OPEN | VERIFIABLE CPD PAPER

Tooth wear CLINICAL

Recommendations and guidelines for dentists using the

basic erosive wear examination index (BEWE)
Vicente Aránguiz,1 Juan Sebastián Lara,2 M. Loreto Marró,1 Saoirse O’Toole,3 Valeria Ramírez4 and David Bartlett*3

Key points
The BEWE is a simple screening toot. THE BEWE is designed to follow a similar procedure THE BEWE should be used for every new patient
at the BPE. examination.

Abstract
This paper explains how to screen tooth wear in general practice using the Basic Erosive Wear Examination (BEWE) index. It
explains how stakeholders in the UK acknowledged the convenience of the BEWE and that it could be recorded at the same
time as the Basic Periodontal Examination (BPE). The article contains examples of anterior and posterior tooth wear for each
BEWE score to help dentists in their evaluation.

Introduction Table 1 BEWE Index assessment (score and description)

Health Education England recently issued Score Description

guidelines that recording tooth wear is 0 No erosive tooth wear
aspirational rather than an essential requirement.1
We know that not every dentist records tooth 1 Initial loss of surface texture (brightness loss, opaque surface or ‘frosted glass’ appearance)

wear, and those that do use a multitude of 2 Distinct defect, hard tissue loss, less than 50% of the surface area. Dentin could be involved
different methods, from indices to terms such
3 Hard tissue loss in more than 50% of the surface area. Dentin could be involved
as mild, moderate or severe. A standardised
BEWE index assesses the damage according to the tooth affected surface regardless its depth in dentin. 2
format to record tooth wear is ideal and one Sextants’ cumulative assessment (maximum 18) defines the BEWE index value per assessed subject, allowing the clinical
that is familiar can facilitate better uptake. The management actions according to risk.

BEWE index (Table 1) was devised in 2008 as a

screening tool for general practitioners to help The group recommended that the BEWE Erosive Wear Examination’. As the BEWE
with routine dental examinations.2 Recently should be performed at the same time as the has evolved from a European consensus, the
in the UK, a group of stakeholders (The Royal BPE to save practitioners time and to utilise term tooth wear has developed a different
College of General Dental Practitioners, The an already established routine and recording connotation for UK dentists compared to
British Society of Dental Hygienists, GSK, Dental grid. The BEWE and the BPE use the same that of our European colleagues. When the
Protection, The Erosive Tooth Wear Foundation, procedure and similar scoring system, thus BEWE was launched, it was felt in Europe
King’s College London and the British Dental can be recorded at the same time. The benefit that erosion was the most important agent
Association) united to promote that every of recording tooth wear at every clinical for tooth wear, hence there was a strong
routine dental examination should include an examination is that it is less likely that tooth influence to refer to ‘erosive tooth wear’. A
assessment of erosive tooth wear.3 wear will be missed. Ensuring it is part of every large emphasis is placed on recognising that
examination limits the risk of early signs not severe tooth wear rarely happens without
1
Facultad de Odontología, Cariology Unit, Universidad de being recognised in patients and prevention a contributing acidic aetiology. In the UK
los Andes; 2Department of Cariology, Operative Dentistry not being started. A toolkit for practitioners and other countries, the term tooth wear is
and Dental Public Health, Indiana University School of
Dentistry; 3Prosthodontics, Faculty of Dentistry, Oral and
has been produced and is available on The preferred. The BEWE gained international
Craniofacial Sciences, Kings College London; 4Facultad de Erosive Tooth Wear Foundation website acceptance and it is now too late to change
Odontología, Cariology, Epidemiology and Public Health
Unit, Universidad de los Andes.
(www.erosivetoothwear.com), which includes the terminology. The index scores changes to
*Correspondence to: David Bartlett free online CPD, uploads to practice-based the surface of teeth regardless of the aetiology,
Email: [email protected]
software to enable recording of the BEWE and so it should be used for all causes of tooth
Refereed Paper. further information. wear – including abrasion and attrition. This
Accepted 11 December 2019 There is some understandable confusion paper provides practical guidance to dentists
https://doi.org/10.1038/s41415-020-1246-y
regarding the application of the term ‘Basic on using the BEWE.

