Evaluating general practitioner attitudes towards screening, risk assessment, and diagnosis of periodontal diseases and tooth wear in the UK

Abstract

This study investigated UK general dental practitioners’ habits and attitudes toward screening, risk assessment, and diagnosis of periodontal diseases and tooth wear in adult patients during routine examinations. Two primary recruiters, UK-based final year post-graduate students enrolled on the MSc in Aesthetic Dentistry at King’s College London distributed a piloted, paper-based, 14-statement questionnaire via secondary recruiters to UK general dentists. The latter participants were based at local dental practices or attending post-graduate courses. The secondary recruiters circulated and collected the questionnaire from the participants on the same day of distribution. Responses were supplied in an anonymised manner, and returned to the primary recruiters, either physically or by the scanning of the responses. Data were analysed using descriptive statistics, Chi-squared, and Fisher’s exact tests (Stata v12; significance at p < 0.05). Of 325 questionnaires distributed, 261 were satisfactorily completed, n = 261 (response rate: 80.3%). During an adult patient dental examination, high agreement was reported for periodontal risk assessment, probing, and diagnosis (≥ 88%). For the same appointment type, tooth wear risk assessments and clinical assessments were routinely performed by ≥ 81% of the sample, and 74% recorded tooth wear clinical diagnoses. While 98.5% used the Basic Periodontal Examination (BPE), only 29.8% regularly reported using a tooth wear index. The Basic Erosive Wear Examination (BEWE) was the most used (22.9%), but 4.3 times less frequently than the BPE. Satisfaction with undergraduate training with assessment and diagnosis was 2.9 times higher for periodontal assessment than for tooth wear. Significant differences were observed in the use of indices for periodontal disease versus tooth wear. The findings of this study support the need for clearer guidelines and a universally accepted tooth wear index in general practice, alongside improved satisfaction with UK undergraduate training in tooth wear assessment and diagnosis.

Introduction

Routine screening and risk assessment for oral disease may offer an improved scope for early detection and timely intervention, help prevent disease progression, alleviate the need for more complex treatment needs, and reduce the impact on the patients’ oral health-related quality of life¹. National Guidance has been made available in the UK to support primary care dental teams to routinely promote oral and general health¹. The latter Guidance supports risk assessment and screening by promoting a structured, risk-based approach to the identification of common oral diseases and by linking clinical findings and individual risk factors to evidence-based preventive interventions.

Dental caries, periodontal disease, and tooth wear are among the most common oral pathologies in the UK^2,3. Periodontal disease, caused by dental plaque bacteria and host-mediated inflammation can lead to, tooth loss, functional challenges, reduced quality of life, and compromised nutrition^4–6. The 2009 UK Adult Dental Health Survey (ADHS) found only 17% of 6469 dentate adults had healthy periodontal tissues, with 45% having at least one periodontal pocket of 4 mm or more². Periodontal disease has been described to affect 45–50% of the adult population, and globally, severe periodontitis was the sixth most prevalent condition from 1990 to 2010, with a prevalence of 11.2%^7,8. In the UK in 2008, the burden to the healthcare economy from periodontitis was estimated to be £2.8 billion, and the disease can also leave a substantial pathological footprint on other organ systems to include diabetes, cardiovascular disease and chronic kidney disease^9,6. Failure to adequately diagnose and manage this condition properly may result in litigation or regulatory challenges¹⁰.

Tooth tissues usually naturally wear with age. However, when there may be atypical wear causing discomfort, pain, functional or aesthetically related issues, the resultant tooth wear is pathological¹¹. The 2009 UK ADHS found 77% of participants had signs of anterior tooth wear, with 15% showing moderate and 2% severe wear². Globally, erosive tooth wear in permanent teeth has been documented to affect 20%-45% of people¹². Like periodontal disease, tooth wear is amenable to prevention and manageable at low cost if diagnosed early³. Severe cases of tooth wear have been shown to have an adverse impact on the patient’s oral health related quality of life and for some of these patients,’ restorative rehabilitation may be required¹³. The latter can be complex and expensive, with high long-term maintenance needs. A National Health Service (NHS) evaluation in the UK reported an average treatment time for the prosthodontic rehabilitation of severe erosive tooth wear within a hospital setting of 20.8 months (24.3 visits), with a mean cost per completed treatment plan of £2,371, and an estimated cost of similar treatment delivered by a specialist private clinic to average £13,353¹⁴.

