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The Prevalence of Non-Carious Cervical Lesions in Modern and Ancient American Skulls: Lack of Evidence for an Occlusal E...


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THE PREVALENCE OF NON-CARIOUS CERVICAL LESIONS IN MODERN AND ANCIENT AMERICAN SKULLS: LACK OF EVIDENCE FOR AN OCCLUSAL ETIOLOGY By GAVIN M. AARON A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2004

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ACKNOWLEDGMENTS I would like to thank Dr. Gregory Horning and Dr. David Hunt for helping to coordinate this research endeavor. I would also like to thank Drs. Arthur Vernino and Hank Towle III for their input on my research. Finally, I want to thank Dr. Misty Lenk, my future wife, for her support, encouragement, and inspiration. ii

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TABLE OF CONTENTS page ACKNOWLEDGMENTS..................................................................................................ii LIST OF TABLES.............................................................................................................iv LIST OF FIGURES.............................................................................................................v ABSTRACT.......................................................................................................................vi CHAPTER 1 INTRODUCTION........................................................................................................1 2 METHODS AND MATERIALS...............................................................................10 3 RESULTS...................................................................................................................12 4 DISCUSSION.............................................................................................................19 5 CONCLUSIONS........................................................................................................24 LIST OF REFERENCES...................................................................................................25 BIOGRAPHICAL SKETCH.............................................................................................27 iii

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LIST OF TABLES Table page 1 Measurements for the Non-Carious Cervical Lesions.............................................12 2 Frequency of NCCLs per Skull................................................................................13 3 Frequency of NCCLs by Tooth Type.......................................................................13 4 Opposing pairs of Teeth and Frequency of NCCLs.................................................14 5 Comparison of Non-Carious Cervical Lesions, Occlusal Wear Score, and PDL Score Between Modern and Ancient Skulls.............................................................15 6 Percentage of Teeth with Non-Carious Cervical Lesions According to Occlusal Wear Score...............................................................................................................16 iv

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LIST OF FIGURES Figure page 1 Number of NCCLs vs. Skull Type...........................................................................15 2 Number of NCCLs vs. Occlusal Wear Score...........................................................16 3 Number of NCCLs vs. Race.....................................................................................17 4 Number of NCCLs vs. Angles Classification.........................................................18 5 Number of NCCLs vs. Gender.................................................................................18 v

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vi Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science THE PREVALENCE OF NON-CARIOUS CERVICAL LESIONS IN MODERN AND ANCIENT AMERICAN SKULLS: LACK OF EVIDENCE FOR AN OCCLUSAL ETIOLOGY By Gavin M. Aaron May 2004 Chair: Gregory Horning Major Department: Periodontology The abfraction lesion is a relatively recent classification that supposedly is derived from malocclusion. However, many studies have suggested that abfraction lesions are in fact non-carious cervical lesions with a multi-factorial etiology. To date, no research has compared the prevalence of abfraction lesions in populations with and without access to toothbrushes. The purpose of this study was to examine the prevalence of non-carious cervical lesions in modern and ancient populations. One-hundred-and-ninety-eight modern and 100 ancient American human skulls were examined for the presence of non-carious cervical lesions (NCCLs). The skull specimens were a part of the collection located at the National Museum of Natural History in Washington, D.C. The modern skulls dated back to the early to mid-twentieth century, while the ancient skulls were derived from two Native American Indian tribes from the eleventh and seventeenth centuries. The age, gender, race, and Angles

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classification were recorded from each skull. Teeth in each skull were examined for the presence and dimension of NCCL, extent of occlusal wear, width of the periodontal ligament space, distance from the cervical border of the NCCL to the alveolar crest, presence or absence of a lingual NCCL, presence of a dental restoration, and presence of class V caries. A total of 6,077 teeth were examined. No NCCLs were observed in the ancient skulls, nor were any lingual NCCLs seen in any of the skulls. Fifty-seven NCCLs were documented in 9.6% of the modern skulls, with a prevalence rate of 1.62% of NCCLs in the 3,524 teeth in the modern skulls. A chi-square test of association showed no relationship between extent of occlusal wear and the presence of NCCLs (p=0.5780), and no significance of race, gender, or pdl width and NCCLs. The angles class II relationship was significantly associated with the presence of NCCLs (p<0.0001). The finding that only modern skulls displayed NCCLs may be explained by toothbrush use and/or acid erosion. Conversely, the ancient skulls may have incorporated more abrasive substances into their diet and may not have had an average lifespan long enough to develop NCCLs. Regardless, both collections included many skulls, which showed heavy occlusal wear but failed to show any NCCLs. From the results of this study it can be suggested that occlusal wear, likely derived from heavy occlusal forces, is not associated with the presence of non-carious cervical lesions. So-called abfraction lesions likely have a multifactorial etiology, rather than an origin in occlusal stress. vii

