Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2012 39; 450–462
Review Article
Non-carious cervical lesions and occlusion: a systematic
review of clinical studies
P . S E N N A * , A . D E L B E L C U R Y * & C . R Ö S I N G †
†
Dental School, Piracicaba, São Paulo and Department of Periodontology, Dental School, Rio Grande do Sul Federal University, Porto Alegre,
Rio Grande do Sul, Brazil
SUMMARY Non-carious cervical lesions (NCCLs) are a
group of lesions that affect the cervical area of the
teeth. Different aetiological factors have been
reported, among them tooth brushing force, erosive
agents and occlusal forces. The aim of this study was
to ascertain, by means of a systematic review, the
association between NCCLs and occlusion. A search
was performed in the MEDLINE database, retriev-
ing a total of 286 articles. After title and abstract
screening, the clinical investigations were read in
full to select those that evaluated the occlusal
aspects of NCCL aetiology. This systematic review
describes the results of three prospective and 25
cross-sectional studies. As there is an extreme
heterogeneity in design, diagnostic criteria, forms
of analysis and associated factors, a meta-analysis
was not possible. The wide variety of classification
and diagnostic criteria reflects a high range of
Introduction
As the prevalence of both caries and periodontal disease
has declined because of oral health promotion strate-
gies, other pathologies have come to the forefront. In
this respect, non-carious cervical lesions (NCCLs) such
as abrasion, erosion and abfraction are now receiving
attention. For this article, we have used the Glossary of
Periodontal Terms (1) to define these terms. Abrasion is
considered the wearing away of a substance or struc-
ture through an abnormal mechanical process. An
example of this is dental abrasion owing to incorrect
brushing. Erosion has been defined as an apparent
chemical dissolution of enamel and dentin, unrelated to
ª 2012 Blackwell Publishing Ltd
*Department of Prosthodontics and Periodontology, Piracicaba
reported prevalence. An extensive heterogeneity of
independent variables was noted, even in occlusal
analysis, which helps to mask any conclusion about
the role of occlusion in NCCL aetiology. The liter-
ature reveals that studies on this topic are subject to
a substantial amount of bias, such as evaluation (use
of non-blinded examiners) and confounding bias
(no control of others aetiological factors). Up to
now, it has been impossible to associate NCCLs with
any specific causal agent, and the role of occlusion in
the pathogenesis of non-carious cervical lesions
seems as yet undetermined. Therefore, additional
studies, properly designed to diminish bias, are
warranted.
KEYWORDS: abfraction, tooth wear, dental occlusion,
occlusal trauma, systematic review
Accepted for publication 28 January 2012
caries, causing a cavity that has a hard, smooth base.
Abfraction is understood to be a hypothetical tooth
surface abrasion in conjunction with occlusal forces.
These three definitions are not well understood by the
dental profession. For example, in the definition of
abfraction, the Glossary states that it is a discrete clinical
entity, yet data supporting this term are not available.
This controversy probably started with a review of
the literature and presentation of three cases published
in 1984 by Lee and Eakle (2), suggesting the possible
role of tensile stress in cervical lesions. Grippo (3)
defined abfraction as a pathological loss of hard tissues
by mechanical forces, because of tooth flexion related
to occlusal forces and consequent enamel and dentin
doi: 10.1111/j.1365-2842.2012.02290.x
 NON-CARIOUS CERVICAL LESIONS AND OCCLUSION
fatigue at a point distant from the force. However,
Järvinen et al. (4), observing the lack of evidence that
specifically defines the characteristics of the lesions in
the cervical area, suggested that they should all be
called NCCLs.
Despite continued published studies on the topic,
there still does not seem to be sufficient evidence to
support this hypothesis, warranting a systematic review
of that subject. The aim of this study is to ascertain, by
means of a systematic review, the association between
NCCLs and occlusion.
Materials and methods
We conducted a search of the English literature on
MEDLINE on 9 December 2011, using the following
search terms: ([cervical lesion] OR [cervical lesions])
AND ([non carious] OR [noncarious]) OR (abfraction).
One examiner (P.S.) screened the titles and abstracts of
the search results and classified the articles according to
the type of study. If this information was not available
in the title and abstract, the full text was then analysed.
Following this, the articles classified as clinical investi-
gations were read in full, and those that did not
evaluate any of the hypothetical aetiological factors of
non-carious cervical lesions were excluded (Fig. 1). To
complement the search, we manually searched the lists
of references to the included articles. Data concerning
the sample characteristics (size, age and location),
Fig. 1. Flow chart and selection process of the included publications.
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451
diagnostic criteria, prevalence of NCCLs, and occlusal
parameters evaluated were summarised.
This systematic review was prepared following the
preferred reporting items for systematic reviews and
meta-analyses (PRISMA) statement guidelines (http://
www.prisma-statement.org/). However, because of the
extreme heterogeneity in design, diagnostic criteria,
forms of analysis and associated factors, a meta-analysis
was not possible. Therefore, this is a descriptive
systematic review.
Results
A total of 146 publications were eligible for full-text
analysis. Further checking of the literature yielded one
additional publication (5). From the 147 eligible clinical
investigations, 28 publications were included in this
systematic review.
Table 1 represents a summary of the clinical inves-
tigations on NCCL diagnostic, prevalence and biases. It
can be observed that the included studies were
performed worldwide using samples of diverse sizes
and ages, causing difficulties in standardising the diag-
nosing, classifying and reporting of NCCL prevalence.
Additionally, the association of NCCL with occlusal
and non-occlusal aetiological factors is presented in
Table 2. Many occlusal parameters in the included
studies were evaluated to find its relevance to NCCL
initiation or progression.
 452

