journal of dentistry 41 (2013) 1007–1013

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Prevalence of tooth wear on buccal and lingual

surfaces and possible risk factors in young
European adults

D.W. Bartlett a,*, A. Lussi b, N.X. West c, P. Bouchard d,

M. Sanz e, D. Bourgeois f,g
a
Prosthodontics, Kings College London Dental School, London, UK
b
Department of Preventive, Restorative and Pediatric Dentistry, University of Bern, CH-3010 Bern, Switzerland
c
Periodontology, Bristol Dental School, Bristol, UK
d
Department of Periodontology, Service of Odontology, Rothschild Hospital, AP-HP, Paris 7-Denis Diderot University,
U.F.R. of Odontology, EA 2496 Paris, France
e
Department of Periodontology Periodontics, Facultad de Odontologia, University Complutense of Madrid, Spain
f
Department of Public Health, EA 4129, University Lyon 1, France
g
International and European Affairs, University Lyon, France

article info abstract

Article history: To assess the prevalence of tooth wear on buccal/facial and lingual/palatal tooth surfaces and
Received 15 July 2013 identify related risk factors in a sample of young European adults, aged 18–35 years. Calibrated
Received in revised form and trained examiners measured tooth wear, using the basic erosive wear examination
20 August 2013 (BEWE) on in 3187 patients in seven European countries and assessed the impact of risk
Accepted 22 August 2013 factors with a previously validated questionnaire. Each individual was characterized by the
highest BEWE score recorded for any scoreable surface. Bivariate analyses examined the
proportion of participants who scored 2 or 3 in relation to a range of demographic, dietary and
Keywords: oral care variables. The highest tooth wear BEWE score was 0 for 1368 patients (42.9%), 1 for 883
Prevalence (27.7%), 2 for 831 (26.1%) and 3 for 105 (3.3%). There were large differences between different
Tooth wear countries with the highest levels of tooth wear observed in the UK. Important risk factors for
Erosion tooth wear included heartburn or acid reflux, repeated vomiting, residence in rural areas,
Risk factors electric tooth brushing and snoring. We found no evidence that waiting after breakfast before
Diet tooth brushing has any effect on the degree of tooth wear ( p = 0.088). Fresh fruit and juice
intake was positively associated with tooth wear. In this adult sample 29% had signs of tooth
wear making it a common presenting feature in European adults.
Crown Copyright # 2013 Published by Elsevier Ltd. All rights
reserved.

permanent dentitions. However, neither review provides

1. Introduction sufficient data to give a clear appraisal of which factors
increase the risk of tooth wear. Hitherto, prevalence studies
Recent systematic reviews1,2 have established that tooth wear have reported data from individual countries without any
is common and increases with age in both the primary and attempt to investigate multiple countries or establish an

