J. Dent.

1994; 22: 195-207

Review

Non-carious cervical lesions

L. C. Levitch, J. D. Bader, D. A. Shugars and H. 0. Heymann
Department of Operative Dentistry, School of Dentistry, University of North Carolina, USA

ABSTRACT
Non-carious cervical lesions are commonly encountered in clinical practice and present in a variety of forms.
A knowledge of the aetiology ofthese lesions is important for preventing further lesions, halting progression of
lesions already present, and determining appropriate treatment. The most commonly cited aetiological factors
thought to lead to the development of cervical lesions are erosion, abrasion and tooth flexure. Evidence
supports a multifactorial aetiology for non-carious cervical lesions. The purpose of this paper is to review the
evidence for each of these aetiological factors as it relates to the development of non-carious cervical lesions.
Specific features of cervical lesions linked to these factors. including their morphology, location, prevalence
and distribution by age and sex will be discussed. Suggestions for future research into the cause and prevention
of non-carious cervical lesions will be presented.

KEY WORDS: Cervical, Erosion, Abrasion, Tooth flexure

J. Dent 1994; 22: 195-207 (Received 22 February 1993; reviewed 8 April 1993; accepted 27 September
1993)

Correspondence should be addressed to: Dr L. C. Levitch, Department of Operative Dentistry, School of

Dentistry, C8-7450, University of North Carolina, Chapel Hill, NC 27599-7450, USA.

INTRODUCTION
Loss of hard tissue at the cementoenamel junction (CEJ)
is a condition commonly encountered in clinical practice.
Non-carious cervical lesions present in a variety of forms.
They vary from shallow grooves to broad dished-out
lesions to large wedge-shaped defects. The floor of the
lesion may range in shape from flat to rounded to sharply
angled. These defects can occur on facial, lingual and/or
interproximal surfaces. A knowledge of the aetiology of
these lesions is important for preventing further lesions
and halting the progression of lesions already present.
Also. treatment of lesions will be ineffective in the long
term unless the aetiological factor(s) are eliminatedlm4.
Miller5 was a pioneer in the study of cervical lesions and
their causes. He was amongst the first to associate the
presence of lesions or ‘wasting of tooth structure’ with
chemical and mechanical factors. Unfortunately, although
cervical lesions have been studied for many years, the
action and more particularly the interaction of abrasion,
erosion, attrition and occlusal forces in the production
of cervical lesions requires clarification before effec-
tive prevention and treatment approaches can be
developed’. 6 Il.
Current information available to dentists about the
mechanisms likely to be associated with the development
of lesions presents these mechanisms (erosion, abrasion,
and tooth flexure) as isolated factors, whereas in any
individual patient factors associated with more than one
mechanism may be acting to initiate and promote the
development of lesions. More needs to be learned about
the aetiology of cervical lesions before they can be
confidently treated and, more importantly, prevented. The
reported prevalence of cervical lesions, regardless of form
or aetiology, varies from 5% to 85%3.9.10.*2~2*. Prevalence
and severity of lesions have been found to increase with
age. The older the patient population the greater the
percentage of individuals having lesions, the larger the
number of lesions found in any individual, and the higher
the percentage of deep lesions among those found in any
individuals i*.13.i7.*3-*5.Sexual differences in prevalence
of cervical lesions have also been reported9. i3.l5.17.
The public health significance of dental cervical lesions
is largely unknown. No information is yet available on
incidence and reported prevalence varies widely among
populations. The impact of cervical lesions on individual
patients also varies. Some patients show no symptoms,
while in others the affected teeth are highly sensitive*O.26.
Severe lesions may extend to the pulp chamber and affect
the vitality of the tooth2O. An extensive lesion may
also undermine the tooth, threatening its structural
integrityi9.
There are substantial differences amongst dentists in
the recognition and treatment of cervical lesions*‘. In part,
this variation also stems from a lack of knowledge of the

@1994 Butterworth-Heinemann Ltd.

