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J Am Dent Assoc, Vol 133, No 6, 725-733.
© 2002 American Dental Association
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RESEARCH

Characteristics of noncarious cervical lesions

A clinical investigation



TAR C. AW, D.D.S., M.S., XAVIER LEPE, D.D.S., M.S., GLEN H. JOHNSON, D.D.S., M.S. and LLOYD MANCL, Ph.D.


   ABSTRACT
TOP
 ABSTRACT
METHOD AND MATERIALS
 DATA COLLECTION AND ANALYSIS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. The purpose of the authors’ in vivo investigation was to analyze the characteristics of noncarious cervical lesions, or NCCLs, in adult patients who had a high incidence of them.

Methods. The patient pool consisted of a total of 57 patients and 171 teeth (three teeth per patient), with one NCCL per tooth. The characteristics the authors evaluated were shape, dimensions, sensitivity, sclerosis and occlusion.

Results. In terms of lesion characteristics, 91 percent of the lesions had axial depths of 1 to 2 millimeters, 49 percent had occlusogingival widths of 1 to 2 mm, 74 percent had an angular shape of 45 to 135 degrees, 76 percent had mild or moderate sclerosis, and 73 percent had no or mild sensitivity. In terms of occlusion, 75 percent of teeth had an Angle Class I occlusion on the involved side, 60 percent had group function or mixed excursive guidance, 82 percent had wear facets, and 99 percent had Type 0 or I mobility. In terms of tooth location, 70 percent of NCCLs were on posterior teeth, 65 percent were on maxillary teeth, and 46 percent were on premolars.

Conclusions. The evaluated NCCLs were found mainly to have small dimensions of depth and width (< 2 mm) and to be roughly right-angled in shape, and many had sclerosis and low sensitivity. A majority of the dentitions studied had Class I occlusion, with group function, prevalent wear facets, and little or no mobility. Cervical lesions were more common with posterior maxillary teeth and premolars, especially first premolars, which had the highest prevalence of lesions. Older patients were more likely to exhibit noncarious cervical lesions, but no great difference in incidence was found between men and women.

Clinical Implications. A knowledge of the NCCL characteristics and etiologic covariables aids in proper case selection for treatment, aids in selection of appropriate treatment protocols and improves assessment of prognosis.

A noncarious cervical lesion, or NCCL, is the loss of tooth structure at the cementoenamel junction, or CEJ, level that is unrelated to dental caries. These lesions can affect tooth sensitivity, plaque retention, caries incidence, structural integrity and pulpal vitality.1–6 The NCCL is being seen with increasing frequency and presents unique challenges for successful restoration.4,7,8

Older patients were more likely to exhibit noncarious cervical lesions, but no great difference in incidence was found between men and women.

Background and review of literature. The prevalence of cervical lesions has been reported to be from 5 to 85 percent in various study populations.1,4,7,9–13 To properly treat such a lesion, it is important to consider its etiology. The CEJ is an area of structural weakness where the enamel layer is at its thinnest.14 Erosion, abrasion and abfraction (stress flexure) are believed to be causative in the formation of NCCLs in this vulnerable area of enamel.15,16 Erosion is the chemical dissolution of tooth structure by acids, which can be intrinsic or extrinsic in origin.17 Abrasion is the mechanical wear of tooth structure by repeated physical contact principally by toothbrushes and/or abrasive dentifrices.1,7,10,18 For abfraction, it has been postulated that the cervical fulcrum area of a tooth is subject to unique stress, torque and moments resulting from occlusal function, bruxing and parafunctional activity.16,19–25 These flexural forces can act to disrupt the normal ordered crystalline structure of the thin enamel and underlying dentin by cyclic fatigue, leading to cracks, chips and ruptures.16,24–31 Stress corrosion and piezoelectric effects also have been theorized to have an effect.14

No single mechanism is adequate to explain all occurrences of NCCLs. Their etiology likely is multifactorial in nature; a combination of all these factors is responsible to varying degrees.9,10,15,21,31–36 It has not been clearly identified as to whether any one process is more responsible for lesion initiation or for progression, or vice versa. Initiation of breakdown by one process can make the tooth more susceptible to damage by the other processes, perhaps in a synergistic manner.3,14,15,21,33 One factor may predominate over another in a given patient, leading to the varied morphological presentations.3,31

