Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2012 39; 217–225
Review Article
Tooth wear and wear investigations in dentistry
A. LEE, L. H. HE, K. LYONS & M. V. SWAIN
of Otago, Dunedin, New Zealand
SUMMARY Tooth wear has been recognised as a major
problem in dentistry. Epidemiological studies have
reported an increasing prevalence of tooth wear and
general dental practitioners see a greater number of
patients seeking treatment with worn dentition.
Although the dental literature contains numerous
publications related to management and rehabilita-
tion of tooth wear of varying aetiologies, our
understanding of the aetiology and pathogenesis of
tooth wear is still limited. The wear behaviour
of dental biomaterials has also been extensively
researched to improve our understanding of the
underlying mechanisms and for the development of
restorative materials with good wear resistance. The
complex nature of tooth wear indicates challenges
Introduction
Wear can be defined as the progressive loss of material
from the contacting surfaces of a body, caused by
relative motion at the surface (1, 2). Wear has been of
interest in materials science and mechanical engineer-
ing for some time and wear testing is common practice
for predicting the service time of a component.
Wear has also been a topic of discussion in dentistry
with several epidemiological studies indicating that
tooth wear, especially erosion-related wear is increasing
in the general population (3, 4). There have been a
number of articles published regarding management
and rehabilitation of the worn dentition of varying
aetiologies (5, 6).
Tooth wear is a complex, multifactorial phenomenon
with the interplay of biological, mechanical, chemical
and tribological factors (2). The amount of tooth wear
depends on factors such as muscular forces, lubricants,
ª 2011 Blackwell Publishing Ltd
Department of Oral Rehabilitation, Faculty of Dentistry, University
for conducting in vitro and in vivo wear investiga-
tions and a clear correlation between in vitro and
in vivo data has not been established. The objective
was to critically review the peer reviewed English-
language literature pertaining to prevalence
and aetiology of tooth wear and wear investigations
in dentistry identified through a Medline search
engine combined with hand-searching of the
relevant literature, covering the period between
1960 and 2011.
KEYWORDS: tooth wear, wear in dentistry, wear
studies, wear testing and worn dentition
Accepted for publication 26 July 2011
patient diet habit and the type of the restorative
material used (7). Of these, the dentist has the most
control of the material selected (8) and thus a great deal
of research has involved improving the wear properties
of dental biomaterials and protecting natural teeth from
excessive wear.
The complex nature of tooth wear leads to difficulties
in conducting wear studies. Although, in vivo wear
studies would seem ideal to evaluate the wear behav-
iour of dental biomaterials, they are time-consuming,
expensive (9) and the results scatter widely due to
patient and dentist related factors (10). Most of all, the
fundamental problem with the in vivo wear model is
that it is impossible to isolate and vary key factors that
may influence the wear process (11). On the other
hand, an in vitro wear study allows precise control of
the environment and variables, which influence the
wear process of dental hard tissues and biomaterials
(12). However, there is no universally accepted wear
doi: 10.1111/j.1365-2842.2011.02257.x
218 A . L E E et al.
testing method (10). Numerous wear simulation
devices, developed for research purposes use different
wear testing concepts and variables such as force,
contact geometry and lubrication make comparative
analysis of wear data difficult (10).
The aim of this review is to provide an insight to
prevalence and aetiology of tooth wear and to scrutinise
wear studies in dentistry including the problems with
these studies. The peer reviewed English-language
literature was searched through the Medline search
engine with the key words, ‘tooth wear’, ‘wear in
dentistry’, ‘wear studies’, ‘wear testing’ and ‘worn
dentition’ between 1960 and the present. A manual
hand search was also conducted through the literature
to identify relevant dental journals.
Tooth wear
Prevalence
It has been recognised that tooth wear is a clinical
problem that is becoming increasingly important in the
aging population (2, 13). This may be due to an
increasing dental awareness, with increased interest in
retaining teeth as opposed to having them extracted
(14). Data from prevalence studies have demonstrated
high levels of tooth wear in adults (15), adolescents
(16) and children (17), indicating that tooth wear is a
clinical finding in all age groups.
Smith and Robb, in a cross-sectional study observed
that tooth wear is common in adults, with up to 97% of
the study cohort experiencing some tooth wear (15).
