Introduction 52 52 52 www.euro.who.int 18 To identify indicators of oral health, of critical oral health care, its quality of care and of essential health resources To strengthen the ability at the local, national and regional levels to measure, compare and determine the effects of oral health services and use of resources To identify indicators of oral health (problems, determinants and risk factors related to lifestyle) of critical oral health care To identify the types of data generation and management problems within the Health Information System To identify principles for guiding the selection and use of oral health indicators To identify a set of core indicators for oral health To review the recent oral health-indicator selection efforts 18 18 52 52 52 25 –The full mouth or partial recording –The examination of primary and/or of only permanent teeth –The examination of all surfaces or partial recording of surfaces 17 48 20 48 17 35 33 19 1 30 39 –Which erosion indexes are mostly used in the scientific literature? –Which quality criteria should indexes possess? –What differences exist between individual- and population-based erosion indexes? Finally in the discussion, we will debate whether it is possible to involve erosion indexes into Health Indicator Sets and into International Classification of Diseases (ICD; e.g. ECHI, HFA21, country databases on oral Health, ICD-11). Erosion index in the scientific literature 1 2 35 39 1 48 n 48 n 17 n 33 n n 47 Table 1 Used dental erosion indexes in human cross-sectional studies for children found in Medline from the years 2000–2006 Aim of the study n Study population Referred index Source Erosive tooth wear 463 Kindergarten, 3- to 5-year-old children O’Sullivan Index 54 Dental erosion 153 11-year-olds O’Sullivan Index 10 Prevalence of dental erosion 499 School setting; 12-year-old children O’Sullivan Index 43 Prevalence of dental erosion 1,949 Preschool children; 3- to 5-year-old children UK Children dental health survey index 32 Prevalence of dental erosion 832 6- and 12-year-old school children Own erosion index 50 SES and ethnicity and oral health 1,753 Random sample of 12- and 14-year-old children UK Children dental health survey index 16 Accuracy and reproducibility of school dental screening 570 Primary-school children New index was developed 24 Prevalence of and risk factors for dental erosion 95 Children and adults Own erosion index 28 Oral health and gastro-oesophageal reflux 52 Children with gastro-oesophageal reflux disease Aine Index 31 Asthma and dental erosion 418 Random Sample of 14-year-old children Smith and Knight TWI 2 Prevalence of dental erosion Oral health and gastro-oesophageal reflux 37 Children with gastro-oesophageal reflux disease Aine Index 15 Prevalence of dental erosions 987 Preschool children, 2- to 5-year-old children UK Children dental health survey index 4 Oral health of children with clefts 91 4-, 8-, and 12-year-old children UK Children dental health survey index 11 Dental erosion and consumption of oranges 1,010 12-year-old children Own erosion index 29 Table 2 Used dental erosion indexes in human cross-sectional studies for adults found in Medline from the years 2000–2006 Aim of the study n Study population Refered index Source Tooth survey (surface?) check! loss 155 Patients attending a dental hospital UK Adult dental health survey index 44 Tooth wear among psychiatric patients 143 Psychiatric patients Smith and Knight TWI 3 Tooth wear in elderly 690 Local survey, elderly Eccles Index 49 Tooth surface in winemakers 36 Winemakers Schweizer-Hirt et al. 1978 12 Workplace and dental erosion 20 Silicon workers Own erosion index 27 Oral and dental health 34 Inpatients in treatment of alcohol disorders No information given 6 Dental erosion and gastro-oesophageal reflux ? Patients with gastro-oesophageal reflux disease Smith and Knight TWI 36 Prevalence of dental erosion 18,555 Permanent dentition Smith and Knight TWI 9 Dental erosion and gastro-oesophageal reflux 253 Patients with gastro-oesophageal reflux disease Eccles Index 37 Monitoring of tooth wear 500 Patients referred for a variety of restorative procecdures Smith and Knight TWI 7 Risk factors of tooth wear 506 Patients attending a dental hospital Smith and Knight TWI 13 Sport drinks and dental erosion 304 