Clinical indices are commonly used in routine dental practice. A clinical index is a standardized, quantitative or qualitative measure used to assess the presence, severity, or extent of a specific oral condition in a systematic and reproducible way. These indices provide objective criteria for evaluating factors such as dental caries, periodontal status, oral hygiene, or treatment outcomes, enabling comparison across patients, populations, and studies. By helping to quantify oral disease severity, the use of a clinical index may aid in replacing descriptive subjective terms applied for tooth wear assessment such as, mild, moderate, and severe¹⁵. The use of a clinical index may help to create a concise patient record, improve reproducibility, and help assess disease progression and intervention impact, also guiding management needs. Susceptibility to tooth wear and periodontal disease varies among adults due to various risk factors^16,17. Risk assessment should take place during patient examination, integrating findings to evaluate current disease status and future risk. The process of risk assessment involves the identification of factors that could potentially cause harm, evaluating the likelihood and severity of the harm that could result from the identified risk factors, taking into consideration aspects that may influence susceptibility to that condition, and insight into the rate of disease progression.

The World Health Organisation (WHO) introduced the Community Periodontal Index of Treatment Needs (CPITN) in 1982, which evolved into the Basic Periodontal Examination (BPE), developed by the British Society of Periodontology in 1986 (Fig. 1)¹⁸. The BPE has been described to offer a quick and simple tool for screening for periodontal disease¹⁹. For the screening of tooth wear, however, currently, there is no universally accepted index for charting in general practice, or the availability of an agreed and unambiguous assessment protocol^20,21. Furthermore, it has been suggested that tooth wear is a condition that is not routinely screened or monitored during standard dental exams¹. A 2016 PubMed search identified 114 grading systems for tooth wear, with the Tooth Wear Index (TWI), Basic Erosive Wear Examination (BEWE), and the Lussi index being the most reported²². The BEWE, proposed by Bartlett et al. in 2008 (Fig. 2),²³ is noted for its ease of use, examiner acceptance, and validity^24–28.

Fig. 1.

Scoring codes of the Basic Periodontal Examination (BPE).

Fig. 2.

Scoring codes for the Basic Erosive Tooth Wear Examination (BEWE).

This study presents the results following the use of a validated questionnaire, aimed to investigate the habits of a convenience sample of general dental practitioners based in the UK with the risk assessment and recording of a diagnosis of tooth wear and periodontal diseases amongst adult dental patients during a dental examination appointment. Both conditions often involve the use of (partial-mouth scoring) indices to grade the extent and level of disease severity, however, differences in the screening, risk assessment and charting have not been previously reported. It also aims to investigate practitioner trends with the screening and charting of these conditions, including using the BPE and the BEWE. The secondary aim of this investigation was to determine the impact of undergraduate training on the assessment and diagnosis of periodontal disease and tooth wear. In addition to describing overall screening and diagnostic habits, this study sought to explore whether years in clinical practice were associated with differences in periodontal and tooth wear risk assessment, index use, and diagnostic recording among UK general dental practitioners.

Methods and materials

Aim design and setting of the study

Ethical approval was granted by the King’s College London Research and Ethics Committee (MRA-22/23–36,734). This study was carried out, adhering to the Helsinki Declaration. Two student volunteers (the ‘primary recruiters’) from the MSc in Aesthetic Dentistry (AES) program at King’s College London recruited a convenience sample of UK general dental practitioners. These primary recruiters were based in the UK (MT and SB). To ensure anonymity, they identified a second layer of recruiters, including dental practice managers, dental training course providers, and course administrators who directly recruited the participants. There was no need for the second layer of recruiters to be dental professionals, as their role was to simply distribute and collect the responses. Participants were either based at local general dental practices or attending post-graduate courses as delegates. A convenience sample was employed in this study due to its efficiency in terms of time, cost, and accessibility, allowing the authors to collect data rapidly from readily available participants. The primary aim of this study was not to compare disease processes but to explore screening and record-keeping behaviours where clinical expectations differ.

