journal of dentistry 36 (2008) 759766

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Review

Non-carious cervical tooth surface loss: A literature review

Ian Wood a, Zynab Jawad b, Carl Paisley b, Paul Brunton b,*

a
Restorative Dentistry, Manchester University, England, United Kingdom
b
Restorative Dentistry, Leeds Dental Institute, Leeds University, Leeds LS2 9LU, England, United Kingdom

article info abstract

Article history: Objectives: As the population ages and teeth are increasingly retained for life the incidence
Received 6 March 2007 of non-carious cervical tooth surface loss is increasing but little is understood about the
Received in revised form aetiology and management of these lesions. The purpose of this literature review was to
11 June 2008 review and critically appraise the literature as it relates to the prevalence, aetiology and
Accepted 11 June 2008 treatment of non-carious cervical tooth surface loss.
Search strategy: An electronic search, using OVID electronic bibliographic databases was
performed with no restriction on the language of publication.
Keywords: Conclusions: Despite the paucity of research into non-carious cervical tooth surface loss it
Occlusal factors was concluded that the number and size of lesions increases with age, lesions are more
Non-carious cervical tooth surface common on the facial aspects of teeth and the formation of lesions appears to be multi-
loss factorial with lesion shape not being a predictor of aetiology. It was also concluded that the
Abfraction value of restoring these lesions, where indicated, is unclear and that occlusal adjustment to
Tooth wear increase the retention of restorations placed to restore lesions or to halt lesion progression
Cervical lesion cannot be supported.
Prevention # 2008 Elsevier Ltd. All rights reserved.
Prevalence

1. Introduction elapse before its investigation will give satisfactory results.1

As an ageing population retains its teeth for longer the issue of
tooth wear is becoming of increasing importance to the dental
profession.
The phrase non-carious cervical tooth surface loss
(NCCTSL) has arisen in attempt to embrace all such lesions
which occur at the neck of the tooth. Unfortunately, much
confusion arises from the use of other terminologies, such as
erosions and abrasions, which have been used at different
times and in different locations to describe similar lesions.
As long ago as 1908, Black,1 in his seminal work on
Operative Dentistry discussed the problematic aetiology of
what he termed erosions and stated that Our information
regarding erosion is far from complete and much time may
He identified eight possible causes:
 Faults in the formation of teeth.
 Friction from an abrasive tooth powder.
 Action of an unknown acid.
 Secretion from a diseased salivary gland.
 Physiological resorption, as with deciduous teeth.
 Acid associated with gouty diarethis.
 Action of alkaline fluids on calcium salts.
 Action of enzymes released by micro-organisms.
After considering each hypothesis in turn, finding fault
with all, he concluded that he had no theory of his own to
offer, which did not have features that rendered it impossible.

* Corresponding author. Tel.: +44 1133436182; fax: +44 1133436165.

E-mail address: p.a.brunton@leeds.ac.uk (P. Brunton).
0300-5712/$ see front matter # 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2008.06.004
760 journal of dentistry 36 (2008) 759766
Other researchers in the early part of the 20th century also
considered these lesions. Miller,2 looked at wastings and
concluded that brushing with coarse tooth powder was the
likely cause.2
In 1931, Ferrier3 was unable to offer a reasonable explana-
tion, for these lesions and in 1932 Kornfeld4 made the
observation that in all cases of cervical erosion he noticed
heavy wear facets on the articulating surfaces of the teeth
involved and that the erosion tended to be at the opposite side
of the tooth to the wear facet.3,4
The confusing use of the term erosion to describe a lesion
which may actually be caused by mechanical abrasion is
further compounded by the fact that to a chemical engineer
the process described by dentists as erosion is known as
corrosion.5 This imprecise terminology has contributed both
to the difficulty of carrying out good quality research and
making accurate diagnoses, which would enable appropriate
treatments to be recommended.
Many practitioners felt that over enthusiastic tooth-
brushing and the use of abrasive toothpastes were the
primary cause of these lesions but Lee and Eakle6 put
forward the hypothesis that tensile stresses created in the
tooth during occlusal loading may have a role in the
aetiology of cervical erosive lesions.6 They described three
types of stress placed on teeth during mastication and
parafunction:
 Compressivethe resistance to compression.