0300-5712/94/040195-13
196 J. Dent. 1994; 22: No. 4

aetiology of non-carious cervical lesions. The decision to lesions on the teeth include vomiting due to gastro-
treat a cervical lesion ‘. . should be based on careful intestinal problems. pregnancy or alcoholismz2. 38.jy, as
consideration of the aetiology and progression of the well as self-induced vomiting practised by people suffering
condition’(see p. 169 in Handetal.)“. Handeta1.i” believe from anorexia nervosa and bulimia40\4r. Other gastro-
restorative treatment may be necessary if: intestinal problems including reflux oesophagitis and
duodenal ulcer have also been associated with dental
1. The structural integrity of the tooth is threatened.
erosion3x. Another intrinsic factor linked to tooth erosion
2. The tooth (dentine) is hypersensitive.
is the quality and quantity of saliva produced23.‘7.42 44.
3. The defect is aesthetically unacceptable to the patient.
Dental erosion is believed to occur as the result of
4. Pulpal exposure is likely.
demineralization of the inorganic matrix of the tooths. 3’.
5. The location of the lesion compromises the design of a
In enamel the eroded surface appears smooth and
removable partial denture.
polished, perikymata are usually absent. and the eroded
The locations of cervical lesions in the dental arch vary area may or may not be discoloured. Mannerbergj4 has
with suspected aetiology. but most are found on non- characterized two erosive phases in the enamel. ‘Manifest’
molar teeth. Angular lesions are seen more frequently erosion is actively occurring and appears in micrographs
than rounded ones1h.2b. It has been suggested that the as a hollowed-out pitted surface resembling honeycomb.
shape of cervical lesions is dependent upon the factors The pits represent ends of enamel prisms that have
causing them 6. 1. II.16.26.28.29 dissolved below the level of the interprismatic matrix.
As noted, the most commonly cited aetiological factors ‘Latent’ erosion is an inactive stage where the prisms are
thought to lead to the development of cervical lesions are much less obvious. Manifest erosion is more common in
erosion, abrasion and tooth flexure. Dental erosion has females than males and appears more often than latent
been detined as chemically induced loss of hard tissue by erosion in young (20-30 year old) people44. Some lesions
processes not involving bacteria30. Erosion is generally have a dull appearance that may indicate they are active
brought about by acid dissolution of tissues. Abrasion ‘manifest’ erosions37.45.
is the wearing away of tooth substance by extrinsic Erosion of dentine occurs upon exposure to the same
mechanical factors. Toothbrushing is believed by many to type ofsubstances that demineralize enamel. Aciderosion
be the primary cause of abrasion. Tooth flexure as a of dentine appears to affect primarily the surface of the
mechanism for loss of dental hard tissue is the least intertubular dentine with decalcification of the peri-
studied of the processes thought to cause cervical lesions. tubular dentine limited to the apertures of the dentine
Flexure of the tooth is thought to produce tensile stresses tubules. Peritubular and intertubular dentine may also be
on the tooth leading to disruption of the crystalline demineralized in a lateral manner from the open
structure of enamel and dentine eventually resulting in tubule4”.47. The subsurface demineralization is never
loss of tissue. found to exceed 100 urn in depth, much less than occurs in
The purpose of this paper is to review the evidence for carious lesions. No subsurface demineralization of the
each of these aetiological factors as it relates to the dentine occurs in purely abrasive lesions4x. Little is known
development of non-carious cervical lesions. Specific about the morphological changes that occur in dentine as
features of cervical lesions linked to these aetiological erosive cervical lesions develop4’. 4y. Erosive lesions are
factors. including their morphology, location. prevalence often painfully sensitive and this is probably due to the
and distribution by age and sex. will be discussed. exposure of vital dentine. 33..cn. Some lesions. however, are
Suggestions for future research into the cause not sensitive and this lack of sensitivity as well as the
and prevention of non-carious cervical lesions will be polished appearance of many lesions is probably due to
presented. formation of a layer of sclerotic dentine that results
from the blockage of the apertures of the dentine
tubulesd7. 5’.

EROSION
lncisal erosive patterns
Dental erosion, defined as loss of tooth structure due to
chemical action of non-bacterial origin, can occur on any In persons exposed to airborne acids at work, ‘industrial’
surface of any tooth. Considerable evidence supports the or ‘occupational’ erosion, lesions are found on the incisal
idea that dental erosion can be caused by both extrinsic one-third to one-half of the labial surface of incisors.
and intrinsic factors. Extrinsic factors associated with occasionally slight involvement ofcanines is detectedr4. (:.
dental erosion include airborne acidsI and chlorinated Industrial erosive lesions do not present commonly at the
swimming pool water31. Acidic food and beverages3. 32 35. cervix.
and orally administered medicines such as iron tonics.
chewable vitamin C tablets and replacement HCl taken
Cervical erosive patterns
by patients with gastric achlorhydria are other extrinsic
factors believed to cause erosionh. 22.jh. 37. Cervical erosive lesions believed to be caused by ingestion
Intrinsic factors linked to the development of erosive of acidic foods, beverages and medicines most commonly
 Levitch et a/. : Non-carious cervical lesions 197

