Original Paper
Caries Res 2016;50:349–362
DOI: 10.1159/000445980
Erosive Tooth Wear and Related
Risk Factors in 8- and 14-Year-Old
Greek Children
Efthymia Provatenou a Eleftherios G. Kaklamanos b Aikaterini Kevrekidou a
Ismini Kosma a Nikolaos Kotsanos a
a
Department of Paediatric Dentistry, School of Dentistry, Faculty of Health Sciences, Aristotle University of
Thessaloniki, Thessaloniki, Greece; b Hamdan Bin Mohammed College of Dental Medicine, Mohammed Bin Rashid
University of Medicine and Health Sciences, Dubai, United Arab Emirates
Key Words
Basic Erosive Wear Examination index · Erosive tooth wear ·
Risk factors
Abstract
The aim of the present study was to investigate the erosive
tooth wear of primary and permanent teeth and its associa-
tion with related risk factors. Two groups of Greek children
aged 8 (n = 329) and 14 years (n = 263) were examined in the
classroom using the Basic Erosive Wear Examination (BEWE)
index. Data concerning risk factors were collected using
questionnaires. Dental caries (DMFS/dmfs) was also record-
ed. The data were analyzed using the t test, one-way ANOVA,
multiple regression analysis, Fisher’s exact test, and the χ2
test. In the 8-year-olds, the primary teeth showed a predom-
inantly medium level of wear and the permanent teeth no
wear. A majority of the 14-year-olds exhibited low risk levels
of wear. The most frequently affected dental surface in both
age groups was the occlusal surface of the mandibular pos-
terior teeth. In the 8-year-olds, BEWE scores and the preva-
lence of wear in the primary teeth was influenced by gender
(p = 0.020). In their permanent teeth, soft drink consumption
(p < 0.0001) and preference for lemon/vinegar (p = 0.041)
significantly affected wear prevalence and BEWE scores,
© 2016 S. Karger AG, Basel
0008–6568/16/0504–0349$39.50/0
E-Mail karger@karger.com
www.karger.com/cre
Received: August 2, 2015
Accepted after revision: April 4, 2016
Published online: June 10, 2016
while habitually retaining soft drinks in the mouth influ-
enced wear prevalence (p = 0.008), risk (p = 0.004), and BEWE
scores (p = 0.022). In the 14-year-olds, wear prevalence was
significantly affected by the consumption of lemon-flavored
candies (p = 0.016) and soft drinks (p = 0.050). BEWE scores
were significantly affected by gender (p = 0.022) and soft
drink consumption (p = 0.030). Gender influenced tooth
wear risk in both age groups (p = 0.010 and p = 0.021, respec-
tively). The results of this study indicate that erosive tooth
wear differed between primary and permanent teeth and
was influenced by gender and dietary factors.
© 2016 S. Karger AG, Basel
Tooth wear is characterized by the gradual loss of den-
tal hard tissues through three processes, individually or
in combination: abrasion (wear induced by the interac-
tion between teeth and other materials), attrition (wear
through tooth-to-tooth contact), and erosion (dissolu-
tion of hard tissues by acidic substances). All three pro-
cesses are easily distinguishable from loss of dental tissues
due to dental caries, on the one hand, or acute trauma on
the other [Grippo et al., 2004]. Nowadays, tooth wear is
increasingly recognized as very common in the pediatric
population. The decreasing incidence of dental caries,
Efthymia Provatenou
Department of Paediatric Dentistry, School of Dentistry, Faculty of Health Sciences
Aristotle University of Thessaloniki, Venizelou 32
GR–59100 Veria (Greece)
E-Mail efi_provatenou @ hotmail.com
combined with changes in dietary habits and lifestyles of
children and adolescents predisposing teeth to more ero-
sive tooth wear, has contributed to a growing awareness
among dentists and researchers regarding this dental dis-
order [Marthaler, 2004].
Signs of each form of tooth wear can be identified in
both primary and permanent teeth, and data on their
prevalence show great variability, ranging from single fig-
ures to 95% [Al-Majed et al., 2002; Luo et al., 2005]. This
wide variation has been attributed to methodological fac-
tors, such as the multiplicity of indices measuring tooth
wear and issues regarding examiner calibration, as well as
population-related factors, such as age, gender, diet, and
socioeconomic background.
The indices used in epidemiological studies on tooth
wear in children include the Tooth Wear Index (TWI) by
Smith and Knight [1984] and its modifications [Rios et
al., 2007; Ratnayake and Ekanayake, 2010], the O’Sullivan
Index [O’Sullivan, 2000; Peres et al., 2005; Mangueira et
al., 2009], the O’Brien index [O’Brien, 1994; Gurgel et al.,
2011; Murakami et al., 2011], the index of the National
Survey of Child Dental Health [Walker et al., 2000; Dug-
more and Rock, 2004; Huew et al., 2011], the criteria sug-
gested by Lussi [Lussi, 1996; El Aidi et al., 2011], the Vi-
sual Erosion Dental Examination (VEDE) [Mulic et al.,
2010], and the more recent Basic Erosive Wear Examina-
tion (BEWE) [Bartlett et al., 2008; Mantonanaki et al.,
2013; Zhang et al., 2014; Alvarez et al., 2015; Alves et al.,
2015; Muller-Bolla et al., 2015]. These indices vary in the
method of assessment and choice of teeth and surfaces,
making the comparison of prevalence among studies
sometimes difficult. For example, indices like the TWI
focus on the depth of dentin loss while others, like the
BEWE, measure the extent (surface area) of wear regard-
less of depth. Moreover, in the TWI all tooth surfaces are
examined, whereas in the O’Brien Index only particular
surfaces of index teeth, specifically the labial and palatal
surfaces of maxillary incisors and the occlusal surfaces of
molars, are examined.
Regarding population-related factors, the investiga-
tion of a gender effect has produced conflicting results, as
a greater prevalence of erosive wear has been found in
both males [Alvarez et al., 2015; Alves et al., 2015] and
females [Wang et al., 2010]. When age is considered,
sparse evidence exists on how tooth wear evolves over
time from the primary to the young permanent dentition
and into adolescence and adulthood [Dugmore and Rock,
2003; Harding et al., 2010; El Aidi et al., 2011; Huang et
al., 2015; Murakami et al., 2016]. Most studies are cross-
sectional, concluding that erosive wear in primary teeth
350 Caries Res 2016;50:349–362
DOI: 10.1159/000445980
increases with age [Wiegand et al., 2006] and that perma-
nent teeth are less prone to wear than their primary pre-
decessors [Kazoulis et al., 2007; Mangueira et al., 2009].
The parameter of diet has been the most extensively
studied factor regarding tooth wear in children and ado-
lescents. Some reports have observed that it was signifi-
cantly associated with acidic drinks and foods [Gatou and
Mamai-Homata, 2012; Luo et al., 2005; Muller-Bolla et
al., 2015; Tao et al., 2015; González-Aragón Pineda et al.,
2016], conflicting with the results of other investigations
[Dugmore and Rock, 2004; Ratnayake and Ekanayake,
2010]. Moreover, the evaluation of socioeconomic status,
something considered to affect eating and drinking hab-
its, has also produced conflicting results. Erosive tooth
wear has been reported to be more prevalent both in chil-
dren of higher [Luo et al., 2005; Peres et al., 2005] and
lower socioeconomic status [Dugmore and Rock, 2004].
The objective of the present cross-sectional study was
to investigate erosive tooth wear and the association with
related risk factors in two groups of Greek children aged
8 and 14 years.
Materials and Methods
The study was conducted from January to May 2012 following
the approval of the Research Ethics Committee of the Dental
School of Aristotle University of Thessaloniki and the Greek Min-
istry of Education.
Subjects
The reference population consisted of 3rd grade primary school
students (8-year-olds) and of 2nd grade secondary school students
(14-year-olds). These age groups were considered appropriate for
obtaining information regarding erosive tooth wear in primary
and early erupting permanent teeth, as both would have existed in
the oral environment for several years.
Sample Size
The minimum sample size was estimated by stratified sampling
