Adhesive restorations for the treatment of dental non-carious

cervical lesions (Protocol)

Veitz-Keenan A, Spivakovsky S, Lo D, Furnari W, ElSayed H

This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
Library 2014, Issue 12
http://www.thecochranelibrary.com

Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol) i
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Protocol]

Adhesive restorations for the treatment of dental non-carious

cervical lesions

Analia Veitz-Keenan1 , Silvia Spivakovsky1 , Danny Lo1 , Winnie Furnari2 , Hend ElSayed3

1 Oral Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, USA. 2 Dental Hygiene

Program, College of Dentistry, New York University, New York, New York, USA. 3 Orthodontics & Paediatric Dentistry, National
Research Center (NRC), Giza, Egypt

Contact address: Analia Veitz-Keenan, Oral Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry,
345 East 24th Street NYC 1st floor, New York, 10010, USA. av244@nyu.edu.

Editorial group: Cochrane Oral Health Group.

Publication status and date: New, published in Issue 12, 2014.

Citation: Veitz-Keenan A, Spivakovsky S, Lo D, Furnari W, ElSayed H. Adhesive restorations for the treatment of dental non-carious
cervical lesions. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD011449. DOI: 10.1002/14651858.CD011449.

Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

This is the protocol for a review and there is no abstract. The objectives are as follows:

To assess the effects of adhesive bonded restorations in reducing dentine hypersensitivity in adults compared with any non-adhesive
interventions or no treatment.