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CHAPTER 1 INTRODUCTION Non-carious cervical lesions (NCCLs) have become a controversial clinical phenomenon in recent decades. These wedge-shaped concavities are predominantly observed on the bucco-cervical region of teeth (Imfeld 1996, Piotrowski et al. 2001, Boston et al. 1999), and have in recent years been termed abfraction lesions because of certain evidence suggesting an origin in malocclusion. Since then, several articles have argued for and against the abfraction classification. Recent publications have disputed the existence of a true abfraction lesion, citing that the lesions may be either erosive, abrasive, or multifactorial in nature (Litonjua et al. 2003a, 2003b, Piotrowski et al. 2001). A lack of understanding of the various forms of noncarious lesions by the dental community has lead to misdiagnosis of lesions as being abfractions (Levitch 1994, Bader 1993). Because not all clinicians have agreed on their origin, researchers have introduced the term non-carious cervical lesion and/or abfractionlike lesion so as not to presume the etiology of the lesions (Grippo 1991, Litonjua et al. 2003b, Piotrowski et al. 2001). Non-carious lesions involve the irreversible loss of enamel or dentin, and may be due to any of the following causes: attrition, erosion, resorption, abrasion, and abfraction/malocclusion. Attrition is the loss of tooth structure due to tooth-to-tooth forces with no intervening foreign objects. Bruxism is a prime example of wear from attrition. 1

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2 Erosion depicts the gradual etching away of tooth structure due to electrolytic or chemical processes. Typically the pathologic loss of enamel and dentin is chronic, localized, painless, and does not involve bacterial infiltration (Imfeld 1996). Clinically, erosion lesions are confined to the buccal and occlusal surfaces of the mandibular premolars and molars (Imfeld 1996). External root resorption is the biological degradation of structures previously produced by the body (i.e. host-mediated destruction). Resorption may be due to cementoclastic, dentinoclastistic and/or ameloclastic activity (Imfeld 1996). Abrasion is the wearing away of tooth structure due to abnormal mechanical processes involving foreign objects, such as toothbrush abrasion (Imfeld 1996, Owens and Gallien 1995, Piotrowski et al. 2001). Toothbrush abrasion may result from incorrect brushing technique, frequency of brushing, time of brushing, force applied during brushing, or even starting point of brushing on the arch (Addy 2000). The hardness of the bristles and abrasiveness of the toothpaste used also make an impact on the extent of these lesions. Abfraction is derived from the Latin verb frangere (to break), and defines a wedge-shaped defect at or near the cemento-enamel junction (CEJ) of the tooth (Imfeld 1996, Piotrowski et al. 2001, Boston et al. 1999, Grippo 1991). The hypothesis that described a new sub-class of cervical lesion that originated from tooth flexure from occlusal loading was first introduced by Lee and Eakle in 1984. Grippo was the first to define the term abfraction as a new classification of hard-tissue lesions in 1991 (Grippo 1991).

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3 Abfractions are hypothesized to result from eccentric occlusal forces which flex the tooth (Grippo 1991, 1992, Adda 2000). Their rationale for the concept of this lesion is as follows: malocclusion due to parafunctional prematurities and hyper occlusion due to bruxism often leads to eccentric occlusal forces, which in turn produce tensile, compressive, and sheering stresses (Owens & Gallien 1992, Rees et al. 2003). These stresses are focused at the CEJ, and microfractures are formed in the enamel and dentin. Over time these microfractures propagate perpendicular to the long axis of the tooth until enamel and dentin break away (Grippo 1992). The enamel breaks off more easily than the dentin because of its brittleness. Enamel is a very hard substance composed of inorganic crystallites, which can only be subjected to a relatively small amount of deformation before fracturing. Dentin on the other hand has a greater organic component to its structure, is more resistant to deformation, and consequently is much more resilient to the tensile and compressive forces which can cause fracture (Owens & Gallien 1992). Canines also play a protective role in that they reduce the amount of force distributed to the posterior teeth during excursive movements. Naturally, occlusal schemes where the canines are not involved in guidance offer no protection of the posterior teeth in lateroscursive movements (Owens & Gallien 1992). Group function occlusal schemes would involve the premolars and canines, which coincidentally are the most common teeth demonstrating non-carious cervical lesions. Clinical research has demonstrated that the group function occlusal scheme is more significantly associated with abfraction lesions than canine guidance (Miller et al. 2003).