with the city of Thessaloniki forming the strata. The selection of
schools was based on a simple random sampling technique. More
specifically, in order to estimate the prevalence of erosive tooth
wear in the population as a percentage proportion with an error of
±3% at a significance level of α = 0.05, the minimum sample size
was estimated to be 253 for the 8-year-olds and 202 for the 14-year-
olds. Fifty percent were added to these minimum figures to allow
for parents or students withholding consent and student absences
for illness. Sixteen primary schools (out of 53) and eight secondary
schools (out of 28), as the latter had more enrolled students per
school, were randomly selected from the relevant list of the Min-
istry of Education for the city of Thessaloniki, Greece. None of the
school directors refused to participate in the study. Children with-
out a written consent signed by parents were not included in the
study.
Provatenou/Kaklamanos/Kevrekidou/
Kosma/Kotsanos
 Clinical Examination
Prior to examination all children brushed their teeth with a
single-use toothbrush following professional instructions. Erosive
tooth wear and caries assessment (DMFS and dmfs indices) were
conducted in the classroom in a sitting position by two trained and
calibrated examiners (E.P. and A.K., respectively) with a dental
mirror and artificial room light aided by a penlight. When neces-
sary, visible remaining plaque was removed with the child’s tooth-
brush. DMFS/dmfs indices were calculated by summating the cu-
mulative score of decayed, absent due to caries, and filled surfaces
of permanent and primary teeth, respectively [World Health Or-
ganization, 1997].
As the focus of the present study was on erosion-related tooth
wear, the BEWE [Bartlett et al., 2008] was chosen. The BEWE is a
convenient, previously validated tool [Mulic et al., 2010; Olley et
al., 2014; Vered et al., 2014], focusing on the extent of erosive tooth
wear in each oral sextant rather than the exposure of dentin, which
represents an advanced stage of tooth surface loss. It consists of a
4-point ordinal scale, in which no evidence of erosive tooth wear
scores 0, initial loss of surface texture scores 1, loss of <50% of the
surface area scores 2, and loss of >50% of the surface area scores 3.
Only the most severely affected surface in each sextant is recorded,
and the 6 scores are summated. The cumulative (final) score may
range from 0 to 18. In the present study, cumulative BEWE scores
were estimated separately for the primary and permanent teeth of
the 8-year-old children. In addition, the risk level for erosive tooth
wear of each child was determined. According to Bartlett el al.
[2008], a BEWE score ≤2 is arbitrarily considered not to be associ-
ated with risk of erosive tooth wear, while scores of 3–8, 9–13, and
≥14 are associated with low, medium, and high wear risk, respec-
tively.
As the BEWE index, unlike most others, does not evaluate wear
depth and dentin exposure, but instead measures erosive tooth
wear semi-quantitatively by its extent on tooth surfaces, dentin
exposure assessment was added to enhance comparability with
other studies in which wear depth was measured [Rios et al., 2007;
Wang et al., 2010; Murakami et al., 2011] and to investigate the as-
sociation with related risk factors. Such a combination of tooth
wear assessment has been employed before [Gatou and Mamai-
Homata, 2012].
Assessments of erosive tooth wear were made for every tooth
surface accessible to observation (buccal/labial, occlusal, and
palatal/lingual), except for the incisal edges of upper and lower
anterior teeth, in line with the suggestions of Bartlett et al.
[2008], based on etiological grounds, that wear in these locations
is considered as being predominantly due to attrition. Further,
a pilot examination has shown that the cusps of the primary ca-
nines were very frequently (depending on the type of occlusion)
the most heavily worn away tooth portions, presumably due to
the same etiology. Therefore, primary canines were excluded
from BEWE recordings in the 8-year-old group, as assessment
of the erosive wear area of their remaining labial and lingual sur-
faces would have been heavily biased for miscalculation. Chil-
dren exhibiting changes in dental structure such as molar-inci-
sor hypomineralization or other enamel anomalies were exclud-
ed from registration as these defects can result in easier loss of
dental hard tissues through attrition [Kazoulis et al., 2007]. Fi-
nally, totally carious teeth and teeth with large restorations or
stainless steel crowns were also excluded on the grounds of re-
cording difficulties.
Erosive Tooth Wear and Risk Factors in
Greek Children
Training and calibration of the examiner (E.P.) assigned to re-
cording erosive tooth wear was carried out before commencing the
clinical examination by studying published photographs of tooth
wear lesions and examining children in the University Clinic. The
caries examiner (A.K.) had already been familiarized with DMFS/
dmfs indices during her postgraduate training in the clinic. Fifteen
of the examined school children were re-examined 2 months later.
The Cohen’s kappa coefficients obtained were, 0.89 for BEWE and
0.96 for DMFS/dmfs, indicating good and excellent intraexaminer
reliability, respectively.
Questionnaire on Tooth Wear Habits and Factors
In conjunction with being clinically examined, the children
completed a questionnaire consisting of open- and closed-ended
questions about their preferences and habits regarding factors re-
lated to tooth wear (see Appendix). The 14-year-old students com-
pleted it on their own, while the 8-year-olds were assisted by two
trained colleagues.
Data Analysis and Statistical Methods
An overview of the extent and severity of erosive tooth wear
in the two age groups was obtained by calculating the distribu-
tion of erosive tooth wear severity by tooth type and the distribu-
tion of BEWE-based erosive tooth wear risk for the two age
groups. Subsequently, these data were tested against the various
factors possibly related to tooth wear. The questionnaire data
together with information on gender and caries activity were
used to draw up two different groups of factors possibly related
to tooth wear:
1 General characteristics (gender, caries-free children in the pri-
mary dentition, dmfs, caries-free children in the permanent
dentition, DMFS). The analysis of caries was conducted in the
total number of individuals.
2 Daily habits (toothbrushing, toothbrushing frequency, pool
swimming, and awareness of tooth grinding) and diet prefer-
ences and habits (preference for sour taste, lemon-flavored
sour candy consumption, lemon-flavored sour candy con-
sumption frequency, fruit juice consumption, fruit juice con-
sumption frequency, soft drink consumption, soft drink con-
sumption frequency, and habitually retaining soft drinks in the
mouth before swallowing).
The Kolmogorov-Smirnov test for normality was used to as-
sess the normality assumption for continuous variables. First, as-
sociations between the prevalence of tooth wear and children’s
general characteristics as well as diet preferences and habits were
explored by the calculation of odds ratios (OR) and the respective
95% confidence intervals (CI). Second, the mean BEWE scores
were compared using the independent samples t test or one-way
ANOVA. Moreover, correlations regarding the severity of the
BEWE index score were explored by multiple regression analysis.
Third, the distribution to the 4 levels of the BEWE-based risk for
erosive tooth wear was compared using the χ2 test for indepen-
dence, Fisher’s exact test, and adjusted residuals (AR; AR >1.96
and AR <–1.96 were considered statistically significant). Finally,
the same last statistical procedures were used to investigate the
presence of dentin exposure in the potential risk factor groups.
The level of significance was set at α = 0.05. The software SPSS
21.0 (IBM Inc., Armonk, N.Y., USA) was used for statistical anal-
ysis.
Caries Res 2016;50:349–362 351
DOI: 10.1159/000445980
 60
Upper right quadrant Upper left quadrant