Athletes Lussi Index 34 Prevalence of tooth wear 126 Patients attending a dental hospital Smith and Knight TWI 41 Recreational drug and tooth surface loss 13 Undergraduate students Smith and Knight TWI 38 Risk factors for dental erosion 10 Male military Saudi inductees Own erosion index 28 Oral health status of workers 68 Workers exposed to acid fumes Smith and Knight TWI 5 Methamphetamine and tooth wear 43 Methamphetamine users Smith and Knight TWI 45 Dental erosion and gastro-oesophageal reflux 20 Patients with gastro-oesophageal reflux disease Smith and Knight TWI 21 Quality criteria of indexes for measuring tooth erosion 8 validity 42 content construct criterion Content validity all all 8 23 gold standard 46 criterion validity 23 construct validity 8 convergent discriminant validity convergent validity 8 discriminant validity 23 reliability 42 14 23 14 22 sensitivity specificity no supposed able 46 Individual versus population-based erosion indexes An individual-based index should fulfill other criteria than a population-based index. The first should allow assessment of the full truth of the construct “tooth erosion”. Therefore, a very good individual-based erosion index should nearly be a gold-standard instrument. Using a population-based erosion index, the individual assessment should take less time to allow an assessment in big population samples. Therefore, for practical reasons, a population-based erosion index is often a short form of an individual-based index. However, a good population-based erosion index should possess very high validity as well as high reliability. Discussion 48 26 29 3 40 29 29 Table 3 48 Score Surface Criterion 0 B/L/O/I/C No loss of surface characteristic, no loss of contour 1 B/L/O/I/C Loss of enamel surface characteristics, minimal loss of contour 2 B/L/O Loss of enamel exposing dentine for less than one third of the surface I Loss of enamel just exposing dentine C Defect less then 1 mm deep 3 B/L/O Loss of enamel exposing dentine for more than one third of surface I Loss of enamel and substantial loss of dentine not exposing secondary dentine or pulp C Defect 1–2 mm deep 4 B/L/O Complete loss of enamel, or pulp exposure, or exposure of secondary dentine I Pulp exposure or exposure of secondary dentine C Defect more than 2 mm deep, or pulp exposure, or exposure of secondary dentine B L O I C Quality criteria of indexes for measuring tooth erosion So far, there is no consensus concerning a gold-standard instrument. However, a gold standard is important for comparison. Otherwise, criterion validity cannot be checked. If one attempts to develop a gold-standard instrument, the first step would be a thorough discussion of which aspects of the construct “tooth erosion” have to be included. This should be conducted by established experts to ensure content validity. When the instrument is constructed, inter-examiner reliability and intra-examiner reliability can be examined as described above. However, this should be done not only in a national but in an international context. calibration study One of the prospective targets ought to be the inclusion of indexes on dental health prevention especially of an internationally agreed “erosion index” into the existing Health Indicator Sets. These would be the Health for All Database of the WHO (HFA21), The European Community Health Indicator Set (ECHI), Country Databases on Oral Health and the inclusion of Dental Erosion into the International Classification of Diseases and Health-Related Problems. 4 Table 4 51 ICD 10 code Description K03.2 Erosion of teeth K03.20 Occupational erosion of teeth K03.21 Erosion of teeth due to persistent regurgitating or vomiting K03.22 Erosion of teeth due to diet K03.23 Erosion of teeth due to drugs and medicaments K03.24 Idiopathic erosion of teeth K03.28 Other specified erosion of teeth K03.29 Erosion of teeth, unspecified 53 Conclusion Further efforts have to be made in the development of an internationally agreed index which is able to assess dental erosion with as much reliability and validity as possible. Current recommendations of the WHO and the European Union and health task forces within countries and Dental Associations should be used to develop and to discuss the concept of tooth erosion and the development of a unified erosion index.