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 CLINICAL Tooth wear

Fig. 1 a) Occlusal surface of a premolar and molar showing no signs of erosive tooth wear.
b) No sign of erosive tooth wear on buccal or occlusal surface. c) A molar with hypoplasia
but no sign of erosive tooth wear. d) BEWE score 1 showing early signs of erosive tooth wear
with discrete, small erosive lesions on occlusal surface. e) BEWE 2 on the premolar. The wear
is just less than 50%. f) BEWE 3 showing erosive tooth wear covering more than 50% of the
tooth surface. g) although erosive tooth wear visible the restoration covers more than 50%
of the surface and therefore cannot be scored

Recommendation and guidelines different scores, the lesser BEWE score should The distinction between grade zero and one is
be used. Each sextant is scored based upon the minor, but the most important distinction is
The severity of tooth wear should be evaluated worst affected surface in that sextant and is between two  and three.  The BEWE is not
in a logical and systematic way and, ideally, recorded in the same grid format as the BPE. designed to be used to assess progression.
at the same time as the BPE at every routine Again, similar to the BPE, single remaining Like the BPE, it is a single assessment and is
clinical examination. In some dental practice teeth in each sextant are added to the adjacent an adjunct to the clinical judgement at the
software applications, this is already possible. sextant. To get an overall score for the mouth, time. It is not sufficiently accurate to enable
Ideally, the teeth should be cleaned before each sextant score can be added together to progression to be assessed over time.
a clinical examination and then the buccal, give a maximum value of 18. This guides the
occlusal and/or incisal and lingual/palatal clinical management actions alongside risk The occlusal surfaces of molars and
surfaces should be assessed in each sextant and patient factors.2 premolars
under good lighting. Third permanent When using the BEWE index with children BEWE score 0
molars are generally excluded but should be and the primary/deciduous teeth, the same • No tooth wear signs on the occlusal surface
considered if they replace a second permanent protocols should be used. The same simple • Occlusal surfaces with no signs of tooth
molar. Restorations that cover more than 50% grid format can be used, with the sextants wear around a restoration interface or cusp
of the total surface should be discarded and divided into anteriors and posteriors. During • Enamel developmental defects, opacities,
other surfaces in the sextant used to indicate the mixed dentition, the assessment should be fluorosis and amelogenesis are scored 0
the score. No sign of erosive tooth wear is the same but it is recognised that deciduous when they do not involve changes to the
allocated a BEWE score of zero. If there is teeth are more prone to wear than adult and shape of teeth due to wear.
initial loss of surface texture (brightness loss, so the scoring is likely to be higher. The risk
opaque surface or ‘frosted glass’ appearance), assessment should account for this and the These are presented in Figures 1a, 1b, and 1c.
a BEWE score of one is allocated. If there is a time interval for repetition of the examination
distinct wear defect with hard tissue loss but should be decreased to between 6  to 12 BEWE Score 1
affecting less than 50% of the surface area, it is months in high-risk cases. • First signs of tooth wear with rounding of
a BEWE score of two. If the loss affects more For patients over the age of 20 years, it is the cusps and grooves
than 50% of the surface, it is a grade three. rare that their dentition is completely wear- • Concavities on cusps (cupping) with
These are explained in more detail for each free. A BEWE score of one is normal but, when diameter ≤0.5 mm (use the WHO probe to
surface below. When doubt occurs between in doubt, the lower score should be chosen. assess its diameter since its tip has a greater

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 Tooth wear CLINICAL

Fig. 2 a) BEWE score 0 on anterior teeth showing unworn teeth. b) BEWE 1 showing a discrete area of wear on the UR1 on the buccal (facial surface)
but no other signs of wear. c) BEWE 2 -shows less than 50% loss with signs of erosive tooth wear on the buccal (facial) surface but also some loss of the
incisal edge. d) BEWE 3 greater than 50% of the surface affected. e) In this case the erosion has removed all of the palatal enamel giving a score 3

BEWE Score 3
• Hard tissue loss signs for more than 50% of
the surface area and dentine is often involved
• Concavities merging (cupping) can be
visible but the total or near-total loss of
the occlusal surface covers more than 50%
• On restored teeth: if tooth wear is seen
adjacent to a proud restoration and
affects >50% of the surface, it is a BEWE
3; however, if the restoration covers more
than 50% of the surface, it cannot be scored.

These are presented in Figures 1f and 1g.