50

40

30

20

10

0
16 55 54 12 11 21 22 64 65 26
Score 1 15 16 22 4 1 3 5 29 18 11
Score 2 6 38 54 3 9 7 1 49 33 2
Score 3 1 31 42 0 1 1 0 34 21 0
0

10

20

30

40

50

60

70

Lower right quadrant Lower left quadrant

80
46 85 84 42 41 31 32 74 75 36
Score 1 19 29 18 2 3 3 0 22 31 22
Score 2 11 48 69 0 2 2 0 49 35 7
Fig. 1. Distribution of erosive tooth wear
Score 3 1 62 74 0 1 0 0 64 57 1
severity (number of affected teeth) by tooth
type (8-year-olds).

Results mary teeth BEWE score: 10.4 ± 4.22; permanent teeth

From the initial sample of 423 primary school and 316
secondary school students, after the exclusion of children
with enamel anomalies and those without a written con-
sent signed by the parents, the final number of children
included in the study was 592; 329 eight-year-olds (pri-
BEWE score: 1.11 ± 2.40) and 263 fourteen-year-olds
(permanent teeth BEWE score: 7.53 ± 4.53). No dentin
exposure was observed in any permanent tooth of either
age group, whereas in the primary teeth of the 8-year-olds
dentin exposure was noted in 77 occlusal surfaces of pri-
mary molars (49 mandibular and 28 maxillary).

352 Caries Res 2016;50:349–362 Provatenou/Kaklamanos/Kevrekidou/

DOI: 10.1159/000445980 Kosma/Kotsanos
 70
Upper right quadrant Upper left quadrant

60

50

40

30

20

10

0
16 12 11 21 22 26
Score 1 44 23 12 16 17 38
Score 2 48 10 31 34 14 61
Score 3 11 1 11 14 0 13
0

20

40

60

80

100

Lower right quadrant Lower left quadrant

120
46 42 41 31 32 36
Score 1 37 18 4 8 15 48
Score 2 114 5 12 11 8 80
Fig. 2. Distribution of erosive tooth wear
Score 3 34 0 5 3 0 28
severity (number of affected teeth) by tooth
type (14-year-olds).

Extent and Severity of Erosive Tooth Wear
An overview of the extent and severity of erosive tooth
wear in the two age groups is provided by presenting data
on the distribution of tooth wear severity and BEWE-
based tooth wear risk (fig. 1–3): 5% of the 8-year-olds
(n = 14) were found to be free from erosive tooth wear
regarding their primary teeth (BEWE score = 0), whereas
concerning their permanent teeth, 85.4% of them (n =
281) had a BEWE score = 0. Regarding the 14-year-olds,
21% (n = 56) were free from erosive tooth wear.
Figures 1 and 2 illustrate the distribution of erosive
tooth wear severity by tooth type in the 8-year-old and
14-year-old groups, respectively. The most commonly af-
fected teeth were the mandibular primary molars in

Erosive Tooth Wear and Risk Factors in Caries Res 2016;50:349–362 353
Greek Children DOI: 10.1159/000445980
 350 BEWE risk level of primary teeth
(8-year-old children)
281 BEWE risk level of permanent teeth
300
85.4% (8-year-old children)

228 BEWE risk level of permanent teeth

250 (14-year-old children)
69.3%

200

Children (n)
150
109
87 41.4%
26.4%
100
56 51
41 47
21.3% 19.4%
Fig. 3. Distribution pattern of erosive tooth 12.5% 17.9%
50
wear risk level by BEWE for the primary 14
4.3% 7
and permanent teeth of 8-year-olds and the 0 0
2.1%
0.0% 0.0%
permanent teeth of 14-year-olds, by adopt- 0
ing 4 risk levels: none, low, medium, and None Low Medium High
high.

