Cervical root caries may be initiated at a single foci on a tooth or at multiple foci, generally along the anatomic step of the tooth's CEJ or at the margin of the restoration. Eventually, the demineralizing lesions progress radially and coalesce into one lesion. Lesions commonly progress along the surface much more aggressively than they do in a pulpal direction, resulting in broad, shallow lesions. If the plaque surrounding the lesions is removed and proper oral hygiene maintained, the lesion could remineralize and progress to an arrested state (Fedele, 1998).

      One significant risk factor in developing cervical root caries is gingival recession, which exposes the cementum to the oral cavity. Other intraoral risk factors include elevated S. mutans count, higher plaque and calculus scores, diminished salivary flow, deep gingival pockets, high sugar diets, and lack of fluoride. Also, increased age, missing teeth, existing restored and unrestored carious lesions, and removable partial dentures are associated with a higher risk for cervical root caries. Locationally speaking, mandibular teeth have increased susceptibility from anterior to posterior, while the opposite is true in the maxilla (Shay, 1997).

      Abfraction lesions are angular, wedge shaped lesions in the cervical portion of the tooth. Current evidence suggests that these lesions are the result of weakened enamel stemming from stresses induced by cuspal flexure forces generated from occlusal loading (Rees, 2000). The basic principle is that when non-axial forces are generated in a tooth, the tooth acts as a lever, with the fulcrum being located near the cervical region of the tooth. Lateral excursive forces create tensile stress on the buccal surface and compressive stress on the lateral surfaces of teeth (Coleman, 2000). The structures of enamel and dentin are well equipped to handle compressive stress, but tensile stress concentrated in the cervical region is believed to disrupt the chemical bonds of the crystalline structures of enamel and dentin. Small molecules then enter the microcracks and prevent reformation of the bonds. Ultimately, this weakens the enamel and dentin, making it increasingly susceptible to fracture, erosion, and abrasion (Lyons, 2001).

      Laboratory studies to support the science of how abfractive lesions form are limited because of difficulty simulating the intraoral environment. The correlation between people who are in malocclusion or bruxism and cervical lesions was made decades ago. Studies that have since supported the theory of abfractive lesion formation include one by Lambrechts et al. that demonstrated that enamel cracks under tensile stress (Lee, 1996). Stereomicroscopic evidence showed evidence of disruptive forces in hydroxyapatite crystals under stress. Observational facts have provided much of the evidence to support the tooth-flexural theory of abfractive lesions. One is that these lesions form on teeth that are subjected to lateral load and fail to form on adjacent teeth that are not exposed to such forces. These lesions are rarely seen on the lingual surfaces of teeth, where tensile stress does not frequently occur. Finally, abfractive lesions can occur subgingivally, which would generally not occur in lesions caused by erosion and abrasion (Coleman, 2000).

      Dental erosion is the "chemically induced loss of hard tissue by processes not involving bacteria" (Bader et al, 1996). This acid attack can be extrinsic or intrinsic. Extrinsic examples include diet, occupation exposures in chemical and metal plants and swimming in chlorinated swimming pools. Intrinsic forms of acid attack focus on gastric acids, and are seen in people with conditions causing unintentional gastric reflux, bulimia, and individuals with "voluntary reflux phenomenon." Voluntary reflux phenomenon is seen in high stress professionals who regurgitate their food holding it in the buccal pouches until it is swallowed again or spit out. Patients with reduced salivary flow lack salivary protection making them more effected by acid attacks (Khan et al, 1999). NCCL due to erosion are smooth oval shaped concave lesions without developmental grooves or ridges. Extrinsic lesions are common in anterior teeth and premolars while intrinsic lesions commonly affect the posterior teeth (Osborne-Smith et al, 1999).

      Toothbrush abrasion was considered the primary etiology of NCCL until the 1980's. Factors that contribute to the lesions are increased frequency and force of brushing and the abrasiveness of the toothpaste. Technique also plays a role; horizontal brush strokes place more abrasion at the cervical area of the tooth and therefore lead to more tissue loss than do longitudinal brushstrokes. Also, lesions were found to be more severe in the area the patient began brushing first and in the area opposite the side of the patients dominant hand. For example, right handed patients had more NCCL on the left hand side of their mouth. NCCL due to abrasion are wedge- or groove-shaped lesions with sharp well-defined margins and scratched surfaces (Osborne-Smith et al, 1999).

