Tooth Surface Loss (TSL)

Sumamry This lesson is intended to give an overview of what to consider when treating patients with TSL, including the causes and management.

Tooth surface loss can be physiological or pathological. These are distinguished by taking into account the patient’s age and the severity of tooth wear e.g. in a young person with severe TSL would be pathological, whereas in an older person with moderate TSL this may be physiological from normal use over the years.

Buzz words:

Erosion Abrasion Attrition Abfraction Tooth Wear Index (TWI) Basic Erosive Wear Examination (BEWE) Occlusal Vertical Dimension (OVD) Centric Occlusion (CO) Retruded contact position (RCP) Intercuspal position (ICP) Dahl Effect Diagnostic wax up Mock upsReviseDental.com Conformative Reorganised Splints (Michigan and Tanner, soft and bilaminar) Epidemiology (1)

77% of the adult population have tooth wear of some degree. (2) 15% of dentate adults exhibited moderate tooth wear (exposing substantial dentine) 2% of adults suffered from severe tooth wear (exposing secondary dentine or pulp) More prevalent in men (70%) than women (61%)

Causes:

There are 4 causes of tooth surface loss:

1. Erosion 2. Abrasion (Think abrasion= brushing aka an object other than an opposing tooth) 3. Attrition (Think attrition = teeth) 4. Abfraction

Tooth surface loss is often a multifactorial problem. The different causes often appear simultaneously which potentiate their effects. It is important to identify the etiological factors of tooth wear so that the patient can be advised of ways to manage it.

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Erosion (3) Erosion is the loss of tooth substance by chemical action, not involving bacteria. (4) Erosion can potentiate the effects of other sources of tooth wear. Erosion can have different aetiologies: Intrinsic and/ or extrinsic

Intrinsic: (3)

Gastro-oesophageal reflux disease (GORD )-Please refer to Gastrointestinal diseases for more information about GORD.

Vomiting - spontaneous or self-induced. This includes morning sickness. Note: Hyperemesis gravidarum. Eating disorders such as bulimia nervosa and anorexia nervosa. (5) A study found that frequency and duration of episodes were not linearly associated with the severity or number of eroded teeth.(6).

Rumination - relaxation of lower oesophageal sphincter allows gastric contents to move into the mouth which is then re-swallowed (effortless regurgitation). This is uncommon.

Extrinsic: (3) ReviseDental.com Drinks - Carbonated drinks, soft drinks (smoothies, juices, fruit flavoured water) and some alcoholic drinks, including dry wine, cider and alcopops are erosive. (7) Alcohol is also the most common cause of heart burn and chronic gastritis. (11)

Food - Including citrus fruits and foods pickled in vinegar. Less well known foods that are acidic in nature include, brown sauce, crisps, ketchup and vinaigrette. Flavoured gum can also be erosive. Medications - Vitamin C, aspirin and some iron preparations. Medications that cause dry mouth (e.g. antihypertensives) potentiate the effects of erosion and other medications can cause nausea and vomiting. Beta-adrenergic bronchodilators that may be used for asthma therapy are associated with reduced saliva flow. This may lead to an increased risk of erosion. (8)

Lifestyle - grazing habits, diet trends e.g. having lemon in water.

Drugs - e.g. ecstasy can increase the risk of erosion. (9)

Environmental - work related exposure e.g. battery workers, laboratory technicians and competitive swimmers.

Predisposing factors - individual saliva flow and buffering capacity as well as clearance rates. (10)

Other factors to look out for: (8)

Some mouth washes can have a very low pH Orthophorphoric acid and guarana extract may be used in diet or normal colas. These can cause erosion. Slimming pills and laxatives cause dehydration and this may be a risk factor for erosion. Acetic acidsReviseDental.com are used to preserve fruits and vegetables so can cause erosion.

Signs: (3)

Restorations that stand proud. (8) Cupping of cusp tips. Extrinsic sources often manifest in TSL of the labial surfaces of maxillary teeth . Intrinsic sources normally manifest on the palatal aspect of maxillary anterior teeth. (11) Chamfered ridges or ledges that may be visible or felt with a probe.

Grooves in incisal edges with dentine show. Incisal chipping. Shortened teeth. Mainly affects maxillary teeth (although can occur on any surface). Dentine exposure can cause the tooth to look darker and patients may complain about the aesthetics.