 Tensilethe resistance to stretching.
 Shearingthe resistance to twisting or sliding.
The authors stated that in a non-ideal occlusion large conflicting results. Shulman and Robinson9 recorded preva-
lateral forces could be created which would result in
compressive stresses on the side of the tooth being loaded
and tensile stresses in the opposite side. As it was
well known that enamel is strong in compression but
weak in tension, it was suggested that those areas in tension
were prone to failure. The region of greatest stress is found
at the fulcrum of the tooth. The characteristic lesion
described was wedge-shaped with sharp line angles and
situated at or near the fulcrum of the tooth, where the
greatest stress is generated. It was suggested that the
direction of the lateral force governed the position of
the lesion and its size was related to the magnitude and
duration of the force.
Grippo put forward a new classification of hard tissue
lesions of teeth.7 He defined four categories of tooth wear.
 Attritionthe wearing away of tooth substance as a result of
tooth to tooth contact during normal or parafunctional
masticatory activity.
 Abrasionthe pathological wear of tooth substance through
bio-mechanical frictional processes, e.g. tooth brushing.
 Erosionthe loss of tooth substance by acid dissolution of
either an intrinsic or extrinsic origin, e.g. gastric acid or
dietary acids.
 Abfractionthe pathologic loss of tooth substance caused
by bio-mechanical loading forces. It was postulated that
these lesions were caused by flexure of the tooth during
loading leading to fatigue of the enamel and dentine at a
location away from the point of loading. The word
abfraction was derived from the Latin to break away.
Grippo then went on to further describe five categories of
abfraction:
 Hairline cracks.
 Striationshorizontal bands of enamel breakdown.
 Saucer-shapeda lesion entirely within enamel.
 Semi-lunar-shapeda crescent-shaped lesion entirely
within enamel.
 Cusp tip invaginationa depression on the cusp tip seen in
molar and premolar teeth.
Lambert and Lindenmuth8 considered that the profession
should now consider occlusal stress as a primary factor in the
creation of cervical notch lesions and a considerable body of
theoretical work was accumulating to support the theory.8 To
date it would appear that practitioners widely accept that
abfraction is related to atypical occlusal loading despite there
being a paucity of evidence other than purely theoretical to
support this hypothesis. The purpose of this review of the
literature was to review and critically appraise the literature as
it relates to the prevalence, aetiology and treatment of non-
carious cervical tooth surface loss.
2. Prevalence
The profession has been aware of NCCTSL for many years and
studies of their prevalence in the population have revealed
lence as low as 2%, whereas Bergstrom and Eliasson10
recorded findings of 90%.9,10 This is partly explained by the
fact that different populations were included in the respective
studies. In the above examples, Shulman and Robinson9 were
examining young male freshmen, whereas Bergstrom and
Eliasson10 examined adult patients in the 3160 age range. All
studies showed a tendency for prevalence to increase with
age, which goes some way to explain the disparity in their
findings.