* Corresponding author at: Floor 25, Tower Wing, Guy’s Hospital, London Bridge, SE1 9RT, UK. Tel.: +44 02071885390; fax: +44 02071881792.
E-mail address: david.bartlett@kcl.ac.uk (D.W. Bartlett).
0300-5712/$ – see front matter . Crown Copyright # 2013 Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2013.08.018
1008 journal of dentistry 41 (2013) 1007–1013
estimate for a region.3–7 Bartlett et al.6 and Lussi et al.7
identified acidic foods, particularly those with high titratable
acidity and reflux of gastric contents as risk factors but in
national studies.
The severity and distribution of tooth wear is normally
measured using indices, which record the change in shape on
teeth which is irrespective of the aetiology, The Basic Erosive
Wear Examination (BEWE)8 was developed primarily as
practice-based assessment for general practitioners, but also
as a suitable index for epidemiological studies. Escarel is a Pan
European study designed to estimate the levels of sensitivity,
periodontal disease and tooth wear in young adults and the
results from the latter are presented here.
The observational, cross-sectional study across seven
European countries reported here was designed to determine
prevalence of tooth wear on the oral and facial surfaces in 18–
35 year olds in the general dental practice setting, across
socioeconomic and demographic groups and identify poten-
tial risk factors. The study hypothesis was that erosive dietary
challenge is a major risk factor for tooth wear.
1.1. Study population
We used a multistage, stratified sampling method to obtain a
representative sample of the adult population, attending
general practices, between the ages of 18–35, on the basis of
gender, geographic location (self disclosed), education and
occupation, in seven European countries, Estonia, Finland,
Latvia, France, Italy, Spain and UK. Because only 122
participants were recruited in Estonia, its data were merged
with those of neighbouring Latvia.
The sample size of 300 used in Finland, Latvia and Spain
estimates a prevalence of tooth wear of the order of 30% to
within 5.2% (with dentine exposure) with 95% confidence.1,2
For France, Italy and UK each with 700 participants, the
prevalence is estimated to within 3.4% with 95% confidence.
With a sample size of approximately 3000, the study is
sensitive to detect quite modest associations between the
endpoint of erosive tooth wear and antecedent factors. For
example, suppose that the prevalence of tooth wear was 30%
overall, but was 33.3% in a subgroup exposed to a risk factor
comprising one-third (1000) of the participants and 28.3% in
the remaining two-thirds (2000) who were not exposed,
corresponding to an odds ratio of 1.26. A difference of this
size is detectable with power 80% using a test at the
conventional two-sided 5% a level.
Ethical approval was granted from Research Ethics Com-
mittees from each country and all subjects gave oral and
written consent to participate in their national language. The
present data are part of a larger study called the European
Study in Non Carious Cervical Lesions (Escarcel). Details of the
survey project can be consulted on the site http://odontolo-
gie.univ-lyon1.fr/recherche/Briefly, participants of either gen-
der attending for routine dental examinations in general
dental practice during the study period were asked to
participate.
Following screening, consenting patients who were in good
health, between 18 and 35 years of age, able to understand and
read the questionnaire, had a minimum of 6 eligible teeth
(without restorations), though the number of teeth scored per
patient was usually far higher than this [mean 27.3, range 9–
28). Subjects were excluded if they were currently wearing
orthodontic appliances, had cervical restorations on any of the
6 minimum score-able teeth, were taking analgesics or who
had undergone oral local anaesthesia in the last 24 h. Subjects
on anticoagulants or who suffered bleeding disorders were
excluded, as were those who required antibiotics for dental
treatment and employees of the study site.
1.2. Methods
Standardized clinical examinations, by the trained examiners,
were included as part of the routine check-up of participating
adults. Ten examiners were involved in Estonia, Finland and
Latvia, 15in France, 17 in Italy, 20 in Spain and 2 in the UK. All
examiners were trained and calibrated by a senior epidemiol-
ogist using study casts and examination of patients. The intra-
and inter-examined reliability were evaluated according to the
World Health Organization (WHO) recommendation giving a
Kappa agreement at the end of the training phase of 0.75.
A self-administered questionnaire was developed, in
English, then translated into the languages of the participating
countries; all translated questionnaires were validated in pilot
studies. The questionnaire was based on those used in
previous studies identifying risk factors for tooth wear and
dentine hypersensitivity6,9 and included data on lifestyle,
dietary and oral health behaviour including tobacco, medica-
tion and erosive dietary factors, and health-associated
preventive behaviours, characterised by weight relative to
height.
Each subject completed the questionnaire, after which the
teeth were dried and cleaned if needed to score the wear, using
compressed air and examined without magnification under
normal dental surgery conditions with good lighting. The
cervical, facial and oral (palatal/lingual) tooth surfaces were
scored on all teeth (second molar to second molar) using the
BEWE8 on a 0–3 ordinal scale (0 = no wear, 1 = early surface
loss, 2 = surface loss < 50%, 3 = surface loss > 50%). Missing
teeth, restored surfaces (greater than 50% of the surface),
traumatised or carious teeth and third molars were not scored.
Data were analysed at patient level: each individual was
characterized by the highest BEWE score recorded for any
scoreable surface. Accordingly, bivariate analyses examined
the proportion of participants who scored 2 or 3 for at least one
tooth in relation to a range of demographic, dietary and oral
care variables.
2. Results
Overall, 3187 adults were recruited from 7 countries (Estonia
122; Finland 344; France 700; Italy 675; Latvia 342; Spain 304;
United Kingdom 700). The highest tooth wear BEWE score was
0 for 1368 patients (42.9%), 1 for 883 (27.7%), 2 for 831 (26.1%)
and 3 for 105 (3.3%).
Table 1 shows the proportion of participants with erosive
tooth wear defined as a BEWE score of 2 or 3 in relation to a
range of antecedent factors including demographic, oral
hygiene (Table 2) and dietary factors (Table 3). There were
large differences between BEWE scores in different countries
 journal of dentistry 41 (2013) 1007–1013 1009

