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Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 74-78

Critical review of noncarious cervical lesions

Department of Conservative Dentistry and Endodontics, Thai Moogambigai Dental College and Hospital, Dr. MGR Educational and Research Institute University, Chennai, Tamil Nadu, India

Date of Web Publication18-Jun-2018

Correspondence Address:
Keerthi Venkatesan
B-13, 308, KendriyaVihar, Velappanchavadi, Chennai - 600 077, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_5_18

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As aging progresses, there is tooth destruction in the cervical portion of the tooth not possibly due to carious process. This may be attributed to either abrasion, erosion or abfraction or a combination. The etiology, extent, and clinical view of these lesions vary, and it is a challenge to the clinician to identify the cause and decide proper restorative materials and treatment plan for each type of lesion.

Keywords: Abfraction, abrasion, erosion, tooth wear

How to cite this article:
Venkatesan K, Kuzhanchinathan M, Prakash P. Critical review of noncarious cervical lesions. SRM J Res Dent Sci 2018;9:74-8

How to cite this URL:
Venkatesan K, Kuzhanchinathan M, Prakash P. Critical review of noncarious cervical lesions. SRM J Res Dent Sci [serial online] 2018 [cited 2023 May 28];9:74-8. Available from:

  Introduction Top

As an aging population retains its teeth for longer periods of time, the issue of tooth wear is becoming of increasing importance to the dental profession.[1] Tooth surface loss describes pathological loss of tooth structure by a disease process other than dental caries.[2] Noncarious cervical lesions (NCCLs) involve loss of hard tissue, and in some instances, restorative material at the cervical third of the crown and subjacent root surface, through processes unrelated to caries.[3] NCCLs are defined as the loss of tooth substance at the cementoenamel junction.[4] These lesions are classified into three main categories:[5]

  • Abrasion – The pathological wear of tooth substance through repeated frictional processes caused by external mechanical means, for example, tooth brushing
  • Erosion – Dissolution of tooth structure due to intrinsic or extrinsic chemical attack by acids
  • Abfraction – The pathological loss of tooth substance due to concentration of stresses in cervical region caused by excessive biomechanical cyclic nonaxial loading forces.[6],[7],[8]

Grippo described five categories of abfraction which include hairline cracks, striations, saucer-shaped, semilunar-shaped lesions and invagination of cusp tip.[9]

  Prevalence Top

It appears that NCCLs are unique to modern man. In an anthropologic study of the skulls of humans living in the copper age and middle ages (2050–2080 BC and 1100–1400 AD), no NCCLs were found in 3927 teeth from 259 individuals.[10] Another study has reported that NCCLs were present in 56.3% of the children at 12 years of age and 64.1% of the same children at 14 years of age.[11] With every 10-year increase in patient age, the lesions became more common. Cervical wear was identified in 48% of the individuals older than 65 years of age.[12]

Levitch et al. in a review of 15 studies carried out between 1941 and 1991 reported prevalence in range from 5% to 85% with strong correlation with age. The older the population studied, the greater the percentage of lesions found. The greater the number of lesions per individual, larger the size of lesion.[13] Xhonga et al. reported a higher incidence of NCCLs in bruxists ranging up to 87% compared to nonbruxists which had only 20%.[14]

  Etiology Top

As long ago as 1908, G. V. Black identified certain possible causes of NCCL lesions listed which include defects during formation of teeth, action due to an acids and friction from an abrasive dentrifice.[15]

In 1932, Ferrier [16] was not able to give a proper explanation for these lesions. In 1932, Kornfeld [17] noticed severe wear facets on the articulating surfaces of the involved teeth and reported that erosion occurs on the opposite side of wear facet in all the cases of cervical erosion which he had encountered and examined.[16],[17]

Lee and Eakle in 1984 put forward a hypothesis that the cause of cervical erosive lesions could be due to tensile stresses created in the tooth during occlusal loading. They described three types of stress, namely compressive, tensile, and shear stress placed on teeth during mastication and parafunction.[6]

To summarise, etiology of NCCLs as suggested by Grippo is due to complex interaction of three basic factors which include stress (abfraction), friction (abrasive wear) and biocorrosion leading to chemical degradation. This represents multifactorial nature of NCCLs.[9] Etiological factors are listed below.

