Non-carious cervical lesions

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Non-carious cervical lesions on an incisor belonging to Australopithecus africanus. Arrows show the location of the lesions. Non-carious cervical lesions on an incisor.jpg
Non-carious cervical lesions on an incisor belonging to Australopithecus africanus. Arrows show the location of the lesions.

Non-carious cervical lesions (NCCLs) are a group of lesions that are characterised by a loss of hard dental tissue at the cementoenamel junction (CEJ) region at the neck of the tooth, without the action of microorganisms or inflammatory processes. [1] These lesions vary in shape from regular depressions that look like a dome or a cup, to deep wedge-shaped defects with the apex pointing inwards. [1] NCCLs can occur either above or below the level of the gum, at any of the surfaces of the teeth.

Contents

An example of non-carious cervical lesions. Abfraction.jpg
An example of non-carious cervical lesions.

Aetiology

NCCL is a complex multifactorial condition and it is believed that multiple factors contribute to the formation of such lesions. Traditionally, the believed aetiological causes for NCCL have been erosion and abrasion. [2] However, in the past few decades, abfraction has been implicated as a possible contributing factor of NCCLs as well. Bartlett and Shah propose that NCCLs arise from a combination of all three factors: erosion, abrasion and possibly abfraction as well. [3] While the role of erosion and abrasion in NCCLs is well proven, more research still needs to be done to prove the abfraction theory. [3]

Erosion and Abrasion

Erosion is the “non-bacterial loss of tooth substance due to chemical agents” [4] with the most common form being acids. There are two form of acids that contribute to erosive tooth wear: intrinsic and extrinsic. [5] [6] Intrinsic acids are from vomiting and regurgitation. [6] Individuals suffering from medical conditions associated with vomiting and regurgitation such as gastroesophageal reflux (GERD), bulimia nervosa, chronic alcoholism, and hyperemesis gravidum in pregnancy are hence at higher risk of developing erosive NCCLs. [5] On the other hand, extrinsic acids include dietary acids in soft drinks, sports energy drinks, fruit juices, chewable vitamin C tablets, sweet-sour candies, herbal teas, dry wine and vinegar-containing foods. [5] [6]

Abrasion is defined as the “non-bacterial loss of tooth tissue due to frictional wear by extrinsic agents”. [4] It is well documented in literature that erosion and abrasion act together in vivo to create NCCLs. [2] [7] Abrasion is believed to arise from toothbrushing, due to the tooth surface coming into contact with “hard abrasive particles in the toothpaste”. [7] Acids within the mouth soften and weaken the cervical tooth surface, making the tooth surface susceptible to the effects of abrasion, leading to the formation of NCCLs. [7] This usually arises when patients brush their teeth after a meal of fruits or fruit juices. [7]

Abfraction

In the last twenty years, an alternative hypothesis has been proposed for the formation of NCCLs. Numerous studies have suggested that abfraction, a term coined by Grippo might contribute to the formation of NCCLs. Abfraction has been reported to be the loss of tooth substance due to the “biomechanical loading forces that result in flexure and failure” of tooth structure “at a location away from the loading”. [8] Numerous studies have suggested that occlusal loading results in the deformation and flexure of the tooth, creating a large amount of stress in the cervical region of the tooth. [5] The persistent stress exerted on the tooth surface creates microfractures on the tooth structure, resulting in tooth breakdown and hence formation of NCCLs. [8]

However, despite many literature reviews supporting abfraction as a contributing factor to the formation of NCCLs, one key clinical finding has significantly put into question the evidence used to support the abfraction theory. The evidence used to back the abfraction theory were primarily obtained from finite element analyses. [3] [8] The finite element studies conducted suggest that based on the abfraction theory, lingual surfaces of teeth should be equally susceptible to cervical wear as the buccal surfaces. [3] However clinical findings reveal lingual NCCLs are much rarer than buccal NCCLs, [3] [7] [8] this means that there is little clinical evidence showing the causal relationship between occlusal stress and NCCLs. More research on this subject matter has to be conducted before the abfraction theory can be recognised as a cause of NCCLs.