There are data to indicate that occlusion, saliva, age, sex, diet and parafunctional habits are factors that may be associated with NCCLs.6,15,16,31,37 Knowing the characteristics of established lesions gives clues and guidance as to if and when intervention is indicated, and likely progression of lesions if left untreated. Identifying affected teeth and susceptible patients enables judicious case selection for treatment and allows modification of treatment protocols, if necessary.3,15,16 The ability to better estimate success and longevity of restorations will be a factor in treatment decision making, or at least provide more realistic expectations of outcomes. This article describes a study in which we examined the characteristics of NCCLs, the teeth and the patients affected to determine trends, risk factors and indicators for intervention and prognosis.

Knowing the characteristics of established lesions gives clues and guidance as to if and when intervention is indicated, and likely progression of lesions if left untreated.


   METHOD AND MATERIALS
TOP
 ABSTRACT
 METHOD AND MATERIALS
DATA COLLECTION AND ANALYSIS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Design. This study was a clinical survey of the baseline pretreatment data, with descriptive analysis and correlational analysis of lesion characteristics, tooth location and patient demographics. While acknowledging that NCCLs are multifactorial in nature, this investigation approached the NCCL as a single entity to determine if there are any trends, risk factors or etiologic covariables—in effect, to suggest a retrospective analysis of the outcome. Patient screening and evaluation of all teeth with NCCLs, identified visually or tactilely, were performed by two clinical investigators (T.C.A. and X.L.). We performed an initial calibration to ensure standardization, as much as possible, of the investigators’ techniques, criteria and procedures. Evaluation calibration also included using standardized models and photographs depicting the range of possible observations. Patients were screened initially to meet the study entry criteria (below) and, if qualified, were enrolled in the study for the evaluation visit. Qualified patients were recruited in the order in which they presented themselves for the screening session, thus forming a convenience sample.

Procedure. The evaluative tools used were a mouth mirror, explorer and periodontal probe. Air from the air-water syringe was used to administer the thermal sensitivity test. The patients were preselected for severity of their condition, being defined as having at least three NCCLs that required restoration. The lesions were deemed to require restoration if they were more than 1 millimeter in depth, had patient-reported thermal sensitivity or both. The investigators screened all teeth in each subject, selecting the largest and/or most sensitive lesions if there were more than three teeth that qualified. They chose no more than three teeth per patient to minimize patient-related effects that might distort the study results and yet obtain a sizeable number of lesions. The other inclusionary criteria were that subjects be older than 18 years of age and in good general health (American Society of Anesthesiology Classification I or II).38 Patients were excluded if they exhibited active, untreated periodontal disease; had rampant, uncontrolled caries; experienced xerostomia; were undergoing orthodontic treatment or bleaching treatment; or were using supplemental fluoride.

We selected a total of 57 subjects, resulting in 171 teeth with NCCLs that were evaluated. Lesions were characterized by shape, dimensions, sensitivity, extent of sclerosis and occlusion.2,15,31,39–41 We also noted tooth location and recorded patient demographic information. These factors have been identified as possible covariables in NCCL formation, and in adhesion of Class V resin-based composite restorations.42 The evaluation was performed after the investigator removed any debris, plaque or surface layer that obscured inspection, by means of gentle toothbrush agitation and use of floss. The investigator took quadrant impressions of the tooth of interest using vinylpolysiloxane and poured stone models to have a three-dimensional record of evaluated teeth and respective NCCLs. Color photographs of each lesion also were taken for documentation.

Evaluation criteria. Shape. The investigators evaluated the shape of the lesion by visually inspecting the vertical buccolingual cross section (Figure 1Go). Being that NCCLs are a saucer or a wedge shape, they categorized the acute angle formed by the occlusal and gingival walls on an ordinal scale as < 45 degrees, 45 to 90 degrees, 90 to 135 degrees and > 135 degrees.



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  		Figure 1. Angular shape of cervical lesion in buccolingual cross section. A. Wedge or V shape. B. Saucer or C shape.

