Non-Carious Class V Lesions:

What's Really Going On?

By Nichole Dicke, LDH, BS

N<

I on-carious class V lesions are a familiar yet perplexing

patient concern. Dentists frequently encounter such lesions
and are faced with the challenge of diagnosing and treating
them. How these lesions are diagnosed directly affects their
treatment and prognoses. What may come as a surprise to
many dental practitioners is that non-carious class V lesions
are quite possibly being misdiagnosed, interfering with
successful (long-term) treatment and prevention of future
lesions.
Patients frequently come to the dental office concerned
about "notched out" areas near the gumline. In many cases,
the first response would be assessing oral hygiene practices
for sources of abrasion, including applying too much pressure
and/or scrubbing while brushing, using a firm toothbrush,
or using too abrasive a dentifrice. If everything in the home
care regimen seems correct, the next move is most likely to
assess the patient's diet and oral environment for erosive
factors, such as a high sugar or acid diet, the chronic use of
lozenges, or acidic saliva. The patient is then sent home with
a new tooth brushing method, an extra soft toothbrush, a
sample of non-abrasive gel toothpaste and dietary recommendations. Six months later, the patient returns and the
clinician notes two more cervical lesions. Is the patient not
complying, or are these lesions being cause by something
else altogether?

Dentifrices are no longer made from

crushed oyster shells, eggshells and
bones. Additionally, patients are using
soft toothbrushes. Is it really plausible
they are still managing to brush away the
, hardest substance in the human body?
There are patients with these lesions who admittedly
hardly ever brush their teeth, thus ruling out toothbrush
abrasion. Dentifrices are no longer made from crushed
oyster shells, eggshells and bones. Additionally, patients are
using soft toothbrushes. Is it really plausible they are still
managing to brush away the hardest substance in the human
body? Even using firm brushes, is it conceivable that brushing back and forth could cause these lesions, which often
affect areas of the teeth notoriously missed when patients
brush? Would a toothbrush head be able to cause these lesions, which range from broad and shallow to very narrow,
deep and angular? A review of the literature reveals little
to no evidence that toothbrushes and dentifrice are capable
of causing significant damage to teeth. There are patients
with these lesions who have never experienced a cavity and
have very low sugar/acid intakes, making diet an unlikely
culprit. Finally, these lesions have been found on the roots of
extracted teeth with no gingival recession, making abrasion
and erosion both virtually impossible. Recent dental research
investigating non-carious cervical lesions has resulted in the
theory of abfraction, where forces cause flexure and deformation of the teeth, usually at the cervical.'

16 NOV 2012

Characteristics of Non-Carious Class IV lesions

Non-carious class V lesions, or cervical lesions, are losses
of tooth structure (enamel and dentin) without the presence
of dental caries.^ The exposed dentin is often smooth and
shiny. The patient may or may not experience increased sensitivity in these areas. There are two morphological types of
these defects: concave and wedge-shaped. Concave lesions
are smaller and shallower than wedge-shaped lesions, which
are deep, with sharp angles, and result in a greater loss of
tooth structure. The concave lesions are generally much less
severe than wedge-shaped, and it has been hypothesized
that wedge-shaped lesions are caused by more stressful,
destructive forces than the concave lesions.^ It is this severe
and rapid destruction that has caused many researchers to
investigate the potential causes and treatments of cervical
lesions.
Wedge-shaped cervical lesions are often found on teeth
with prominent occlusal wear.^ Interestingly, these lesions
are most frequently found on surfaces opposite the surface
with the most severe wear facet/attrition. Literature as early
as the 1977 study by Xhonga documented higher prevalence
of cervical lesions in bruxers." In 1987, Lambrechts et al.
also concluded bruxism, in addition to malocclusion, were
also seemingly associated with abfractive lesions.= In agreement was the study by Burke et al. in 1995, in which the
authors noted cervical lesions in teeth subjected to lateral
forces while the adjacent teeth (not subjected to lateral
forces) presented with no lesions.'' Cervical lesions are rarely
found on calm, low-stress individuals with ideal (class I)
bites. More often, they are found in individuals with malocclusions resulting in mal-aligned cusps subject to heavy and/
or oblique occlusal loads.^