present on the facial surface of anterior teeth. They are U- foods. Fruit-flavoured candies had a high index of enamel
or dish-shaped. broad but shallow, smooth-edged dissolution, four to 27 times higher than chocolate or
depressions*l. 22.33. The type of food or beverage and the chocolate-coated candies, licorice- or cinnamon-flavoured
manner in which it is ingested may cause variation in the candies, chewing gum, and peanut brittle. The non-fruit-
location of these lesions among individuals. Fruits seem flavoured candy types were comparable or often lower in
to cause lesions mainly on anterior teeth while fruit juices their erosiveness than cakes, breads and puddings, and
and other beverages may lead to erosive lesions on much lower than acidic beverages and fresh fruit.
premolars and molars 33.Lingually located cervical lesions
may also be produced in some people by these same
foods32. Concomitant with the cervical lesions many
patients will also exhibit incisal edges that are feathered or
Lingual erosive patterns
dished out as well as depressions on molar cusps giving
them a ‘cupped’ appearance. In addition, restorations are Cervical erosive lesions thought to be due to reflux of
often raised above the eroded surface of the tooth3*.33. In gastric contents or regurgitation are generally located on
severe cases there can be complete loss of enamel from the the lingual and incisal surfaces of the teeth. Anterior teeth
entire surface of the tooth53. Cervical surfaces may be and maxillary teeth are the most commonly affected38. 39.@.
most prone to erosion because these areas close to the In cases reporting long-term repeated vomiting, severe
gingiva are less self-cleaning and foods and beverages destruction of enamel on all surfaces of the anterior teeth
may be harboured on the tooth surface for longer periods has been reported 41. Even though erosion due to intrinsic
of time54. factors is most likely to present on lingual surfaces and
The prevalence rate for cervical dental erosion among erosion linked to dietary factors is most commonly seen
people who eat a lactovegetarian diet was reported to be on facial surfaces, location alone is not indicative of the
33.1%53. Older individuals exhibited more severe erosion cause of erosive lesions in any given patient59. Palatal
overall and severity generally increased with duration of surfaces of maxillary teeth are thought to be affected more
the diet, although those exhibiting grave lesions had spent often because accumulation of vomitus on the dorsum of
less time on average on a vegetarian diet than those with the tongue first reaches and is in most prolonged contact
incipient or moderate lesions53. The foods most strongly with these surfaces40. However, evidence that pH levels on
associated with erosive lesions were vinegars, vinegar the tongue very quickly return to normal after ingesting
conserves and citrus fruits**. 53. low pH foods and beverages brings into question the
Foods containing citric acid have great potential to validity of this belief60. Many individuals experiencing
cause cervical erosion. The citrate ions bind with calcium anorexia and bulimia also reported eating diets high in
in enamel and dentine forming soluble calcium citrate. citrus fruits and juices and acidic carbonated beverages,
Citric acid also causes increased salivary flow, but this so dietary factors may be contributing to their risk of
increased flow is not enough to completely buffer the developing dental erosions40.41. Jarvinen et al.22 found the
erosive action of the acid54a. population attributable risk of gastric factors to be high
In viva testing in rats has shown that fruit juices are because gastric disorders are so common in the popula-
more destructive to the enamel than fruit pulp. The same tion. even though their relative risk was less than dietary
study also found that on average the carbonated beverages factors. They suggested that elimination of these factors
tested were less erosive than the non-carbonated oness5. would reduce the overal prevalence of dental erosion.
The pH value of foods is not a reliable predictor of the Severity of dental lesions was not strongly correlated with
actual amount of erosion produced55,56. Acidity of the duration of gastrointestinal symptoms, but the most
food acts in combination with other components of the severe lesions were more frequently seen in patients who
food item to produce varying degrees of erosion, which had experienced symptoms for more than 10 years38.
may explain the more erosive properties of the non- An interesting finding of lingual surface attrition of the
carbonated beverages tested by Miller55. The effect of maxillary anterior teeth (LSAMAT) has been documented
sugar in combination with acid food or beverages is in several skeletal populations6i*3. Progressive wear/
equivocal. Sugar itself probably does not increase the erosion of this type has been linked to hypothesized
erosive properties of acidic foods and may actually lower dietary/mechanical factors (i.e. maniac processing)61.
enamel dissolution rates, but by acting to reduce the Nevertheless. this condition is also found in skeletal
clearance time from the mouth and lowering salivary flow populations not known to have eaten maniac?. Robb et
rates sugar may keep low pH foods in longer contact with al.64 conclude that LSAMAT is actually erosion due to
the teeth5’. 58.Animal experiments have found that foods regurgitation. This conclusion has been rebutted by
with high concentrations of sugar produced less erosion of Turneret al.‘j5 who point out the small likelihood that such
enamel than did foods with lower concentrations of sugar a large percentage (85% in a Brazilian population) of
combined with starch5X. people were regularly regurgitating their stomach con-
Bibby and Mundorff5* in a study of the erosive tents, and state as well that LSAMAT appears as flattened
properties of common snack foods, reported wide ranges wear rather than the concave wear seen in chemical
in the degree of demineralization produced by various erosion.
198 J. Dent. 1994; 22: No. 4

Effects of saliva considerably higher. Facially located erosion was observed

in 16% of patients. Lingually located lesions had a
Salivary quantity and quality has long been thought to be
prevalence of 3.6% in younger (26-30 years old) versus
a factor in dental erosion233 42.Citrate content of saliva has
over 6% of older (46-50 years old) individuals. Occlusal
been linked to severity of cervical erosions23, although
erosive lesions had the highest prevalence with 29.9% of
Shulman and Robinson4* found no appreciable difference
younger and 42.6% of older individuals exhibiting at least
in citrate content between patients with erosive lesions
one occlusal erosive lesion severe enough to involve the
and those with no lesions. However, the question of
dentine. Severity of all lesion types increased with age. All
whether or not the erosion cases were active or latent at the
lingually located lesions were found on maxillary teeth
time the saliva was collected could not be answered.
with central incisors most commonly affected. In general
Pyrophosphate, a natural calcium chelating agent, was
more facially located lesions were seen on maxillary teeth.
found in salivary debris from individuals with erosion
with canines and premolars most likely to be affectedIs.
and not in controls, but this in vitro experiment may not
Zipkin and McClure*” found that 27% of their subjects
closely approximate in vivo conditions43.
exhibited cervical erosive lesions on facial surfaces. The
Saliva acts to rinse away and buffer demineralizing
prevalence and severity of lesions in this group increased
acids on tooth surfaces22.41. Low salivary flow may
with increasing age and more lesions were found on
therefore be an initiating factor in dental erosion22,‘4.
maxillary than mandibular teeth. The first premolars
Individuals with low unstimulated salivary flow rates were
were most commonly affected. These results are in general
found to have a five-fold increased risk for development of
agreement with the lindings of Lussi et a1.2s and the
cervical erosive lesions22. Patients with idiopathic erosion
observations from case studies linking dietary factors to
were found to have significantly lower salivary flow rates
erosion3”. 53.
than patients without erosive lesions65a. Several cases
An earlier study of incoming male college freshmen
where erosion was linked to gastrointestinal disorders
found a prevalence of erosive dental lesions of only 2. I ?h42.
also experienced low stimulated salivary flow rates3*.
This lower percentage is most likely explained as the
Many persons suffering from anorexia and bulimia also
result of the (presumed) very young age of the population
develop xerostomia and their saliva may also have a lower
studied. SognnaesetaL’in a study of 10000 extracted teeth
buffering and remineralizing capacity4°.41.
found 18% of teeth to be affected by erosive lesions.
The ability of saliva to remineralize eroded tooth
though their class of erosive lesions included what most
surfaces may vary between cases and controls.
would call abrasive lesions as well. In this study mandibu-
Mannerberg3’ reported that although amount, pH value.
lar teeth exhibited more lesions than their maxillary
buffering capacity and calcium and phosphorus content
counterparts and incisors showed the highest percentage
of saliva did not differ between cases and controls, mucin
overall for presence of lesions’.
content did vary. A high mucin content may act to prevent
The erosive action of acids. both intrinsic and extrinsic.
precipitation of calcium phosphate out of the saliva and
in the development of non-carious cervical lesions is well
onto the surface of the teeth, preventing the reparative
supported by both in vifro and in viva studies. The
effect noted in scratches produced by toothbrushing37. 44.
characteristic lesions described above seem to be primarily
In general, though, the roles of salivary calcium
the result of chemical erosion. but the effects of erosion
and phosphorus as they relate to dental erosion are
cannot always be easily separated from those of abrasion.
unknown**.
In many. if not most. individuals these forces act in
Other intrinsic factors have been postulated to cause
concert”. 16.44.4s.4x.The initiating factor in some cases may
production of cervical lesions. Bddecker@ proposed that
be chemical erosion that is then exacerbated by abrasion
gingival exudate could initiate erosion. Kornfeld6’ believed
or vice versa. Abrasion as a factor in production of
disturbance of pulp tissues could lead to decalcification.
cervical lesions has been studied for over a century but is
The factor common to these two proposals and that of
still not completely understood.
Bird6X is that poor occlusion results in forces passing
through the tooth not in line with its long axis, and leads to
the tissue and fluid disturbances. More recent theories
about stressful occlusion and its relationship to cervical ABRASION
lesions are presented below.
Abrasion is the pathological wearing away of dental hard
tissue by mechanical forces. The aetiology of abrasive
dental lesions located at the cervix is still the subject ot
Prevalence
some debate. Generally it is believed that factors related to
The prevalence rate of dental erosion has not been well toothbrushing produce this type of lesion. although
documented. Jarvinen et al.22 found a prevalence of 5% in abrasive wear on the proximal surfaces of teeth is often
their case-control study of a Finnish population. Only caused by friction from objects such as toothpicks’(,. l:.
facial and occlusal surfaces were examined. Employing Cervical lesions thought to be due to abrasive forces
different diagnostic criteria, Lussi et al.25 reported the generally have sharply defined margins and a hard
prevalence of dental erosion in a Swiss population to be smooth surface that may exhibit scratches. This is in
 Levitch et a/.: Non-carious cervical lesions 199

