Nichole Dicke, LDH, BGS
NON-CARIOUS CLASS V LESIONS:
ASSESSING THE CAUSE
Identify the clinical characteristics of non-carious class V lesions
Discuss the traditional suspected causes of these lesions
Describe the theory of abfraction
Compare the various types/sources of abfractive forces
Identify potential co-contributers to class V lesions
Describe patient evaluation procedures for diagnosing the cause of the lesions
Describe the management and treatment of these lesions and their causes
OBJECTIVES
A FAMILIAR SIGHT
These lesions are typically diagnosed as or . abrasion erosion
* Home self-care….what if they’re doing it right?
* Are we giving toothbrushes and toothpastes too much
credit? Researchers think so. 1,2,3,4,5,6
ABRASION:
THOUGHTS TO CONSIDER
How can oral hygiene
technique, which all too
often results in this….
ABRASION:
THOUGHTS TO CONSIDER
….also result in this?
* Location, location, location.
* Where’s the acid source?
EROSION:
THOUGHTS TO CONSIDER
How could abrasion and/or erosion cause this?
ABRASION AND EROSION:
A FINAL THOUGHT
Imagine Grandpa at the dining table.
SO WHAT’S REALLY GOING ON?
ABFRACTION = PHYSICS
Causes of excessive occlusal forces:
* Bruxism
* Misalignment
* Tongue thrust
ABFRACTION = PHYSICS
* Bruxism, by definition, IS excessive occlusal force.
* This is potentially problematic when combined with
misaligned teeth.
ABFRACTION = PHYSICS
BRUXISM
Remember our table?
ABFRACTION = PHYSICS
MISALLIGNMENT
=
Remember our table?
ABFRACTION = PHYSICS
=
Misallignment may cause teeth to:
* “Hit early”
* Occlude with the opposing tooth on a cuspal incline
* Have heavy contact with opposing teeth
ABFRACTION = PHYSICS
* Tongue thrust applies lateral pressure to the crown.
* Remember: it’s the cumulative effect of repeated
forces, not necessarily the amount of force applied.
* And remember grandpa! He may not be very strong
or heavy, but he can still cause damage over time.
ABFRACTION = PHYSICS
* Controversial
* Burden of Proof
* Does it matter?
ABFRACTION: THE RESEARCH
Innocent until proven guilty!
Research tells us that:
* Occlusal forces are concentrated at the cervical
region.7,8,9
* Cervical enamel is inherently weak. 10,11,12
ABFRACTION: THE RESEARCH
*Occlusal forces cause teeth to flex.
*Cycles of occlusal loads on extracted teeth have caused
cervical fractures after 2.5 months worth of “chewing”.8,9
*Forces applied to cuspal inclines = more stress.13
*Heavy occlusal contact areas are directly associated with
cervical lesions.14
ABFRACTION: THE RESEARCH
Research that DOES suggest toothbrush abrasion (such
as the 1960’s study pictured below) resulted in distinctive
lesions.
ABFRACTION: THE RESEARCH
Abrasion from toothbrushing machine abfraction
* Cervical lesions are frequently found on teeth
with heavy wear facets.15
* Cervical lesions not commonly found on
mobile teeth.12,16 Why?
* Patient profiling15
ABFRACTION: OBSERVATIONAL
EVIDENCE
*Occlusal indicator wax
*Articulating paper
*Pressure detecting sheets
*Computerized assessment
ASSESSING FOR ABFRACTION:
CONTACT POINTS
T-Scan II by Tekscan
ASSESSING FOR ABFRACTION:
CONTACT POINTS
Heavy contact markings Heavy markings on cuspal inclines
ASSESSING FOR ABFRACTION:
CANINE GUIDANCE
Canine
Guidance
Illustration
ASSESSING FOR ABFRACTION:
CANINE GUIDANCE
ASSESSING FOR ABFRACTION:
TONGUE THRUST
*A healthy swallow involves the tongue and the palate.17
*A tongue thrust swallow involves the tongue, palate, and
the teeth.17
*Some patients are at risk of developing a tongue thrust
swallow. 17
*With the patient in centric
occlusion, ask him to swallow, watch
the tongue.
*Watch for bubbles and saliva.
*Tongue thrust may easily be
corrected through therapy.
ASSESSING FOR ABFRACTION:
TONGUE THRUST
Tongue thrust with abfraction
* The question
remains…..erosion, abrasion,
or abfraction?
* Why Does it have to be
either-or? Why not both, or
even all?
ASSESSING FOR ABFRACTION:
MULTIFACTORIAL CONSIDERATIONS
?
