Noncarious cervical lesions and abfractions: a re-evaluation

BACKGROUND: The concept of abfraction is controversial. The authors present the fundamental basis of abfraction and review studies that describe the condition. TYPES OF STUDIES REVIEWED: The authors used data on masticatory forces, enamel and dentin properties, as well as stress studies related to abfraction, for background information. They also analyzed the genesis of the abfraction theory, experimental evidence, case presentations, clinical investigations and restorative studies. RESULTS: The theory of abfraction is based primarily on engineering analyses that demonstrate theoretical stress concentration at the cervical areas of teeth. While some recent stress studies support earlier findings, others have provided significant deviating information. Few controlled studies exist that demonstrate the relationship between occlusal loading and abfraction lesions. The role of occlusal loading in noncarious cervical lesions (as shown by clinical data) appears to be part of a multifactorial event that may not necessarily follow the proposed classic abfraction mechanism, and other mechanisms or factors may explain cervical restoration failure just as well. CLINICAL IMPLICATIONS: There is little direct evidence supporting the theory of abfraction as the primary factor in the formation of noncarious cervical lesions. Controlled clinical trials are necessary to elucidate more fully the etiology of those lesions.     

Noncarious cervical lesions in adults: prevalence and occlusal aspects

BACKGROUND: The factors that induce the formation of noncarious lesions are not understood fully, particularly those that are related to occlusal aspects. The authors conducted a study to evaluate the prevalence of noncarious cervical lesions in adults and their association with occlusal aspects. METHODS: The authors examined 70 people (35 men and 35 women) aged 25 to 45 years to determine the presence and type of noncarious cervical lesions, wear facets, tooth contacts in maximal intercuspal position, and lateral and protrusive movements. The assessment involved a questionnaire and clinical examination. RESULTS: Among the teeth the authors evaluated, 17.23 percent had cervical lesions, 80.28 percent of which had wear facets (P < .01). The authors found a significant difference between the prevalence of noncarious lesions and the presence of wear facets (P = .0484). CONCLUSIONS: The authors found that cervical lesions were related significantly to wear facets. These findings strengthen evidence for the role of occlusal forces as an etiologic factor for noncarious lesions. CLINICAL IMPLICATIONS: The presence of wear facets should be considered in the treatment of noncarious cervical lesions.     

Noncarious cervical lesions: Morphology and progression,prevalence, etiology,pathophysiology, and clinical guidelines for restoration

Purpose

To synthesize the literature regarding noncarious cervical lesions (NCCLs) and propose clinical guidelines when lesion restoration is indicated.

Material and methods

A PubMed search was performed related to NCCL morphology, progression, prevalence, etiology, pathophysiology, and restoration.

Results

NCCLs form as either rounded (saucerlike) depressions with smooth, featureless surfaces that progress mainly in height or as V-shaped indentations that increase in both height and depth. Prevalence ranges from less than 10% to over 90% and increases with age. Common locations are the facial surfaces of maxillary premolars. They have a multifactorial etiology due to personal habits such as excessive horizontal toothbrushing and consumption of acidic foods and drinks. Occlusal factors have been identified as contributing to the prevalence of NCCLs in some studies, whereas other studies indicate there is no relationship. The concept of abfraction has been proposed whereby mechanical stress from occlusal loading plays a role in the development and progression of NCCLs with publications supporting the concept and others indicating it lacks the required clinical documentation. Regardless of the development mechanism, demineralization occurs and they are one of the most common demineralization diseases in the body. Treatment should be managed conservatively through preventive intervention with restorative treatment delayed until it becomes necessary due to factors such as lesion progression, impact on patient's quality of life, sensitivity, poor esthetics, and food collection may necessitate restoration. Composite resins are commonly used to restore NCCLs although other materials such as glass ionomer and resin-modified glass ionomer are also used. Sclerotic dentin does not etch like normal dentin and therefore it has been recommended to texture the dentin surface with a fine rotary diamond instrument to improve restoration retention. Some clinicians use mechanical retention to increase retention. Beveling of enamel is used to increase the bonding area and retention as well as enhance the esthetic result by gradually creating a color change between the restoration and tooth. Both multistep and single-step adhesives have been used. Dentin etching should be increased to 30 seconds due to the sclerotic dentin with the adhesive agent applied using a light scrubbing motion for 20 seconds but without excessive force that induces substantial bending of a disposable applicator. Both flowable and sculptable composite resins have been successfully used with some clinicians applying and polymerizing a layer of flowable composite resin and then adding an external layer of sculptable composite resin to provide enhanced resistance to wear. When caries is present, silver diamine fluoride has been used to arrest the caries rather than restore the lesion.