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4 Miller and colleagues examined 61 patients displaying 309 NCCLs for excessive brushing and occlusal interferences. They also evaluated each patients occlusal scheme and the presence of plaque, calculus, periodontitis, wear facets, and mobility. Group function was associated with almost three-quarters of the NCCLs, and wear facets were associated with 94.5% of the NCCLs. In addition, balancing side prematurities were associated with approximately 20% of the NCCLs. Interestingly, visible plaque and calculus were found on the buccal surfaces of over 40% of the NCCLs, and 32.5% of the NCCLs exhibited subgingival limits without signs of marginal gingival ulceration. His study supported the notion of the abfraction lesion, which was derived from occlusal disturbances as opposed to excessive toothbrushing (Miller et al.2003). Computer simulations have also been developed to determine if occlusal forces could cause non-carious cervical lesions. Finite stress analysis studies using computer models have demonstrated that malocclusion could create microfractures in the enamel at the CEJ (Rees 1998, Rees et al. 2003, Lee et al. 2002). These studies have shown that that different teeth in the arch accommodate varying amounts of stress prior to reaching their fracture point (Rees 1998, Rees et al. 2003, Lee et al. 2002). The incisor, canine, and premolar have all been shown to manifest non-carious cervical lesions when heavy excursive forces were directed onto the teeth; however, in all of the finite stress studies, each tooth was evaluated individually, which failed to account for the compensating effect of the other teeth in the arches. A review of studies conducted by Lyons in 2001 concluded that non-carious cervical lesions were multifactorial in nature, but conceded that occlusal loading was the primary initiating factor (Lyons 2001).

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5 While the much of the research on abfraction lesions has implicated malocclusion as the primary etiology (Owens & Gallien 1995, Lee et al. 2002, Grippo 1992, Rees 1998, Rees et al. 2003), other mechanisms have been described for the formation of abfractions (Boston et al. 1999, McCubbin 2002, Piotrowski et al. 2001). Piotrowski in 2001 examined 103 teeth with NCCLs and 103 control teeth within a population of U.S. veterans, and recorded each participants toothbrush habits, the presence and location of NCCLs, the presence of excursive interferences, plaque, and occlusal wear on the teeth with lesions. Teeth exhibiting NCCLs had significantly more surfaces with plaque than the control teeth; however, there were no significant differences in wear-facet dimensions or in occlusal discrepancies between the NCCL and control teeth. The statistical analysis suggested that toothbrush abrasion could be a strong contributing factor, in that at least 75% of the participants reported using a firm-bristled toothbrush and displayed improper toothbrushing technique (Pietrowski et al. 2001). Litonjua in his review article pointed out that many of the studies advocating the abfraction lesion were based on engineering and computer models that neglected the influence of the periodontal attachment apparatus in absorbing the forces from occlusion. He further noted that many of the clinical models that failed to investigate the participants history of toothbrush abrasion and current toothbrushing technique He concluded that the occlusal etiology for the formation of the abfraction lesion was not solidly founded, and that abfraction lesions are likely NCCLs manifested from multiple causes (Litonjua et al. 2003b).

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6 Boston et al. in their case study implicated a combination of abrasion, erosion, abfraction, linear enamel hypoplasia as the etiology of the non-carious lesions that he observed (Boston et al. 1999). Although the patient exhibited numerous periodontally involved teeth with wedge-shaped lesions, .a histologic examination after their extraction lacked sufficient evidence to support malocclusion as the sole factor in the lesions formation. Kahn et al. in 1999 examined 122 cervical lesions in 250 patients with tooth wear. Using epoxy resin replicas of their dentitions and scanning electron microscopy, associations of occlusal attrition, erosion, and occlusal wear with cervical lesions were recorded. They concluded that acid demineralization of teeth causes occlusal erosion and attrition, and causes shallow and wedge-shaped cervical lesions. Moreover, Kahn concluded that non-carious lesions have a multifactorial etiology in which erosion and salivary protection play central roles (Kahn et al. 1999). Indeed abfraction, abrasive, and erosive lesions do have similarities which could lead to misdiagnosis. All three lesions can be located on the buccal surfaces of the canines and premolars. However, the effects of erosion can be observed in many other places in the dentition, namely the occlusal surfaces of teeth (Imfeld 1996). In addition, abfraction lesions have been described as displaying sharp margins along their borders, while most erosion and abrasion lesions exhibit a rounder margin (Piotrowski et al. 2001). This difference in appearance has been explained by the rationale that the surface of erosive lesions are hypomineralized and consequently are less resistant to abrasive forces from toothbrushing and eating (Imfeld 1996, Lambrechts et al. 1996). The acid

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7 degradation, in turn, makes the tooth more susceptible to toothbrush abrasion and/or abfraction lesions (McCubbin 2002). Abrasion lesions from overzealous toothbrushing have been well established in periodontal literature, and their clinical features are very similar to abfraction lesions (Addy et al. 2003, Litonjua et al. 2003a, Gorman 1967). Like abfractions, these lesions are located on the buccal tooth surface along the cemento-enamel junction, are non-carious in nature, and are found in similar teeth in the arch (Addy et al. 2003, Litonjua et al. 2003a). The distinction between the diagnoses of abfraction versus erosive and abrasive lesions is important because the treatment of the phenomena are different. The primary treatment of an abfraction lesion involves an occlusal adjustment and possible restoration of the tooth (Imfeld 1996, Grippo 1992). Restorative therapy is recommended particularly if the tooth is susceptible to a fracture or pulp exposure in the near future. Glass ionomers are a popular choice because of the fluoride-releasing capacity; however, microfilled composite resin with a low modulus of elasticity is another viable option (Lambrechts et al. 1996). The low modulus of elasticity allows the restoration to absorb occlusal forces without transferring them to the surrounding tooth structure. According to one author, the most beneficial treatment for abfraction lesions is an occlusal adjustment and nightguard fabrication to eliminate or at least reduce the suspected occlusal etiology (Lambrechts et al. 1996). The treatment of abrasion lesion, on the other hand, centers on the modification of oral hygiene techniques and may involve the placement of a gingival graft (Litonjua et al. 2003a, Sullivan and Atkins 1968). Recommended treatment of erosive lesions includes

