Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2019; 64:(1 Suppl): S59–S62

doi: 10.1111/adj.12681

Tooth wear and aging

D Bartlett, S O’Toole
Department of prosthodontics, King’s College London Faculty for Dental, Oral and Craniofacial Sciences, London Bridge, UK.

ABSTRACT
Background: In an ageing population, tooth wear is likely to increase. It is increasing in prevalence in the younger popu-
lation and a greater number of patients are retaining their teeth into old age.
Methods: This paper is a narrative review of the clinical presentation, the epidemiology and the restorative intervention
for erosive tooth wear. The dilemmas in managing this common condition with the aging dentition in mind are
described. The paper discusses evidence-based prevention methods and highlights how preventive intervention may be
preferable over extensive restorative care and high maintenance needs. Patient wishes, expectations and commitment to
treatment and maintenance require consideration during clinical decision making.
Conclusion: Successful management of erosive tooth wear in an ageing population depends on effective diagnosis, pre-
ventive intervention and holistic advice regarding restorative intervention.

might be acceptable, whereas similar levels seen in a

INTRODUCTION
Tooth wear is a common condition which increases in
severity with age. For many, the gradual change in
appearance and shape does not necessitate the need for
restorative intervention, but for some the rate of wear
or severity becomes so pronounced that care should be
considered. This can take the form of prevention and
monitoring, or restorations with composites or crowns.
The terminology used to describe the wear of teeth
has evolved. For some, particularly in Europe, the
focus is on erosion and that has meant an acknowl-
edgement that acids are crucially important to the
process. In other cultures, the focus has remained
more broadly on tooth wear; erosion, attrition and
abrasion. To alleviate and find common ground, the
term erosive tooth wear has been proposed to capture
the meaning that erosion often is involved, even if it
is not dominant. Acknowledging that, attrition and
abrasion remain causative factors, and they can exac-
erbate the condition, they are rarely the sole agent.
Some experts use the term pathological levels of wear
to describe the situation when restorative intervention
could be justified. The term yields support from many,
but it is a subjective opinion, mainly held by dentists.
The patient is either concerned about their appearance
or not. The appropriateness of the term “pathological
tooth wear” is complex. It can be useful in trying to
explain to patients that their tooth wear experience is
not severe and might not demand intervention. In prin-
ciple, the level of wear seen in an older aged person
© 2019 Australian Dental Association
much younger person may justify care. These decisions
are themselves subjective and influenced by the patient.
An older actor or television personality may demand
the same level of appearance as a younger person, so
each situation needs a careful approach.
EPIDEMIOLOGY
Recent evidence suggests that erosive tooth wear or
tooth wear is common with up to 29% of young
adults showing some signs of the condition.1 It is
likely that the deciduous dentition shows even higher
levels and almost reaches normal levels.2 But it is the
older age groups that show higher levels of wear as
the ravages of time and use impact on the shape of
teeth. There is evidence that tooth wear is correlated
to aging3 and this matches clinical experience.
Scoring the level of tooth wear or using indices such
as the BEWE4 are essential tools to allow dentists to
record the severity of wear. When used in research for
epidemiology the reproducibility of the scoring can be
challenging. Some screening tools have been criticised
for being too detailed, meaning it is difficult for two dif-
ferent dentists to agree on a score. Conversely, some
screening tools have been criticised for not being
detailed enough making it difficult to monitor small
changes in tooth wear progression. However, in an age
where clinical record keeping is so important, using a
scoring system to screen and report on tooth wear is
essential. The BEWE fulfils this need and as the name
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D Bartlett and S O’Toole

implies it allows assessment of erosive tooth wear and

for reasons given above it has international acceptance.

CLASSIFYING WEAR IN AN AGING POPULATION

In an ageing population where the overall levels of wear
are high, there is conflict over what would constitute as
severe wear. A BEWE score of 3 (wear affecting over
50% of a surface) present in every sextant constitutes
severe wear. But in an 18-year-old the implication is
greater than that of an older person as the longevity of
the tooth is questionable. Other clinical indicators such
as reduced crown height, compromising the placement
of restorations, could also be classified as severe wear.
Fig. 1 Distinguishing the appearance of unworn to worn teeth in the
If the underlying risk factors can be addressed, then early stages is very difficult. It is only when noticeable changes occur,
wear progression should be slowed and treatment may often with dentine exposure that it can be diagnosed.
not be necessary. This means that for both younger and
older adults, the primary indicator for intervention is
when the patient feels it impacts on their appearance
and self-esteem and would like treatment. The conflict
occurs when severe wear is present in young adults who
request restorations and who are then expecting a life
time of use from their teeth. Conversely, someone
around 70 years old with teeth worn so severely worn
they are unrestorable, suffers the dilemma of either
accepting extractions or no intervention. Neither choice
is wrong as the patient needs to consider their options
and make an informed decision.
In summary, tooth wear is a common experience
and for most, almost a universal outcome of aging. A
relatively small proportion of adults have severe
levels, around 2–4% for younger ages but this Fig. 2 The incisal edge of the upper and lower incisors are often one of
increases to around 10% in old age. the first clinical signs of tooth wear.