As outlined in the participant questionnaire (Figure 3) participation in this study was entirely voluntary and submission of a completed questionnaire was stated to imply the attainment of consent for the inclusion of responses in the analysis. Owing to the anonymised nature of data collection, potential participants were advised that it would not be possible to withdraw their responses after questionnaire submission.

Fig. 3.

Questionaries used as part of this investigation.

Characteristics of the participants

Inclusion criteria were current registration with the General Dental Council (GDC UK), fluency in spoken English, and the ability to complete the questionnaire. Exclusion criteria included dental specialists, individuals who declined consent, or those affiliated with the AES program. Participants completed a validated 14-item paper-based questionnaire, piloted by seven general dentists working with one of the authors (SBM). Responses were collected by secondary recruiters on the day of distribution and returned to the primary recruiter via electronic scans, post, or hand delivery. All responses were anonymized. Data collection took place from January to November 2024.

Figure 3 presents examples of questionnaire items. Question 1 (Q1) captured participants’ years in practice. Questions 2–3 (Q2–Q3) explored habits and barriers to routine risk assessments during adult dental exams, including time, cost, relevance, training, and medico-legal concerns. Questions 4–6 (Q4–Q6) addressed periodontal probing, BPE use, and diagnosis recording. Questions 7–8 (Q7–Q8) focused on tooth wear risk assessments and related barriers. Questions 9–11 (Q9–Q11) examined clinical tooth wear assessments and index use (e.g., BEWE, TWES, TWI). Question 12 (Q12) assessed habits around recording tooth wear diagnoses. Questions 2–12 required ‘yes’/ ‘no’ responses, with optional free-text comments. No prior explanation of BPE or BEWE was provided, assuming participants using these tools were familiar with their application and scoring. Questions 13–14 evaluated satisfaction with undergraduate training in periodontal and tooth wear assessment using a 5-point Likert scale²⁹.

To clarify the analytical direction, we pre-specified four objectives and mapped questionnaire items accordingly:

• RQ1 (screening behaviours for periodontal disease vs tooth wear): Q2–Q3, Q4–Q6, Q7–Q12.

• RQ2 (index use and type): Q9–Q11 (e.g., BEWE, TWES, TWI).

• RQ3 (association with clinical experience): all outcomes above, stratified by < 5 years vs ≥ 5 years.

• RQ4 (perceived adequacy of undergraduate training): Q13–Q14.

This mapping underpinned our descriptive and inferential analyses, which were organised thematically (risk assessment, clinical assessment, index use, and diagnostic recording).

Statistical analysis

The power calculation used in this study was based on a conservative assumption of maximum population variability (p = 0.5), a 95% confidence level, and a 5% margin of error, which yielded a minimum required sample size of 73 participants. This approach was selected due to the exploratory nature of the study and the absence of prior UK-wide prevalence data on general dental practitioners’ screening and diagnostic behaviours for tooth wear. The final sample size of 261 respondents substantially exceeded this minimum threshold, increasing the precision and robustness of the descriptive and inferential analyses. Years of experience were summarized using mean, standard deviation, median, and quartiles. The Mann–Whitney U test was used to compare experience levels, with normality assessed via histograms, boxplots, the Shapiro–Wilk test, and the Kolmogorov–Smirnov test. Categorical variables were presented as counts and percentages. Participants were grouped by experience: “less experienced” (< 5 years) and “experienced” (≥ 5 years), reflecting the larger proportion of younger dentists. Associations between categorical variables were tested using Chi-squared or Fisher’s exact tests, with significance set at p < 0.05. All analyses were conducted using Stata, Version 12.

Results

Participant demographic characteristics, including years in clinical practice, are summarised in Table 1. Subsequent results are presented according to screening, risk assessment, and diagnostic practices for periodontal disease and tooth wear. Of the 325 questionnaires distributed by primary recruiters in the UK, 278 responses were received. After excluding incomplete submissions, the final sample included 261 participants, yielding an overall response rate of 80.3%. Recruitment was split between two recruiters: MT (157) and SB (104). Participants had between 1 and 43 years of practice experience (median: 6 years; mean: 10.65 ± 8.05 years), with 78.2% (204/261) having practiced for five years or more.

Table 1.

Breakdown by the years of service of the UK participant responses for routinely undertaking risk assessment, probing during screening, using the BPE, and recording a diagnosis for periodontal disease for adult patients during a dental examination appointment.

