Guidance

Chapter 7: Tooth wear

Updated 9 November 2021

This guidance is issued jointly by the Department of Health and Social Care, the Welsh Government, the Department of Health Northern Ireland, Public Health England, NHS England and NHS Improvement, and with the support of the British Association for the Study of Community Dentistry.

Delivering Better Oral Health has been developed with the support of the 4 UK Chief Dental Officers.

Whilst this guidance seeks to ensure a consistent UK-wide approach to prevention of oral diseases, some differences in operational delivery and organisational responsibilities may apply in Wales, Northern Ireland and England. In Scotland the guidance will be used to inform oral health improvement policy.

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Definitions

Tooth wear is the cumulative loss of mineralised tooth substance due to chemical and/or mechanical factors^{[footnote 1]}.

Its components are:

• dental erosion (chemical loss due to exposure to either intrinsic or extrinsic non-bacterial acids)
• dental attrition (physical loss due to tooth-to-tooth contact)
• dental abrasion (physical loss caused by objects other than teeth, such as a toothbrush, hard object, or the tongue)

The term dental abfraction (a notched out area of the tooth at the gingival edge, associated with vigorous brushing) has been used to describe micro-stress fractures of the tooth due to occlusal loading, although there is a lack of clinical evidence that this is a separate cause of tooth wear, and so the term is not recommended.

Tooth wear is normally multi-factorial^{[footnote 2][footnote 3]}; it involves a combination of erosion, attrition and abrasion, leading to a change in shape or form of the tooth. It is now commonly accepted that dental erosion is a more complex process than merely chemical wear^{[footnote 1]}.

By definition, dental erosion is the dissolution of tooth mineral where plaque is not involved in its aetiology^{[footnote 4]}. Remineralisation is possible only in enamel, provided there is no corresponding mechanical loss; once tissue is lost, tooth wear becomes irreversible^{[footnote 5]}. As the condition progresses, which is not inevitable, visible changes to the tooth shape occur^{[footnote 6]}. On the occlusal surfaces of molars, discrete lesions exposing dentine appear, which can merge to create a wider and deeper lesion, thus causing the crown height to reduce. On anterior teeth, attritional wear combined with erosion on the incisal surface is common. On the buccal/facial surface flattening of the contour can, without prevention, lead to loss of crown height if it merges with incisal wear.

Tooth wear terminology has developed in recent years. The use of the term ‘tooth surface loss’ in the clinical situation is now discouraged^{[footnote 1]}.Terms such as non-age-related tooth wear and accelerated tooth wear are used to reflect a more nuanced holistic approach to this condition. Erosive tooth wear (that is, tooth wear with erosion as its primary aetiological factor) is used in recognition that severe tooth wear rarely happens without a contributing acidic aetiology. Since a range of terms is commonly used, and this can be confusing, this document uses the generic term tooth wear, which is internationally recognised^{[footnote 1]}.

Identifying and monitoring tooth wear in clinical practice

Tooth wear is a natural part of ageing and so the extent and seriousness of any wear must be judged against a patient’s age^{[footnote 1]}. It can occur in children, and in primary as well as permanent teeth. Severe tooth wear may lead to poor aesthestics and a reduced lifespan of the teeth involved. Sensitivity is not necessarily an indication of progression. Sensitivity occurs when there is stimuli of patent dentinal tubules, and this can occur with minimal wear, particularly in the cervical region. Sensitivity is a common complaint (60% report concerns) among those attending specialist care for tooth wear^{[footnote 7]}.

Secondary prevention is therefore key to management of tooth wear. This means identifying ‘non-age-related tooth wear’ as early as possible and focusing on identifying and preventing the risk factors that can lead to progress in affected individuals. In doing so, dental team members may identify people with eating disorders and medical conditions for which they require additional support for their overall health and wellbeing.

