HOW DENTISTS CLASSIFIED AND
TREATED H U B C EM A l LESIONS
JAMES D. BADER, D.D.S., M.P.H.; LINDA C. LEVITCH, PH.D.; DANIELA. SHUGARS, D.D.S., PH.D., M.P.H.;
HARALD O. HEVMANN, D.D.S., M.ED.; FRANCES MCCLURE, D.D.S.
on-carious cervical lesions,
characterized by the loss of
hard tissue a t the cemento-
enamel junction in the absence
of caries, are conditions
commonly encountered in
dental practice. Little is known
about their overall prevalence,
particularly in the United
States.'
Most case studies suggest
th a t prevalence increases with
age,25but substantial numbers
are found in people younger
than 35.610 The aging of the
population, coupled with
prolonged retention of teeth
into old age, means that
dentists are likely to encounter
more patients with non-carious
cervical lesions.1'7,1112
Non-carious cervical lesions
are usually classified by their
commonly accepted causes.
Three major types are believed
to be caused by abrasion
associated with toothbrushing,
by chemical erosion and by
tooth flexure. The criteria used
to differentiate among lesion
types are based on
morphological characteristics,
and these types are fairly well-
defined in the literature.1315 The
differential diagnosis of a lesion
in clinical practice is more
problematic because any
46 JADA, Vol. 124, May 1993
ABSTRACT
All North Carolina
general dentists were
shown color photographs
of three non-carious
cervical lesions. A fourth
picture showed cervical
caries. Respondents were
asked how they defined
each lesion, its cause,
treatment and frequency
of appearance in practice.
Cervical caries was
identified and treated by
almost all responding
dentists, but they applied
more varied terms, causes
and treatments to non-
carious defects.
individual lesion is likely to
result from the interaction of
one or more etiologic factors.316
Preventing the development
of additional lesions and halting
the progression of lesions
already present depend on a
determination of the etiologic
factors acting in each individual
patient. Without this knowl­
edge, appropriate prophylactic
measures cannot be used.
Treating lesions with restora­
tions or through other means
also may be ineffective in the
long-term unless the causes are
eliminated.17'18
Yet almost nothing is known
about how these factors and
their interactions relate to the
morphological structure of a
lesion, how they relate to the
presence of multiple lesions in
an individual and which factors
are most important in
determining the natural history
of the lesion(s). Many questions
remain about the action and
interaction of abrasion, erosion,
attrition and occlusal forces in
producing these
conditions.4'10’13'141719'20
There are no dental practice
standards to determine how or
when to treat non-carious
cervical lesions. Although the
assumption has been th a t all
cervical lesions should be
treated in the same way,
regardless of their cause, recent
clinical investigations belie this
notion.2022The first step in
effective treatm ent is, again,
recognizing their cause.
Although the prevalence of
these lesions is thought to be
increasing, we do not know the
frequency with which they are
being restored.
Textbooks of operative
Figure 1. Condition A.
Figure 3. Condition C.
dentistry recommend restoring
non-carious cervical lesions
when the patient is experienc­
ing pain or sensitivity
associated with the lesion, or
when the patient is concerned
about the unesthetic appear­
ance.23'26 Retention of food or
plaque in the lesion and
potential for tooth fracture or
pulpal exposure are also cited
as reasons for restoration.2526
The extent to which practi­
tioners classify non-carious
cervical lesions according to
current criteria, identify their
commonly accepted causes and
initiate appropriate control,
prevention and restorative
strategies is completely
unknown. Our survey
Figure 2. Condition B.
Figure 4. Condition D.
represents an initial attem pt to
identify these issues by
examining the extent of
variation among dentists in how
they classify and treat non-
carious cervical lesions. In
addition, we used the survey to
assess variation in dentists’
identification of factors likely to
have produced lesions as well as
in the types of patient education
used by dentists.
M ETHO DS
One section of the questionnaire
designed to explore the charac­
teristics of North Carolina
general dentists’ restorative
treatm ent practices was
devoted to questions concerning
cervical lesions. Clinical
photographs of three non-
carious cervical lesions (Figures
1-3), each with different charac­
teristics, were selected as
“conditions.” A fourth photo­
graph (Figure 4) was an
example of root caries.
If we assume th a t root caries
offers a relatively unambiguous
visual presentation, the extent
of variation among respondents
in their identification of this
“condition” would help define
the limitations of the photo­
graphic presentations. V aria­
tion in responses concerning
causes and treatm ent of the
carious lesion would also serve
as a comparison for variation in
similar responses associated
with non-carious conditions.
JADA, Vol. 124, M ay 1993 47
TABLE 1

