Erosive tooth wear is the third most common oral condition in Europe. Professor David Bartlett from King’s College London and Dr Soha Dattani of GSK Consumer Healthcare examine the importance of documenting it as part of a standard dental examination.
Despite being the third most commonly observed oral condition after caries and periodontal disease, and affecting up to 30% of European adults, erosive tooth wear is currently not routinely screened or monitored as part of the standard dental examination.
With modern lifestyles resulting in a “snacking” culture, and an ageing population where people are living longer and retaining their teeth into later life, the overall potential tooth wear risk is rapidly increasing. This, coupled with increasing expectations of patients and the public, means that there is an increased potential for litigation in this area.
Managing the consequences of severe erosive tooth wear can be both expensive and time consuming. According to a study by O’Toole et al, costs could be up to £13,000 for private treatment (£4,500 for NHS treatment) and treatment could take up to 24 months. As with periodontal disease, it is therefore important that examination for erosive tooth wear is part of the routine oral health assessment and clearly documented in the patient’s records.
Communicating risk factors
We know that communication is key in the dentist/patient relationship. So if a patient frequently snacks on acidic food or drink, at least twice per day between meals, then it’s a good idea to discuss with your patient the potential need for treatment at a later date.
A patient’s history can reveal a lot about any future treatment they may need. If they suffer from acid reflux or have bad dietary habits, such as swishing or holding drinks in their mouth that may lead to erosive tooth wear, then this should be discussed and noted.
This should be recoded on a 4-point scale (0-3) with 0 indicating no wear; 1 – very early signs such as loss of surface features (perikaymata, softening of the cingular contour); 2 – wear that is visible on a surface but less than 50%; and 3 – over 50%. Like the basic periodontal examination (BPE), all teeth are examined but only the most severe in each sextant are recorded in the notes in the same way as the BPE. A score of three in any sextant or any combined score over 9 should alert the dentist that tooth wear is active and prevention needs to be started. In cases where the teeth become shorter, further advice is needed.
Prevention is better than treatment
A patient’s attitude may help direct whether prevention or treatment is advised. They may be fully aware of their tooth wear or be completely surprised when told. It’s important for dentists to broach the subject delicately, especially with patients where the erosive tooth wear could be down to other conditions such as bulimia.
Talk to your patient and explain the examination findings. If they are worried or suffering from pain, poor function or poor appearance then they may ask for treatment. If possible, the dentist should advise looking at prevention or a minimal intervention treatment to prevent symptoms from reoccurring or getting worse.
Patients with severe erosive tooth wear may need extensive treatment. It’s important dentists know when the treatment required is outside their scope of practice and better referred to a specialist.
Making a decision
It’s key that a patient plays their part in deciding about their teeth and any treatment plan put in place. The dentist must ensure that valid consent has been given by the patient. To secure this, they must have informed the patient what the problem is (including being shown the evidence from the examination) and what treatment options are available (and any risks involved). They also need to talk through the costs that may be associated with a treatment plan.
Recording erosive tooth wear
Unfortunately, little is known about the natural history and progression risks for erosive tooth wear. For some, progression is slow and gradual, but for others rapid hard tissue destruction occurs that can compromise the longevity of the dentition. Even in late stages, the condition is usually painless, and the only clinical feature is shortened teeth. It should be noted that as erosive tooth wear is not triggered by high levels of plaque, the condition usually affects the ‘committed’ patient. In summary, given there are no clinical guides to identify ‘at risk’ patients, assessment and documentation of erosive tooth wear should occur at every clinical examination.
The Basic Erosive Wear Examination (BEWE) is a well-recognised clinical tool specifically designed for general practice. It has been increasingly adopted internationally and used in 96 peer-reviewed publications in more than 34 countries to date. It follows the same sextant approach as the Basic Periodontal Exam (BPE) and can be conducted at the same time, therefore requiring little additional clinical time. It is not designed to be reproducible but is a straightforward way to record that tooth wear has been examined in the clinical notes.
Keeping accurate, detailed, up-to-date notes including the BEWE results, the decision-making process, the joint decision making process and any actions taken or treatments carried out, is vital in managing risk. If the patient and dentist together decide to just monitor erosive tooth wear then it’s key to include this in the patient’s notes, to protect against a claim that could be made down the line.
Conclusion and further resources
Erosive tooth wear affects 30% of the population, but is not routinely assessed and documented as part of the clinical dental examination. The BEWE provides clinicians with a simple screening tool to efficiently detect and document erosive tooth wear in clinical practice. Its use is advocated to protect the oral healthcare provider and the patient, as the prevalence and awareness of this condition increases. Resources and online training for the BEWE can be found at erosivetoothwear.com and gskhealthpartner.com
Additional information which was printed in Riskwise Scotland
The Faculty of General Dental Practice (UK) supports the campaign for routine screening of erosive tooth wear1 and the Dean of the Faculty, Ian Mills, has recently written a blog on the subject2.
1.fgdp.org.uk/news/fgdpuk-supports-campaign-routine-screening-erosive-tooth-wear Accessed 14 August 2019
2.fgdp.org.uk/news/we-need-act-now-identify-and-manage-erosive-tooth-wear Accessed 14 August 2019