The Basic Erosive Wear Examination (BEWE) index

Several indices have been developed to measure and monitor tooth wear^{[footnote 1][footnote 8][footnote 9][footnote 10][footnote 11]}. For example, the Tooth Wear Index by Smith and Knight^{[footnote 10]}, which proposes a distinction of pathological levels of wear based on a patient’s age, is widely used – although limitations in the index have been recognised, and adaptations subsequently developed^{[footnote 9]}. There is also the Tooth Wear Evaluation System (TWS), which is now in its second version^{[footnote 8]}.

The BEWE is a simple screening tool based on the principles of the Basic Periodontal Examination (BPE). The BEWE records the most severely affected surface for each sextant, which means it entails a similar clinical procedure to the BPE’s sextant approach. The BEWE is a 4 point scale from 0 to 3, with 1 representing early change, 2 less than 50% and 3 more than 50% of the surface involved. All teeth are examined and the surface with the highest score in a sextant is recorded. The cumulative score highlights the extent of the condition and can assist in the management of the condition for the practitioner^{[footnote 11]}. This tool has been validated for use^{[footnote 12]}, including in primary dental care^{[footnote 13]}. It provides evidence to inform discussions with affected patients and its use is recommended during all patients’ routine examinations^{[footnote 14]}. A BEWE score of 3 (wear affecting over 50% of a surface) present in every sextant justifies further investigation and multiple level 3 scores indicate severe wear.

BEWE Score 1

First tooth wear signs. Initial loss of surface texture (brightness loss, opaque surface or ‘frosted glass’ appearance) but with a discrete area on the buccal (facial) surface and minimal loss of the incisal edge.

BEWE Score 2

Distinct defect. Hard tissue loss less than 50% of the surface area. Dentine is often involved. Loss of clinical crown height less than 50% from the buccal aspect.

BEWE Score 3

Hard tissue loss signs, with more than 50% of the surface area. Dentine is often involved but is not a prerequisite for a BEWE score of three. For restored teeth, the tooth wear can only be scored provided that the size of the restoration does not exceed 50%.

Source: ^{[footnote 14]}.

Tooth wear in the UK

The 2009 national (England, Wales and Northern Ireland) survey of dentate adults found that 2% had severe tooth wear (exposing the pulp or secondary dentine), 15% had moderate wear (exposing a large area of dentine on any surface) and 77% had some wear present^{[footnote 15][footnote 16]}. This varied with age, since damage is cumulative: 44% of dentate adults aged 75 to 84 years had some moderate wear compared with 4% of 16 to 24 year olds. Moderate wear was more common in men (19%) than women (11%)^{[footnote 15][footnote 16]}.

Prevalence of tooth wear amongst adults had increased slightly since the 1998 survey, when 11% of adults had moderate wear. The increase was greatest in younger adults: in 2008, 4% of 16 to 24 year olds had moderate tooth wear, compared with only 1% in 1998^{[footnote 17]}.

Tooth wear is present in primary as well as permanent teeth. The 2013 national survey of children (England, Wales and Northern Ireland) found that one-third (33%) of 5 year olds had evidence of tooth wear on one or more of the buccal surfaces of their primary upper incisors, although only 4% of 5 year olds had wear which involved dentine or pulp^{[footnote 18]}. The 2013 child survey also looked for tooth wear on permanent upper incisors and first permanent molars of 12 and 15 year olds. Although some evidence of tooth wear was common: 38% of 12 year olds and 44% of 15 year olds had some tooth wear on the lingual surfaces of incisors, only 2% and 4% respectively had tooth wear involving the dentine or pulp^{[footnote 18]}. Amongst children, tooth wear involving dentine or pulp in these index teeth was similar to the prevalence reported in the 2003 survey data for these age groups. Tooth wear is more common on lingual surfaces of upper central incisors than buccal surfaces, and more common on buccal than lingual surfaces of premolars.

