|
 
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| REVIEW ARTICLE |
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| Year : 2018 | Volume
: 9
| Issue : 2 | Page : 74-78 |
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Critical review of noncarious cervical lesions
Keerthi Venkatesan, Manigandan Kuzhanchinathan, Prashanth Prakash
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 Publication | 18-Jun-2018 |
Correspondence Address:
Keerthi Venkatesan
B-13, 308, KendriyaVihar, Velappanchavadi, Chennai - 600 077, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/srmjrds.srmjrds_5_18
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 |
| Introduction | |  |
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 | | |
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 | | |
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.
Friction
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].
| Abrasion | | |
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 | | |
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 | | |
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 | | |
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 | | |
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 | | |
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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