Preventative management (3)

Pt education

Counselling on erosive habits Can be facilitated with information leaflets. Advise on acid attacks and importance of limiting acidic food and drink consumption to meal times. Acid attacks should be limited to 4 times a day. Better to drink a fizzy drink quickly than constantly sipping for a longer period of time. Role of milk or cheese in neutralising intra-oral acids and chewing sugar-free gum to increase saliva flow. The bufferingReviseDental.com effect of saliva Diet diaries to identify erosive food and drink. This should be recorded 3 days in a week including a day at the weekend. Advise against the frequent consumption of sports drinks if this is applicable, especially after exercise when saliva flow is lower. Behaviour education- holding drinks in the mouth or swishing the drink around the mouth increases the risk of erosion because it affects the tooth surface pH (13). Better to drink through a straw directed straight to the back of the mouth Oral hygiene advice

Fluoride is important in remineralisation. Consider fluoride varnish application and prescription of a high fluoride toothpaste If the patient has just had an episode of vomiting, recommending to not brush their teeth for at least 20 minutes (ideally up to 60 mins) after the episode will help, as this will increase the risk of abrasive wear on the softened tooth surface.(14) Rinse with water or milk after an episode. Not to eat or drink anything after brushing their teeth before bed. Not to brush their teeth after consuming erosive food/ drink

Referrals

If suspected GORD then refer to a GP or gastroenterologist. Ensure the patient has given consent for this. If patients have an eating disorder, a referral to receive medical and psychological advice and counselling will help them, but ensure the patient has given consent and that confidentiality is maintained, e.g. the patient may not want a family member to know.

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Abrasion

Abrasion is tooth wear caused by an object other than an opposing tooth. Sources of abrasion:

Brushing (too hard) Biting pen lids Hobbies e.g. using teeth to hold onto fishing hooks or sewing needles. This can cause defects where the object would usually be placed. Musical instruments involving reeds can also cause abrasion. Industrial abrasives include dusts of silica, carborundum and diamond.

Preventative management:

Patient education on abrasive habits- holding objects between their teeth. Warning of brushing their teeth too aggressively. Recommendation of a softer toothbrush. The use of a non-abrasive toothpaste. (note: tooth paste abrasion count)

ReviseDental.com Note: remember TSL can be multifactorial. This, alongside brushing aggressively may also have a high acidic diet.

Attrition (8)

Attrition is tooth wear caused by tooth to tooth contact.

Risk factors:

Parafunctional habits e.g. bruxism Conditions with abnormal neuromuscular activity and bruxism e.g. cerebral palsy Drug use e.g. MDMA, cocaine ("gurning") ReviseDental.com

Signs:

Scalloped tongue/ tooth indentations Masseter hypertrophy (tenderness in the muscle on palpation) Pronounced linea alba Reports of clenching and grinding (at night or during the day) Note: association with headaches

Preventative treatment:

Splint therapy (discussed later)

ReviseDental.com Abfraction

Occlusal loading leads to compression and flexion of the tooth. This can cause microfractures in the enamel rods in the cervical region leading to TSL.

Signs

Sharp cervical cavities ("Class V")

Note: Degradation refers to the fusion of tooth wear on occlusal/ incisal surfaces with tooth wear on a cervical area. This occurs in a late stage of wear. (8)

Tooth wear can expose the pulp but in adults this is very rare since the rate of wear is normally slow enough to allow sclerotic and reparative dentine to be formed. In these cases indirect pulp capping should be attempted and elective endodontics should be avoided because there is no bacterial invasion, unlike with caries.(8)

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Summary of clinical presentations: (8) Type Presentation Primarily affects the cusps of posterior teeth and palatal of anterior teeth. Chipping of the thin enamel margins of incisors.Molar and premolar teeth show cupping of the cusps. Erosion Anterior teeth can show cupping of the incisal edges. These can merge across the oblique and marginal ridges to form a bowl shape. Mandibular molar teeth often most severely affected in this instance. Margins of restoration may stand proud of the natural tooth. Flat, well defined and demarcated.Shiny if active progression. Complementary facets often present on the opposing teeth. Primarily affects the cusps of posterior teeth and the incisal edges and palatal of Attrition anterior teeth. Tooth indentations on the tongue (scalloped tongue). Pronounced linea alba. Masseter hypertrophy.Reports of clenching and grinding (at night or during the day). Cervical lesions. Abrasion Specific shaped lesions on incisal edges from holding objects in between teeth. Wedge-shaped cervical lesions. Abfraction Likely to be present with signs of attrition. Most common in locations least protected by serous saliva.