Activity/ Question
Yrs of service	Yes	%	No	%
Routinely undertake risk assessments for periodontal disease
< 5 yrs	55	21.7	2	28.6
>  = 5 yrs	199	78.3	5	71.4
Total	254		7
Routinely undertake periodontal probing as part of the screening
< 5 yrs	54	20.9	3	100.0
>  = 5 yrs	204	79.1	0	0.0
Total	258		3
Usually use the Basic Periodontal Examination (BPE) to undertake this assessment
< 5 yrs	54	21.0	1	50.0
>  = 5 yrs	203	79.0	1	50.0
Total	257		2
Routinely record a diagnosis for periodontal disease
< 5 yrs	53	22.8	4	13.8
>  = 5 yrs	179	77.2	25	86.2
Total	232		29

As shown in Table 1, 97.3% (254/261) of the participants reported routinely performing periodontal risk assessments during adult dental exams. Table 2 outlines reasons for not doing so, with the most common being: “not relevant,” “unlikely to lead to litigation,” and “not a regulatory concern.” Additionally, 98.9% (258/261) of the sample reported routinely conducting periodontal probing during adult patient screenings.

Table 2.

Breakdown by by the years of service participants that answered ‘no’ for not routinely undertaking risk assessment for periodontal disease during adult dental patient examinations and the reasons.

Reason
Yrs of service	Yes	%	No	%
Not Relevant
< 5 yrs	0	0.0	2	28.6
>  = 5 yrs	0	0.0	5	71.4
Total	0		7
Insufficent Time
< 5 yrs	0	0.0	2	50.0
>  = 5 yrs	3	100.0	2	50.0
Total	3		4
Lack Of Funding
< 5 yrs	1	50.0	1	20.0
>  = 5 yrs	1	50.0	4	80.0
Total	2		5
Lack of Knowledge And Training
< 5 yrs	1	50.0	1	20.0
>  = 5 yrs	1	50.0	4	80.0
Total	2		5
Does Not Lead To Litigation
< 5 yrs	0	0.0	2	28.6
>  = 5 yrs	0	0.0	5	71.4
Total	0		7
Not an area for regulatory concern
< 5 yrs	0	0.0	2	28.6
>  = 5 yrs	0	0.0	5	71.4
Total	0		7
Other reasons
< 5 yrs	0	0.0	2	40.0
>  = 5 yrs	1	0.0	3	60.0
Total	1		5

In this study, 98.5% (257/261) of participants reported routinely using the BPE for periodontal screening (Table 1), and 88.9% (232/261) recorded a periodontal diagnosis during adult exams; a significant finding (p < 0.0001).

For tooth wear, 82.3% (215/261) of the UK dentist participants reported routinely conducting risk assessments (Table 3), with no significant association with years of experience, (p = 0.71). Among the 46 participants who did not perform tooth wear risk assessments, the most common reason was that it was “not of regulatory concern” (Table 4). Optional free-text responses were reviewed descriptively to contextualise quantitative findings. These comments were not subjected to formal qualitative content or thematic analysis; rather, they were used to illustrate common explanatory patterns reported by participants, such as reliance on clinical presentation and the tendency to prioritise assessment in more severe cases. These responses indicated that such assessments were typically guided by clinical presentation and more likely to be performed in severe cases.

Table 3.

Breakdown by the years of service for participants that routinely undertook risk assessments, clinical assessments, use of an index for and recording a diagnosis for tooth wear for adult patients during a dental examination appointment.

Activity/ Question
Yrs of service	Yes	%	No	%
Routinely undertake risk assessments for tooth wear
< 5 yrs	46	21.4	11	23.9
>  = 5 yrs	169	78.6	35	76.1
Total	215		46
Routinely undertake clinical tooth wear assessment
< 5 yrs	44	20.7	13	27.1
>  = 5 yrs	169	79.3	35	72.9
Total	213		48
Routinely use a tooth wear index
< 5 yrs	20	25.6	37	20.2
>  = 5 yrs	58	74.4	146	79.8
Total	78		183
Routinely record a diagnosis for tooth wear
< 5 yrs	38	19.5	19	29.2
>  = 5 yrs	157	80.5	46	70.8
Total	195		65

Table 4.

