Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2012 39; 217225

Review Article

Tooth wear and wear investigations in dentistry

A. LEE, L. H. HE, K. LYONS & M. V. SWAIN
of Otago, Dunedin, New Zealand Department of Oral Rehabilitation, Faculty of Dentistry, University

SUMMARY Tooth

wear has been recognised as a major problem in dentistry. Epidemiological studies have reported an increasing prevalence of tooth wear and general dental practitioners see a greater number of patients seeking treatment with worn dentition. Although the dental literature contains numerous publications related to management and rehabilitation of tooth wear of varying aetiologies, our understanding of the aetiology and pathogenesis of tooth wear is still limited. The wear behaviour of dental biomaterials has also been extensively researched to improve our understanding of the underlying mechanisms and for the development of restorative materials with good wear resistance. The complex nature of tooth wear indicates challenges

for conducting in vitro and in vivo wear investigations and a clear correlation between in vitro and in vivo data has not been established. The objective was to critically review the peer reviewed Englishlanguage literature pertaining to prevalence and aetiology of tooth wear and wear investigations in dentistry identied through a Medline search engine combined with hand-searching of the relevant literature, covering the period between 1960 and 2011. KEYWORDS: tooth wear, wear in dentistry, wear studies, wear testing and worn dentition Accepted for publication 26 July 2011

Introduction
Wear can be dened as the progressive loss of material from the contacting surfaces of a body, caused by relative motion at the surface (1, 2). Wear has been of interest in materials science and mechanical engineering for some time and wear testing is common practice for predicting the service time of a component. Wear has also been a topic of discussion in dentistry with several epidemiological studies indicating that tooth wear, especially erosion-related wear is increasing in the general population (3, 4). There have been a number of articles published regarding management and rehabilitation of the worn dentition of varying aetiologies (5, 6). Tooth wear is a complex, multifactorial phenomenon with the interplay of biological, mechanical, chemical and tribological factors (2). The amount of tooth wear depends on factors such as muscular forces, lubricants,
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patient diet habit and the type of the restorative material used (7). Of these, the dentist has the most control of the material selected (8) and thus a great deal of research has involved improving the wear properties of dental biomaterials and protecting natural teeth from excessive wear. The complex nature of tooth wear leads to difculties in conducting wear studies. Although, in vivo wear studies would seem ideal to evaluate the wear behaviour of dental biomaterials, they are time-consuming, expensive (9) and the results scatter widely due to patient and dentist related factors (10). Most of all, the fundamental problem with the in vivo wear model is that it is impossible to isolate and vary key factors that may inuence the wear process (11). On the other hand, an in vitro wear study allows precise control of the environment and variables, which inuence the wear process of dental hard tissues and biomaterials (12). However, there is no universally accepted wear
doi: 10.1111/j.1365-2842.2011.02257.x

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testing method (10). Numerous wear simulation devices, developed for research purposes use different wear testing concepts and variables such as force, contact geometry and lubrication make comparative analysis of wear data difcult (10). The aim of this review is to provide an insight to prevalence and aetiology of tooth wear and to scrutinise wear studies in dentistry including the problems with these studies. The peer reviewed English-language literature was searched through the Medline search engine with the key words, tooth wear, wear in dentistry, wear studies, wear testing and worn dentition between 1960 and the present. A manual hand search was also conducted through the literature to identify relevant dental journals. (82%) of children had at least one primary tooth with dentine exposure. The severity of tooth wear was not signicantly associated with dietary factors, but appeared to be related to early weaning from the breast. In a study from the United Kingdom, the prevalence of tooth wear was high (57%) in adolescents aged between 11 and 14 years, but dentine involvement was rare (16). A recent systemic review on prevalence of tooth wear in children and adolescents has indicated that the prevalence of tooth wear leading to dentine exposure in deciduous teeth increases with age, while wear of permanent teeth in adolescents does not correlate with age (21). However, one longitudinal study has demonstrated an association between tooth wear recorded at age 5 and molar tooth wear recorded at age 12 (22). It was emphasised that tooth wear is a lifelong cumulative process and should be recorded in both the primary and permanent dentitions. Although numerous epidemiological studies seem to indicate that tooth wear is prevalent and increasing in the general population, the results are not easily comparable due to the wide range of tooth wear indices used and the variation in diagnostic criteria (23). Currently there is no agreed consensus on a universally acceptable tooth wear index for quantifying tooth wear (24). These factors complicate the evaluation of whether a true increase in prevalence is being reported (25) and therefore conclusion from prevalence studies should be considered with caution (26).

