Exam 0309 Module Three Review and Practice Test
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A plea for the development of an universally accepted modular molar wear evaluation system
BMC Oral Health volume sixteen, Article number:115 (2016) Cite this article
Abstract
Background
Tooth wear is considered an increasing oral health trouble. Due to its multifactorial nature, recognizing and diagnosing of tooth wear is difficult only nevertheless of import. Over the years, a broad variety of evaluation systems has been adult, yet none of them is universally accepted. This has implications for both research and clinical practice.
Give-and-take
This paper describes an in-depth analysis of four commonly used molar wear evaluation systems, namely, the Eccles index, the Molar Wearable Index, the Lussi index, and the Basic Erosive Habiliment Exam. Comparing those systems revealed that despite several similarities, they differ considerably from each other. Notably, all four systems have their specific advantages and disadvantages. However, neither ane of them meets all necessary characteristics of a hypothetical, broadly applicative tooth habiliment evaluation organisation. In fact, information technology is non realistic that a unmarried system qualifies for all purposes (for instance, diagnosing or monitoring individual patients, performing epidemiological studies, etc.).
Summary
Every bit a potentially viable solution for this issue, the evolution of an evaluation system is recommended that consists of multiple, coherent modules, which cover different purposes.
Peer Review reports
Background
Molar wear is considered an increasingly prevalent oral health problem, which volition mainly manifest in the future. Information technology can be divided in the subtypes "mechanical wear" (compunction and abrasion), and "chemical wearable" (erosion, or erosive tooth article of clothing) [i]. Since nowadays about people grow onetime with their own dentition, tooth vesture occurs more frequently [ane]. Because molar vesture is always a multifactorial process, its diagnosis can be difficult [ii]. Within dentistry, several widely accepted diagnostic tools for various pathologies are used (e.g., Decayed Missing Filled Teeth (DMFT) for caries and the periodontal screening index [3] for periodontal diseases). Then far, all the same, no universally accepted diagnostic tool is available for the evaluation of tooth wear [4]. Most probable, this is due to the fact that a broadly applicable tooth vesture evaluation system has not been developed yet. Ideally, such system should have the post-obit characteristics: 1. being able to assess all subtypes of tooth wear, viz., mechanical habiliment and chemical wear; 2. being useful for inquiry purposes (east.g., epidemiological and etiological assessments) besides as for clinical applications (e.g., screening, diagnosing, and monitoring); Information technology is very of import to have an evaluation system for molar wear, that tin can be used for epidemiological purposes, because in that way, wellness care providers tin estimate the need for dental care regarding tooth vesture. Regarding individuals, since molar clothing is an irreversible procedure, it is important to screen for tooth wear on a regular footing, in order to preclude habiliment equally much as possible and past doing this, to try to preserve dentitions equally long as possible in an ageing population. 3. having well-divers, reproducible scoring criteria; and 4. being easy to utilise. Information technology was this study'south outset aim to perform an in-depth analysis of the characteristics of 4 ordinarily used tooth wear evaluation systems and to determine if, and if then, to what extent these systems show whatever one or more than of the to a higher place-described characteristics of a hypothetical, broadly applicable evaluation organization. The post-obit systems will exist analyzed: the Eccles index [5], the Molar Wearable Index, TWI [half dozen], the Lussi index [7], and the Bones Erosive Wear Examination, BEWE [viii]. The upshot of the analyses of the 4 systems volition provide input for the second aim of this study, namely to codify recommendations for the evolution of a broadly applicative tooth vesture evaluation system for employ in adults. By using the Eccles index, the Lussi index and the BEWE, chemical tooth wearable is overestimated, because the ii subtypes of tooth wear (chemical article of clothing and mechanical habiliment) are summated.