Diagnosis (8)

History taking-ReviseDental.com talking to the patient about their occupation, hobbies, oral hygiene routine and diet may help point towards a diagnosis. Extraoral examination- look for TMJ dysfunction, masseter hypertrophy which may point towards bruxism. Intraoral soft tissue examination- Linea alba and tooth indentations on the tongue (scalloped tongue) may be indicative of bruxism. Intraoral hard tissue examination- Existing restorations may have high margins in cases of erosion. Visually inspect all surfaces of the tooth for wear. Occlusion- to see if there is TSL where the teeth come into contact. May be indicative of attrition. This can also be carried out with study casts and articulating paper. Saliva tests- most patients will not suffer from xerostomia but suffer from work or sports related dehydration; however, tests can play a role in confirming medically induced xerostomia. The methods of monitoring tooth surface loss described below are also important in its diagnosis:

Putty matrices (sectioned labio-palatally) - this is not as applicable for children because dento- alveolar growth will prevent the seating of the putty matrix at review appointments. Clinical photographs Study casts 3D scanners Clinical indices

In addition to a diagnosis, it is also important to assess whether the tooth wear is active or has stabilised. Below are the signs to look out for: (8)

Active TSL Stabilised TSL Sensitivity No sensitivity Shiny facets Matte/ Dull surfaces Little or no calculus Significant calculus present Little or no staining Staining present Frothy or bubbly saliva Pooling saliva Dry mucosa Moist mucosa Mucosal changes Existing restorations intact. Missing restorations

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Measuring tooth surface loss:

There are many indices for measuring tooth wear. Two of the most commonly used are described below: Tooth Wear Index (TWI) - Smith and Knight

Records any type of tooth wear

How to perform:

Each surface of each tooth is recorded (buccal/ labial, lingual/palatal, occlusal/ incisal, cervical), irrespective of how it has occurred. If in doubt, the lower score is given The score is recoded on a table (resembling the 6PPC)

ReviseDental.com Score Criteria (15) No loss of enamel surface characteristics 0 No loss of contour Loss of enamel surface characteristics 1 Minimal loss of contour Loss of enamel exposing dentine for <1/3 of the surface 2 Aka- Loss of enamel just exposing dentine Defect < 1mm deep Loss of enamel exposing dentine for >1/3 of the surface Aka- Loss of enamel and substantial 3 loss of dentine Defect < 1-2 mm deep Complete enamel loss (excluding ‘halo’ of enamel) 4 Pulp exposure or exposure of secondary dentine Defect > 2 mm deep

Limitations:

Time consuming to record for every surface of the dentition. Too much data is generated. The thresholds for physiological tooth wear were high leading to an understatement of tooth wear. (16)

BEWE (Basic Erosive Wear Examination) (13)

An examination for erosive tooth wear should be part of every oral health assessment. One way to do this is to recordReviseDental.com a BEWE routinely.

Used for screening purposes. Most widely used index for erosive tooth wear. How to perform:

The severity of tooth wear is assessed and each sextant is given a score of 0-3 (highest scoring tooth). Then, this score from each sextant is added together to make a cumulative total. The total suggests a risk level which may be used to guide the management of the tooth wear.

Sextant Score:

Score Appearance 0 No erosive tooth wear 1 Initial loss of surface texture 2 Distinct defects, hard tissue loss <50% of surface area 3 Hard tissue loss >50% surface area Note: It is the highest scoring tooth that gives the sextant its score

Cumulative Total:

Risk level Cumulative score of all sextants None ≤2 Low 3-8ReviseDental.com Medium 9-13 High ≥14

Management: Cumulative Recommended management (13) score ≤2 Repeat BEWE as part of each routine clinical examination OHI, dietary assessment and adviceRoutine maintenance and recommend low 3-8 abrasion toothpasteRepeat BEWE as part of each routine clinical examination As above plus:Identify main aetiological factors in erosive tooth wearConsider additional fluoride measures/ strategies to increase resistance of the tooth 9-13 surfaceAvoid placement of restorationsMonitor with study casts, clinical photographs, silicone impressions etcRepeat BEWE at least every 6-12 months ≥14 As above plus:Consider restorative intervention Consider specialist referral

Limitations (17)

Pathological or physiological tooth wear not directly ascertained. Results may include false positives or false negatives. Because the scores are cumulative for each sextant, it may mask severe wear in one sextant when the rest of the dentition is comparatively unaffected. Edentulous sextants will not have a score and this can be reflected in an underestimated total score. Was set up initially to be used for erosive wear. (May transfer to record other tooth wear types going into the future).