Tooth wear
Prevalence It has been recognised that tooth wear is a clinical problem that is becoming increasingly important in the aging population (2, 13). This may be due to an increasing dental awareness, with increased interest in retaining teeth as opposed to having them extracted (14). Data from prevalence studies have demonstrated high levels of tooth wear in adults (15), adolescents (16) and children (17), indicating that tooth wear is a clinical nding in all age groups. Smith and Robb, in a cross-sectional study observed that tooth wear is common in adults, with up to 97% of the study cohort experiencing some tooth wear (15). However, only 57% of 1007 adults in the study exhibited severe tooth wear, for which interventive restorative treatment was justied. The retrospective study by Bartlett examined study models over a median time of 26 months and reported slow progression of tooth wear in the study sample, suggesting that progression of tooth wear is not inevitable (18). However, one systematic review on prevalence of tooth wear in adults reported that the predicted percentage of adults presenting with severe tooth wear increases from 3% at age 20 years to 17% at age 70 years, indicating a tendency for accumulative wear with age (19). Ayers et al. conducted a cross-sectional study to investigate the prevalence and severity of tooth wear in the primary dentition of New Zealand school children aged between 5 and 8 (20). A high percentage

Aetiology The terms attrition, abrasion, abfraction and erosion have been used interchangeably to describe the loss of tooth structure and dental biomaterials (2). These terms, however are not in themselves descriptive of the wear process, nor do they imply the causative factor, but instead describe clinical manifestations of a number of underlying events (6). Attrition is dened as a gradual loss of hard tooth substance from occlusal contacts with an opposing dentition or restorations (27). It is related to aging, but may be accelerated by extrinsic factors such as parafunctional habits of bruxism, traumatic occlusion in the partially edentulous dentition, and malocclusion (27, 28). Clinically, occlusal wear attributable to attrition will produce equal and matching wear facets on opposing teeth. In early stages, there appears a small polished facet on a cusp tip or slight attening on an
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incisal edge, while severe attrition leads to dentine exposure, which may result in an increased rate of wear (29, 30). It has been suggested that progressively greater loss of tooth structure occurs towards the anterior teeth, due to leverage changes produced by eccentric posterior interferences (31, 32). Instead of occurring at the temporomandibular joints, posterior occlusal contacts become the fulcrum point with greater forces applied to the anterior teeth. One author has proposed that the steepness of the condylar eminence has a signicant effect on the development and occurrence of posterior interferences during mandibular movement (32, 33). It was observed that patients with a at condylar eminence tended to have signicant posterior interferences, causing attening of posterior teeth. On the other hand, patients with steep condylar eminences have minimal posterior interferences and hence little or no posterior wear. However, there have been no experimental studies that have conrmed the relationship between the angle of the condylar eminence and posterior teeth contact and moreover, controversy remains regarding the relationship between functional occlusal contact and tooth wear (34, 35). Abrasion is the loss of tooth substance through mechanical means, independent of occlusal contact (36). The site and pattern of abrasion wear can be diagnostic as different foreign objects produce different patterns of abrasion wear (27). Some forms of abrasion may be associated with habit or occupation, such as a rounded ditch on the cervical aspects of teeth due to vigorous horizontal toothbrushing or incisal notching caused by pipe smoking or nail biting (28, 34, 36). The most common cause of dental abrasion found in the cervical areas is toothbrushing and the severity and distribution of toothbrushing abrasion wear may be related to brushing technique, time, frequency, bristle design and the abrasiveness of the dentifrice (27, 34). Abfraction is a relatively new term that describes loss of hard tooth substance in the cervical region as a result of crack formation during tooth exure (11, 30). Some authors have proposed that tensile and compressive stresses from mastication and malocclusion play a major role in the formation and progression of wedge-shaped abfraction lesions (37). However, the true aetiology of abfraction lesions has been controversial as other causative factors such as abrasion and erosion have been considered in the development of these lesions
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(38, 39). Many authors agree that the aetiology is multifactorial and the term, non-carious cervical lesion (NCCL) is preferred to describe the loss of tooth substance at the cementumenamel junction without bacterial involvement (38, 40, 41). Dental erosion is dened as loss of tooth structure by a nonbacterial chemical process (29, 36). Some authors however, disagree with the term erosion due to its remarkably different meaning between dentistry and engineering tribology (13), and the term corrosion has been advocated to correctly describe the process of tooth surface loss due to chemical or electrochemical action (28, 41). In this review, the term erosion will be used to denote chemical dissolution of teeth or restoration. Erosive lesions present as a smooth concave defect in the early stage, while in the advanced stage, restorations may project above the occlusal surface and the cusps on premolars and molars exhibit concavities known as cupping (29). The source of acid can be endogenous, such as from gastric reux, or exogenous from acidic foods and drinks (42); the distribution and wear pattern of erosion is specically associated with the origin of the acid and the posture of the head when the acid is present (32, 33). As intrinsic acid enters the oral cavity from the eosophagus, it tends to produce signicant tooth surface loss on the lingual and occlusal surfaces of teeth. On the other hand, extrinsic acid often results in erosive wear on facial and occlusal surfaces of teeth by its nature of entering the oral cavity from the anterior aspect. Tooth wear may involve the entire dentition (generalised) or be localised to anterior or posterior teeth, depending on the causative factor of the tooth wear. For instance, patients with bulimia or gastric reux, the lingual surfaces of the maxillary anterior teeth are severely affected, while the mandibular teeth are protected from the erosive effect by the tongue and saliva (32). In attrition, the occlusal condition inuences the quantity and distribution of the tooth wear pattern. One longitudinal study demonstrated that increased incisal wear correlates with horizontal overjet and vertical overbite. Therefore, the anterior guidance as determined by the overbite and overjet, and the ratio between these, can be used as predictors of attrition tooth wear of the maxillary and mandibular incisors (43). In the case of the anterior open bite, where no occlusal contact exists between the maxillary and mandibular anterior teeth, greater wear is anticipated on the posterior teeth than on the anterior teeth (33).