BACKGROUND
Description of the condition
A non-carious cervical lesion (NCCL) is a dental hard tissue defect
of unknown origin that has two very distinct variations, a wedge-
shape and a saucer-shaped lesion (Walter 2013). The lesion is
characterised by the loss of structure in the coronal part of the
tooth, known as the cementum-enamel junction, placing it at the
union between the enamel of the crown and the root of the tooth
(Ceruti 2006).
Oral health providers have been aware of NCCLs for a long time.
As for its diverse aetiology, Black 1908 and Grippo 1992 describe
some possible causes of NCCLs, including occlusal force, erosive
agents and mechanical abrasion due to intense tooth brushing.
However, a systematic review was unable to determine any specific
Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
aetiological factors for NCCLs due to the risk of bias and other
confounding factors in the literature available (Senna 2012).
Studies of the prevalence of NCCLs have reported conflicting
results (Levitch 1994; Wood 2008) with rates ranging from 2% in
early studies (Shulman 1948) to 85% in later studies (Bergstrom
1988). All studies found an increased prevalence with age: older
individuals have a greater number of lesions than younger people
and the lesions tend to be larger. Wood 2008). A recent study
found the proportion of individuals with hypersensitive teeth due
to the presence of NCCLs increased significantly with age (Que
2013).
Gingival recession (apical migration of the gingiva) is when the
gum recedes and exposes a cervical zone of the tooth to the oral
environment. When that area is exposed there is a trend toward
hard structure loss in that area, and sometimes sensitivity is re-
ported (Perez Cdos 2012). Tooth hypersensitivity is defined as
pain caused by a non-noxious stimulus. Teeth with exposed dentin
or gingival recession are subject to dentin hypersensitivity. Tooth
1
hypersensitivity can occur because of abrasion, erosion or attri-
tion of the enamel surface, which exposes the underlying dentin,
or to gingival recession, which exposes the root surface. Such ex-
posed surfaces near the gingival crest are referred to as NCCLs
(Veitz-Keenan 2013).
NCCLs can affect individuals in different ways: some individuals
have no symptoms, others show transient sensitivity and others
can experience a more serious painful condition affecting the tooth
vitality. In some instances, the severity of the dentin hypersensi-
tivity can affect the individual’s quality of life (Bekes 2009). Hy-
persensitivity is related to the flow of fluid in open dentin tubules
exposed during the progression of the lesion (Cuenin 1991).
At what point an NCCL requires the dentist’s intervention remains
controversial, and information on this matter is as diverse as the
materials available for such interventions (Bader 1993). However,
when symptoms are present it is important to be able to decide
how best to treat these lesions.
The treatments recommended for NCCLs vary. Some experts ad-
vocate ’wait and watch’ as an option; others recommend early
restorative intervention (Perez Cdos 2012; Wood 2008), and oth-
ers suggest gingival grafting or some type of periodontal surgery
(Santamaria 2013). Practitioners have reported in surveys that the
choice of restoration procedure is determined by the severity and
sensitivity of the lesions (Bader 1993; Little 1998). Patients’ aes-
thetic concerns also appear to influence the decision about whether
NCCLs should be restored (Nieri 2013).
Some literature suggests that active treatment is necessary and that
restoring the teeth is important for several reasons (Gallien 1994;
Grippo 1992). For example, it has been claimed that NCCLs may
increase plaque accumulation and potentially lead to caries and
periodontal disease (Michael 2009).
Description of the intervention
With regard to restorative treatment, there is an extensive number
of adhesive options, with diverse aesthetic and bonding character-
istics, available for the professional to choose from (Onal 2005).
When a restorative procedure is selected for an NCCL it is ac-
cepted that the aim of the procedure is not to treat the lesion or to
correct its underlying aetiology, but to replace the structure that
has been lost, obliterate the open dentinal tubules, reduce symp-
toms, if present, and possibly halt the progression of the problem
(Levitch 1994; Michael 2009; Perez Cdos 2012).
The majority of NCCLs exhibit mixed cavity margins positioned
on both the enamel and the dentin or the cementum. As a result,
restoration of this type of cavity can be difficult with restorative
materials that bond equally to enamel and dentin. Different struc-
tural features may adversely affect the performance of the restora-