A study in Ireland measured tooth wear at 5 years of age, and again when the children were 12 years old^{[footnote 19]}. There was a significant association between the presence of tooth wear with dentine exposed in the primary dentition, and tooth wear on the occlusal surfaces of the first permanent molars at 12 years old. Screening for tooth wear in younger children is therefore important, to enable early preventive advice and support to be given^{[footnote 19]}.

General population advice for patients

Although the prevalence of tooth wear may be increasing and we are more aware of the condition, most people do not have accelerated tooth wear. General oral health advice for patients without visible signs of accelerated tooth wear is shown in Chapter 2: Table 4 and is the same as in the dental caries and periodontal disease tables. It includes the adoption of good dietary practice enjoying a healthy diet (Chapter 10), and cleaning teeth effectively (Chapter 8), with a standard fluoride toothpaste (Chapter 9).

Research at population level increasingly highlights the role of acidic beverages, particularly soft drinks^{[footnote 20][footnote 21][footnote 22]} and fruit juices^{[footnote 22]}. Whilst concerns have also been raised about fruit[^23, national surveys within the UK over the past 9 years show that the majority of children and adults do not consume enough fruit and vegetables for a healthy diet^{[footnote 24]}. The vast majority of the population, therefore, are not at risk of accelerated tooth wear because of excessive fruit consumption and should not be given advice to reduce the volume or frequency of fruit consumption which is beneficial for general health. Snacking on fruit should not be discouraged amongst the general population.

Risk factors

Tooth wear is multifactorial. Much of the available evidence to date relates to epidemiological and laboratory research, together with professional advice. The former involving cross-sectional studies of associations at population level and from higher risk groups attending specialist services, suggest that increased tooth wear is associated with extrinsic acid (from food, drink and medications), as well as intrinsic acid (from the stomach due to gastro-oesophageal reflux, rumination, vomiting and eating disorders), or a mixture of factors.

Unlike demineralisation in dental caries, there is no clear-cut critical pH for dental erosion to occur, because other influences such as a drink’s mineral content may moderate its erosive action. For example, the calcium content in calcium enriched drinks may reduce the erosive effect of those drinks^{[footnote 25]}. Furthermore, saliva plays an important role in diluting and buffering acids and facilitating their clearance through swallowing^{[footnote 26]}.

Increased erosive potential of extrinsic acids occurs when there is:

• lower pH value
• lower salivary flow
• lower buffering capacity (takes longer for saliva to neutralise the acid)
• higher titratable acidity (more available H+ ions in solution)
• lower calcium and phosphate content in saliva (influences degree of saturation)
• lower fluoride content
• higher temperature (that is, if drinks are warmed, erosive potential is increased)^{[footnote 26][footnote 27][footnote 28][footnote 29]}

The ‘erosive potential’ of a wide range of food, drinks and medicines is measured by laboratory findings which suggest that drinks, juices, fruits, and some medications and alcoholic drinks cause a significant decrease in pH of enamel samples^{[footnote 27][footnote 29]}.

It is generally accepted that acidic drinks are the most common unhealthy type of drinks in respect to acid erosion^{[footnote 27][footnote 29][footnote 30]}, as outlined in Table 7.1.

Carbonated water, with fruit flavouring or lemon has been shown to have high erosive potential^{[footnote 28]}, as have ‘fruit juices’ or fruit teas^{[footnote 30][footnote 31][footnote 32]}. Multiple products are marketed as fruit juices. It is therefore increasingly important to distinguish between fruit juice and fruit drinks. Fruit juice is a drink that is prepared by mashing the pulp of the fruit, while a fruit drink is a sugary solution that contains the colour and flavour of the fruit but not the real fruit juice. Some fruit drinks do contain a little of the fruit juice, but the rest is essentially flavour and colour.

Unflavoured water (still and sparkling), milk, tea and coffee have the ‘lowest erosive potential’^{[footnote 27]}. Although carbonated mineral water is more acidic than still water, it is fine for teeth, as long as it is unflavoured^{[footnote 27][footnote 31]}.