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8 changes in dietary or behavior patterns, application of desensitization products, and intensive fluoride therapy (Lambrechts et al. 1996, Owens & Gallien 1995). A majority of the current research into non-carious cervical lesions has been conducted on human subjects, which is beneficial because an inquiry into the patients dietary and hygiene habits can be obtained, and parafunctional habits can also be accurately measured and reproduced. Unfortunately, current studies have failed to include a patient population which does not incorporate toothbrush use. Toothbrush use is a significant factor because it can lead to non-carious cervical lesions, and possibly contribute to the formation of non-carious cervical lesions. In order to best eliminate the impact of oral hygiene factors on the formation on abfraction lesions, a modern group of subjects with access to toothbrushes and dentifrices was compared to a pre-modern group with no access to toothbrushes. In this regard, the suggested primary etiologic factor of abfraction lesions occlusion can be more fairly isolated. In this study, two groups of American skulls were examined for the presence and extent of non-carious cervical lesions and occlusal wear. However, only one of the two groups had access to modern oral hygiene devices. Theoretically by eliminating toothbrush use, any non-carious cervical lesions observed in the pre-modern skulls can be more confidently attributed to occlusal factors. Comparing the prevalence of non-carious cervical lesions in the two groups hopefully will increase the understanding of the non-carious cervical lesion and its etiology.

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9 The purpose of this study was to document the prevalence of non-carious cervical lesions in modern and ancient American human skulls.

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CHAPTER 2 METHODS AND MATERIALS This study was conducted at the Natural Museum of Natural History in Washington D.C. Two hundred modern American human skulls from the early to mid-twentieth century and 100 ancient American Indian skulls from the eleventh and seventeenth century were evaluated. The modern skulls were a part of the Terry anatomic collection, which consisted of 1,760 skeletons consisted of persons who donated their bodies to science or were unclaimed after death. The ancient skulls in this investigation were excavated from American Indian burial mounds from Northern Illinois (11 th century) and from South Dakota (17 th century). The gender, race, and Angles classification were recorded from each skull specimen. The age at the time of death was only collected from the modern skulls because the age was not available for the ancient skulls. The following inclusion criteria were employed: 1. The estimated age of the individual at his/her time of death must have been at least 40 years old. 2. At least 10 teeth must have been intact. 3. Intact but fractured teeth were not included in the data collection. A non-carious cervical lesion was defined as: Any lesion located at the cemento-enamel junction of the tooth, which extended axially at least .5mm into the dentin without signs of previous dental caries. The teeth still intact in the skulls were examined for the following: 1. Presence of a non-carious cervical lesion on the buccal and lingual tooth surfaces. The circumferential border of any lesions detected were classified as having either 10

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11 sharp or round margins. The height, width, and depth was measured to the nearest half-millimeter using a UNC-15 probe. 2. Presence of caries. Lesions were considered carious if they displayed elliptical as opposed to wedge-shaped defects, were black in appearance, exhibited enamel undercuts, or were soft and leathery upon probing with a UNC-15 probe. The height, width, and depth was measured to the nearest half-millimeter using a UNC-15 probe. 3. Presence of restorations. Any artificially created restoration was recorded, including amalgam and gold foil restorations and crowns. 4. Distance from the cervical border of the lesion to the alveolar crest. The distance was measured to the nearest .5mm using a UNC-15 probe. 5. Extent of occlusal wear. The occlusal wear was visually classified according to a four-point scale: 1 = very minimal to no occlusal wear 2 = occlusal wear is confined to the enamel 3 = occlusal wear extents into the dentin 4 = occlusal wear extents into the dentin involving all cusps and the central fossa, thereby giving a table top appearance 6. Extent of pdl width. No radiographs were taken. The pdl width was measured using a UNC-15 probe and was classified according a three-point scale: 1 = pdl width < .5mm 2 = pdl width .5mm and 1mm 3 = pdl width > 1mm The data was analyzed using descriptive statistical analysis (means, averages, etc.), chi-square tests, Mantel-Haenszel chi-square tests, and logistical regression analysis.

