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Non-Carious Cervical Lesions: From Diagnosis to Treatment

Article · February 2024

DOI: 10.47991/2835-9496/AJCMR-116

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 ISSN: 2835-9496 Kikly A, et al. (2024): 371
DOI: 10.47991/2835-9496/AJCMR-116

Research Article American Journal of Clinical and Medical Research

Non-Carious Cervical Lesions: From Diagnosis to Treatment

Amira Kikly1*, Sabra Jaâfoura2, Afif Bouslema3, Emna Garouachi4, Ameni chadlia Belghuith4, Wided Glii4, Neila Zokkar5,
Nabiha Douki5
1
DDS, Associate professor, Department of Dentistry, university hospital, Sahloul, Tunisia
Faculty of Dental Medicine, University of Monastir, Avicenna Street, 5000 Tunisia.
Research Laboratory LR12ES11, University of Monastir.
2
DDS, Msc, Associate professor, Department of Dental Biomaterials, Faculty of Dental Medicine, University of Monastir, Avicenna
Street, 5000 Tunisia.
Laboratory of Dento-Facial, Clinical and Biological Approach (ABCDF) LR12ES10, University of Monastir.
3
DDS, Assistant, Department of Dentistry, university hospital, Sahloul, Tunisia
Faculty of Dental Medicine, University of Monastir, Avicenna Street, 5000 Tunisia.
Research Laboratory LR12ES11, University of Monastir.
4
DDS, Department of Dentistry, university hospital, Sahloul, Tunisia
Faculty of Dental Medicine, University of Monastir, Avicenna Street, 5000 Tunisia.
Research Laboratory LR12ES11, University of Monastir.
5
DDS, Professor, Department of Dentistry, university hospital, Sahloul, Tunisia
Faculty of Dental Medicine, University of Monastir, Avicenna Street, 5000 Tunisia.
Research Laboratory LR12ES11, University of Monastir.
*
Corresponding author: Amira Kikly, 1DDS, Associate professor, Department of Dentistry, university hospital, Sahloul, Tunisia
Faculty of Dental Medicine, University of Monastir, Avicenna Street, 5000 Tunisia. Research Laboratory LR12ES11, University of
Monastir. [email protected]
Citation: Kikly A, Jaâfoura S, Bouslema A, Garouachi E, Belghuith AC, et al. (2024) Non-Carious Cervical Lesions: From
Diagnosis to Treatment. Ameri J Clin Med Re: AJCMR-116.
Received Date: 22 January, 2024; Accepted Date: 31 January, 2024; Published Date: 07 February, 2024
Abstract
Non-carious cervical lesions have always posed difficulties in terms of etiological diagnosis, prevention and restoration.
Interception of the causative factors is sometimes not enough to meet patients' needs, and curative treatment is required.
Restoration of the loss of substance with an adhesive biomaterial is essential, to reduce thermal sensitivity and improve
aesthetics. Such restoration is a complex exercise for the clinician, due to the difficulties that may be encountered. These
difficulties are indeed linked to the particular location of these lesions, making their isolation, visibility and access complex.
The aim of this paper is to describe the management of non-carious cervical lesions, detailing both the therapeutic and
preventive approaches.
Keywords: Cervical lesion, Sclerotic dentin, Adhesion, Composite resin.

Introduction exerted during brushing, duration of brushing) and the

The incidence of carious disease has declined over the last few equipment used (toothbrush, toothpaste) must therefore be
decades, due in particular to preventive measures and the analyzed [2].
development of fluoride therapies. Nevertheless, another form
of lesion has emerged in parallel, and has increased in The aim of this paper is to illustrate, through a case report, the
prevalence and severity. This is non-carious tissue loss. The keys to successful management of non-carious cervical lesions.
development of these lesions is associated with changes in
lifestyles and the longevity of teeth on the arch. They have Case Report
aesthetic, functional and biomechanical consequences. This is a 60-year-old patient who consulted the dental medicine
Depending on the etiology, the clinical appearance is different. department of the sahloul university hospital, Tunisia, for cold
It's important to differentiate between possible etiologies to sensitivity in the lower left premolo-molar sector. Interrogation
adapt preventive treatment, as opposed to restorative treatment, revealed the notion of traumatic brushing using a horizontal
which will be similar [1]. technique. Endobuccal clinical examination revealed non-
carious cervical lesions on 33, 34 and 35 (Fig.1), compromising
Dental abrasion is the abnormal loss of tooth substance or aesthetics and associated with gingival recession and
structure through a mechanical process. It is considered a traumatogenic occlusion. The treatment plan was based on
pathological process. A 3-body abrasion is the displacement of eliminating the factors that had led to the development of non-
two bodies against each other, but with the interposition of carious cervical lesions. The aim of treatment in this situation
abrasive particles between them, constituting the third body. The was to restore the loss of tooth substance and re-establish
presence of an abrasion lesion and gingival recessions, coupled function and aesthetics, thus resolving the problem of
with good oral hygiene, confirms the involvement of the hypersensitivity. The light-curing dam was placed opposite the
"brushing" factor in the etiology of these lesions. Brushing causal teeth (Fig.2). Fluid composite resin restorations were
parameters (brushing technique, brushing frequency, force performed on 33, 34 and 35. (Fig.3-5).
Citation: Kikly A, Jaâfoura S, Bouslema A, Garouachi E, Belghuith AC, et al. (2024) Non-Carious Cervical Lesions: From
Diagnosis to Treatment. Ameri J Clin Med Re: AJCMR-116.
Discussion
The clinician must have a good knowledge of the clinical
characteristics and etiological factors of non-carious cervical
lesions in order to make an accurate diagnosis and identify
potential etiological factors. A clinical investigation must be
carried out on the basis of these characteristics. It is generally
accepted that lesions are not caused by a single etiology, but by
a combination of factors. [3] Abrasion is the abnormal loss of
tooth substance through a mechanical process. It is considered a
pathological process.
Figure 1: Preoperative clinical view showing non-carious Two types of abrasion exist:
cervical lesions on 33, 34 and 35. *2-body abrasion, which is friction between two solid bodies in
movement and in direct contact (dento-dental contacts or wear
by interposed objects).