Whether the erosive potential translates into tooth wear depends on patient factors and exposure conditions^{[footnote 33]}, including the length of time involved^{[footnote 27]}, and number of acidic attacks per day^{[footnote 30][footnote 32]}.

There is also likely to be individual variation in response to the erosive effects of acids, due to:

• the quantity and quality of saliva
• features of the pellicle
• individual habits which might include swishing, swilling, rinsing or holding drinks in the mouth before swallowing (retention may prolong the effect and overwhelm any protective capacity of saliva)^{[footnote 29]}
• the presence of calcium and phosphate in associated beverages and foods^{[footnote 29]}
• lower frequency of toothbrushing with a fluoride toothpaste^{[footnote 34]}
• individual susceptibility, for example, tooth anatomy and structure^{[footnote 5][footnote 34]}

The most important aspect of patient care, once the presence of tooth wear has been identified, is to identify all possible sources of risk, chemical and/or mechanical, recognising that acids may be extrinsic or intrinsic, healthy or unhealthy.

Current evidence suggests that in individuals who do not have a medical condition or consume carbonated drinks, there may be other sources of acid; which highlights the importance of detailed and careful dietary investigation as part of risk factor identification. It may therefore be helpful to use the example diet diary (PDF, 76.6KB).

Whilst fruit is a possible healthy dietary risk factor, it has mainly been identified amongst adults referred for specialist management of erosion in dental hospitals, where eating fruit over an extended period was one of the risk factors for severe erosive tooth wear^{[footnote 30]}.

Table 7.1 provides a list of possible factors which increase the risk of tooth wear to explore with high risk patients. Several caveats are important. Firstly, it has been compiled based on expert opinion and the best evidence available on risks and their management. Secondly, further research is required to better understand risk factors which may be multifactorial and build evidence for their management. Thirdly, it is not a definitive or exhaustive list.

Table 7.1 Possible sources of chemical and mechanical wear to explore with high risk patients with signs of tooth wear

Chemical wear: extrinsic sources of acid	Possible actions to consider (related to the specific risk for an individual patient)
Drinks: • carbonated drinks (except non-flavoured sparkling water) • wine (white and red) • alcopops and designer drinks • fortified wines with fruity flavours • smoothies • energy drinks • drinks containing citric acid, including natural fruit juices – such as orange, grapefruit, lemon, blackcurrant • fruit teas (excluding non-fruit flavoured herbal teas such as camomile or peppermint) • sports drinks	Limit carbonated and acidic drinks to meal-times. Substitute with plain water or non-flavoured sparkling water. Drink regular tea or coffee (without sugar). Reduce the temperature of fruit teas or other hot erosive drinks – this slows the erosion, but it’s preferable to swap to a safer alternative.
Foods: • vinegar-based foods, including pickles • fruit-based sauces	Limit if consumed frequently.
Confectionary: • acidic sweets, for example sour jelly-based sweets, acid drops, sherbet lemons, and so on • fruit-based sugar and certain sugar free sweets	Avoid, or, for patients with reduced salivary flow, replace with sugar free alternatives that have neutral pH and/or are designed for dry mouth and saliva stimulation.
Fruit (healthy acids): • acidic fresh fruit, particularly in high quantities • lemons, oranges and grapefruit are the most acidic fruit acids (most fruits may be erosive, other than banana and avocado)	Fruit eating should not be discouraged unless identified as a risk factor. Avoid grazing on fruit (only if this is identified as a risk factor). Substitute acidic fruit with vegetables, bananas or avocados, particularly between meals and ensure a wide variety of vegetables. Address any higher risk habits such as holding against teeth.
Medication: • chewable vitamin C tablets • aspirin • asthmatic inhalers • some iron preparations	Replace with tablets which may be swallowed. Consider replacement of medication with non-acidic alternatives. Discuss options with pharmacist or GP as appropriate.
Reduced saliva: • conditions which reduce salivary flow including intense sport and anxiety • saliva reducing medications	Consider saliva substitutes (toothpastes, mouthwashes, gels). Discuss options with pharmacist, GP or specialist as appropriate.
Chemicals: • tooth whitening materials	Consider alternatives for whitening in dental practice.
Other rare sources: • occupational exposure to acid, for example mists in the workplace air, wine tasters • swimming	Explore possibilities to remove risk factor, where possible.

