Current erosion indices--flawed or valid? Summary

The problem of erosive tooth wear appears increasingly to be encountered by clinicians and researchers. An adequate way of defining and recording erosive tooth wear is essential in order to assess the extent of this clinical phenomenon, both on an individual level and in the population, and for the adequate provision of preventive and therapeutic measures. Well-established erosion indices have been used in most of these studies, although in many cases modifications have been made to suit the different research aims. This use of different indices is one reason why it still cannot be claimed that there is enough current knowledge on this clinical phenomenon. This article summarises the proceedings of a workshop to discuss the topic of dental erosion indices. The result of the workshop is the proposal for a new scoring system (Basic Erosive Wear Examination, BEWE) designed for use both within the research field and for dental clinicians, with the aims of standardising assessment of erosion for international comparisons, raising awareness and providing guidelines for treatment of erosive tooth wear in dental practice.

Buonocore Memorial Lecture. Dental erosion

There is some evidence that dental erosion is steadily spreading. To diagnose erosion, dental professionals have to rely on clinical appearance, as there is no device available to detect it. Adequate preventive measures can only be initiated if the different risk factors and potential interactions between them are known. When substance loss, caused by erosive tooth wear, reaches a certain degree, oral rehabilitation becomes necessary. Prior to the most recent decade, the severely eroded dentition could only be rehabilitated by the provision of extensive crown and bridgework or removable dentures. As a result of the improvements in composite restorative materials and in adhesive techniques, it has become possible to rehabilitate eroded dentitions in a less invasive manner.

Toothbrushing after an erosive attack: will waiting avoid tooth wear?

The purpose of this study was to determine if storage for up to 4 h in human saliva results in a decrease of erosive tooth wear (ETW) and in an increase of surface microhardness (SMH) of enamel samples after an erosive attack with subsequent abrasion. Furthermore, we determined the impact of individual salivary parameters on ETW and SMH. Enamel samples were distributed into five groups: group 1 had neither erosion nor saliva treatment; groups 2-5 were treated with erosion, then group 2 was placed in a humid chamber and groups 3-5 were incubated in saliva for 30 min, 2 h, and 4 h, respectively. After erosion and saliva treatments, all groups were treated with abrasion. Surface microhardness and ETW were measured before and after erosion, incubation in saliva, and abrasion. Surface microhardness and ETW showed significant changes throughout the experiment: SMH decreased and ETW increased in groups 2-5, regardless of the length of incubation in saliva. The results of groups 3-5 (exposed to saliva) were not significantly different from those of group 2 (not exposed to saliva). Exposure of eroded enamel to saliva for up to 4 h was not able to increase SMH or reduce ETW. However, additional experiments with artificial saliva without proteins showed protection from erosive tooth wear. The recommendation to postpone toothbrushing of enamel after an erosive attack should be reconsidered.

Erosive tooth wear in children.

Erosive tooth wear in children is a common condition. Besides the anatomical differences between deciduous and permanent teeth, additional histological differences may influence their susceptibility to dissolution. Considering laboratory studies alone, it is not clear whether deciduous teeth are more liable to erosive wear than permanent teeth. However, results from epidemiological studies imply that the primary dentition is less wear resistant than permanent teeth, possibly due to the overlapping of erosion with mechanical forces (like attrition or abrasion). Although low severity of tooth wear in children does not cause a significant impact on their quality of life, early erosive damage to their permanent teeth may compromise their dentition for their entire lifetime and require extensive restorative procedures. Therefore, early diagnosis of erosive wear and adequate preventive measures are important. Knowledge on the aetiological factors of erosive wear is a prerequisite for preventive strategies. Like in adults, extrinsic and intrinsic factors, or a combination of them, are possible reasons for erosive tooth wear in children and adolescents. Several factors directly related to erosive tooth wear in children are presently discussed, such as socio-economic aspects, gastroesophageal reflux or vomiting, and intake of some medicaments, as well as behavioural factors such as unusual eating and drinking habits. Additionally, frequent and excessive consumption of erosive foodstuffs and drinks are of importance.