* Erosion-Abfraction: Erosive agents seep into microfractures,
undermining and the enamel. Even GCF may be errosive. 12,15,18
* Abrasion-Abfraction occurs when occlusal forces cause stress
concentration in areas with external friction sources.12
* Erosion-Abrasion, likewise, combines corrosive chemical
exposures with external friction sources.12
* Caries can also combine with erosion, abrasion, and abfraction.12
ASSESSING FOR ABFRACTION:
MULTIFACTORIAL CONSIDERATIONS
* Many practitioners do not restore cervical lesions unless necessary.
* If the occlusal forces are not corrected, a cervical lesion will likely
fail.
* It is recommended that dentists consider making fine adjustments to
the occlusion prior to placing composite restorations.17
* It has been speculated that isolated areas of recession, or clefting, is a
precursor to abfraction and warrants an occlusal assessment.17,19
TREATING ABFRACTIONS
Occlusal adjustment example
TREATING ABFRACTIONS
Classic abfraction affecting
Canines and premolars.
Patient experiences severe
sensitivity tooth #12.
Heavy contacts on cuspal
inclines. Contact points reduced.
Example continued
TREATMENT OF ABFRACTION
Heavy markings on opposing
tooth #21
Contact point reduced.
Sensitivity on tooth
#12 eliminated!
Canine guidance restored.
End of case.
REMEMBER…
The treatment is
only as good as
the diagnosis.
REFERENCES
1. Radentz WH, Barnes GP, Cutright DE. A survey of factors possibly associated with
cervical abrasion of tooth surfaces. J Periodontol. 1976; 47: 148-54
2. Sangnes G, Gjermo P. Prevalence of oral soft and hard tissue lesions related to
mechanical toothcleansing proceedures. Community Dent Oral Epidemiol. 1976;4:77-83
3. Saxton CA, Cowell CR. Clinical investigation of the effects of dentifrices on dentin wear
at the cementoenamel junction. J Am Dent Assoc. 1981; 10:, 38-43.
4. Sognnaes R, Wolcott R, Xhonga F. Dental erosion: erosion-like patterns occurring in
association with other dental conditions. J Am Dent Assoc. 1972; 84: 571-82.
5. Volpe A, Mooney R, Zumbrunnen C, et al. A longterm clinical study evaluating the
effect of two dentifrices on oral tissue. J Periodont. 1975; 46: 113-8.
6. Joiner A, Pickles MJ, Tanner C, et al. An in situ model to study the toothpaste abrasion
of enamel. J Clin Periodontol. 2004; 31: 434-8.
7. Nohl FS, McCabe JF, Walls AWG. The Effect of Load Angle on Strains Induced in
Maxillary Premolars in vitro. British Society of Dental Research Meeting. University of
Leeds. April 12-15 1999; Abstract no. 200.
8. Palamara D, Palamara JE, Tyas MJ, et al. Effect of stress on acid dissolution of
enamel. Dent Mater. 2001; 17(2):109-15.
9. Hanaoka K, Magao D, Mitusi K, et al. A biomechanical approach to the etiology and
treatment of non-carious dental cervical lesions. Bull Kanagawa Dent Coll. 1998;
26(2) 103-11.
10. Scott JH, Symons NBB. Introduction to Dental Anatomy, 9 th ed. 1982. Churchill
Livingstone, Edinburgh, UK.
11. Stanford JW, Paffenbarger GC, Kampula JW. Determination of some compressive
properties of human enamel and dentine. J Am Dent Assoc. 1958; 57: 487-95.
12. Grippo JO, Simring M, Schreiner S. Attrition, abrasion, corrosion, and abfraction
revisited. J Am Dent Assoc 2004; 135: 1109-18.
13. Rees J. The effect of variation in occlusal loading on the development of
abfraction lesions: a finite element study. J Oral Rehabil. 2002; 29: 188-93.
14. Takehara J, Tomotsugu T, Akhter R, et al. Correlations of noncarious cervical
lesions and occlusal factors determined by using pressure-detecting sheet. J Dent.
2008; 36: 774-9.
15. Rees J, Hammadeh M. Undermining of enamel as a mechanism of abfraction
lesion formation: a finite element study. Eur J Oral Sci. 2004; 112: 347-52.
16. Kuroe T, Itoh H, Caputo AA, et al. Potential for load-induced cervical stress
concentration as a function of periodontal support. J Esthet Dent. 1999; 11: 215-
22.
17. Palmer B. The significance of lateral forces to the development of dental
abfractions. Available at http://www.brianpalmerdds.com/lateralforce_abfract.htm.
Accessed Jan 27, 2011.
18. Bodecker CF. Local acidity: a cause of dental erosion-abrasion. Ann Dent. 1945;
4(1): 50-55.
19. Solnit A, Stambaugh R. Treatment of gingival clefts by occlusal therapy. Int J
Periodont Rest. March 1983:38-55.
Intra-oral images used with explicit permission from Dr. Brian Palmer, DDS.
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