*3-body abrasion, in which two bodies move against each other,

with abrasive particles interposed between them to form a third
body.

In our case, we're talking about a focal 3-body abrasion caused

by brushing with toothpaste interposition in the cervical region,
with soft tissue integrity compromised by the appearance of
recessions. Traumatic brushing can cause gingival lesions,
which should alert the clinician. The presence of non-carious
Figure 2: Light-curing dam installation. cervical lesions and gingival recessions, coupled with good oral
hygiene, confirms the involvement of the "brushing" factor in
the etiology of these lesions. We therefore need to analyze
brushing parameters (technique, frequency, force exerted during
brushing, duration) and the equipment used (toothbrush and
toothpaste). Horizontal brushing has been shown to be the most
traumatic method, causing two to three times more abrasion than
adapted brushing. It has also been shown that brushing twice a
day or more increases the risk of developing non-carious
cervical lesions. However, it is still advisable to brush twice a
day. Excessive pressure on the brush seems to aggravate the
abrasive process. Ganss et al. found a brushing force of 2.9 N in
Figure 3: Etching with 35% orthophosphoric acid. patients with wedge-shaped lesions, compared with 2.1 N in
patients with no abrasion. It has also been shown that areas at
the start of brushing are the most affected. These areas were
brushed longer and with greater intensity than others [4].

Excessive brushing times, coupled with a faulty brushing

method, can however exacerbate the abrasion phenomenon. It
has been shown that the use of a hard-bristled and/or worn brush
is correlated with gum damage, so a soft-bristled brush is still
recommended [5].

Toothpastes contain abrasive agents to remove stains and

surface deposits from tooth surfaces. Toothpaste compositions
vary, and an index is used to indicate the degree of abrasivity:
Figure 4: Adhesive application and light-curing.
the RDA (relative dentine abrasivity). A higher RDA score
makes a toothpaste more abrasive. Researchers have attempted
to verify the correlation between RDA and the appearance and
development of non-carious cervical lesions. They concluded
that there is a weak correlation between RDA values and
abrasiveness on dentine. He adds that, when used excessively,
toothpaste brushing has little effect on enamel, but can reach
pathological proportions on dentine [4].

Toothpaste thus contributes to the abrasive phenomenon, as

does bristle hardness, but both in minor proportions compared
to brushing method and frequency. The degree of abrasion thus
depends on the technique, frequency and duration of brushing,
Figure 5: Final result after fluid resin application. the material used and the abrasivity index of the toothpaste.
Horizontal brushing combined with hard bristle toothbrushes

Ameri J Clin Med Re, 2024 Page: 2 of 4

Citation: Kikly A, Jaâfoura S, Bouslema A, Garouachi E, Belghuith AC, et al. (2024) Non-Carious Cervical Lesions: From
Diagnosis to Treatment. Ameri J Clin Med Re: AJCMR-116.