A Theory of Physics and Engineering

What if repeated forces, namely lateral and oblique
forces, could cause stress points on teeth that eventually
break loose? These forces could be due to malocclusion or
tongue thrust. At first, the idea of a tongue movement causing tooth breakage may seem unrealistic. An analogy would
be a new dining room table with a pedestal base, made of
solid and very strong maple wood. Imagine the person sitting at the "head" of the table pushes his hands against the
table top to help him stand up from sitting in a chair. This
action alone is not likely to break the table. However, if this
person does this repeatedly, hundreds or even thousands of
times per day (as often as humans swallow), it is plausible
this force could cause such stress on the table that it breaks.
The table top is analogous to the crown of a tooth, and the
pedestal base is analogous to the root. Repeated pressure on
the crown, albeit slight and undamaging as a single incident,
may accumulate as chronic stress that eventually manifests
as fractures.
Abfraction is based on principals in physics and engineering. Ideally, occlusal forces are transmitted vertically along
the axis of the tooth and absorbed by the periodontium. In
the table analogy, this would be similar to a person push-

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ing their bodyweight perfectly downward on the very middle of the

dining table where the pedestal base attaches beneath - the force
would pass through the pedestal to the floor beneath with no damage done. If forces are applied in a non-axial direction as lateral or
oblique pressure, or if the forces are repeated excessively, they may
concentrate in the cervical area of the tooth and cause enamel and
dentin destruction (Figure 1).
Strains on teeth are concentrated into the cervical region,
particuiarly forces not directed onto the occiusal surface along the
axis of the tooth.' Cervical enamel is inherently weaker, with poorer
structure and greater pore volume, and with fewer areas of gnarled
enamel (interwoven enamel rods that produce stronger enamel).^
Cervical enamel also has less compressive strength than enamel
found on cusps' and is considerably thinner and more brittle."
Occiusal loads, particularly lateral forces, may cause the teeth to
flex. This flexure may in turn break the bonds in the hydroxyapatite,
which leads to cracks and fractures in the enamei and underlying
structures. Oblique stresses applied to the cuspal inclines, rather
than cusp tips, put more stress on the tooth structure (Figure 2).^
Teeth are better able to withstand direct vertical pressure than lateral or oblique pressures. Heavy occiusal contact areas, determined
by heavy markings using pressure-detecting sheets, have been
significantly linked to the occurrence of cervical lesions (Figure 3).^
Several studies have revealed the impact chewing has on cervical
enamel. Extracted teeth subjected to cycles of occiusal loading began to suffer fractures in the cervical enamel after only 2.5 months'
worth of chewing (200,000 cycles)." These fractures worsened as
more cycles were applied. Networks of microcracks have been noted
near the CEJ when on teeth subjected to cyclic occiusal pressures.'^
Occiusal forces pass through the teeth into the periodontium, where
the supporting structures help to absorb the forces and provide a
cushion. Mobile teeth are less prone to cervical concentration of
these forces." A relationship between mobility and cervical lesions
was discovered where less mobile teeth (with more rigid support)
exhibited higher rates of cervical lesions."
If no heavy attrition, wear facets, or markings on cuspal inclinations are present, pressure from tongue movements may be the culprit (Figures 4 and 5). An ideal swallow involves placing the tip of the
tongue on the palate, behind the anterior teeth. As the swallow proceeds, the body of the tongue continues to press upward against the
palate, pushing the food towards the throat in a peristaltic manner."
The tongue should not press against any teeth during the swallowing
action. A tongue-thrust swallow, one where the tongue pushes the
teeth in order to force the food towards the throat, may be the result
of habit, an abnormally large tongue or a congested airway." It has
been theorized that abnormal swallows in infants may actually cause
malocclusions such as narrow arches, crowding and overjets.'^The
repeated pressing of the tongue against the tooth acts as a person
pushing against the edge of a table when standing up; over time, it
may cause enough stress for a fracture to occur. These lesions are
most common on anteriors and premolars, the teeth most affected
by abnormal tongue movements."
Abfraction may also serve as a co-contributor to cervical lesions.
One possible hypothesis is that non-carious class V lesions could
occur when erosive dietary fluids (which affect buccal surfaces
more than lingual surfaces) leak into the microscopic cracks in the
hydroxyapatite that resulted from occiusal loads concentrated into
the cervical areas. A 2004 study examined abfraction in teeth with
cervical enamel that has been undermined (the dentine beneath has
begun to erode).'"^ The researchers applied 100 Newtons of oblique
load pressure (bruxers may apply as much as 500 Newtons) to
intact teeth and teeth with varying degrees of undermined enamel
and measured the resulting levels of stress on the buccal enamel
near the amelo-dentine junction. Teeth with cervical enamel defects
exhibited much higher stress values; the larger the enamel defect,
the higher the stress value. Enamel defects as small as 0.34 mm in
length resulted in stress values above the known fracture limit. Gingival crevicular fluid has been shown to be acidic and may contribute
to enamel undermining."

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Figure 1. Oblique occiusal forces may cause concentrated stress in the

cervical area, resulting in microfractures and eventual ioss of enamel
and dentin.