PERCENT DISTRIBUTION OF TERMS OENTISTS ÖSE TO REFER TO CONDITIONS.

Condition

Term
A B C D

(n=700) (n=704) (n=697) (n=702)

Abrasion 50 16 85 Ol

Erosion 23 74 IO 02

Caries 14 Ol OO 93

Other 07 02 03 Ol

Combination 06 07 02 03

TABLE 2

Condition
< 10

T reatment B C D
- «

**
(0

(n=653)
c

(n=675)
II

(n=690)

None 35 44 63 03

Restoration 41 41 95
24

Occlusal adjustment 05 02 OO
03

Other 03 OO
05 02

Combination 16 08 Ol
08

A set of questions was
developed to identify the term s
practitioners used to refer to
the conditions as well as to
elicit their thoughts about the
causes, treatm ents, prevention
and frequency of appearance of
the conditions. The same
questions were asked for each of
the four conditions. For the
question on terminology, the
response options were abrasion,
erosion, caries, other. For the
question on causes, the options
were toothbrushing, dietary
factors, oral habits, occlusal
forces, medications, gastric
reflux, other. For treatm ent, the
options were none, restoration,
occlusal adjustment, other.
No instructions were given
concerning how many response
options could be identified for
these questions, and “combi­
nation” responses (two or more
options indicated) constituted
another response category.
Respondents also were asked if
they routinely stressed
toothbrushing instruction or
dietary counseling to patients
with these conditions.
The photographs and ques-