      In summary, the etiology of NCCL is related to a variety of factors. With the current research the exact cause(s) and promoting factor(s) is unknown but it is thought to be a multifactorial process consisting of cervical flexure due to occlusal forces, acidic erosion and mechanical abrasion. The process may be best described as "stress corrosion" supplemented by mechanical abrasion (Bader et al, 1996). By stress corrosion, it is meant that cervical flexure and acidic attack work together synergistically to weaken and demineralize the enamel and dentin in the cervical area of the tooth (Lyons, 2001). The weakening of the cervical hard tissue decreases the "wear resistance" to the mechanical abrasion of tooth brushing, allowing the further loss of hard tissue (Khan et al, 1999).

      The hypersensitivity of dentin might seem a trivial part of patient management, but when you consider that over 15% of the population experiences some degree of cervical dentin sensitivity (Idle et al, 1998) you can quickly come to the conclusion that as practitioners we will run into this complaint quite commonly throughout our careers.

      The most widely accepted theory of dentin sensation is that fluid movement inside the dentinal tubules leads to nerve stimulation and the sensation of pain. In addition to transient shifts of fluid a permeable dentin can also permit the diffusion of bacterial products into the pulp (Pashley, 1986). The amount of diffusion is dependent upon the remaining dentin thickness, the surface area of the exposed permeable dentin, the presence or absence of a smear layer, and the amount of pulpal blood flow (Pashley, 1986). If this is the case, then the ideal goal in the treatment of dentin hypersensitivity is to restore the impermeability of the dentin tubules. This can be accomplished by using topical agents or plastic resins.

      In a recent study done in 1999 an experimental Gluma Desensitizer with reduced glutardialdehyde was used to measure sensitivity after a single topical application of the cervically exposed area. It was determined that the Gluma Alternate, with a 2.5% concentration of glutardialdehyde, a biological fixer, was able to react with proteins inside the tubules forming a precipitate and leading to tubule occlusion (Jain et al, 2000).

      In another study by Zhang the effects of a resin-based product were studied for their ability to reduce sensitivity in the dentin. The results showed that a single treatment of the resin desensitizer produced significant reduction in permeability. The application of this resin was done with etching and without. In either case dentin permeability was reduced by several days (Jain et al, 2000).

      In yet another study it was concluded that Gluma Dentin Desensitizer and etching plus resin did not reduce dentin permeability and that the greatest reduction in permeability occurred with All-Bond, which is placed without etching (Jain et al, 2000). The difference in this study was that toothbrushing and immersion in saliva were performed on the treated cervical areas.

      In another study in which topical agents were applied to the cervical lesion over a period of 10 days with the patients scoring the pain both before the procedure and afterwares, it was concluded that a 10% strontium chloride solution, 2% sodium fluoride solution, and 40% formalin solution all reduced significantly the amount of sensitivity experienced by the patient (Kishore et al, 2002).

      In closing, there are many agents that can be used to treat cervical dentin hypersensitivity. It is recommended that in order to control a patient's dentin sensitivity and to prevent complications after composite restorations have been completed, a resin-based desensitizer without etching is key.

      There are several materials available to choose from to treat cervical lesions. There are the metal materials, which consist of gold foil and amalgam, and then there are nonmetal materials, which are composed of composite and glass ionomers. In the past, gold foil was the metal of choice to treat these types of lesions. Gold foil was a great restorative material for cervical lesions because it was strong and polished nice, but the drawback was a less conservative approach when removing tooth structure (Ziegler, 2002). Although it was effective, it was very non-conservative and sometimes non-esthetic. Therefore, gold foil is rarely put in the mouth anymore. The main three materials used today are amalgam, composite, and glass ionomer.