Stress (abfraction)

This includes both endogenous and exogenous mechanisms. Endogenous factors include parafunctional habits such as bruxism and clenching, deglutition and occlusal premature contacts or loading. Exogenous factors include denture base clasps and occupations such as playing wind instruments.


Endogenous factors (attrition) may be due to parafunctional habits.

Exogenous factors in abrasion include mastication of coarse foods, occupation like playing wind instruments, habits such as fingernail biting, mastication of coarse foods and excessive brushing force.

Biochemical corrosion (erosion)

Etiology includes endogenous factors such as gingival crevicular fluid, acidogenic bacteria, and gastric juice. Exogenous factors include consumption of acid beverages and occupational exposure to acids.

Apart from these, there are modifying factors which includes saliva, teeth, diet and application of force [Figure 1].
Figure 1: Modifying factors in noncarious cervical lesions

Click here to view

  Abrasion Top

Friction between tooth substrate and any extrinsic agent leads to abrasion. Masticatory abrasion is frequently encountered on incisal and occlusal surfaces due to friction from the food bolus.[8] Toothbrush abrasion is influenced by many factors. Horizontal brushing was suggested as causing wear ranging up to three times compared with vertical brushing.[18] If there is prolonged contact between bristles and tooth surface, rate of abrasion is increased further.[19] The force and frequency applied to the brush also play an important role in abrasion.[20] However, the force of brushing varies with the brushing technique, the stiffness of the bristles, age and brushing habits of each specific individual.[19],[21]

Abrasive lesions are characterized by linear outline, following the path of brush bristles. The peripheries of the lesion are extremely angularly demarcated in comparison to the adjacent tooth surface. The surface of the lesion is extremely smooth and polished. Probing or stimulation of the lesion can elicit pain.[22],[23]

  Erosion Top

It is the loss of tooth substance through chemical dissolution.[24],[25] Perimolysis is an erosive condition occurring due to vomiting which is marked on the palatal surfaces of maxillary anterior teeth and buccal surfaces of maxillary posterior teeth.[26] Endogenic erosion can happen in patients with gastroesophageal reflux disease, enamel appears thin and translucent, and enamel is lost on the posterior occlusal and anterior palatal surfaces. Dentinal cupping occurs due to action of pepsin and hydrochloric acid. Depressions occur on the cervical areas of anterior teeth.[27]

Extrinsic sources of erosion include occupational factors such as exposure to industrial acids, diet such as citrus fruit juices, acid beverages, carbonated beverages, and medicaments which include ascorbic acid.[8]

  Abfraction Top

Abfraction is said to result from forces associated with mastication, swallowing and malocclusion. Abfraction lesion is a typical wedge-shaped lesion located in the area of greatest tensile stress concentration. The direction of lateral forces acting on the tooth also plays an important role in location of abfraction.[6]

  Treatment Options Top

Before any treatment is performed for a patient with NCCLs, a careful examination and identification of possible causes for the lesions should be made. A better understanding of the etiology is essential for executing therapeutic and preventive therapy. While there may be a primary etiology, other contributing factors must also be considered. In each and every case of NCCLs, the dentist should obtain a careful health history and provide a thorough dental examination.[28]

The objective of the restoration should be to prevent further destruction of the tooth structure.

  • If the lesions are shallow not exceeding 0.5 mm or not involving dentin, there is no need to restore the defect
  • If restoration is not planned, the edges of the lesion should be eradicated to a smooth nondemarcating pattern relative to adjacent tooth surface
  • If the lesion is wedge shaped and exceeds 0.5 mm, it should be restored [23]

Grippo in 1992 suggested that restoration is must for NCCLs due to following reasons:[5]

  • Decreases stress concentration; flexure and progress of the abfractions
  • Strengthens the tooth
  • Prevents pulp involvement and tooth fracture
  • Eliminates acid dissolution or corrosion (erosion) and stress corrosion; cervical hypersensitivity (thermal, tactile, and chemical)
  • Improves esthetics
  • Improves gingival health by providing food deflection.
  • Eases oral hygiene maintenance for the patient.