48 JADA, Vol. 124, May 1993

TABLE 3
PERCENT DISTRIBUTION OF FREQUENCY ESTIMATES AND ESTIMATED MEAN PREVALENCE FOR CONDITIONS.
Estimate
Frequency
0-1 patients/month
2-5 patients/month
6-10 patients/month
More than 10
patients/month
Combination
Mean prevalence
Proportion of patients
with condition
tions were reviewed initially by
a small panel of restorative
faculty, which resulted in
format changes. Additional
modifications were made after
pretesting the photographs and
questions on a group of 30
practitioners who were attend­
ing a continuing education
course. Their comments led to
wording changes to improve
ease of completion by relating
response options to clinical
practice.
In January 1992, the
questionnaire was sent to all
active general dentists
(n=2,146) licensed by the North
Carolina State Board of Dental
Examiners. The questionnaire
was accompanied by a cover
letter from the chair of the
Departm ent of Operative
Dentistry requesting assistance
with the project. Eight weeks
later, a new letter and second
Condition
>
B C
©
(0
0)
(n=696)
3
II
03 25
21 42
28 20
47 12
Ol Ol
05 03
copy of the questionnaire were
sent to those who had not yet
responded. All non-respondents
remaining after the two
mailings received a letter
requesting them to complete
three practice-related survey
questions taken from the
questionnaire and printed on a
postcard. Responses to these
questions and demographic
characteristics available from
the state board were compared
for respondents and non­
respondents.
The analyses reported here
do not include dentists
employed by local, state or
federal government (7.7 percent
of respondents), or working less
than 32 hours per week (22.8
percent of respondents). These
restrictions were imposed to
maximize generalizability of the
results to an easily defined
group—full-time private
D
(n=692) (n=696)
io 03
34 35
29 37
27 25
OO OO
04 04
general practitioners. Thus,
responses from practitioners
operating within limited
treatm ent protocols typical in
some governmental programs,
and from practitioners with a
limited activity status were
dropped from the analysis.
For each of the four
conditions, distributions were
calculated for the term s used to
refer to the condition, the usual
treatm ent provided and the
number of patients seen each
week with the condition.
Numbers of responses vary
because of missing data for
specific survey items. In
addition, distributions of causes
and treatm ents associated with
each term were calculated.
Each respondent’s estimate of
the number of patients seen
each month with each of the
four conditions was divided, by
four times the total number of
JADA, Vol. 124, May 1993 49
TABLE 4
PERCENT DISTRIBUTION RE CAUSES ASSOCIATED WITH TERMS USED TO DESCRIBE CERVICAL LESIONS.
Cause
Dietary factors
Oral habits and other
Occlusal forces
Medications and
gastric reflux
Combination
patients reported to be seen in
the practice each week. The
quotients, expressed as
percentages,represented
estimated prevalence rates,
th a t is, the proportion of
patients with the condition.
RESULTS
Of 2,146 questionnaires sent to
licensed active general dentists,
38 were returned as
undeliverable or returned by
dentists no longer in active
practice. Six weeks after the
second mailing, 959 dentists
(45.5 percent) had responded.
Because returned postcards
indicated th a t 4.7 percent of
these survey non-respondents
were not active in dentistry, a
final adjusted response rate of
46.7 percent was calculated.
D ata from licensure files
indicated that respondents and
non-respondents did not differ
by gender, practice setting,
employment status or number
of other dentists in the practice.
However, respondents were
50 JADA, Vol. 124, May 1993
Term
Abrasion Erosion Caries
(n=1,059) (n=7,26) (n=727)
79 14 IO
OO 26 45
05 09 26
04 21 Ol
Ol 11 Ol
11 19 17
more likely to be white (96
percent vs. 89 percent) and to
have graduated more recently
(1974 ±10.6 years vs. 1971 ±12.8
years). Respondents worked
more total hours per week (37.3
±6.9 vs. 36.3 ±8.6) and
employed more dental team
members (3.1 ±1.9 vs. 2.7 ±2.0).
Respondents were more likely
to be graduates of the state
dental school (68 percent vs. 54
percent), and controlling for
dental school did not eliminate
the other differences. Non­
respondents who returned the
postcard reported similar
patient care hours each week
(33.8 ±8.3 vs. 33.3 ±6.3), but did
indicate extracting or referring
for extraction fewer patients
each month (20.6 ±32.0 vs. 26.0
±32.2) and seeing fewer
fractured teeth each week (2.8
±1.4 vs. 3.0 ±1.4).
The term s respondents used
to refer to the four conditions
are shown in Table 1. The
greatest variation in
terminology occurred for
Other Combination
(n=77) (n=123)
11 12
Ol 03
14 09
57 IO
05 02
13 63
condition A; half of dentists
used the term abrasion. The
remaining respondents referred
to the condition as erosion,
caries, or another term or a
combination of terms. For
conditions B and C, substantial
majorities of dentists agreed on
a single term —erosion for
condition B and abrasion for
condition C. In both instances,
however, at least 15 percent of
dentists used another term.
Almost all dentists referred to
condition D as caries.
The treatm ents th a t dentists
reported performing for each of
the conditions are shown in
Table 2. For condition A, 41
percent of respondents
indicated th a t treatm ent was a
restoration. Because most of the
combination treatm ents
dentists reported for this
condition (69 percent of all
combinations) consisted of
placing a restoration and
performing an occlusal
adjustment, condition A would
receive restorative treatm ent by
TABLE 5

PERCENT DISTRIBUTION DF INTERVENTIONS BY ATTRIBUTED CAUSE, ALT CONDITIONS COMBINED.