8-year-olds and the mandibular posterior teeth in 14-year-
olds. The first permanent molars and the permanent inci-
sors always exhibited higher BEWE scores than the pre-
molars/second permanent molars, or permanent canines
in the respective sextants. Regarding dental surfaces, the
most frequently affected was the occlusal surface of man-
dibular posterior teeth in both groups, which always ex-
hibited higher BEWE scores than the buccal and lingual
surfaces of the same teeth. In anterior sextants the labial
surface was more commonly affected than the palatal/lin-
gual one (78 and 22%, respectively).
The different pattern of risk for erosive tooth wear
based on the BEWE assessment is presented in figure 3.
It can be observed that the primary teeth of 8-year-olds
showed predominantly medium levels of wear, but their
permanent teeth mostly showed no wear. Low risk levels
of wear predominated in the 14-year-olds.
Factors Related to Tooth Wear
The results from analyzing the above data against the
various factors potentially related to tooth wear are pre-
sented in tables 1–6. The associations between the preva-
lence of erosive tooth wear and children’s general charac-
teristics as well as daily habits and diet preferences and
habits are shown in tables 1 and 2. In 8-year-olds, being a
girl decreased the chance of showing any sign of wear in
the primary teeth (p = 0.020). Those 8-year-olds consum-
ing soft drinks and retaining them in their mouths were
more likely to show wear in their permanent teeth (p <
0.0001 and p = 0.008, respectively). Fourteen-year-olds
had more chances of having dental wear if they consumed
lemon-flavored sour candies (p = 0.016) and soft drinks
(p = 0.050).
Tables 3 and 4 present the comparison of BEWE scores
according to general characteristics and daily habits and
dietetic preferences and habits, respectively. The 8-year-
old boys and 14-year-old girls had statistically significant-
ly higher mean BEWE scores for their primary teeth (p =
0.020) and permanent teeth (p = 0.022), respectively.
Eight-year-old children who had the habit of retaining
soft drinks in their mouth before swallowing (p = 0.022)
and liked to consume lemon or vinegar (p = 0.041) exhib-
ited statistically significantly higher mean BEWE scores
for their permanent teeth. Similarly, the permanent teeth
of 14-year-olds consuming soft drinks (p = 0.030) and
more specifically, the teeth of those drinking more than 7
cans per week compared to those not drinking, showed
statistically significantly higher mean BEWE scores
(mean difference = 3.67, 95% CI: 0.21–7.14; p = 0.035).
Correlations between BEWE scores and children’s
general characteristics and daily habits as well as diet pref-
erences and habits are presented in tables 5 and 6. The
parameters of toothbrushing and toothbrushing frequen-
cy were excluded from multiple regression analysis be-
cause only two 8-year-olds and one 14-year-old did not
brush their teeth. Multiple regression analysis suggested

354 Caries Res 2016;50:349–362 Provatenou/Kaklamanos/Kevrekidou/

DOI: 10.1159/000445980 Kosma/Kotsanos
Table 1. Presence (BEWE score >0) and absence (BEWE score = 0) of erosive tooth wear in the various groups according to some gen-
eral characteristics and the respective ORs

8-year-olds, n 14-year-olds, n
BEWE primary BEWE permanent BEWE permanent
0 >0 total OR 0 >0 total OR 0 >0 total OR

Gender
Girls 13 168 181 0.088 (0.011 – 0.680) 153 28 181 1.171 (0.630 – 2.177) 27 107 134 1.149 (0.637 – 2.075)
Boys 1 147 148 p = 0.020 128 20 148 p = 0.617 29 100 129 p = 0.644
Caries-free primary teeth
Yes 5 114 119 0.980 (0.321 – 2.994) NA NA NA NA NA NA NA NA
No 9 201 210 p = 0.971 NA NA NA
dmfs
0 5 114 119 0.632 (0.177 – 2.259) NA NA NA NA NA NA NA NA
1–2 5 72 77 p = 0.480a NA NA NA NA NA NA NA NA
≥3 4 129 133 1.415 (0.371 – 5.395) NA NA NA NA NA NA NA NA
p = 0.612a
Caries-free permanent teeth
Yes NA NA NA 184 31 215 1.040 (0.548 – 1.974) 17 57 74 1.147 (0.601 – 2.189)
No NA NA 97 17 114 p = 0.904 39 150 189 p = 0.677
DMFS
0 NA NA NA 184 31 215 17 57 74 0.713 (0.329 – 1.542)
p = 0.390a
1–2 NA NA 53 12 65 1.344 (0.646 – 2.797) 18 43 61
p = 0.429a
≥3 NA NA 44 5 49 0.675 (0.248 – 1.834) 21 107 128 1.520 (0.743 – 3.11)
p = 0.440a p = 0.252a

Values in parentheses are 95% CI. Significant differences are indicated in italics. NA = Not applicable. a Compared to 0 value group.