Archaeological non-carious cervical lesions

When NCCLs are present in archaeological samples they can provide insight into behaviour and diet. [9] Abrasion is the most common mechanism of NCCLs observed in archaeological samples, and results from non-masticatory contact of an object with teeth, often through cultural or therapeutic behaviour. [10] Most NCCLs in archaeological examples are attributed to abrasion, with ‘toothpick grooves’ particularly common. [10] Less commonly acid erosion can cause NCCLs, and is caused by the chemical dissolution of dental tissues by acids of non-bacterial origin, most commonly low pH diets. Abfraction, is almost never seen in the pre-modern samples, leading some researchers to suggest it is a uniquely modern issue caused by recent dietary and behavioural changes.

Epidemiology

There is wide variation in the reported worldwide prevalence rates of NCCLs. According to the literature, the NCCL prevalence ranges from 9.1% to 93% in adults aged 16–75 years. [11] The worldwide weighted average prevalence of NCCLs among adults is 46.7%. [11] When geographical regions are compared, South America has the highest reported prevalence of NCCLs, whilst the United States has the lowest. [11] Studies show a tendency for prevalence to increase with age. The older the population studied, the greater the percentage of lesions found, the greater the number of lesions per individual and the larger the lesions. [12] Many studies also show a link between good oral hygiene and a higher frequency of NCCLs. People who brush twice daily have a statistically significant higher prevalence of NCCLs than those who brush less frequently. [12]

Diagnosis

Due to the multi-factorial aetiology of NCCL, a comprehensive medical and dental history is imperative in ensuring an accurate clinical diagnosis. [13] This includes obtaining information about the patient’s diet, social history, lifestyle and brushing habits.

A systematic review by Teixeira et al. reported that most diagnoses of NCCL are derived from a combination of visual and tactile clinical examinations [11] under adequate illumination. This is depicted as a clinical loss of mineralized dental tissue at the cementoenamel junction (CEJ) in the buccal or lingual dental surfaces. There is also a consensus that visual dentine exposure is a reliable indicator of loss of tooth tissue. [14]

Tactile clinical examination involves running an exploratory probe laterally against the cervical surfaces of the tooth at the location of the suspected lesion. The lesion should feel smooth and non-cavitated.

Diagnostic Criteria

Aw TC et al. summarizes the diagnostic clinical characteristics of NCCLs based on an in vivo investigation carried out on 57 patients and 171 teeth. [15] These are described in the table below:

CharacteristicDescription
ShapeSaucer or wedged shape, at right-angles
Size1- 2mm depth and width
Extent of SclerosisSclerotic dentine present
SensitivityNo or mild sensitivity to air and pressure from exploratory probe
OcclusionClass I occlusion, group function, visible wear facets and no mobility in teeth
Demographic InformationMainly affects patients in their old age, no specific gender differences, or patterns

The Smith and Knight Tooth Wear Index (1984) can be used in combination with visual and tactile examination to grade extent of tooth wear. It seeks to monitor and measure all types of tooth wear, regardless of how it occurred. Furthermore, it measures acceptable and pathological levels of wear by putting the results against threshold normal values of the particular age group studied.

Teixeira et al.’s systematic review highlights that 19 out of 24 studies used visual and tactile examination as diagnostic assessment while 4 studies conducted in Asia used the Smith and Knight Index. [11]

After an initial diagnosis has been established, monitoring through intra-oral photographs, study casts, and tooth wear indices should be done regularly before formulating a definite diagnosis and appropriate management.