 
Dimensions. The investigators measured lesions’ dimensions by using a periodontal probe. They categorized the axial depth, judged by the estimated ideal buccal contour compared to adjacent or contralateral normal teeth to the most axial portion of the lesion, on an ordinal scale as 1 to 2 mm, 2 to 3 mm, 3 to 4 mm and > 4 mm (Figure 2Go). The occlusogingival width is the vertical distance at the widest extent between the occlusal and gingival margins of the lesion, also categorized on an ordinal scale as 1 to 2 mm, 2 to 3 mm, 3 to 4 mm and > 4 mm (Figure 2Go).



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  		Figure 2. Dimensions of cervical lesion in buccolingual cross section. A. Horizontal depth. B. Vertical width.

 
Extent of sclerosis. The investigators evaluated the extent of sclerosis by visual inspection and tactile feedback with a dental explorer, to determine extent of discoloration (yellow or brown), glassy appearance (shiny, hard or smooth) and translucency or transparency of the enamel/dentin. They categorized their observations on an ordinal scale as "none," "mild," "moderate" or "heavy" (as described in Duke and colleagues39,43) (Figure 3Go).



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  		Figure 3. Cervical lesions in a quadrant demonstrating the range of sclerosis: none (no. 22), mild (no. 21), moderate (no. 20) and heavy (no. 19).

 
Sensitivity. The investigators evaluated sensitivity by applying a blast of air from an air-water syringe at a distance of approximately 1 inch away, with adjacent teeth under rubber dam isolation (Figure 4Go). The application of air was for a maximum of five seconds. The subjective patient response of level of sensitivity (discomfort) was recorded on a 10-point continuous visual-analog ratio scale, ranging from "no discomfort" (a score of zero) to "extreme discomfort" (a score of 10).



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  		Figure 4. Air sensitivity testing of a single tooth isolated with a rubber dam.

 
Occlusion. Occlusion was observed by visual inspection. Observations were in multiple categories of nominal scales of Angle’s classification (Class I, II and III), excursive guidance (canine guidance, group function or a mixture), wear facets (absent or present) and ordinal scale of mobility (Lindhe44 Type I, II and III). Angle’s classification and guidance were examined in the quadrant of the tooth in question. Wear facets were identified visually by flat, smooth surfaces on the cusp ridges, triangular ridges or inclined planes of the involved tooth. The investigators measured tooth mobility using pressure exerted between the ends of two mirror handles.

Tooth location. The investigators noted the position of the teeth, anterior or posterior, maxillary or mandibular, on a nominal scale. They also categorized the teeth as first molars, second premolars, first premolars, canines, lateral incisors or central incisors.

Patient demographic information. Patients were grouped by age on an ordinal scale: 21 to 40 years, 41 to 60 years and 61 to 80 years. Patients’ sex was recorded on a nominal scale as either male or female. This information was self-reported by the subject and not independently verified.


   DATA COLLECTION AND ANALYSIS
TOP
 ABSTRACT
 METHOD AND MATERIALS
 DATA COLLECTION AND ANALYSIS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
For each evaluation criterion, the statistical expert on the research team (L.M.) calculated the category frequencies. He assessed pairwise associations between the evaluation criteria by logistic regression analysis using generalized estimating equations to account for the possible dependence between multiple lesions within a patient. All tests were performed at a .05 significance level.


   RESULTS
TOP
 ABSTRACT
 METHOD AND MATERIALS
 DATA COLLECTION AND ANALYSIS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Table 1Go shows the breakdown of the lesion characteristics of 171 teeth in 57 subjects (three lesions per subject); Table 2Go shows the tooth location information; and Table 3Go shows the subject demographic information. The angular shape of the lesions tended to be roughly right-angled (90 degrees), with 74 percent in the 45- to 135-degree range and only 6 percent less than 45 degrees. The axial depth tended to be shallow, with 91 percent being in the 1 to 2 mm range and only 1 percent greater than 3 mm. The occlusogingival width tended to be narrow, with 49 percent in the 1- to 2-mm range and 42 percent in the middle 2- to 4-mm range. Extent of sclerosis tended to be rated "mild" (54 percent); an equivalent number was split between "none" and "moderate," and 3 percent of the sclerosis was judged to be "heavy." For air sensitivity, 73 percent felt either no or mild sensitivity (in the 0–3 range), with roughly equal numbers in the moderate (4–6 range) and extreme (7–10 range) categories.


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  		TABLE 1 LESION CHARACTERISTICS IN TEETH STUDIED.