Erosive tooth wear: a multifactorial condition of growing concern and increasing knowledge.

Dental erosion is often described solely as a surface phenomenon, unlike caries where it has been established that the destructive effects involve both the surface and the subsurface region. However, besides removal of the surface, erosion shows dissolution of mineral within the softened layer - beneath the surface. In order to distinguish this process from the carious process it is now called 'near surface demineralization'. Erosion occurs in low pH, but there is no fixed critical pH value concerning dental erosion. The critical pH value for enamel concerning caries (pH 5.5-5.7) has to be calculated from calcium and phosphate concentrations of plaque fluid. In the context of dental erosion, the critical pH value is calculated from the calcium and phosphate concentrations in the erosive solution itself. Thus, critical pH for enamel with regard to erosion will vary according to the erosive solution. Erosive tooth wear is becoming increasingly significant in the management of the long-term health of the dentition. What is considered as an acceptable amount of wear is dependent on the anticipated lifespan of the dentition and is, therefore, different for deciduous compared to permanent teeth. However, erosive damage to the teeth may compromise the patient's dentition for their entire lifetime and may require repeated and increasingly complex and expensive restorations. Therefore, it is important that diagnosis of the tooth wear process in children and adults is made early and that adequate preventive measures are undertaken. These measures can only be initiated when the risk factors are known and interactions between them are present.

Oral hygiene products, medications and drugs - hidden aetiological factors for dental erosion.

Acidic or EDTA-containing oral hygiene products and acidic medicines have the potential to soften dental hard tissues. The low pH of oral care products increases the chemical stability of some fluoride compounds and favours the incorporation of fluoride ions in the lattice of hydroxyapatite and the precipitation of calcium fluoride on the tooth surface. This layer has some protective effect against an erosive attack. However, when the pH is too low or when no fluoride is present these protecting effects are replaced by direct softening of the tooth surface. Oral dryness can occur as a consequence of medication such as tranquilizers, antihistamines, antiemetics and antiparkinsonian medicaments or of salivary gland dysfunction. Above all, patients should be aware of the potential demineralization effects of oral hygiene products with low pH. Acetyl salicylic acid taken regularly in the form of multiple chewable tablets or in the form of headache powder, as well as chewing hydrochloric acids tablets for the treatment of stomach disorders, can cause erosion. There is most probably no direct association between asthmatic drugs and erosion on the population level. Consumers and health professionals should be aware of the potential of tooth damage not only by oral hygiene products and salivary substitutes but also by chewable and effervescent tablets. Several paediatric medications show a direct erosive potential in vitro. Clinical proof of the occurrence of erosion after use of these medicaments is still lacking. However, regular and prolonged use of these medicaments might bear the risk of causing erosion. Additionally, it can be assumed that patients suffering from xerostomia should be aware of the potential effects of oral hygiene products with low pH and high titratable acidity.

Erosion in relation to nutrition and the environment.

When considering the erosive potential of a food or drink, a number of factors must be taken into account. pH is arguably the single most important parameter in determining the rate of erosive tissue dissolution. There is no clear-cut critical pH for erosion as there is for caries. At low pH, it is possible that other factors are sufficiently protective to prevent erosion, but equally erosion can progress in acid of a relatively high pH in the absence of mitigating factors. Calcium and phosphate concentration, in combination with pH, determine the degree of saturation with respect to tooth minerals. Solutions supersaturated with respect to enamel or dentine will not cause them to dissolve, meaning that given sufficient common ion concentrations erosion will not proceed, even if the pH is low. Interestingly, the addition of calcium is more effective than phosphate at reducing erosion in acid solutions. Today, several calcium-enriched soft drinks are on the market, and acidic products with high concentrations of calcium and phosphorus are available (such as yoghurt), which do not soften the dental hard tissues. The greater the buffering capacity of the drink or food, the longer it will take for the saliva to neutralize the acid. A higher buffer capacity of a drink or foodstuff will enhance the processes of dissolution because more release of ions from the tooth mineral is required to render the acid inactive for further demineralization. Temperature is also a significant physical factor; for a given acidic solution, erosion proceeds more rapidly the higher the temperature of that solution. In recent years, a number of interesting potentially erosion-reducing drink and food additives have been investigated.