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However, a correlation between attrition and other occlusal parameters has not been reported, and thus no single occlusion-based treatment protocol can be recommended in the management of attrition (44). Although research into tooth wear has grown considerably over recent years, our understanding of its aetiology and pathogensis is still lacking (45). Differentiation among attrition, abrasion, erosion and abfraction is difcult, since these aetiological factors may act synchronically or additively with other entities masking the true nature of tooth wear (29). The occurrence and pattern of tooth wear is closely associated with educational, cultural, dietary, occupational and geographic factors in the population (27). Mair et al. suggested that the aetiology of clinical wear may be considered in terms of site, timing and underlying wear mechanism rather than nomenclature (Fig. 1) (2). Thegosis is dened as the action of sliding teeth laterally and it has been proposed that this is a genetically determined habit, originally established to sharpen teeth (46). Bruxism is the action of grinding teeth without the presence of food (11). Mastication is the action of chewing food and is composed of two phases, the open phase and the closed phase (2). Initially, the teeth approximate from an open position to a position of a near contact (open phase), and the abrasive particles are suspended and free to move in the food (slurry). This is followed by a closed phase, in which the teeth are brought close together and the food particles become trapped between the tooth surfaces. Entrapment of food particles is largely inuenced by textural characteristics of the surfaces; rougher surfaces are more likely to trap food particles than smooth tooth surfaces. Following compression and crushing of the food bolus, grinding occurs either with tooth-foodtooth contact (indirect) or direct toothtooth contact of the opposing teeth surfaces (47). Masticatory parameters such as the magnitude of the force and duration of the masticatory cycle vary widely among individuals and depend largely on the food type, size of food bolus and chemical and physical action of saliva (13, 48). The total duration of the masticatory cycle was reported to be approximately 070 s (49, 50), whilst the mean duration of the occlusion is about 010 s, and these periods amount to 1530 min of contact loading each day (11, 13).

Wear investigation in dentistry

In vitro wear testing Numerous wear testing devices have been developed to predict the clinical performance of many dental biomaterials, but they differ in the degree of complexity and use different variables including force, contact geometry, displacement, lubricant, antagonist, and cycles (12, 13). Most of the wear simulation devices are used for two-body wear testing, in which the surfaces move against each other in direct contact, and these conditions occur during non-masticatory movement in the mouth (11, 12). During mastication, food particles present in the mouth play an important role in the wear of teeth and dental biomaterials, and some simulation devices include abrasive slurries to replicate this as three-body wear (12, 51). Among the many geometric designs, a pin-on-disk wear-test rig has been commonly used to simulate twobody wear between the sample and the antagonist (52, 53). This method uses a simple relative movement between the wear pair and gives relatively quick results (53). However, it does not properly simulate the oral environment (48) and repeatability of results using the same condition (i.e. load, contact pressure, sliding speed) is poor (54). More complex in vitro wear testing devices have been developed to provide a more accurate simulation of the masticatory movement (5557). Some testing devices incorporate unidirectional sliding movement of mastication, where the specimen slides in one direction for a specied duration, after which it is repositioned to its original position (55). DeLong and Douglas in the early 1980s developed an articial oral environment which simulates the physiological movement of the oral cavity through two
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Thegosis Bruxism Mastication (closed phase) Habits (pipe, smoking, etc.) Mastication (opened phase) Toothbrushing