Variations in diagnosis and terminology outlined earlier,
along with possible local variables, such as dietary differences
and oral hygiene habits between one population and another,
also contribute to the variable picture which emerges from
considering previous studies. Levitch et al.,11 in a review of 15
studies carried out between 1941 and 1991 reported prevalence
in the range 585% with a strong correlation with age.11 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. They also noted that many studies
had shown a link between good oral hygiene and the
frequency of NCCTSL. People who brush twice daily have a
statistically significant higher prevalence of NCCTSL than
those who brush less frequently.12 Bruxism is also identified as
a source of occlusal stress and the work of Xhonga13 is
frequently quoted which reported that 87% of bruxists had
NCCTSL while only 20% of non-bruxists exhibited similar
lesions.13 This was, however, a small study with only 15
patients examined in each category hence the results should
 journal of dentistry 36 (2008) 759766 761

be interpreted with caution. Graehn et al.14 however studied Table 2 Prevalence of cervical abrasions according to
915 patients, identifying 23% as having wedge-shaped lesions. tooth type
Of these, 65% had confirmed parafunctional habits.14,15 Tooth type Number of teeth
The idea of classifying lesions according to their possible with abrasion
aetiology was put forward by Levitch et al.11 They proposed cavities (%)
that an erosive lesion could be found on either the lingual or Maxillary first molars 30 (17.3)
facial aspect of the tooth, be shallow, U-shaped or disc-like Maxillary first bicuspids 25 (14.5)
and would have smooth angles and a smooth surface. An Mandibular first bicuspids 25 (14.5)
abrasion lesion would be facially located, wedge-shaped or Maxillary second bicuspids 23 (13.3)
Mandibular second bicuspids 21 (12.1)
grooved with sharp angles and possibly a smooth or scratched
Maxillary cuspids 13 (7.5)
surface. A lesion associated with tooth flexure would be found
Mandibular cuspids 9 (5.2)
facially and would be wedge-shaped or composed of over- Mandibular first molars 8 (4.6)
lapping wedges, have sharp angles and a rough or corrugated Maxillary second molars 8 (4.6)
surface. Oddly this classification ignores the fact that a small Mandibular central incisors 5 (2.9)
number of wedge-shaped lesions thought to be of flexural Maxillary lateral incisors 3 (1.7)
origin have been identified in epidemiological studies.11 Maxillary central incisors 2 (1.2)
Mandibular lateral incisors 1 (0.6)
Levitch et al.11 go on to point out that the methodology of
many of the earlier studies was flawed and a significant
number of co-factors exist, which have not always been
considered. Another problem identified was the failure to with a pre-existing diagnosis of erosion.19 They also found that
define criteria for lesions or consider a possible multifactorial maxillary teeth were more severely affected than mandibular
aetiology. Most studies are limited to looking at factors teeth with no significant difference between the right and left
associated with a single aetiological mechanism. sides of the mouth. They, however, found the maxillary first
premolars to be the worst affected teeth, also noting that the
maxillary first molars were twice as badly affected as the
3. Intraoral distribution mandibular first molars.
Both the Zipkin and McLure19 study as well as Radentz
NCCTSL lesions do not present with an equal distribution et al.12 note a very low occurrence of lingual lesions in either
within a given individual. Rees et al.,16 in a recent paper on the arch. A figure of 2% has been suggested by Khan et al.20 in a
formation of abfraction lesions in maxillary incisors, canines more recent study to compare the relationship between
and premolars reported that these lesions were more cervical lesions and occlusal erosion and attrition. They also
prevalent on the labial surface of maxillary incisors.16,17 found less erosion in maxillary teeth than mandibular, with
Sognnaes et al.,18 also found a preponderance of abrasion/ more NCCTSL on mandibular molars and premolars than on
erosion type lesions in the incisors.18 Radentz et al.12 however, maxillary teeth.20 They did, however, find more lesions on
undertook a study on 100 enlisted military personnel aged mandibular premolars than mandibular canines, which is in
from 17 to 45 which identified 80 of them as being suitable for line with the findings of Radentz et al.12 They concluded that if
inclusion in the study. Before assessing factors which may be wedge-shaped lesions were caused solely by stresses arising
associated with cervical abrasions (the term abfraction was from occlusal forces they would only be found on teeth with
not yet in use) the distribution of existing lesions was wear facets and they would tend to appear in pairs on
recorded. Their findings are summarised below (Tables 1 opposing teeth.
and 2) and show maxillary first molars to be the most Pegoraro et al.21 in a study on 48 dental students aged
commonly affected teeth with maxillary incisors amongst the between 16 and 24 found that 52% of the students had NCCTSL
least affected. This report, written before occlusal stress was (Table 3).
considered a possible aetiological cause, concluded that
cervical abrasion is related to factors associated with the
initial stages of tooth brushing and that the excessive use of 4. Theories of NCCTSL formation
dentifrices, habitually placed undiluted in the same area of the
mouth, may produce abrasion.12 Much of the historical thinking around the formation of
A study by Zipkin and McLure19 analysed the distribution of NCCTSL centres on abrasive damage caused primarily by
erosive cavities in a sample largely drawn from a population toothbrushing, and erosion caused by acid of a non-bacterial
origin, which may be either intrinsic or extrinsic in origin.