      When dealing with cervical lesions and material choice there must be good isolation in order for the restoration to work. Besides the need to meet esthetic demands, marginal sealing ability, especially in dentin or cementum appears to be the major priority when choosing an appropriate filling material (Powell, Gordon, and Johnson,1991). Seperately, one of the authors of the paper you are reading conducted three interviews with University of Minnesota faculty dentists and all three came up with the unanimous decision that amalgam was the material of choice in cervical lesions if and only if the ability to isolate was jeopardized. Otherwise, they all agreed on the use of composite for cervical lesions.

      Amalgam is a very durable, highly polishable material that is used frequently for restorations. Its ability to resist wear and have minimal marginal leakage also makes this a suitable material. Also, the use of an adhesive system with amalgam restorations gives them an even better prognosis. Using a multi-purpose adhesive system resulted in both a statistically significant increase in bond strength and a statistically significant decrease in extent of microleakage (Neme, Evans, and Maxson, 2000). The drawbacks of amalgam are somewhat similar to the drawbacks of the gold foil. Amalgam can have very poor esthetic results if it is placed on visible teeth, but the major concern deals with the preparation. Preparations for placement of amalgam require proper retention and thickness and this can compromise the tooth due to the loss of tooth structure. Therefore, amalgam can and should be used for areas of poor isolation, but areas that allow proper isolation should include the use of a nonmetal restorative material.

      Nonmetal materials include glass ionomers and composites. They are both tooth colored materials that provide promising alternatives to conventional materials for restoring cervical defects. Glass ionomers have traditionally been used to restore cervical lesions due to their ease of use, their ability to adhere to the teeth, and the release of fluoride. Glass ionomer restorative materials are well proven as adhesive restorations of non-retentive cervical cavities but have been poorly accepted, primarily due to inconvenient setting characteristics (Matis, Cochran, and Carlson, 1996). There are three types of glass ionomers to briefly talk about; they are classified as conventional, resin-modified, and compomers. The disadvantages of the conventional glass ionomer cements include low fracture toughness, poor wear resistance, sensitivity to moisture and high opacity, which causes poor esthetic results (Folwaczny et al, 2000). These are reasons why conventional glass ionomer is seldom used.

      Resin-modified glass ionomers (RMGIs) offer a few more advantages than conventional, but also share some similarities. For instance, RMGIs allow greater flexural strength, tensile strength, compressive strength, and the elasticity is more equal to that of tooth substance. Also, esthetic properties seem to be improved because of the increase in translucency due to differences in the optical properties between the polyacid and the resin components (Sidhu and Watson, 1995). The two things that have not changed since introduction of resin-modified cements are wear resistance and fluoride release.

      The last type of glass ionomer is compomers. These materials are easier to handle and their physical characteristics (compressive, tensile, and flexural strength) are comparable to the physical characteristics of composites. Using the acid-etch technique in combination with a dentin bonding agent, the adhesive strength of compomers to enamel and dentin is almost equal to that of the composite resins (Fritz et al, 1996). Several clinical studies comparing glass ionomers to composites show poor color stability, rough surface texture, poor wear resistance, and higher prevalence of marginal defects. The results of the study revealed a significantly better quality of the composite restorations, which showed no cases of non-acceptable clinical condition in any aspects and the ratings of the compomer fillings were only slightly worse (Folwaczny et al, 2000). During the three aforementioned interviews, the authors found that even after evidence of the compomers being somewhat similar to composite, not one of the instructors used glass ionomers to fix cervical lesions. It was almost always composite that was the material of choice.

      The composite most widely used and studied is the new Z250 composite material. All three dentists interviewed by the author confirmed that the composite of choice was Z250. Composite requires great isolation technique and the result is a very good and appealing product. The esthetics is its greatest advantage because it can even be placed on anterior teeth. Composites demonstrate satisfactory esthetic properties and high wear resistance (Neo et al, 1996). Also, the modulus of elasticity is high for composite, which allows it to resist the stresses of occlusion that cervical lesions undergo. There has been concern that extensive curing shrinkage of composite materials may lead to the formation of marginal gaps. Studies show, though, that with the use of an adhesive, bond strength significantly increases while the extent of microleakage decreases. Composites do tend to wear over time but they have great color, their surface texture is smooth, and they have good marginal integrity. Therefore, with all these materials, the research comparisons and the testimonies by practicing dentists all lean toward one final statement. The two most commonly used materials that are most successful are amalgam and composite and the way to deduce which one to use all boils down to isolation and good technique.