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CHAPTER 3 RESULTS Out of 300 specimens, 2 modern skulls were not included because of incomplete collection of data. A total of 6,077 teeth in 298 skulls were examined. The distribution was as follows for the modern skulls: 59 White males, 57 Black males, 20 White females, 60 Black females, and 2 Asian males. The average age was 53 years old (range: 40-87 years, standard deviation: 11.3 years). 39 restorations and 50 class V carious lesions were observed. 101 class I, 34 class II, and 52 class III Angle malocclusions were observed. Out of 3,524 teeth in the modern skulls, 57 NCCLs were observed with a prevalence of 1.62%. For the NCCLs, the average width was 4.01mm (range: 2-8mm, sd: 1.54mm), the average height was 1.92mm (range: 1-5mm, sd: 0.69mm), and the average depth was 0.73mm (range: 0.5-1.5mm, sd: 0.34mm). The average distance from the NCCL to the alveolar crest was 2.75mm (range: 2-6mm, sd: 1.15mm), and in 4 teeth (canines) the distance was not recorded because a buccal dehiscence exposed the roots almost to the apices. The average occlusal wear score was 2.49 (range: 1-4, sd: 0.57), and the average pdl score was 1.26 (range: 1-3, sd: 0.25). See Table 1. Table 1: Measurements for the Non-Carious Cervical Lesions Parameters Average Range Standard Deviation Width (mm) 4.01 2-8 1.54 Height (mm) 1.92 1-5 0.69 Depth (mm) 0.73 0.5-1.5 0.34 Distance to Crest (mm) 2.75 2-6 1.15 12

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13 Of the 3,524 teeth in the modern skulls, 9.6% percent exhibited NCCLs. No lingual NCCLs were observed. The amount of NCCLs per skull ranged from 0 to 10, with the majority having only one lesion. The distribution of the lesions is shown in Table 2. Table 2: Frequency of NCCLs per Skull # of Skulls # of NCCLs Percentage 179 0 90.4 8 1 4.04 5 2 2.53 2 3 1.01 1 5 0.51 1 6 0.51 1 7 0.51 1 10 0.51 When each tooth type was taken into consideration, the data showed that the canines, premolars, and molars were the most susceptible to developing a NCCL. However, tooth type by itself was not a significant predictor of NCCL formation (p=0.0429). The distribution of NCCLs for each tooth is shown in Table 3. Table 3: Frequency of NCCLs by Tooth Type Tooth # # of Teeth # of NCCLs Percentage 1 78 0 0 2 116 0 0 3 108 3 2.78 4 117 1 0.85 5 119 2 1.68 6 131 3 2.29 7 73 1 1.37 8 59 0 0 9 56 0 0 10 69 1 1.45 11 121 1 0.83 12 128 1 0.78 13 115 0 0 14 118 1 0.85 15 114 0 0 16 69 0 0

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14 Table 3 contd. Tooth # # of Teeth # of NCCLs Percentage 17 92 0 0 18 114 1 0.88 19 94 1 1.06 20 140 1 0.71 21 163 5 3.07 22 161 4 2.48 23 135 3 2.22 24 135 1 0.74 25 121 0 0 26 136 0 0 27 150 4 2.67 28 168 8 4.76 29 136 3 2.21 30 99 4 4.04 31 133 3 2.26 32 81 0 0 When pairs of opposing teeth were analyzed, the teeth on the right side of the skull exhibited more NCCLs. Certain pairs of teeth were significantly associated with NCCLs. (p=0.007). Table 4 shows the trends in teeth pairing and NCCLs. Table 4: Opposing pairs of Teeth and Frequency of NCCLs Teeth Pair # of Teeth # of NCCLs Percentage of NCCLs 1 & 32 159 0 0 2 & 31 249 3 1.2 3 & 30 207 7 3.38 4 & 29 253 4 1.58 5 & 28 287 10 3.48 6 & 27 284 7 2.49 7 & 26 209 1 0.48 8 & 25 180 0 0 9 & 24 191 1 0.52 10 & 23 204 4 1.96 11 & 22 282 5 1.77 12 & 21 291 6 2.06 13 & 20 255 1 0.39 14 & 19 212 2 0.94 15 & 18 228 1 0.44 16 & 17 161 0 0

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15 For the ancient skulls the distribution was 26 Northern Illinois males, 24 Northern Illinois females, 25 South Dakota males, and 25 South Dakota females. The age of death of each specimen was not available. Four carious lesions were observed. Thirty-three class I, 6 class II, and 60 class III Angles malocclusions were observed. No NCCLs were present. The average occlusal wear score was 3.32 (range: 1-4, sd: 0.57), and the average pdl score was 1.28 (range: 1-3, sd: 0.25). See Table 5 and figure 1. Table 5: Comparison of Non-Carious Cervical Lesions, Occlusal Wear Score, and PDL Score Between Modern and Ancient Skulls Skulls Parameters Total # Average (mm) Range (mm) SD (mm) Modern # of NCCLs 57 Occlusal Wear Score 2.49 1-4 1.26 PDL Score 1.26 1-3 0.25 Ancient # of NCCLs 0 Occlusal Wear Score 3.32 1-4 0.57 PDL Score 1.28 1-3 0.25 020406080100Number of Lesion s ModernAncientSkull Typ e Figure 1. Number of NCCLs vs. Skull Type The proceeding chi-square and statistical regression analyses are only for the modern skulls.