However, only 5–7% of 1007 adults in the study
exhibited severe tooth wear, for which interventive
restorative treatment was justified.
The retrospective study by Bartlett examined study
models over a median time of 26 months and reported
slow progression of tooth wear in the study sample,
suggesting that progression of tooth wear is not inev-
itable (18). However, one systematic review on prev-
alence of tooth wear in adults reported that the
predicted percentage of adults presenting with severe
tooth wear increases from 3% at age 20 years to 17% at
age 70 years, indicating a tendency for accumulative
wear with age (19).
Ayers et al. conducted a cross-sectional study to
investigate the prevalence and severity of tooth wear
in the primary dentition of New Zealand school chil-
dren aged between 5 and 8 (20). A high percentage
(82%) of children had at least one primary tooth with
dentine exposure. The severity of tooth wear was
not significantly associated with dietary factors, but
appeared to be related to early weaning from the breast.
In a study from the United Kingdom, the prevalence
of tooth wear was high (57%) in adolescents aged
between 11 and 14 years, but dentine involvement was
rare (16). A recent systemic review on prevalence of
tooth wear in children and adolescents has indicated
that the prevalence of tooth wear leading to dentine
exposure in deciduous teeth increases with age, while
wear of permanent teeth in adolescents does not
correlate with age (21). However, one longitudinal
study has demonstrated an association between tooth
wear recorded at age 5 and molar tooth wear recorded
at age 12 (22). It was emphasised that tooth wear is a
lifelong cumulative process and should be recorded in
both the primary and permanent dentitions.
Although numerous epidemiological studies seem to
indicate that tooth wear is prevalent and increasing in
the general population, the results are not easily
comparable due to the wide range of tooth wear indices
used and the variation in diagnostic criteria (23).
Currently there is no agreed consensus on a universally
acceptable tooth wear index for quantifying tooth wear
(24). These factors complicate the evaluation of
whether a true increase in prevalence is being reported
(25) and therefore conclusion from prevalence studies
should be considered with caution (26).
Aetiology
The terms attrition, abrasion, abfraction and erosion
have been used interchangeably to describe the loss of
tooth structure and dental biomaterials (2). These
terms, however are not in themselves descriptive of
the wear process, nor do they imply the causative
factor, but instead describe clinical manifestations of a
number of underlying events (6).
Attrition is defined as a gradual loss of hard tooth
substance from occlusal contacts with an opposing
dentition or restorations (27). It is related to aging, but
may be accelerated by extrinsic factors such as para-
functional habits of bruxism, traumatic occlusion in the
partially edentulous dentition, and malocclusion (27,
28). Clinically, occlusal wear attributable to attrition
will produce equal and matching wear facets on
opposing teeth. In early stages, there appears a small
polished facet on a cusp tip or slight flattening on an
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incisal edge, while severe attrition leads to dentine
exposure, which may result in an increased rate of wear
(29, 30). It has been suggested that progressively
greater loss of tooth structure occurs towards the
anterior teeth, due to leverage changes produced by
eccentric posterior interferences (31, 32). Instead of
occurring at the temporomandibular joints, posterior
occlusal contacts become the fulcrum point with
greater forces applied to the anterior teeth. One author
has proposed that the steepness of the condylar
eminence has a significant effect on the development
and occurrence of posterior interferences during man-
dibular movement (32, 33). It was observed that
patients with a flat condylar eminence tended to have
significant posterior interferences, causing flattening of
posterior teeth. On the other hand, patients with steep
condylar eminences have minimal posterior interfer-
ences and hence little or no posterior wear. However,
there have been no experimental studies that have
confirmed the relationship between the angle of the
condylar eminence and posterior teeth contact and
moreover, controversy remains regarding the relation-
ship between functional occlusal contact and tooth
wear (34, 35).
Abrasion is the loss of tooth substance through
mechanical means, independent of occlusal contact
(36). The site and pattern of abrasion wear can be
diagnostic as different foreign objects produce different
patterns of abrasion wear (27). Some forms of abra-
sion may be associated with habit or occupation, such
as a rounded ditch on the cervical aspects of teeth due
to vigorous horizontal toothbrushing or incisal notch-
ing caused by pipe smoking or nail biting (28, 34, 36).