Pick of the well-nigh widely quoted tooth article of clothing evaluation systems
The option of the first three evaluation systems (i.e., the Eccles alphabetize, the TWI, and the Lussi index) was based on the frequency of them being quoted in the literature of the past four decades. This was based on several PubMed searches, the terminal ane being performed on the 12th of September 2016. The used query was: "(tooth wear OR molar surface loss OR attritive molar wear OR annoying tooth article of clothing OR erosive tooth article of clothing OR tooth attrition OR teeth compunction OR dental compunction OR tooth erosion OR teeth erosion OR dental erosion OR tooth abrasion OR teeth abrasion OR dental abrasion) AND (alphabetize OR indices OR scale OR scales OR measurement OR measurements OR class OR grades OR grading system OR grading systems OR recording organization OR recording systems OR evaluation organization OR evaluation systems)". The PubMed search yielded 114 different grading systems for the quantification of molar wear, including adaptations of already existing systems. It was revealed that in inquiry, the TWI is the most frequently used system, followed past the BEWE and the Lussi alphabetize respectively. Of importance for our pick was that these three systems were also used by other authors than those who developed the systems, while for the bulk of the organisation, the use was restricted to the developers. Additionally, Margaritis and Nunn [4] described in their article in Table 3 their PubMed search of the most recently cited indices used in the assessment of erosive clothing (years 2000–2013). They found a frequency of use of 13 times for the Lussi index, 11 times for the TWI, 6 times for the BEWE, and five times for the Eccles index respectively, when the target group was adults. No other indices with adults as the target group were included in their table. Hence, this is in line with our findings. The Eccles index is considered as one of the basic evaluation systems from which many others originate [9]. The TWI and the Lussi index are the 2 most commonly used tooth vesture evaluation systems, and many other systems are adult based on them. The fourth system that was included, the BEWE, was recently introduced past a group of experts and is since and then quoted frequently as well. Although the BEWE is a relatively new alphabetize and population-based studies are scarce, the amount of studies is increasing with recent reports from around the globe. The characteristics of these four evaluation systems are described below.
Eccles alphabetize
The Eccles index [5] consists of three classes, viz., I, 2, and III (Table 1). Classes I and Ii apply to all surfaces, while Class Iii differentiates between diverse surfaces, namely facial surfaces as IIIa, lingual and palatal surfaces as IIIb, incisal and occlusal surfaces as IIIc, and severe multi-surface involvement as IIId.
Tooth Clothing Index (TWI)
The Tooth Wear Index (TWI) [6] consists of a five-point ordinal scale. The descriptions of the various grades are shown in Table 2. The grading is identical for all teeth, but dissimilar criteria are present for the various surfaces, viz., for the buccal/lingual/occlusal, incisal, and cervical surfaces.
Lussi index
The Lussi alphabetize [7] consists of two ordinal scales for all teeth, viz., a four-bespeak ordinal scale for the facial surfaces and a 3-point ordinal scale for the occlusal/lingual surfaces. The descriptions of both scales are shown in Tabular array 3.
Basic Erosive Habiliment Test (BEWE)
The Basic Erosive Clothing Examination (BEWE) [viii] consists of a single four-signal ordinal scale; the descriptions of the diverse grades are shown in Tabular array iv.
Characteristics of a hypothetical, broadly applicable tooth habiliment evaluation arrangement
A hypothetical, broadly applicable molar wear evaluation system should take the following characteristics:
Molar wear subtypes: existence capable to evaluate both mechanical wear (attrition and abrasion) and chemical wear (erosion), and not only ane subtype, since the subtypes rarely act lonely.
Cess mode: being applicable to all assessment modes, similar chair side, dental casts, photographs, and/or scans, and not only for 1 or a few of them. This gives the clinician the possibility to choose the virtually appropriate cess mode under the given clinical conditions.
Purpose: being capable of screening (both in the dispensary and/or in epidemiological studies), diagnosing, and monitoring, and not for just one or two of these purposes.
Clusters of teeth: being suitable for both a partial assessment and a full cess of the dentition. Examples of a partial cess are grading only some key elements and grading of teeth per sextant. Also hither, researchers and clinicians have the possibility to choose the most advisable cess way.
Surfaces: being suitable for all possible (combinations of) surfaces, viz., occlusal, incisal, lingual/palatal/oral, buccal/labial/facial, cervical, occlusal/incisal, and/or non-occlusal/non-incisal surfaces. It should be noted that tooth wear rarely occurs on only ane surface.
