Most tooth wear doesn't need treatment. It needs a baseline, a re-measurement, and an honest answer about whether it's actually moving.
Tooth wear is one of the areas where general practice tends to split into two camps: watch everything indefinitely, or treat anything that looks worn. Neither is right. The question that actually matters isn't how worn a tooth looks today — it's whether the wear is active, how fast it's moving, and what's driving it. Here's the framework I use, built from tracking wear data across an ongoing cohort of my own patients.
Why "It Looks Worn" Isn't a Diagnosis
A single snapshot of a worn dentition tells you almost nothing about risk. A 60-year-old with flattened incisal edges and no active symptoms may have accumulated that wear steadily over four decades — biologically unremarkable. A 25-year-old with a similar-looking pattern may be losing tooth structure at a rate that will cause real functional problems within years. Same appearance, completely different clinical pictures. The only way to tell them apart is measurement over time, not a single visual impression.
Objective Baselines, Not Impressions
I record two things at every wear assessment: a BEWE (Basic Erosive Wear Examination) score across all sextants, and an incisal height measurement — from the CEJ to the worn edge on the upper central incisors specifically, since they give the most reproducible reference point.
The reference values I use: an unworn upper central incisor averages around 11.5mm, a lower central around 9.0mm (Magne, 2003). Natural wear from age 20 progresses at roughly 0.030mm per year on average, with a standard deviation of about ±0.70mm. That gives a usable clinical threshold — wear within ±1SD of the expected rate for a patient's age is unremarkable. Beyond ±1SD, it's worth flagging and monitoring more closely. Beyond ±2SD, it's a red flag that warrants active management, not another six-month watch.
Tracking this across an ongoing cohort of my own patients (155 to date) has made one thing clear: the patients who end up needing rehabilitation are very rarely the ones with the most visually dramatic wear. They're the ones whose rate, plotted against that baseline, is clearly accelerating.
Etiology Changes the Decision, Not Just the Diagnosis
Alongside BEWE and incisal height, I record a dietary and etiology history for every patient — erosive (acid-driven, dietary or reflux), attritive (tooth-on-tooth, often parafunction-driven), or abrasive (mechanical, usually toothbrushing or habit-related). This matters clinically because it changes what "manage" actually means.
Erosive wear with an identifiable dietary or reflux cause can often be arrested by addressing the cause — dietary modification, reflux management, a fluoride or remineralising protocol — without restorative intervention, provided the rate is still within a reasonable range. Attritive wear from unmanaged parafunction rarely resolves on its own; a night guard is often the first intervention, not a crown. Wear with no identifiable, controllable cause, or wear that's continued to progress despite intervention, is a different conversation entirely.
The Decision Points
Monitor when: wear falls within roughly ±1SD of the expected rate for the patient's age, there's an identifiable and controllable etiology that's being actively managed, there are no symptoms of sensitivity or functional compromise, and the patient isn't requesting a cosmetic correction. Re-measure at 6 to 12 months against the same baseline, not just a new visual impression.
Rehabilitate when: the rate is beyond roughly ±2SD for age, wear has progressed despite the causative factor being addressed, there's measurable loss of occlusal vertical dimension affecting function or appearance, or the patient is symptomatic. This is also where full mouth rehabilitation planning genuinely earns its place over piecemeal restoration — worth its own separate conversation.
What This Looks Like for a Referral
If you're tracking a patient's wear and it's accelerating past what the baseline would predict, or a diagnostic wax-up and full occlusal analysis feels like it's moving beyond what's practical in a routine appointment slot, that's the point to refer rather than continue monitoring indefinitely. Bring what you've measured — even an approximate incisal height and a sense of the timeline — and it makes the first consultation considerably more useful for both of us.
References: Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach. Quintessence, 2003. Bardsley PF. The evolution of tooth wear indices. Clinical Oral Investigations, 2008. Bartlett DW et al. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clinical Oral Investigations, 2008. Smith BGN, Knight JK. An index for measuring the wear of teeth. British Dental Journal, 1984.