Breakdown by the years of service for participants that answered ‘no’ for not routinely undertaking risk assessment for tooth wear during adult dental patient examinations.

Reason
Yrs of service	Yes	%	No	%
Not relevant
< 5 yrs	2	66.7	9	29.0
>  = 5 yrs	1	33.3	22	71.0
Total	3		31
Insufficent time
< 5 yrs	2	14.3	9	37.5
>  = 5 yrs	12	85.7	15	62.5
Total	14		24
Lack of funding
< 5 yrs	0	0.0	11	33.3
>  = 5 yrs	4	100.0	22	66.7
Total	4		33
Lack of knowledge and training
< 5 yrs	5	25.0	6	30.0
>  = 5 yrs	15	75.0	14	70.0
Total	20		20
Does not lead to litigation
< 5 yrs	0	0.0	11	34.4
>  = 5 yrs	1	100.0	21	65.6
Total	1		32
Not of regulatory concern
< 5 yrs	0	0.0	12	31.6
>  = 5 yrs	1	100.0	26	68.4
Total	1		38
Other
< 5 yrs	1	0.0	6	31.6
>  = 5 yrs	5	0.0	13	68.4
Total	0		19

As shown in Table 3, 81.6% (213/261) of participants reported routinely conducting clinical tooth wear assessments during adult dental exams. This activity was significantly more common among experienced practitioners, (p < 0.0001). However, only 29.8% (78/261) used an index for scoring and recording tooth wear, with no significant difference based on years in practice, (p > 0.05). Among those using an index (Table 5), the BEWE was the most popular (72.2%), however, it was used by only 22.9% of the overall sample. Not all of the participants used the BEWE for charting tooth wear; hence the discrepancy (29.8% versus 22.9%). Use of the BEWE use was more prevalent among less experienced dentists (< 5 years: 89.5% vs. 67.2%). Some free-text responses mentioned the use of intraoral scanners for this purpose. Additionally, 74.7% (195/261) of the participants reported routinely recording a tooth wear diagnosis, with no significant difference by experience level, (p = 0.101).

Table 5.

Breakdown by the years of service for participants for the type of tooth wear index most used.

Index used	Yrs of service
	< 5 yrs	%	>  = 5 yrs	%
BEWE	17	89.5	43	67.2
TWES	0	0.0	1	1.6
Smith and Knight	2	10.5	9	14.1
Any other	0	0.0	11	17.2
Total	19		64

Tables 6 and 7 present satisfaction levels with undergraduate training in assessing and diagnosing periodontal disease and tooth wear. For periodontal disease, 34.5% (90/261) of the participants ‘strongly agreed’ and 50.2% (131/261) ‘agreed’ that their training was satisfactory, with no significant differences by experience level, (p = 0.12). In contrast, only 3.8% (10/261) ‘strongly agreed’ and 21.5% (56/261) ‘agreed’ that their training in tooth wear assessment and diagnosis was satisfactory, again with no significant difference by experience, (p = 0.09).

Table 6.

Participant satisfaction with undergraduate training with the assessment and diagnosis of periodontal disease.

	Yrs of service
	< 5 yrs	%	>  = 5 yrs	%
Strongly agree	27	47.4	63	30.9
Agree	25	43.9	106	52.0
Uncertain	3	5.3	9	4.4
Disagree	2	3.5	21	10.3
Strongly disagree	0	0.0	5	2.5
Total	57		204

Table 7.

Participant satisfaction with undergraduate training with the assessment and diagnosis of tooth wear.

	Yrs of service
	< 5 yrs	%	>  = 5 yrs	%
Strongly agree	3	5.3	7	3.4
Agree	19	33.3	37	18.1
Uncertain	18	31.6	39	19.1
Disagree	11	19.3	83	40.7
Strongly disagree	6	10.5	38	18.6
Total	57		204

Discussion

In this study, a convenience sample of UK-based general dentists reported high compliance with periodontal care during adult dental exams (≥ 88.9%) routinely performed risk assessments, periodontal probing, and recorded diagnoses, with 98.5% using the BPE for screening. Tooth wear assessments were also common, with ≥ 74.4% conducting risk assessments, clinical evaluations, and recording diagnoses for their adult patients during a dental examination appointment. However, only 29.8% regularly used an index to score and record tooth wear, with the BEWE being the most popular. The latter index was reported to be used by 22.9% of the sample.

