BEWE Guidance 2020 PDF

OPEN | VERIFIABLE CPD PAPER Tooth wear CLINICAL Recommendations and guidelines for dentists using the basic erosive wear examination index (BEWE) V...

OPEN | VERIFIABLE CPD PAPER Tooth wear CLINICAL Recommendations and guidelines for dentists using the basic erosive wear examination index (BEWE) Vicente Aránguiz,1 Juan Sebastián Lara,2 M. Loreto Marró,1 Saoirse O’Toole,3 Valeria Ramírez4 and David Bartlett*3 Key points The BEWE is a simple screening toot. THE BEWE is designed to follow a similar procedure THE BEWE should be used for every new patient at the BPE. examination. Abstract This paper explains how to screen tooth wear in general practice using the Basic Erosive Wear Examination (BEWE) index. It explains how stakeholders in the UK acknowledged the convenience of the BEWE and that it could be recorded at the same time as the Basic Periodontal Examination (BPE). The article contains examples of anterior and posterior tooth wear for each BEWE score to help dentists in their evaluation. Introduction Table 1 BEWE Index assessment (score and description) Health Education England recently issued Score Description guidelines that recording tooth wear is 0 No erosive tooth wear aspirational rather than an essential requirement.1 We know that not every dentist records tooth 1 Initial loss of surface texture (brightness loss, opaque surface or ‘frosted glass’ appearance) wear, and those that do use a multitude of 2 Distinct defect, hard tissue loss, less than 50% of the surface area. Dentin could be involved different methods, from indices to terms such 3 Hard tissue loss in more than 50% of the surface area. Dentin could be involved as mild, moderate or severe. A standardised BEWE index assesses the damage according to the tooth affected surface regardless its depth in dentin. 2 format to record tooth wear is ideal and one Sextants’ cumulative assessment (maximum 18) defines the BEWE index value per assessed subject, allowing the clinical that is familiar can facilitate better uptake. The management actions according to risk. BEWE index (Table 1) was devised in 2008 as a screening tool for general practitioners to help The group recommended that the BEWE Erosive Wear Examination’. As the BEWE with routine dental examinations.2 Recently should be performed at the same time as the has evolved from a European consensus, the in the UK, a group of stakeholders (The Royal BPE to save practitioners time and to utilise term tooth wear has developed a different College of General Dental Practitioners, The an already established routine and recording connotation for UK dentists compared to British Society of Dental Hygienists, GSK, Dental grid. The BEWE and the BPE use the same that of our European colleagues. When the Protection, The Erosive Tooth Wear Foundation, procedure and similar scoring system, thus BEWE was launched, it was felt in Europe King’s College London and the British Dental can be recorded at the same time. The benefit that erosion was the most important agent Association) united to promote that every of recording tooth wear at every clinical for tooth wear, hence there was a strong routine dental examination should include an examination is that it is less likely that tooth influence to refer to ‘erosive tooth wear’. A assessment of erosive tooth wear.3 wear will be missed. Ensuring it is part of every large emphasis is placed on recognising that examination limits the risk of early signs not severe tooth wear rarely happens without 1 Facultad de Odontología, Cariology Unit, Universidad de being recognised in patients and prevention a contributing acidic aetiology. In the UK los Andes; 2Department of Cariology, Operative Dentistry not being started. A toolkit for practitioners and other countries, the term tooth wear is and Dental Public Health, Indiana University School of Dentistry; 3Prosthodontics, Faculty of Dentistry, Oral and has been produced and is available on The preferred. The BEWE gained international Craniofacial Sciences, Kings College London; 4Facultad de Erosive Tooth Wear Foundation website acceptance and it is now too late to change Odontología, Cariology, Epidemiology and Public Health Unit, Universidad de los Andes. (www.erosivetoothwear.com), which includes the terminology. The index scores changes to *Correspondence to: David Bartlett free online CPD, uploads to practice-based the surface of teeth regardless of the aetiology, Email: [email protected] software to enable recording of the BEWE and so it should be used for all causes of tooth Refereed Paper. further information. wear – including abrasion and attrition. This Accepted 11 December 2019 There is some understandable confusion paper provides practical guidance to dentists https://doi.org/10.1038/s41415-020-1246-y regarding the application of the term ‘Basic on using the BEWE. BRITISH DENTAL JOURNAL | VOLUME 228 NO. 3 | February 14 2020 153 © The Author(s), under exclusive licence to British Dental Association 2020  CLINICAL Tooth wear Fig. 1 a) Occlusal surface of a premolar and molar showing no signs of erosive tooth wear. b) No sign of erosive tooth wear on buccal or occlusal surface. c) A molar with hypoplasia but no sign of erosive tooth wear. d) BEWE score 1 showing early signs of erosive tooth wear with discrete, small erosive lesions on occlusal surface. e) BEWE 2 on the premolar. The wear is just less than 50%. f) BEWE 3 showing erosive tooth wear covering more than 50% of the tooth surface. g) although erosive tooth wear visible the restoration covers more than 50% of the surface and therefore cannot be scored Recommendation and guidelines