C.incisal and occlusal surfaces
• D.multiple surfaces
• For each ordinal scale, the discription are
identical while the surfaces differ
 ECCLES INDEX FOR DENTAL EROSION OF
NON-INDUSTRIAL ORIGIN
CLASS SURFACE CRITERIA
CLASS I Early stage of erosion,
absence of developmental
ridges, smooth surfaces of
maxillary incisors and
canine

CLASS II Facial Dentine involved for less

than 1/3 surfaces; there
are two types
Type I (commonest): ovoid
or crescentic in outline,
concave in cross
differentiate from wedge
shaped abrasion lesions
Type 2: Irregular lesion
entirely within crown.
lesion is punched out.
CLASS IIIa FACIAL More extensive destruction
of dentine,affecting part of
the surface of anterior
teeth,but some are
localised and hollowed out

CLASS IIIb LINGUAL OR PALATAL Dentine eroded for more

than 1/3 of the surface
area .with etched
appearance.
Incisal edge is translucent
due to loss.
its flat or hollow out, often
extending into secondary
dentine
CLASS IIIc INCISAL OR OCCLUSAL -Surfaces involved into
dentine,appearing
flattened or with cupping.
-Undermined enamel;
restorations are raised
above surrounding enamel

CLASS IIId MULTIPLE SURFACES Severely affected

teeth,where both labial
and lingual surfaces are
affected ;teeth are
shortened
• Eccles index is broken down into three classes
of erosion,denoting the type of lesion
assigned to four surfaces,representing the
surface where erosion was detected.
• However the system is time consuming.
• Xhanga and Valdmanis designed a similar
score with greater accuracy but could not
address the issue of inter or intra examiner
variability.
 Xhonga and Valdmanis
• The levels are
• None
• Minor: less than 2mm
• Moderate: up to 3mm
• Severe: greater than 3mm
• They further differentiate types of erosion by
morphological descriptions, such as wedge, saucer,
groove and atypical.
• They did not address the issue of inter or intra examiner
variability
 TOOTH WEAR INDEX
(by Smith B G and Knight JK )
• Tooth wear index was developed by Smith and Knight in
1984.TWI has three separate point ordinal scale.namely
• Buccal-B
• Cervical-C
• Lingual-L
• Occlusal-O
• incisal-I
• For each ordinal scale,the discription differ.It is widely
used in epidemiological studies.
 Tooth wear index scoring
SCORE SURFACE CRITERIA
0. B/L/O/I No loss of enamel surface
characteristics

C No loss of contour
1. B/L/O/I Loss of enamel surfaces
characteristics

C Minimal loss of contour

2. B/L/O Loss of enamel exposing
dentine for less than 1/3 of
the surfaces

I Loss of enamel just

exposing dentine

C Defect less than 1mm deep

SCORE SURFACE CRITERIA
3. B/L/O Loss of enamel exposing
dentine for more than 1/3
of surfaces
I Loss of enamel and
substantial loss of dentine
C Defect less than 1-2mm
deep
4. B/L/O Complete enamel loss
pulp exposure
Secondary dentine
exposure
I Pulp exposure or exposure
of secondary dentine
C Defect more than 2mm
deep pulp exposure
Secondary dentine
exposure
 BASIC EROSIVE WEAR EXAMINATION
INDEX(BEWE)
• The Basic Erosive Wear Examination index was
first described in 2007 by Barlett,Ganss and
Lussi.This partial scoring system is based on
the surface area affected within a sextant (i.e.
teeth in mouth divided into 6 parts),the most
severely affected tooth surface
(buccal,occlusal or lingual/palatal) is recorded
according to the severity of the wear.
• The BEWE has only one 4-point ordinal scale
the description of which are used for all
surfaces. A cumulative score is then matched
to a risk level and guidance for its
management by a clinician.
BASIC EROSIVE WEAR EXAMINATION INDEX
BEWE SCORE CLINICAL APPEARANCE DESCRIPTION