      Cavity preparation for carious cervical lesions has been carried out in one of two manners: the traditional approach or the non-traditional approach. GV Black established the traditional theory in 1891, (Operative Dentistry, 2000). In summary, his theory stated that carious lesions, in our case class V cervical lesions, need to first be removed. Then, retentive parallel walls are formed in the preparation. The mesial and distal walls of the cavity preparation must be convergent in order to be in alignment of outward extending enamel rods. This preparation for amalgam needs no isolation, which can prove to be a complication for composite or glass-ionomer preparations. The traditional preparation for a class V lesion requiring composite placement involves rounded internal line angles instead of the sharp internal line angles involved in amalgam placement. The traditional preparation for composite also involves a bevel on the cavosurface margin for a better bond; hence more enamel is bonded to.

      By contrast, the non-traditional preparation of class V lesions involves lesion-specific preparations. This is when only the decay is removed and a composite or glass-ionomer material bonds to the remaining tooth structure. This type of preparation conserves tooth structure maximally, whereas the traditional approach requires the excess removal of dentin and enamel (Quintessence International, 2002). However, even in the lesion-specific preparations, a beveled cavosurface margin is desired for maximal retention because a stronger bond can be achieved in enamel than in dentin.

      In the cervical area of a tooth, non-carious lesions are sometimes present. These lesions can arise from attrition, abrasion, erosion, and abfraction. These lesions should be treated when the structural integrity of the tooth is threatened, if the dentin is exposed and hypersensitive, if it is esthetically unacceptable to the patient, or if pulpal exposure is likely. This can be treated one of two ways, an invasive way, or a non-invasive approach. The invasive technique would involve the placement of a traditional box form composite. This approach is not common anymore and requires the excessive unnecessary removal of tooth structure. The non-invasive technique involves acid-etching the surface and applying primer and adhesive to the dentin where it is exposed. The non-invasive approach also involves beveling the enamel cavosurface margins (European Journal of Oral Sciences, 1996). Once again, the beveling is performed to increase overall bond strength of the restoration. Investigators have also noted that cervical lesions needing a V-shape preparation retain their restorations better than a preparation of a U-shape. This difference in retention is demonstrated during occlusal loading.

      The most invasive preparation to restore a non-carious class V lesion would be a porcelain veneer. Veneers pose the problem of unnecessary removal of tooth structure, supereruption causing a decreased vertical space, and increased wear on opposing teeth.

      Once the need to treat a cervical lesion has been determined, the first key step in successfully restoring the lesion is isolation, especially when a resin composite or glass ionomer filling material is utilized. When determining which isolation technique to use, look at each lesion separately in order to determine what will work best. The standard of care for isolation is the placement of a rubber dam. For anterior teeth the 212 clamp performs well and in premolars and posterior teeth the Schultz clamps also work well. The rubber dam helps eliminate problems such as bleeding, and provides salivary and moisture control along with a clear vision of the field. If the lesion is subgingival or is present on a tooth that cannot be isolated with a rubber dam the placement of a retraction cord is another option. This holds the tissue away from the gingival margin of the lesion. Along with the retraction cord other isolation techniques may be utilized such as cotton roll and holder, dry angle, gauze, high volume suction, saliva ejector and the use of auxiliary personnel. The control of moisture leads to a more favorable and predictable bonding outcome. A third technique for isolation in the restoration of class V lesions is surgical management of the gingiva through a gingivectomy followed by the use of a rubber dam or retraction cord. This is most useful when the lesion is subgingival and/or other means of retraction are not possible. It is important to note that there is a conception that without adequate isolation amalgam must be used in class V lesions. This is no longer a useful rule. With the ability of tooth colored materials to bond to dentin and especially enamel the esthetic aspect of a class V lesion should be addressed, especially in the anterior region. As dentists respond to patients' needs and requests it is expected that they not only restore teeth properly but that they also have an esthetic end point. Amalgam, especially in the cervical of anterior teeth is no longer necessary when tooth colored material is available and has good clinical data to suggest that it is an adequate, predictable filling material. With the above techniques for isolation, the dentist should be able to properly isolate for clinical success with tooth-colored material.