and abrasive toothpaste can cause damage to the cervical region. integrity. This integrity degrades over time more rapidly than
Because of their location, they may be accompanied by gingival that of composites [9].
recession and hypersensitivity. These lesions present a hard,
smooth, polished surface. Slight striations caused by toothbrush The coefficient of thermal expansion is very similar to that of
bristles can also be observed. Localization varies according to the tooth, thus avoiding joint failure due to variations in oral
the etiology. In the case of traumatic brushing, they are seen on temperature. Aesthetics remain a major problem with resin-
the vestibular surfaces of maxillary canines and premolars, with modified glass ionomer cements. The porosity of the surface
greater involvement on the opposite side of the brushing hand makes it difficult to maintain good shade stability [10,11].
[4].
Although there in vitro results are not as good as those of
Parafunctional masticatory forces may also expose one or more composites, they give very good clinical results. To overcome
teeth to cervical stresses. These will cause flexion of the affected the defects of resin-modified glass ionomer cements, the
tooth, resulting in microcracks in the hard tissue, which may be Sandwich technique can be used. This technique preserves the
a starting point for the abfraction lesion. The tooth would then advantages of each material. The Sandwich technique reduces
be more susceptible to cofactors such as abrasion. composite setting contraction and preserves bioactivity and
chemical adhesion. Due to the presence of resin in resin-
Abfraction occurs mainly in the V-shaped cervical region, with modified glass ionomer cements, a bond between the two
sharp, clean edges and extends towards the root. The depth of materials is easily established. However, this technique is time-
these lesions may be more than their width, leading to consuming and complex. It is indicated for deep lesions [12].
hypersensitivity. It has been shown that a combination of
traumatic brushing and occlusal stress can lead to increased Some authors recommend occlusal equilibration to remedy the
tissue loss. This is a phenomenon of synergy between abfraction abfraction phenomenon and halt the progression of damage.
and abrasion. Abfraction is confirmed by the deep wedge shape Indeed, pathological interfering contacts are thought to
and the presence of sharp edges, and abrasion is confirmed by contribute to the evolution of these lesions [13,14,15].
the presence of horizontal grooves, gingival recessions and the
A periodontal approach may be considered when a large lesion
notion of traumatic brushing. The final lesion is thus the result
causes aesthetic discomfort, hypersensitivity or rapid
of different factors, which may coexist and potentiate the effects
progression. In order to achieve quantitative and qualitative
of one through the action of another. Consequently, it is difficult
tissue reconstruction, it is important to achieve rapid healing,
to classify a lesion in a distinct category (abrasion, abfraction),
with primary healing being an essential factor for success [16].
as the different etiologies may act together in varying
proportions to form the final lesion [6,7]. The choice of surgical approach depends on several factors:
- Defect-related factors: number and size of recessions,
Management of non-carious cervical lesions requires patient
quality/quantity of keratinized tissue apical and lateral to the
information and motivation. It is vital to make patients aware
defect, height and width of the papilla.
that their hygiene habits have potentially harmful
- Patient factors: Aesthetic demand and the need to reduce post-
characteristics. Patients should be encouraged to learn
operative discomfort.
atraumatic brushing techniques, and an electric toothbrush
should be prescribed if necessary, as some have an "off" In addition, the clinician must consider literature data in order to
function when brushing becomes too aggressive for tooth tissue select the most predictable and reproducible surgical approach
[8]. among those achievable in a given clinical situation [17].
This is followed by restoration of the loss of substance with an Long-term maintenance of restorations requires follow-up care.
adhesive biomaterial, to reduce thermal sensitivity and improve Because these lesions usually develop silently, the patient does
aesthetics. Restoration is a complex exercise for the clinician, not become aware of them until later, and bad habits quickly
due to the difficulties that can be encountered. These difficulties return. For this reason, it is advisable to monitor the evolution
are indeed linked to the particular location of these lesions, of these lesions at regular intervals, every 6 to 12 months,
making their isolation, visibility and access complex. They are depending on their severity. Macroscopic photographs and
also linked to the difficulty of achieving optimal bonding on plaster casts enable clinicians to follow the evolution of lesions.
sclerotic dentine. For this reason, etching with ortho-phosphoric This can also be used to illustrate the problem to the patient,
acid is essential. The combination of an adhesive system and a motivating them to change their habits [18].
flowable composite resin remains the procedure of choice.
Indeed, given its excellent aesthetic properties and satisfactory Conclusion
clinical performance, composite is the material of choice for As non-carious cervical lesions can be the cause of aesthetic
non-carious cervical lesions. It has been shown that cervical discomfort, this factor is a frequent reason for consultation. The
lesions, whose initial cause is abfraction, should be restored with multi-factorial origin of non-carious cervical lesions explains
a micro-filled composite resin or a flowable resin with a low the difficulties in diagnosing and implementing effective
modulus of elasticity, so that the latter can flex with the tooth preventive treatment, given the large number of risk factors
without compromising retention. Like glass ionomer cements, involved. Restorative treatment is required in cases of
resin-modified glass ionomer cements can chemically adhere to compromised tooth structural integrity, cervical hypersensitivity
dentin. Surface pre-treatment is required. The addition of resin with exposed dentine or unacceptable aesthetics for the patient.
enables the establishment of mechanical bonds similar to those Restoration is a complex exercise for the clinician because of
of the hybrid layer. Compared with glass ionomer cements, the difficulties that can be encountered. Today, effective
resin-modified glass ionomer cements have better marginal bonding is the key to the success and longevity of aesthetic
restorations. It is essential to understand the obstacles and

Ameri J Clin Med Re, 2024 Page: 3 of 4

Citation: Kikly A, Jaâfoura S, Bouslema A, Garouachi E, Belghuith AC, et al. (2024) Non-Carious Cervical Lesions: From
Diagnosis to Treatment. Ameri J Clin Med Re: AJCMR-116.

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Copyright: © 2024 Kikly A. This Open Access Article is licensed under a Creative Commons Attribution 4.0 International (CC BY 4.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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