Intervention Cause

Tooth- Dietary Oral Occlusal Medication Combi­ Total

brushing factors habit forces and gastric nation (N=2,704)

T reatment (n=1,028) (n=523) and (n=260) reflux i(n=459)

other (n=94)

(n=340)

None 57 20 21 25 39 26 36

Restoration 36 78 74 22 48 51 50

Occlusal

adjustment OO OO OO 23 OO Ol 03

Other 02 Ol 02 04 io 03 03

Combination 05 Ol 03 26 03 19 08

Counseling

Percent

stressing

dietary

counseling 32 91 57 20 91 68 56

Percent

stressing

toothbrushing

instruction lOO 92 90 80 84 93 94

slightly more than half of all
respondents.
Condition B would be
restored by slightly less than
half of respondents, including
those who indicated
combination treatm ents.
Condition C would be treated by
a minority of respondents and
condition D by nearly all.
Although not shown in the
table, the proportion of respond­
ents indicating their treatm ent
would be a restoration (alone or
in combination) was also
calculated for all uses of each
classification term. Of those
term ing a condition abrasion,
38 percent treated with a
restoration. For the term
erosion, 47 percent of trea t­
ments included a restoration.
This proportion was 49 percent
for other, 73 percent for
combinations of term s and 99
percent when a condition was
termed caries.
The distributions of
responses about the frequency
with which conditions are seen
are shown in Table 3, together
with the estimated prevalence
for each condition. Condition A
had the highest estimated
prevalence at 5 percent of all
patients. Almost half of