The most common cause of dental abrasion found in
the cervical areas is toothbrushing and the severity
and distribution of toothbrushing abrasion wear may
be related to brushing technique, time, frequency,
bristle design and the abrasiveness of the dentifrice
(27, 34).
Abfraction is a relatively new term that describes loss
of hard tooth substance in the cervical region as a result
of crack formation during tooth flexure (11, 30). Some
authors have proposed that tensile and compressive
stresses from mastication and malocclusion play a major
role in the formation and progression of wedge-shaped
abfraction lesions (37). However, the true aetiology of
abfraction lesions has been controversial as other
causative factors such as abrasion and erosion have
been considered in the development of these lesions
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TOOTH WEAR 219
(38, 39). Many authors agree that the aetiology is
multifactorial and the term, non-carious cervical lesion
(NCCL) is preferred to describe the loss of tooth
substance at the cementum–enamel junction without
bacterial involvement (38, 40, 41).
Dental erosion is defined as loss of tooth structure by
a nonbacterial chemical process (29, 36). Some authors
however, disagree with the term erosion due to its
remarkably different meaning between dentistry and
engineering tribology (13), and the term ‘corrosion’ has
been advocated to correctly describe the process of
tooth surface loss due to chemical or electrochemical
action (28, 41). In this review, the term erosion will be
used to denote chemical dissolution of teeth or resto-
ration. Erosive lesions present as a smooth concave
defect in the early stage, while in the advanced stage,
restorations may project above the occlusal surface and
the cusps on premolars and molars exhibit concavities
known as cupping (29). The source of acid can be
endogenous, such as from gastric reflux, or exogenous
from acidic foods and drinks (42); the distribution and
wear pattern of erosion is specifically associated with
the origin of the acid and the posture of the head when
the acid is present (32, 33). As intrinsic acid enters the
oral cavity from the eosophagus, it tends to produce
significant tooth surface loss on the lingual and occlusal
surfaces of teeth. On the other hand, extrinsic acid
often results in erosive wear on facial and occlusal
surfaces of teeth by its nature of entering the oral cavity
from the anterior aspect.
Tooth wear may involve the entire dentition (gener-
alised) or be localised to anterior or posterior teeth,
depending on the causative factor of the tooth wear.
For instance, patients with bulimia or gastric reflux, the
lingual surfaces of the maxillary anterior teeth are
severely affected, while the mandibular teeth are
protected from the erosive effect by the tongue and
saliva (32). In attrition, the occlusal condition influ-
ences the quantity and distribution of the tooth wear
pattern. One longitudinal study demonstrated that
increased incisal wear correlates with horizontal overjet
and vertical overbite. Therefore, the anterior guidance
as determined by the overbite and overjet, and the ratio
between these, can be used as predictors of attrition
tooth wear of the maxillary and mandibular incisors
(43). In the case of the anterior open bite, where no
occlusal contact exists between the maxillary and
mandibular anterior teeth, greater wear is anticipated
on the posterior teeth than on the anterior teeth (33).
220 A . L E E et al.
However, a correlation between attrition and other
occlusal parameters has not been reported, and thus no
single occlusion-based treatment protocol can be rec-
ommended in the management of attrition (44).
Although research into tooth wear has grown con-
siderably over recent years, our understanding of its
aetiology and pathogensis is still lacking (45). Differen-
tiation among attrition, abrasion, erosion and abfrac-
tion is difficult, since these aetiological factors may act
synchronically or additively with other entities masking
the true nature of tooth wear (29). The occurrence and
pattern of tooth wear is closely associated with educa-
tional, cultural, dietary, occupational and geographic
factors in the population (27). Mair et al. suggested that
the aetiology of clinical wear may be considered in
terms of site, timing and underlying wear mechanism
rather than nomenclature (Fig. 1) (2).
Thegosis is defined as the action of sliding teeth
laterally and it has been proposed that this is a
genetically determined habit, originally established to
sharpen teeth (46). Bruxism is the action of grinding
teeth without the presence of food (11). Mastication is
the action of chewing food and is composed of two
phases, the open phase and the closed phase (2).