Table 1 – Bivariate analyses for relationship of facial/oral tooth wear in young adults for demographics.
n Erosive tooth wear Odds ratio 95% CLs Chi-square p-Value

BEWE2-3 % Lower Upper

All subjects 3187 936 29.4%

Age [a]
18–25 1341 356 26.5% 1 8.89 0.003
26–35 1846 580 31.4% 1.27 1.08 1.48

Gender [a]
Male 1420 406 28.6% 1 0.75 0.39
Female 1767 530 30.0% 1.07 0.92 1.25

Country [b]
France 700 183 26.1% 1 287 <0.0001
Spain 304 80 26.3% 1.01 0.74 1.37
Italy 675 148 21.9% 0.79 0.62 1.02
United Kingdom 700 381 54.4% 3.37 2.69 4.22
Finland 344 61 17.7% 0.61 0.44 0.84
Latvia/Estonia 464 83 17.9% 0.62 0.46 0.82

Area of residence [c]

Rural 514 200 38.9% 1.80 1.45 2.23 8.81 0.003
Urban 1364 357 26.2% 1
Metropolitan 1309 379 29.0% 1.15 0.97 1.36

Education [c]
Total age 15 148 42 28.4% 0.96 0.66 1.40 0.07 0.80
Total age 16–19 827 244 29.5% 1.02 0.84 1.23
Total age 20+ 1404 409 29.1% 1
Still studying 808 241 29.8% 1.03 0.86 1.25

Occupation/socio-economic class [b]

Self employed 248 82 33.1% 1.20 0.89 1.63 29.5 <0.0001
Managers 166 76 45.8% 2.05 1.46 2.89
Other white collar 810 236 29.1% 1
Manual 685 173 25.3% 0.82 0.65 1.03
House persons 208 59 28.4% 0.96 0.69 1.35
Unemployed 246 67 27.2% 0.91 0.66 1.25
Student 824 243 29.5% 1.02 0.82 1.26

( p = 0.0001) with the highest levels of tooth wear observed in

the UK, where 54.4% of participants scored BEWE 2 or 3. The
distribution of the wear graded 2 and 3 was evenly spread
throughout the mouth with no sextant with statistically
higher levels of wear. However, in the UK higher levels of
BEWE grade 2 and 3 were present on the molars and premolars
rather than the anterior teeth the latter being a more typical
distribution found in other countries.
Of the personal factors, the most marked increase in
association was found in participants who reported fre-
quent taking of sleeping medications or antidepressants,
followed by frequent heartburn or acid reflux. The small
number of participants who classified themselves as
managers had a much higher tooth wear prevalence than
other groups. Other important associated factors included
repeated vomiting, residence in rural areas, electric tooth
brushing. Tooth wear was associated with all acidic intakes
studied, especially with fresh fruit and isotonic/energy
drinks. A moderate increase in tooth wear with age was
detectable, despite the limited age range. There was little
difference in tooth wear by gender, educational level,
smoking or chewing gum, or by dominant hand, body mass
index, regular sport/exercise, use of fluoride or history of
wearing an orthodontic appliance (not shown).
3. Discussion
This is the first study to report unified data on prevalence of
tooth wear on the facial and oral surfaces of teeth in relation to
associated factors in more than one country. Whilst by no
means all countries in Europe are represented, this dataset
gives some indication of the risk and prevalence across large
and small countries in very different parts of the continent
from those attending dental practices. In this respect the
results need some interpretation as not all adults routinely
attend general dental practice so depending on the country the
representative nature of the study needs to be considered.
The observation that 57.1% of the study population had a
maximum BEWE score of 1 or higher implies that the majority
had some evidence of tooth wear, although severe wear was
relatively uncommon, with only 1 in 30 participants scoring 3.
The prevalence of significant tooth wear (BEWE scores 2 or 3)
affected 26.1% and 3.3% of the participants, respectively, on at
least one tooth. So over one quarter of the study population
had BEWE score 2, which represents surface change over less
than 50% of the tooth surface. As tooth wear is irreversible and
the understanding that it increases with age the influence in
these relatively young adults means that the condition will
1010 journal of dentistry 41 (2013) 1007–1013