 

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  		TABLE 2 LOCATION OF TEETH WITH NONCARIOUS CERVICAL LESIONS.

 

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  		TABLE 3 SUBJECT DEMOGRAPHIC INFORMATION.

 
Occlusion was another major characteristic that we examined extensively. Angle’s classification tended to be Class I, with a 75 percent majority; the remaining proportions were almost equally divided between Class II and Class III. Excursive guidance was 40 percent canine guidance, 37 percent group function, and 23 percent a mixture of the two. Wear facets were present in most (82 percent) of the patients. Tooth mobility tended to be not or only slightly mobile, with 99 percent Type 0 or I, only 1 percent Type II and none Type III.

Seventy percent of the NCCLs were on posterior teeth and 30 percent on anterior teeth, and 65 percent were on maxillary teeth and 35 percent on mandibular teeth. First premolars (26 percent) and first molars (25 percent) were affected the most often, followed by second premolars (20 percent) and canines (20 percent). NCCL incidence was least likely in central incisors (7 percent) and lateral incisors (4 percent). Patients tended to be older, with 60 percent in the group aged 41 to 60 years and 23 percent in the group aged 61 to 80 years. Only 16 percent were in the group aged 21 40 years. Subjects’ overall age range was 29 to 75 years, with a mean of 51 (± 13 standard deviation). Subjects were almost equally divided between male (54 percent) and female (46 percent).


   DISCUSSION
TOP
 ABSTRACT
 METHOD AND MATERIALS
 DATA COLLECTION AND ANALYSIS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Shape and dimensions. It would appear that most lesions were not very deep, were not vertically wide and were approximately right-angled in shape. It has been found that lesions are more prevalent in the older population, and older patients are more likely to have lesions that are deeper, larger or both.7 This is not surprising because older patients and their teeth have been exposed to the pertinent etiologic factors for a much longer period than younger patients (and their teeth), and thus should be expected to have more lesions, and of greater severity.15,24 In addition, older populations are more likely to have gingival recession and bone loss, with more root surface and cementum exposure, increasing the risk of cervical lesions.45,46 In this study, 83 percent of the subjects were older than 40 years of age, and 23 percent were older than 60 years, and yet axial depth—the primary diagnostic criterion for restoring NCCLs—was greater than 2 mm in only 9 percent of these cases. This might suggest that NCCL progression is a slow process, that early restorative intervention may not be necessary, and that monitoring and re-evaluation may be acceptable, even appropriate, for small, asymptomatic incipient NCCLs.

Sclerosis and sensitivity. The majority of lesions were sclerosed to some extent, mostly in the "mild" category. Contrary to what might be expected for such macroscopic loss of tooth structure, sensitivity was mostly minimal or nonexistent. Since NCCL development tends to be a slow, chronic process that occurs over an extended period, it was not surprising to find sclerosis and lack of sensitivity. Secondary dentin, occlusion of open dentinal tubules, pulpal retreat and other natural tooth protective measures have slowly adapted to the noxious stimuli, thereby minimizing symptoms and maintaining pulpal integrity.43 This does correspond to the expectation that logically there should be an inverse relationship between sclerosis and sensitivity, with 76 percent of lesions classified with mild or moderate sclerosis, and 73 percent with mild or no sensitivity. These findings are in accord with other reports that NCCLs generally exhibit a lack of thermal sensitivity.2,31 From a restorative standpoint, with the presence of sclerosis and absence of sensitivity, preparation design may require additional retention and alleviated sensitivity should be a routine outcome. However, one should bear in mind that sclerosis is a difficult category to measure, in that it is fraught with subjectivity and susceptible to inter- and intraexaminer variation on features such as discoloration, smoothness and translucency. Sensitivity to cold air is also a difficult measurement, relying solely on the subject’s subjective response and perception of pain severity.

Posterior teeth were more likely to exhibit noncarious cervical lesions, possibly owing to the fact that greater occlusal forces and more lateral forces are exerted in the posterior teeth.