Determining: providing a expert insight in the amount of molar wear. To that cease, the assessed grades should exist noted separately. When the grades are added together, the severity can exist camouflaged. Therefore, separate scores are to be preferred.
Type of scale: making use of articulate scores, and not of descriptions that are open up for multiple interpretations. Therefore, an ordinal scale is to be preferred over a nominal ane.
Direction of cess: using a combination of both surface area criteria (horizontal) and depth criteria (vertical, loss of clinical crown height), since early detection of tooth surface loss can amend be determined with the sometime mentioned, while stages of more than advanced tooth wear can meliorate be determined with the latter mentioned.
Corporeality of subscales/descriptions: using as picayune subscales as possible, in order to make the use as straightforward as possible, and past this, avoiding the easy introduction of mistakes.
Analysis of the iv ordinarily used tooth article of clothing evaluation systems
The characteristics of the four evaluation systems are described below and summarized in Table 5. In this paragraph, the descriptions are literal according to the mentioned authors.
Tooth wear subtypes
As indicated by the authors themselves, the Eccles index, the Lussi index, and the BEWE focus only on chemical article of clothing (erosion) [5, vii, 8]. The TWI is the only alphabetize of the four selected evaluation systems that is applicative to all subtypes of molar wear [vi].
Cess manner
All iv evaluation systems (Eccles index, TWI, Lussi index, and BEWE) are suitable for chair side use [5–8]. For the use on dental casts, only the TWI and the BEWE are suitable [6, 8]. For the apply on photographs, only the Lussi index is not suitable [seven]. For none of the 4 evaluation systems, it is indicated whether they are suitable for the utilise with scans, simply it must be noted that all systems were introduced earlier scans were broadly introduced.
Purpose
The BEWE is suitable for screening and monitoring [8]. For screening, a quick but non detailed overview of the dentition is needed. The Eccles index, the TWI, and the Lussi index are simply suitable for diagnosing [5–7]. All teeth and surfaces are examined and recorded. This corresponds with the purpose of diagnosing, because this requires a detailed overview of the entire dentition.
Clusters of teeth
The Eccles index, the TWI, and the Lussi index examine and record all teeth [5–7]. The BEWE is the only index of the four selected evaluation systems that uses a fractional assessment. The BEWE examines all teeth, but only the almost severely afflicted tooth in a sextant is recorded [viii].
Surfaces
The Eccles index grades the occlusal/incisal, facial, and lingual/palatal surfaces [five] (Table 1); the TWI the buccal/lingual/occlusal, incisal, and separately the cervical surfaces [6] (Table 2); the Lussi index the facial and occlusal/lingual surfaces [7] (Table 3); and the BEWE the buccal/facial, occlusal, and lingual/palatal surfaces [8] (Table iv).
Determining
The Eccles index [5], the TWI [half-dozen], and the Lussi index [7] decide the scores separately. Simply the BEWE uses a cumulative score, whereby the six carve up scores of each sextant are added to one cumulative score [8].
Type of scale
All four evaluation systems take an ordinal scale [5–8].
Direction of assessment
All four evaluation systems are based on a combination of grading the amount of the surface surface area that is involved and the depth of the tooth surface loss [5–8].
Amount of subscales/descriptions
The Eccles index tin be considered as having four separate iii-point ordinal scales, namely for the facial surfaces (a), for the lingual and palatal surfaces (b), for the incisal and occlusal surfaces (c), and when multiple surfaces are involved at the same time (d). For each ordinal scale, the descriptions are identical, while the surfaces differ [5] (Table 1). The TWI has iii separate 5-indicate ordinal scales, namely for the buccal/lingual/occlusal surfaces, for the incisal surfaces, and for the cervical surfaces. For each ordinal scale, the descriptions differ [half-dozen] (Table 2). The Lussi alphabetize consists of a four-point ordinal calibration for the facial surfaces and of a 3-bespeak ordinal sale for the occlusal/lingual surfaces. The clarification of form 0 is identical for both scales, while for the other grades (ane, 2, and three) the descriptions differ [seven] (Table three). The BEWE has only one iv-bespeak ordinal scale, the descriptions of which are used for all surfaces [8] (Tabular array four).