Initially, the teeth approximate from an open position
to a position of a near contact (open phase), and the
abrasive particles are suspended and free to move in the
food (slurry). This is followed by a closed phase, in
which the teeth are brought close together and the food
particles become trapped between the tooth surfaces.
Entrapment of food particles is largely influenced by
textural characteristics of the surfaces; rougher surfaces
are more likely to trap food particles than smooth tooth
surfaces. Following compression and crushing of the
Thegosis Direct
tooth
contact
Bruxism Wear at
sites of
Indirect
Mastication Contact occlusal
(closed phase) (trapped contact
Chemical
particles) effects
Habits
Wear at
(pipe, smoking, etc.) contact
Slurry free sites
Mastication effects
(opened phase) (suspended
particles)
Toothbrushing
Fig. 1. Tooth wear mechanisms and their interactions [from Mair
et al. (2)].
food bolus, grinding occurs either with tooth-food-
tooth contact (indirect) or direct tooth–tooth contact of
the opposing teeth surfaces (47). Masticatory parame-
ters such as the magnitude of the force and duration of
the masticatory cycle vary widely among individuals
and depend largely on the food type, size of food bolus
and chemical and physical action of saliva (13, 48). The
total duration of the masticatory cycle was reported to
be approximately 0Æ70 s (49, 50), whilst the mean
duration of the occlusion is about 0Æ10 s, and these
periods amount to 15–30 min of contact loading each
day (11, 13).
Wear investigation in dentistry
In vitro wear testing
Numerous wear testing devices have been developed to
predict the clinical performance of many dental bioma-
terials, but they differ in the degree of complexity and
use different variables including force, contact geome-
try, displacement, lubricant, antagonist, and cycles (12,
13). Most of the wear simulation devices are used for
two-body wear testing, in which the surfaces move
against each other in direct contact, and these condi-
tions occur during non-masticatory movement in the
mouth (11, 12). During mastication, food particles
present in the mouth play an important role in the wear
of teeth and dental biomaterials, and some simulation
devices include abrasive slurries to replicate this as
three-body wear (12, 51).
Among the many geometric designs, a pin-on-disk
wear-test rig has been commonly used to simulate two-
body wear between the sample and the antagonist (52,
53). This method uses a simple relative movement
between the wear pair and gives relatively quick results
(53). However, it does not properly simulate the oral
environment (48) and repeatability of results using the
same condition (i.e. load, contact pressure, sliding
speed) is poor (54). More complex in vitro wear testing
devices have been developed to provide a more accu-
rate simulation of the masticatory movement (55–57).
Some testing devices incorporate unidirectional sliding
movement of mastication, where the specimen slides in
one direction for a specified duration, after which it is
repositioned to its original position (55).
DeLong and Douglas in the early 1980s developed an
‘artificial oral environment’ which simulates the phys-
iological movement of the oral cavity through two
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servo-hydraulic units that control horizontal and ver-
tical movements (58). Physiological conditions of the
oral cavity are reproduced by controlled setting of the
biting force, temperature, and artificial saliva. They
compared their simulative wear data on amalgam,
composite resin and dental porcelain with clinical data
and found a good correlation between them (59–61).
Some authors have also incorporated abrasive discs or
slurries in the wear testing devices, to investigate the
influence of food particles on wear behaviour of dental
biomaterials (51, 62). The composition of food simula-
tion slurry varies widely in different studies, such as
ground rice in phosphate buffer (51), cornmeal grit and
wholemeal flour in distilled water (63) and polymethyl
methacrylate beads (62).
Heintze et al. have investigated the wear resistance of
10 restorative dental materials (eight composite resins,
an amalgam and a ceramic) using five different wear
simulation methods in order to validate the compatibility
of different wear simulation devices (64). The relative
ranking of the tested materials varied significantly
between the different wear testing methods. The authors
suggested that varying the wear simulation device
settings results in measuring different wear mechanisms
and thus care must be taken when interpreting and
comparing the results of in vitro wear data.
Despite the development of sophisticated and com-
plex wear simulators, a clear correlation between in
vitro and clinical data has not been established (11) and
the clinical performance of dental biomaterials cannot
be precisely predicted. Sajewicz and Kulesza argued
that the emphasis in previous in vitro wear studies has
been on the development of a wear simulator, that
produces physiological movements or a force pattern
similar to the oral environment, however there are no
standard oral conditions (48). Also, material wear can
be influenced by various factors including load, contact
area and contact geometry.