tive materials used in the cervical area.
Popular choices for the restoration of NCCLs are adhesive mate-
rials including resin-based composites (RBcs) and glass ionomer
cements (GICs).
Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
GICs have been used for the purpose of restoring cervical lesions
for many years because they bind chemically to enamel and dentin,
they release fluoride and they prevent caries. However, GICs are
associated with aesthetic concerns, and their lower wear resistance
has limited their use for the restoration of cervical lesions compared
to resin -based composites (Pecie 2011).
RBc materials are considered more aesthetically acceptable than
GICs. They are, however, associated with shrinkage during poly-
merisation and with possible side effects such as microleakage,
marginal discolouration, postoperative sensitivity and recurrent
caries. Some authors have expressed their concern regarding the
longevity of the marginal seal obtained with RBcs (Ichim 2007).
In addition, the application of the adhesive resin composites dur-
ing restoration can involve several steps depending on the material
selected. Multistep adhesive systems have now been replaced by
self-etching techniques, and the manufacturers’ claims that these
newer techniques are less technique- and operator-sensitive and
are associated with fewer side effects (van Dijken 2008).
It appears that the success of composite restorations is dependent
upon the type of RBc or bonding system used (Peumans 2005).
Newer generations of these adhesive restorative materials (hybrid
materials) have been developed in order to overcome the complica-
tions associated with the restoration of cervical lesions: resin-mod-
ified GICs (RM-GICs) and polyacid-modified RBcs (PM-RCs).
The composition and application methods of these newer materi-
als differ substantially from those of their earlier counterparts, and
it is claimed that they have greater wear resistance, better aesthetics
and improved bond strength and acceptability (Folwaczny 2001;
Francisconi 2009; Pecie 2011).
The longevity of this type of restoration depends on many factors:
some related to the technique, how the material is applied, and
the degree of isolation and moisture control that is used. Newer
materials appear very often on the market claiming to reduce some
negative side effect or shortcoming of previously available restora-
tive materials (Loguercio 2003; Folwaczny 2000).
How the intervention might work
Adhesive restorations have been on the market for more than 50
years. They are widely accepted and used by practitioners world-
wide (Buonocore 1955; Tyas 2004).Adhesive restorations are used
to replace the missing tooth structure characteristic of NCCLs,
with the purpose of obliterating the exposed dentinal tubules and,
as a result, reducing sensitivity and possibly halting lesion pro-
gression (Bader 1993; Levitch 1994). Composite restorations are
dependent on adhesive systems, whereas glass ionomers establish
a chemical bond to enamel and dentin.
Why it is important to do this review
2
Because the aetiology of NCCLs is unclear, the approach to clinical
management is uncertain. As reported by studies, there is wide
variability in clinical practice for the diagnosis and treatment of
NCCLs. The treatment provided by dental practices ranges from
monitoring, to fluoride applications, dental sealers and restoration.
A recent study from a Dental Practice Based Research Network
found that a RBc was the material of choice for most of practi-
tioners, and that restorations using GICs and RM-GICs was low
(4%) (Nascimento 2011).
In a limited study by Nieri 2013, of individuals with gingival
recession and NCCLs, a small percentage of individuals presented
with symptoms or a request for treatment for those lesions.
Hence, the decision to restore NCCLs should be evaluated care-
fully, with the aim being to address the possible aetiology as well.
A systematic review investigating the best research evidence con-
cerning the clinical performance of different adhesive restorative
materials, bonding agents and available techniques for the treat-
ment of NCCLs is important for both practitioners and individ-
uals with NCCLs.
OBJECTIVES
To assess the effects of adhesive bonded restorations in reducing
dentine hypersensitivity in adults compared with any non-adhesive
interventions or no treatment.
METHODS
Criteria for considering studies for this review
Types of studies
All randomised controlled clinical trials comparing the use of ad-
hesive restorations ton non- adhesive restorations in NCCLs in
permanent teeth, with a minimum follow up of one week. We will
include both parallel and split-mouth designs.
Types of participants
Adults aged 18 years and over with permanent teeth and at least