These techniques are then re-recorded at the appropriate recall, to identify whether the wear has progressed or stabilised.

ReviseDental.com Consequences of TSL (18)

Diminished dental aesthetics. Pain and/ or sensitivity. Loss of occlusal vertical dimension OR/ OVD maintained through dento-alveolar compensation. Loss of posterior occlusal stability, leading to increased tooth wear, mechanical failure of teeth and/ or restorations, hypermobility and drifting of teeth.

Dento-alveolar compensation: (18)

In cases where a patient has TSL, you might think that there would be a decrease in OVD and excessive interocclusal space due to the loss of tooth structure. However, in many cases, these measurements remain unchanged. This has been found to be the case in 80% of patients with severe tooth wear. (18) This is predominantly caused by dento-alveolar compensation.

What is it?

Dento-alveolar compensatory mechanisms assist in the establishment of an occlusion, that works by altering the alveolar bone and the axial orientation of the teeth. (19) ReviseDental.com Management of TSL:

The management of the worn dentition is a very broad and detailed topic. This lesson will cover the fundamental concepts and management options (refer to the 3rd party references for further reading).

The main management options include:

Monitoring the tooth surface loss. Providing preventative advice. Managing dentine sensitivity. Restorative intervention: via the conformative or re-organised approach.

Monitoring tooth surface loss: (3)

In many cases monitoring tooth wear will be the appropriate treatment, especially where tooth wear is mild, the patient is asymptomatic and has no aesthetic complaints. ReviseDental.com

Preventative advice:

Some of this preventative advice has already been discussed in the conservative management of specific causes of tooth surface loss, but these are summarised to re-cap below: (20) Fluoride Desensitising therapy Dietary analysis and advice Habit modification Splint therapy GP referrals

As we have not yet discussed splint therapy, this is covered in more detail below.

Splints: (21)

A full coverage hard acrylic splint may be used to disrupt the parafunctional habit of bruxism by causing tooth separation and changing the habitual pathway of closure into centric occlusion.

Two types of splints commonly mentioned are the Michigan and Tanner splints:

Michigan = Maxillary

Tanner = Mandibular

It has been advised that centric stops on each tooth, canine guidance and shared anterior guidance on protrusion should be included in the design to provide an ideal occlusion during wearing of the appliance. ReviseDental.com

Care should be taken when providing these splints to patients with erosive tooth wear, because acid may build up within the splint, exacerbate the problem. However, reservoirs can be incorporated within the design into which fluoride gels or alkali (milk of magnesia or sodium bicarbonate solute) can be added. Managing dentine sensitivity:

Desensitising toothpastes can reduce sensitivity. Tooth Mousse ®may help. Fluoride is important in remineralisation. Fluoride varnish application. Prescription of high fluoride toothpaste. Dentine bonding agents may be applied to exposed dentine to seal the tubules and reduce sensitivity (22) Flossing instruction. If flossing is carried out too aggressively may abrade dentine and cementum would could already softened by acids (8) The use of astringent mouthwashes in contraindicated in patients with TSL because they precipitate protective salivary proteins, which reduces the protective effects of saliva. (8)

Restorative intervention:

Although in many occasions a preventative approach is preferred, some cases of tooth wear indicate a restorative intervention: (23)

Aesthetic concerns Symptoms of pain and discomfort Functional difficulties The presence of an unstable occlusion Where the rate of TSL is of major concern and may lead to pulpal exposure ReviseDental.com

Pre- treatment:

Before undertaking restorative treatment, always consider the prognosis of each tooth (periodontal, endodontic, restorative) as you would with any treatment. Where the tooth wear is generalised a tooth-by-tooth prognosis is required (see lesson). When restoring the worn dentition, it is important to take the following factors into account: (21)

Pattern of TSL Inter-occlusal space Space requirements of the restorative intervention The quantity and quality of available tooth structure Aesthetic demands of the patient

It is also advisable not to undertake restorative intervention if the TSL is still active (see diagnosis section). Preventative advice should be carried out first to stabilise the TSL, and restorative treatment carried out only when it has done so.Occasionally if underlying TSL factors cannot be controlled; in this case, it may help prevent wear to the tooth, but the restoration is likely to fail and need replacing in a matter of time. The patient should be warned of this. (8)

Delaying the restorative phase of treatment has the following benefits: (24)

Delays initiation of the restorative cycle The patient has the time to comprehend the nature of the TSL Allows the patient to understand the complexities of the treatment that. This can help them decide what treatment is best for them and whether they still want to undertake it. Enhance the likelihood of a successful outcome and the long-term prognosis from treatment.