Table 2 – Bivariate analyses for association of facial/oral tooth wear in young adults to oral hygiene factors.
n Erosive tooth wear Odds ratio 95% CLs Chi-square p-Value

BEWE2-3 % Lower Upper

Brushing frequency [c] [d]
1perday 457 112 24.5% 0.74 0.59 0.94 2.30 0.13
2perday 1858 565 30.4%
3perday 844 250 29.6% 0.96 0.81 1.15

Toothbrush used [a] [d]

Manual 2375 659 27.7% 1 8.26 0.004
Electric 708 236 33.3% 1.30 1.09 1.56

Brushing movement [b]

Circular 519 176 33.9% 1.22 0.99 1.51 8.79 0.032
Horizontal 474 141 29.7% 1.01 0.81 1.26
Vertical 434 109 25.1% 0.80 0.63 1.02
Variable 1526 451 29.6% 1

Brush before breakfast? [c]

Often 729 237 32.5% 1.30 1.06 1.60 6.32 0.012
Sometimes 473 149 31.5% 1.24 0.98 1.58
Rarely 580 179 30.9% 1.21 0.96 1.51
Never 1007 272 27.0% 1

Brush after breakfast? [c]

Often 1969 570 28.9% 1 2.00 0.16
Sometimes 468 146 31.2% 1.11 0.89 1.38
Rarely 272 62 22.8% 0.72 0.54 0.98
Never 284 105 37.0% 1.44 1.11 1.87

Interval breakfast to brushing [e]

0–7 min 1077 300 27.9% 1 2.91 0.088
8–12 min 821 252 30.7% 1.15 0.94 1.40
13–17 min 349 97 27.8% 1.00 0.76 1.31
18–25 min 204 65 31.9% 1.21 0.88 1.67
26–44 min 284 100 35.2% 1.41 1.07 1.86
45+ min 98 27 27.6% 0.98 0.62 1.56

Brush after lunch? [c]

Often 794 215 27.1% 0.89 0.72 1.11 1.02 0.31
Sometimes 565 186 32.9% 1.18 0.93 1.48
Rarely 626 206 32.9% 1.17 0.94 1.47
Never 808 238 29.5%

Brush after dinner? [c]

Often 2599 748 28.8% 1 3.12 0.078
Sometimes 287 90 31.4% 1.13 0.87 1.47
Rarely 117 39 33.3% 1.24 0.83 1.83
Never 89 31 34.8% 1.32 0.85 2.06

Soporifics or antidepressants [c]

Often 56 34 60.7% 4.05 2.35 6.97 41.4 <0.0001
Sometimes 128 54 42.2% 1.91 1.33 2.74
Rarely 313 107 34.2% 1.36 1.06 1.75
Never 2588 715 27.6% 1

worsen as they age (Table 1). In this study, only facial and oral
surfaces were scored, so it is possible that occlusal surfaces
might show greater wear.
Comparative data from cohort studies and systematic
reviews have also shown relatively high levels of wear
within countries.1,7 Most studies have reported tooth wear
expressed as the percentage of surfaces with dentine
exposed and are normally analysed as the highest score
per subject, which is the method used in this study. We
analysed data for two criteria; those with sores 1 and 2 and
those with 2 and 3. The latter was chosen to represent tooth
wear as early signs are more difficult to identify but also
scores 2 and 3 represent more severe levels and therefore
has more impact. The BEWE score assesses damage to tooth
surfaces irrespective of the aetiology, but does not evaluate
dentine exposure specifically. The prevalence reported in
this study therefore cannot be compared directly to figures
from other studies relating to dentine exposure.10 Also the
occlusal surfaces were not scored, nevertheless this study
suggests that tooth wear is highly prevalent in Europeans,
with nearly 30% of a young adult population affected by
wear of oral and facial tooth surfaces to a degree that may
have important oral health and health economic implica-
tions. Tooth wear is an important risk to teeth, which may
 journal of dentistry 41 (2013) 1007–1013 1011

Table 3 – Bivariate analyses for association of facial/oral tooth wear in young adults to dietary factors.
n Erosive tooth wear Odds ratio 95% CLs Chi-square p-Value