Discussion
The analyzed iv evaluation systems (viz., Eccles index, TWI, Lussi index, BEWE) accept several similarities, only on the other manus, they differ considerably and exercise not complement each other (Table five). None of the four systems shows all characteristics of a hypothetical, broadly applicative tooth clothing evaluation system (Table 5). Below, those characteristics volition be discussed.
Tooth wear subtypes
Information technology is oft stated that the subtypes of tooth wear hardly exist separately [ii, 10]. Also the developers of the four selected tooth wear evaluation systems mentioned that in their articles. For example, Eccles [5] stated:" Loss of tooth substance as a outcome of erosion is oft made worse by chafe, so that it may be impossible to make a clear distinction between the two conditions" and "Compunction, wear due to opposing teeth, will besides exacerbate the effects of erosion." [7] stated for other than facial surfaces: "Erosion, compunction and abrasion are difficult to distinguish in their initial stages," and "When erosion is present, abrasion and compunction can crusade it to increase.". While the BEWE was originally developed for the assessment of erosion [8], the system was subsequently described every bit "a proposed organisation for screening tooth wearable" [11]. Smith and Knight [6] designed a tool for diagnosing all 3 subforms of tooth wear and their combinations. They stated: "Together with the fact that there is often a combined cause, the uncomplicated term tooth wear is proposed to embrace all three atmospheric condition plus their combination." [6]. Since it can be concluded that the different subtypes of molar wearable are difficult to differentiate, it tin exist stated that the Eccles index, the Lussi index, and the BEWE do measure different types of molar clothing, and not only one of the subtypes.
Assessment style
All four evaluation systems were designed to assess tooth habiliment chairside. For three of them, the authors stated that the use of photographs was possible as well [5, 6, eight], while for two of them the authors stated that the employ of dental casts was a tertiary pick [6, 8]. Lussi and coauthors just mention the chairside apply [7]. There is evidence that several evaluation systems can be used both on dental casts and on photographs [12] as well as both clinical and on casts [13]. Although this show concerns other evaluation systems than the 4 described in this commodity, namely the Visual Erosion Dental Examination (VEDE) [14] and an occlusal and not-occlusal Molar Vesture Grading Organisation [13], it is an interesting finding. In the future, when dentals casts are possibly replaced by intraoral scans, it must exist tested if the use of scans is equally accurate as assessments performed chairside, on casts, and on photographs.
Purpose
All four evaluation systems were designed, co-ordinate to the authors, to diagnose (erosive) molar wear. It goes without saying that merely grading (quantifying) the amount of tooth surface loss is nowhere most a proper diagnosis [2]. As well qualification, recognizing the clinical signs of tooth wear [15], a proper oral history [ii], and perhaps saliva tests are required [x]. Nevertheless, quantification is necessary, and for an individual patient, a thorough assessment of the present amount of tooth wearable must be performed. The 4 evaluation systems all seem to exist appropriate for this purpose. For screening (of individual patients and in epidemiological studies), a uncomplicated and short assessment is preferred. For this purpose, a partial assessment is appropriate. The BEWE uses a partial assessment past only writing downwardly the surfaces/teeth with the highest amount of tooth surface loss per sextant [8]. For a more than detailed cess per individual, the BEWE grading could be used to assess all teeth and surfaces. The other way around is possibly too possible, namely using the Eccles index, the TWI, or the Lussi index to assess the amount of tooth surface loss of all elements and surfaces (every bit aimed past the developers), simply then only writing downwardly the worst affected surfaces/teeth per sextant. Information technology should be tested if the evaluation systems tin can be used in this style. Concerning monitoring, it showtime needs to be clarified what is meant by this term. The authors of the BEWE consider monitoring a management strategy, that follows the effects the preventive measurements later counseling, and a guidance towards other treatment modalities (e.g., restorative handling) [viii]. In general, monitoring is considered a technique to measure out progression. The authors of the BEWE mention that their system is non suitable for monitoring, because the stardom between the various levels is too crude [eight]. The authors of the other three indices practise not mention monitoring in their respective manufactures [5–7]. Information technology is obvious that these evaluation systems neglect twofold in this respect: I. the distinction betwixt the levels is also rough, and II. for more avant-garde stages of tooth surface loss, there are no grades described. Regarding the also crude distinctions (I.), adaptations for all the iv evaluation systems could be the introduction of intermediate steps (for case separating a score 2 into sub-scores 2a, 2b, and 2c). Regarding the more advanced stages of tooth surface loss (Two.), for example for the TWI, this was already mentioned and adjusted by Donachie & Walls [16]. They extended the TWI with a score 5, so changing the original v-betoken ordinal scale into a 6-indicate ordinal scale [17].