However, the exception to delaying treatment with preventative advice is in the situation of a young patient with an eating disorder. Preventative advice should still be given as the first course of action along with a GP referral (note: consent/ any safeguarding issues), but there is often rapid TSL with symptoms. Deferring the restorative treatment may have a significant effect on the patients oral health, aesthetics,ReviseDental.com and therefore psychological wellbeing. (24)

Pre-treatment occlusal analysis is an invaluable technique to be able to effectively and safely treatment plan TSL cases. This involves: (25) Examination of the dentition in intercuspal position (ICP). Examination of the dentition in retruded contact position (RCP). Identify whether the tooth wear is localised or generalised. Take alginate impressions of both arches. Take a facebow record in RCP (this will allow the models to be reproducibly articulated on a semi-adjustable articulator). Note: centric relation (retruded axis position) is a reproducible position if choosing to reorganise with no stable contact position. The position relates to the condyles, rather than the teeth themselves. Prescription of a diagnostic wax up from the lab. It is helpful to enclose a photo of the patient with unworn teeth so that the lab can try to replicate the look of this.

Conformative vs Reorganised approach

When restoring the worn dentition, the dentist must decide whether it is most appropriate to use the conformative or reorganised approach. This is a very large topic in itself so the fundamentals will be discussed in this lesson. However, it is first important to understand what the 2 approaches are: (26)

Conformative approach

Placement of restorations without changing the existing occlusion. In order to do so, the occlusion (both dynamic and static) should be assessed prior to commencing treatment. This ensures that the contact points, ReviseDental.comand therefore occlusion, are the same after treatment as they were before.

Reorganised approach

The restoration of a dentition with the intention of changing the occlusion (to one that is ideal). The indications in relation to tooth wear are described in the table below:

Approach Indications (27) Satisfactory OVD and adequate coronal tooth tissue for adhesive or conventional casting. Conformative Adequate occlusal clearance for the restorative material Reproducible occlusal contacts Localised tooth wear Inadequate coronal tooth structure for adhesive or conventional casting Unsatisfactory OVD Reorganised Inadequate occlusal clearance for restorative material. Unstable occlusion without reproducible contacts Generalised tooth wear

If there is space for restorations when the patient is in ICP, then these may be provided relatively easily. However, if there is not space (often the case), then this must be created by one of the following methods:

Method Description (25) Where there is tooth wear in one arch with no dento-alveolar compensation, the OVD will be decreased due to overclosure. The teeth can therefore be restored to the original OVD or normal resting face height which the patient Increasing the normally tolerates. (3) Occlusal Vertical Where there has been dento-alveolar compensation, the OVD can be Dimension (OVD) increased to create space between the teeth. A hard occlusal splint to assess ReviseDental.comwhether the patient can tolerate the new OVD or being ‘opened up’ can be used. The permanent restorations are then made to fit the new OVD. Useful when there is localised tooth wear e.g. palatal of maxillary incisors. The worn teeth are built up using composite which brings the other teeth The Dahl Effect out of occlusion. Over time (normally months) the other teeth erupt slightly to re-establish occlusion. The adjustment of teeth in one or both arches to provide space. This is useful where only one tooth is needed to be restored, however removing Enameloplasty tooth structure from an already worn dentition should be avoided due to risk of loss of vitality, sensitivity and loss of height of the teeth. Used when there is a large slide between RCP and ICP. The mandible can be Distalization of the distalized by removing a premature contact found in RCP. This means that mandible restorations can be placed in the new position negating the need to increase the OVD. Used when there is insufficient crown height for definitive restorations. This Crown lengthening is invasive and often bone is needed to be removed to protect the biological width. This is a conservative method; however, is very time consuming. Increasing the overjet or reducing the overbite can create space. Any alignment Orthodontics discrepancies can also be carried out. There is unreliability when intruding teeth and a risk of root resorption. Elective root canal When there is insufficient tooth height to retain a crown. In this case treatment and post elective devitalisation with RCT and a post- crown may be considered. crowns

Mock ups/ Wax ups: (24)

Intra-oral mock-ReviseDental.com ups

These can be carried out free hand or using a diagnostic wax up constructed by the lab.