Prevalence, incidence and distribution of erosion.

There is evidence that the presence of erosion is growing steadily. Due to different scoring systems, samples and examiners, it is difficult to compare the different studies. Preschool children from 2 to 5 years showed erosion on deciduous teeth in 1 to 79% of the subjects. Schoolchildren (aged from 5 to 9 years) already had erosive lesions on permanent teeth in 14% of the cases. In the adolescent group (aged between 9 and 20 years), 7 to 100% of the persons examined showed signs of erosion. Incidence data (the increase in the number of subjects presenting signs of dental erosion) was evaluated in four of these studies and presented average annual values between 3.5 and 18%, depending on the initial age of the examined sample. In adults (aged from 18 to 88 years) prevalence data ranged between 4 and 100%. Incidence data are scarce in this age group, and only one study was found analysing the increase of affected surfaces, showing an incidence of 5% for the younger and 18% for older age groups. In general, males present more erosive tooth wear than females. The distribution showed a predominance of affected occlusal surfaces (mandibular first molars) followed by facial surfaces (anterior maxillary teeth). Oral erosion was frequently found on maxillary incisors and canines. Overall, prevalence data are not homogeneous. Nevertheless, there is a trend towards a more pronounced rate of erosion in younger age groups. Furthermore, a tendency was found for more erosive lesions with increasing age and these erosions progressed with age.

Diagnosis of erosive tooth wear.

The clinical diagnosis 'erosion' is made from characteristic deviations from the original anatomical tooth morphology, thus distinguishing acid-induced tissue loss from other forms of wear. Primary pathognomonic features are shallow concavities on smooth surfaces occurring coronal from the enamel-cementum junction. Problems from diagnosing occlusal surfaces and exposed dentine are discussed. Indices for recording erosive wear include morphological as well as quantitative criteria. Currently, various indices are used, each having their virtues and flaws, making the comparison of prevalence studies difficult. The Basic Erosive Wear Examination (BEWE) is described, which is intended to provide an easy tool for research as well as for use in general dental practice. The cumulative score of this index is the sum of the most severe scores obtained from all sextants and is linked to suggestions for clinical management. In addition to recording erosive lesions, the assessment of progression is important as the indication of treatment measures depends on erosion activity. A number of evaluated and sensitive methods for in vitro and in situ approaches are available, but the fundamental problem for their clinical use is the lack of reidentifiable reference areas. Tools for clinical monitoring are described.

Consensus report of the European Federation of Conservative Dentistry: erosive tooth wear-diagnosis and management

OBJECTIVE Due to an increased focus on erosive tooth wear (ETW), the European Federation of Conservative Dentistry (EFCD) considered ETW as a relevant topic for generating this consensus report. MATERIALS AND METHODS This report is based on a compilation of the scientific literature, an expert conference, and the approval by the General Assembly of EFCD. RESULTS ETW is a chemical-mechanical process resulting in a cumulative loss of hard dental tissue not caused by bacteria, and it is characterized by loss of the natural surface morphology and contour of the teeth. A suitable index for classification of ETW is the basic erosive wear examination (BEWE). Regarding the etiology, patient-related factors include the pre-disposition to erosion, reflux, vomiting, drinking and eating habits, as well as medications and dietary supplements. Nutritional factors relate to the composition of foods and beverages, e.g., with low pH and high buffer capacity (major risk factors), and calcium concentration (major protective factor). Occupational factors are exposition of workers to acidic liquids or vapors. Preventive management of ETW aims at reducing or stopping the progression of the lesions. Restorative management aims at reducing symptoms of pain and dentine hypersensitivity, or to restore esthetic and function, but it should only be used in conjunction with preventive strategies. CONCLUSIONS Effective management of ETW includes screening for early signs of ETW and evaluating all etiological factors. CLINICAL RELEVANCE ETW is a clinical condition, which calls for the increased attention of the dental community and is a challenge for the cooperation with other medical specialities.