surface of the upper incisors. With more progression,

CONSEQUENCES OF TOOTH WEAR
The early signs of change, are clinically, difficult to
detect. The signs are subtle and involve loss of surface
characteristics, cingula, mamellons and smoothing of
facial surfaces (Fig. 1). Distinguishing these changes
from the natural appearance of teeth and then assessing
the surfaces as worn is challenging. Subtle changes can
be readily confused with the natural appearance as
teeth vary so much. But as the condition progresses,
often during early adulthood, in the 20–300 s age group,
the incisal edges of the upper and lower incisors are
worn, leaving a line of dentine exposed (Fig. 2). This
change may reflect the outcome of attrition or its com-
bination with erosion but is the first sign that wear has
developed. Together with the occlusal surfaces of lower
molars these can be considered to be index teeth as they
are generally the first to show signs of change.
As the condition deteriorates, more obvious shape
change occurs which become noticeable to dentists.
This can include cupped out lesions, particularly on
lower first molars, and thinning of the facial/buccal
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thinning of the palatal or buccal surfaces can lead to
unsupported enamel resulting in the incisal edges crum-
bling and shorter teeth. At this stage the process
becomes noticeable to patients (Fig. 3). But at this
point other changes to the occlusion occur too. Teeth
generally tend to maintain contact with opposing teeth.
If tooth wear is slow the opposing teeth remain in con-
tact and a sort of over-eruption occurs. This results in
shorted teeth without any space to place restorations
making rehabilitation very complex to provide. The
alveolar compensation can be reversed using principles
such as the Dahl concept5 but it means the restorative
process becomes more complex, requires more experi-
ence from the dentist and costlier to the patient.
RESTORATIVE CARE
Prevention
Most dental healthcare providers tend to focus the
concept of prevention on early wear lesions.
© 2019 Australian Dental Association

