2. This research paper is about non carious lesions in teeth .
It includes the definition , the cause , the treatment and
the prevention techniques for them
3. MANAGING NONCARIOUS CERVICAL LESIONS
Noncarious cervical lesions (NCCLs) are defined as a loss
of hard dental tissue near the cementoenamel junction,
usually on the buccal surfaces of teeth, resulting in a
grooved or wedge-shaped area of missing tooth structure.
These lesions are increasing in prevalence, especially
among adolescentsand older adults.1 In particular,
lifestyle changes — includingthe increased consumption
of acidic drinks among younger patients and the number
of olderadults who take prescription medications, which
can cause hyposalivation and xerostomia — raise the risk
of NCCLs. Hyposalivation increases acidity in the oral
cavity, softening the tooth surface and facilitating tooth
loss (Figure 1).
FIGURE 1. Noncarious cervical lesions are present on
the buccal of upper and lower teeth.
A study reported that the prevalence of NCCLs in
teenagers and adultsranges from 11% to 62%, and the
number of lesions increases with age.2 Lesions most often
occur on the buccal of maxillary premolars, but are also
commonly found on other maxillary and mandibular
anterior and premolar teeth. The exact etiology of NCCLs
4. is unknown, but it is generally accepted that their cause is
multifactorial.1,3,4 The clinical endpointof NCCLs is the
wearing away of dentition. The mechanisms involved
includeacid erosion (the loss of tooth structureby acid
demineralization without the involvement of bacteria);
abrasion (friction resulting in loss of tooth structurefrom
dentifrices and toothbrushing); and abfraction (breaking
away of tooth structuredue to tensile stresses in the
cervical area).1,3,4
Acid erosion is the most important factor involved in the
development of NCCLs. Saliva normally keeps the oral
environment in the 7.0 pH range (neutral) due to its
ability to buffer acids. The source of acids can be intrinsic
— bulimia or gastroesophageal reflux disease (GERD),
for example — or extrinsic, such as acids from fruit
juices, sports and energy drinks, and wine, to name a few.
When oral acids bring the pH of the tooth surface below
4.5, demineralization of enamel and dentin can begin.5
EROSIVE CONCERNS
The action of strong acids causes the loss of calcium
(inorganic matter) from the tooth surface, followed by a
softening of the top layers of dentin and enamel. This
softened layer then becomes susceptibleto abrasive forces
in the oral cavity and is easily removed, potentially
causing wedge-shaped cervical lesions. The thin, softened
layer is between 0.2 µm and 3 µm thick and is repeatedly
5. removed by abrasive forces, leading to permanent loss of
tooth volume in the cervical area.6
The pH (less than 4.5), duration and the strength
(buffering capacity) of the acid challengeneed to be
considered. For example, cola (phosphoricacid) and
certain energy drinks (citric acid) have a similar pH, but
drinks containing citric acid are more erosive because
more buffering is required to return the pH above the
“critical” erosive point of pH 4.5.3Regular and diet sodas
and sports and energy drinks range from a pH of 2.5 to
3.4, respectively.7 Lemon, grapefruit and orange juices
also cause erosive damage to enamel. Gastric acids from
GERD are the most erosive, with a pH of 1.0 to 2.0.1 In
addition, patientswith gastric reflux often suffer from
hyposalivation.8
FIGURE 2. This patient has severe noncarious cervical
lesions.
Saliva plays an important role in oral health by cleansing
the oral cavity and diluting and buffering acids.
Individuals with xerostomia are much more susceptibleto
acid erosion. Patients are often advised to avoid brushing
6. for 30 minutes to 60 minutes immediately after an acid
exposure, presumably to allow softened surface enamel to
remineralize — but, in truth, more effective preventive
strategies (such as various fluoride-based therapies)
should be recommended. The reality is that softened
enamel is not remineralized by saliva over short time
periods, and will be worn away even in the absence of
tooth brushing by normal abrasive forces in the oral
cavity, such as chewing and tongue action.
Dental abrasion, anothercontributingfactor to NCCLs, is
defined as wearing away of dental hard tissues by
frictional forces.1 This can include wear caused by
toothbrushing, flossing, tongue action, abrasive foods, and
rubbing from opposing surfaces that are hard or rough,
such as unpolished porcelaincrowns.3 The effects of such
actions are usually more pronounced on dentin surfaces
than on enamel (Figure 2 and Figure 3).9
FIGURE 3. Toothbrush abrasion may be part of the
multifactorial etiology of noncarious cervical lesions.
