Basic Erosive Wear Examination (2008): score the worst surface in each sextant 0 to 3, add the six, and the sum sets the risk level and the recall

What it says#

The BEWE was written to solve a problem the authors describe bluntly: there are a myriad of tooth wear indices, they vary in assessment, scale and choice of teeth, they cannot be compared to each other, and none of them is usable at the chair. General dentists, the paper says, have no convenient and simple method of recording the level of tooth wear apart from the subjective terms mild, moderate and severe, whose interpretation varies considerably between clinicians. The model it names is the Basic Periodontal Examination, an index accepted not only by academics but as part of the routine clinical examination by general practitioners, which raised awareness of periodontal disease as much as it measured it. The BEWE is meant to do the same job for erosive wear.

The mechanics are four lines long. Examine the buccal or facial, occlusal and lingual or palatal surfaces of every tooth in a sextant, and record only the highest score found in that sextant. The four levels are 0, no erosive tooth wear; 1, initial loss of surface texture; 2, distinct defect with hard tissue loss of less than 50% of the surface area; and 3, hard tissue loss of 50% or more. A footnote adds that in scores 2 and 3 dentine often is involved, and the body of the paper explains why the wording is deliberately loose: distinguishing lesions restricted to enamel from lesions into dentine is difficult, particularly in the cervical area, so the index removes the clear distinction between enamel loss and exposed dentine rather than build a diagnostic uncertainty into the score. The six sextants are given in FDI notation as 17-14, 13-23, 24-27, 37-34, 33-43 and 44-47, which is to say the three upper and three lower segments in the usual order. The six highest scores are added into a single score sum.

That sum is where the index turns into a plan. Four risk levels are defined. A cumulative score of 2 or less is no risk: routine maintenance and observation, repeated at 3-year intervals. Between 3 and 8 is low risk: oral hygiene and dietary assessment and advice, plus routine maintenance and observation, repeated at 2-year intervals. Between 9 and 13 is medium risk, and the column gets longer: oral hygiene and dietary assessment and advice, identify the main etiological factors for tissue loss and develop strategies to eliminate their impacts, consider fluoridation measures or other strategies to increase the resistance of tooth surfaces, ideally avoid the placement of restorations and monitor erosive wear with study casts, photographs or silicone impressions, and repeat at 6 to 12 month intervals. Fourteen and over is high risk, which repeats every line of the medium column and adds one: especially in cases of severe progression, consider special care that may involve restorations. The paper adds that for patients particularly exposed to intrinsic or extrinsic acids the examination should be repeated at 6-month intervals, while for most other cases annually is acceptable.

Two admissions sit in the same paper. The footnote to the risk table says the cut-off values rest on the experience and studies of one author and have to be reconsidered. And the discussion says the proposed system will need to be validated against existing data or in field trials, that the levels defined are suggestions at the present stage, and that the BEWE is a basic structure meant to start the development of an internationally accepted, standardized and validated index rather than to be one.

Later consensus work has largely accepted it. The European Federation of Conservative Dentistry's 2015 consensus report defines erosive tooth wear as a chemical-mechanical process resulting in a cumulative loss of hard dental tissue not caused by bacteria, characterized by loss of the natural surface morphology and contour of the teeth, and states that a suitable index for classification is the BEWE. That report groups the causes as patient-related (predisposition, reflux, vomiting, drinking and eating habits, medications and dietary supplements), nutritional (low pH and high buffering capacity as major risk factors, calcium concentration as a major protective factor) and occupational (workers exposed to acidic liquids or vapors), and says restorative management should only be used in conjunction with preventive strategies. The 2017 European consensus statement on severe tooth wear goes further in the same direction: restorative intervention is typically best delayed as long as possible, and when it is indicated and agreed with the patient, a conservative, minimally invasive approach is recommended.

Who it applies to#

Every adult and adolescent in a general practice, at screening. The BEWE's whole design premise is that it is quick enough to be run by the person already doing the examination, and its authors point to a survey finding that only a third of practitioners noted erosion on a frequent basis and that the majority underestimated how common it was.

It does not apply to the restorative decision. The paper says outright that it does not provide guidance for the most appropriate prosthodontic or operative technique, because there is too much variation between clinicians at that level. Nor does it establish cause; that is a separate step, assigned in the management column to the medium and high bands, and the EFCD consensus is the better reference for the list of causes to work through.

And it does not settle what is normal. The introduction notes there is no conclusive knowledge of how much erosive wear is physiological or acceptable in relation to age, which is worth remembering before a score of 1 in a sextant turns into a treatment plan.

What changed#

Before the BEWE there was no screening index for erosive wear in general practice at all, only research indices written for particular studies and the words mild, moderate and severe. The BEWE is the first edition of a chairside index for this condition, and its own stated ambition was to let the older indices be collapsed into one comparable unit.

What changed after it is the surrounding consensus. The EFCD adopted it in 2015 as the suitable classification index. The 2017 severe tooth wear statement supplied the management philosophy the BEWE only gestures at, namely that restoration is delayed as long as possible and that when it happens it should be adhesive and minimally invasive. And in 2020 ORCA and the IADR Cariology Research Group ran a two-day workshop with 15 experts and a modified Delphi process to fix the vocabulary, reaching at least 80% agreement on every term, because, as they put it, new terms have been continuously introduced that frequently describe the same aspects while other terms are used inappropriately.

Where the source is#

The BEWE is a four-page article in a 2008 supplement of Clinical Oral Investigations devoted to erosion, and it is open access: the PubMed Central copy linked under the title carries both tables in full, including the risk levels and the footnote about the cut-off values, and the Springer page opens the same article at the publisher. The acknowledgement names the eight additional contributors who took part in the consensus procedure behind it. The later documents are not free. The EFCD consensus report, the 2017 severe tooth wear management statement and the ORCA and IADR terminology consensus are behind publisher access, and only their abstracts, which are the source of everything quoted from them here, are readable on the PubMed records linked above.