contrast to erosive lesions, which often are disk-shaped significant differences in brushing technique between
and broad, with less well-defined margins, and with those with lesions and those withouty, 15,24.
adjoining enamel smooth, shiny and lacking in develop- In vitro studies of toothbrushing technique have shown
mental ridges. Abrasive lesions are free of plaque and not that cross-brushing can produce more wear on dentine
discoloured6. 8. il. than vertical brushing72. Cross-brushing also consistently
Cervical lesions believed to be produced by abrasion produces V-shaped notches in dentine, independent of
are often recognized or even defined by their shape. bristle stiffness and dentifrice abrasiveness72. 73. Vertical
Wedge-shaped lesions located at the CEJ are often brushing tends to produce U-shaped notches72. Cross-
assumed to have an abrasive aetiology, although this brushing also tends to produce more grooving of the tooth
assumption has recently been called into question (see surface than does a vertical technique74. Cross-brushing
below). Equating abrasive cervical lesions with ‘wedge- applies less maximum force to the tooth surface than
shaped’ defects is somewhat of a misnomer. These lesions vertical brushing, but the toothbrush bristles remain in
appear in a variety of shapes. Types commonly seen contact with the tooth surface longer and apply more
include simple flat-floored grooves, defects that are C- consistent force than during vertical brushing75.
shaped in cross-section with rounded floors, undercut Males apply significantly greater force when brushing
defects with a flat cervical wall and a semicircular occlusal by either technique than do females75. The prevalence of
wall, as well as typical V-shaped grooves with oblique abrasive cervical lesions by sex is equivocal. Ervin and
walls that intersect axially16.20.26. Klimm et a1.6y have Bucher13 report individual males to have more lesions
recognized 12 categories of ‘wedge-shaped’ defects, based than females, while Sangnes and Gjermo” reported a
upon size, shape and contour. slightly higher prevalence in females. No statistically
significant differences between the sexes were reported by
others’5. 17. Any overall differences between males and
Effects of toothbrushing
females in the amount of force applied during brushing
The common association between the presence of cervical do not appear to be significant enough to be reflected in a
lesions, gingival recession and good oral hygiene has difference in prevalence between the sexes. However,
supported the idea that toothbrushing factors are involved force may play a significant role in the distribution of
in their development 8.9. 12.13.15.17.19.26.70. Both patient- cervical lesions within the dental arch. Right-handed
related and materials-related factors have been considered people show a preponderance of lesions on the left side
when trying to determine how toothbrushing could of the mouth, while left-handed people show the
produce cervical lesions. Patient factors include frequency opposite9.12.13. Lesions were also reported to be pre-
of brushing, time spent brushing, the amount of force dominant on the left side by Bergstrom and Lavstedt17, but
applied during brushing, and where on the arch brushing Radentz et al. l5 report slightly more right-sided lesions.
is begun. Materials factors investigated include the The sequence in which the teeth are brushed also
stiffness of the toothbrush bristles, and the abrasiveness correlates with the location of lesions, more lesions are
and amount of the dentifrice being used. present in the quadrants brushed first, this finding may
Increased brushing frequency has been linked to the reflect greater force being used early in the toothbrushing
presence of cervical lesions’. ‘7. Bergstrom and Lavstedt17 episode15,26. The amount of force used during brushing
found a statistically significant increase in the frequency may play a role in the development of lesions. Several
of cervical lesions in those who brushed at least twice factors, including the age of the individual, brushing
daily, compared to patients who brushed less often. This technique. bristle stiffness and individual habits may
increased frequency applied to all age groups. Frequent influence the amount of force applied during brushingR.
brushing may promote or accelerate hard tissue loss by Bristle stiffness does not appear to contribute signiti-
negating any effect of remineralizationin vivo8. 44.Overall cantly to the abrasiveness of toothbrus,hing17. z4,72.T3.76.
oral hygiene has been found to be better in patients with Studies suggesting a role for hard bristles in the produc-
lesions than in those withoutg. i2. 13.17.19. tion of lesions do so only as a possible alternative
The length of time spent brushing may also influence mechanism. as their studies show no link between degree
the development of lesions. In one study 90% of patients of dentifrice abrasivity and lesion presencei5,71.77.
exhibiting lesions reported brushing longer than 1 min
and some longer than 3 min71.
Effect of dentifrice
Brushing technique has been considered by several
investigators as a factor in lesion formation. Using a The ability of dentifrices to abrade enamel and dentine
horizontal or cross-brushing technique was associated was first demonstrated by Miller in 1907. Since then
with a significant increase in the frequency of cervical numerous studies have supported his conclusions71 73,76-R1.
lesions compared to patients using a vertical or roll The evidence from both in vi&o and in viva studies
technique17. Additionally among those patients who suggests that abrasive dentifrice must be present for
brushed at least twice a day using a horizontal technique significant cervical abrasion to occur71. 76.77.However, the
the prevalence of cervical lesions was greater than 65% degree of abrasiveness of modern dentifrices seems to play
versus 3 1% overall. Other clinical studies have reported no an insignificant role in the progression of lesionsi7,71.77.
Table 1. Epidemiological studies of non-carious cervical lesions