gender and preference for lemon or vinegar as risk indi-
cators for erosive tooth wear. Eight-year-old boys and
14-year-old girls were more likely to exhibit wear of their
primary and permanent teeth, respectively, than their
counterparts (p = 0.025 and p = 0.034, respectively). The
8-year-olds who preferred sour tastes (lemon or vinegar)
were more prone to having erosive wear of their perma-
nent teeth (p = 0.004).
Concerning the comparison of BEWE-based erosive
tooth wear risk with general characteristics and dietetic
factors, it should be noted that 8-year-old boys and
14-year-old girls had higher risk for wear in their prima-
ry (p = 0.010) and permanent teeth (p = 0.021), respec-
tively. Specifically, the percentage of 8-year-old boys in
the no wear risk group was statistically significantly low-
er (AR = –2.9) than the respective percentage of 8-year-
old girls, and the percentage of 14-year-old girls in the
high wear risk group was statistically significantly higher
(AR = 2.6) than the respective percentage of 14-year-old
boys. Additionally, 8-year-olds with the habit of retaining
soft drinks in their mouth had a greater percentage
(AR = 3.1) of higher BEWE-based risk for wear in their
permanent teeth (p = 0.004).
No parameter was associated with dentin exposure in
the primary teeth of 8-year-olds: brushing frequency (p =
0.787), soft drink consumption frequency (p = 0.488),
fruit juice consumption frequency (p = 0.637), retaining
soft drinks in the mouth (p = 1.000), preference for lemon
or vinegar (p = 0.051), pool swimming (p = 0.195), and
awareness of tooth grinding (p = 1.000).
Discussion
In the present study the BEWE was chosen as a record
of erosive tooth wear because of its simplicity and conve-
nience in recording using 4 discernible categories. The
BEWE index has been previously employed in erosive
wear studies in children and adolescents with either pri-
mary or permanent dentitions [Bartlett et al., 2008; Man-
tonanaki et al., 2013; Zhang et al., 2014; Alvarez et al.,
2015; Alves et al., 2015; Muller-Bolla et al., 2015] but not

Erosive Tooth Wear and Risk Factors in Caries Res 2016;50:349–362 355
Greek Children DOI: 10.1159/000445980
Table 2. Presence (BEWE score >0) and absence (BEWE score = 0) of erosive tooth wear in the various groups according to daily habits
and diet preferences and habits and the respective ORs

Related 8-year-olds, n 14-year-olds, n

factors
BEWE primary BEWE permanent BEWE permanent
0 >0 total OR 0 >0 total OR 0 >0 total OR

Toothbrushing
No 0 2 2 4.324 (0.198 – 94.25) 1 1 2 0.168 (0.010 – 2.730) 0 1 1 1.218 (0.049 – 30.314)
Yes 14 313 327 p = 0.352 280 47 327 p = 0.210 56 206 262 p = 0.904
Toothbrushing frequency (times/week)
0 0 2 2 5.444 (0.227 – 130.770) 1 1 2 0.20 (0.012 – 3.326) 0 1 1 1.523 (0.060 – 38.468)
1–7 4 122 126 p = 0.296a 105 21 126 p = 0.262a 25 116 141 p = 0.799a
>7 10 182 192 3.476 (0.157 – 77.124) 168 24 192 0.143 (0.009 – 2.360) 27 77 104 0.939 (0.037 – 23.75)
p = 0.431a p = 0.174a p = 0.970a
Pool swimming
No 13 278 291 1.730 (0.220 – 13.612) 248 43 291 0.874 (0.323 – 2.363) 54 199 253 0.543 (0.097 – 3.043)
Yes 1 37 38 p = 0.602 33 5 38 p = 0.791 2 4 6 p = 0.487
Awareness of tooth grinding
Yes 2 50 52 1.132 (0.246 – 5.213) 45 7 52 0.895 (0.378 – 2.122) 3 21 24 1.978 (0.568 – 6.893)
No 12 265 277 p = 0.874 236 41 277 p = 0.802 52 184 236 p = 0.284
Preference for sour taste (lemon or vinegar)
No 9 174 183 1.417 (0.464 – 4.326) 161 22 183 1.640 (0.886 – 3.037) 25 78 103 1.313 (0.722 – 2.387)
Yes 5 137 142 p = 0.540 116 26 142 p = 0.115 31 127 158 p = 0.372
Lemon-flavored sour candy consumption
No 10 177 187 1.921 (0.590 – 6.257) 158 29 187 0.856 (0.458 – 1.598) 30 79 109 2.184 (1.158 – 4.117)
Yes 4 136 140 p = 0.279 121 19 140 p = 0.625 20 115 135 p = 0.016
Lemon-flavored sour candy consumption frequency (times/week)
0 10 177 187 1.921 (0.590 – 6.257) 158 29 187 0.856 (0.458 – 1.598) 30 79 109 2.165 (1.148 – 4.082)
1–7 4 136 140 p = 0.279a 121 19 140 p = 0.625a 20 114 134 p = 0.017a
>7 0 0 0 0.059 (0.001 – 3.132) 0 0 0 5.373 (0.105 – 276.17) 0 1 1 1.151 (0.046 – 29.031)
p = 0.163a p = 0.403a p = 0.932a
Fruit juice consumption
No 3 33 36 2.331 (0.619 – 8.782) 27 9 36 0.461 (0.202 – 1.053) 2 6 8 1.241 (0.244 – 6.322)
Yes 11 282 293 p = 0.211 254 39 293 p = 0.066 54 201 255 p = 0.795
Fruit juice consumption frequency (times/week)
0 3 33 36 2.446 (0.640 – 9.339) 27 9 36 0.473 (0.207 – 1.083) 2 6 8 1.222 (0.239 – 6.250)
1–7 10 269 279 p = 0.191a 241 38 279 p = 0.077 a 48 176 224 p = 0.810a
>7 0 9 9 1.985 (0.094 – 41.897) 8 1 9 0.375 (0.041 – 3.424) 5 16 21 1.067 (0.161 – 7.056)
p = 0.659a p = 0.385a p = 0.947a
Soft drink consumption
No 1 36 37 0.596 (0.076 – 4.693) 15 22 37 5.351 (2.528 – 11.324) 13 26 39 2.105 (1.000 – 4.430)
Yes 13 279 292 p = 0.623 33 259 292 p < 0.0001 43 181 224 p = 0.050
Soft drink consumption frequency (times/week)
0 1 36 37 0.596 (0.076 – 4.693) 15 22 37 5.351 (2.528 – 11.324) 13 26 39
1–7 13 279 292 p = 0.623a 33 259 292 p < 0.0001a 37 144 181 1.946 (0.912 – 4.151)
p = 0.085a
>7 0 0 0 0.041 (0.001 – 2.871) 0 0 0 1.452 (0.027 – 77.147) 0 12 12 12.736 (0.700 – 231.865)
p = 0.141a p = 0.854a p = 0.086a
Soft drink prolonged retention in mouth
No 14 300 314 1.496 (0.085 – 26.253) 272 42 314 4.318 (1.462 – 12.751) 48 168 216 1.393 (0.610 – 3.180)
Yes 0 15 15 p = 0.783 9 6 15 p = 0.008 8 39 47 p = 0.432

Values in parentheses are 95% CI. Significant differences are indicated in italics. a Compared to 0 value group.