one NCCL in a vital tooth with a prescribed adhesive restoration,
non-adhesive restoration or not treatment
Types of interventions
Any type of adhesive restoration placed on a vital tooth with
an NCCL, including but not limited to resin-based restorations,
Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
flowable composite, compomers glass ionomers and resin glass
ionomers.
We will include studies where the comparison groups received any
non-adhesive intervention, such as amalgam, or any other inter-
vention (e.g. periodontal therapy or chemical therapy, including
but not limited to dentifrices and any other desensitiser agents),
or no treatment.
Types of outcome measures
Primary outcomes
• Sensitivity. Postoperative sensitivity may be measured using
a visual analogue scale (VAS), administered by the practitioner or
self-report by the participant
• Adverse reactions (biocompatibility, progression of the
lesion, pulpal involvement, other)
• Patient satisfaction, including quality of life (QoL)
Secondary outcomes
• Survival
• Mechanical/functional failure, Including marginal
adaptation, fracture, partially missing restoration, mobility,
secondary caries, discolouration
• Aesthetics
• Cost
Depending on the data available, we will group the outcomes and
analyse the results according to clinically important time points,
such as one week, one month, one year and three years after place-
ment of the restoration.
Search methods for identification of studies
For the identification of studies included or considered for this
review, we will develop detailed search strategies for each database
searched. We will base these on the search strategy developed for
MEDLINE, but will revise them appropriately for each database
to take account of differences in controlled vocabulary and syntax
rules.
We will link the above search strategy to the Cochrane Highly Sen-
sitive Search Strategy for identifying randomised controlled trials
in MEDLINE (sensitivity-maximising version (2008 revision)),
as published in Box 6.4c in the Cochrane Handbook for Systematic
Reviews of Interventions (Higgins 2011).
Electronic searches
We will search the following databases:
• the Cochrane Oral Health Group Trials Register (to
present);
3
 • the Cochrane Central Register of Controlled Trials
(CENTRAL; latest issue);
• MEDLINE via OVID (1946 to present);
• EMBASE via OVID (1980 to present);
• LILACs via BIREME Virtual Health Library (1980 to
present).
We will place no restrictions on language or date of publication.
Searching other resources
We will search the following trial registries for ongoing studies:
• the US National Institutes of Health Clinical Trials
Database (http://clinicaltrials.gov);
• the World Health Organization International Clinical Trials
Registry Platform (http://apps.who.int/trialsearch/).
We will also search the reference lists of related relevant articles
for additional trials. We will attempt to search for unpublished
studies if available and will contact recognised authorities in the
field in an attempt to collect all possible data.
We will also search abstracts from the scientific meetings and con-
ferences of the American Association for Dental Research and
the International Association for Dental Research for appropriate
studies.
We will handsearch relevant journals for relevant articles. We will
obtain translations of studies written in a language other than
English from the authors of those studies and their collaborators,
if needed.
Data collection and analysis
Selection of studies
Two review authors (AVK and SS) will independently screen ti-
tles and abstracts identified by the electronic searches in order to
identify potentially eligible studies for further evaluation to de-
termine whether they meet the inclusion criteria for this review.
A third review author (HE) will moderate any disagreements. We
will obtain full-text copies of all eligible and potentially eligible
studies, which will be further evaluated in detail by two review
authors (AVK and SS) to identify those studies that actually meet
all the inclusion criteria. A third review author (HE) will moderate
any disagreements. We will record those studies not meeting the
inclusion criteria in the excluded studies section of the review and
will note the reasons for exclusion in a ’Characteristics of excluded
studies’ table. A PRISMA study flow chart will be created to sum-
marise this process.
Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Data extraction and management
We will design a data extraction form specifically for use in this
review, which two review authors (AVK and SS) will pilot inde-
pendently. We will enter details of all included studies in a ’Char-
acteristics of included studies’ table in Review Manager (Revman)