BEWE2-3 % Lower Upper

Chewing gum [c]
Often 912 271 29.7% 1 0.48
Sometimes 1143 313 27.4% 0.89 0.74 1.08
Rarely 691 232 33.6% 1.20 0.97 1.48
Never 344 97 28.2% 0.93 0.71 1.22

Heart burn, reflux or acid? [c] [f]

Often 156 82 52.6% 3.21 2.31 4.45 87.9 <0.0001
Sometimes 290 128 44.1% 2.29 1.78 2.94
Rarely 325 106 32.6% 1.40 1.09 1.80
Never 2416 620 25.7% 1

Repeated vomiting? [c]

Often 137 54 39.4% 1.75 1.23 2.51 22.6 <0.0001
Sometimes 354 133 37.6% 1.62 1.28 2.06
Rarely 700 215 30.7% 1.20 0.99 1.45
Never 1856 502 27.0% 1

Fresh fruit? [c]

Often 1135 415 36.6% 1 48.0 <0.0001
Sometimes 1456 389 26.7% 0.63 0.53 0.75
Rarely 455 96 21.1% 0.46 0.36 0.60
Never 80 16 20.0% 0.43 0.25 0.76

Fruit/veg juice? [c]

Often 961 318 33.1% 1 13.9 0.0002
Sometimes 1376 406 29.5% 0.85 0.71 1.01
Rarely 666 154 23.1% 0.61 0.49 0.76
Never 120 35 29.2% 0.83 0.55 1.26

Isotonic/energy drinks? [c]

Often 191 78 40.8% 1.97 1.44 2.70 13.1 0.0003
Sometimes 586 169 28.8% 1.16 0.93 1.44
Rarely 1061 334 31.5% 1.31 1.09 1.57
Never 1279 332 26.0% 1

Soft drinks [c]

Often 602 195 32.4% 1 4.3 0.038
Sometimes 1213 358 29.5% 0.87 0.71 1.08
Rarely 988 276 27.9% 0.81 0.65 1.01
Never 309 83 26.9% 0.77 0.57 1.04

Dairy products [c]

Often 1690 526 31.1% 1 7.44 0.006
Sometimes 1033 291 28.2% 0.87 0.73 1.03
Rarely 307 74 24.1% 0.70 0.53 0.93
Never 83 21 25.3% 0.75 0.45 1.24
[a] Chi-square (1 df) for binary explanatory variable.
[b] Chi-square (k 1 df) for categorical explanatory variable with k groups.
[c] Chi-square (1 df) for trend across k categories for ordinal explanatory variable.
[d] Omitting respondents who claimed not to brush.
[e] Clustered into 6 categories to reflect marked figure preference for responding 5, 10, 15, 20, 30 or 60 min.
[f] Imputing ‘never’ for missing.