Clusters of teeth
The Eccles index, the TWI and the Lussi index utilize full assessment, which means, all teeth and all surfaces are graded [5–7]. Only the BEWE uses a fractional cess, past which the authors mean that all teeth and surfaces are assessed, merely simply the surface/tooth with the highest grade per sextant is recorded [8]. In fact, this is a full assessment as well, but with partial recording. During a real partial assessment, just so called key elements are graded and noted. An example of this way of assessing is the simplified erosion partial recording arrangement (SEPRS) by Hasselkvist and coauthors, using only 4 permanent surfaces [18]. For screening purposes (on a patient level and/or in epidemiological studies), a partial assessment or a full cess with a partial recording could be sufficient. For diagnosing, a full cess is a necessity, while for monitoring (i.eastward., measuring progression) a full assessment is required.
Surfaces
All 4 evaluation systems class all surfaces of the clinical crown [v–8]. Only the TWI likewise grades the cervical surfaces [6]. Although information technology is clear that the surface structure of the roots is dissimilar from that of crowns, the necessity to grade the cervical surfaces separately can exist discussed. The other three evaluation systems grade the cervical areas as part of the not-occlusal/non-incisal surfaces (buccal/lingual/palatal/oral). Since for the cervical areas in the TWI an actress ordinal scale with different description is necessary, this tin can make the use of the TWI unnecessarily difficult.
Determining
The Eccles index [v], the TWI [6], and the Lussi alphabetize [7], determine the scores separately. Only BEWE uses a cumulative score, whereby the six split scores of the sextants are combined into a unmarried cumulative score [viii]. Although it is highly attractive to give a tooth wear patient merely one score, this not realistic. When calculation up the different scores and calculating a cumulative score, the take a chance is that higher grades of tooth wear in 1 of the sextants are masked by lower ones in the other sextants. For example, a patient with severe tooth wearable on the palatal surfaces of the second sextant, mayhap needs restorative handling. When the scores remain separate, the clinician is warning, simply when the scores are combined, the clinician can overlook the necessity for restorative handling.
Type of scale
All four evaluation systems accept an ordinal calibration (Table v). A nominal calibration is simply useful for determining which subtype of tooth wear is present, based on clinical signs [15].
Direction of assessment
All four evaluation systems are based on a combination of grading the corporeality of the surface area (horizontal) that is involved and the depth of the tooth surface loss (vertical, loss of clinical crown height). For assessing the early stages of tooth article of clothing, grading the surface area is necessary. When the tooth surface loss progresses, grading in depth is necessary.
Amount of subscales/descriptions
For an easy-to-use evaluation system, with well-defined, reproducible scoring criteria, it is useful that the organization but has 1 ordinal scale, like the BEWE [viii] has. Nevertheless, the occlusal/incisal surfaces differ that much from the non-occlusal/non-incisal surfaces, that this is not possible when the index is used for monitoring or diagnosing. The most of import difference between these two groups of surfaces is the loss of clinical crown peak, which is the case on occlusal/incisal surfaces, while on not-occlusal/non-incisal surfaces the clinical crown length is not affected.