version 5.1.0. AVK will enter the final data. We will resolve any
disagreements by discussion and, if necessary, by consulting a third
review author (HE).
The following details will be recorded for each study:
• publication details (e.g. year of publication, language);
• trial methods;
• participants;
• intervention;
• control (comparison);
• outcomes;
• duration of follow-up;
• sample size calculation;
• funding details.
Assessment of risk of bias in included studies
We will assess the risk of bias in all included studies using the crite-
ria suggested in Chapter 8 of the Cochrane Handbook for Systematic
Reviews of Interventions (Higgins 2011).
We will grade each study for risk of bias in the seven specific
key domains suggested in the Cochrane Handbook for Systematic
Reviews of Intervention:
1. sequence generation (selection bias);
2. allocation concealment (selection bias);
3. blinding of participants and personnel (performance bias);
4. blinding of outcome assessor (detection bias);
5. completeness of outcome data (attrition bias);
6. risk of selective data reporting (reporting bias);
7. risk of other bias.
We will make an overall judgement of a low risk of bias for a study
when we consider that any plausible bias across all seven domains
was unlikely to have altered the results. We will make an overall
judgement of unclear risk of bias for a study when any plausible
bias across one or more of the key domains raises some doubt that
it may have altered the results. We will make an overall judgement
of high risk of bias for a study when any plausible bias across one
or more of the key domains seriously weakens our confidence in
the results reported in that study.
Two review authors (AVK and SS) will conduct the assessment
of risk of bias independently and in duplicate. A third review
author (HE) will moderate any disagreement. A ’Risk of bias’ table,
as described in the Cochrane Handbook for Systematic Reviews of
Interventions (Higgins 2011), will be presented for each included
study. Our judgement of the risk of bias in studies will be presented
graphically.
4
Measures of treatment effect
For dichotomous outcomes, we will express estimates of treatment
effect as risk ratios (RRs) (e.g. the number of failed restorations in
each group) together with 95% confidence intervals (CIs).
For continuous outcomes (such as mean VAS scores), we will use
mean differences and 95% CIs.
We will use the methods for estimating missing standard devi-
ations as described in Section 7.7.3 of the Cochrane Handbook
for Systematic Reviews of Interventions, where appropriate (Higgins
2011).
Unit of analysis issues
It is anticipated that the trials included in this review may ran-
domise either participants or teeth. In order to avoid unit of analy-
sis errors, we will follow the guidance in Chapter 9 of the Cochrane
Handbook for Systematic Reviews of Interventions (Higgins 2011).
Our final analysis will take into account the level at which ran-
domisation occurred.
The number of observations in the analysis should match the
number of ’units’ that were randomised.
We will consider in each study:
• participants who were individually randomised to one of
the interventions (e.g. single parallel-group clinical trials);
• participants undergoing more than one intervention (e.g.
split-mouth designs).
Dealing with missing data
We will contact the authors of included trials to request any miss-
ing data, unclear data or for clarification of the trial methodology.
We will exclude missing data from our analyses until further clar-
ification is provided. We will consider and discuss the potential
impact of missing data in the overall conclusions of the review.
The analysis will include only the available data other than imput-
ing missing standard deviations, as necessary. The methods used
for this will be those outlined in Section 7.7.3 of the Cochrane
Handbook for Systematic Reviews of Interventions (Higgins 2011) if
appropriate.
Assessment of heterogeneity
A minimum of two review authors will assess the extent of clini-
cal heterogeneity by examining the type of interventions and out-
comes in each study.
We will also assess statistical heterogeneity by inspection of the
point estimates and CIs on forest plots. The lack of overlap of CIs
may indicate heterogeneity.
We will assess the variation in treatment effects by means of
Cochran’s Q test for heterogeneity and the I² statistic. We will
consider heterogeneity to be statistically significant if the P value
is < 0.1. A rough guide to the interpretation of the I² statistic given
Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
in the Cochrane Handbook for Systematic Reviews of Interventions is:
0 to 40% might not be important, 30 to 60% may represent mod-