Many of these studies have already been referred to
previously.
Table 1 Prevalence of cervical abrasion according to
intraoral region Miller2 created cervical lesions in vitro with abrasive tooth
powders and toothbrushing. Radentz et al.12 and Levitch
Intraoral region Number of teeth with abrasion (%)
et al.11 discussed the fact that people with good oral hygiene
Maxillary 104 (60.1) are more prone to NCCTSL and state that patients who brush
Mandibular 69 (39.9) twice daily have a statistically significant higher incidence of
Right side 95 (54.9)
NCCTSL than those who brush less frequently. Right-handed
Left side 78 (45.1)
people have more lesions on the left side of their mouths and
762 journal of dentistry 36 (2008) 759766

Table 3 Distribution of NNCTSL in a dental student lingual or palatal direction and may support the finding that
population more NNCTSL are found on the facial surfaces of the teeth.
Teeth affected Percentage In 1991, Goel et al.,26 published a paper in which they
developed a three-dimensional, linear, elastic finite element
First mandibular molar 21.3
First maxillary molar 16
stress model of a maxillary first premolar.26 Finite element
First maxillary premolar 12.8 stress analysis is a mathematical-modelling technique which
First mandibular premolar 11.7 examines the deformations of a model composed of a
Second mandibular premolar 11.7 meshwork of elements with given properties. They were
Second maxillary premolar 9.6 interested in the stresses arising at the amelodentinal junction
Second mandibular molar 3.2
(ADJ) during function and had noted that the shape of the ADJ
Maxillary central incisors 3.2
was different under working cusps than under non-working
Second maxillary molar 2.1
Mandibular central incisors 2.1 cusps. Functional cusps had a concave ADJ in the occlusal
Lower second molar 2.1 third and non-functional cusps did not. Their theory was that
Maxillary lateral incisors 1.1 this difference in ADJ anatomy may contribute in some way to
the instigation of cervical lesions. The results of the study
showed that tensile stresses were elevated towards the
conversely left-handed people have more lesions on their right cervical enamel and also that although enamel and dentine
side. The first quadrant to be cleaned also has a higher were organically bonded they had the capability to respond to
incidence of lesions but the stiffness of the brush used did not forces differently. They suggested that mechanical interlock-
have any impact and the low abrasivity of modern toothpastes ing between the enamel and the dentine is weaker in the
was thought to minimise their impact. It was suggested by cervical region than in other areas of the tooth which may
Radentz et al.12 that teeth in the middle of the brushing arc make it susceptible to cracking which could eventually
were more severely affected. There is an acceptance that contribute to cervical caries.
many lesions may have a multifactorial aetiology but no One of the problems associated with early finite element
explanation has satisfactorily explained the isolated lesions in models was the difficulty of allocating appropriate physical
otherwise healthy mouths, the lingual lesions which were characteristics to the different constituent parts of the tooth.
impossible to reach with a toothbrush or multiple lesions on Spears27 looked at the data available for the Youngs Modulus
the same tooth. for enamel which varied considerably.27 He proposed a model
As early as 1932 Kornfeld4 had made the observation that which functioned at two levels. At a crystalline level enamel
many teeth with cervical erosions also had heavy wear facets behaves as a simple composite, i.e. long parallel crystals in an
on their articulating surfaces, but it was not until 1984 that Lee organic matrix with a stiffness dependant on chemical
and Eakle6 published a paper which explored the possible role composition and crystal orientation. At a prismatic level
of tensile stress in the aetiology of these idiopathic cervical enamel is considered to behave like a hierarchical composite
lesions.4,6 Work had been published in the 1970s by Thresher made up of prisms within which the crystal orientation is
and Saito,22 Selna et al.23 and Yettram et al.,24 which showed heterogeneous. The actual stiffness of the enamel is then
by finite element analysis that stresses were concentrated in dependant on the chemical composition and prism orienta-
the cervical regions of the teeth and the authors suggested tion. He concluded that values for stiffness were greater along
that these tensile stresses were the primary aetiological factor the direction of the prisms than across them and that
in creating wedge-shaped cervical lesions.6,2224 consequently enamel behaved in an anisotropic manner.