  Restorative Approach Top

Isolation and management of gingival tissues is a great challenge for clinicians in restoring NCCLs.[29],[30],[31] Rubber dam clamps, gingival retraction cord, and periodontal surgery are methods which help in proper access and also control moisture. Restoration of NCCL is a challenge due to margin in cervical region which is composed of either sclerotic dentin or cementum which renders it to be more susceptible to microleakage leading to recurrent caries, cavosurface stains, and postoperative sensitivity. Hypermineralized cervical surfaces may be resistant to acid etching leading to lower microtensile bond strengths verified in these types of lesions.[32]

Glass ionomer cements (GICs), resin-modified GICs (RMGICs), GIC/RMGIC liner base laminated with a resin composite, and resin composite in combination with a dentine bonding agent are all indicated for restoration of NCCLs.[31],[33],[34],[35],[36] There are various studies comparing the restorative materials for restoring NCCLs.

Many studies have evaluated composite as material of choice for restoration of NCCLs. Within this group of materials, some authors recommend that abfraction lesions should be restored with a microfilled resin composite or a flowable resin that has a low modulus of elasticity, as it will flex with the tooth and not compromise retention by accommodating the change in cavity shape.[35],[37] Flowable resin composites have reduced filler particle loading, a lower elastic modulus, a higher coefficient of thermal expansion, and low fracture toughness relative to traditional composites. However, clinical trials have proven that stiff restorations have performed as well or better than the flexible resin composites in long-term clinical trials.[38] However, a study reported up to 80% loss of composite restorations in NCCLs after 4 years.[39] The low retention rate of resin composite is possibly due to degradation of the adhesive bond. However, another 13-year clinical evaluation of etch-and-rinse and self-etch adhesive systems in NCCLs revealed no degradation of bond.[40]

The 5-year clinical performance of a primer adhesive/resin composite system compared with RMGIC proved that retention was considerably better for resin-modified glass ionomer restorations.[33] The high retention index of Vitremer restorations may be attributed to their good mechanical properties and better adhesion to dental tissues.[41],[42] The combination of autoadhesive mechanism and micromechanical interlocking of polymer is also responsible for higher retention of Vitremer.[43] GIC, light or chemically cured, is the most retentive material for NCCLs.[44],[45] In a recent study by Stewardson et al., 94% of cervical RMGIs were retained which exceed the success rate of composites (85%–88%) and far exceeded that of conventional glass ionomer (67%).[46] A review of cervical restorations by Heintze and Roulet et al. concluded that both glass ionomer and RMGIs showed highest retention rates.[47]

Another restorative option is glass ionomer base veneered with a layer of composite. As autocured glass ionomer materials often provide less than optimal esthetics, sandwich technique is preferred. Glass ionomer is used to replace the missing dentin, reduce leakage, improve the potential for tissue attachment for subgingival restorations, and potentially increase retention. A veneer of resin composite is placed to enhance esthetics, increase color stability, improve marginal performance, provide a smoother surface, and increase abrasion resistance. Clinical study reported 100% retention rates after 3 years and 96% retention rates after 5 years, demonstrating the success rate attainable with this type of restoration.[44],[48]