Recommendations for the evolution of a broadly applicable tooth wear evaluation system
After analyzing the four commonly used tooth wear evaluation systems in depth, comparing their characteristics towards an hypothetically broadly applicable tooth habiliment evaluation system, the following recommendations for the development of a broadly applicable tooth wearable evaluation system are raised. It must be concluded that, taking into account all the dissimilar characteristics, only one unmarried evaluation systems is not realistic. Therefore, the evolution of a modular evaluation organization seems to be a workable solution. Below, a possible solution is proposed, based on the higher up described analyses of the four evaluation systems. In a modular evaluation system, the following modules should exist included: one. A screening module (both for epidemiological studies and for screening individual patients in the clinic) (Table six); and 2. A module for diagnosing or monitoring individual patients, for which both occlusal/incisal and not-occlusal/not-incisal (effectively grained) evaluation systems are needed (Tabular array 7). Regarding the management of an individual patient, we recall that during every retrieve date, assessment of tooth wearable is a necessity. Because a lack of time can exist a factor, the screening module is suitable. When the health care provider want to monitor the progress of the tooth wearable, the finer grained cess tin can be performed during the recall sessions. Also, when a treatment plan for an individual patient is needed, one can assess the molar wearable in detail. One must realize that by the proposed modular evaluation system only quantification is performed and no qualification is washed. Apropos the screening module, the proposal is a iv-signal ordinal scale as shown in Tabular array 6. One tin discuss well-nigh the cluster of teeth, equally well as virtually the surfaces. One can assess only some central elements, per sextant, or all elements. I can assess but occlusal/incisal or also not-occlusal/not-incisal. Until agreement is reached, every individual researcher and/or dental clinician can make his/her own decision, based on the specific goal of the assessment. Concerning the diagnosing/monitoring module, the proposals are a 6-point ordinal scale for the occlusal/incisal surfaces, and a 5-bespeak ordinal scale for the non-occlusal/non-incisal surfaces. These ordinal scales are based on the descriptions of the four analyzed tooth wear evaluation systems [five–8], and on the tooth wear evaluation systems every bit described past Lobbezoo and Naeije [xix] and Wetselaar and coworkers [13]. The modular evaluation system consists of iii different ordinal scales. The descriptions for these 3 scales are similar for scores 0 and 1. For score 2, a unlike description exists; in the screening module the stardom in clinical crown height is ≤1/2, while in the effectively grained diagnosing/monitoring scale the cutoff point is ≤1/iii. The same applies to score 3; in the screening module the distinction in clinical crown pinnacle is >ane/2, while in the finer grained diagnosing/monitoring calibration the cutoff betoken is >1/3 but <2/3. Score four is similar for the occlusal/incisal surfaces and the not-occlusal/non-incisal surfaces. Score 5 only exists for the occlusal/incisal effectively grained module. By this, the amount of scales and descriptions are as limited as possible.
Conclusion
Four of the well-nigh normally used evaluation systems have been analyzed in this paper to formulate recommendations for the evolution of a universally and broadly applicable "platonic" tooth wearable evaluation system. The analyses reveal that none of the systems is suitable as a universal evaluation system in its current grade. In addition, the report reveals that it is not feasible that a single evaluation qualifies for all purposes as a universal evaluation system should do. As the purpose determines which cluster of teeth and which surfaces should be examined, and since each purpose dictates a different test, it is non realistic to accept a single multi-purpose universal evaluation system for clinical use.
A potentially viable solution could be a modular evaluation system that consists of multiple modules. It is stated that the modular system must be able to grade all subtypes of tooth wearable, be applicable for all mentioned assessment modes, all purposes, all surfaces, and all directions of cess. The types of scales are ordinal, the scores remain separate. One can choose for partial or full cess, and the amount of subscales or descriptions must exist every bit limited as possible.
More research is required to explore the feasibility of such a modular evaluation system. The dental community must take its responsibility to attain an understanding upon this topic.
Abbreviations
- BEWE:
-
Basic erosive wear examination
- DMFT:
-
Decayed missing filled teeth
- SEPRS:
-
Simplified erosion fractional recording organization
- TWES:
-
Tooth wear evaluation system
- TWI:
-
Tooth wear index
- VEDE:
-
Visual erosion dental exam
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Wetselaar, P., Faris, A. & Lobbezoo, F. A plea for the evolution of an universally accepted modular tooth wear evaluation arrangement. BMC Oral Wellness xvi, 115 (2016). https://doi.org/10.1186/s12903-016-0309-6
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DOI : https://doi.org/10.1186/s12903-016-0309-6
Keywords
- Diagnosis
- Evaluation arrangement
- Index
- Modular evaluation system
- Tooth wear
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