erate heterogeneity, 50 to 90% may represent substantial hetero-
geneity, 75 to 100% considerable heterogeneity (Higgins 2011).
When possible, we will use independent variables to subgroup
outcome data in order to investigate possible the effects of hetero-
geneity.
Assessment of reporting biases
If there are more than 10 studies included in a meta-analysis, we
will consider using a funnel plot to explore potential publication
bias.
Data synthesis
Using RevMan 5.3 software (RevMan 2014), we will conduct a
meta-analysis only if there are studies involving similar compar-
isons reporting the same outcome measures. We will combine RRs
for dichotomous data and mean differences for continuous data
using the random-effects model. If there are three studies or fewer,
we will use a fixed-effect model.
If there are insufficient data, we will present a narrative synthesis.
Subgroup analysis and investigation of heterogeneity
If possible, we will analyse the data by:
• age of participants;
• adhesive systems/etching technique used;
• tooth preparation and surface treatment;
• duration of follow-up;
• extent of lesion.
If sufficient data are available, we will attempt to classify partici-
pants’ baseline sensitivity into degrees of severity so that the out-
come can be assessed in relation to baseline severity. If there are
insufficient data, we will pool the results together as one category.
Sensitivity analysis
Provided that a sufficient number of trials is included in the review,
we will conduct sensitivity analyses to evaluate the impact of the
following factors:
• studies at high or unclear risk of bias
• unpublished studies;
• studies with imputed missing data;
• use of fixed- or random-effect model of analysis;
• impact of funding.
5
Summarising main results and assessing the quality of
the evidence
We will develop a ’Summary of findings’ table for the main out-
comes of this review using GRADEPro software. We will assess the
quality of the body of evidence with reference to the overall risk
of bias of the included studies, the directness of the evidence, the
inconsistency of the results, the precision of the estimates, the risk
of publication bias, the magnitude of the effect and whether or
not there is evidence of a response. We will categorise the quality
of the body of evidence for each of the primary outcomes as high,
REFERENCES
Additional references
Bader 1993
Bader JD Levitch LC, Shugars DA, Heymann HO,
McClure F. How dentists classified and treated non-carious
cervical lesions. Journal of the American Dental Association
1993;124(5):46–54.
Bekes 2009
Bekes K, John MT, Schaller HG, Hirsch C. Oral health-
related quality of life in patients seeking care for dentin
hypersensitivity. Journal of Oral Rehabilitation 2009;36(1):
45–51.
Bergstrom 1988
Bergstrom J, Eliasson S. Cervical abrasion in relation
to toothbrushing and periodontal health. Scandinavian
Journal of Dental Research 1988;96(5):405–11.
Black 1908
Black GV. A work on operative dentistry. Operative
Dentistry. Vol. 1, Medico-Dental Publishing, 1908:39–59.
Buonocore 1955
Buonocore MG. A simple method of increasing the
adhesion of acrylic filling materials to enamel surfaces.
Journal of Dental Research 1955;34(6):849–53.
Ceruti 2006
Ceruti P, Menicucci G, Mariani GD, Pittoni D, Gassino
G. Non carious cervical lesions. A review. Minerva
Stomatologica 2006;55(1-2):43–57.
Cuenin 1991
Cuenin MF, Scheidt MJ, O’Neal RB, Strong SL, Pashley
DH, Horner JA, et al.An in vivo study of dentin sensitivity:
the relation of dentin sensitivity and the patency of dentin
tubules. Journal of Periodontology 1991;62(11):668–73.
Folwaczny 2000
Folwaczny M, Loher C, Mehl A, Kunzelmann KH, Hinkel
R. Tooth-colored filling materials for the restoration of
cervical lesions: a 24-month follow-up study. Operative
Dentistry 2000;25(4):251–8.
Folwaczny 2001
Folwaczny M, Mehl A, Kunzelmann KH, Hickel R. Clinical
performance of a resin-modified glass-ionomer and a
Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
moderate, low or very low.
ACKNOWLEDGEMENTS
We are extremely thankful to the Cochrane Oral Health Group ed-
itorial team (Helen Worthington, Anne Littlewood, Janet Clark-
son, Phil Riley, Valeria Marinho, Helen Wakeford and Laura Mac-
Donald) for their comments and support in the development of
this protocol.
compomer in restoring non-carious cervical lesions. 5-year
results. American Journal of Dentistry 2001;14(3):153–6.
Francisconi 2009
Francisconi LF, Scaffa PM, de Barros VR, Coutinho M,
Francisconi PA. Glass ionomer cements and their role in
the restoration of non-carious cervical lesions. Journal of
Applied Oral Science 2009;17(5):364–9.
Gallien 1994
Gallien GS, Kaplan I, Owens BM. A review of noncarious