  Conclusion Top

NCCLs are of multifactorial origin. The clinician should be able to identify the cause, characteristics, and risk factor for these lesions. Occlusion should also be examined. Resin-modified glass ionomer proved to be the best option in treating NCCLs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wood I, Jawad Z, Paisley C, Brunton P. Non-carious cervical tooth surface loss: A literature review. J Dent 2008;36:759-66.  Back to cited text no. 1
Eccles JD. Tooth surface loss from abrasion, attrition and erosion. Dent Update 1982;9:373-4, 376-8, 380-1.  Back to cited text no. 2
Bader JD, McClure F, Scurria MS, Shugars DA, Heymann HO. Case-control study of non-carious cervical lesions. Community Dent Oral Epidemiol 1996;24:286-91.  Back to cited text no. 3
Mair LH. Wear in dentistry – Current terminology. J Dent 1992;20:140-4.  Back to cited text no. 4
Grippo JO. Noncarious cervical lesions: The decision to ignore or restore. J Esthet Dent 1992;4 S1:55-64.  Back to cited text no. 5
Lee WC, Eakle WS. Possible role of tensile stress in the etiology of cervical erosive lesions of teeth. J Prosthet Dent 1984;52:374-80.  Back to cited text no. 6
Rees JS. A review of the biomechanics of abfraction. Eur J Prosthodont Restor Dent 2000;8:139-44.  Back to cited text no. 7
Grippo JO, Simring M, Schreiner S. Attrition, abrasion, corrosion and abfraction revisited: A new perspective on tooth surface lesions. J Am Dent Assoc 2004;135:1109-18.  Back to cited text no. 8
Grippo JO, Simring M, Coleman TA. Abfraction, abrasion, biocorrosion, and the enigma of noncarious cervical lesions: A 20-year perspective. J Esthet Restor Dent 2012;24:10-23.  Back to cited text no. 9
Aubry M, Mafart B, Donat B, Brau JJ. Brief communication: Study of noncarious cervical tooth lesions in samples of prehistoric, historic, and modern populations from the South of France. Am J Phys Anthropol 2003;121:10-4.  Back to cited text no. 10
Dugmore CR, Rock WP. The progression of tooth erosion in a cohort of adolescents of mixed ethnicity. Int J Paediatr Dent 2003;13:295-303.  Back to cited text no. 11
Borcic J, Anic I, Urek MM, Ferreri S. The prevalence of non-carious cervical lesions in permanent dentition. J Oral Rehabil 2004;31:117-23.  Back to cited text no. 12
Levitch LC, Bader JD, Shugars DA, Heymann HO. Non-carious cervical lesions. J Dent 1994;22:195-207.  Back to cited text no. 13
Xhonga FA. Bruxism and its effect on the teeth. J Oral Rehabil 1977;4:65-76.  Back to cited text no. 14
Black GV. A Work on Operative Dentistry. Vol. 1. Chicago: Medico-Dental Publication Co.; 1908. p. 39-59.  Back to cited text no. 15
Ferrier WI. Clinical observations on erosions and their restoration. J Calif State Dent Assoc 1931;7:187-96.  Back to cited text no. 16
Kornfeld B. Preliminary report of clinical observations of cervical erosions, a suggested analysis of the cause and the treatment for its relief. Dent Items Interest 1932;54:905-9.  Back to cited text no. 17
Mannerberg F. Appearance of tooth surface as observed in shadowed replicas in various age groups, in long-term studies, after tooth brushing, in cases of erosion and after exposure to citrus fruit juice. Odontol Revy 1960; 11:70-86.  Back to cited text no. 18
Björn H, Lindhe J, Gröndahl HG. The abrasion of dentine by commercial dentifrices. Odontol Revy 1966;17:109-20.  Back to cited text no. 19
Manly RS, Wiren J, Manly PJ, Keene RC. A method for measurement of abrasion of dentin by toothbrush and dentifrice. J Dent Res 1965;44:533-40.  Back to cited text no. 20
Kakudo Y, Hieda T, Matsuzawa S, Ishida A, Yoshihara M. Relations between brushing force and the number of strokes during tooth brushing in pre-school children and primary school pupils. J Osaka Dent Univ 1969;3:187-99.  Back to cited text no. 21
Swift EJ, Heymann HO, Ritter AV, GopiKrishna V. Sturdevant's Art and Science of Operative Dentistry – South Asian Edition. Elsevier; 2013.  Back to cited text no. 22
Marzouk MA, Simonton AL, Gross RD. Operative dentistry modern theory and practice. St. Louis: Ishiyaku EuroAmerica, Inc.; 1985.  Back to cited text no. 23
Mohl ND. Diagnostic rationale: An overview. In: A Textbook of Occlusion. Chicago: Quintessence; 1988.  Back to cited text no. 24