Chemical wear: intrinsic sources of acid	Possible actions to consider (related to the specific risk for an individual patient)
Gastric acid reflux including GORD (gastro oesophageal reflux disease). Laryngopharyngeal reflux (LPR).	Seek medical advice and support to control the reflux.
Chronic vomiting in pregnancy.	Avoid brushing after vomiting and rinse mouth with water. Apply fluoride toothpaste with finger to improve taste in mouth or use fluoride mouthwash.
Eating disorders including Bulimia Nervosa.	Support patient to seek medical advice and support. Avoid brushing after vomiting. Rinse mouth with water. Apply fluoride toothpaste with finger to improve taste in mouth or use fluoride mouthwash.

Mechanical wear: intrinsic sources of acid	Possible actions to consider (related to the specific risk for an individual patient)
High abrasive toothpastes (for example smokers toothpastes – more common in the US).	Use standard or low abrasive toothpaste.
Filing teeth. Opening objects with teeth.	Avoid trauma to teeth.
Brushing aggressively or inappropriately.	Advise on adapting brushing technique and using a soft-medium brush.
Piercings.	Advise on removal of piercings.
Bruxism.	Increase awareness of bruxism – consider stress-related factors.
Workplace particulate.	Suggest workers use available PPE for protection in workplace.

Note: the quality of evidence is low. All the above findings are based on weak clinical evidence or laboratory studies.

Sources informing expert opinion: Lussi and others^{[footnote 27][footnote 28]}; O’Toole and others^{[footnote 30]}; Saads Carvalho^{[footnote 29]}; Ganss and others^{[footnote 35]}; Goswami and others^{[footnote 36]}; Sovik and others^{[footnote 37]}; Souza and others^{[footnote 38]}; Vertuan^{[footnote 39]}; Buzalaf and others^{[footnote 26][footnote 40]}.

Risk factor management: professional action for high risk patients

Secondary prevention for patients with tooth wear should focus on identifying, minimising or removing the source of risk, ideally at an early stage as outlined in Chapter 2: Table 4. It is important to note that there are few clinical studies assessing the prevention of tooth wear, particularly dental erosion, with the majority of the evidence being of low certainty.

Patients should be active participants in identifying the main sources of risk and in discussions about managing them. These conversations can be sensitive and take time, since they may involve exploring lifestyle and even expose possible mental health issues which require supportive referral. This provides the basis for the provision of tailored, specific advice for each individual patient, to manage their risks of tooth wear. Chapter 3 on behaviour change provides important tools for the dental team.

Professional consensus suggests that tackling intrinsic and extrinsic sources of acid is more important than relying on adjustments relating to toothpastes and toothbrushing. For high risk patients displaying signs of accelerated tooth wear, focus on the main risk(s) of tooth wear such as diet, medications and general health and help the patient to understand that such changes will be of greater benefit than possible sources of protection such as specialised pastes. Evidence from insitu and invitro (laboratory) studies suggests that specialised toothpastes containing fluoride, or fluoride plus a stannous-based ingredient, can play a supplementary role in managing erosive wear^{[footnote 41]}.

Diet (including drinks)

Where there is evidence of dietary risk responsible for tooth wear, patients should be advised to reduce the frequency of intake of the identified acidic foods or drinks.

Keep the identified acidic food and drinks to mealtimes and explore safe alternatives, particularly between meals.

Advise against methods of drinking that promote tooth wear such as swilling and swishing.