JADA, Vol. 124, M ay 1993 51

respondents indicated th a t they
saw more than 10 patients each
month with this condition. The
mean estim ated prevalence for
condition B was the lowest.
Most respondents indicated
they saw between two and five
patients each month with the
condition.
For each term dentists
selected to identify a condition,
Table 4 shows the percent
distribution of causes th at
respondents associated with the
term. Each distribution
includes all uses of a term,
regardless of the condition to
which it was applied. More than
three-fourths of respondents
using the term abrasion
associated this condition with
toothbrushing. Additionally, 11
percent of the respondents
indicated th a t abrasion was
caused by a combination of
factors. Most of these respond­
ents included toothbrushing in
th a t combination.
Causes associated with
conditions term ed as erosion
were much more varied, with no
more than about a fourth of
respondents who used this term
agreeing on any single
attributed cause. A majority of
respondents who indicated
more than one cause for erosion
conditions included medication
and gastro-esophageal reflux
among the causes. Conditions
referred to as caries were most
frequently associated with
dietary factors and oral habits,
although toothbrushing and
combinations were also
frequently indicated.
Most of those indicating th a t
they used a term not among the
response options (other) did so
when attributing the cause of
the condition as occlusal forces.
The most frequently mentioned
other term was “abfraction,” a
52 JADA, Vol. 124, May 1993
term defined as “pathologic loss
of hard tissue tooth substance
caused by biomechanical
loading forces.”27Several
respondents referred to the
condition simply as a defect
associated with occlusion.
For each of the causes to
which dentists attributed a
condition, Table 5 shows the
distribution of associated
treatm ents. For each cause, the
table also shows the percent of
respondents indicating th a t
they would stress dietary
counseling and toothbrushing
instruction. Conditions
attributed to toothbrushing and
occlusal forces were the least
likely to be treated with a
restoration, while those
attributed to dietary factors or
oral habits were the most likely
to be restored.
Occlusal adjustments figured
only in conditions thought to be
caused by occlusal forces, and
even then were mentioned in
less than half of these
instances, including
combinations. Toothbrushing
instruction was stressed by
more than 80 percent of
respondents regardless of the
cause(s) attributed to the lesion,
while dietary counseling was
stressed by more than this
percentage only if the lesion’s
attributed cause(s) included
dietary factors or medications
and gastro-esophageal reflux.
DISCUSSION
The results of this survey illus­
trate three areas of professional
uncertainty concerning non-
carious cervical lesions:
classification, cause and
treatm ent.
™ C lassification. Uncertainty
about classification is reflected
in the extent of agreement on
terms used to refer to the
conditions. P art of this problem
may be the result of the terms
available for use. As noted
earlier, none of the term s in
common use describes the
physical characteristics of the
lesion; all refer to a probable
cause. Respondents thus found
it necessary to “diagnose” from
a photograph without any
additional information from the
patient th a t could help identify
a cause.
The substantial proportion of
respondents who indicated two
term s also may signal
uncertainty in classifying the
condition without additional
information. It is likely th a t the
variation in selecting a term to
describe condition A, and to a
lesser extent conditions B and
C, is in good part the result of
the absence of a standard set of
term s for non-carious cervical
lesions based on anatomical
features, rather than attributed
causes.
Respondents nearly com­
pletely agreed about condition
D, which was almost univers­
ally identified as caries. This
condition apparently offers a
unique clinical presentation
th at dentists are unlikely to
attribute to any other cause.
Also, the high level of
agreement for this condition
suggests th a t the photographs
offered reasonably clear
presentations of the clinical
conditions, thus minimizing
concern about this possible
source of variation in
practitioners’ responses.
■■ Cause. The second area of
uncertainty is reflected in the
relative lack of agreement on
the cause of some of these
lesions—despite the convention
of referring to them by names
th a t imply causal processes.
The term abrasion was
associated specifically with
toothbrushing by almost four-
fifths of the respondents using
the term. Thus, while the term
abrasion was used to refer to a
variety of clinical presentations,
the commonly accepted
causative agent, toothbrushing,
was fairly well agreed on by
those using the term.
Among those referring to a
condition as erosion, there were
three separate causes, each
comprising about 20 percent of
attributions. One of these was
the combination cause in which
a majority of responses included
yet another attributed cause.
Thus term erosion also was
used to refer to a variety of
clinical presentations, but
causal attributions were much
more varied, perhaps reflecting
both our current knowledge and
the wider range of conditions
th a t dentists term erosion.
Causes attributed to the
term caries generally reflected
current understanding of the
multifactorial causes of dental
caries as well as possibly
differing interpretations of the
response options, th a t is,
toothbrushing may have been
interpreted as a lack thereof,
and combination responses may
have been attem pts to
demonstrate an awareness of
multiple etiologic factors.
Finally, the small number of
respondents indicating a term
other than abrasion, erosion or
caries to refer to a condition
most often attributed the
condition to occlusal forces,
reflecting a growing awareness