Direct tooth contact Indirect Contact (trapped particles) Slurry effects (suspended particles)

Wear at sites of occlusal contact Wear at contact free sites

Chemical effects

Fig. 1. Tooth wear mechanisms and their interactions [from Mair et al. (2)].

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servo-hydraulic units that control horizontal and vertical movements (58). Physiological conditions of the oral cavity are reproduced by controlled setting of the biting force, temperature, and articial saliva. They compared their simulative wear data on amalgam, composite resin and dental porcelain with clinical data and found a good correlation between them (5961). Some authors have also incorporated abrasive discs or slurries in the wear testing devices, to investigate the inuence of food particles on wear behaviour of dental biomaterials (51, 62). The composition of food simulation slurry varies widely in different studies, such as ground rice in phosphate buffer (51), cornmeal grit and wholemeal our in distilled water (63) and polymethyl methacrylate beads (62). Heintze et al. have investigated the wear resistance of 10 restorative dental materials (eight composite resins, an amalgam and a ceramic) using ve different wear simulation methods in order to validate the compatibility of different wear simulation devices (64). The relative ranking of the tested materials varied signicantly between the different wear testing methods. The authors suggested that varying the wear simulation device settings results in measuring different wear mechanisms and thus care must be taken when interpreting and comparing the results of in vitro wear data. Despite the development of sophisticated and complex wear simulators, a clear correlation between in vitro and clinical data has not been established (11) and the clinical performance of dental biomaterials cannot be precisely predicted. Sajewicz and Kulesza argued that the emphasis in previous in vitro wear studies has been on the development of a wear simulator, that produces physiological movements or a force pattern similar to the oral environment, however there are no standard oral conditions (48). Also, material wear can be inuenced by various factors including load, contact area and contact geometry. In 2001, the International Standard Organisation (ISO) published a technical specication termed wear by two- and or three-body contact, and in the specication, eight different wear testing methods were described (10). However, the specication did not provide any information about validity or accuracy of the testing methods and whether the testing devices with which the methods were conducted were qualied for that purpose. The lack of an internationally acceptable in vitro method for evaluating wear behaviour of dental biomaterials, combined with the various meth 2011 Blackwell Publishing Ltd

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ods used in the past makes it difcult or even impossible to compare in vitro wear data. The limitations and issues of in vitro wear studies in dentistry have been addressed elsewhere (10, 12). The current trend with in vitro wear studies has shifted from developing a physiological wear simulator to identifying the underlying wear mechanisms. This includes the factors that inuence the wear of dental biomaterials, using some of the concepts used in mechanical engineering (tribology) and physics (65, 66). For example, using the Hertz theory in contact mechanics, the ballon-disk experimental design is becoming popular to investigate and compare the wear mechanisms of dental biomaterials (67, 68). Understanding the in vitro wear propensity of a dental restorative material will help researchers and clinicians predict the response of a particular material in a clinical setting (69).

In vivo wear testing An in vivo wear investigation of dental biomaterials usually encompasses two parts; subjective performance assessment of the material and quantitative measurement of wear (9). The clinical performance of a restoration is assessed based on specied criteria such as marginal adaptation, gingival health, structural integrity and patient satisfaction after a certain period of use (70). This is accompanied with quantitative wear measurement using various methods including study casts, intraoral photographs and tooth wear indices that can be used alone or in combination to identify morphological changes of teeth over time (71, 72). Tooth wear indices are the most popular method of quantifying wear over a long period of time as they are readily available and do not require special equipment (73). Numerous indices have been developed for use in clinical studies and most are based on numerical grades to quantify the amount of hard tissue loss (25). The Smith and Knight tooth wear index is the most frequently used index in the dental literature (19) and it records wear on all four surfaces (buccal, cervical, lingual and incisalocclusal), irrespective of the aetiology of tooth wear (Table 1) (74). Some indices such as the Basic Erosive Wear Examination (BEWE) or the classication for dental attrition investigate one aetiological factor, specic for erosion, attrition or abrasion (7577). However, a universally acceptable tooth wear index has yet to be found (24) and new indices are continually being designed and applied in clinical