Table 1. Sample characteristics (size, age and location), Non-carious cervical lesions (NCCL) diagnostic criteria, study outcome, prevalence and limitation ⁄ bias of the selected
clinical studies

Study Sample characteristics NCCL diagnostic criteria Study outcome NCCL prevalence Limitations ⁄ Bias

Brandini et al. 58 students Clinical examination and To assess the potential 53% of the subjects No control of brushing
P . S E N N A et al.

(11) Mean age 22Æ9 ! 2Æ1 years questionnaire relation between buccal present NCCLs technique
Araçatuba, Brazil Tissue loss near the hygiene habits and the Correlation with No evaluation ⁄ control of
cementoenamel junction presence and number of toothbrush firmness and erosive or occlusal factors
was considered NCCL NCCLs toothbrushing force
Jiang et al. 2160 subjects grouped by Clinical examination and To describe the prevalence 38Æ8% for 35 to No independent examiners
(12) age (35–44 or questionnaire of NCCLs and to assess 44-year-olds and 56Æ6% to assess cervical and
65–74 years) NCCLs were scored the relative effects of risk for 65 to 74-year-olds occlusal conditions
Hubei Province, China through the Tooth Wear factors on NCCLs in presented NCCLs
Index (TWI; modified) middle-aged and elderly First premolars, canines
subjects and second premolars
showed the highest
prevalence
Pikdoken et al. 30 patients presenting Clinical examination (TWI; To investigate whether 475 teeth exhibited NCCL Subjects presenting
(9) multiple NCCLs minimal loss of contour cervical wear was (74Æ1%) multiple NCCLs should
Mean age [score 1]) was not associated with occlusal Premolars were the most have high exposure to
59Æ3 ! 8Æ89 years, considered NCCL wear and clinical affected teeth one or more aetiological
45–80 range periodontal parameters Occlusal wear was not factors
Istanbul, Turkey found to be associated No independent examiners
with NCCLs to assess cervical and
occlusal conditions
Ahmed et al. 95 patients presenting Clinical examination and To determine factors First premolars were the No independent examiners
(22) NCCLs questionnaire associated with NCCLs most affected teeth to assess cervical and
Mean age 50Æ3 years and the teeth most No correlation of NCCL occlusal conditions
Karachi, Pakistan commonly involved in with occlusal wear,
such lesions excursive guidance or
Angle’s classification
Reyes et al. (18) 46 patients Clinical examination by To determine whether 50% of subjects exhibited Reduced sample size
Median age 45 years; independent examiners associations were present wedge-shaped lesions presenting NCCL and
23–82 range Only wedge-shaped lesions between premature 10% of the teeth exhibited premature contact
Illinois, USA were included contacts in centric wedge-shaped lesions No independent examiners
relation, clinical Premolars were the most to assess cervical and
attachment loss and affected teeth occlusal conditions
abfraction lesions Premature contacts are not
related with NCCL or loss
of insertion