Promote a healthy diet as outlined in Chapter 10.

Toothbrushing

Use toothpaste containing an age-relevant fluoride content twice daily as outlined in Chapters 8 and 9.

Avoid using high abrasive toothpaste.

Consider the use of specialised pastes containing fluoride or fluoride plus a stannous-based ingredient.

There is no strong evidence to suggest that the timing of toothbrushing is of great importance.

For people who experience vomiting on a frequent basis and wish to refresh their mouth after vomiting, it may be helpful good practice to rinse the mouth and apply fluoride toothpaste, or a fluoride mouthrinse.

General health

Medical advice and/or referral to their GP should be considered, if required, for management of intrinsic sources of acid involving reflux or eating disorders, or medications.

Medications

Many people are on long-term medication which suppresses salivary flow. It is important to be aware of medications that reduce the flow of saliva, and thus impact on the clearance of acids and ensure regular medication is acid free.

Saliva

Saliva may be a very important biological factor affecting the progression of dental erosion^{[footnote 26]}, playing a role in dilution, buffering (chemically lessening the impact) and clearance of dietary acids and supporting re-mineraliation after an erosive challenge. Patients with reduced salivary flow, of any aetiology, may therefore be at increased risk of tooth wear. Active encouragement in seeking medical support and considering saliva or medication substitutes will be important.

Given the potential for erosive drinks to be a risk factor for tooth wear, the use of drinking straws may be considered as part of risk management. Current professional guidelines recommend the use of a wide bore straw, plus avoidance of holding acidic drinks in the mouth^{[footnote 42]}. There is some weak evidence that straws are more likely to be beneficial if positioned to the back of the mouth to minimise contact between the drink and the tooth surfaces^{[footnote 40]}. However, there is insufficient evidence to know whether drinking through a straw does lead to a reduction in the risk of tooth erosion given that people generally want to enjoy the taste of a drink. Thus, any benefit is likely to depend upon drinking behaviour and positioning of the straw.

Monitoring tooth wear

Tooth wear is generally a slow process and may be episodic. Tools to help monitor tooth wear progression include clinical assessment using indices if it is early tooth wear; and if more severe, study models and photographs.

It is important to recognise that we do not yet have accurate methods for measuring tooth wear over time; however, rapid advancement of digital technologies such as intra-oral scans and registration may result in adjuncts for monitoring tooth wear progression in clinical practice alongside history taking and clinical judgement^{[footnote 43]}.

Where accelerated tooth wear and its aetiology have been identified, it may be helpful to consider a shortened dental recall period to support behaviour change and to monitor progress of the condition.

Resources

Recommendations and guidelines for dentists using the basic erosive wear examination index (BEWE).

RCS Clinical Guidelines: Diagnosis, Prevention and Management of Dental Erosion.

References

1. Loomans B, Opdam N, Attin T, Bartlett D, Edelhoff D, Frankenberger R, and others. Severe Tooth Wear: European Consensus Statement on Management Guidelines. Journal of Adhesive Dentistry. 2017;19(2):111-9. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

2. Shellis RP, Addy M. The interactions between attrition, abrasion and erosion in tooth wear. Monographs of Oral Science. 2014;25:32-45. ↩

3. Lussi A, Carvalho T. Erosive tooth wear: a multifactorial condition of growing concern and increasing knowledge. Monographs in oral science. 2014;25:1-15. ↩

4. Lussi A, Schlueter N, Rakhmatullina E, Ganss C. Dental Erosion – An Overview with Emphasis on Chemical and Histopathological Aspects. Caries Research. 2011;45(suppl 1)(Suppl. 1):2-12. ↩

5. Lussi A, Hellwig E, Zero D, Jaeggi T. Erosive tooth wear: diagnosis, risk factors and prevention. Americal Journal of Dentistry. 2006;19(6):319-25. ↩ ↩²