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Table 1. Tooth wear index [from Smith and Knight (74)] Criteria 0 1 2 No loss of enamel surface characteristics Loss of enamel surface characteristics Buccal, lingual, and occlusal loss of enamel, exposing dentine for less than 1 3 of the surface; incisal loss of enamel; minimal dentine exposure Buccal, lingual, and occlusal loss of enamel, exposing dentine for more than 1 3 of the surface; incisal loss of enamel; substantial loss of dentine Buccal, lingual, and occlusal complete loss of enamel, pulp exposure, or exposure of secondary dentine; incisal pulp exposure or exposure of secondary dentine

regime and toothbrushing, each individual represents a variable and this confounds the interpretation of wear results (11). In addition, the sensitivity of measurement and replica techniques are an important consideration (11). Lambrechts et al. claimed that many of the deviations in the results occur due to an inaccurate replica technique, repositioning problems and restrictions of the measuring devices (84). Therefore, appropriate training and calibration are important to minimise subjective errors and a combination of methods should be used for a more reliable quantitative analysis.

studies (78). Bardsley, in a recent review claimed that there are too many indices with a lack of standardisation in terminology, resulting in difculty in interpreting and comparing the results of many of the epidemiological studies (25). Study casts are a valuable diagnostic tool for monitoring progression of tooth wear and quantifying the amount of wear (18). Silicone impressions of teeth or restorations are taken at regular intervals to make replica models in stone or epoxy resin, which are then compared for quantitative analysis (9). Measurements can be recorded by using a number of methods including stylus or laser prolometry (79) and stereomicroscopy images and computerised image tting (80). With advancement in measuring techniques, 3D laser scanning can be used to scan the surface of a replica to construct a 3D image for quantifying the wear more accurately (81). However, despite improved accuracy and reliability, new sophisticated measuring tools are costly and require specialised hardware and software, restricting their use in everyday dental practice (82). Al-Omiri et al. compared the reliability of three different methods to detect incisal wear over a 6-month period. The methods used were a CADCAM laser scanning machine, a tool maker microscope for micromeasurement applications and a conventional tooth wear index (Smith and Knight wear index) (73). It was found that the tooth wear index was the least sensitive for tooth wear quantication and was unable to identify wear progression in most cases. However, the fundamental problem with in vivo wear studies is the inherent patient factor (83). Although, measurements can be taken to standardise the testing conditions among the participants, such as the dietary