356 Caries Res 2016;50:349–362 Provatenou/Kaklamanos/Kevrekidou/

DOI: 10.1159/000445980 Kosma/Kotsanos
Table 3. Comparison of BEWE scores (mean ± SD) according to some general characteristics

8-year-olds 14-year-olds
n BEWE primary p value BEWE permanent p value n BEWE permanent p value

Gender
Girls 181 8.96 ± 3.09 0.020a 1.11 ± 2.47 0.987a 134 8.16 ± 4.78 0.022a
Boys 148 9.68 ± 2.45 1.11 ± 2.31 129 6.88 ± 4.17
Caries-free primary teeth
Yes 119 9.25 ± 2.73 0.884a NA NA NA NA NA
No 210 9.3 ± 2.91
dmfs
0 119 9.25 ± 2.72 0.134b NA NA NA NA NA
1–2 77 8.86 ± 3.04 NA NA NA
≥3 133 9.56 ± 2.82 NA NA NA
Missing 0 NA NA NA NA
Caries-free permanent teeth
Yes 215 NA NA 1.09 ± 2.45 0.802a 74 6.85 ± 4.42 0.130a
No 114 1.16 ± 2.29 189 7.79 ± 4.56
DMFS
0 215 NA NA 1.05 ± 2.45 0.227b 74 6.85 ± 4.41 0.577b
1–2 65 NA 1.46 ± 2.69 61 6.80 ± 4.72
≥3 49 NA 0.76 ± 1.52 128 8.27 ± 4.42
Missing 0 NA NA 0 NA

Significant differences are indicated in italics. NA = Not applicable. a t test. b ANOVA.

in subjects with mixed dentition. Taking primary and
permanent teeth together in the assessment of wear in a
sextant (teeth with different characteristics and posterup-
tive age) does not seem appropriate. Therefore, with the
8-year-olds in the present study, BEWE scores were esti-
mated separately for primary and permanent teeth.
In line with the study of Bartlett et al. [2008] as well as
studies using various other wear indices [Sanhouri et al.,
2010; Gurgel et al., 2011], the incisal edges of the upper
and lower anterior teeth were excluded as being particu-
larly vulnerable to attrition. In general, studies including
incisal wear in the assessment [Kazoulis et al., 2007; Ga-
tou and Mamai-Homata, 2012] reported an increased
prevalence of tooth wear compared to investigations
where it was excluded [Luo et al., 2005; Gurgel et al.,
2011]. In addition, in the present study, the primary ca-
nines were excluded in determining the primary teeth
BEWE index in 8-year-olds because of frequently seen
heavy attrition of their cusps. This phenomenon poten-
tially prevents accurate BEWE assessments in the canine
labial and palatal/lingual surfaces, thus predisposing to
exaggerated increases in erosive wear recordings.
In line with other studies [Dugmore and Rock, 2004;
Gatou and Mamai-Homata, 2012; Mantonanaki et al.,
2013], erosive tooth wear proved to be a common finding
in 8- and 14-year-old Greek children in the present inves-
tigation: 21% of the 14-year-olds were found to be free
from erosive tooth wear, and only 5% of the 8-year-olds
were likewise free from erosive tooth wear regarding their
primary teeth. In both age groups the occlusal surface of
the posterior mandibular teeth was most frequently af-
fected, a finding in agreement with previous studies [Wie-
gand et al., 2006; Ratnayake and Ekanayake, 2010] and
irrespective of the different indices (TWI or O’Sullivan
Index) used by them.
Among the various factors related to tooth wear, gen-
der was found to influence the results. Multiple regres-
sion analysis suggested it as a risk indicator for erosive
wear of the primary teeth of 8-year-old boys and the per-
manent teeth of 14-year-old girls. This observation cor-
roborates data from some previous studies reporting dif-
ferences between genders: either increased tooth wear
prevalence in males [Dugmore and Rock, 2004; Gatou
and Mamai-Homata, 2012; Alvarez et al., 2015; Alves et

Erosive Tooth Wear and Risk Factors in Caries Res 2016;50:349–362 357
Greek Children DOI: 10.1159/000445980
Table 4. Comparison of BEWE scores (mean ± SD) according to daily habits and diet preferences and habits

