class v lesions

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:


….also result in this?

* Location, location, location.

* Where’s the acid source?

EROSION:


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


* Bruxism, by definition, IS excessive occlusal force.

* This is potentially problematic when combined with

misaligned teeth.


BRUXISM

Remember our table?


MISALLIGNMENT

=

Remember our table?


=

Misallignment may cause teeth to:

* “Hit early”

* Occlude with the opposing tooth on a cuspal incline

* Have heavy contact with opposing teeth


* 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.


* 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


*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


Research that DOES suggest toothbrush abrasion (such

as the 1960’s study pictured below) resulted in distinctive

lesions.


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


CONTACT POINTS

Heavy contact markings Heavy markings on cuspal inclines


CANINE GUIDANCE

Canine

Guidance

Illustration

http://www.youtube.com/watch?v=Yu39riukfTc




CANINE GUIDANCE


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.


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?


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


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.

http://www.brianpalmerdds.com/lateralforce_abfract.htm

class v lesions

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