A further finite element study by Rees28 has shown that
4.1. Occlusal loading premolar teeth with occlusal restorations present had a
greater concentration of peak tensile and shear stress in the
The behaviour of a tooth under occlusal load is governed by a buccal cervical region when loaded with an eccentric force of
number of factors: 100 N than unrestored teeth. The recorded stresses were in
excess of the known failure stresses for enamel. Rees28 also
 The support provided by the bony socket. noted that the deeper the restoration present, the greater the
 The gross morphology of the tooth. amount of cusp flexure that was found and he concluded that
 The microscopic structure of the tooth. the weakening effect of cavity preparation may contribute to
 The presence and size of restorations. the development of NNCTSL.28
 The direction of the force applied. In 2003 Rees et al.16 published a further paper comparing
the cervical stress profiles of individual tooth types in the
The anatomy of the periodontal ligament and the maxilla using two-dimensional finite element stress analy-
surrounding alveolar bone is designed to absorb the forces sis.16 They found that the labial/buccal stress profile in the
applied to the teeth during mastication. Picton25 reported that cervical region of a maxillary incisor was always greater than
alveolar bone surrounding a tooth distorted under loads of less that found in a canine or premolar tooth with canines having
than 100 g.25 Horizontal loads caused initially compression of the lowest readings. They concluded that these findings
the periodontal ligament and then dilatation of the alveolar provide a bio-mechanical explanation for the clinical variation
bone. The labial plates tended to distort more than the lingual seen in the prevalence of NCCTSL which ties in with their
plates. This would imply that more force would be transmitted statement that these lesions are most common in the
to the tooth itself when horizontal forces were applied in a maxillary incisors but does not agree with the results of the
 journal of dentistry 36 (2008) 759766
prevalence studies described earlier.12,21 This suggests that
the hypothesis as proposed is flawed.
The theory that occlusal forces can result in tensile
stresses in the cervical regions of the teeth is however,
supported by the work of Chen et al.,29 who measured cervical
strain perpendicular to the tooth using strain gauges attached
to extracted maxillary second premolars when a force was
applied to the lingual (palatal) cusp.29 They found that an
occlusal load could produce a tensile strain in the cervical
region of the tooth and that this strain increased with the
load. Tensile forces were detected on both the lingual and
buccal aspects of the tooth but were greater on the buccal
aspect. This again supports the theory that the formation of
cervical wedge-shaped lesions may be related to occlusal
forces.
This conclusion is further supported by the research of
Nohl et al.30 into the effect of load angle on strains induced in
maxillary premolars in vitro which showed that near axial
tensile strains were induced on the contra lateral side of the
tooth when loads were applied to the inner cusp inclines.30
The authors felt that this may be of significance in the
aetiology of NCCTSL.
4.2. Tooth susceptibility
The reaction of a tooth to the occlusal stresses set up under
occlusal loading may also be influenced by factors other than
the load itself. Cervical enamel is held to be of a poorer quality
than occlusal enamel with a greater pore volume, higher
protein content and lower mineral content. This is particularly
true of the subsurface enamel. Hammadeh and Rees31 carried
out a study to compare the erosive susceptibility of gingival
and occlusal enamel and to see if the subsurface layer was
more vulnerable to acid attack.31 They found that all samples
showed a linear loss of substance but although the rate varied
it was felt to be more to do with biological variation from
individual to individual than variation within the tooth
structure. It was considered possible that the porosity of the
cervical region was reduced by a process of post-eruption
maturation. The study concluded that it could only provide
limited support for the hypothesis that abfraction lesions may
be linked to acid erosion but went on to say that as dentine is
more easily eroded than enamel its loss could undermine
cervical enamel and hence contribute to increased enamel
failure under loading.