Treatment

In order for NCCLs to be treated effectively and to ensure longevity, the cause of the lesion should be deduced and this factor eliminated. Otherwise the treatment may be limited to only palliative care involving monitoring and efforts to minimise growth of the lesion. [2] Primary indications for intervention in NCCLs include: poor aesthetics, dentine hypersensitivity and food stagnation. There may also be a requirement for treatment if the lesion affects the design of a partial denture. [2]

Treatment of NCCLs to relieve symptoms of dentine hypersensitivity involve either chemical or physical occlusion of the dentinal tubules. [16]

Direct resin composite restorations are used commonly in dentistry and are effective in treating aesthetic issues as they are tooth coloured. [17] The success of a resin composite restoration does not rely greatly on traditional tooth preparation involving mechanical retention from the cavity. Instead adhesion to tooth structure is utilised. [17] This makes composite resin the treatment option of choice in the case of NCCLs as the lesions offer minimal retention or resistance form naturally and would require further tissue removal for this to be achieved. Choosing resin composite to treat NCCLs protects the teeth from further loss of healthy tooth structure. [18]

NCCLs are located mainly in dentine [17] and most adhesive processes rely on adhesion to enamel. Sclerotic dentine compromises the restoration as it is difficult to bond composite resin to this type of tissue. [18] This has led to discussions around tooth surface treatments of NCCLs prior to the restoration being placed. [18] Surface irrigation with EDTA works to remove the smear layer from the cavity to allow bonding of the restoration. [18] Studies have shown that application of the adhesive with a frictional technique has also increased adhesion. [18]

Treatment of NCCLs can also be carried out with glass ionomer. [2]

Related Research Articles

<span class="mw-page-title-main">Tooth decay</span> Deformation of teeth due to acids produced by bacteria

Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating. Complications may include inflammation of the tissue around the tooth, tooth loss and infection or abscess formation.

Dental products are specially fabricated materials, designed for use in dentistry. There are many different types of dental products, and their characteristics vary according to their intended purpose.

Dental restoration, dental fillings, or simply fillings are treatments used to restore the function, integrity, and morphology of missing tooth structure resulting from caries or external trauma as well as to the replacement of such structure supported by dental implants. They are of two broad types—direct and indirect—and are further classified by location and size. A root canal filling, for example, is a restorative technique used to fill the space where the dental pulp normally resides.

Tooth whitening or tooth bleaching is the process of lightening the color of human teeth. Whitening is often desirable when teeth become yellowed over time for a number of reasons, and can be achieved by changing the intrinsic or extrinsic color of the tooth enamel. The chemical degradation of the chromogens within or on the tooth is termed as bleaching.

Dental sealants are a dental treatment intended to prevent tooth decay. Teeth have recesses on their biting surfaces; the back teeth have fissures (grooves) and some front teeth have cingulum pits. It is these pits and fissures that are most vulnerable to tooth decay because food and bacteria stick in them and because they are hard-to-clean areas. Dental sealants are materials placed in these pits and fissures to fill them in, creating a smooth surface which is easy to clean. Dental sealants are mainly used in children who are at higher risk of tooth decay, and are usually placed as soon as the adult molar teeth come through.

<span class="mw-page-title-main">Dental composite</span> Substance used to fill cavities in teeth

Dental composite resins are dental cements made of synthetic resins. Synthetic resins evolved as restorative materials since they were insoluble, of good tooth-like appearance, insensitive to dehydration, easy to manipulate and inexpensive. Composite resins are most commonly composed of Bis-GMA and other dimethacrylate monomers, a filler material such as silica and in most applications, a photoinitiator. Dimethylglyoxime is also commonly added to achieve certain physical properties such as flow-ability. Further tailoring of physical properties is achieved by formulating unique concentrations of each constituent.

<span class="mw-page-title-main">Abrasion (dental)</span> Medical condition

Abrasion is the non-carious, mechanical wear of tooth from interaction with objects other than tooth-tooth contact. It most commonly affects the premolars and canines, usually along the cervical margins. Based on clinical surveys, studies have shown that abrasion is the most common but not the sole aetiological factor for development of non-carious cervical lesions (NCCL) and is most frequently caused by incorrect toothbrushing technique.