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 Table 1. (Continued)

Study Sample characteristics NCCL diagnostic criteria Study outcome NCCL prevalence Limitations ⁄ Bias

Wood et al. (8) 39 subjects who had two Clinical examination and To evaluate whether Premolars were the most Confounding bias with no
NCCLs that did not cast analysis 30 months reducing occlusal loading affected teeth control of the other
require restoration and after baseline by adjusting the occlusion Occlusal adjustment does hypothetical, aetiological
presenting group function One of the teeth was on a tooth during lateral not appear to halt the factors

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Mean age 51 ! 9Æ1 years;
35–70 range
Takehara et al. 159 male self-defence
(21) officials
Mean age
36Æ2 ! 12Æ3 years
Hokkaido, Japan
Smith et al. (25) 156 patients
Mean age 40Æ6 years;
16–73 range
Trinidad, West Indies
Tsiggos et al. 102 patients presenting
(19) anterior teeth and no
more than 2 missing
posterior (excluding third
molars) teeth
Mean age 44Æ6 ! 5Æ7 years
Thessaloniki, Greece
randomly selected to
have the excursive
occlusal contacts reduced
(centric occlusal contacts
were not reduced)
Clinical examination and To examine the
questionnaire
Minimal loss of contour
(TWI score 1) was not
considered NCCL and
only wedge-shaped
lesions were included
Clinical examination and To investigate the
questionnaire
Only teeth between and
including the first molars
were examined
Classification of NCCL
according to dentine
exposure
Questionnaire and cast To determine whether
analysis
Wedge-shaped lesions
were recorded when
found at least 2 teeth
per subject
No gradation of depth
or width
excursive movements progression of NCCL Reduced evaluation time
had any effect on the rate
of progression of existing
NCCL
78 subjects exhibited Concave lesions should
relationships of NCCL (49Æ1%) not be used as control
wedge-shaped NCCL Premolars were the most for v-shaped cervical
formation with occlusal affected teeth lesions, as it was not
factors NCCL has positive established that they
correlation with result from different
toothbrushing pressure aetiological agents
or occlusal contact area No independent examiners
to assess cervical and
occlusal conditions
62Æ2% of subjects No independent examiners
relationship of NCCLs exhibited NCCL to assess cervical and
with medical and dental 13Æ1% of teeth exhibited occlusal conditions
histories, oral hygiene NCCL
practices, dietary habits Premolars were the most
and occlusion affected teeth
Positive correlation with
group function or occlusal
wear
34% of bruxers exhibited No independent examiners
there was an association NCCL to assess cervical and
between self-reported 15Æ4% of non-bruxers occlusal conditions
bruxism and occurrence exhibited NCCL
of dental attrition Attrition and abfraction
(anterior, posterior), are associated with
abfractions and occlusal bruxism
pits on natural teeth
NON-CARIOUS CERVICAL LESIONS AND OCCLUSION
453