Figures 2 and 3. Abfraction lesions present on teeth with heavy indicator maridngs. The mari<s indicate iarge contact areas present on the
cusp inclinations rather than the ideai small contact points on the cusp
tips. Reprinted with permission from Dr. Robert Palmer, DDS.

Figures 4 and 5. Tongue thrust upon swallowing, evident by tongue

buiging through space behind abfracted tooth #28, which was then
extracted. The extracted tooth shows a iarge abfraction lesion, most
of which was hidden beneath the gingiva, protected from abrasive effects of toothbrushing and dentifrice. Reprinted with permission from Dr.
Robert Palmer, DDS.

In addition to the corrosion-abfraction theory, there are several

other types of possible multifactorial causes of cervical lesions.'"
Attrition-abfraction may occur in bruxers, where tooth-to-tooth
contact causes friction, which combines with the concentration of the
stress in the cervical area. In abrasion-abfraction, tooth structure is
lost when an external friction (such as partial denture clasp) is applied to an area where occiusal loading has caused stress concentration, making it more susceptible to abrasion. Attrition-corrosion
is the result of corrosive agents damaging areas already worn by
attrition. Abrasion-corrosion, likewise, combines corrosive chemical
exposures with external friction sources. Biocorrosion-abfraction is
the damaging of enamel due to a combination of caries and stress
concentration." To complicate the issue, cervical lesions may involve
more than two factors. The clinician needs to keep all of this in mind
when trying to identify the cause(s) of the patient's lesions,

NOV 2012 17

Figure 6. Heavy indicator

markings on cuspal inclines
tooth #12 (slightly rotated).
Note gingival cleft and beginning of abfractlon lesion. Patient was experiencing sensitivity. Reprinted with permission
from Dr. Robert Palmer, DDS.

to assessing for corrosion-abfraction, other possible co-contributors

siiould be identified. Areas of severe attrition also need to be noted,
as well as abrasion from partial denture clasps, habits such as excessive tootiipick use, parafunctionai habits or any other finding that
may weaken the tootii structure.

Treatment of Abfractions

Figure 7. Selective minor

adjustment to contact
points reduced the side of
the contact area removing
the oblique occlusal forces.
Patient reported relief of
sensitivity. Reprinted witli
permission from Dr. Robert
Palmer, DOS.

Patient Assessment
As stated earlier, a tongue-thrust swallow results in tiie tongue
pressing against the lingual surfaces of the teeth rather than against
tiie palate. Assessing patients for tongue-thrust is quite simpie.
Wiiile retracting the patient's cheeks, tiie clinician should ask tiie
patient to swallow. If any teeth are missing, or if large interproximal
spaces are present, the clinician can watch for tiie tongue to pusii
into tiiese gaps while the patient swallows. If dentition is full and
contacts are closed, a tongue-tiirust swallow will usually result in
saiiva and/or bubbles being forced through the interdentai spaces."
Tine patient may need to swailow more than once for this to be seen
and/or ineard by the clinician.
The typical occlusai assessment during office exams consists of
noting Class I, II and III malocclusions, over/underbite, overjet,
crossbite, openbite and end-to-end reiationships. Tinese indeed are
important factors for many aspects of dental health. However, winen
evaluating for the potential of abfractive lesions, more detective
work is necessary. Articuiating paper, occiusal indicator wax, pressure detecting sheets and otiner occlusal pressure analyzers are
useful tools for assessing the risk of abfraction. A inealthy occlusion
sinould resuit in small areas of contact on cusp tips or in occiusal
fossae. The clinician should look for large areas of contact, particulariy on cuspal inclinations and on buccal and lingual surfaces.
Canine guidance is anotiner key element of the occlusal exam. While
tiie patient is in centric occiusion, ask him to very siowly slide their
mandible to the right (and then left), until tiie buccal surfaces of the
mandibular and maxiilary molars are flush with one another At this
point, only the patient's canines should be in contact. Similarly, when
the patient extrudes their mandible forward, the incisors should
first guide the movement, followed by the canines alone being in
contact with one anotiner. If non-canine teeth are guiding occlusion
movement, they are experiencing more occlusal load than tiiey are
designed to handle and therefore may be at risk for periodontal
damage, excessive wear and abfraction.
Assessing tiie patient's diet and oral environment for sources of
erosive elements is aiso necessary, as erosion and occlusal/tongue
forces may serve as co-contributors to cervical lesions. Saliva pH
and salivary flow rates can be tested in the office. Interviewing the
patient can reveal dietary sources, such as carbonated beverages,
fruit juices and alcohol. Foods and beverages high in sugars also
need to be identified as contributors to erosion due to tiie wellknown oral "acid attack" that occurs after consuming fermentable
carboinydrates. Frequency of consumption will be the key to determining which dietary factors are likely to be contributors. In addition

18 NOV 2012

There are mixed viewpoints about restoring these lesions.