<span class="mw-page-title-main">Acid erosion</span> Medical condition

Acid erosion is a type of tooth wear. It is defined as the irreversible loss of tooth structure due to chemical dissolution by acids not of bacterial origin. Dental erosion is the most common chronic condition of children ages 5–17, although it is only relatively recently that it has been recognised as a dental health problem. There is generally widespread ignorance of the damaging effects of acid erosion; this is particularly the case with erosion due to consumption of fruit juices because they tend to be considered as healthy. Acid erosion begins initially in the enamel, causing it to become thin, and can progress into dentin, giving the tooth a dull yellow appearance and leading to dentin hypersensitivity.

<span class="mw-page-title-main">Abfraction</span> Loss of tooth structure not caused by tooth decay

Abfraction is a theoretical concept explaining a loss of tooth structure not caused by tooth decay. It is suggested that these lesions are caused by forces placed on the teeth during biting, eating, chewing and grinding; the enamel, especially at the cementoenamel junction (CEJ), undergoes large amounts of stress, causing micro fractures and tooth tissue loss. Abfraction appears to be a modern condition, with examples of non-carious cervical lesions in the archaeological record typically caused by other factors.

<span class="mw-page-title-main">Dentine bonding agents</span>

Also known as a "bonderizer" bonding agents are resin materials used to make a dental composite filling material adhere to both dentin and enamel.

<span class="mw-page-title-main">Dentinogenesis imperfecta</span> Medical condition

Dentinogenesis imperfecta (DI) is a genetic disorder of tooth development. It is inherited in an autosomal dominant pattern, as a result of mutations on chromosome 4q21, in the dentine sialophosphoprotein gene (DSPP). It is one of the most frequently occurring autosomal dominant features in humans. Dentinogenesis imperfecta affects an estimated 1 in 6,000-8,000 people.

Dentin hypersensitivity is dental pain which is sharp in character and of short duration, arising from exposed dentin surfaces in response to stimuli, typically thermal, evaporative, tactile, osmotic, chemical or electrical; and which cannot be ascribed to any other dental disease.

<span class="mw-page-title-main">Glass ionomer cement</span> Material used in dentistry as a filling material and luting cemen

A glass ionomer cement (GIC) is a dental restorative material used in dentistry as a filling material and luting cement, including for orthodontic bracket attachment. Glass-ionomer cements are based on the reaction of silicate glass-powder and polyacrylic acid, an ionomer. Occasionally water is used instead of an acid, altering the properties of the material and its uses. This reaction produces a powdered cement of glass particles surrounded by matrix of fluoride elements and is known chemically as glass polyalkenoate. There are other forms of similar reactions which can take place, for example, when using an aqueous solution of acrylic/itaconic copolymer with tartaric acid, this results in a glass-ionomer in liquid form. An aqueous solution of maleic acid polymer or maleic/acrylic copolymer with tartaric acid can also be used to form a glass-ionomer in liquid form. Tartaric acid plays a significant part in controlling the setting characteristics of the material. Glass-ionomer based hybrids incorporate another dental material, for example resin-modified glass ionomer cements (RMGIC) and compomers.

<span class="mw-page-title-main">Attrition (dental)</span>

Dental attrition is a type of tooth wear caused by tooth-to-tooth contact, resulting in loss of tooth tissue, usually starting at the incisal or occlusal surfaces. Tooth wear is a physiological process and is commonly seen as a normal part of aging. Advanced and excessive wear and tooth surface loss can be defined as pathological in nature, requiring intervention by a dental practitioner. The pathological wear of the tooth surface can be caused by bruxism, which is clenching and grinding of the teeth. If the attrition is severe, the enamel can be completely worn away leaving underlying dentin exposed, resulting in an increased risk of dental caries and dentin hypersensitivity. It is best to identify pathological attrition at an early stage to prevent unnecessary loss of tooth structure as enamel does not regenerate.

Dental compomers, also known as polyacid-modified resin composite, are used in dentistry as a filling material. They were introduced in the early 1990s as a hybrid of two other dental materials, dental composites and glass ionomer cement, in an effort to combine their desirable properties: aesthetics for dental composites and the fluoride releasing ability for glass ionomer cements.

