By: Dr. Andrea Shepperson
Tooth wear is an increasingly common condition in modern dentistry, with more patients presenting signs of erosion, attrition, and abrasion. As a result, clinicians need a standardized method for assessing tooth wear that is both simple and reliable.
One tool that has gained significant recognition for its effectiveness and ease of use is the Basic Erosive Wear Examination or BEWE. In this article, we’ll explore the BEWE index, its origins, and why it’s become a ‘go to’ tool for managing all types of tooth wear—not just erosion.
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Defining "Erosive" in the BEWE: More Than Just Erosion:
While the term "erosive" in the Basic Erosive Wear Examination (BEWE) may imply that this index focuses solely on chemical wear, it is a comprehensive tool designed to assess all forms of tooth wear.
Tooth wear can result from several factors, including abrasion (mechanical wear), attrition (tooth-on-tooth contact), and erosion (acid-induced wear). The BEWE allows clinicians to track the extent and progression of wear, regardless of its cause, while looking for the role acids may play in accelerating that wear.
In tooth wear investigations, we often say, "If there’s wear, there’s an acid." That’s because acids, whether dietary or intrinsic, are almost always involved in some capacity when significant wear is observed.
This is why the BEWE emphasizes looking for acid related wear, encouraging dentists to always consider the presence of an acid source—whether from dietary acids, gastric reflux, or other environmental factors.
Key Features Dentists Look For:
When assessing tooth wear using BEWE, dentists focus on several key features that reveal the extent of damage:
Loss of texture: This includes the smoothing out of natural ridges, cusps, perikymata and surface textures (secondary and tertiary anatomy).
Depth of wear: How deep the wear extends into the tooth surface is crucial in assessing severity.
Colour change: A visible darkening or yellowing may indicate the exposure of dentine.
Increased translucency: As the enamel thins, the teeth may appear more translucent, particularly at the incisal edges or on the labial face.
These characteristics allow the dentist to gauge both the extent and the cause of tooth wear, helping to determine the right course of treatment. The BEWE score helps quantify this, guiding clinical decision-making based on how much wear is present.
The Importance of a Risk Assessment Tool
The BEWE is not just about identifying existing wear; it’s also a risk assessment tool. By assigning a score based on the degree of tooth wear across the mouth, dentists can categorize patients into risk levels and recommend interventions. This risk assessment is essential for developing a long-term preventive strategy, especially when it comes to acid exposure.
For example:
A low-risk patient with minimal wear may only need regular monitoring and lifestyle advice, such as avoiding acidic foods or beverages.
A moderate-risk patient might require more active management, such as fluoride treatments or dietary adjustments, to halt the progression of wear.
A high-risk patient with significant tooth surface loss may need restorative work, occlusal adjustments, and a comprehensive review of lifestyle factors, including a referral to a gastroenterologist if reflux is suspected or a sleep study.
The Role of an Erosion Checklist
Since acid is such a common factor in tooth wear, incorporating an Erosion Checklist into patient assessments can significantly enhance the use of the BEWE index. This checklist focuses on identifying potential sources of acid exposure, whether they come from extrinsic sources like diet (e.g., citrus fruits, carbonated beverages, and wine) or intrinsic sources like gastroesophageal reflux disease (GERD) or medication.
Dr Andrea Shepperson has designed a customised checklist for dentists and patients to help pinpoint acid sources. By identifying these acid risks, dentists can address the root cause of wear and implement preventive strategies to mitigate further damage.
Origins and Simplicity of the BEWE
The BEWE index was introduced in 2008 by Professor David Bartlett and his team at King’s College London, who sought to create a tool that was easy for clinicians to use while still providing meaningful data on tooth wear. Prior indices were effective but often complex and inconsistent across practitioners, focusing heavily on dentine loss.
BEWE, by contrast, focuses on simplicity and consistency. It offers a four-point scale (from 0 to 3) that grades the most affected tooth in each sextant of the mouth, providing a total score that informs treatment planning.
To use the BEWE:
Examine each sextant clockwise, in the order shown in Figure 1, measuring the surface with the greatest amount of wear. Register only the highest BEWE score (0-3) per sextant. Combine sextant scores to create a cumulative score. This score gives an indication of how much tooth wear is present in the mouth. It measures all wear - mechanical wear alone does not tend to progress at an accelerated rate - we assume that all accelerated wear rates have an underlying erosive component along with the mechanical - hence erosive wear.
Figure 1: A simple BEWE recording chart.
BEWE GRADING:
0 – no wear
1 – early damage to the teeth. Initial loss of enamel
2 – less than 50%. Distinct defect, hard tissue loss <50% of the surface area
3 – greater than 50%. Hard tissue loss >50% of the surface area
Why the BEWE is a ‘Must Use’ Tool in Modern Dentistry
While it’s reasonable to say we don’t need an index to identify severe wear (Fig.2), it is the subtle signs of wear that are often overlooked (Figure 3). The BEWE prompts a conversation early with a patient, mitigating ongoing risk of further tooth surface loss. By capturing wear severity in a standardized format, the BEWE empowers dentists to take a proactive approach to patient care.
Figure 2: BEWE Cumulative Score in a case of severe, pathological wear.
The BEWE is a quick, simple prompt to include in any routine dental checkups and hygiene recare:
It prompts us to look for wear.
If we see it, we discuss it with patients.
If we note it, we are covered medicolegally.
Figure 3: A moderate case of tooth wear in a 40 year old patient. The Cumulative Score of 12 draws attention to the role of erosion in an otherwise intact and largely unrestored dentition.
Figure 3 highlights how easy it is to overlook wear, particularly when cervical restorations have been placed and the dentition is intact and functioning. The Cumulative score was 12 in this case, a surprisingy figure and raising concerns about the cause of wear.
By incorporating it into regular dental practice, clinicians can ensure they are providing comprehensive care that addresses both the symptoms and the underlying causes of wear, helping patients preserve their teeth for the long term.
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For more detail on the BEWE protocol visit the Erosive Tooth Wear Foundation: https://www.erosivetoothwear.com/bewe/
Dr. Andrea Shepperson is the author of Managing Tooth Wear: A Comprehensive Guide to General Practice. She teaches a week-long Tooth Wear Masterclass at her Center in New Zealand, as an in-person hands-on component of a mentoring programme that includes, webinars, online content and one:one mentoring.
Find out more at https://www.andreashepperson.com/tooth-wear-masterclass/
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References:
Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clin Oral Investig. 2008 Mar;12 Suppl 1(Suppl 1):S65-8. doi: 10.1007/s00784-007-0181-5. Epub 2008 Jan 29. PMID: 18228057; PMCID: PMC2238785.
Ganss C, Klimek J, Lussi A. Accuracy and consistency of the visual diagnosis of exposed dentine on worn occlusal/incisal surfaces Caries Res. 2006;40(3):208-12.
Aránguiz, V., Lara, J., Marró, M. et al. Recommendations and guidelines for dentists using the basic erosive wear examination index (BEWE). Br Dent J 228, 153–157 (2020). https://doi.org/10.1038/s41415-020-1246-y