Conclusions

Noncarious cervical lesions (NCCLs) form as smooth saucerlike depressions or as V-shaped notches. Prevalence values as high as 90% and as low as 10% have been reported due to habits such as excessive toothbrushing and an acidic diet. Occlusal factors have been proposed as contributing to their presence but it remains controversial. Publications have both supported and challenged the concept of abfraction. They are one of the most common demineralization diseases in the body. Conservative treatment through prevention is recommended with restorative treatment delayed as long as possible. When treatment is needed, composite resins are commonly used with proposed restorative guidelines including texturing the sclerotic dentin, beveling the enamel, potential use of mechanical retention, 30 seconds of acid etching, and use of either multistep or single-step adhesives in conjunction with a light scrubbing motion for 20 seconds without excessive force placed on disposable applicators.     

Non‐carious cervical lesions (NCCLs) in a random sampling community population and the association of NCCLs with occlusive wear

This study investigated the prevalence, risk factors and association of occlusive wear with non‐carious cervical lesions (NCCLs) in the general Chinese population. A total of 1320 subjects were recruited, and multistage and random sampling methods of survey spots were performed. All age groups comprised similar numbers of participants and equal numbers of males and females. Each subject completed a structured interview, and all teeth of each subject were examined by a practitioner to determine NCCLs and occlusive wear. Binary logistic regression was conducted by analysing the association of risk factors with the occurrence of NCCLs. Bivariate correlation analysis was performed by determining the association of NCCLs dimension or depth with the range of occlusive wear facets. Clinical assessment showed that the overall prevalence of subjects diagnosed with NCCLs was 63%. The proportion of subjects or teeth with NCCLs significantly increased with age. Pre‐molars were the most commonly affected teeth. Single variables and interactive effects of variables associated with the occurrence of NCCLs include the following: age group, intensity of toothbrushing, frequency of fresh fruit consumption and interactive effect between intensity of toothbrushing and frequency of fresh fruit consumption. A weak positive correlation of the grading index was found between NCCLs dimension, size or depth and range of occlusive wear facets. This study reported the higher prevalence of NCCLs in the general Chinese population. Implementation of a combined strategy to reduce risk factors of NCCLs could be more effective than individual techniques; meanwhile, the occurrence of NCCL could be related to the wear degree of occlusive defects in the population studied.     

Restoring cervical lesions with flexible composites.

OBJECTIVES: Flexure at the tooth cervix has been suggested to dislodge cervical restorations more rapidly. The objective of this randomized controlled clinical trial was to test the hypothesis that a higher composite flexibility better withstands tooth flexure stress. METHODS: One hundred and forty-two non-carious cervical lesions were restored with composites with contrasting stiffness. Seventy-one patients randomly received two cervical restorations placed following two out of the three experimental groups: (1) the three-step etch-and-rinse adhesive Permaquick applied with the stiff micro-hybrid composite Amelogen Hybrid (PMQ/A-Hy, Ultradent), (2) Permaquick applied with the more flexible micro-filled composite Amelogen Microfill (PMQ/A-Mi, Ultradent), or (3) the 'golden standard' three-step etch-and-rinse adhesive Optibond FL applied with the micro-hybrid composite Prodigy (O-FL/Pro, Kerr). RESULTS: The recall rate at 7 years was 80%. No statistically significant difference was found for any of the parameters evaluated neither between both adhesives, nor between both composites (McNemar, p>0.05). Eleven percent of the O-FL/Pro restorations were clinically unacceptable due to loss of retention (5.5%) and severe marginal discoloration (5.5%). In the PMQ-group, 22% of the PMQ/A-Mi restorations (8% loss of retention, 5% severe enamel margin defects, 3% severe dentin margin defects, 6% severe marginal discoloration, 3% extreme sensitivity) and 19% of the PMQ/A-Hy restorations (13% loss of retention, 3% severe enamel margin defects, 3% severe marginal discoloration) needed repair or replacement. SIGNIFICANCE: The clinical performance of the three adhesive/composite combinations was good and reliable during the 7-year clinical trial. It was concluded that the composite stiffness does not affect the clinical longevity of cervical composite restorations.     

Prevalence and etiologic factors of non-carious cervical lesions. A study in a Senegalese population]

The non carious cervical lesion (NCCL) is a loss of tooth tissue at the neck of affected teeth that is unrelated to tooth decay. They are commonly encountered in clinical practice and present in a variety of forms. The purpose of this paper is to determine the prevalence of the NCCL in a Senegalese population. From 655 patients, 112 with cervical lesions were identified i.e. a global prevalence of 17.10%. The prevalence rate for abrasion was reported to be 77.70%, 12.50% for abfraction and 9.80% for erosion. Etiological factors were studied for abrasion and erosion. 54% of the patients with abrasion used their toothbrush horizontally. For erosion, only external factors were identified: consumption of acidic drinks (9 patients) or alcohol (1 patient) and professional environment (1 patient). Dentists should consider these lesions in their daily practice.     