The Hall Technique is a non-invasive treatment for decayed baby back (molar) teeth. Decay is sealed under preformed crowns, avoiding injections and drilling. It is one of a number of biologically orientated strategies for managing dental decay.

<span class="mw-page-title-main">Tooth wear</span> Medical condition

Tooth wear refers to loss of tooth substance by means other than dental caries. Tooth wear is a very common condition that occurs in approximately 97% of the population. This is a normal physiological process occurring throughout life; but with increasing lifespan of individuals and increasing retention of teeth for life, the incidence of non-carious tooth surface loss has also shown a rise. Tooth wear varies substantially between people and groups, with extreme attrition and enamel fractures common in archaeological samples, and erosion more common today.

Silver diammine fluoride (SDF), also known as silver diamine fluoride in most of the dental literature, is a topical medication used to treat and prevent dental caries and relieve dentinal hypersensitivity. It is a colorless or blue-tinted, odourless liquid composed of silver, ammonium and fluoride ions at a pH of 10.4 or 13. Ammonia compounds reduce the oxidative potential of SDF, increase its stability and helps to maintain a constant concentration over a period of time, rendering it safe for use in the mouth. Silver and fluoride ions possess antimicrobial properties and are used in the remineralization of enamel and dentin on teeth for preventing and arresting dental caries.

<span class="mw-page-title-main">Molar incisor hypomineralisation</span> Medical condition

Molar incisor hypomineralisation (MIH) is a type of enamel defect affecting, as the name suggests, the first molars and incisors in the permanent dentition. MIH is considered a worldwide problem and usually occurs in children under 10 years old. This developmental condition is caused by the lack of mineralisation of enamel during its maturation phase, due to interruption to the function of ameloblasts. Many factors have been suggested, such as genetics and medical problems during pregnancy, but only childhood illness, fever in particular, seems to be associated with MIH. However, further studies on the aetiology of MIH are required because it is believed to be multifactorial.

Atraumatic restorative treatment (ART) is a method for cleaning out tooth decay from teeth using only hand instruments and placing a filling. It does not use rotary dental instruments to prepare the tooth and can be performed in settings with no access to dental equipment. No drilling or local anaesthetic injections are required. ART is considered a conservative approach, not only because it removes the decayed tissue with hand instruments, avoiding removing more tissue necessary which preserves as much tooth structure as possible, but also because it avoids pulp irritation and minimises patient discomfort. ART can be used for small, medium and deep cavities caused by dental caries.