This questionnaire-based study has several limitations. The use of a convenience sampling strategy introduces an inherent risk of selection bias and limits the generalisability of the findings. Overall, this study is exploratory and hypothesis-generating rather than confirmatory. Recruitment pathways may have favoured general dental practitioners who were engaged in postgraduate education or professional development activities, potentially over-representing clinicians with a greater interest in risk assessment, diagnosis, and record-keeping. Consequently, the results should not be interpreted as fully representative of all UK general dental practitioners across England, Scotland, Wales, and Northern Ireland. While it provides insights into practice trends and professional perceptions, responses may be influenced by social desirability bias. Social desirability bias in a questionnaire-based study refers to the tendency of respondents to answer questions in a way that they believe will be viewed favourably by others, rather than providing truthful responses. Several contextual factors that may have influenced the findings warrant consideration. The geographical distribution of respondents across the UK was not captured, and it is possible that the sample disproportionately reflected practitioners based in England, particularly those practising in urban or metropolitan settings. Additionally, the location of undergraduate training (UK versus international qualification) was not recorded; this may have influenced familiarity with indices such as the BPE and BEWE, given known variability in undergraduate curricula. Exposure to postgraduate education or continuing professional development relating specifically to periodontal assessment or tooth wear was also not assessed and may have contributed to the higher uptake of structured indices among some practitioners. Furthermore, practice environment (NHS, private, or mixed practice) was not explored, despite its potential influence on time allocation, record-keeping expectations, and perceived regulatory pressures. The high response rate suggests strong engagement, likely due to well-designed questions and effective distribution via local secondary recruiters. The study focused on adult patient care during routine exams and record-keeping by general dentists, though some assessments may have been performed without being routinely documented. The convenience sample used in this study (which also introduces a substantial risk of selection bias, limiting external validity) may not fully represent the UK dental profession, especially given the relatively younger age of the sample (mean: 10.65 ± 8.05 years). However, the findings may offer valuable perspectives on UK-based dentists’ attitudes and practices.

In this study, 98.5% of general dentists reported using the BPE for periodontal screening. This aligns with earlier findings, such as Tugnait et al.³⁰, which showed 91% of UK NHS dentists used the BPE for new adult patients and 84% for recalls, with younger and postgraduate-trained dentists using it more consistently. Nearly two decades later, the present study found near-universal BPE use among UK dentists, regardless of experience level, likely reflecting its inclusion in UK undergraduate training since the late 1980s and longstanding endorsement by the British Society of Periodontology (BSP). BSP has promoted BPE use through policy statements for nearly 40 years^31,32. Additionally, 84.7% of participants expressed satisfaction with their undergraduate training in periodontal assessment and diagnosis, with no significant variation by experience, (p = 0.12). This may contribute to the high levels of periodontal screening observed. Internationally, similar trends have been reported, with 70% of general dentists routinely screening new patients using indices such as the DSPI in the Netherlands and CPITN in Australia ^33–35.

In this study, 97.3% of general dentist participants reported routinely conducting periodontal risk assessments during adult dental exams. In the UK, various tools and nationally accepted guidelines supporting periodontal risk assessment have long been available and implemented in primary care^36–39. Their use has been shown to improve diagnostic accuracy and treatment outcomes^40,41, and positive professional attitudes toward these tools have been documented⁴.

Comprehensive guidelines and classification systems have been developed to support accurate periodontal diagnosis and treatment planning. The 1999 Classification,⁴² faced criticism for diagnostic inconsistencies, leading to misdiagnosis and inappropriate treatment^43–45. A 2005 study reported that only 62% of Australian general dentists felt confident diagnosing aggressive periodontitis³⁵. The updated 2018 Classification introduced staging, grading, and risk factor modifiers to improve diagnostic accuracy and planning⁴⁶, and its UK implementation aligns with BPE guidelines. In the present study conducted several years after the 2018 update, 88.8% of participants recorded periodontal diagnoses during adult exams, a statistically significant finding (p < 0.0001). A 2021 USA study also found fair agreement among dentists using the 2018 Classification, though risk factor identification remained challenging across educational backgrounds⁴⁵.