in time affect the longevity of the dentition, and hence will
require intervention.
Differing numbers of examiners examined and recorded
the tooth wear in each country. For the most part the intention
was to utilize an existing network of general dental practi-
tioners, which was successful in most countries apart from the
UK where no established network was in place. In part the data
from the UK showing higher levels of more severe tooth wear
than other countries is difficult to explain. All examiners used
similar criteria and had similar training. Those in France, Italy,
Latvia and Estonia were already trained in collecting data in
research carried out in primary care settings and were
therefore experienced researchers (European EGOHID,
www.egohid.eu). The results imply that the UK indeed showed
higher levels of wear (BEWE 2-3) when compared with no or
slight wear (BEWE 0-1). From the questionnaire data, the diet
in UK had significantly higher levels of fruit when compared to
other countries. It is, however, not possible to infer any sound
explanations for these differences and further investigations
would be appropriate, but the observation that UK subjects
1012 journal of dentistry 41 (2013) 1007–1013
had higher levels of severe wear than the other countries
should be noted by UK healthcare authorities. In the
systematic review by Kreulen et al. three studies11–13 all
collecting data in adolescents in the UK had higher levels of
wear compared to those from other countries.
The recruitment in to the study was limited to subjects
aged 18–35 years as the literature suggests sensitivity is
common.14 However, not all individuals within this age range
routinely attend a general dental practice, consequently this
sample may not be fully representative of the relevant
population. It is obviously both convenient and cost-effective
for recruitment to a large study of this kind to be based on
patients attending a general dental practice for routine care;
the reported results must be interpreted accordingly.
The data for the prevalence is descriptive as it related to a
measurement performed on the teeth. The analysis of the risk
factors is more subjective. When constructing the question-
naire the authors considered in some depth what terms could
be used to capture dietary and habit practices and we chose
often, sometimes and rarely. We appreciated that when
asking someone to remember what they eat or drink or
routinely perform the quality of the data is variable. In other
studies data has been captured by giving responders ranges of
intakes, for example, once a day, 2/3 times a day and so forth.6
But this too is subjective and we needed to consider the impact
across so many countries. So on reflection we opted to choose
the descriptors and accept the consequences. Whichever
method used to collect data, which relies on the honesty of the
responder and their memory, is flawed. The choice of using
these criteria gave us some understanding of the dietary
habits of over 3000 people. As such the data are complex.
Fruits and fruit-based products have been previously
identified as risk factors in tooth wear,3,15 but this is the first
study to show that these intakes remain an important and
consistent associated factor across seven countries with
differing climatic environments, cultural behaviour and
economic status. Interestingly one of the most commonly
associated risks identified by dentists is the consumption of
carbonated or soft drinks and its use has been reported as a
significant risk.16 In our study, the consumption was not
strongly associated with high levels of tooth wear. These
differences may be due to the low amount of titratable acidity
in these drinks, since we found a significant association with
consumption of fruits, which have high titratable acidity. The
results showed classical dose–response relationships for the
acidic intakes studied, in line with the current clinical advice
that the frequency of acidic consumption is important as well
as the type or origin of the acid.
There is a need to provide specific preventive advice for
those reporting excessive consumption of fruits and acidic
foods, or counselling or medication to prevent repeated
vomiting. Dentists should identify risk patients in order to
initiate specific preventive measures.
The timing of tooth brushing in relation to tooth wear is still
a matter of controversy. Some studies17 reported a minimal
protective capability of saliva in counteracting the acidic
damaging effect. Other research indicated that re-hardening
of the erosive damaged dental hard tissue is a process that
takes longer time.18All these studies used a small sample size.
We found in our large sample study no evidence that waiting
after breakfast before tooth brushing has any effect on the
degree of tooth wear ( p = 0.088). In contrary, delaying tooth
brushing for up to 44 min was associated with more tooth
wear and might not be considered protective (OR up to 1.41).
Based on these results, dentists should not advise patients
that they should delay brushing after breakfast. However,
more research directly targeting acidic diet and brushing is
needed to elucidate this problem further to assess whether
any associations are relevant to increasing wear of teeth.
There were stronger associations with managerial type jobs
and use of antidepressant medications. The former might imply
within this sample that higher socioeconomic groups have an
increasing risk of developing tooth wear. The use of anti-
depressants was found to occur in a relatively small number of
subjects but the association to higher levels of wear was strong.
It is not possible to predict exactly why this finding was
observed but possibly the associated reduction in output and
quality of saliva might have influenced the wear. The influence
of antidepressants on tooth wear needs more evaluation and
investigation. Further investigations may involve observing
wear on the occlusal surfaces as this might indicate the
outcome of attrition/bruxism, which might be expected to have
a higher impact in this group. Further work is needed.
There was a surprising difference in the wear between
those using an electric and manual toothbrush. The authors
are unaware of any data comparing tooth wear between these
two methods of tooth cleaning and so this could be considered
unique. It is not too easy to explain but the higher odds ratio
suggests that this finding has an impact. Theoretically, it
might be possible to predict that those individuals cleaning
their teeth with an electric toothbrush may be more motivated
than those using manual and this would need further
investigation. The other factor influencing this might be that
in the UK and Finland just over 35% admitted to using an
electric toothbrush compared to the other major European
countries of between 18 and 24%. So it is possible that this
might have influenced the outcome.
In conclusion, this study showed that facial and oral tooth
wear in adults aged 18–4 years was common and affected
more than 25% of this adult population. Regular consumption
of fruit, repeated vomiting increased the association with high
levels of tooth wear.
Acknowledgements
This study was supported by grants from GlaxoSmithKline
Consumer Healthcare, Weybridge, UK to the Universities of
Lyon. The authors declare no conflicts of interest with respect
to the authorship and/or publication of this article. The
authors would also like to thank Professor Robert Newcombe
for his help with the statistical analyses.
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