The future of fluorides and other protective agents in erosion prevention

The effectiveness of fluoride in caries prevention has been convincingly proven. In recent years, researchers have investigated the preventive effects of different fluoride formulations on erosive tooth wear with positive results, but their action on caries and erosion prevention must be based on different requirements, because there is no sheltered area in the erosive process as there is in the subsurface carious lesions. Thus, any protective mechanism from fluoride concerning erosion is limited to the surface or the near surface layer of enamel. However, reports on other protective agents show superior preventive results. The mechanism of action of tin-containing products is related to tin deposition onto the tooth surface, as well as the incorporation of tin into the near-surface layer of enamel. These tin-rich deposits are less susceptible to dissolution and may result in enhanced protection of the underlying tooth. Titanium tetrafluoride forms a protective layer on the tooth surface. It is believed that this layer is made up of hydrated hydrogen titanium phosphate. Products containing phosphates and/or proteins may adsorb either to the pellicle, rendering it more protective against demineralization, or directly to the dental hard tissue, probably competing with H(+) at specific sites on the tooth surface. Other substances may further enhance precipitation of calcium phosphates on the enamel surface, protecting it from additional acid impacts. Hence, the future of fluoride alone in erosion prevention looks grim, but the combination of fluoride with protective agents, such as polyvalent metal ions and some polymers, has much brighter prospects.

Effect of conservation tillage on soil physical properties, in-situ rainwater harvesting, and erosion control in arid and semi-arid regions