In many countries, professional standards emphasize delivering high-quality care based on current evidence and authoritative guidance, alongside maintaining accurate patient records⁴⁷. Deviations from these standards require justification, and failure to meet them can lead to serious consequences. In England, clinical examination and record-keeping guidelines mandate the use of the BPE for initial periodontal assessment^48,49. The risk of litigation or regulatory scrutiny may influence clinical practice⁵⁰, especially since misdiagnosis of periodontal disease is a leading cause of dental litigation in industrialized nations¹⁰. This is likely linked to widespread risk management training aimed at raising awareness and reducing liability.

Approximately 82% of respondents in this investigation reported routinely conducting tooth wear risk assessments during adult examinations, with no significant association with experience level, (p ≥ 0.61). Similarly, Mehta et al.⁵⁰, found that while 81% of dentists acknowledged the importance of risk assessing new patients for tooth wear, only 59% did so for severe cases, and just 13.5% routinely used an index. This trend may reflect growing awareness of tooth wear, particularly in the UK, where prevalence is higher among younger European adults⁵¹. Effective risk assessment requires a thorough history and clinical examination, which can be supported by indices like the BEWE¹⁵. The BEWE scores each sextant, with a maximum score of 18: scores ≤ 6 indicate low risk, 7–13 medium risk, and ≥ 13 high risk, with age and wear pattern also considered¹⁶.

In line with the present study, O'Toole et al.⁵², also found the BEWE to be the most widely used tooth wear index amongst a sample of London (UK) dentists, with newly qualified practitioners being 19 and 16 times more likely to chart tooth wear and perform risk assessments, respectively, than their more experienced counterparts. In the present study, whilst only 29.8% of respondents routinely used a tooth wear index, the BEWE was the most popular, used by just 22.9%; however, of the less experienced dentists who used a tooth wear index, 89.5% reported use of the BEWE opposed to 67.2% of the experienced participants. With appropriate training⁵³, such indices (as with the BPE) can support consistent screening, quantification, risk-assessment and record-keeping. In their study, O’Hara and Millar⁵⁴, also reported that fewer than half of 20 interviewed clinicians were aware of BEWE, most with under five years of practice, and only 10% used it routinely. Collectively, these findings suggest that BEWE use is more common among less experienced UK dentists.

Tooth wear and periodontal disease are among the three most prevalent oral conditions in the UK^2,3. This study found higher compliance with regular risk assessments and clinical assessment for both conditions among adult patients. However, despite the availability of Consensus statements¹¹ and further UK-based Guidance such as Delivering Better Oral Health⁵⁵, notable differences emerged with the use of the BPE and BEWE indices; with the former being 4.3 times more frequently used by this sample of participants. These discrepancies may stem from several factors, including the absence of consensus on tooth wear charting in general practice, lack of clear guidelines and protocols, limited understanding of tooth wear progression, growing reliance on intraoral scanners, and inconsistent training in this area. Periodontal disease and tooth wear were examined together in this study because both represent highly prevalent, largely preventable chronic oral conditions that rely on systematic screening, risk assessment, and structured documentation within general dental practice. While the disease processes differ, their comparison provides insight into how widely embedded, guideline-driven indices (such as the BPE) contrast with less standardised approaches to charting conditions like tooth wear. The intent was therefore not to treat these as independent sub-studies, but to explore differences in clinical behaviours where levels of professional consensus, regulatory expectation, and educational exposure diverge.

In this study, the most common reason cited for not routinely conducting tooth wear risk assessments during adult dental examinations was the absence of regulatory pressure. This may reflect the General Dental Council’s (GDC- the UK’s regulator for the dental profession) approach, where their clinical advisors in fitness to practise investigations typically focus on issues that would be reasonably expected. Since evidence suggests lower compliance with tooth wear charting and risk assessment unless it is central to the investigation, it would be inappropriate for advisors to raise criticism in such cases⁵⁶.