Table 1. (Continued)
Study Sample characteristics
Ommerborn 91 subjects presenting
et al. (17) anterior teeth and no
more than 2 missing
posterior (excluding third
molars) teeth
Mean age
28Æ37 ! 4Æ89 years;
20–39 range
Duesseldorf, Germany
Bernhardt 2707 subjects with more
et al. (5) than four teeth
presenting NCCL
Mean age
40Æ6 ! 11Æ1 years;
20–59 range
Greifswald, Germany
Faye et al. (30) 102 subjects
non-toothbrushers
Age range 20–77 years
Rural villages of
Senegal, Africa
Matos et al. (31) 120 patients with complete
cleft lip and palate
Mean age 27Æ5 years;
25–35 range
São Paulo, Brazil
Telles et al. (7) 40 students (total of
1139 teeth)
Age range 16–22 years
Bauru, Brazil
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454
NCCL diagnostic criteria Study outcome NCCL prevalence Limitations ⁄ Bias
Clinical examination To determine potential 39Æ7% of bruxers exhibited No independent examiners
Only wedge-shaped lesions occlusal differences NCCL to assess cervical and
P . S E N N A et al.
were included between sleep bruxism 12Æ1% of non-bruxers occlusal conditions
subjects and healthy exhibited NCCL Young sample
control subjects First premolars were the
most affected teeth
No correlation with
disoccluding excursive
contacts
Clinical examination and To determine risk 5Æ3% of teeth exhibited No independent
interview indicators for the NCCL examiners to assess
Only wedge-shaped lesions aetiology of Premolars were the cervical and occlusal
were included, without wedge-shaped most affected teeth conditions
gradation of depth cervical defects Abfraction is correlated
or width with occlusal wear,
inlays and tooth brushing
Clinical examination To examine the presence 48 subjects exhibited No independent examiners
Classification according of NCCLs in NCCL (47%) to assess cervical and
to aetiological non-toothbrushing Hyposalivation and acidic occlusal conditions
mechanisms: stress, subjects with Hansen’s diet may exacerbate the Erosion was not controlled
corrosion or friction disease prevalence of NCCL to isolate occlusal
(abrasion was not component
considered a factor)
Clinical examination To verify whether there is 9 teeth exhibited NCCL No independent
NCCLs were identified relationship between (0Æ8%) examiners to assess
by visual inspection and pattern of disocclusion Despite high prevalence cervical and occlusal
rated as present or absent and the presence of of occlusal interferences, conditions
occlusal ⁄ cervical no correlation was found
pathologies with abfraction or
gingival recession
Clinical examination and To associate the 18 subjects exhibited No independent examiners
cast analysis 36 months occurrence of new NCCLs NCCL (45%) at baseline to assess cervical and
after baseline with the presence of wear and 29 subjects (72Æ5%) occlusal conditions
Any irregularity felt with facets within a period exhibited NCCL after No control of other
a probe at the CEJ region of 3 years 3 years hypothetical, aetiological
was recorded as NCCL First molars were the factors
most affected teeth Reduced evaluation time
 Table 1. (Continued)

Study Sample characteristics NCCL diagnostic criteria Study outcome NCCL prevalence Limitations ⁄ Bias

Madani and 77 patients (total of Clinical examination and To investigate the 167 teeth exhibited NCCL No independent examiners
Ahmadian- 1974 teeth) questionnaire relationship between (8Æ45%) to assess cervical and