The same authors went on to publish a paper which was a
finite element study looking at the undermining of enamel as a
mechanism for abfraction lesion formation.32 They compared
maximum principal stresses along a buccal horizontal
sampling plane 1.1 mm above the cement enamel junction
in intact teeth and in teeth which had had an undermining
discontinuity introduced between the cervical enamel and
dentine. The discontinuity caused a dramatic rise in the
numerical value of the maximum principal stresses recorded
and in many instances these exceeded the known failure
stress for enamel. This study would seem to indicate that
lesions may be initiated by loss of cervical dentine following
gingival recession which then undermines the enamel
predisposing to mechanical failure and for the subsequent
tooth substance loss.
763
4.3. Other possible theories
A further possible source of disruption to the structure of the
tooth in the cervical region is the existence of electric
potentials which arise when some materials are put under
stress. This phenomenon, known as a piezo-electrical effect
was first recorded by Braden et al.33 They suspected that
although enamel, which is principally hydroxyapatite did not
give rise to any electrical potential, dentine did. This is thought
to arise from the presence of collagen in dentine and was of a
similar value to that recorded for bone. It is possible that the
bending forces arising during bruxism would be sufficient to
create a significant charge within the tooth structure and it is
postulated that this could attract active ions of, for example,
erosive agents such as organic acids and contribute to tooth
substance loss. However, the electrical response did not vary
linearly with stress so heavy occlusal loading would not give
rise to a proportionately greater electrical response and any
possible significance of this effect is not well understood.
The role of saliva in the possible formation of NCCTSL has
been considered previously. Black1 wondered whether a
possible cause of erosions might be secretions from diseased
salivary glands and Zipkin and McLure19 carried out experi-
ments to assess the amount of citrate present in saliva of
patients who had been diagnosed with erosions and compared
it to levels in a group without erosions.1,19 Their results were
not conclusive but indicated a trend of higher citric acid
content in individuals with erosions than in those without.
More recently the role of saliva has come to be thought of as
protective to the dental tissues. Levitch et al.11 stated that
patients with low unstimulated salivary flow rates are five
times more prone to cervical lesions than those with normal
flow rates and patients with xerostomia and reduced buffering
capacity are also more prone to developing lesions.11 They also
considered that the ability of saliva to remineralise tooth
structure could be important.
Khan et al.20 called in to question the idea that occlusal
loading should be considered the primary aetiological factor in
the formation of NCCTSL and proposed instead a theory of site
specific erosion.20 They concluded that occlusal erosion is as
common in bruxists as attrition is and postulated that patient
dehydration reduces salivary protection against erosion and
suggested that acid demineralisation is not only the primary
cause of the cupped lesions of erosion but also of attritional
wear facet development. In contrast to this the theory of
abfraction postulates that occlusal strains caused during
attrition are transmitted to the cervical sites causing direct
breakdown. Their study found that 96.2% of NCCTSL were
found on teeth that showed signs of either erosion or attrition
on their incisal or occlusal surfaces. Interestingly 5.2% of the
NCCTSL occurred on teeth with no occlusal wear. More lesions
were found on mandibular premolars than mandibular
canines despite the fact that less premolars had occlusal
wear and unlike Radentz in common with other studies more
wedge-shaped lesions were found on the left than on the right
side of the mouth. No consistent association was found
between either attrition and or erosion and cervical wedge-
shaped lesions in the canines or premolars.
The hypothesis of site specificity is explained in terms of
salivary physiology. The labial surfaces of the maxillary teeth
764 journal of dentistry 36 (2008) 759766
are more prone to attack because the teeth tend to dry out
during breathing and the minor labial salivary glands do not
have good buffering capabilities. The lingual surfaces of the
mandibular teeth are protected by the secretions of the
sublingual salivary glands and only a few wedge-shaped
lesions (2%) were found in this area of the mouth. The authors
were however unable to explain why the mandibular
premolars and molars are less protected from occlusal erosion
and associated buccal cervical lesions.
They concluded that a hypothesis that wedge-shaped
lesions arise primarily due to the occlusal forces responsible
for attrition was unsustainable and the primary aetiology
should be regarded as being acid demineralisation at sites
unprotected by saliva, possibly involving stress corrosion as a
pathogenic mechanism or abrasion related to right- or left-
handed tooth brushing.
