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Multicenter study to develop and validate a risk assessment tool as part of composite scoring system for erosive tooth wear



(i) To develop, validate, and apply in practice a new risk assessment tool for erosive tooth wear (ETW) including a risk factors questionnaire and a saliva secretion evaluation, which combined with a clinical index, can be part of an ETW composite scoring system; (ii) to assess ETW lesions and current and past erosive challenges in younger age groups.


The Tooth Surface Loss/Erosion Working Group of the European Association of Dental Public Health consisted of an international panel of experts designed the survey component of the new tool (Erosive Wear Assessment of Risk—EWAR) and confirmed its construct and content validity. After receiving ethical approvals and informed consents, the EWAR tool (questionnaire + saliva secretion evaluation) was applied in a multicenter cross-sectional study with 207 participants aged 15–21 years old from four countries (Finland, Greece, Romania, the USA). BEWE score was used for the clinical assessment of ETW.


A total of 58.5% of participants had ETW. 10.9% and 20.3% of participants had low secretion of stimulated (< 1 ml/min) and unstimulated saliva (< 0.25 ml/min), respectively. The following factors were bivariately significantly associated with ETW: energy drink consumption, low secretion of stimulated saliva, juices consumption, erosive drink consumption for quenching thirst between meals, erosive drink kept in the mouth, feeling pain/icing after consuming something acidic or cold, and co-existence of other type of tooth wear. In regression analysis, only energy drink consumption (OR = 3.5, 95% CI: 1.39, 8.9), low secretion of stimulated saliva (OR = 36.3, 95% CI: 4.71, 78.94), and feeling pain/icing (OR = 8.8, 95% CI: 1.92, 40.04) remained significant.


The examiners of the study reported that the EWAR tool appeared to be an affordable and easy-to-use instrument. Some challenges occurred during the saliva collection process. Inferential analysis revealed that the risk factors/indicators of low stimulated salivary flow, energy drink consumption, and pain/icing with ETW were considered the most important in ETW occurrence.

Clinical relevance

EWAR tool combined with the BEWE clinical index can be used for ETW risk assessment for epidemiological studies and chairside use.

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The authors would like to thank Professor Carolina Ganss for her support and commentary on this research.


The study was not funded by any institution or company.

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Authors and Affiliations



All 11 authors contributed to the study conception and design. Material preparation and data collection were performed by VM, VA, M-LL, VA, AB, MS, and PA. Formal statistical analysis and report was supervised by VM and PA. The first draft of the manuscript was written by VM and all authors commented on previous versions of the manuscript. All 11 authors read and approved the final manuscript.

Corresponding author

Correspondence to Vasileios Margaritis.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee of each research site (in Finland by the Ethical Committee of the Northern Ostrobothnia Hospital District (11.9.2017, #70/2017 240§); in Romania, by the Research Ethics Committee of the University of Medicine and Pharmacy of Tirgu-Mures (27.09.2017, #312); in the USA/Greece by the Walden University Institution Review Board (#03-01-17-6274274)) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent forms were received from all the participants and parents/guardians when needed and confidentiality of the data was confirmed.

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Margaritis, V., Alaraudanjoki, V., Laitala, ML. et al. Multicenter study to develop and validate a risk assessment tool as part of composite scoring system for erosive tooth wear. Clin Oral Invest 25, 2745–2756 (2021).

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  • Erosive tooth wear
  • Risk assessment
  • Erosive risk factors
  • Saliva flow
  • BEWE