Examining the prevalence and characteristics of abfractionlike cervical lesions in a population of U.S. veterans.

BACKGROUND: Abfraction is believed to be caused by biomechanical loading forces. It may be due to flexure and ultimate fatigue of tooth tissues that occur away from the point of occlusal loading. Other possible causes of cervical lesions include toothbrush abrasion and erosion. The purpose of this study was to investigate the characteristics and prevalence of abfraction-like lesions in a population of U.S. veterans. METHODS: The authors evaluated 103 teeth with noncarious cervical lesions in 32 subjects and characterized them based on the surface on which the lesion was located, history of toothbrush abrasion, size of the lesion, presence of plaque, surface texture, and presence and size of occlusal wear facets. RESULTS: Clinical examination revealed that adjacent control teeth had a significantly lower percentage of surfaces with plaque than did teeth with cervical lesions. Control teeth also had significantly less gingival recession than did affected teeth. Seventy-five percent of subjects reported a history of using a firm toothbrush, and 78.1 percent reported using a brushing technique that is known to cause toothbrush abrasion in the affected area. Affected teeth had neither significantly different occlusal wear facets nor occlusal contacts than control teeth. No significant correlations were found between cervical lesion dimensions and facet area. CONCLUSIONS: Toothbrush abrasion is strongly suspected as contributing to the formation of the majority of wedge-shaped lesions in this group of subjects. A small subset of lesions is thought to have resulted from some other phenomenon. Although the presence or contribution of occlusal stresses in the direct formation of these lesions could not be measured directly, the possibility of abfraction could not be eliminated. CLINICAL IMPLICATIONS: Because the existence of abfraction could not be ruled out in about 15 percent of the cases, teeth with noncarious, wedge-shaped lesions warrant careful occlusal evaluation, with the possible need for occlusal adjustment or bitesplint therapy to treat bruxism.     

Non-carious cervical lesions associated with gingival recessions: a decision-making process

Background: A method to predetermine the maximum root coverage level (MRC) was recently demonstrated to be reliable in predicting the position of the soft tissue margin after root coverage surgery. The aim of the present study is to suggest a decision‐making process for treating non‐carious cervical lesions (NCCLs) associated with gingival recessions based upon the topographic relationship between the MRC and NCCL and to assess patient and independent‐periodontist esthetic evaluations. Methods: Five treatments were performed in 94 patients with NCCLs associated with a single gingival recession: 1) coronally advanced flap (CAF); 2) bilaminar procedure; 3) coronal odontoplasty plus restoration plus root odontoplasty plus CAF; 4) restoration plus CAF; and 5) restorative therapy. Clinical and esthetic evaluations made by the patient and an independent periodontist were done 1 year after treatments. Results: The satisfaction of the patient and periodontist with esthetics was very high in all NCCL treatments and Miller Class gingival recessions. The patient satisfaction and evaluation of root coverage and the periodontist evaluation of root coverage were statistically correlated with color‐match evaluations and not with the amount of root coverage clinically achieved in each patient. Conclusion: The proposed approaches provided good esthetic appearance and correct emergence profile for the great majority of NCCLs associated with gingival recessions.     

Orofacial lesions in treated southeast Brazilian leprosy patients: a cross-sectional study

AIM: The aim of the present study was to clinically evaluate the oral mucosa lesions of leprosy patients during and after multi-drug therapy. METHODS: Clinical examination, medical and dental history examination was performed in 100 leprosy patients. RESULTS: The results revealed that 71 patients, 50 men and 21 women, exibited oral lesions. The most frequent lesions were: fissured tongue (18 cases), inflammatory papillary hyperplasia (16 cases), chronic atrophic candidiasis (10 cases), fibroma (10 cases), erythematous candidiasis (eight cases), and traumatic ulceration (seven cases). CONCLUSION: We conclude that leprosy-related lesions are not present in patients undergoing treatment for leprosy, probably due to response to multidrug therapy.     

The prevalence of non-carious cervical lesions (NCCLs) with or without erosive etiological factors among adults of different ages in Tokyo

Clinical Oral Investigations - To evaluate the prevalence of non-carious cervical lesions (NCCLs) on teeth with or without erosive etiological factors across a broad range of ages of Japanese...     

Oral roentgenologic findings in a Norwegian urban population.

Orthopantomograms were taken of 111 subjects constituting a random sample of 35-year-old citizens of Oslo. The most frequent pathologic finding was marginal bone loss, which was found in seventy-one persons (64%). Fifty-one impacted and unerupted teeth in twenty-eight persons were seen, the third molars predominating. Ten retained roots were found in nine persons, and apical radiolucent areas were found on forty-four teeth in thirty-three persons. In addition to the pathologic findings, 101 endodontically treated teeth in fifty-five persons were observed.     