References

  1. 1 2 Ceruti, P.; Menicucci, G.; Mariani, G. D.; Pittoni, D.; Gassino, G. (January 2006). "Non carious cervical lesions. A review". Minerva Stomatologica. 55 (1–2): 43–57. ISSN   0026-4970. PMID   16495872.
  2. 1 2 3 4 5 Osborne-Smith, K. L.; Burke, F. J. T.; Wilson, N. H. F. (1999-06-01). "The aetiology of the non-carious cervical lesion". International Dental Journal. 49 (3): 139–143. doi:10.1002/j.1875-595X.1999.tb00898.x. ISSN   0020-6539. PMID   10858746.
  3. 1 2 3 4 5 Bartlett D., Shah P. A Critical Review of Non-carious Cervical (Wear) Lesions and the Role of Abfraction, Erosion, and Abrasion. Journal of Dental Research. 2006;85(4):306–12.
  4. 1 2 Ireland R. Dictionary of Dentistry. Oxford: Oxford University Press; 2010.
  5. 1 2 3 4 Donovan, Terence; Nguyen‐Ngoc, Caroline; Abd Alraheam, Islam; Irusa, Karina (January 2021). "Contemporary diagnosis and management of dental erosion". Journal of Esthetic and Restorative Dentistry. 33 (1): 78–87. doi:10.1111/jerd.12706. ISSN   1496-4155. PMID   33410255. S2CID   230818089.
  6. 1 2 3 Moynihan, Paula; Petersen, Poul Erik (February 2004). "Diet, nutrition and the prevention of dental diseases". Public Health Nutrition. 7 (1A): 201–226. doi:10.1079/phn2003589. ISSN   1368-9800. PMID   14972061. S2CID   549784.
  7. 1 2 3 4 5 Rees JS. The biomechanics of abfraction. Proceedings of the Institution of Mechanical Engineers Part H, Journal of engineering in medicine. 2006;220(1):69–80.
  8. 1 2 3 4 Sarode GS, Sarode SC. Abfraction: A review. Journal of oral and maxillofacial pathology : JOMFP. 2013;17(2):222–7.
  9. ↑ "Root grooves on two adjacent anterior teeth of Australopithecus africanus". ResearchGate. Retrieved 2019-01-10.
  10. 1 2 Estalrrich, Almudena; Alarcón, José Antonio; Rosas, Antonio (2017). "Evidence of toothpick groove formation in Neandertal anterior and posterior teeth". American Journal of Physical Anthropology. 162 (4): 747–756. doi:10.1002/ajpa.23166. hdl:10261/159768. ISSN   1096-8644. PMID   28035661.
  11. 1 2 3 4 5 Teixeira, Daniela Navarro Ribeiro; Thomas, Renske Z.; Soares, Paulo Vinicius; Cune, Marco. S.; Gresnigt, Marco M.M.; Slot, Dagmar Else (April 2020). "Prevalence of noncarious cervical lesions among adults: A systematic review". Journal of Dentistry. 95: 103285. doi:10.1016/j.jdent.2020.103285. ISSN   0300-5712. PMID   32006668. S2CID   211004709.
  12. 1 2 Wood, Ian; Jawad, Zynab; Paisley, Carl; Brunton, Paul (October 2008). "Non-carious cervical tooth surface loss: A literature review". Journal of Dentistry. 36 (10): 759–766. doi:10.1016/j.jdent.2008.06.004. ISSN   0300-5712. PMID   18656296.
  13. ↑ Hussain, Asra Sabir; Melibari, Rehab; Al Toubity, Meteib Joraib; Sultan, Mujahed Sami; Alnahhas, Abdulrahman (December 2021). "Diagnosis of non-carious cervical lesions". Clinical Dentistry Reviewed. 5 (1): 1. doi:10.1007/s41894-020-00089-5. ISSN   2511-1965. S2CID   231615669.
  14. ↑ Penoni, Daniela Cia; Gomes Miranda, Maria Elisa da Silva Nunes; Sader, Flávia; Vettore, Mario Vianna; Leão, Anna Thereza Thomé (May 2021). "Factors Associated with Noncarious Cervical Lesions in Different Age Ranges: A Cross-sectional Study". European Journal of Dentistry. 15 (2): 325–331. doi:10.1055/s-0040-1722092. ISSN   1305-7456. PMC   8184301 . PMID   33535250.
  15. ↑ Aw, Tar C.; Lepe, Xavier; Johnson, Glen H.; Mancl, Lloyd (June 2002). "Characteristics of noncarious cervical lesions". The Journal of the American Dental Association. 133 (6): 725–733. doi:10.14219/jada.archive.2002.0268. PMID   12083648.
  16. ↑ Moraschini V, da Costa L, dos Santos G. Effectiveness for dentin hypersensitivity treatment of non-carious cervical lesions: a meta-analysis. 2022.
  17. 1 2 3 Chee B, Rickman L, Satterthwaite J. Adhesives for the restoration of non-carious cervical lesions: A systematic review. 2022.
  18. 1 2 3 4 5 Rocha A, Da Rosa W, Cocco A, Da Silva A, Piva E, Lund R. Influence of Surface Treatment on Composite Adhesion in Noncarious Cervical Lesions: Systematic Review and Meta-analysis. Operative Dentistry. 2018;43(5):508-519
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