Shafer WG, Hine MK, Levy BM, Tomich CE. Textbook of Oral Pathology. 4th ed. Philadelphia: W.B. Saunders Company; 1983. p. 160-1.  Back to cited text no. 25
Milosevic A, Brodie DA, Slade PD. Dental erosion, oral hygiene, and nutrition in eating disorders. Int J Eat Disord 1997;21:195-9.  Back to cited text no. 26
Howden GF. Erosion as the presenting symptom in hiatus hernia. A case report. Br Dent J 1971;131:455-6.  Back to cited text no. 27
Bader JD, Levitch LC, Shugars DA, Heymann HO, McClure F. How dentists classified and treated non-carious cervical lesions. J Am Dent Assoc 1993;124:46-54.  Back to cited text no. 28
Meraner M. Soft tissue management for difficult cervical restorations. Gen Dent 2006;54:117-20.  Back to cited text no. 29
Owens BM. Alternative rubber dam isolation technique for the restoration of Class V cervical lesions. Oper Dent 2006;31:277-80.  Back to cited text no. 30
Ichim I, Li Q, Loughran J, Swain MV, Kieser J. Restoration of non-carious cervical lesions Part I. Modelling of restorative fracture. Dent Mater 2007;23:1553-61.  Back to cited text no. 31
Tay FR, Pashley DH. Resin bonding to cervical sclerotic dentin: A review. J Dent 2004;32:173-96.  Back to cited text no. 32
Franco EB, Benetti AR, Ishikiriama SK, Santiago SL, Lauris JR, Jorge MF, et al. 5-year clinical performance of resin composite versus resin modified glass ionomer restorative system in non-carious cervical lesions. Oper Dent 2006;31:403-8.  Back to cited text no. 33
Tyas MJ. The Class V lesion – Aetiology and restoration. Aust Dent J 1995;40:167-70.  Back to cited text no. 34
Vandewalle KS, Vigil G. Guidelines for the restoration of Class V lesions. Gen Dent 1997;45:254-60.  Back to cited text no. 35
Geerts SO, Seidel L, Albert AI, Gueders AM. Microleakage after thermocycling of three self-etch adhesives under resin-modified glass-ionomer cement restorations. Int J Dent 2010;2010:728453.  Back to cited text no. 36
Peumans M, De Munck J, Van Landuyt KL, Kanumilli P, Yoshida Y, Inoue S, et al. Restoring cervical lesions with flexible composites. Dent Mater 2007;23:749-54.  Back to cited text no. 37
Hilton TJ, Ferracane JL, Broome JC. Summitt's Fundamentals of Operative Dentistry: A Contemporary Approach. 4th ed. London: Quintessence Publishing Ltd; 2013.  Back to cited text no. 38
van Dijken JW. Clinical evaluation of four dentin bonding agents in Class V abrasion lesions: A four-year follow-up. Dent Mater 1994;10:319-24.  Back to cited text no. 39
van Dijken JW, Pallesen U. Long-term dentin retention of etch-and-rinse and self-etch adhesives and a resin-modified glass ionomer cement in non-carious cervical lesions. Dent Mater 2008;24:915-22.  Back to cited text no. 40
Sidhu SK, Watson TF. Resin-modified glass ionomer materials. A status report for the American journal of dentistry. Am J Dent 1995;8:59-67.  Back to cited text no. 41
Yap AU, Lim CC, Neo JC. Marginal sealing ability of three cervical restorative systems. Quintessence Int 1995;26:817-20.  Back to cited text no. 42
Loguercio AD, Reis A, Barbosa AN, Roulet JF. Five-year double-blind randomized clinical evaluation of a resin-modified glass ionomer and a polyacid-modified resin in noncarious cervical lesions. J Adhes Dent 2003;5:323-32.  Back to cited text no. 43
Powell LV, Johnson GH, Gordon GE. Factors associated with clinical success of cervical abrasion/erosion restorations. Oper Dent 1995;20:7-13.  Back to cited text no. 44
Burrow MF, Tyas MJ. 1-year clinical evaluation of one-step in non-carious cervical lesions. Am J Dent 1999;12:283-5.  Back to cited text no. 45
Stewardson DA, Thornley P, Bigg T, Bromage C, Browne A, Cottam D, et al. The survival of Class V restorations in general dental practice. Part 2, early failure. Br Dent J 2011;210:E19.  Back to cited text no. 46
Heintze SD, Roulet JF. Glass ionomer derivates have better retention rates in cervical restorations compared to self-etching adhesive systems. J Evid Based Dent Pract 2010;10:18-20.  Back to cited text no. 47
Tyas MJ, Burrow MF. Adhesive restorative materials: A review. Aust Dent J 2004;49:112-21.  Back to cited text no. 48


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