0 No erosive tooth wear

1 Initial loss of surface texture

2 Distinct defect, hard tissue loss < 50% of

the surface area

3. Hard tissue loss greater than and equal to

50% of the surface area
• The management includes steps which
identify and eliminate the main aetiological
factors, preventative treatment and also any
operative and symptomatic intervention
required by the patient. The frequency of
repeating the index range from 6-12 months
depending on the risk level of the patient.
 EROSION INDEX
• It is a scoring system created by LUSSI et al.by
• Modifying the classification of LINKOSALO and
MARKKANEN.
• It utilises a qualitative index with listed
diagnostic criteria to confirm lesions as erosive
and a four scale grading of severity, relating to
involvement of dentine.
• The facial ,lingual and occlusal surfaces of all
teeth are scored except the molars
• The Lussi index consist of a 4-point ordinal
scale for the facial surfaces, and of a 3-point
ordinal scale for the occlusal/lingua surfaces.
• The description of grade 0 is identical for both
scales,while for the other grades ( 1,2 and 3)
the description differ.
SURFACE SCORE CRITERIA
FACIAL 0 No erosion, surface with
smooth, silky glaze
appearance, possible
absence of developmental
ridges

1 Loss of surface enamel,

intact enamel cervical to the
erosive lesion; concavity on
enamel where breadth
clearly exceed depth, thus
distinguishing it from
toothbrush abrasion. With
or without undulating
borders of the lesion and
dentine is not involved.
 2 Involvement of dentine for
less than half of tooth
surface

3 Involvement of dentine for

more than half of the tooth
surface

OCCLUSAL/LINGUAL 0 No erosion(surface with a

smooth silky glaze
appearance) with or without
absence of developmental
ridges

1 Slight erosion, rounded

cusps,edges of restorations
arising above the level of
adjacent tooth
surfaces,groove on occlusal
aspects.loss of surface
enamel.dentine is not
involved
2 Severe erosions, more
pronouced sign than in grade
1.
Dentine is involved
 SIMPLIFIED SCORING CRITERIA FOR
TOOTH WEAR INDEX
• Pioneered by Bardley.
• Use in epidemiological studies with large
numbers of patient
• In this index,the tooth wear scoring is
essentially dichotomised into the presence or
absent of dentine exposure.
 SIMPLIFIED SCORING CRITERIA FOR TOOTH
WEAR INDEX
SCORE CRITERIA

0 No wear into dentine

1 Dentine just visible (including cupping) or

dentine exposed

2 Dentine just exposed greater than 1/3 of

surface

3 Exposure of pulp or secondary dentine

 PURPOSE AND USES OF TOOTH
WEAR INDICES
Tooth wear index can be
• 1.An individual oral health assessment score
• 2.A clinical trial or
• 3.A community health epidemiological survey
• All of which has various purpose and uses in
oral health.
 Tooth wear index as an Individual clinical
score
• PURPOSE:
• In clinical practice it can be used for education,
motivation and evaluation.
• USES
• 1.To provide individual assessment to help a
patient recognise an oral problem
• 2.It reveal the degree of effectiveness of the
present oral health practices.
• 3.To evaluate treatment outcome.
Tooth wear index as a clinical trial
• PURPOSE
• A clinical trial is planned for the determination
of the effect of an agent or procedure on the
progression ,control, or prevention of disease.
It is conducted by comparing an experimental
group with a control group that is similar to
the experimental group in every way except
for the variable being studied.
• E.g.
• Tooth wear index can be used to measure the
effectiveness of mechanical devices for
personal care, such as toothbrushes,
• interdental cleaning devices or water
irrigators.
 Tooth wear index as a community health
epidemiological survey
• Tooth wear index can be used to show the
prevalence and incidence of a particular
condition occurring within a given population
• E.g. simplified scoring criteria for tooth wear
index by Bardley et al records presence or
absent of Dentine exposure.
 CONCLUSION
• Tooth wear is a normal physiological process which
can have an interesting pathologic outcome.Its
measurement had long been attempted by several
authors.
• To date,there is no one ideal index that can be used
for epidermiological prevalence studies,clinical
staging and monitoring.
• However improvement of these indices makes it
relevant in clinical practice and gives it a global
acceptance.
 REFERENCES
 Lopez-Frias FJ,Castellanos-Cosano L,Martin-Gonzalez
J,Llamas-Carreras JM,Segura-Egea JJ (Februrary
2012).’’Clinical measurement of tooth wear:Tooth
wear indices.”Journal of clinical and Experimental
Dentistry.4(1):e48-53

 Kaidonis J A(August 2012).”Oral diagnosis and

treatment planning:part 4.Non carious tooth surface
loss and assessment of risk’’.British Dental Journal
213(4):155-61
 Smith B.Holly (1984). “Patterns of molar wear
in hunter-gatherers and
agriculturalist”.American Journal of Physical
Anthropology.63(1):39-56
THANK YOU ..