Fig. 3 Changes to the incisal edge lead to shorter teeth. As the palatal
enamel and dentine is worn the loss of support leads to fracture of the teeth.
Prevention is appropriate at any stage of the tooth
wear process, from the early unworn surface to the
most severe wear. Justifiably, most tend to focus on
early intervention, but it should always be kept in
mind that no matter how severe the case, giving pre-
ventive advice may restrict further progression.
Most of the preventive actions revolve around tooth-
pastes/mouthrinses and dietary modification. There is a
growing body of opinion to suggest that fluoride can
either harden enamel surfaces making them more resis-
tant to erosion or remineralise newly eroded surfaces.6
It is also possible that different toothpastes act differ-
ently at different stages in the erosive process as their
chemical components react differently to enamel.7
Overall, it’s likely that toothpastes, containing fluorides
or calcium-based products, reduce progression, but
probably the largest controllable factor is dietary acids.
We have known for some time that acids can cause ero-
sive tooth wear. More recently, the highest risk has
been identified as snacking between meals on dietary
acids more than two times a day, on acidic beverages,
fruit or fruit-based products.8 Changing diets is a chal-
lenge but when successful it should result in the pro-
gression of tooth wear becoming part of the aging
process and no longer compromising the longevity of
the teeth.9
Composites
Resin-based composites absorb the underlying colour
of teeth and mimic the natural colour creating a pleas-
ing result (Fig. 4). Additive techniques have proven to
be popular and, on the whole, create an acceptable
result.10 However, increasing clinical evidence suggests
that these brittle materials are liable to fracture and
require replacement which, if it occurs regularly, results
in an expensive and time-consuming process. Many
patients will readily accept a minimal intervention to
preserve tooth tissue to avoid further damage to their
teeth. However, repeated fractures and breakages car-
ries a cost which is borne by the patient and provided
this is an irregular expense will be acceptable. How-
ever, if the restorations require replacement after a few
© 2019 Australian Dental Association
Tooth wear and aging
Figure 4 Composites added to the worn surfaces can rebuild the tooth
shape creating a pleasing image. Their main challenge is maintenance.
months the treatment plan may need to be questioned.
A recent audit undertaken by the team at Kings College
showed that the overall longevity of all restorations
was comparable to other studies but individually, teeth
or the restorations repeatedly fractured, even after a
few months.11 Provided the patient accepts this com-
promise the acceptability of the restorations remains
but this might not be acceptable to everyone.
Crowns
Preparing teeth for crowns is destructive and irre-
versible. Understandably, for some dentists and patients
this limitation removes their acceptability (Fig. 5), but
they remain an option provided the patient understands
what is involved. Once the restorative cycle has started
it’s not possible to go back and allow things to deterio-
rate again. Under ideal clinical conditions, crowns and
bridges can last 10–15 years and maintenance is less
onerous. If composite restorations continually fail, they
need replacing with another technique which only
leaves crowns. Also, where the tooth wear is severe,
with more than 50% of the crown lost, composites may
Fig. 5 Crowns can improve the appearance of worn teeth but involve
tooth preparation and are not reversible procedures. Unlike composites
they have better longevity but if they fail the options to replace them are
more complex.
S61
D Bartlett and S O’Toole
not survive, particularly if there is an underlying brux-
ism component. The level of experience and confidence
of the dentist makes this care complex.
An early assessment, at the initial visit, should be
made on how much tooth tissue remains available for
conventional crowns. If the tooth height is too short,
additional crown length is needed either from surgical
repositioning of the gingival tissues or encompassing
the root within the restoration, utilising posts. How-
ever, if the latter is planned the role of bruxism,
which may be involved with tooth wear, needs consid-
ering as clenching or grinding can overwhelm the
materials used to restore teeth. Surgical crown length-
ening is uncomfortable for the patient but creates
optimum crown height provided the periodontal con-
dition is healthy. But if the crown height of teeth is
compromised, then surgical intervention may be the
only choice remaining to restore the teeth.
Maintenance
Once treatment is complete, patients should be aware
of the need for good oral hygiene, maintain regular
check-ups and to consume a low cariogenic and acid
diet. This is possibly more important in an ageing
patient. Xerostomia is common in elderly patients and
increases the risk of dental caries. Motor skill difficul-
ties which would impair oral hygiene around restora-
tions should be identified from the initial visit and
methods to overcome any difficulties discussed.
Cost
No aspect of dentistry can ignore the impact of cost.
Tooth wear rarely involves single teeth and more com-
monly intervention is justified in multiple sextants or
quadrants. This factor, combined with the additional
level of experience needs to carry out complex rehabil-
itation if indirect restorations are considered, means
that the management of tooth wear is costly. To com-
plicate the situation more, the interplay of bruxism
can risk the survival of restorations meaning that the
longevity associated with a particular material cannot
be guaranteed as they are liable to fracture or more
wear. A recent audit undertaken in the UK estimated
the cost in private practice varied between £4,000 to
£31,000 per case and this did not include maintenance
costs.12 These figures mean the restorative intervention
is not universally affordable and so patients need to
make choices on whether to prevent further damage
and monitor change or intervene. Prevention and mon-
itoring remain a choice for many patients, even for
those who can afford the intervention.
S62
Summary
Tooth wear is a universal experience but fortunately
severe levels, justifying intervention is less common.
Prevention is the most important intervention,
whether it is with fluoride or other remineralising
solutions or dietary modification. Restorative inter-
vention is expensive and at risk of failure because of
the interplay with erosion, attrition and abrasion.
REFERENCES
1. Bartlett DW, Lussi A, West NX, Bouchard P, Sanz M, Bour-
geois D. Prevalence of tooth wear on buccal and lingual sur-
faces and possible risk factors in young European adults. J Dent
2013;41:1007–1013.
2. Dugmore CR, Rock WP. The prevalence of tooth erosion in 12-
year-old children. Br Dent J 2004;196:279–282.
3. Van’t Spijker A, Rodriguez JM, Kreulen CM, Bronkhorst EM,
Bartlett DW, Creugers NH. Prevalence of tooth wear in adults.
Int J Prosthodont 2009;22:35–42.
4. Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination
(BEWE): a new scoring system for scientific and clinical needs.
Clin Oral Investig 2008;12:65–68.
5. Gough MB, Setchell D. A retrospective study of 50 treatments
using an appliance to produce localised occlusal space by rela-
tive axial tooth movement. Br Dent J 1999;187:134–139.
6. Austin RS, Rodriguez JM, Dunne S, Moazzez R, Bartlett DW. The
effect of increasing sodium fluoride concentrations on erosion and
attrition of enamel and dentine in vitro. J Dent 2010;38:782–787.
7. O’Toole S, Mistry M, Mutahar M, Moazzez R, Bartlett D.
Sequence of stannous and sodium fluoride solutions to prevent
enamel erosion. J Dent 2015;43:1498–1503.
8. O’Toole S, Bernabe E, Moazzez R, Bartlett D. Timing of diet-
ary acid intake and erosive tooth wear: a case-control study. J
Dent 2017;56:99–104.
9. O’Toole S, Newton T, Moazzez R, Hasan A, Bartlett D. Ran-
domised controlled clinical trial investigating the impact of
implementation planning on behaviour related to the diet. Sci
Rep 2018;8(1):8024.
10. Milosevic A, Burnside G. The survival of direct composite
restorations in the management of severe tooth wear including
attrition and erosion: a prospective 8-year study. J Dent
2016;44:13–19.
11. Bartlett D, Varma S. A retrospective audit of the outcome of
composites used to restore worn teeth. Br Dent J 2017;223:33–
36.
12. O’Toole S, Pennington M, Varma S, Bartlett DW. The treat-
ment need and associated cost of erosive tooth wear rehabilita-
tion-a service evaluation within an NHS dental hospital. Br
Dent J 2018;224:957–961.
Address for Correspondence:
Professor. David Bartlett
Department of Prosthodontics
King’s College London Faculty for Dental
Oral and Craniofacial Sciences
London Bridge, SE19RT
UK
Email: david.bartlett@kcl.ac.uk
© 2019 Australian Dental Association