6. Bartlett D. Tooth wear. British Dental Journal. 2018;224(5):283-. ↩

7. Wazani BE, Dodd MN, Milosevic A. The signs and symptoms of tooth wear in a referred group of patients. British Dental Journal. 2012;213(6):E10-E. ↩

8. Wetselaar P, Wetselaar-Glas MJM, Katzer LD, Ahlers MO. Diagnosing tooth wear, a new taxonomy based on the revised version of the Tooth Wear Evaluation System (TWES 2.0). Journal of Oral Rehabilitation. 2020:10. ↩ ↩²

9. Hemmings K, Truman A, Shah S, Chauhan R. Tooth Wear Guidelines for the BSRD Part 1: Aetiology, Diagnosis and Prevention. Dental Update. 2018;45:3–10. ↩ ↩²

10. Smith BG, Knight JK. An index for measuring the wear of teeth. British Dental Journal. 1984;156(12):435-8. ↩ ↩²

11. Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clinical oral investigations. 2008;12 Suppl 1(Suppl 1):S65-S8. ↩ ↩²

12. Olley RC, Wilson R, Bartlett D, Moazzez R. Validation of the Basic Erosive Wear Examination. Caries Research. 2014;48(1):51-6. ↩

13. Dixon B, Sharif MO, Ahmed F, Smith AB, Seymour D, Brunton PA. Evaluation of the basic erosive wear examination (BEWE) for use in general dental practice. British Dental Journal. 2012;213(3):E4. ↩

14. Aránguiz V, Lara JS, Marró ML, O’Toole S, Ramírez V, Bartlett D. Recommendations and guidelines for dentists using the basic erosive wear examination index (BEWE). British Dental Journal. 2020;228(3):153-7. ↩ ↩²

15. NHS Digital. Adult Dental Health Survey 2009, England, Wales and Northern Ireland. London: NHS Digital; 2011. ↩ ↩²

16. HSCIC. Adult Dental Health Survey 2009 – Summary report and thematic series [NS] London: The Health and Social Care Information Centre; 2011. ↩ ↩²

17. HSCIC. 2. Disease and related disorders – a report from the Adult Dental Health Survey 2009 (PDF, 317KB) London: The Health and Social Care Information Centre; 2011. ↩

18. NHS Digital. Report 2: Dental Disease and Damage in Children: England, Wales and Northern Ireland. London: The Health and Social Care Information Centre; 2015 Published 19 March 2015. ↩ ↩²

19. Harding MA, Whelton HP, Shirodaria SC, O’Mullane DM, Cronin MS. Is tooth wear in the primary dentition predictive of tooth wear in the permanent dentition? Report from a longitudinal study. Community Dental Health. 2010;27(1):41-5. ↩ ↩²

20. Al-Zwaylif LH, O’Toole S, Bernabe E. Type and timing of dietary acid intake and tooth wear among American adults. Journal of Public Health Dentistry. 2018;78(3):214-20. ↩

21. Li H, Zou Y, Ding G. Dietary Factors Associated with Dental Erosion: A Meta-Analysis. PLOS ONE. 2012;7(8):e42626. ↩

22. Salas MMS, Nascimento GG, Vargas-Ferreira F, Tarquinio SBC, Huysmans MCDNJM, Demarco FF. Diet influenced tooth erosion prevalence in children and adolescents: Results of a meta-analysis and meta-regression. Journal of Dentistry. 2015;43(8):865-75. ↩ ↩²

23. Public Health England, Food Standards Agency, NatCen, MRC. National Diet and Nutrition Survey: Years 1 to 9 of the Rolling Programme (2008/2009 – 2016/2017): Time trend and income analyses. London: Public Health England,; 2019. ↩

24. Wang X, Lussi A. Functional foods/ingredients on dental erosion. European Journal of Nutrition. 2012;51:39-48. ↩

25. Buzalaf MA, Hannas AR, Kato MT. Saliva and dental erosion. Journal of Applied Oral Science. 2012;20(5):493-502. ↩ ↩² ↩³ ↩⁴