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16 Of all of the teeth with no occlusal wear (OW score = 1), 4 (1.76%) had NCCLs. In teeth with moderate occlusal wear (OW score = 2), 26 (1.41%) had NCCLs. Of the teeth with severe occlusal wear (OW score = 3), 19 (1.63%) had NCCLs. Finally, 3 (0.72%) of the teeth with very severe occlusal wear (OW score = 4) had NCCLs. The association between occlusal wear and NCCL formation was not significant (p=0.4492). Table 6 and figure 2 visualize these findings. Table 6: Percentage of Teeth with Non-Carious Cervical Lesions According to Occlusal Wear Score Occlusal Wear Score # of Teeth # of NNCLs % of Teeth w/ NCCL 1 (no wear) 227 4 1.76 2 (mild wear) 1840 26 1.41 3 (moderate wear) 1167 19 1.63 4 (severe wear) 414 3 0.72 0102030# of NCCLs 1234Occlusal Wear Score Figure 2. Number of NCCLs vs. Occlusal Wear Score A Mantel-Haenszel chi-square test of association determined that no significant trend existed between increasing or decreasing occlusal wear scores and NCCL formation (p = 0.0243).

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17 The effect of race was insignificant. Anglo-Americans and African-Americans exhibited approximately the same amount of teeth with NCCLs. Asian skulls had almost half as many NCCLs.The number of African-American teeth displaying NCCLs was 19 (0.83%); the number of Anglo-American teeth displaying NCCLs was 21 (1.61%); and the number of Asian-American teeth displaying NCCLs was 12 (28.57%). These findings are visualized in Figure 3. 0510152025of NCCLs BlackWhiteAsianRace Figure 3. Number of NCCLs vs. Race Skulls with Angles class I occlusion had 10 (0.50%) of teeth with NCCLs; Thirty (5.12%) of the teeth in skulls with Angles class II occlusion showed NCCLs; and 9 (0.97%) of the teeth in skulls with Angles class III occlusion showed NCCLs. The Angles class II occlusion was significantly related to the rate of NCCLs (p < 0.0001). See figure 4.

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18 0510152025303540# of NCCLs IIIIIIAngles Classification Figure 4. Number of NCCLs vs. Angles Classification When gender was taken into account, males and females exhibited similar number of teeth with NCCLs Twenty-seven (1.18%) of the males teeth displayed NCCLs, while 25 (1.84%) of the females teeth displayed NCCLs. This was not statistically significant (p = .1045). See figure 5. 051015202530# of NCCLs MaleFemaleGender Figure 5. Number of NCCLs vs. Gender

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CHAPTER 4 DISCUSSION Most of the skulls did not have all of their teeth intact, and several teeth had fractured crowns. Teeth that were partially fractured were later excluded from the results. Many skulls had teeth which were glued into the socket, and some of the teeth were glued out of the plane of occlusion. Occasionally, the crania were sagitally split. In most of the cases however, the teeth in the two halves of the skull could be accurately articulated, thereby allowing the Angles classification to be recorded. Because teeth that were glued into the sockets were not differentiated from teeth that were not glued, the pdl width was not extensively incorporated into the results and discussion. Because previous studies focused primarily on only those teeth displaying non-carious lesions, the 1.62% prevalence of NCCLs in the modern skulls is without comparison. Out of 6,077 teeth, no lingual NCCLs were observed. There is no previous research citing lingual NCCLs, which implies that NCCLs occur only on the buccal surfaces of teeth or that lingual NCCLs are extremely rare. Both modern and ancient skull collections demonstrated advanced occlusal wear; however, only the modern skulls displayed NCCLs. In addition, the average occlusal wear score for the modern skulls was less than the average occlusal wear score for the ancient skulls. Regardless, in both collections there were numerous teeth which exhibited heavy occlusal wear but failed to show any NCCLs. Perhaps the studies advocating the notion of the abfraction lesion are focusing too much on those teeth with lesions, and are 19

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20 not taking into consideration all of other teeth which display malocclusion without NCCL formation. Why would only the modern skulls exhibit non-carious cervical lesions despite having a lower overall amount of occlusal wear? This discrepancy may be explained by unique factors found in each of the two populations. The NCCLs in the modern skulls may have been facilitated by overzealous toothbrushing. Improper toothbrushing technique could form non-carious cervical lesions independent of the extent of occlusal wear. On the other hand, the Native Americans may have developed advanced occlusal wear without necessarily exerting heavy occlusal forces. According to anthropologists, the diet of the Native Americans was largely meats, grains, and vegetables, which likely were not adequately cleansed of dirt and debris. Incorporating a more abrasive diet would have lead to an increased level of occlusal wear. The advanced occlusal wear in the ancient skulls may also have been due to bruxism. Perhaps the Native American muscles of mastication may have been hypertrophied compared to modern Americans from eating less tender food. Or, Native Americans may have bruxed their teeth because of the greater stress level associated with survival. Many of the ancient skulls displayed full arch table-top occlusal wear. Usually, table-top occlusal wear in modern Americans is attributed to bruxism. If the Native Americans had an etiology of bruxism for their advanced occlusal wear, then they should have displayed abfraction lesions according to current dental concepts. Perhaps the Native Americans would have developed non-carious cervical lesions, but they did not live long enough on average to manifest these lesions clinically. The