The palatal/lingual and buccal surfaces of

anterior teeth
When evaluating the surface in relation to the
crown, consider the concept of clinical crown
Fig. 3 a) However slight wear is visible on the incisal surface of the canines so a sextant height as the area from the gingival margin
score of 1 is representative of wear in this sextant. b) the whole of the incisal edge of the (regardless of periodontal status) to the incisal/
two central incisors has wear and given a score 3 whereas on the canines the wear is less and occlusal edge.
would be a 2. The sextant score is 3. c) The wear has clearly involved the whole incisal edge
and is given a 3. d) The wear is clearly seen on the incisal edge but there has also been some
shortening of the teeth
BEWE Score 0
• No tooth wear signs on the buccal/palatal/
lingual surface
size). More than one cupping can be found • Concave wear on cusps (cupping) with • Enamel developmental defects, opacities,
on a single surface. diameter ≥0.5 mm (it is possible to use the fluorosis, amelogenesis and others are
WHO probe to assess its diameter since scored 0 when they do not involve changes
These are presented in Figure 1d its tip fits perfectly into the defect) and to the shape of teeth due to wear
overall <50% • Anatomical defects can be present but,
BEWE Score 2 • On restored teeth: tooth wear is not related provided they show no signs of wear, they
• Distinct defect with tooth wear less than to the restoration marginal interface. can be scored as 0.
50% of the whole surface area. Dentine is
often involved These are presented in Figure 1e. These are presented in Figure 2a.

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 CLINICAL Tooth wear

BEWE Score 1
• First tooth wear signs: initial loss of surface
texture (brightness loss, opaque surface
or ‘frosted glass’ appearance) but with a
discrete area on the buccal (facial) surface
and minimal loss of the incisal edge.

This is presented in Figure 2b.

BEWE Score 2
• Distinct defect. Hard tissue loss less than 50%
of the surface area. Dentine is often involved
• If there is loss of clinical crown height less
than 50% from the buccal aspect, a score Fig. 4 If a blunt end probe is run along the margin it is easier to determine as a normal feature
of 2 is given.

This is presented in Figure 2c.

BEWE Score 3
• Hard tissue loss signs with more than 50% of
the surface area. Dentine is often involved but
is not a prerequisite for a BEWE score of three
• For restored teeth, the tooth wear can only
be scored provided that the size of the
restoration does not exceed 50%.

This is presented in Figure 2d and 2e.

Incisal edges of anterior teeth

Evaluating the wear along the incisal edges
Fig. 5 Even though tooth wear has produced the lesions associated with the crowns they cover
(Fig. 3a) can be challenging. However, the same more than 50% of the surface and therefore the sextant cannot be scored
criteria must be used as for other surfaces, even
though this might result in a higher sextant score.

Gingival recession
A differential diagnosis between erosive tooth
wear with exposure of root and gingival recession
(Fig. 4) is needed. The area can present a small
depression or notch, anatomically normal. In
case of doubts, a ball-ended probe (WHO) can
be used to make a tactile assessment, comparing
with neighbouring teeth. The apparent concavity
around the gingival margin is not wear but the
Fig. 6 a) The lesion is carious and not erosive. b) Again a primarily carious lesion even though
normal architecture of the tooth. it appears to have some evidence of wear

Crowns
When erosive tooth wear has been restored Missing teeth • Tactile sensation: carious lesions can
with crowns (Fig. 5), there may be a clinical If a single tooth remains in a sextant, add the present a friable surface. Non-carious wear
suspicion that the reason is tooth wear, but if scoring to the adjacent sextant. will present a hard surface. Use the WHO
the restoration covers more than 50% then the probe in case of doubts and compare with
surface cannot be scored. Differential diagnosis between erosive neighbouring teeth
tooth wear and root/cervical caries lesion • Plaque assessment: plaque stagnation will
Rotated teeth • Colour assessment: root caries lesions be associated with a caries lesion
In cases of tooth rotation, the surface facing the appear brown-orange in colour. Non- • If you detect a caries lesion associated with
cheek would be buccal even if that would not carious wear will have the corresponding an erosive tooth wear lesion, consider the
be correct anatomically. The result of a rotation tooth structure colour. Compare the colour corresponding BEWE score for the affected
would not influence the sextant score. with the adjacent teeth surface, regardless of the caries lesion

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 Tooth wear CLINICAL

• If still in doubt whether it is a caries lesion BEWE; however, the most important aspect is References
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