In 2001, the International Standard Organisation
(ISO) published a technical specification termed ‘wear
by two- and ⁄ or three-body contact’, and in the spec-
ification, eight different wear testing methods were
described (10). However, the specification did not
provide any information about validity or accuracy of
the testing methods and whether the testing devices
with which the methods were conducted were qualified
for that purpose. The lack of an internationally accept-
able in vitro method for evaluating wear behaviour of
dental biomaterials, combined with the various meth-
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TOOTH WEAR 221
ods used in the past makes it difficult or even impossible
to compare in vitro wear data.
The limitations and issues of in vitro wear studies in
dentistry have been addressed elsewhere (10, 12). The
current trend with in vitro wear studies has shifted from
developing a physiological wear simulator to identify-
ing the underlying wear mechanisms. This includes the
factors that influence the wear of dental biomaterials,
using some of the concepts used in mechanical engi-
neering (tribology) and physics (65, 66). For example,
using the Hertz theory in contact mechanics, the ball-
on-disk experimental design is becoming popular to
investigate and compare the wear mechanisms of
dental biomaterials (67, 68). Understanding the in vitro
wear propensity of a dental restorative material will
help researchers and clinicians predict the response of a
particular material in a clinical setting (69).
In vivo wear testing
An in vivo wear investigation of dental biomaterials
usually encompasses two parts; subjective performance
assessment of the material and quantitative measure-
ment of wear (9). The clinical performance of a
restoration is assessed based on specified criteria such
as marginal adaptation, gingival health, structural
integrity and patient satisfaction after a certain period
of use (70). This is accompanied with quantitative wear
measurement using various methods including study
casts, intraoral photographs and tooth wear indices that
can be used alone or in combination to identify
morphological changes of teeth over time (71, 72).
Tooth wear indices are the most popular method of
quantifying wear over a long period of time as they are
readily available and do not require special equipment
(73). Numerous indices have been developed for use in
clinical studies and most are based on numerical grades
to quantify the amount of hard tissue loss (25). The
Smith and Knight tooth wear index is the most
frequently used index in the dental literature (19) and
it records wear on all four surfaces (buccal, cervical,
lingual and incisal–occlusal), irrespective of the aetiol-
ogy of tooth wear (Table 1) (74). Some indices such as
the Basic Erosive Wear Examination (BEWE) or the
classification for dental attrition investigate one aetio-
logical factor, specific for erosion, attrition or abrasion
(75–77). However, a universally acceptable tooth wear
index has yet to be found (24) and new indices are
continually being designed and applied in clinical
222 A . L E E et al.
Table 1. Tooth wear index [from Smith and Knight (74)]
Criteria
0 No loss of enamel surface characteristics
1 Loss of enamel surface characteristics
2 Buccal, lingual, and occlusal loss of enamel, exposing
dentine for less than 1 ⁄ 3 of the surface; incisal loss
of enamel; minimal dentine exposure
3 Buccal, lingual, and occlusal loss of enamel, exposing
dentine for more than 1 ⁄ 3 of the surface; incisal loss
of enamel; substantial loss of dentine
4 Buccal, lingual, and occlusal complete loss of enamel,
pulp exposure, or exposure of secondary dentine; incisal
pulp exposure or exposure of secondary dentine
studies (78). Bardsley, in a recent review claimed that
there are too many indices with a lack of standardisa-
tion in terminology, resulting in difficulty in interpret-
ing and comparing the results of many of the
epidemiological studies (25).
Study casts are a valuable diagnostic tool for moni-
toring progression of tooth wear and quantifying the
amount of wear (18). Silicone impressions of teeth or
restorations are taken at regular intervals to make
replica models in stone or epoxy resin, which are then
compared for quantitative analysis (9). Measurements
can be recorded by using a number of methods
including stylus or laser profilometry (79) and stere-
omicroscopy images and computerised image fitting
(80). With advancement in measuring techniques, 3D
laser scanning can be used to scan the surface of a
replica to construct a 3D image for quantifying the wear
more accurately (81). However, despite improved
accuracy and reliability, new sophisticated measuring
tools are costly and require specialised hardware and
software, restricting their use in everyday dental
practice (82).