Proposed Age range/ How cofactors

Study/date n Design Sample Lesion aetiology prevalence Cofactors measured Analysis

Kitchin, 1941 I2 200 Cross-sect. Dental clinic Depth Abrasion 20-29/42% Age Descriptive (%)
patients, 30-39/> 42 % Oral hygiene Unknown
students, staff 40-49/7 6% Gingival retract Absolute measure
50-59/< 76%

Ervin and Bucher 1252 Cross-sect. Dental patient, Depth Abrasion 20-29/45% Age Descriptive (%)
1944’3 40 practices, 30-39/68% 66% Sex
over 19 yrs 40-49/83% overall Oral hygiene Unknown
> 50/87% Ging. retract relative
US region

Shulman and 1345 Cross-sect. Males entering Location Erosion Young men/2% Salivary Pentabromacetone Descriptive (%)
Robinson, 1 94842 freshman class Citrate content tests

Zipkin and 83 Cross-sect. Dental clinic Loss of Erosion 27-39/2 1% 27% Salivary citrate Pentabromacetone Descriptive (%, t-
McClure, 1 94gz3 patients substance > 40/32% overall content test test, carrel. coef.)
I
Age Total erosion score/ Age adjust. by
Erosion index
number of teeth ANOVA, multiple
linear regression

5. ten Bruggen 555 Cohort British industrial Loss of Erosion 15-65/320/o Acid exposure Type of job Descriptive (%)
Cate, 1 96814 workers substance on the job
Length of
employment
Age
Attrition Unknown
Lip posture Self-report 8 exam
Periodontal status Exam
Oral hygiene Calculus
Environ. (job) Inspection
controls

6, Sangnes and 533 Cross-sect. Dental clinic Depth/ Abrasion 18-29/32% 45% Age Descriptive (%)
Gjermo, 1 9769 patients, factory v-shape > 30/50% overall Sex
workers Oral hygiene Plaque/teeth
relative measure
Gingival retract/
pocket depth
Gingival status Appearance
Brushing technique Self-report

7. Radentz et al, 80 Cross-sect. Lab tech. students Depth Abrasion and 17-45/50% Age Descriptive
1 97615 (enlisted military) erosion Sex Between group
Race (Chi-square,
Students, t
Handedness
ANOVA)
Brushing freq. Self-report
observation
Dentifrice amt.
Brushing tech. Observation
Gingival recession
Salivary pH Absolute measure
Jab/e I continued

8. Brady and Woody, 900 Cross-sect. Dentists Shape Occlusal N.A./5 % Shape of lesion Exam. Descriptive (%)
1977’6 stress/
abrasion

9. Bergstrijm and 8 18 Cross-sect. Stratified sample Depth/ Abrasion 18-25/l 6% Age Cross-tabulations
Lavstedt, 1979” of Stockholm county wedge-shape 26-35/38% 31% Brushing habits Self-report multiple linear
36-45/4 1% overall Toothbrush type Self-report regression, t-test,
46-55/40% Abrasiveness of AID analysis
Measure
56-65/‘4 1% dentifrice
Observation
Brushing technique

10. Xhonga and 52 7 Cross-sect. Dental clinic Depth/shape - 14-88/-25% Patient’s residence Descriptive (%)
Valdmanis, patients, two cities Caries/fillings Exam.
1 98318 Crowns Exam.
Shape of lesion Exam.

1 1. Hand et a/. 520 Cross-sect. Non-institutionalized, Depth Abrasion > 65/56% Age Age and sex
1 9861s rural, elderly Iowans Sex adjusted, multiple
No. of teeth Exam. linear regression
Calculus Exam.
Tooth mobility Exam.
Caries Exam.
Gingival recession Exam.

12. Natusch and 300 Cross-sect. Dental clinic Shape Erosion/ 16-35/l 3% abrasion Age Descriptive (%)
Klimm, 1989’O patients abrasion 4% erosion Tooth

13. Bergstrdm and 250 Cross-sect. Dental clinic Loss of Abrasion 21-30/67% 85% Age Descriptive (%)
Eliasson, 1 98824 patients substance 31-60/90% overall Brushing freq. Self-report (t-test, %)
I
Brushing technique Observation multivariate
Toothbrush stiffness Self-report regression
Dentifrice
abrasiveness Measure
Oral hygiene Plaque index
Periodontal health Exam.