Related factors 8-year-olds 14-year-olds

n BEWE primary p value BEWE permanent p value n BEWE permanent p value

Toothbrushing
No 2 12 ± 0.00 0.176a 4 ± 5.66 0.087a 1 8 ± 0.00 0.456a
Yes 318 9.27 ± 2.84 1.09 ± 2.37 245 7.53 ± 4.54
Toothbrushing frequency (times/week)
0 2 12.00 ± 0.00 0.348b 4.00 ± 5.65 0.135b 1 8.00 ± 0.00 0.953b
1–7 126 9.41 ± 2.87 1.23 ± 2.63 141 7.62 ± 4.36
>7 192 9.22 ± 2.84 0.97 ± 2.08 104 7.44 ± 4.85
Missing 9 – – 17 –
Pool swimming
No 291 9.33 ± 2.85 0.372a 1.13 ± 2.41 0.642a 253 7.47 ± 4.51 0.871a
Yes 38 8.89 ± 2.82 0.95 ± 2.30 6 7.17 ± 5.64
Awareness of tooth grinding
No 277 9.19 ± 2.90 0.179a 1.12 ± 2.41 0.957a 236 7.39 ± 4.52 0.114a
Yes 52 9.77 ± 2.52 1.1 ± 2.34 24 8.92 ± 4.32
Preference for sour taste (lemon or vinegar)
No 183 9.24 ± 2.88 0.596a 0.87 ± 1.92 0.041a 103 7.02 ± 4.46 0.184a
Yes 142 9.41 ± 2.76 1.45 ± 2.89 158 7.78 ± 4.54
Lemon-flavored sour candy consumption
No 187 8.77 ± 3.42 0.694a 1.05 ± 2.31 0.960a 109 7.41 ± 4.80 0.908a
Yes 140 8.89 ± 3.26 1.06 ± 2.37 135 7.46 ± 4.36
Lemon-flavored sour candy consumption frequency (times/week)
0 187 9.27 ± 9.93 0.919b 1.10 ± 2.30 0.878b 109 7.31 ± 4.71 0.464b
1–7 140 9.30 ± 2.75 1.14 ± 2.52 134 7.95 ± 4.33
>7 0 NA NA 1 5.00 ± 0.00
Missing 2 – – 19 –
Fruit juice consumption
No 36 9.31 ± 3.16 0.959a 1.67 ± 2.78 0.204a 8 6.88 ± 4.79 0.679a
Yes 288 9.28 ± 2.81 1.04 ± 2.34 245 7.55 ± 4.53
Fruit juice consumption frequency (times/week)
0 36 9.31 ± 3.16 0.664b 1.67 ± 2.77 0.342b 8 6.88 ± 4.79 0.757b
1–7 279 9.31 ± 2.79 1.07 ± 2.38 224 7.39 ± 4.49
>7 9 8.44 ± 2.83 0.78 ± 1.09 21 8.29 ± 4.47
Missing 5 – – 10 –
Soft drink consumption
No 234 9.13 ± 2.88 0.123a 0.85 ± 2.04 0.101a 39 6.08 ± 4.56 0.030 a
Yes 60 10.51 ± 2.22 1.22 ± 3.66 193 7.78 ± 4.49
Soft drink consumption frequency (times/week)
0 234 10.51 ± 2.22 0.171b 3.19 ± 3.66 0.337b 39 6.08 ± 4.56 (d) 0.035 c (d–f)
1–7 60 9.73 ± 2.56 2.47 ± 3.52 181 7.68 ± 4.48 (e) 0.105c (d–e)
>7 0 NA NA 12 9.75 ± 3.49 (f) 0.265c (e–f)
Missing 35 – – 31 –
Soft drink prolonged retention in mouth
No 314 9.25 ± 2.84 0.275a 1.00 ± 2.27 0.022a 216 7.30 ± 4.50 0.075a
Yes 15 10.07 ± 2.94 3.40 ± 3.58 47 8.60 ± 4.54

Soft drink consumption frequency: comparisons are indicated in parentheses. Significant differences are indicated in italics. NA =
Not applicable. a t test. b ANOVA. c Tukey’s post hoc test.

358 Caries Res 2016;50:349–362 Provatenou/Kaklamanos/Kevrekidou/

DOI: 10.1159/000445980 Kosma/Kotsanos
Table 5. Multiple regression analysis for the BEWE scores (coefficient B) according to some general characteristics and daily habits

8-year-olds 14-year-olds
BEWE primary (n = 320) BEWE permanent (n = 320) BEWE permanent (n = 245)

Gender (female/malea) –0.713 (–1.337 to –0.088) 0.098 (–0.418 to 0.614) 1.232 (0.091 to 2.373)
p = 0.025 p = 0.710 p = 0.034
Caries-free primary teeth 0.075 (–0.568 to 0.718) NA NA
(no/yesa) p = 0.819
Caries-free permanent NA 0.013 (–0.524 to 0.550) 0.678 (–0.578 to 1.933)
teeth (No/yesa) p = 0.962 p = 0.290
Pool swimming 0.274 (–0.727 to 1.274) –0.074 (–0.904 to 0.755) –0.037 (–0.136 to 0.062)
(yes/noa) p = 0.592 p = 0.860 p = 0.467
Awareness of tooth 0.665 (–0.187 to 1.516) 0.074 (–0.626 to 0.774) 1.436 (–0.463 to 3.336)
grinding (yes/noa) p = 0.126 p = 0.836 p = 0.138

Values in parentheses are 95% CI. Significant differences are indicated in italics. n indicates the number of children included in the
multiple regression analysis. NA = Not applicable. a Reference group.

Table 6. Multiple regression analysis for the BEWE scores (coefficient B) according to diet preferences and habits

Related factors 8-year-olds 14-year-olds

BEWE primary BEWE permanent BEWE permanent
(n = 290) (n = 290) (n = 228)

Preference for sour taste (lemon or vinegar) 0.002 (–1.045 to 1.049) 1.960 (0.617 to 3.303) 0.701 (–0.470 to 1.872)
(yes/noa) p = 0.997 p = 0.004 p = 0.241
Lemon-flavored sour candy consumption 0.196 (–1.200 to 1.592) 0.640 (–1.151 to 2.431) 0.914 (–0.734 to 2.561)
(yes/noa) p = 0.783 p = 0.484 p = 0.277
Lemon-flavored sour candy consumption 0.110 (–0.387 to 0.608) 0.778 (–0.140 to 1.696) 0.471 (–0.107 to 1.050)
frequency (times/week)b p = 0.664 p = 0.263 p = 0.110
Fruit juice consumption (yes/noa) 0.193 (–1.555 to 1.941) 0.791 (–1.374 to 2.956) 0.373 (–0.355 to 1.101)
p = 0.643 p = 0.474 p = 0.348
Fruit juice consumption frequency (times/ 0.117 (–0.367 to 0.600) 0.057 (–0.191 to 0.305) 0.045 (–0.126 to 0.216)
week)b p = 0.567 p = 0.652 p = 0.606
Soft drink consumption (yes/noa) 0.093 (–1.654 to 1.840) 1.820 (–0.421 to 4.061) 1.540 (–0.084 to 3.164)
p = 0.917 p = 0.111 p = 0.063
Soft drink consumption frequency (times/ 0.470 (–0.364 to 1.304) 0.116 (–0.954 to 1.186) 0.074 (–0.056 to 0.203)
week)b p = 0.270 p = 0.831 p = 0.264
Soft drink prolonged retention in mouth 0.003 (–1.498 to 1.504) 1.277 (–0.648 to 3.201) 1.047 (–0.465 to 2.559)
(yes/noa) p = 0.997 p = 0.194 p = 0.175

Values in parentheses are 95% CI. Significant differences are indicated in italics. n indicates the number of children included in the
multiple regression analysis. a Reference group. b Reference group = 0 times/week.