26. Lussi A, Megert B, Peter Shellis R, Wang X. Analysis of the erosive effect of different dietary substances and medications. British Journal of Nutrition. 2012;107(2):252-62. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

27. Lussi A, João-Souza SH, Megert B, Carvalho TS, Baumann T. The erosive potential of different drinks, foodstuffs and medicines – a vade mecum. Swiss Dental Journal. 2019;129(6):479-87. ↩ ↩² ↩³

28. Carvalho TS, Lussi A. Chapter 9: Acidic Beverages and Foods Associated with Dental Erosion and Erosive Tooth Wear. Monographs in Oral Science. 2020;28:91-8. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

29. O’Toole S, Bernabé E, Moazzez R, Bartlett D. Timing of dietary acid intake and erosive tooth wear: A case-control study. Journal of Dentistry. 2017;56:99-104. ↩ ↩² ↩³ ↩⁴ ↩⁵

30. Lussi A, Megert B, Shellis RP, Wang X. Analysis of the erosive effect of different dietary substances and medications. British Journal of Nutrition. 2012;107(2):252-62. ↩ ↩²

31. O’Toole S, Bernabé E, Moazzez R, Bartlett D. Timing of dietary acid intake and erosive tooth wear: A case-control study. Journal of Dentistry. 2017;56:99-104. ↩ ↩²

32. Schlueter N, Amaechi BT, Bartlett D, Buzalaf MAR, Carvalho TS, Ganss C, and others. Terminology of Erosive Tooth Wear: Consensus Report of a Workshop Organized by the ORCA and the Cariology Research Group of the IADR. Caries Research. 2020;54(1):2-6. ↩

33. Chadwick RG, Mitchell HL, Manton SL, Ward S, Ogston S, Brown R. Maxillary incisor palatal erosion: no correlation with dietary variables? Journal of Clinical Pediatric Dentistry. 2005;29(2):157-63. ↩ ↩²

34. Ganss C, Schlechtriemen M, Klimek J. Dental erosions in subjects living on a raw food diet. Caries Research. 1999;33(1):74-80. ↩

35. Goswami U, O’Toole S, Bernabé E. Asthma, long-term asthma control medication and tooth wear in American adolescents and young adults. Journal of Asthma. 2020:1-7. ↩

36. Sovik JB, Skudutyte-Rysstad R, Tveit AB, Sandvik L, Mulic A. Sour sweets and acidic beverage consumption are risk indicators for dental erosion. Caries Research. 2015;49(3):243-50. ↩

37. Souza BMd, Vertuan M, GonÇalves IVB, MagalhÃes AC. Effect of different citrus sweets on the development of enamel erosion in vitro. Journal of Applied Oral Sciences. 2020;28:e20200182-e. ↩

38. Vertuan M, de Souza BM, Machado PF, Mosquim V, Magalhães AC. The effect of commercial whitening toothpastes on erosive dentin wear in vitro. Archives of Oral Biology. 2020;109:104580. ↩

39. Buzalaf MAR, Magalhães AC, Rios D. Prevention of erosive tooth wear: targeting nutritional and patient-related risks factors. British Dental Journal. 2018;224(5):371-8. ↩ ↩²

40. Abdelwahed AG, Temirek MM, Hassan FM. Antierosive Effect of Topical Fluorides: A Systematic Review and Meta-Analysis of In Situ Studies. Open Access Maced Journal of Medical Science. 2019;7(9):1523-30. ↩

41. British Society for Restorative Dentistry. Tooth wear Guidance for the BSRD. London: BSRD; 2019. ↩

42. Marro F, Jacquet W, Martens L, Keeling A, Bartlett D, O’Toole S. Quantifying increased rates of erosive tooth wear progression in the early permanent dentition. Journal of dentistry. 2020;93:103282. ↩