14. Jarvinen et a/., 206 Case control Cases: Helsinki Shape/ Erosion 13-83/5% Sex Logistic regression
199122 dental patients features Diet history Self-report Adjusted odds-
screened in 1 yr Medical historv Self-report ratio
controls: random Salivary/
sample dental Flow rate Direct measure
patients from same Calcium Direct measure
dentists as cases Phosphorus Direct measure
Protein, pH Direct measure

1 5. Lussi et a/., 391 Cross-see? Residents of Berne Loss of Erosion 26-30, 16% facial Age Multiple linear
199126 and Lucerne substance 46-50/ - 5% lingual Oral health habits Self-report regression
cantons Diet history Self-report
Medical history Self-report
202 J. Dent. 1994; 22: No. 4

Longitudinal studies of dentine wear in vivo have ing the highest frequency of lesions’. ‘0. 12.Is. Ih.I* 21).Zh.The
reported the average rate of dentine loss to vary between preponderance of lesions on premolars may be due to
1 pm a day and 1 vrn a week”. x2. The amount of dentine prolonged and more powerful contact during tooth-
lost appears to be relative to the abrasiveness of the brushing. Manly and Foster’” reported that the middle
dentifrice. but the absolute amount of dentine lost varies tooth was more heavily abraded than the flanking teeth in
little even with large differences in abrasivity71.79. The an in vitro experiment. The premolars could be considered
abrasive potential of a given dentifrice can also vary middle teeth. A bony anatomical deficiency in the area of
among individuals. The amount of dentifrice applied, the the facial surface of the first premolar and first molar.
degree of salivary dilution in the mouth and toothbmshing along with the facial prominence of these teeth, has also
technique and force applied, all influence the amount of been suggested to predispose these teeth to abrasion
abrasion produced15, 77.7y. Thus. abrasive cervical lesions by causing them to be more susceptible to gingival
appear to have a multifactorial aetiology. Patient-related recessionIs. Finally. maxillary teeth are reported to
and materials-related toothbrushing factors may all play a have a higher frequency of lesions than mandibular
role in the initiation and progression of lesions. teeth 12. 15.X. 26,

Prevalence
The reported prevalence of cervical lesions believed to be
caused by abrasion varies widely among studies (Table I).
Brady and Woody Ih found that only 5.3% of dentists
examined had wedge- or C-shaped lesions. which they
called ‘cervical erosion’. In contrast. approximately two-
thirds of all patients examined showed evidence of hard
tissue loss at the CEJ in earlier studies by KitchinlZ and
Ervin and Bucher13. while Bergstrom and Eliasson24
reported that 85% of their patients had lost some hard
tissue. More conservative estimates of the prevalence of
cervical lesions were reported by Sangnes and Gjermo”
who reported an overall prevalence of 45%, Bergstrdm and
Lavstedt” who reported a prevalence of 3 1%, and Hand
et al.” who found 56% of their study population had
cervical lesions. Part of the variation in reported preva-
lence may be due to differing methodology in these
studies. In most studies the lesions were classified into two
or more categories based upon the depth/size of the lesion.
Recognition of a small lesion as any loss of normal
cervical contour may have increased prevalence in some
studies (e.g. Kitchen l2, Ervin and Bucher13 and Bergstrom
and Eliassonz4), while consideration of lesion shape as
well as loss of contour may have led to underestimation
others (e.g. Brady and Woody’“). Highly abrasive denti-
frices that were generally available more than 50 years ago
may also contribute to the higher prevalence reported in
earlier studiesy. Another factor that probably accounts for
some of the variation in estimates of prevalence is the
variation in the age distribution among the study
populations. All of the studies that grouped their partici-
pants into multiple age categories reported that the
prevalence of lesions increased with increasing
age’. lo. 12.13.17.20.24.The percentage of patients with more
severe (deeper/larger) lesions also increased with increas-
ing age’. 12.13.17.
Location of lesions
Any tooth may exhibit an abrasive cervical lesion. They
are most commonly located however. on the canine
through first molar, with the premolars generally exhibit-
TOOTH FLEXURE THEORY
Clinical observations of wedge-shaped defects occurring
on a single tooth or on non-adjacent teeth have led several
workers to conclude that factors intrinsic to the tooth (i.e.
tooth flexure) are responsible for hard tissue loss at the
CEJ4. 1h.2X.2y.X3. They propose that many of the cervical
defects supposedly due to extrinsic factors acting directly
upon the surface of the tooth (e.g. toothbrush abrasion)
are actually due to eccentrically applied occlusal forces.
such as those produced during bruxing, causing the tooth
to flex. As the tooth flexes, the tensile stresses generated
may cause disruption of the bonds between hydroxyapatite
crystals, leading to cracks in the enamel and eventual loss
of enamel and the underlying dentine2x.29.X3.X4. In the
initial stages of stress-induced damage the surface enamel
may appear corrugated. with sharp rims at the outer
surface4. This type of hard tissue loss at the CEJ has been
termed ‘abfraction’ by Grippe*“, to distinguish it from
erosion and abrasion.
Masticatory and parafunctional behaviours place stress
on teeth by producing tensile. compressive and shearing
stresses. Tensile stress is resistance to forces causing the
in tooth to stretch or elongate: compressive stress resists
forces acting to compress the teeth, and shearing stress
resists forces causing twisting or sliding of the teethz8.
Several studies have shown that enamel and dentine are
less resistant to tensile stress than compressive stressX5 x1(.
In compression enamel can withstand forces up to 35
times greater than when subjected to tensile stressxh.x7.
while dentine can resist compressive forces at least seven
times greater than the amount of tensile stress that will
cause it to failxs,xx.
With ideal functional occlusion the forces produced
during mastication are directed primarily along the long
axis of the tooth?X. x3. When eccentric occlusal forces are
applied to a tooth. both compressive and tensile stress are
placed on the tooth structure. The stress produced causes
the tooth to flex. The fulcrum of this bending movement
and the place where eccentric occlusal forces are concen-
trated is the cervix of the tooth2R.X95y0.The side towards
which the tooth is bending experiences compression
 Levitch et a/. : Non-carious cervical lesions 203