4.4. Experimental evidence
Whitehead et al.34 described an experiment to investigate the
effect of stress corrosion on intact enamel.34 An incidental
finding of this experiment was that 8% of the teeth subjected
to a combination of acid and cervical stress developed cervical
notch lesions. The low rate of occurrence lends weight to the
feeling that the development of this type of lesion is multi-
factorial and that not all factors are yet understood.
5. Treatment
One of the consequences of the unclear aetiology and
diagnosis of NCCTSL is a confused approach to clinical
management. Bader et al.35 reported this to be an area of
great professional uncertainty with no agreement between
practitioners on how to describe lesions or their aetiology.35
Even root caries did not have 100% agreement. The options
considered for restoration were:
 Nothing.
 Restoration.
 Restoration with occlusal adjustment.
The response to their survey showed 38% of practitioners
would restore a lesion they described as abrasion, 47% would
restore a lesion they described as an erosion and 49% would
restore a lesion they describe as other and is now commonly protected by the bodys proprioceptive mechanisms but these
called abfraction. Ninety nine percent would restore a root
caries lesion. The level of variation in treatment options was
almost a perfect split and indicated a maximum level of
disagreement.
Owen and Gallien36 suggested that active treatment is
required to prevent further stress concentration occurring
which may lead to pulpal exposure or tooth fracture.36 Grippo5
was strongly in favour of restoring these lesions and listed 19
reasons for doing so, ranging from decreasing the stress
concentration to enhancing the patients feeling of complete-
ness as listed below5:
 Decreases stress concentration.
 Decreases flexure.
 Decreases the progress of the abfraction.
 Strengthens the tooth.
 Prevents pulp involvement.
 Eliminates acid dissolution or corrosion.
 Prevents tooth fracture.
 Eliminates stress corrosion.
 Moderates the effects of piezo-electricity.
 Prevents root caries.
 Prevents toothbrushing abrasion.
 Eliminates cervical sensitivity.
 Provides comfort to the adjacent soft tissues.
 Improves aesthetics.
 Provides an area that is more easily cleaned by the hygienist.
 Prevents food collecting in these areas.
 Improves gingival health by providing food deflection.
 Eases oral hygiene for the patient.
 Provides the patient with a feeling of good health or
completeness.
A contradiction which emerges from Grippos philosophy is
that the placement of resin composite restorations is
recommended to prevent tooth flexure. In contrast he records
a high rate of restoration loss which is thought to be due to
heavy functional loading forces causing further tooth flexure.
Braem et al.37 in their article on stress induced cervical
lesions, also pointed out that any restoration placed in one of
these lesions would be prey to the stresses and strains which
had caused it in the first place and therefore would make it
more likely to fail.37
Levitch et al.11 gave a list of indications which they felt
necessitated active treatment.11 They were:
 If the structural integrity of the tooth is threatened.
 If exposed dentine is hypersensitive.
 If the aesthetics are unacceptable.
 If pulpal exposure is likely.
 If tooth shape modification is necessary to allow partial
denture design.
This is a very reasonable list of clinical situations requiring
intervention but does not go into detail of what treatment is
suggested.
Spranger38 described the genesis of angular NCCTSL and
went on to postulate that normal tooth to tooth contacts are
are overridden by parafunctional activity which results in
excessive forces arising when eccentric loads occur on the
non-working side.38 The authors conclusion was that occlusal
adjustment should be undertaken prophylactically to inter-
rupt the pathogeneic process along with the placement of a
resin composite restorations to resist the tensile and com-
pressive forces coupled with the use of bite guards if
necessary. However, there is no clinical evidence to sub-
stantiate this conclusion.
The advent of reliable dentine adhesive systems and
adhesive materials has increased the options available to
restore NCCTSL. Prior to this, practitioners were faced with
treating a loss of tooth substance by removing more tooth
substance to try and create a retentive preparation. Heyman
 journal of dentistry 36 (2008) 759766
et al.39 in a study to examine the effects of tooth flexure on
restoration retention found that microfilled resins were better
retained than macrofilled resins, possibly due to their greater
flexibility, but that patients rated as having active bruxism had
statistically higher rates of restoration loss.39 No occlusal
adjustments had been carried out. A recent study by Carre and
Brunton40 of restoration retention rates for cervical lesions in
occlusally adjusted and non-adjusted teeth did not, however,
show a statistically significant difference between the two
groups, which suggests that occlusal adjustment is ineffective
as a means of prolonging retention of cervical restorations.