of this possible etiologic factor.
21,22
■■ Treatm ent. The third area
of uncertainty is reflected in the
lack of agreement on treatm ent
approaches, either for the three
specific conditions illustrated or
for responses grouped by
attributed cause. In contrast,
nearly complete agreement was
found for condition D. Almost
all respondents recommended a
restoration. About 50 percent of
the respondents indicated th a t
they would restore conditions B
and C—with or without
additional treatm ent—which
represents the maximum
possible level of disagreement.
While some of this disagree­
m ent is undoubtedly a result of
an incomplete presentation of
the clinical and non-clinical
factors necessary for classif­
ication, there is clearly no
consensus on the usual
approach to treatm ent. Again,
some of the lack of agreement
might be the result of the
incomplete presentation. Treat­
ment decisions often depend on
patient concerns about tooth
sensitivity or appearance. Even
with th a t limitation, however,
there is considerable variation
in treatm ent approaches.
Respondents indicated th at
toothbrushing instruction
would be stressed for all
conditions, which may reflect
both the usual practice routine
for all patients and the fact th a t
toothbrushing was the most
common causal agent indicated
across all conditions. Respond­
ents were more selective in the
circumstances under which they
indicated they would stress
dietary counseling. In more
than 90 percent of instances
where a condition was
attributed to dietary factors or
medications and gastro­
esophageal reflux, respondents
indicated th at dietary
counseling would be stressed.
Across all causes, dietary
counseling would be stressed in
56 percent. Without clear
causal links between specific
dietary factors and specific
cervical lesions, some of this
counseling may be ineffective.
Again, a better understanding
of the causes would
undoubtedly improve the
effectiveness of therapeutic and
preventive interventions.
The estimated mean
prevalences of the four
conditions reinforce the need to
better understand their causes
and natural histories. The
prevalence estimates are not
additive because some lesions
were thought to be two
presentations of the same
condition by some respondents,
and some patients may have
more than one condition.
Nevertheless, even the simple
prevalence estimate for condi­
tion A of 5 percent, coupled with
a 50 percent likelihood th a t
such a condition will be treated
with a restoration, illustrates
the magnitude of the treatm ent
activity associated with cervical
lesions.
The lower prevalence
estimate for condition D, which
was almost universally termed
“caries,” may be the result of
the higher probability th a t such
conditions will be restored.
Although the incidence of
condition D may be equal to or
greater than th a t of other
cervical lesions, the prevalence
is lower because of higher
treatm ent rates.
The lower than usual
response rate to this survey
may well reflect dentists’
uncertainty both about cervical
lesions and the methods
necessary to assess this
uncertainty. Anecdotal
comments indicate th a t some
non-respondents regarded the
survey as a test, and this
perception discouraged their
response. Comparing respond-
JADA, Vol. 124, May 1993 53
ents and non-respondents
reflects the usual pattern of
lower response rates among
older dentists and non-white
dentists, and shows practice-
related differences that are
generally age-related.28 There
are no reasons to expect the
extent of variation among all
North Carolina dentists to be
different from that reported
here.
This variation in responses
concerning terminology,
causation and treatment
underscores the necessity for a
better understanding of non-
carious cervical lesions.
Without a better understanding
of the etiologic factors involved
in the initiation and progression
of these various conditions,
differentiation in practice will
continue to be difficult. If causal
factors are not eliminated,
because selection of an
approach to treatment and
efforts to achieve behavioral
change for a patient are not
based on knowledge of the
associated etiologic factors, then
treatment success could be
threatened.21Finally, without
standard terminology based on
observable aspects of a given
condition, communication to
and among practitioners also is
more difficult.
CONCLUSION
Responses to a survey of North
Carolina dentists about non-
carious cervical lesions and
carious cervical lesions indicate
that cervical caries was
identified and treated by almost
all respondents. There was,
however, great variety in
responses to terms, treatment
and causes for non-carious
cervical lesions. The prevalence
54 JADA, Vol. 124, May 1993
of cervical lesions reported in
this survey suggests that we
need to improve our under­
standing of these conditions. ■
This study was supported by a g ran t from
ILSI N orth America (the N orth American
branch of the Intern atio n al Life Sciences
Institute) and g ran t HS06669 from th e
Agency for H ealth C are Policy and Research.
The authors th a n k Eric L andis for his efforts
in m anaging th e survey, and Jim Beck for his
advice.
Dr. B ader is research associate professor,
D epartm ent of O perative D entistry, School of
D entistry, U niversity of N orth Carolina, CB
No. 7450, Chapel Hill, N.C. 27599-7450.
Address rep rin t requests to Dr. Bader.
Dr. Levitch is research associate,
D epartm ent of O perative D entistry, School of
D entistry, U niversity of N orth Carolina.
Dr. Shugars is associate professor,
D epartm ent of O perative D entistry, School of
D entistry, U niversity of N orth Carolina.
Dr. H eym ann is associate professor and
chair, D epartm ent of O perative D entistry,
School of D entistry, U niversity of North
Carolina.
Dr. McClure is research associate,
D epartm ent of O perative D entistry, School of
D entistry, U niversity of N orth Carolina.
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