La escasez del agua en las regiones áridas y semiáridas se debe a la escasez de precipitaciones y la distribución desigual en toda la temporada, lo que hace de la agricultura de secano una empresa precaria. Un enfoque para mejorar y estabilizar el agua disponible para la producción de cultivos en estas regiones es el uso de tecnologías de captación de agua de lluvia in situ y su conservación. La adopción de los sistemas de conservación de la humedad del suelo in situ, tales como la labranza de conservación, es una de las estrategias para mejorar la gestión de la agricultura en zonas áridas y semiáridas. El objetivo general de esta tesis ha sido desarrollar una metodología de aplicación de labranza de depósito e investigar los efectos a corto plazo sobre las propiedades físicas del suelo de las diferentes prácticas de cultivo que incluyen labranza de depósito: (reservoir tillage, RT), la laboreo mínimo: (minimum tillage, MT), la no laboreo: (zero tillage, ZT) y laboreo convencional: (conventional tillage, CT) Así como, la retención de agua del suelo y el control de la erosión del suelo en las zonas áridas y semiáridas. Como una primera aproximación, se ha realizado una revisión profunda del estado de la técnica, después de la cual, se encontró que la labranza de depósito es un sistema eficaz de cosecha del agua de lluvia y conservación del suelo, pero que no ha sido evaluada científicamente tanto como otros sistemas de labranza. Los trabajos experimentales cubrieron tres condiciones diferentes: experimentos en laboratorio, experimentos de campo en una región árida, y experimentos de campo en una región semiárida. Para investigar y cuantificar el almacenamiento de agua a temperatura ambiente y la forma en que podría adaptarse para mejorar la infiltración del agua de lluvia recolectada y reducir la erosión del suelo, se ha desarrollado un simulador de lluvia a escala de laboratorio. Las características de las lluvias, entre ellas la intensidad de las precipitaciones, la uniformidad espacial y tamaño de la gota de lluvia, confirmaron que las condiciones naturales de precipitación son simuladas con suficiente precisión. El simulador fue controlado automáticamente mediante una válvula de solenoide y tres boquillas de presión que se usaron para rociar agua correspondiente a diferentes intensidades de lluvia. Con el fin de evaluar el método de RT bajo diferentes pendientes de superficie, se utilizaron diferentes dispositivos de pala de suelo para sacar un volumen idéntico para hacer depresiones. Estas depresiones se compararon con una superficie de suelo control sin depresión, y los resultados mostraron que la RT fue capaz de reducir la erosión del suelo y la escorrentía superficial y aumentar significativamente la infiltración. Luego, basándonos en estos resultados, y después de identificar la forma adecuada de las depresiones, se ha diseñado una herramienta combinada (sistema integrado de labranza de depósito (RT)) compuesto por un arado de una sola línea de chisel, una sola línea de grada en diente de pico, sembradora modificada, y rodillo de púas. El equipo fue construido y se utiliza para comparación con MT y CT en un ambiente árido en Egipto. El estudio se realizó para evaluar el impacto de diferentes prácticas de labranza y sus parámetros de funcionamiento a diferentes profundidades de labranza y con distintas velocidades de avance sobre las propiedades físicas del suelo, así como, la pérdida de suelo, régimen de humedad, la eficiencia de recolección de agua, y la productividad de trigo de invierno. Los resultados indicaron que la RT aumentó drásticamente la infiltración, produciendo una tasa que era 47.51% más alta que MT y 64.56% mayor que la CT. Además, los resultados mostraron que los valores más bajos de la escorrentía y pérdidas de suelos 4.91 mm y 0.65 t ha-1, respectivamente, se registraron en la RT, mientras que los valores más altos, 11.36 mm y 1.66 t ha-1, respectivamente, se produjeron en el marco del CT. Además, otros dos experimentos de campo se llevaron a cabo en ambiente semiárido en Madrid con la cebada y el maíz como los principales cultivos. También ha sido estudiado el potencial de la tecnología inalámbrica de sensores para monitorizar el potencial de agua del suelo. Para el experimento en el que se cultivaba la cebada en secano, se realizaron dos prácticas de labranza (RT y MT). Los resultados mostraron que el potencial del agua del suelo aumentó de forma constante y fue consistentemente mayor en MT. Además, con independencia de todo el período de observación, RT redujo el potencial hídrico del suelo en un 43.6, 5.7 y 82.3% respectivamente en comparación con el MT a profundidades de suelo (10, 20 y 30 cm, respectivamente). También se observaron diferencias claras en los componentes del rendimiento de los cultivos y de rendimiento entre los dos sistemas de labranza, el rendimiento de grano (hasta 14%) y la producción de biomasa (hasta 8.8%) se incrementaron en RT. En el experimento donde se cultivó el maíz en regadío, se realizaron cuatro prácticas de labranza (RT, MT, ZT y CT). Los resultados revelaron que ZT y RT tenían el potencial de agua y temperatura del suelo más bajas. En comparación con el tratamiento con CT, ZT y RT disminuyó el potencial hídrico del suelo en un 72 y 23%, respectivamente, a la profundidad del suelo de 40 cm, y provocó la disminución de la temperatura del suelo en 1.1 y un 0.8 0C respectivamente, en la profundidad del suelo de 5 cm y, por otro lado, el ZT tenía la densidad aparente del suelo y resistencia a la penetración más altas, la cual retrasó el crecimiento del maíz y disminuyó el rendimiento de grano que fue del 15.4% menor que el tratamiento con CT. RT aumenta el rendimiento de grano de maíz cerca de 12.8% en comparación con la ZT. Por otra parte, no hubo diferencias significativas entre (RT, MT y CT) sobre el rendimiento del maíz. En resumen, según