Clinical management of worn dentition

Considering the multifactorial nature of the tooth wear process, a thorough clinical examination including a medical and dental history, occupation, diet and parafunctional habit is crucial for diagnosis and treatment planning (27). The quantity and positional wear pattern are pathognomonic of the causative factor and thus the clinician should carefully observe the wear patterns on diagnostic casts in order to differentiate various causes and conrm the diagnosis (31). Since tooth wear is a progressive phenomenon that affects the dentition throughout life, a lifelong approach to management should be undertaken rather than short-term interventive treatment measures (85). Long-term monitoring is essential for assessing the effectiveness of preventive measures taken and any further progression of the wear before embarking on interventive treatment. If the cause of tooth wear is related to medical conditions such as severe erosive tooth wear induced by eating disorders, gastric problems or alcoholism, the medical management of these causes must be coordinated by the general medical practitioner in concert with dental treatment (45). Early diagnosis and appropriate prevention measures can avoid the complicated restorative treatment in the future (18). The restorative treatment decisions should be based on the patients needs, severity of wear and potential for progression of the wear (86). Restorative treatment is indicated when the patient presents with clinical symptoms such as tooth sensitivity or pain that cannot be controlled conservatively, or progressive, uncontrolled wear is occurring that is altering the occlusal vertical dimension with functional and aesthetic decit (85). The articulated study casts and a diagnostic
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wax-up should be carried out prior to formulating comprehensive treatment options for each individual. Various restorative treatment approaches for severely worn dentition have been discussed elsewhere (8789). Nevertheless the complexity of treatment of the severely worn dentition emphasises the importance of instituting an effective prevention regime.
4. Arnadottir IB, Holbrook WP, Eggertsson H, Gudmundsdottir H, Jonsson SH, Gudlaugsson JO et al. Prevalence of dental erosion in children: a national survey. Comm Dent Oral Epidemiol. 2010;38:521526. 5. Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent. 1984;52:467474. 6. Johansson A, Johansson A, Omar R, Carlsson G. Rehabilitation of the worn dentition. J Oral Rehabil. 2008;35:548566. 7. Mahalick J, Knap F, Weiter E. Occlusal wear in prosthodontics. J Am Dent Assoc. 1971;82:154159. 8. Hudson J, Goldstein G, Georgescu M. Enamel wear caused by three different restorative materials. J Prosthet Dent. 1995; 74:647654. 9. Sulong M, Aziz RA. Wear of materials used in dentistry: a review of the literature. J Prosthet Dent. 1990;63:342349. 10. Heintze SD. How to qualify and validate wear simulation devices and methods. Dent Mater. 2006;22:712734. 11. Lewis R, Dwyer-Joyce R. Wear of human teeth: a tribological perspective. J. Engineering Tribology. 2005;219:219. 12. Lambrechts P, Debels E, Van Landuyt K, Peumans M, Van Meerbeek B. How to simulate wear?: overview of existing methods. Dent Mater. 2006;22:693701. 13. Zhou Z, Zheng J. Tribology of dental materials: a review. J Phys D: Appl Phys. 2008;41:113001. 14. Jagger D, Harrison A. An in vitro investigation into the wear effects of unglazed, glazed, and polished porcelain on human enamel. J Prosthet Dent. 1994;72:320323. 15. Smith B, Robb N. The prevalence of toothwear in 1007 dental patients. J Oral Rehabil. 1996;23:232239. 16. Bartlett DW, Coward PY, Nikkah C, Wilson RF. The prevalence of tooth wear in a cluster sample of adolescent schoolchildren and its relationship with potential explanatory factors. Br Dent J. 1998;184:125129. 17. Dugmore CR, Rock WP. The prevalence of tooth erosion in 12-year-old children. Br Dent J. 2004;196:279282. 18. Bartlett DW. Retrospective long term monitoring of tooth wear using study models. Br Dent J. 2003;194:211213. 19. Vant Spijker A, Rodrigues JM, Kreulen CM. Prevalence of tooth wear in adults. Int J Prosthodont. 2009;22:3542. 20. Ayers K, Drummond B, Thomson W, Kieser J. Risk indicators for tooth wear in New Zealand school children. Int Dent J. 2002;52:4146. 21. Kreulen C, Vant Spijker A, Rodriguez J, Bronkhorst E, Creugers N, Bartlett D. Systematic review of the prevalence of tooth wear in children and adolescents. Caries Res. 2010;44:151159. 22. Harding MA, Whelton HP, Shirodaria SC, OMullane DM, Cronin MS. Is tooth wear in the primary dentition predictive of tooth wear in the permanent dentition? Report from a longitudinal study. Comm Dent Health. 2010;27:4145. 23. Bardsley PF, Taylor S, Milosevic A. Epidemiological studies of tooth wear and dental erosion in 14-year-old children in North West England. Part 1: the relationship with water uoridation and social deprivation. Br Dent J. 2004;197:413416. 24. Bartlett D, Dugmore C. Pathological or physiological erosion is there a relationship to age? Clin Oral Investig. 2008;12: 2731.

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Summary
Wear of teeth is an increasing clinical problem as life expectancy increase and teeth are retained for longer. Dental practitioners need to be aware of the underlying issues and inuencing factors of tooth wear to appropriately manage patients with a worn dentition. The oral environment is extremely complex to replicate in its contribution to the wear of dental biomaterials. Despite many attempts to simulate the oral environment in vitro, an appropriate wear testing device has not yet been found contributing to the great difculty in relating in vitro results to in vivo tooth wear. In vitro wear testing cannot simulate the oral environment because of all the biological variables, but with a well controlled experimental design, the factors that lead to a certain type of wear can be identied. In addition, understanding the wear propensity of a dental biomaterial demonstrated in vitro will also help researchers and clinicians understand and predict the response of a particular material in a clinical setting. Although there has been progress in understanding the underlying mechanisms and inuencing factors of tooth wear in dentistry, it is evident that collaboration among material scientists, tribologists and dentists will help advance the progress of this eld of study in the future.

Conicts of interest
The authors declare no conicts of interest.

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Correspondence: Ahreum Lee, Department of Oral Rehabilitation, Faculty of Dentistry, University of Otago, PO Box 647, Dunedin 9054, New Zealand. E-mail: leeahreum@hotmail.com

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