Risk Factors Associated With Non Carious Cervical Lesions At A Teaching Hospital

Fouzia Mujeeb¹                                      BDS, MCPS

Zaheer Ahmed Soomro²                      BDS

Saqib Rashid³                                        BDS, MSc, FCPS

Tasleem Hosein⁴                                  BDS, FDSRCS

INTRODUCTION

Non carious cervical lesions (NCCL) refer to pathological loss of tooth tissue as a result of factors other than dental caries at the cemento-enamel junction¹. Non carious tooth loss occurs throughout the life of every individual and is thought to be a normal physiological process, however, if the rate at which it is occurring threatens the life of the tooth or becomes a source of concern to the patient, it is then considered to be pathological¹. Tooth surface loss rarely occurs in isolation. It arises as a multifactorial problem involving erosion, abrasion, attrition and abfraction². It has been suggested that the term ‘tooth surface loss’ should be used when it is not possible to identify a single etiological factor. Hardness of the tooth brush and ingredients of the toothpaste are culprits of tooth wear, but this factor particularly depends on the technique of brushing³. Enamel erosion is caused by frequent acidification of the oral cavity by excess intake of citrus juices, carbonated beverages, alcohol consumption and vitamin C. Inappropriate oral habits like nail biting, pipe smoking habitually holding something between the teeth causes atypical tooth loss as well as loss of the entire tooth⁵. Nocturnal bruxism results in non-physiological wear of tooth surfaces⁶. Lesions in the cervical area may cause discomfort to the patient because of hypersensitive dentine and are aesthetically displeasing. These lesions are classified according to their appearance: wedge-shaped, circular, flattened and irregular areas⁷.These shapes range from shallow grooves to broad dished out lesions to large wedge shaped defects with sharp internal and external line angles⁸.

Past clinical studies and observations reveal that these lesions mostly occur on the buccal aspects of the teeth⁹, more commonly found in the maxilla with incisors, canines, and premolars being most commonly affected teeth¹⁰.  Studies have shown that the prevalence of NCCL range from 5 to 85%¹¹.There have been enormous debates on etiology and pathogens involved in NCCL, but even till now uncertainties still exist in the field¹². Various studies have suggested that the cause of NCCLs is multifactorial rather than an individual¹³ in  Differences in diagnosing these lesions in literature, might be the reason of these uncertain results when compared with one another¹⁴. Cervical dentinal hypersensitivity is another factor associated with these lesions. The proportion of teeth with cervical dentinal hypersensitivity associated with NCCLSs increased significantly with age¹⁵. The increase in frequency of these lesions presents us with unique challenges to restore them successfully. Etiology of the lesion must be understood so that we can treat the cause along with providing the restoration.

Previous studies have concluded that the prevalence of non carious cervical lesions is increasing and the identification of risk factors is very important for diagnosis, prevention and treatment. The purpose of this clinical study was to analyze the etiology, assess the factors associated with non carious cervical lesions and to determine the most commonly involved teeth and their inter/intra arch relations. The study of possible factors and knowing about the degree of prevalence of these lesions can be useful in finding ways for preventing and curing them.

METHODOLOGY

This was a cross sectional study conducted in Fatima Jinnah Dental Hospital and College. The duration of this study was of six months and a hundred patients were included in the study. Purposive consecutive sampling was done, the inclusion criteria were; 1) all teeth with non carious cervical lesions, 2) all age groups, 3) permanent dentition. Exclusion criteria included;1) active, untreatable periodontal disease, 2) rampant uncontrolled caries, 3) patients undergoing orthodontic procedure and 4) primary dentition.

The authors examined patients coming to the dental OPD for the presence of NCCLs. The assessment involved a clinical examination and a questionnaire to help determine the cause of the presence of the lesion. Informed consent was taken before asking questions and conducting clinical examination. The questionnaire included was administered to purposive consecutive sampling of patients that came to the dental OPD. The questionnaire included basic patient demographic information (name, age, gender and locality). The patients were asked if they felt sensitivity after blowing air from triple syringe, any aesthetic issues associated with the lesions. A complete medical history and subsequent drug history was taken. History of presence and frequency of vomiting, gastric reflux and heartburn was asked. Inquiries were made about any para-functional (bruxism and teeth clenching), and nervous (nail/ tooth biting) habits. Dietary practices of the patient were analyzed, emphasizing on the frequency of intake of carbonated beverages citric juices and sour foods. Lastly, the patient were asked which was the dominant working hand and whether he was a bilateral or a unilateral chewer.

QUESTIONNARE

1. Do you have any parafunctional habit such as tooth clenching or grinding?
2. Do you chew unilaterally?
3. Do you have or have had regurgitation problem?
4. Do you have any health problems?
5. Have you taken any drug for long period? 6. Do you regard yourself as a nervous person?
6. Do you have sensitivity in teeth?
7. Do you have any aesthetic concern with reference to the lesions?
8. Do you drink acidic beverages like colas or orange juices?
9. Are you right handed or left handed?

After asking the questions, all the patients were clinically examined. A dental mirror and a probe was used under high intensity light. All surfaces of the teeth including the buccal, lingual and palatal were examined from the central incisors to the third molars in both the arches. The tip of the probe was positioned perpendicular to the surface of the tooth and it was moved along the cervical margin to detect any irregularity was found, it was considered to be a non carious cervical lesion. The finding from each tooth was recorded on a table present in each questionnaire.