los resultados de estos experimentos, se puede decir que mediante el uso de la labranza de depósito, consistente en realizar depresiones después de la siembra, las superficies internas de estas depresiones se consolidan de tal manera que el agua se mantiene para filtrarse en el suelo y por lo tanto dan tiempo para aportar humedad a la zona de enraizamiento de las plantas durante un período prolongado de tiempo. La labranza del depósito podría ser utilizada como un método alternativo en regiones áridas y semiáridas dado que retiene la humedad in situ, a través de estructuras que reducen la escorrentía y por lo tanto puede resultar en la mejora de rendimiento de los cultivos. ABSTRACT Water shortage in arid and semi-arid regions stems from low rainfall and uneven distribution throughout the season, which makes rainfed agriculture a precarious enterprise. One approach to enhance and stabilize the water available for crop production in these regions is to use in-situ rainwater harvesting and conservation technologies. Adoption of in-situ soil moisture conservation systems, such as conservation tillage, is one of the strategies for upgrading agriculture management in arid and semi-arid environments. The general aim of this thesis is to develop a methodology to apply reservoir tillage to investigate the short-term effects of different tillage practices including reservoir tillage (RT), minimum tillage (MT), zero tillage (ZT), and conventional tillage (CT) on soil physical properties, as well as, soil water retention, and soil erosion control in arid and semi-arid areas. As a first approach, a review of the state of the art has been done. We found that reservoir tillage is an effective system of harvesting rainwater and conserving soil, but it has not been scientifically evaluated like other tillage systems. Experimental works covered three different conditions: laboratory experiments, field experiments in an arid region, and field experiments in a semi-arid region. To investigate and quantify water storage from RT and how it could be adapted to improve infiltration of harvested rainwater and reduce soil erosion, a laboratory-scale rainfall simulator was developed. Rainfall characteristics, including rainfall intensity, spatial uniformity and raindrop size, confirm that natural rainfall conditions are simulated with sufficient accuracy. The simulator was auto-controlled by a solenoid valve and three pressure nozzles were used to spray water corresponding to different rainfall intensities. In order to assess the RT method under different surface slopes, different soil scooping devices with identical volume were used to create depressions. The performance of the soil with these depressions was compared to a control soil surface (with no depression). Results show that RT was able to reduce soil erosion and surface runoff and significantly increase infiltration. Then, based on these results and after selecting the proper shape of depressions, a combination implement integrated reservoir tillage system (integrated RT) comprised of a single-row chisel plow, single-row spike tooth harrow, modified seeder, and spiked roller was developed and used to compared to MT and CT in an arid environment in Egypt. The field experiments were conducted to evaluate the impact of different tillage practices and their operating parameters at different tillage depths and different forward speeds on the soil physical properties, as well as on runoff, soil losses, moisture regime, water harvesting efficiency, and winter wheat productivity. Results indicated that the integrated RT drastically increased infiltration, producing a rate that was 47.51% higher than MT and 64.56% higher than CT. In addition, results showed that the lowest values of runoff and soil losses, 4.91 mm and 0.65 t ha-1 respectively, were recorded under the integrated RT, while the highest values, 11.36 mm and 1.66 t ha -1 respectively, occurred under the CT. In addition, two field experiments were carried out in semi-arid environment in Madrid with barley and maize as the main crops. For the rainfed barley experiment, two tillage practices (RT, and MT) were performed. Results showed that soil water potential increased quite steadily and were consistently greater in MT and, irrespective of the entire observation period, RT decreased soil water potential by 43.6, 5.7, and 82.3% compared to MT at soil depths (10, 20, and 30 cm, respectively). In addition, clear differences in crop yield and yield components were observed between the two tillage systems, grain yield (up to 14%) and biomass yield (up to 8.8%) were increased by RT. For the irrigated maize experiment, four tillage practices (RT, MT, ZT, and CT) were performed. Results showed that ZT and RT had the lowest soil water potential and soil temperature. Compared to CT treatment, ZT and RT decreased soil water potential by 72 and 23% respectively, at soil depth of 40 cm, and decreased soil temperature by 1.1 and 0.8 0C respectively, at soil depth of 5 cm. Also, ZT had the highest soil bulk density and penetration resistance, which delayed the maize growth and decreased the grain yield that was 15.4% lower than CT treatment. RT increased maize grain yield about 12.8% compared to ZT. On the other hand, no significant differences among (RT, MT, and CT) on maize yield were found. In summary, according to the results from these experiments using reservoir tillage to make depressions after seeding, these depression’s internal surfaces are consolidated in such a way that the water is held to percolate into the soil and thus allowing time to offer moisture to the plant rooting zone over an extended period of time. Reservoir tillage could be used as an alternative method in arid and semi-arid regions and it retains moisture in-situ, through structures that reduce runoff and thus can result in improved crop yields.