6. Discussion
The small number of prevalence studies suffer from several
limitations not least that the lesions are ill defined, some of the
studies have studied a small population and different studies
have classified lesions in a different way. The picture is further
complicated by the wide number of variables within a
population and even within a given individual mouth over a
period of time. It is therefore not surprising that a confusing
and unclear picture emerges from the accumulated preva-
lence data. Despite these limitations it is clear however that
the older the population the greater the percentage of lesions
found, the greater the number of lesions per individual and the
larger the lesions. This raises two important points namely
can this lesions be prevented or their progress arrested at an
earlier age with a view to preventing a future treatment need?
It would seem that when the intraoral distribution of
NNCTSLs is considered as with their prevalence in the general
population, that an unclear picture emerges where limited
conclusions can be drawn. This is possibly also related to the
confusing terminologies and variable diagnoses which have
been used in different studies at different times.
There appears to be no doubt that occlusal forces are
implicated in the formation of the majority of lesions. Whilst
this cannot explain the aetiology of all lesions, e.g. lingual
wedge-shaped lesions and isolated lesions in otherwise
healthy mouths which have never had an opposing occlusion
it seems to be a common factor that has been highlighted as a
probable cause in the majority of studies of lesions of this type.
This is reinforced by the fact that potentially destructive
tensile stresses do occur in the cervical regions of teeth due to
occlusal loading and the observation that eccentric loading
causes greater stresses than axial loads.
Other theories which have been postulated in relation to
lesion formation include the role of saliva, the site specificity
hypothesis, a possible association with a piezo-electrical
effect and experimental evidence of lesion formation when
teeth are subjected to vertical barrelling in an acidic environ-
ment. There is little or no evidence to support or refute these
theories and therefore it must be concluded that further
research is needed to establish the precise role, if any, of these
aetiological factors in lesion formation.
In terms of treatment for lesions, when operative inter-
vention is indicated, the situation is equally unclear which is a
direct reflection of the confusion around the aetiology of lesion
formation. This is supported by the conclusions of Bader
et al.s study35 where practitioners showed considerable
765
confusion and variation in treatment planning for these
lesions. The reasons for restoration are generally accepted to
be similar to the list of indications proposed by Levitch et al.11
Poor retention rates for resin composite restorations placed in
such lesions are likely to be explained by continued tooth
flexure but also the modulus of elasticity of the material which
can make it unsuitable for the restoration of these lesions.
Further robust studies are required to investigate the ideal
material for restorations of lesions of this type.
Adjusting the occlusion to prevent lesion progression or to
improve the retention of restorations cannot be supported as
there is no evidence that occlusal adjustment is helpful in
terms of slowing down lesion formation or improving the
retention of restorations when placed to restore lesions of this
type. This suggests however that occlusal forces whilst
implicated in the formation of most lesions cannot be the
single aetiological factor in lesion formation.
7. Conclusions
Despite the paucity of research in this area, a number of
conclusions can be drawn:
1. The older the population the greater the percentage of
lesions found, the greater the number of lesions per
individual and the larger the lesions.
2. NCCTSLs are more common on the facial aspects of teeth
than the lingual, more common in premolars than canines,
and it would seem more common in the buccal segments of
the mouth than in the labial.
3. Oral hygiene habits, and the right or left-handedness of the
patient when tooth brushing, affects the prevalence and
distribution of NCCTSL.
4. The formation of NCCTSL appears to be multifactorial. The
shape of a cervical lesion is not an accurate guide to its
aetiology.
5. A combination of occlusal load and an acid environment
can create cervical notch lesions in vitro.
6. The use of a resin composite with an appropriate modulus
of elasticity in conjunction with a dentine adhesive system
can be an effective and non-destructive means of restoring
NCCTSL.
7. Occlusal adjustment cannot be supported to prevent lesion
progression or to improve restoration retention.
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