In this study, only 25.3% of respondents were satisfied with their undergraduate training in assessing and diagnosing tooth wear—2.9 times lower than for periodontal disease, highlighting potential gaps in awareness and education. Satisfaction levels did not significantly vary with years in practice (p = 0.09). However, as a limitation of the present study, only two questions were devoted to this area, and this is an area which would require further studies for a more comprehensive evaluation and understanding. Undergraduate teaching of the BEWE remains limited; Bartlett et al.³, surveyed 18 UK dental schools (13 responded), revealing that two did not teach any index, two taught only BEWE, six taught both BEWE and TWI, and two taught only TWI. Just five schools recommended recording tooth wear using an index, while most preferred study models to monitor progression. However, limitations of gypsum models and digital scans for scoring tooth wear have been documented⁵⁷. Given that BEWE was introduced over two decades after BPE, older dentists may be less familiar with it, increasing the risk of inaccurate use without proper training⁵³. Rather than aiming to provide population-level prevalence estimates, this study was designed to explore contemporary trends, habits, and attitudes among a broad cross-section of practising UK general dentists. Despite limitations in external validity, the findings offer valuable insight into current clinical behaviours and educational influences within primary dental care and highlight areas requiring further investigation using nationally representative sampling frameworks.

Overall, this study highlights the need for improved satisfaction with undergraduate training and ongoing postgraduate education in the UK about the assessment and diagnosis of tooth wear and supports the call for the need for clear guidelines with tooth wear assessment, and a universally accepted index for charting tooth wear in general practice.

Future research should focus on nationally representative samples of UK general dental practitioners and include variables such as geographical location, practice type, undergraduate training background, and engagement with postgraduate or CPD education. Studies dedicated specifically to tooth surface loss and tooth wear charting would be particularly valuable, given the inconsistent uptake of indices such as the BEWE. Longitudinal investigations assessing how educational exposure influences diagnostic behaviour over time may further inform the development of clearer guidelines and training frameworks for tooth wear assessment in primary care.

Conclusion

This study revealed high compliance among UK-based general dentists in routinely conducting periodontal and tooth wear risk assessments, probing for periodontal disease, and recording diagnoses during adult dental exams. However, the BPE was used nearly 4.3 times more frequently than a tooth wear index such as the BEWE. The most cited barrier to tooth wear assessment was its perceived lack of regulatory importance, and only a quarter of participants expressed satisfaction with their undergraduate training in this area.

Given the growing emphasis on preventive dentistry, there is a clear need for consensus on tooth wear assessment and diagnosis. Enhancing undergraduate education in the UK and integrating structured clinical and risk assessment protocols into routine primary care practice will be essential for improving outcomes in this under-recognized area.

Abbreviations

BPE

Basic Periodontal Examination

BEWE

Basic Erosive Wear Examination

ADHS

Adult Dental Health Survey

NHS

National Health Service

TWES

Tooth Wear Evaluation System

TWI

Tooth wear index

DSPI

Dutch periodontal screening index

CPITN

Community periodontal index of treatment need

Author contributions

SBM is the co-project leader and contributed to design, data interpretation, drafted and critically revised the manuscript. SB, MT contributed to data collection and critically revised the manuscript and GV critically revised the manuscript. SB is the co- project, contributed to conception, design, data interpretation, and critically revised the manuscript.

Funding

The authors did not receive any financial support and declare no potential conflicts of interest with respect to the authorship and/ or publication of this article.

Data availability

All data generated or analysed during this study are included in this published article.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

Ethical approval was granted by the King’s College London Research and Ethics Committee (MRA-22/23-36734). This study was carried out, adhering to the Helsinki Declaration. Data collection occurred from January 2024 to November 2024. Two student volunteers from the MSc in Aesthetic Dentistry (AES) program at King’s College London recruited a convenience sample of general dental practitioners. Participation was voluntary and this was explained in the background section of the questionnaire. Participants completed a printed, paper-based validated 14-question questionnaire, returned to the primary recruiter either via electronic scans or in physical format (by post or by hand delivery), with all responses fully anonymized. Consequently, there was no option to withdraw data once submitted. All authors gave their final approval and agreed to be accountable for all aspects of the work. As outlined in the participant questionnaire (a complete copy is available in the Supplementary Materials), participation in this study was entirely voluntary and submission of a completed questionnaire was stated to imply the attainment of consent for the inclusion of responses in the analysis. Owing to the anonymised nature of data collection, potential participants were advised that it would not be possible to withdraw their responses after questionnaire submission.

Consent for publication

This study did not include the use of any identifying images or other personal or clinical details of participants. Data was collected anonymously.

Informed consent

Informed consent was obtained from all subjects and/or their legal guardian(s).