The purpose of mock ups are to assess the aesthetics, occlusion and speech of the planned treatment prior to commencement. It allows the patient to make more of an informed decision and is important in consent. Free-hand

The teeth are built up using unbonded composite on unprepared enamel without any matrix or impression serving as a guide. If the patient and clinician are both happy with the design, an impression or 3D scan is taken. This is so that the design can be replicated in a permanent material.

Please refer to the 3rdparty references for guidance on considerations on how to complete an intra- oral mock up e.g. smile design.

Diagnostic wax ups:

With a prescription, the technician will devise a diagnostic wax up to meet the aesthetic and functional requirements of the patient. This is where wax is placed onto a model to show the shape of the final restorations and should ideally be carried out so the occlusion is mutually protected.

An impression is taken in PVS or a vacuum formed PVC matrix is prepared so that the design can be transferred from the model to the teeth. Initially this is constructed in a provisional crown material so that the patient can visualise the results. This is carried out by filling the impression/ matrix with the provisional material and seating it in the mouth. Once the material is set, the impression/ matrix is removed and the flash/ excess trimmed away. ReviseDental.com The intra-oral mock up is then assessed for speech, aesthetics and occlusion. At this stage it is beneficial for photographs to be taken so that the patient can think about the design and have input from friends and family.

Alternatively this can be achieved with digital smile technology but this is not included in the lesson. Restorative options: (25)

The restorative options that exist are:

Bonded composite Crowns: Ceramic, PFM, Metal

These have the same advantages and disadvantages as when used in other restorative situations. When considering composite restorations ensure that there is a ring of enamel present around the periphery of the tooth. This is also referred to as the ring of confidence because the bond strength to enamel is superior to that of dentine.

It is also important to keep in mind that composite is easily reparable if fractured, whereas crowns need preparation and when opposing natural tooth, some types of ceramic may potentiate the effects of tooth wear.

Please refer to other lessons on restorative materials for the advantages and disadvantages of each option as these will provide more in depth detail.

Alternatively, where severe wear is apparent with little supra-gingival tooth structure, there is also the option of an overdenture, often requiring RCT and abutment preparation. However, this is a whole topic in itself.ReviseDental.com

Post-treatment splints (22)

After treatment, a splint may be made for the patient to protect the restorative treatment. This may be in the form of a soft splint or a bi-laminar guard. These are both worn at night to prevent tooth wear from bruxism which may also result in damage to restorations.

Conclusion Hopefully this lesson has provided an overview of the types of tooth wear and different management options. This is a very broad topic and you can read about it too many depths. As a general dentist you are expected to identify tooth wear and manage some cases, but it is important to recognise the limitations of your abilities/ experience and know when cases are beyond your competency and so are appropriate to refer. Note: Tooth wear in children another large topic which is important to cover. Please refer to the 3rdparty references for information on this topic.

Third Party Links

1. O'Sullivan E, Barry S, Milosevic A, Brock G. Diagnosis, Prevention and Managment of Dental Erosion. RCS; 2013. 2. Lussi A. Toothwear: The ABC of the worn dentition. John Wiley & Sons; 2011 Jul 20. 3. Bartlett D, Sundaram G, Moazzez R. Trial of protective effect of fissure sealants, in vivo, on the palatal surfaces of anterior teeth, in patients suffering from erosion. Journal of dentistry. 2011 Jan 1;39(1):26-9. 4. Chu FC, Siu AS, Newsome PR, Chow TW, Smales RJ. Restorative management of the worn dentition: 4. Generalized toothwear. Dental update. 2002 Sep 2;29(7):318-24. 5. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. Current concepts on the management of tooth wear: part 1. Assessment, treatment planning and strategies for the prevention and the passive management of tooth wear. British dental journal. 2012 Jan;212(1):17-27. 6. Yule PL, Barclay SC. Worn down by toothwear? Aetiology, diagnosis and management revisited. Dental update. 2015 Jul 2;42(6):525-32.