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21 main disadvantage of working with ancient skulls is the lack of demographic and cultural information that is helpful in formulating theories. Without the age at the time of death of each of the skull specimens, the age factor can only be speculative at best. Based on the finding that only the modern American skulls displayed NCCLs, one could hypothesize that non-carious cervical lesions are a modern phenomenon. In other words, non-carious cervical lesions including abfraction lesions are a product of the modern lifestyle. One obvious facet of the modern lifestyle is an increased awareness about personal oral hygiene. With the advent of the modern toothbrush and dentifrice, people were more likely to brush their teeth in order to remove plaque. However, improper toothbrushing technique has been known to create abrasive lesions at the buccal surfaces of the CEJs of teeth. Just as the current population displays a proportion of toothbrush abrasion, so would the mid-20 th century population representing the skulls. Another phenomenon of modern society is the mass availability and consumption of sugar into the diet. Compared to the ancient populations, modern society certainly has incorporated more food products with a higher sugar content on a regular basis. While too much sugar can lead to dental caries, a sugar consumption below the caries threshold could lead to hypomineralization of the enamel. The hypomineralized enamel would in turn be more susceptible to abrasion from toothbrushing or to the forces that lead to abfraction lesions. This theory however, is minimally supported by publications and would need more dedicated research to access its validity. The more accepted notion is that occlusal factors are responsible for the non-carious cervical lesions exhibited in modern society. The question arises as to whether

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22 the ancient Native Americans had such different occlusion from modern Americans that NCCLs failed to form. There has been no research to suggest that occlusal patterns and forces have spontaneously increased in complexity in the last thousand years, so the idea that abnormal or excessive occlusal forces are unique to modern society is unfounded. The x-factor in discussing occlusal schemes and abfraction lesions in this study is race. It is possible that the Anglo-Americans, the African-Americans, the Sino-Americans, and the Native Americans all had different dento-skeletal relationships from one another. As the results demonstrated, those modern skulls with an Angles class II dental relationship where much more susceptible to forming NCCLs than either class I or class III. Moreover, the Anglo-Americans as an independent variable were significantly associated with the proclivity to form NCCLs. Compared to African-Americans and Sino-Americans, Anglo-Americans have a stronger genetic predisposition towards the class II phenotype because of their Northern European ancestry Perhaps those of Northern European decent have a stronger susceptibility to forming non-carious cervical lesions. Of course, a small proportion of the ancient skulls had an Angles class II dental relationship and did not have any NCCLs. Although the Angles relationship may play a part in abfraction susceptibility, the argument still circles back to occlusion because the Angles classification ultimately affects the dental occlusion. The periodontal ligament is a biologic structure which physiologically absorbs the forces from occlusion to an extent. In health, the periodontal ligament is approximately 20 microns wide. Widening of the periodontal ligament is thought to be derived from heavy occlusal forces. This study hoped to include the variations in the periodontal

PAGE 30

23 ligament width to help determine the extent of occlusal forces upon each tooth. Unfortunately, many of the teeth were glued back into their respective tooth sockets, so the parameter of periodontal ligament width was not included in the results of this study. The results of the paper do not eliminate occlusal forces from contributing to the formation of non-carious cervical lesions. The correlation drawn can only describe an association and cannot assign causality. What the results of this research demonstrate however is that factors that lead to occlusal wear are probably not justified to create a specific subclass of non-carious cervical lesions, namely the abfraction lesion. The next step for future research on this controversy would be to examine a live human population that has no access to toothbrushes or dental care. The participants would also be examined for maladaptive occlusal forces and occlusal prematurities. Then perhaps a cause-effect relationship relating to the formation of abfraction or other non-carious cervical lesions could be more confidently supported.