Characteristics of noncarious cervical lesions: a clinical investigation

BACKGROUND: The purpose of the authors' in vivo investigation was to analyze the characteristics of noncarious cervical lesions, or NCCLs, in adult patients who had a high incidence of them. METHODS: The patient pool consisted of a total of 57 patients and 171 teeth (three teeth per patient), with one NCCL per tooth. The characteristics the authors evaluated were shape, dimensions, sensitivity, sclerosis and occlusion. RESULTS: In terms of lesion characteristics, 91 percent of the lesions had axial depths of 1 to 2 millimeters, 49 percent had occlusogingival widths of 1 to 2 mm, 74 percent had an angular shape of 45 to 135 degrees, 76 percent had mild or moderate sclerosis, and 73 percent had no or mild sensitivity. In terms of occlusion, 75 percent of teeth had an Angle Class I occlusion on the involved side, 60 percent had group function or mixed excursive guidance, 82 percent had wear facets, and 99 percent had Type 0 or I mobility. In terms of tooth location, 70 percent of NCCLs were on posterior teeth, 65 percent were on maxillary teeth, and 46 percent were on premolars. CONCLUSIONS: The evaluated NCCLs were found mainly to have small dimensions of depth and width (< 2 mm) and to be roughly right-angled in shape, and many had sclerosis and low sensitivity. A majority of the dentitions studied had Class I occlusion, with group function, prevalent wear facets, and little or no mobility. Cervical lesions were more common with posterior maxillary teeth and premolars, especially first premolars, which had the highest prevalence of lesions. Older patients were more likely to exhibit noncarious cervical lesions, but no great difference in incidence was found between men and women. Clinical Implications. A knowledge of the NCCL characteristics and etiologic covariables aids in proper case selection for treatment, aids in selection of appropriate treatment protocols and improves assessment of prognosis.     

Temporomandibular disorders, headaches, and cervical pain among females in a Sami population

OBJECTIVE: The aim of this study was to examine the prevalence and co-morbidity of long-standing, intense, and frequent symptoms of pain and dysfunction in the jaw-face, head, and cervical region among adult females drawn from the Sami population in northern Sweden. METHODS: A total of 487 females, taken from the register of the Swedish Sami Parliament or registered as reindeer owners or reindeer herders in the Swedish Board of Agriculture and living in the Arctic region of northern Sweden, participated in a questionnaire study. RESULTS: The prevalence of pain and/or dysfunction in the jaw-face region was 32%, of headaches 61%, and of pain in the cervical region 56%. When the criterion of frequent symptoms (once a week or more often) was used, prevalence dropped to 17%, 19%, and 30%, respectively, and when that of intense symptoms, defined as 5 or more on an 11-point numerical rating scale, was added, prevalence dropped further to 8%, 11%, and 20%, respectively. The majority reported long-standing symptoms (67-98% depending on symptom). A high statistically significant relationship was found between frequent symptoms of pain and/or dysfunction in the jaw-face, frequent headaches, and frequent cervical pain (p<0.0001). CONCLUSIONS: Symptoms in the jaw-face, headaches, and cervical pain were frequently reported among a sample of Sami females living in the Swedish Arctic region. The prevalence of symptoms was strongly dependent on criteria of frequency and intensity.     

Temporomandibular disorders,headaches, and cervical pain among females in a Sami population

Objective. The aim of this study was to examine the prevalence and co-morbidity of long-standing, intense, and frequent symptoms of pain and dysfunction in the jaw-face, head, and cervical region among adult females drawn from the Sami population in northern Sweden. Methods. A total of 487 females, taken from the register of the Swedish Sami Parliament or registered as reindeer owners or reindeer herders in the Swedish Board of Agriculture and living in the Arctic region of northern Sweden, participated in a questionnaire study. Results. The prevalence of pain and/or dysfunction in the jaw-face region was 32%, of headaches 61%, and of pain in the cervical region 56%. When the criterion of frequent symptoms (once a week or more often) was used, prevalence dropped to 17%, 19%, and 30%, respectively, and when that of intense symptoms, defined as 5 or more on an 11-point numerical rating scale, was added, prevalence dropped further to 8%, 11%, and 20%, respectively. The majority reported long-standing symptoms (67–98% depending on symptom). A high statistically significant relationship was found between frequent symptoms of pain and/or dysfunction in the jaw-face, frequent headaches, and frequent cervical pain (p<0.0001). Conclusions. Symptoms in the jaw-face, headaches, and cervical pain were frequently reported among a sample of Sami females living in the Swedish Arctic region. The prevalence of symptoms was strongly dependent on criteria of frequency and intensity.