while the side opposite the direction of force is placed in

Supportive arguments
tension28. Since the ability of the tooth substance to resist
compression is great, no disruption of enamel or dentine The greater prevalence of cervical lesions in older
would usually occur on the compressed side, but tensile populations (see above) may be due in part to features
forces could cause the bonds between hydroxyapatite common to older teeth, such as the increased brittleness of
crystals to break on the surface in tension. The spaces enamel and dentine that occurs with increasing age92.94.
formed when the chemical bonds are broken may be This increased brittleness could exacerbate the effects of
invaded by small molecules (e.g. water) preventing occlusal forces. Since damage to dental hard tissues may
reestablishment of the bonds. These cracks in the enamel also be a function of duration of applied force as well as
and dentine would then be propagated by subsequent the magnitude ofthe force. more lesions would be likely to
tensile stresses. The weakened enamel and dentine could occur with increasing agezx. ‘)I.
then chip and break away due to forces generated during Bruxism has been reported as a likely source of occlusal
functional or parafunctional behaviours and/or be stress that would cause a patient to develop cervical
eroded or abraded away due to chemical or mechanical lesions29.X3. In a study of 15 bruxers and 15 non-bruxers.
factors2x. Xhongay5 reported that 87% of bruxers exhibited one or
more cervical ‘erosions’ while only 20% of non-bruxers
had developed cervical ‘erosions’.
Theoretical clinical appearance
Other supporting evidence for tooth flexure as a
Lee and Eakle** state that cervical lesions caused by mechanism for hard tissue loss at the CEJ comes from
tensile stress should be characterized by several features. clinical trials examining Class V restoration retention9h. 97.
First a lesion should be located at or near the fulcrum (the Stressful occlusion is strongly implicated as a factor in
fulcrum of bending moment can move apically from the early loss of restorations. A significant number of patients
cervix as alveolar bone is lost)83,91. Second, the region of with retention failures showed evidence of bruxism.
greatest concentration of tensile stresses is a wedge- malocclusion or other forms of stressful occlusiony7.
shaped volume at the fulcrum, which should produce a Debonding of the restorations may have been due to
wedge-shaped cervical lesion. Third, since the direction of tensile stresses caused by lateral deformation of the
lateral force determines the location of the lesion, if there teeth9h. 97.
are two different lateral forces acting upon a tooth the At this time it is not known how factors such as presence
tooth should present two overlapping wedge-shaped of a restoration in a tooth may affect the development of
lesions. Fourth, the size of the lesion should be propor- cervical lesions. Amalgam restorations are associated
tional to the magnitude and frequency of the lateral with increased cusp flexure and can weaken overall tooth
force(s). Finally, since occlusal forces are generally structure9R.99. If tooth flexure with its consequent produc-
applied over a plane of contact rather than at a single tion of tensile stresses does create cervical lesions. any
point, and because each point along the plane would factor that lessened the tooth’s ability to withstand stress
generate slightly different forces near the fulcrum, the could play a role in lesion formation.
contour of the lesion (i.e. the occlusal line angle) should Likewise. it is not known how periodontal status relates
conform to the angle of the occlusal contact plane. to development of cervical lesions. Alveolar bone loss
Two other intrinsic features of the tooth may contribute changes the position of the fulcrum of bending moment
to loss of hard tissue as a consequence of occlusal loading. causing more apically placed lesionsx3. Loss of periodontal
When a tooth is subject to tension or compression, an support leading to a high degree of tooth mobility may
electrical potential gradient develops between regions in conversely be a protective factor in that instead of flexing
the tooth. This so-called piezoelectric effect may promote at the CEJ the entire tooth moves away from the occlusal
loss of tooth substance9*. Additionally, the thickness of force. The study by Hand et al.” found a negative
the enamel and dentine layer vary over the cusps of the correlation between tooth mobility and presence of a
posterior teeth, causing variation in the contour of the lesion. Lack of a dorsal supporting zone has also been
dentinoenamel junction (DEJ)92. A concavity on the DEJ cited as a contributing factor in the formation of stress-
is found in the occlusal third of the functional cusps of the induced cervical lesions4.
mandibular premolars and in the non-functional cusps of The role of tooth flexure in the development of wedge-
the maxillary premolars93. The location of the concavity shaped cervical lesions is a fruitful area for future
in the DEJ correlates with the most common location of research. The degree of which occlusal forces initiate and
premolar cervical lesions. below mandibular functional propagate cervical lesions is unknown. These forces
cusps and above maxillary non-functional cusps (i.e. on probably do not act in isolation from acidic erosion and
the facial surfaces of premolars)9. 18,19.92. When this abrasion in producing cervical lesions. The theory of
concavity was eliminated, in a finite element analysis of stress-induced cervical lesions does seem to explain the
an artificial model, so were the tensile stresses on both development of cervical lesions that could not be
facial and lingual surfaces 92. These findings suggest that adequately explained as being the rqsult of toothbrush
the cuspal contour of the DEJ may alter the amount of abrasion alone. lesions on isolated or non-adjacent teeth
stress produced at the cervix9*. and subgingivally located lesions. Cervical lesions found
204 J. Dent. 1994; 22: No. 4