7. It appears that toothbrushingalone — regardless of the
brush stiffness, filament size, aggressiveness or the
frequency of brushing — causes littleabrasive tooth
wear.1 Rather, it is the abrasiveness of the toothpaste
combined with brushing that is responsiblefor the loss of
tooth structure.10,11 Dentifrices that includewhitening
agents or productspromoted for their ability to control
tartar tend to be more abrasive than other types. That said,
all popularbrandsmarketed in the U.S. today comply
with abrasivity “safe limits” set by American Dental
Association and InternationalOrganization for
Standardization.12,13 Any toothpastewith a Relative
Dentin Abrasivity (RDA) value of 250 or below can be
used safely on a daily basis for a lifetime. Toothbrushes
with stiffer bristles, however, have been linked to gingival
recession.14
Abfraction is the microstructural loss of tooth structure
due to excessive occlusal forces transmitted to the
cervical area as flexural forces.1 These flexural forces,
usually caused by cyclic loading, may lead to the breaking
away of enamel rods in the cervical region of the tooth,
causing microfractures of cementum and dentin.4 Bruxism
may also contribute, although in the absence of acid there
is minimal erosive tooth wear.15
Anotherpossible modifying factor in abfraction formation
involves the mobility of teeth and the effects of occlusal
stresses in the formation of cervical lesions. A
relationship has been found between tooth cervical
8. lesions, tooth stability and periodontalsupport.15 Thus, as
tooth mobility increases, teeth are actually less susceptible
to excessive occlusal forces, as the teeth move under
occlusal loads, resulting in less concentrationof forces in
the cervical areas.16
While these interocclusal relationshipsmay be
contributingfactors in the formation of some NCCLs, it is
likely that clinical signs of abfraction in cervical areas are
not simply related to stress concentrations. Rather, they
may play a role, alongwith acid erosion and toothbrush
abrasion, in the multifactorial etiology of NCCLs.1,4
LESION MANAGEMENT
It’s important to note that NCCLs can occur at any time
and may worsen throughout a patient’slifetime. Without
intervention, they can result in tooth fracture,
hypersensitivity and cosmetic problems. Therefore, early
diagnosis is important in order to initiate behavioral
changes and avoid future invasive and expensive
restorative interventions.
Clinical management of NCCLs includes first identifying
the various etiologic factors present in a given patient. For
example, if a patient is an active bruxer, has wear facets
on the teeth, and presents with NCCLs, the clinician may
decide to prescribe an occlusal splint or night
guard.4 Occasionally, judicious occlusal adjustments of
9. interferences may be performed. Acid intake must also be
reduced.
Through the process of taking a comprehensive medical
history, clinicians should question patients regarding their
intake of acidic foods or beverages, includingfruits, wine,
and sports and energy drinks. It is important to monitor
the frequency, duration, sequencing, and the mode of
intake of these beverages. Sipping and swishing a drink,
for example, are much more erosive than gulping the
beverage, as the acidic beverage stays in contact with the
tooth surface for longer periods.17 Consuming dairy after
an acid challenge will help raise the pH and shorten the
duration of erosive insult.18 Medication use, especially
among older patients, should be reviewed, as drug-related
xerostomia can contributeto tooth surface loss.19 Finally,
patients should be asked about GERD, because there is a
correlation between this disorder and dental
erosion.20 These medical and behavioral factors have the
net, and possibly cumulative, effect of demineralizing the
tooth surface, which ultimately leads to the irreversible
loss of surface enamel via abrasive forces such as
toothbrushing, eating hard foods, and even cleaning with
toothpicks. If the risk factors cannot be eliminated
through behavioral changes or medical treatment, other
preventive actions should be taken.
10. KEY TAKEAWAYS
Clinicians are seeing an increasing prevalence of
noncariouscervical lesions (NCCLs), especially
among adolescentsand older adults.1
Lesions most often occur on the buccal of maxillary
premolars, but are also commonly found on other
maxillary and mandibularanterior and premolar teeth.
While the exact etiology of NCCLs is unknown, it is
generally accepted their cause is multifactorial.1,3,4
Early diagnosis is important in order to initiate
behavioral changes and preventive therapies that can
help patientsavoid invasive restorative interventions.
Treatment should includeminimizing the intrinsic or
extrinsic acids that are the primary cause(s) of the
lesions.
Brushing with a stannousfluoride toothpasteis a key
element in prevention management.
PREVENTION AND TREATMENT
Conservative preventive measures using fluoride
mouthrinses and topical fluoride should be professionally
managed.21 The use of fluoride varnish and bonding
agents can protect the teeth from acid attacks, but their
long-term effects may be limited.22 Stannousfluoride is
11. an important preventive tool to protect the tooth surface
from an acid challenge.23,24 It provides superior protection
for acid erosion versus sodium fluoride or
monofluorophosphateproducts. It has been shown that a
stabilized stannousfluoride toothpasteis effective in
preventing erosive tooth wear.25 The mode of action of
stannousfluoride is to form a thin layer of stannous-based
complexes on the surface of enamel, protectingthe
surface from acid attack.26,27 The patient also receives the
benefit of fluoride.26
Remineralization after an acid attack may be possible
with the use of topically applied pastes containingcasein
phosphopeptidesand amorphouscalcium
phosphate.28 These materials are supersaturatedwith
calcium and phosphateand can “recharge” and
remineralize demineralized tooth surfaces.
Treatment should includeminimizing the intrinsic or
extrinsic acids that are the primary cause(s) of lesions.
Treatment for cervical hypersensitivity due to NCCLs
may also be necessary. Using desensitizing dentifrices,
such as those containing potassium nitrateor stannous
fluoride, can be helpful.29 Other studies have shown that
the use of a self-etching adhesive, sealant or resin-bonded
flowable composite restoration may provide
comprehensive and rapid controlof
hypersensitivity.30 More advanced lesions can usually be
managed using resin-bonded composite restorations. In
12. rare instances, a crown or porcelain veneer may be
necessary.
Understandingthe etiology of NCCLs and making a
timely diagnosis will allow early and minimally invasive
interventions, such as the use stannousfluoride toothpaste
or fluoride varnish and sealants. Counselingfor
behavioral modifications — reducing the intake of acidic
foods and beverages, for example — is of utmost
importance. Emphasizing the need to take preventive
measures to help avoid enamel erosion in the first place
will help patientsmanage this common problem.
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