References

1. Steele J, O’Sullivan A. Adult Dental Health Survey 2009—Summary report. London: National Health Service Health and Social Care Information Centre. 2011. 2. Delivering better oral health: an evidence-based toolkit for prevention [Internet]. 3rd ed. London: PublicReviseDental.com Health England; 2020 [cited 26 July 2020]. Available 3. O'Sullivan E, Barry S, Milosevic A, Brock G. Diagnosis, Prevention and Managment of Dental Erosion. RCS; 2013. 4. Eccles JD. Tooth surface loss from abrasion, attrition and erosion. Dental update. 1982 Aug;9(7):373. 5. Lussi A, Ganss C, editors. Erosive tooth wear: from diagnosis to therapy. Karger Medical and Scientific Publishers; 2014 Jun 24. 6. Milosevic A, Slade PD. The orodental status of anorexics and bulimics. British dental journal. 1989 Jul;167(2):66-70. 7. Smith BG, Robb ND. Dental erosion in patients with chronic alcoholism. Journal of Dentistry. 1989 Oct 1;17(5):219-21. 8. Lussi A. Toothwear: The ABC of the worn dentition. John Wiley & Sons; 2011 Jul 20. 9. Duxbury AJ. Ecstasy--dental implications. British dental journal. 1993 Jul;175(1):38-. 10. O’Sullivan EA, Curzon ME. Salivary factors affecting dental erosion in children. Caries research. 2000;34(1):82-7. 11. Hattab FN, Yassin OM. Etiology and diagnosis of tooth wear: a literature review and presentation of selected cases. International Journal of Prosthodontics. 2000 Mar 1;13(2). 12. Johansson AK, Lingström P, Imfeld T, Birkhed D. Influence of drinking method on tooth‐surface pH in relation to dental erosion. European journal of oral sciences. 2004 Dec;112(6):484-9. 13. Bartlett D, Dattani S, Mills I, Pitts N, Rattan R, Rochford D, Wilson NH, Mehta S, O’Toole S. Monitoring erosive toothwear: BEWE, a simple tool to protect patients and the profession. British dental journal. 2019 Jun;226(12):930-2. 14. Davis WB, Winter PJ. The effect of abrasion on enamel and dentine after exposure to dietary acid. British dental journal. 1980;148(11/12):253-6. 15. Smith BG. An index for measuring the wear of teeth. Br Dent J. 1984;156:435-8. 16. López-Frías FJ, Castellanos-Cosano L, Martín-González J, Llamas-Carreras JM, Segura-Egea JJ. Clinical measurement of tooth wear: Tooth wear indices. Journal of clinical and experimental dentistry. 2012 Feb;4(1):e48. 17. Yim VK. Tooth wear: screening, diagnosis and management in general dental practice. Dental Update. 2017 Jun 2;44(6):502-17. 18. Davies SJ, Gray RJ, Qualtrough AJ. Management of tooth surface loss. British dental journal. 2002 Jan;192(1):11-23. 19. Zengingul A, Eskimez Ş, Değer Y, Kama J. Tooth wears and dentoalveolar compensation of vertical height. Biotechnology & Biotechnological Equipment. 2007 Jan 1;21(3):362-5. 20. bdj.2011.1099 21. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. Current concepts on the management of tooth wear: part 1. Assessment, treatment planning and strategies for the prevention and the passive management of tooth wear. British dental journal. 2012 Jan;212(1):17-27. 22. Azzopardi A, Bartlett DW, Watson TF, Sherriff M. The surface effects of erosion and abrasion on dentine with and without a protective layer. British dental journal. 2004 Mar;196(6):351-4. 23. Bartlett D, Sundaram G, Moazzez R. Trial of protective effect of fissure sealants, in vivo, on the palatal surfaces of anterior teeth, in patients suffering from erosion. Journal of dentistry. 2011 Jan 1;39(1):26-9. 24. Banerji S, Mehta SB, Opdam N, Loomans B. Practical Procedures in the Management of Tooth Wear. John Wiley & Sons; 2019 Dec 4. 25. Yule PL, Barclay SC. Worn down by toothwear? Aetiology, diagnosis and management revisited. Dental update. 2015 Jul 2;42(6):525-32. 26. Davies S. Conformative, re-organized or unorganized?. Dental update. 2004 Jul 2;31(6):334-45. 27. Chu FC, Siu AS, Newsome PR, Chow TW, Smales RJ. Restorative management of the worn dentition: 4. Generalized toothwear. Dental update. 2002 Sep 2;29(7):318-24. 28. Longridge NN, Milosevic A. The bilaminar (dual-laminate) protective night guard. Dental Update. 2017ReviseDental.com Jul 2;44(7):648-54.

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