Al-Omiri et al. compared the reliability of three
different methods to detect incisal wear over a 6-month
period. The methods used were a CAD–CAM laser
scanning machine, a tool maker microscope for micro-
measurement applications and a conventional tooth
wear index (Smith and Knight wear index) (73). It was
found that the tooth wear index was the least sensitive
for tooth wear quantification and was unable to
identify wear progression in most cases.
However, the fundamental problem with in vivo wear
studies is the inherent patient factor (83). Although,
measurements can be taken to standardise the testing
conditions among the participants, such as the dietary
regime and toothbrushing, each individual represents a
variable and this confounds the interpretation of wear
results (11). In addition, the sensitivity of measurement
and replica techniques are an important consideration
(11). Lambrechts et al. claimed that many of the
deviations in the results occur due to an inaccurate
replica technique, repositioning problems and restric-
tions of the measuring devices (84). Therefore, appro-
priate training and calibration are important to
minimise subjective errors and a combination of meth-
ods should be used for a more reliable quantitative
analysis.
Clinical management of worn dentition
Considering the multifactorial nature of the tooth wear
process, a thorough clinical examination including a
medical and dental history, occupation, diet and para-
functional habit is crucial for diagnosis and treatment
planning (27). The quantity and positional wear pattern
are pathognomonic of the causative factor and thus the
clinician should carefully observe the wear patterns on
diagnostic casts in order to differentiate various causes
and confirm the diagnosis (31).
Since tooth wear is a progressive phenomenon that
affects the dentition throughout life, a lifelong approach
to management should be undertaken rather than
short-term interventive treatment measures (85).
Long-term monitoring is essential for assessing the
effectiveness of preventive measures taken and any
further progression of the wear before embarking on
interventive treatment. If the cause of tooth wear is
related to medical conditions such as severe erosive
tooth wear induced by eating disorders, gastric prob-
lems or alcoholism, the medical management of these
causes must be coordinated by the general medical
practitioner in concert with dental treatment (45).
Early diagnosis and appropriate prevention measures
can avoid the complicated restorative treatment in the
future (18).
The restorative treatment decisions should be based
on the patients’ needs, severity of wear and potential
for progression of the wear (86). Restorative treatment
is indicated when the patient presents with clinical
symptoms such as tooth sensitivity or pain that cannot
be controlled conservatively, or progressive, uncon-
trolled wear is occurring that is altering the occlusal
vertical dimension with functional and aesthetic deficit
(85). The articulated study casts and a diagnostic
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wax-up should be carried out prior to formulating
comprehensive treatment options for each individual.
Various restorative treatment approaches for severely
worn dentition have been discussed elsewhere (87–89).
Nevertheless the complexity of treatment of the
severely worn dentition emphasises the importance of
instituting an effective prevention regime.
Summary
Wear of teeth is an increasing clinical problem as life
expectancy increase and teeth are retained for longer.
Dental practitioners need to be aware of the underlying
issues and influencing factors of tooth wear to appro-
priately manage patients with a worn dentition.
The oral environment is extremely complex to
replicate in its contribution to the wear of dental
biomaterials. Despite many attempts to simulate the
oral environment in vitro, an appropriate wear testing
device has not yet been found contributing to the great
difficulty in relating in vitro results to in vivo tooth wear.
In vitro wear testing cannot simulate the oral environ-
ment because of all the biological variables, but with a
well controlled experimental design, the factors that
lead to a certain type of wear can be identified. In
addition, understanding the wear propensity of a dental
biomaterial demonstrated in vitro will also help
researchers and clinicians understand and predict the
response of a particular material in a clinical setting.
Although there has been progress in understanding
the underlying mechanisms and influencing factors of
tooth wear in dentistry, it is evident that collaboration
among material scientists, tribologists and dentists will
help advance the progress of this field of study in the
future.
Conflicts of interest
The authors declare no conflicts of interest.
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Correspondence: Ahreum Lee, Department of Oral Rehabilitation,
Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054,
New Zealand. E-mail: leeahreum@hotmail.com