The data was analyzed on SPSS  version 17. Descriptive statistics and frequencies of the data were determined to know the prevalence of the NCCLs. Chi-square test and

cross tabs were applied to determine the relationship (table no.3). between the number of NCCLs in groups and the associated It was also found that patients with right working hand factors. A p value of less than 0.05 was considered ( P=0.012) had more nccls lesions than those of the left significant.

RESULTS

A total 100 patients (51 males and 49 females) were included, all had at least one tooth with non-carious cervical lesion. The age of the patients ranged from 21 to 70 with a mean age of 49.3(table no.1). The number of lesions per subject in the group with non carious cervical lesions ranged from 1 to 24, with a mean of 9.94 lesions per subject (standard deviation [SD] = 5.231). We found 558 lesions in the maxilla and 436 in the mandible. We found that having sensitivity ( P= 0.471), aesthetic concern ( P= 0.077), diet concerns (P = 0.557), regurgitation ( P= 0.810), medical condition ( P= 0.344), nervous habits

Table no 1: Age in groups in relation to the number of lesions

Table no 2: Non significant variables when tested with the number of lesions in groups

( P= 0.799), drug use ( P= 0.880), Unilateral chewing habits ( P= 0.159) were not associated with the presence
of lesions. We also found that sex of the patient ( P= 0.659) was not associated with the presence of lesions (table.no.2). However we did find significant results in patients with parafuctional habits ( P= 0.039) , suggesting that patients having more than 11 NCCLs had parafuntional habits (table no.3).
It was also found that patients with right working hand ( P=0.012) had more nccls lesions than those of the left handed patients (table no.4).

Table no 3: Relation between NCCLs and Parafunctional habits

Table no 4: Relation between NCCLs and Working hand

First premolars were found to be the most affected teeth (bar chart no.1), and crosstab results between the premolars showed that if there was a lesion in the maxillary first premolar, the mandibular first premolar of the same side was also involved (table no.5a & 5b).

Table no 5a: Relationship between 14 abd 44

Table no 5a: Relation between NCCLs and Working hand b: Relationship between 24 and 34

Bar chart no. 1: Frequency of nccls in fdi notation of teeth

DISCUSSION

Non carious cervical lesions have been found to be more prevalent in aged patients. This is a logical statement, as with the increase in age, the teeth get more exposed to the persistent etiological factors16. Our study showed similar results when comparing four age groups with the total number of nccl, but with patients upto 60 years and above, the results showed decreased nccl. This was suggested to be probable because most patients above 55 years have their teeth extracted rather than treated in Pakistan, and hence the number of lesions were particular to the teeth they had.
Sensitivity tests did not show significant results, concluding that nccl tend to be a chronic process that occurs over an extended period of time, hence allows deposition of secondary dentine occluding dentinal tubules and thereby preventing sensitivity17. These finding are similar with other studies conducted checking sensitivity in relation to nccl. Some researches have shown bruxers having greater incidence of nccl than non bruxers while others have disagreed. Our study showed significant results and stated that there was some association between patients with parafunctional habits and nccl17. As quoted by many studies18,19,20, our study agreed that premolars were the most frequent teeth affected with nccl. This is thought to be because of their anatomical position in the arch of being placed in the center. We further observed the relationship between involvement of premolars of the opposite side of the same arch and opposing arch. The crosstabs showed that there were significant results for the involvement of nccl of the opposing premolars. Which concluded that if a maxillary premolar of left side had nccl, there are more chances of nccl in the mandibular premolar of the same side.Our study also compared the presence of nccls between patients that were left handed and right handed and the results obtained were significant. It was concluded that right handed patients had more chances of nccl than those who were left handed. Other studies which were conducted with similar variables, showed no significance and disagreed with any relation of nccl with the working side21. Our study may have shown different results as the number of patients who were left handed were less (12 %) when compared to those who were right handed (88%). The etiological factors associated with nccl are still unclear amongst practitioners, who differ in identifying these lesions and treat cervical lesions accordingly. The literatures available are inconclusive of establishing any one factor being associated with non carious cervical lesions. Rather, a variety of factors are involved in the formation of non carious cervical lesions. NCCLs being multi-factorial in etiology, the treatment protocol for them requires special understanding of the primary cause. Patients need to be educated regarding the etiologic factors of nccls, so that they may be able to identify and prevent progression of nccls.
This study was conducted in a private hospital setup from patients with non carious cervical lesions only, hence the results cannot be generalized to general population.

CONCLUSION

Within the limitations of our study, we make following conclusions

• Premolars were the most affected teeth
• If a premolar of maxillary arch was affected, it is most likely that the premolar of mandible on the same side will be affected.
• Parafunctional habits were significantly associated with nccls

Authors’ Contributions:

FM conceived the idea, contributed to manuscript writing and collected the data, ZAS collected the data and did the statistical analysis, SR and TH critically analysed the manuscript and gave final approval Disclosure: None disclosed

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1. Operative Department, Fatima Jinnah Dental College Hospital, Karachi.
2. Head of Department, Professor, Operative Department, Fatima Jinnah Dental College Hospital, Karachi.
3. Principal, Fatima Jinnah Dental College, Karachi.

Corresponding author: “Dr. Zaheer Ahmed Soomro ” <drzaheersoomro@hotmail.com>