Erosive Tooth Wear and Risk Factors in Caries Res 2016;50:349–362 359
Greek Children DOI: 10.1159/000445980
al., 2015] or females [Nayak et al., 2010; Wang et al.,
2010], but is in conflict with other investigations [Peres et
al., 2005; Correr et al., 2009]. In the present study, gender
did not influence the occurrence of tooth wear involving
dentin as shown in previous investigations [Gatou and
Mamai-Homata, 2012].
Diet has also been widely considered as a risk factor for
erosive tooth wear, despite studies recording absolutely
no association [Correr et al., 2009; Gurgel et al., 2011].
Multiple regression analysis suggested liking sour tastes
as a risk indicator for erosive wear of the permanent teeth
in the 8-year-old group. Preference for lemon-flavored
sour candies appeared only in the 14-year-olds, whereas
soft drinks influenced both age groups. These findings are
in agreement with other studies [Murakami et al., 2011;
Hamasha et al., 2014; Alves et al., 2015; Tao et al., 2015;
Zhang et al., 2015]. Frequency of fruit juice consumption
did not reach statistical significance in any age group, in
contrast to other reports [Luo et al., 2005; Zhang et al.,
2015]. In the present study, dietetic factors did not influ-
ence the occurrence of tooth wear involving dentin as
shown in previous investigations [Gatou and Mamai-
Homata, 2012].
The prolonged retention of erosive beverages in the
mouth has been mentioned as a potentially hazardous be-
havioral habit for erosive tooth wear due to increased di-
rect contact time between the acidic liquid and the teeth.
In our study, this habit in the 8-year-olds influenced the
prevalence, the BEWE scores, and the BEWE-based risk
of their permanent teeth. These findings are in agreement
with some previous reports [Rios et al., 2007; Nayak et al.,
2010; Huew et al., 2011; Hamasha et al., 2014].
As to other factors possibly associated with tooth
wear, dental caries is a commonly studied indicator, as
some sugar-containing beverages (e.g. soft drinks) are
likely to predispose the child to both caries and erosion
[Linnet and Seow, 2001]. Unlike studies showing a posi-
tive correlation between caries and erosion [Dugmore
and Rock, 2004; Kazoulis et al., 2007], the present study
did not reveal such a correlation. Moreover, contrary to
two reports connecting swimming in chlorinated pools
with erosive tooth wear [Sanhouri et al., 2010; Zhang et
al., 2015], no such association was apparent in the pres-
ent study.
Tooth grinding as a possible factor related to tooth
wear has also been investigated previously. In the pri-
mary dentition, this parafunctional habit reported by
parents was correlated positively only with canine wear
[Rios et al., 2007]. In the other extant 3-year longitudinal
study, 10- to 12-year-olds, in conjunction with their
360 Caries Res 2016;50:349–362
DOI: 10.1159/000445980
guardians, were asked about the habit at each 6-monthly
recall [El Aidi et al., 2011]. Tooth grinding was found to
be associated with the incidence of erosive wear of per-
manent teeth. In the present study, tooth grinding did
not affect wear prevalence, BEWE scores, or tooth wear
risk.
Oral hygiene habits were included in the present study
as a possible protective factor. In a previous study [Hard-
ing et al., 2010], children brushing their teeth twice a day
or more had less tooth wear than those brushing less fre-
quently, although our study failed to confirm this.
Limitations of the Study
In relating various parameters and factors to the
BEWE-based risk for erosive tooth wear, age must be tak-
en into account. Wear affects primary and permanent
teeth in the components of mixed dentition differentially,
in probable relation to post-eruptive age and to different
enamel thicknesses in the two dentitions. Therefore, the
term ‘risk for erosive tooth wear’ is better applied to lon-
gitudinal studies, in which the progression and severity of
the disease can be monitored in the same children. Then,
the individual risk can be determined, and the signifi-
cance of various etiological factors can be better explored.
In epidemiological studies conducted in schools this is
quite difficult, especially if, as in the present study, obtain-
ing permission is conditional on student anonymity. Fur-
thermore, since the data were collected based on ques-
tionnaires, there is a potential risk of systematic error
arising from the formulation of the questionnaire. This
should be taken into account together with a parental re-
sponse to the questions, which might have modified the
data.
In conclusion, erosive tooth wear was a common find-
ing in both age groups and was related to dentition, gen-
der, and certain dietetic preferences and habits. None of
the studied risk factors was associated with dentin expo-
sure.
Acknowledgments
We wish to thank all the children, and their parents for permit-
ting them to participate in the study, as well as the school head
masters for facilitating access to classes. Special thanks go also to
Dr. Vanessa Boka, DDS, and Dr. Zoe Tzelepi, DDS, for their as-
sistance in the data collection through the questionnaires.
Provatenou/Kaklamanos/Kevrekidou/
Kosma/Kotsanos
 Author Contributions Appendix

N.K. and E.P. conceived and designed the study. E.P. and A.K. English Translation of the Questionnaire on Children’s
performed the clinical examination. E.P., E.G.K., I.K., and N.K. Preferences and Habits Regarding Factors Related to Tooth
analyzed the data. The manuscript was prepared by E.P., E.G.K. Wear
and N.K.
1 Do you brush your teeth? How many times per week?
2 Do you like sour taste? Do you prefer lemon or vinegar?
3 Do you consume fruit juices? How many times per week?
Disclosure Statement
4 Do you consume lemon-flavored sour candies? How many
times per week?
There is no conflict of interest for any of the authors.
5 Do you consume soft drinks? How many times per week?
6 Do you have the habit of retaining the soft drink in your
mouth or do you swallow it straight away?
7 Do you practice pool swimming? How many times per week?
8 Are you aware of grinding your teeth at night?

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