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Yazdi (16) Mashad, Iran Only wedge-shaped lesions
were included
Pegoraro et al. 70 subjects Clinical examination and
(14) Age range 25–45 years questionnaire
Bauru, Brazil Any irregularity felt with
a probe in cervical region
was considered to be
a NCCL
Estafan et al. 299 casts from dental Casts analysis
(23) students NCCL was classified as
Mean age 28Æ9 years absent, wedge- shaped or
New York, USA concave The severity was
recorded as mild (slight),
moderate (<1 mm deep)
or severe (‡1 mm deep)
Borcic et al. (27) 1002 subjects grouped Clinical examination
in six age groups NCCL was scored with
Rijeka, Croatia the TWI
NCCLs and dental First premolars were the occlusal conditions
premature contacts most affected teeth The sample age was not
(29Æ34%) referred to
Premature contacts and
working excursive
interferences were more
prevalent in teeth
presenting NCCL
To associate NCCLs 62 subjects exhibited No independent
with occlusal aspects NCCL (85Æ71%) examiners to assess
355 teeth exhibited cervical and occlusal
NCCL (17Æ23%) conditions
To evaluate the 66% of subjects exhibited No independent examiners
relationship between 1–5 NCCLs to assess cervical and
NCCLs and occlusal Premolars were the most occlusal conditions
wear affected teeth Mounting in centric
No correlation of NCCL relation position should
with occlusal wear give better accuracy in
evidencing occlusal wear
To determine whether 16% of teeth presented Occlusal condition was
there is any difference NCCLs not evaluated
in the occurrence of Premolars were the most
NCCL with regard to affected teeth (34Æ2%)
age and which teeth The most frequent index
are most affected level was 1 (minimal
loss of contour)
Prevalence and severity
increased with age
NON-CARIOUS CERVICAL LESIONS AND OCCLUSION
455
 456

Table 1. (Continued)

Study Sample characteristics NCCL diagnostic criteria Study outcome NCCL prevalence Limitations ⁄ Bias
P . S E N N A et al.

Oginni et al. (29) 106 patients presenting Clinical examination and To determine the 382 teeth exhibited No independent examiners
NCCL questionnaire proportion of NCCLs that abfraction (37Æ7%), while to assess cervical and
Ile-Ife, Nigeria NCCL was classified as were either abrasion- or abrasion was diagnosed occlusal conditions
saucer- or wedge-shaped abfraction-like and to test in 62Æ3% of teeth
and dimension was the validity of the No difference between
scored with the TWI assumption that right and left sides
right-handed patients NCCLs are not the result
cause more abrasion on of abfraction alone
the cervical surfaces of Wedge-shaped lesions
teeth on the left side are related to occlusal
of the mouth wear
Miller et al. (32) 61 patients presenting Clinical examination To verify the occurrence 211 of teeth exhibited No independent examiners
NCCL NCCL classified as of signs of excessive wedge-shaped lesions to assess cervical and
Mean age 48Æ8 years; wedge-shaped or saucer brushing or occlusal (68Æ3%), of which occlusal conditions
range 22–81 form, and the apical limit disturbances associated 94Æ5% were associated
Nancy, France was also recorded with NCCLs with occlusal wear and
77Æ2% with group
function disocclusion
There were no clinical
signs of excessive
brushing
Aw et al. (20) 57 subjects presenting at Clinical examination To analyse the 65% of NCCLs were on No independent examiners
least three NCCLs that NCCL more than 1 mm characteristics of NCCLs maxillary teeth to assess cervical and
required restoration in depth, and subject in adult patients who had Premolars were the most occlusal conditions
(>1 mm in depth or must have reported a high incidence of them affected teeth
thermal sensitivity) thermal sensibility 82% of NCCLs were
Mean age 51 ! 13 years; associated with occlusal
range 29–75 wear; 75% had Angle
Seattle, USA Class I occlusion and
60% had group function
disocclusion

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 Table 1. (Continued)

Study Sample characteristics NCCL diagnostic criteria Study outcome NCCL prevalence Limitations ⁄ Bias

Young and 174 subjects with salivary Cast analysis under To characterise and 145 buccal sites exhibited No independent examiners
Khan (26) hypofunction presenting stereoscopic light contrast the sites at which NCCL (83Æ3% of sites) to assess cervical and
NCCLs microscope occlusal pathology was Wedge-shaped lesions occlusal conditions