Occlusion. There is an increasing amount of evidence that occlusal factors, involving repeated occlusal stresses and tooth flexure, play a significant role in NCCL etiology. The majority of affected teeth (75 percent) were in Class I occlusion (considered the most desirable, "normal" occlusion), which concurs with results of other studies.31 With a Class I occlusion, maximal inter-arch tooth contact in centric occlusal function can occur during maximum intercuspation. The more contact there is between opposing teeth, the more cyclic lateral and compressive forces are exerted at the cervical fulcrum area of the teeth, as occurs during chewing. More subjects were in group function than in canine guidance, with more opposing tooth contact in the former than the latter. Excursive tooth contacts can exert powerful tensile and shearing forces, especially if there are occlusal interferences. Thus the concept of "freedom in centric" should diminish NCCL formation, whereas bruxing, clenching and other parafunctional habits that increase the magnitude of cervical stress would increase NCCL formation.31 Indirect evidence is provided by the finding that bruxers have a greater incidence of NCCLs than nonbruxers.19,20 Over-whelmingly, wear facets, a sign of stressful occlusion, were present (rather than absent) on teeth with NCCLs, providing support for occlusal forces and flexure as causal factors. The presence of wear facets has been a common finding with cervical lesions.31,32 The theory of occlusal loading is given further support by the finding that almost all (99 percent) of NCCL teeth had little or no mobility. If teeth are mobile, then concentration of forces at the cervical area could not occur. Others also have found a definite negative correlation between tooth mobility and presence of an NCCL.4

Tooth location. Posterior teeth were more likely to exhibit NCCLs, possibly owing to the fact that greater occlusal forces and more lateral forces are exerted in the posterior teeth. Maxillary teeth seem more prone to NCCLs, possibly owing to the lingual tilt. Premolars, in particular first premolars, appeared in our study to have the highest prevalence of NCCLs, whereas incisors, especially laterals, have the lowest prevalence. Prevalence in first molars also was high, second only to first premolars. These findings confirm those of many previous studies, that posterior maxillary teeth, specifically first premolars and first molars, are most susceptible to cervical lesions.1,2,10,11,15,31,36,47 This has been attributed to the greater occlusal forces in the posterior teeth or to natural relative anatomical morphology of the teeth, periodontium and vestibule.3,10,31,32 Other possibilities are the natural progressive development of group function from anterior to posterior or the relative accessibility of toothbrushes and brushing mechanics.3,10,31,32

Subject demographics. As with other studies,7,10,15,18,36,47 the prevalence of NCCLs increased with increasing age; the majority of this study population was older than 40 years of age, with a mean age of 51 years. As mentioned previously, older patients who have been exposed to the etiologic factors for a longer time, coupled with marginal tissue or gingival recession, are at greater risk for cervical lesions and, thus, more likely to have more lesions and lesions of greater severity.15,24,44 In addition, older subjects are more likely to have fewer teeth to bear the occlusal load, with a loss of the protective mechanisms of natural dentition and diminished quantity and quality of saliva.13,15,16,37,48 Also, compositional and microstructural changes to enamel and dentin associated with the aging process may render the tooth structure more susceptible to lesion formation; the precise role of these changes still is not fully understood.16,26,39,45 Reflecting past findings, our findings do not appear to point to any sex difference in NCCL prevalence.7,10

Lesions of smaller widths were associated with greater sensitivity, perhaps owing to less sclerosis.

Pairwise associations. Geometry dictates that lesion shape (angle) should be associated with occlusogingival width—and indeed, the smaller the shape, the smaller the vertical dimension. Perhaps not surprisingly, occlusogingival width also was associated with axial depth; the smaller the vertical width, the smaller the axial depth. Lesions with smaller depth were associated with less sclerosis, reflecting more sclerosis at the later stage of a lesion. Lesions of smaller widths were associated with greater sensitivity, perhaps owing to less sclerosis. As expected, lesions with no or mild sclerosis were more sensitive than those with moderate or heavy sclerosis.

Also not surprising was our finding that wear facets were more likely with group function and mixed guidance than with canine guidance. Posterior teeth were more likely to have less mobility, probably owing to their multirooted nature. Mandibular lesions were more likely to be on posterior teeth than were maxillary lesions, consistent with the rarity of finding mandibular anterior NCCLs. Associations do not appear to be transitive; in other words, two related associations do not necessarily imply a third association.