different scores, the lesser BEWE score should The distinction between grade zero and one is be used. Each sextant is scored based upon the minor, but the most important distinction is The severity of tooth wear should be evaluated worst affected surface in that sextant and is between two and three. The BEWE is not in a logical and systematic way and, ideally, recorded in the same grid format as the BPE. designed to be used to assess progression. at the same time as the BPE at every routine Again, similar to the BPE, single remaining Like the BPE, it is a single assessment and is clinical examination. In some dental practice teeth in each sextant are added to the adjacent an adjunct to the clinical judgement at the software applications, this is already possible. sextant. To get an overall score for the mouth, time. It is not sufficiently accurate to enable Ideally, the teeth should be cleaned before each sextant score can be added together to progression to be assessed over time. a clinical examination and then the buccal, give a maximum value of 18. This guides the occlusal and/or incisal and lingual/palatal clinical management actions alongside risk The occlusal surfaces of molars and surfaces should be assessed in each sextant and patient factors.2 premolars under good lighting. Third permanent When using the BEWE index with children BEWE score 0 molars are generally excluded but should be and the primary/deciduous teeth, the same No tooth wear signs on the occlusal surface considered if they replace a second permanent protocols should be used. The same simple Occlusal surfaces with no signs of tooth molar. Restorations that cover more than 50% grid format can be used, with the sextants wear around a restoration interface or cusp of the total surface should be discarded and divided into anteriors and posteriors. During Enamel developmental defects, opacities, other surfaces in the sextant used to indicate the mixed dentition, the assessment should be fluorosis and amelogenesis are scored 0 the score. No sign of erosive tooth wear is the same but it is recognised that deciduous when they do not involve changes to the allocated a BEWE score of zero. If there is teeth are more prone to wear than adult and shape of teeth due to wear. initial loss of surface texture (brightness loss, so the scoring is likely to be higher. The risk opaque surface or ‘frosted glass’ appearance), assessment should account for this and the These are presented in Figures 1a, 1b, and 1c. a BEWE score of one is allocated. If there is a time interval for repetition of the examination distinct wear defect with hard tissue loss but should be decreased to between 6 to 12 BEWE Score 1 affecting less than 50% of the surface area, it is months in high-risk cases. First signs of tooth wear with rounding of a BEWE score of two. If the loss affects more For patients over the age of 20 years, it is the cusps and grooves than 50% of the surface, it is a grade three. rare that their dentition is completely wear- Concavities on cusps (cupping) with These are explained in more detail for each free. A BEWE score of one is normal but, when diameter ≤0.5 mm (use the WHO probe to surface below. When doubt occurs between in doubt, the lower score should be chosen. assess its diameter since its tip has a greater 154 BRITISH DENTAL JOURNAL | VOLUME 228 NO. 3 | February 14 2020 © The Author(s), under exclusive licence to British Dental Association 2020  Tooth wear CLINICAL Fig. 2 a) BEWE score 0 on anterior teeth showing unworn teeth. b) BEWE 1 showing a discrete area of wear on the UR1 on the buccal (facial surface) but no other signs of wear. c) BEWE 2 -shows less than 50% loss with signs of erosive tooth wear on the buccal (facial) surface but also some loss of the incisal edge. d) BEWE 3 greater than 50% of the surface affected. e) In this case the erosion has removed all of the palatal enamel giving a score 3 BEWE Score 3 Hard tissue loss signs for more than 50% of the surface area and dentine is often involved Concavities merging (cupping) can be visible but the total or near-total loss of the occlusal surface covers more than 50% On restored teeth: if tooth wear is seen adjacent to a proud restoration and affects >50% of the surface, it is a BEWE 3; however, if the restoration covers more than 50% of the surface, it cannot be scored. These are presented in Figures 1f and 1g. The palatal/lingual and buccal surfaces of anterior teeth When evaluating the surface in relation to the crown, consider the concept of clinical crown Fig. 3 a) However slight wear is visible on the incisal surface of the canines so a sextant height as the area from the gingival margin score of 1 is representative of wear in this sextant. b) the whole of the incisal edge of the (regardless of periodontal status) to the incisal/ two central incisors has wear and given a score 3 whereas on the canines the wear is less and occlusal edge. would be a 2. The sextant score is 3. c) The wear has clearly involved the whole incisal edge and is given a 3. d) The wear is clearly seen on the incisal edge but there has also been some shortening of the teeth BEWE Score 0 No tooth wear signs on the buccal/palatal/ lingual surface size). More than one cupping can be found Concave wear on cusps (cupping) with Enamel developmental defects, opacities, on a single surface. diameter ≥0.5 mm (it is possible to use the fluorosis, amelogenesis and others are WHO probe to assess its diameter since scored 0 when they do not involve changes These are presented in Figure 1d its tip fits perfectly into the defect) and to the shape of teeth due to wear overall