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Mean age 31 years NCCL was classified associated with either were the second most
Queensland, Australia as shallow, grooved facial ⁄ buccal or frequent NCCL type on
or wedge-shaped palatal ⁄ lingual cervical buccal sites (8Æ82%)
lesions in a selected group Mandibular premolars and
of subjects with excessive molars were the most
tooth wear and cervical affected teeth (30%)
pathology NCCL is rare in the
absence of occlusal wear
(<1%)
Saliva protects lingual
surface against erosion
Piotrowski et al. 32 male veterans as Clinical examination To investigate the 81 teeth exhibited No independent examiners
(24) patients NCCL was classified characteristics and wedge-shaped lesions to assess cervical and
Mean age 60Æ4 years; as saucer- or prevalence of (78Æ64% of NCCLs) occlusal conditions
range 38–80 wedge-shaped abfractions Premolars were the
Indianapolis, USA most affected teeth
Wedge-shaped lesion’s
dimensions did not
correspond with the
dimensions of occlusal
wear facets
Telles et al. (15) 48 students Clinical examination and To asses NCCLs in young 25 subjects exhibited No independent
Age range 16–24 years casts analysis patients and to establish NCCLs (52Æ08%) with examiners to assess
Bauru, Brazil Any irregularity felt with a possible relation with 94 lesions cervical and occlusal
a probe in cervical region occlusal aspects First molars (37Æ3%) and conditions
was considered to be first premolars (24Æ5%)
a NCCL were the most affected
teeth
65 teeth with NCCLs
present wear facets
(78Æ5%)
NON-CARIOUS CERVICAL LESIONS AND OCCLUSION
457

Table 1. (Continued)
Study Sample characteristics NCCL diagnostic criteria
Pintado et al. 1 subject (30 years) Cast analysis 14 years after
(6) Minnesota, USA baseline
3 wedge-shaped lesions
were included
Khan et al. 122 subjects presenting Cast analysis under
(28) one or more NCCLs stereoscopic light
Mean age 33Æ46 years, microscope
range 14–70 NCCL was classified
Queensland, Australia as shallow, grooved
or wedge-shaped
Mayhew et al. 43 patients presenting Clinical examination
(13) NCCLs and questionnaire
Mean age 56 ! 13 years Any loss of hard tissue
Houston, USA perceptible on visual or
tactile examination was
considered an NCCL and
classified as a saucer-
or wedge-shaped lesion
Bader et al. (10) 264 patients Clinical examination,
Chapel Hill, USA questionnaire and cast
analysis
Any loss of hard tissue by
tactile perception was
considered NCCL
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Study outcome
To evaluate whether
occlusal wear was
correlated with an
increase in size
of NCCLs after
14 years
To describe the incidence
and site specificity of
various types of cervical
lesions and their
association with occlusal
attrition or with occlusal
erosion
To investigate in vivo the
relationship of occlusal
stress factors, periodontal
health status and acidic
dietary patterns with
the presence of NCCLs
To examine the relation-
ships between NCCLs and
exposure to a variety of
candidate risk indicators
458
NCCL prevalence Limitations ⁄ Bias
Positive correlation Selection bias with this
between occlusal wear extremely short sample
and increased NCCL size No independent examiners
to assess cervical and
P . S E N N A et al.
occlusal conditions
No control of other
hypothetical aetiological
factors
Shallow lesion was the No independent examiners
most common cervical to assess cervical and
lesion, followed by occlusal conditions
wedge-shaped ones
Mandibular premolars
were the most affected
teeth
96% of NCCLs were
associated with occlusal
wear
74 teeth exhibited No independent
wedge-shaped lesions examiners to assess
(42%) cervical and occlusal
First premolars were conditions
the most affected teeth
95% of NCCLs were
associated with occlusal
wear and 64% presented
non-working
interferences
Cervical lesions have mul- No independent examiners
tifactorial aetiology to assess cervical and
occlusal conditions
 NON-CARIOUS CERVICAL LESIONS AND OCCLUSION 459

Table 2. Association of non-carious cervical lesions with non-occlusal and occlusal parameters reported by the included studies

Occlusion

Occlusal Premature
guidance contact ⁄ Occlusal Wear Parafunctional
Study Age Abrasion Erosion schemes interferences restoration facets habits