      After isolation the operator must either perform an invasive or non-invasive preparation. This depends on the etiology of the lesions explained earlier in the paper in the preparation section. It is important in either the invasive or non-invasive prep to place a bevel on the enamel surface for bonding as the bond to enamel is stronger than to dentin, and is an integral aspect of bonding the restoration.

      Once that the lesion has been prepared as the operator specifically determines, a filling material must be chosen. Along with the proper material, the bonding system is another important aspect of material that the dentist much choose. Because of the lack of mechanical retention, this particular preparation relies heavily on the micromechanical aspect of the bonding of the material to the tooth surface. It is important to note that J.W.V. van Dijken found one-bottle adhesive had a high failure rate while the three-step resin adhesive had an acceptable retention rate in Class V restoration. The author thus stated the importance of clinical testing of materials before use and marketing.

      Once the material and bonding application system has been chosen, the operator first etches the surface of the tooth for fifteen seconds. After the etchant has been rinsed, the surface of the dentin is left moist and the adhesive is placed according to the directions, agitating the material while placing. The adhesive is then light cured and followed by the filling material. The simple placement of resin composite, followed by 40 seconds of light curing is then performed. Once the material has been placed and cured, it must be finished to the tooth surface with the correct contour and marginal adaptation. The bur of choice should be the small S2, a composite finishing bur. The bur is painted across the surface removing excess and contouring the material. Note that it is best to place the correct amount of filling material rather than an excess as the contouring step is then less time consuming. Another instrument for removal of excess filling material is the number 12 Bard Parker. This can be used in a shaving manner to remove a small amount of excess from marginal areas; it works especially good interproximally and gingivally. After the operator is satisfied with the contour and the marginal adaptation of the filling material, Soflex discs can be used for polishing. The discs are used from course grit to fine grit with the medium-fine being the coarsest needed for most cases. The disc runs along the tooth and material finalizing the margin, contour and smoothness of the placed material. The restoration is confirmed to be finished when an explorer is run over the margins testing for excess or deficiencies, if anything is noted the operator returns to previous steps till nothing is detected with the explorer. Flossing is another check for adequate finishing. Noting the absence of catches, the procedure is finished.

      Failures of class V restorations are found in three main categories. The first category is the broad failure of the material to either stay in place, failure through microleakage, or failure through lack of bonding. The second category is the recurrence of secondary caries. Finally, the third category is the failure of the restoration to decrease dentin hypersensitivity. The first reason for failure is a result of operator error and the limitation of the restorative material. This can be minimized through proper isolation and bonding agents. While the preparation is not very involved, strict adherence to isolation and correct procedure in the placement of the filing material is crucial to the long-term success of the restoration. It is important to note that authors Gladys, Van Meerbeek, Lambrechts, and Vanherle found that the retention rate of cervical lesions is good to excellent, but perfect marginal adaptation deteriorated too fast and marginal sealing remained a problem in comparing both resin composites and glass ionomers. They suggest that future research must concentrate on this issue. In the instance of secondary caries it is important to remember that the patient has the disease and if the disease is not controlled secondary caries will return. It is the responsibility of the dentist to work with the patient through oral hygiene, dietary analysis, and fluoride supplementation to bring the patient into the caries controlled group. Lastly, there can be a presumed success through retention of the restoration yet continued hypersensitivity of the lesion. Authors Swift Jr, May Jr. and Mitchell found that Prime and Bond 2.1 performed well for treating cervical dentin hypersensitivity. If after a period of time when hypersensitivity does not diminish, it can be assumed there are still exposed or open dentinal tubules that need to be occluded. In the placing of the Prime and Bond 2.1 the authors found that hypersensitivity could be diminished. They also extrapolated that a second application of the material could be useful if the hypersensitivity remained after the first application. Also authors Prati, Cervellati, Sanasi, and Montebugnoli found that a dentin bonding with Scotchbond 1 (similar to Single Bond) and MS Coat (a resin emulsion) showed that both treatments reduced cervical dentin hypersensitivity. In conclusion, if cervical dentin hypersensitivity remains, there are options for the reduction of this post-operative problem that have been proven to have a good clinical success.

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