A similar study by Mayhew and colleagues31 of 43 subjects with 178 lesions demonstrated strikingly analogous results to ours, with almost identical frequency distributions. However, it must be noted that the measurement criteria in our study were post hoc data collected after the fact and provide only indirect evidence of NCCL formation. Our study was conducted on a very specific subset of patients with NCCLs, namely those with at least three lesions of defined severity. The data may not reflect a true random survey of the entire general population of people with NCCLs. There also may be unknown possible sampling bias of self-selected subjects of which we are unaware, since they essentially volunteered to be recruited into the study population. Nonetheless, since a sizable number of patients were recruited, and they had a high incidence of lesions, this can be considered a sufficiently randomized group, and these lesions accurately represent the true nature of the NCCL.

There are many misconceptions of the causes of such lesions and substantial differences among dentists in the recognition and treatment of cervical lesions.5 The results from this study should aid the clinician in identifying and deciding which teeth require restoration and which patients are the best candidates for the procedure. It also helps in predicting the likely progression of lesions if they are left untreated. The treatment plan may include pre-treatment adjustment or alteration of occlusion. In selecting restorative materials, the clinician should look for a low modulus of elasticity, resistance to wear and ability to withstand acid dissolution.3,16 Preparation design may need to be changed, depending on whether adhesive retention is adequate or if mechanical retention is necessary.3,16 Preventive interventions include use of a protective nightguard, changing toothbrushes and dentifrices, and use of neutralizing mouthrinses. A patient’s behavior and habits may require modifications such as changes in diet; changes in brushing technique, force and frequency; and reduction of clenching or bruxing.5,48

The same characteristics that have been identified as associated with NCCL formation have been hypothesized to be predictive of restoration success or failure.19 A prospective, longitudinal, randomized clinical trial of Class V cervical restorations on these lesions can yield insights as to what determines clinical success rates and the variables that are important to this outcome.


   CONCLUSION
TOP
 ABSTRACT
 METHOD AND MATERIALS
 DATA COLLECTION AND ANALYSIS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
We examined 57 subjects who had a total of 171 teeth with multiple NCCLs of significant size. We found that NCCL progression was a slow process, with most lesions remaining quite small even in subjects of advanced age. Most NCCLs were sclerotic, leading to diminished sensitivity. Occlusion tended to be Class I, with a group function excursive guidance, with a preponderance of wear facets and little or no mobility, lending indirect evidence to an occlusal stress/tooth flexure etiology. Cervical lesions were more common with posterior maxillary teeth. Premolars as a group, and first premolars in particular, were most likely to have cervical lesions, and incisors, especially lateral incisors, were the least likely. NCCLs were more likely in older patients, but prevalence by sex was equivalent. These characteristics and covariables help identify whether to intervene and how to treat NCCLs, as well as which teeth and patients are more susceptible.



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  		Dr. Aw is an assistant professor, Division of Operative Dentistry, Department of Restorative Dentistry, University of Washington, School of Dentistry, D-770 Health Sciences Building, Box 357456, Seattle, Wash. 98195-7456, e-mail "tcaw{at}u.washington.edu". Address reprint requests to Dr. Aw.

 


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  		Dr. Lepe is an associate professor, Division of Fixed Prosthodontics, Department of Restorative Dentistry, University of Washington, School of Dentistry, Seattle.

 


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  		Dr. Johnson is a professor, Division of Bio-materials and Research, Department of Restorative Dentistry, University of Washington, School of Dentistry, Seattle.

 


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  		Dr. Mancl is a research assistant professor, Department of Dental Public Health Sciences, University of Washington, School of Dentistry, Seattle.

 


   FOOTNOTES
 

The authors acknowledge the support of 3M ESPE Corp., St. Paul, Minn., and Coltène AG, Altstätten, Switzerland, for providing materials and funding for this study.


The authors acknowledge the support of the study site, the University of Washington Regional Clinical Dental Research Center, for the facilities, equipment and particularly the efforts of the staff members, all of which have been instrumental in the conduct of this clinical trial.


   REFERENCES
TOP
 ABSTRACT
 METHOD AND MATERIALS
 DATA COLLECTION AND ANALYSIS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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D.W. Bartlett and P. Shah
A Critical Review of Non-carious Cervical (Wear) Lesions and the Role of Abfraction, Erosion, and Abrasion.
J. Dent. Res., April 1, 2006; 85(4): 306 - 312.
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