Brandini et al. (11) + +

Jiang et al. (12) + + +
Pikdoken et al. (9) ) + )
Ahmed et al. (22) + ) ) ) )
Reyes et al. (18) ) )
Wood et al. (8) + )
Takehara et al. (21) + + + )
Smith et al. (25) + + + + + +
Tsiggos et al. (19) +
Ommerborn et al. (17) ) + +
Bernhardt et al. (5) + + ) + + )
Faye et al. (30) ) +
Matos et al. (31) )
Telles et al. (7) + +
Madani and Ahmadian-Yazdi (16) +
Pegoraro et al. (14) ) ) + )
Estafan et al. (23) ) ) ) )
Borcic et al. (27) +
Oginni et al. (29) + +
Miller et al. (32) ) + +
Aw et al. (20) + +
Young and Khan (26) + + +
Piotrowski et al. (24) + + ) +
Telles et al. (15) + +
Pintado et al. (6) +
Khan et al. (28) + + +
Mayhew et al. (13) + ) +
Bader et al. (10) + + + ) +

+, statistically significant positive correlation; ), no statistically significant correlation.

Blank cells are variables that were not evaluated in the study.

The first idea about NCCLs and occlusion was to see

Discussion
The reason for performing a systematic review is the
fact that professionals tend to interpret their clinical
experiences without having supporting evidence.
Therefore, this study was designed to review the
literature on NCCLs to verify whether there is any
association between these lesions and occlusion.
The results found many articles related to this topic;
however, the diversity of study designs and the heter-
ogeneity of purposes prevent a meta-analysis. There-
fore, based on the available literature, we decided to
present an overview of the current thinking on the
relationship of NCCLs and occlusion.
whether there were any prospective studies supporting
a causal relationship. Surprisingly, we observed that
this supporting causality is scarce, as most of the
prospective studies focused mainly on evaluation of
Class V restorations. As of 9 December 2011, only three
prospective studies (6–8) dealt with establishing a
causal relationship between NCCLs and occlusion. In
2000, Pintado et al. (6) measured NCCL progression in a
14-year follow-up; however, they evaluated only three
NCCLs in one subject, which limits any extrapolation of
their results. More recently, Wood et al. (8) showed, in
a split-mouth design, that the elimination of excursive
contacts in 39 subjects by occlusal adjustment did not