dental cervical lesions. Compendium 1994;15(11):1366–74.
Grippo 1992
Grippo JO. Noncarious cervical lesions: the decision to
ignore or restore. Journal of Esthetic Dentistry 1992;4
(Suppl):55–64.
Higgins 2011
Higgins JPT, Green S (editors). Cochrane Handbook
for Systematic Reviews of Interventions Version 5.1.0
[updated March 2011]. The Cochrane Collaboration,
2011. Available from www.cochrane-handbook.org.
Ichim 2007
Ichim IP, Schmidlin PR, Li Q, Kieser JA, Swain MV.
Restoration of non-carious cervical lesions Part II.
Restorative material selection to minimise fracture. Dental
Materials 2007;23(12):1562–9.
Levitch 1994
Levitch LC, Bader JD, Shugars DA, Heymann HO. Non-
carious cervical lesions. Journal of Dentistry 1994;22(4):
195–207.
Little 1998
Little HA, Sidhu N, Smyth B. A study of the classification
and treatment of noncarious cervical lesions by general
practitioners. The Journal of Prosthetic Dentistry 1998;79(3):
342–6.
Loguercio 2003
Loguercio AD, Reis A, Barbosa AN, Roulet JF. Five-year
double-blind randomized clinical evaluation of a resin-
modified glass ionomer and a polyacid-modified resin in
noncarious cervical lesions. The Journal of Adhesive Dentistry
2003;5(4):323–32.
6
Michael 2009
Michael JA, Townsend GC, Greenwood LF, Kaidonis JA.
Abfraction: separating fact from fiction. Australian Dental
Journal 2009;54(1):2–8.
Nascimento 2011
Nascimento MM, Gordan VV, Qvist V, Bader JD, Rindal
DB, Williams OD, et al.Restoration of noncarious tooth
defects by dentists in The Dental Practice-Based Research
Network. Journal of the American Dental Association 2011;
142(12):1368–75.
Nieri 2013
Nieri M, Pini Prato GP, Giani M, Magnani N, Pagliaro U,
Rotundo R. Patient perceptions of buccal gingival recessions
and requests for treatment. Journal Clinical Periodontology
July 2013;40(7):707–12.
Onal 2005
Onal B, Pamir T. The two-year clinical performance of
esthetic restorative materials in noncarious cervical lesions.
Journal of the American Dental Association 2005;136(11):
1547–55.
Pecie 2011
Pecie R, Krejci I, García-Godoy F, Bortolotto T. Noncarious
cervical lesions (NCCL) - a clinical concept based on the
literature review. Part 2: restoration. American Journal of
Dentistry 2011;24(3):183–92.
Perez Cdos 2012
Perez C dos R, Gonzalez MR, Prado NA, de Miranda MS,
Macêdo Mde A, Fernandes BM. Restoration of noncarious
cervical lesions: when, why, and how. International Journal
of Dentistry 2012;2012:687058.
Peumans 2005
Peumans M, Munck J, Van Landuyt K, Lambrechts P, Van
Meerbeek B. Three-year clinical effectiveness of a two-step
self-etch adhesive in cervical lesions. European Journal of
Oral Sciences 2005;113(6):512–8.
Que 2013
Que K, Guo B, Jia Z, Chen Z, Yang J, Gao P. A cross-
sectional study: non-carious cervical lesions, cervical
dentine hypersensitivity and related risk factors. Journal of
Oral Rehabilitation 2013;40(1):24–32.
Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
RevMan 2014
Review Manager (RevMan) Version 5.3. Copenhagen: The
Nordic Cochrane Centre, The Cochrane Collaboration,
2014.
Santamaria 2013
Santamaria MP, da Silva Feitosa D, Casati MZ, Nociti FH
Jr, Sallum AW, Sallum EA. Randomized controlled clinical
trial evaluating connective tissue graft plus resin-modified
glass ionomer restoration for the treatment of gingival
recession associated with non-carious cervical lesion: 2-year
follow-up. Journal of Periodontology 2013;84(9):e1–8.
Senna 2012
Senna P, Del Bel Cury A, Rösing C. Non-carious cervical
lesions and occlusion: a systematic review of clinical studies.
Journal of Oral Rehabilitation 2012;39(6):450–62.
Shulman 1948
Shulman EH, Robinson HB. Salivary citrate content and
erosion of teeth. Journal of Dental Research 1948;27(4):
541–4.
Tyas 2004
Tyas MJ, Burrow MF. Adhesive restorative materials: a
review. Australian Dental Journal 2004;49(3):112–21.
van Dijken 2008
van Dijken JW, Pallesen U. Long-term dentin retention of
etch-and-rinse and self-etch adhesives and a resin-modified
glass ionomer cement in non-carious cervical lesions. Dental
Materials 2008;24(7):915–22.
Veitz-Keenan 2013
Veitz-Keenan A, Barna JA, Strober B, Matthews AG, Collie
D, Vena D, et al.Treatments for hypersensitive noncarious
cervical lesions: a Practitioners Engaged in Applied
Research and Learning (PEARL) Network randomized
clinical effectiveness study.. Journal of the American Dental
Association 2013;144(5):495–506.
Walter 2013
Walter C, Kress E, Götz H, Taylor K, Willershausen I,
Zampelis A. The anatomy of non-carious cervical lesions.
Clinical Oral Investigations 2014;18(1):139–46.
Wood 2008
Wood I, Jawad Z, Paisley C, Brunton P. Non-carious
cervical tooth surface loss: a literature review. Journal of
Dentistry 2008;36(10):759–66.
∗
Indicates the major publication for the study
7
APPENDICES