Resin-based composites are frequently used to reduce sensitivity and improve esthetics. Many dental practitioners do not restore
abfractions for two main reasons: the lesions are non-carious, and
they are likely to return if the cause of abfraction has not been addressed. The longevity of resin class V restorations is questionable
in patients who experience tinese lesions due to occiusal stresses.
In 2009, Friscisconi et al. investigated tiie effects of occlusal pressure on resin Class V restorations." The researciiers created class V
lesions in 40 extracted teeth, restored them witin resin composites,
and tinen subjected tine teeth to 150 Newtons of occiusal pressure on
the buccal cusps, lingual cusps and central fossae. The restoration
margins were inspected using fluorescein to evaiuate defects. Occiusal pressure, regardiess of location, contributed to tine formation
of margin gaps. This occurred on resins of varying sizes and depths.
The researciners concluded tinat occlusal loading must be addressed
in patients being treated for abfraction lesions to ensure that resin
margin integrity is maintained.
Treating the cause of abfraction may require retraining the
individual to swallow correctly. Patients may be referred to speech
tinerapists for help in breaking the tongue tiirust habit. Bruxers
should be fitted witii splints or guards. Tiie clinical work of Robert
Paimer, DDS, iias demonstrated success witii creating equiiibrium.
Palmer performs fine modification of the contact areas, reducing
tiieir size (Figures 6 and 7). Palmer's patients reported immediate
reiief of sensitivity, indicating that tine sensitivity may be caused by
flexure resulting from occlusai load." Occlusal therapy may be useful
in treating gingival clefts, whicii Palmer identified as a precursor to
abfraction."'" In 1983, Solnit and Stambaugii reported tinat refining
contact points on teeth with gingival ciefts actually resulted in a partiai to complete reversal of tiie clefts in all 25 cases studied." It is
Paimer's standard to refine occlusion for teeth witii abfractions that
are being restored with resin-based composites to prevent recurrence."
If co-contributors are identified, tiiey wiil also need to be addressed as part of the treatment plan. Sources of erosion need to
be reduced or eliminated. Salivary replacement products siiould
be recommended for those with xerostomia. Fiuoride rinses, gels
or varnishes are appropriate for patients wino are at high risk for
erosion, tinougin researcin has produced mixed results regarding
fluoride's ability to prevent erosion in inighiy acidic environments."""
Products that contain the casein pinospinopeptide-amorphous calcium
pinospinate (CPP-ACP) complex have been sinown to reduce acidity and strengthen the tooth surface."-^^ Xyiitoi products, such as
chewing gums and mints, inhibit microbial metabolism, thus lowering
oral acidity; research suggests this effect may persist after using the
products."'^^ Ortinodontia may be recommended to reduce endto-end occlusion areas or other maiocclusion. If abrasion is being
caused by partial denture clasps, the dentist may need to make
adjustments to the partial or consider recontouring and/or restoring
the abutment tooth.

Conclusion
As with any tineory, tinere are conflicting viewpoints tinat must
be considered. Abfraction is a theory based on engineering principals of occlusal stress being concentrated at the cervical portions of
teeth. While the evidence is compelling, tinere is limited conclusive
research on occlusal forces causing cervicai lesions, indicating a need

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for further research,^^ Rees' 2002 studies demonstrated occlusal

loads cause stress on the lingual cervical areas also, yet lesions are
rarely found here, suggesting a multifactorial nature,' It is difficult
to "prove" abfraction, as the lesions resemble those thought to be
caused by toothbrush abrasion and erosion, though research has
historically failed to prove toothbrushing and dentifrice are causes of
significant cervical wear.'"'= Many practitioners feel more definitive
data is needed to attribute these lesions solely to abfraction and
caution against making permanent changes to patients' teeth based
on abfraction theory alone. When patients present with non-carious
class V lesions, the clinician may be faced with a complex mystery to
solve, one with a multifactorial answer. It is in patients' best interest
for the clinician to be open-minded and thoroughly investigate all
possible causes, as a treatment is only as good as the diagnosis.

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Nichoie Dicke, LDH, BS, works part time as a
dentai hygienist in private practice in Indiana.
She graduated with her associate's degree in
2003 and completed her bachelor degree in
2008 from Indiana University - Purdue University in Fort Wayne, Ind., where she currently
also works as a clinicai instructor. She is finishing her thesis research through Idaho State
University and wiil earn a Master of Science in
dental hygiene with an emphasis in education.

NOV 2012 19

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