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460 P . S E N N A et al.
prevent NCCL progression after 2Æ5 years. On the other
hand, Telles et al. (7) found an increased incidence (45–
72Æ5%) after a 3-year follow-up of a sample of 40 young
dentists. However, considering NCCL as a chronic
condition (5), the short follow-up period might not
have produced sufficient changes to be detected espe-
cially with a probe.
Besides occlusion, NCCLs are claimed to be related to
other hypothetical agents such as chemical (corro-
sion ⁄ erosion), association of occlusion and chemical
(stress corrosion) and ⁄ or physical agents (abrasion).
The three prospective studies cited (6–8) did not control
erosion or abrasion to isolate the influence of occlusion
on NCCL promotion or progression. Thus, erosion and
abrasion can be considered important confounding
biases in their experimental design.
Cross-sectional studies were the most prevalent to be
included in this systematic review. Using our experi-
mental design, the exposure data are collected after the
pathology is under way, and all the variables must be
evaluated simultaneously as it is difficult to isolate the
aetiological agents at only one assessing time. Thus, it is
not possible to define a causal factor; the hypothesis can
be tested only by estimating associations and risk
factors. The most appropriate way to isolate the influ-
ence of each of the evaluated variables is by means of
multivariate analysis, which was used in only two
studies (5, 9). All other cross-sectional studies included
in this review used traditional associations with a
univariate analysis.
Table 1 identifies the classification and diagnostic
criteria, prevalence of NCCLs and potential bias of
included clinical investigations. Many approaches have
been used to classify NCCLs; some studies reported any
loss of tissue at the cementoenamel junction as NCCLs
(7, 10–15), while others included only wedge-shaped
(5, 6, 16–19) or 1-mm-deep lesions (9, 20, 21). One
study did not specify the diagnostic criteria used to
classify the NCCLs (22). This diversity in diagnostic and
classification confounded our efforts to accomplish a
meta-analysis.
The prevalence of NCCLs ranged from 0Æ8% to
85Æ7%. Despite the diagnostic and classification differ-
ences, this widespread data reflect the different ways of
presenting results. These differences were revealed
when reporting the prevalence in all evaluated teeth
or only those affected by NCCLs. Any tooth can present
this pathology, although there is a strong tendency for
premolars to be the most affected teeth (5, 8, 10, 19,
21–26), more specifically first premolars (13, 14, 17, 18,
27), followed by first molars (7, 15). Incisors and
canines are not immune to NCCLs; however, the
prevalence of premolars is believed to be because of
the higher incidence of premature contacts (16) and
limited protection from saliva (26, 28).
We were unable to establish a clear association
between NCCLS and occlusion because of the difficulty
in identifying by cross-sectional studies without per-
forming a dynamic analysis of occlusion to predict the
bending movement to which teeth are submitted.
Table 2 presents the associations between NCCLs and
age, abrasion, erosion and occlusal factors.
The positive correlation between NCCLs and age (5,
7, 8, 11, 12, 15, 20–22, 25, 27) can be considered the
natural consequence of longstanding exposure to the
risk factors, characterising this pathology as a chronic
condition. Thus, age is an important variable that
permits comparing the study results.
It is interesting to note that the main association
between occlusion and NCCLs is through the presence
of occlusal wear facets (Table 2). However, all positive
correlations were made only by the presence of both
conditions using a single, non-blinded examiner to the
outcome or independent variable. It is likely that an
examiner who has observed NCCL would be more
careful while evaluating the occlusion than when
NCCL was absent, trying to confirm his or her suspected
hypothesis. Indeed, from the 28 included publications,
this important evaluation bias was controlled in only
one study, which used two independent examiners to
evaluate NCCL and occlusal wear and found no
significant correlation between them (23).
Despite reporting a positive association at the pres-
ence level, three studies did not find any significant
correlation between NCCL and wear facets when the
level of occlusal wear was correlated with NCCL size (9,
24, 29). Only one study (21) quantified the occlusal
contacting area and the NCCL dimensions to find a
positive correlation. We believe that occlusal facets are
nature’s way that of eliminating occlusal disturbances
and that NCCLs develop before or during the establish-
ment of occlusal facets, when the teeth are under
occlusal stress. However, this assumption cannot be
evaluated by experimental cross-sectional designs,
because they report only post hoc data.
If occlusion has a true role in NCCL aetiology, it
would be expected that parafunctional habits are an
exacerbating factor for the development of NCCL, as
ª 2012 Blackwell Publishing Ltd
 NON-CARIOUS CERVICAL LESIONS AND OCCLUSION
shown by two studies that evaluated subjects with sleep
bruxism (17, 19). Despite criticism of the self-reported
bruxism, a correlation was established with, again, only
the two conditions being present.
An interesting aspect of this systematic review is the
large number of review articles. It is surprising that so
many literature reviews are published, revising scarce
published original data. Additionally, an analysis of
these reviews (data not shown) demonstrates that most
of them fail to admit the fact that they are only
reiterating a literature that is both quantitatively and
qualitatively weak in terms of types of study design.
As this systematic review has demonstrated, it seems
that a causal relationship between NCCLs and occlusion
has not yet been demonstrated clinically by prospective
studies. Cross-sectional studies point to an association
between occlusal wear and NCCLs; however, this is
very light evidence because of the use of non-blinded
examiners. Therefore, researchers are encouraged to
plan further studies to seek a causal relationship, taking
into consideration the necessity of eliminating bias.
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Correspondence: Plinio Senna, Av. Limeira, 901. Piracicaba, São Paulo
13414-903, Brazil. E-mail: plinio@senna.odo.br
ª 2012 Blackwell Publishing Ltd
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