Appendix 1. MEDLINE (OVID) Search Strategy

1. (“non-carious cervical lesion$” or “noncarious cervical lesion$” or “class v lesion$” or “non-carious lesion$” or “noncarious lesion$”
or “abfraction lesion$” or “class v restor$”).mp.
2. Tooth Cervix/ and (lesion$ or cavit$).mp.
3. (“cementoenamel junction$” and (lesion$ or cavit$)).mp.
4. (flexure adj3 (tooth or teeth)).mp.
5. ((tooth or teeth) adj3 sclerosis).mp.
6. (((tooth or teeth) adj3 (cervix or cervical)) and (lesion$ or cavit$)).mp.
7. or/1-6
8. Dental Restoration, Permanent/
9. Dental Restoration, temporary/
10. exp Dental Bonding/
11. ((tooth or teeth or dental) and (adhesiv$ or bond$)).mp.
12. Glass Ionomer Cements/
13. Composite Resins/
14. Resin cements/
15. (adhesive adj restor$).mp.
16. (“acid etch$” or acid-etch$ or compomer$ or composite$ or nanocomposite$ or resin$ or “polyacid-modified composite resin$” or
“polyacid modified composite resin$” or “polyacid-modified resin-based composite$” or “glass ionomer$” or glass-ionomer$ or “self
etch$” or self-etch$ or PM-RC$ or RM-GIC$).mp.
17. or/8-16
18. 7 and 17
The above search strategy will be linked to the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in
MEDLINE: sensitivity maximising version (2008 revision), as referenced in Chapter 6.4.11.1 and detailed in Box 6.4.c of the Cochrane
Handbook for Systematic Reviews of Interventions (Higgins 2011).
1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
3. randomized.ab.
4. placebo.ab.
5. drug therapy.fs.
6. randomly.ab.
7. trial.ab.
8. groups.ab.
9. or/1-8
10. exp animals/ not humans.sh.
11. 9 not 10

CONTRIBUTIONS OF AUTHORS
Analia Veitz-Keenan: will co-ordinate the review. She will undertake searches, extract data, obtain and screen data on unpublished
studies, enter data into RevMan, write to authors of papers for additional information, analyse and interpret data, and assess study risk
of bias and overall quality of the evidence.
Silvia Spivakovsky: will undertake searches, extract data, obtain and screen data on unpublished studies, and analyse and interpret data,
and assess study risk of bias and overall quality of the evidence.
Hend ElSayed: will undertake searches, extract data, and analyse and interpret data, and assess study risk of bias and overall quality of
the evidence.
Danny Lo and Winnie Furnari: arbiters; will check data extraction and analysis.
Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol) 8
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
All authors helped to write the protocol and will write the review.

DECLARATIONS OF INTEREST
Analia Veitz-Keenan: none known
Silvia Spivakovsky: none known
Danny Lo: none known
Winnie Furnari: none known
Hend ElSayed: none known

SOURCES OF SUPPORT

Internal sources
• No sources of support supplied

External sources
• New York Univeristy College of Dentistry, USA.
• Cochrane Oral Health Group Global Alliance, Not specified.
All reviews in the Cochrane Oral Health Group are supported by Global Alliance member organisations (British Association of Oral
Surgeons, UK; British Orthodontic Society, UK; British Society of Paediatric Dentistry, UK; British Society of Periodontology, UK;
Canadian Dental Hygienists Association, Canada; Mayo Clinic, USA; National Center for Dental Hygiene Research & Practice,
USA; New York University College of Dentistry, USA; and Royal College of Surgeons of Edinburgh, UK) providing funding for the
editorial process (http://ohg.cochrane.org/).
• National Institute for Health Research (NIHR), UK.
The NIHR is the largest single funder of the Cochrane Oral Health Group.
Disclaimer:
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the
Department of Health.

Adhesive restorations for the treatment of dental non-carious cervical lesions (Protocol) 9
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.