Tooth wear: diet analysis and advice

Diet analysis and advice for patients with tooth wear is potentially the most logical intervention to arrest attrition, erosion and abrasion. It is saliva that protects the teeth against corrosion by the acids which soften enamel and make it susceptible to wear. Thus the lifestyles and diet of patients at risk need to be analysed for sources of acid and reasons for lost salivary protection. Medical conditions which put patients at risk of tooth wear are principally: asthma, bulimia nervosa, caffeine addiction, diabetes mellitus, exercise dehydration, functional depression, gastroesophageal reflux in alcoholism, hypertension and syndromes with salivary hypofunction. The sources of acid are various, but loss of salivary protection is the common theme. In healthy young Australians, soft drinks are the main source of acid, and exercise dehydration the main reason for loss of salivary protection. In the medically compromised, diet acids and gastroesophageal reflux are the sources, but medications are the main reasons for lost salivary protection. Diet advice for patients with tooth wear must: promote a healthy lifestyle and diet strategy that conserves the teeth by natural means of salivary stimulation; and address the specific needs of the patients' oral and medical conditions. Individualised, patient-empowering erosion WATCH strategies; on Water, Acid, Taste, Calcium and Health, are urgently required to combat the emerging epidemic of tooth wear currently being experienced in westernised societies.

Dietary and nutritional aspects of tooth wear

There is a general perception that the problem of tooth wear is increasing due to elements of the modern diet and due to increased retention of dentition into older age. Tooth wear encompasses erosion, abrasion and attrition of dental tissues – these often co-exist – yet in general, erosion is of more significance to the young and attrition is of more significance to the older population. Diet plays a significant role in the aetiology of tooth wear and likewise advanced tooth wear in older age may impose dietary restrictions with consequences for dietary intake and nutritional status. There is a need to increase the awareness of the disease of tooth wear and the associated nutritional problems. At present, the aetiology of tooth wear is poorly understood – especially with respect to the role of diet. Clearer information on how best to measure and monitor the incidence and prevalence is needed in order to obtain longitudinal data on trends in tooth wear and to monitor the factors that contribute to this condition. These issues will be addressed in the following presentations: 1) What is tooth wear? Aetiology, measurement and monitoring, 2) The role of diet in the aetiology of dental erosion, 3) Groups at increased risk of tooth wear: Eating disorders, ‘dieters' sportsmen and those with impairments, 4) Tooth wear in older adults: nutritional implications. In summary this symposium seeks to: 1) increase awareness of the disease of tooth wear, and its associated nutritional problems 2) increase understanding of the aetiology of tooth wear, especially the dietary role, 3) provide information on how to measure and monitor tooth wear, 4) highlight future research requirements in the area of tooth wear and diet.

Does psychological stress mediate social deprivation in tooth loss?

It is unclear which theoretical dimension of psychological stress affects health status. We hypothesized that both distress and coping mediate the relationship between socio-economic position and tooth loss. Cross-sectional data from 2915 middle-aged adults evaluated retention of < 20 teeth, behaviors, psychological stress, and sociodemographic characteristics. Principal components analysis of the Perceived Stress Scale (PSS) extracted 'distress' (a = 0.85) and 'coping' (a =0.83) factors, consistent with theory. Hierarchical entry of explanatory variables into age- and sex-adjusted logistic regression models estimated odds ratios (OR) and 95% confidence intervals [95% CI] for retention of < 20 teeth. Analysis of the separate contributions of distress and coping revealed a significant main effect of coping (OR = 0.7 [95% CI = 0.7-0.8]), but no effect for distress (OR = 1.0 [95% CI = 0.9-1.1]) or for the interaction of coping and distress. Behavior and psychological stress only modestly attenuated socio-economic inequality in retention of < 20 teeth, providing evidence to support a mediating role of coping.