Tab/e II. Possible risk factors associated with cervical looking only at factors associated with a single aetiological
lesions* mechanism.
Chemical erosion has clearly been demonstrated to be a
Risk factor Erosion t Abrasion t
mechanism for producing cervical lesions, although the
++ ++ overall prevalence of lesions caused primarily by acid-
Age
Sex _ + induced erosion appears to be only about 5% in contrast to
Good oral hygiene + +/- the much higher prevalence rates reported for abrasive
Brushing technique - -/+ lesions (Table I). Studies reporting higher rates for
Handedness ‘erosion’ generally were less rigorous in defining their
Brushing frequency +/-
Bristle stiffness + criteria for an erosive lesion (e.g. Zipkin and McClure’”
Dentifrice + +/- and Radentz et al.‘“).
Salivary pH In vitro studies have consistently reported that enamel
Salivary citrate and dentine are dissolved by acidic beverages having a pH
Salivary flow
less than 450.101. Animal studies have confirmed the
Diet ++
Medical factors ++ erosive effect on enamel when acidic beverages are
Good periodontal health consumed1”2. Epidemiological and case studies have also
strongly supported an association between shallow. disk-
* Data from studies listed in Table I. shaped cervical lesions and intrinsic and extrinsic factors
t Proposed aetiology.
+, One reported association; + +, two or more reported associa- that lower the pH level in the oral cavity. Dietary and
tions; -, one reported non-association; - -, two or more reported medical factors are most clearly associated with erosive
non-associations. cervical lesions. The role of saliva in the development 01
retardation of cervical lesions is uncertain (Table II).
in non-human species could also be the result of Salivary citrate and pH levels have not been found to
occlusally produced stresses; certainly in these cases there differ significantly between persons with lesions and
is no toothbrushing factor involved’OO. Several case those without =’ -. 23.a? Low salivary flow rates may. however.
studies have found an association between stressful play a role in the development of lesions22. Salivar).
occlusion and the presence of cervical lesions4.*‘. factors may be more important than indicated by the
Additional supporting evidence for the role of tooth studies cited. Flow rates. pH levels and chemical compo-
flexure in promoting hard tissue loss at the CEJ is sition of the saliva have been measured by these
supplied by those clinical trials that have found an investigators in non-functional situations. Flow rates and
association between stressful occlusion and Class V chemical composition of the saliva may vary in response
restoration failureyh. 97. to different foods and beverages and need to be studied in
patients during and just after eating.
Abrasion due to patient and/or materials related
toothbrushing factors is thought by most clinicians and
DISCUSSION
researchers to be the primary cause of cervical lesions.
TablesI and I1 summarize the epidemiological studies of Which factor or factors is most important is unclear
non-carious cervical lesions. Many of the earlier studies (Table II). Supporting the idea that toothbrushing factors
followed a less than rigorous methodology when choosing cause cervical lesions, several studies have reported bettel
subjects, measuring co-factors and defining their defect overall oral hygiene (measured by a variety of means, not
criteria. Most of the studies are not population based and always specified) in patients with lesions than those
may therefore not be good indicators of the true prevalence withoutq. 12.15.IX.“1. BergstrGm and Eliasson=” found.
of lesions in actual populations. Also most of these studies however. no association between lesion presence and oral
did not consider a possible multifactorial aetiology in the hygiene status. but this may be attributable to the overall
development of cervical lesions and limited themselves to high standard of oral hygiene in their sample.

Table 111.Characteristics of cervical lesions by proposed aetiology

Erosion Abrasion Tooth flexure

Location Lingual or facial Facial Facial

Shape U- or disk-shaped, Wedge-shaped or Single or overlapping
shallow groove wedge-shape
Margins Smooth Sharp Sharp
Enamel surface Smooth, may be Smooth, scratched Rough, initial stages
polished may have corrugated
appearance
 Levitch et al. : Non-carious cervical lesions 205

In vitro experiments have proved that wedge-shaped Until clinicians have better morphological and epidemi-
cervical lesions can be produced by toothbrushing ological guidelines for recognizing aetiology in specific
techniques and materials commonly employed by patients cases, treatment and prevention of these lesions will
(see above). Isolating the contribution of each factor to the remain haphazard.
production of individual lesions is difficult as patients Epidemiological studies that directly examine occlusal
change techniques. materials and brushing habits over stress in combination with dietary and toothbrushing
time. factors are needed. Additionally, morphological variation
While abrasion may be primarily responsible for the (both gross and microscopic) among lesions needs to be
progression of cervical lesions it may not be solely examined in association with the epidemiological data.
responsible for initiating them. It is not known how or if Finally. more detailed investigation of chemical action at
chemical erosion and abrasion act together to promote the the tooth surface during function, along with further study
development of lesions. but it may be that chemical of biophysical conditions during tooth flexure are neces-
erosion acts to demineralize dental tissues, particularly sary. With these types of data we can begin to standardize
enamel, facilitating mechanical abrasion and loss of and improve clinical practice.
tissue. The high and possibly increasing prevalence of
abrasive cervical lesions (Table I) indicates that more
research needs to be done in order to discover if chemical Acknowledgements
and mechanical factors act in synergy to produce non- This work was supported by a grant from ILSI North
carious cervical lesions. America (the North American branch ofthe International
Tooth flexure as a proposed aetiology for cervical Life Sciences Institute). We thank Drs Frances McClure,
lesions does seem to explain some clinical findings related Stephen Bayne and two anonymous reviewers for their
to Class V restoration loss and retention as well as the advice on the manuscript, and Pam Fogleman and Eric
presence of lesions that do not seem likely to be the result Landis for their assistance in its preparation.
of erosion or toothbrush abrasion alone. The scientific
basis of the tooth flexure theory remains largely un-
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 Levitch et al. : Non-carious cervical lesions 207

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