PAGE 31

CHAPTER 5 CONCLUSIONS 6,077 teeth in 298 skulls (198 modern, 100 ancient) were examined for non-carious cervical lesions. Of the 3,524 modern teeth, 1.62% or 57 teeth exhibited NCCLs. None of the teeth in the ancient skulls demonstrated NCCLs. One-hundred percent of the NCCLs were located on the buccal surfaces, whereas 0% were found on the lingual surfaces. Occlusal wear was not significantly associated with the presence of NCCLs, nor was any trend of an increasing or decreasing amount of occlusal wear associated with the presence of NCCLs. Neither race nor gender were significantly associated with the presence of NCCLs. Finally, the Angles class II relationship was shown to significantly associated with the presence of NCCLs. Occlusal wear, derived from factors affecting the occlusion, are not likely to be causative of NCCLs. 24

PAGE 32

LIST OF REFERENCES Addy M. Tooth Wear and Sensitivity Martin Dunitz. 2000 161-163, 219-233. Addy M, Hunter ML. Can tooth brushing damage your health? Effects on oral and dental tissues. Int Dent J. 2003; 53 Suppl 3:177-86. Bader JD, Levitch LC, Shugars DA, Heymann HO, McClure F. How dentists classified and treated non-carious cervical lesions. J Am Dent Assoc. 1993 May;124(5):46-54. Boston DW, Al-Bargi H, Bogert M. Abrasion, erosion, and abfraction combined with linear enamel hypoplasia: a case report. Quintessence Int. 1999 Oct;30(10):683-7. Gorman WJ. Prevalence and etiology of gingival recession. J Periodontol. 1967 Jul-Aug;38(4):316-22. Grippo JO. Abfractions: a new classification of hard tissue lesions of teeth. J Esthet Dent. 1991 Jan-Feb;3(1):14-9. Grippo JO. Noncarious cervical lesions: the decision to ignore or restore. J Esthet Dent. 1992;4 Suppl:55-64. Imfeld T. Dental erosion. Definition, classification and links. Eur J Oral Sci. 1996 Apr;104(2 ( Pt 2)):151-5. Jarvinen VK, Rytomaa II, Heinonen OP. Risk factors in dental erosion. J Dent Res 1991; 2:153-159. Khan F, Young WG, Shahabi S, Daley TJ. Dental cervical lesions associated with occlusal erosion and attrition. Aust Dent J. 1999 Sep;44(3):176-86. Lambrechts P, Van Meerbeek B, Perdigao J, Gladys S, Braem M, Vanherle G. Restorative therapy for erosive lesions. Eur J Oral Sci. 1996 Apr;104(2 ( Pt 2)):229-40. Lee HE, Lin CL, Wang CH, Cheng CH, Chang CH. Stresses at the cervical lesion of maxillary premolar--a finite element investigation. J Dent. 2002 Sep-Nov;30(7-8):283-90. Lee WC, Eakle SE. Possible Role of tensile stress in the etiology of cervical erosive lesions of teeth. J Pros Dent 1984; 52:374-379. 25

PAGE 33

26 Levitch LC, Bader JD, Shugars DA, Heymann HO. Non-carious cervical lesions. J Dent 1994; 22:195-207. Litonjua LA, Andreana S, Bush PJ, Cohen RE. Toothbrushing and gingival recession. Int Dent J. 2003a Apr;53(2):67-72. Litonjua LA, Andreana S, Bush PJ, Tobias TS, Cohen RE. Noncarious cervical lesions and abfractions: a re-evaluation. J Am Dent Assoc. 2003b Jul;134(7):845-50. Lyons K. Aetiology of abfraction lesions. N Z Dent J. 2001 Sep; 97(429):93-98. McCubbin J. Abfraction. J Am Dent Assoc. 2002 Jun;133(6):694, 696; author reply 696. Miller N, Penaud J, Ambrossini P, Bisson-Boutelliez C, Briancon S. Analysis of etiologic factors and periodontal conditions involved with 309 abfractions. J Clin Periodontol 2003; 30:828-832. Owens BM, Gallien GS. Noncarious dental "abfraction" lesions in an aging population. Compend Contin Educ Dent. 1995 Jun;16(6):552, 554, 557-8 passim; quiz 562 Piotrowski BT, Gillette WB, Hancock EB. Examining the prevalence and characteristics of abfractionlike cervical lesions in a population of US veterans. J Am Dent Assoc. 2001 Dec;132(12):1694-701; quiz 1726-7. Rees JS. The role of cuspal flexure in the development of abfraction lesions: a finite element study. Eur J Oral Sci. 1998 Dec;106(6):1028-32. Rees JS. The effect of variation in occlusal loading on the development of abfraction lesions: a finite element study. J Oral Rehabil. 2002 Feb;29(2):188-93. Rees JS, Hammadeh M, Jagger DC. Abfraction lesion formation in maxillary incisors, canines and premolars: a finite element study. Eur J Oral Sci. 2003 Apr; 111(2):149-54. Sullivan HC, Atkins JH. Free autogenous gingival grafts. 3. Utilization of grafts in the treatment of gingival recession. Periodontics 1968 Aug; 6(4):152-160. Young WG, Khan F. Sites of dental erosion are saliva-dependent. J Oral Rehabil. 2002 Jan;29(1):35-43.

PAGE 34

BIOGRAPHICAL SKETCH Dr. Gavin M. Aaron received his undergraduate degree in psychology from the University of Virginia. He received his doctoral degree in dental surgery from Virginia Commonwealth University. After completing his matriculation at the University of Florida periodontology residency, he plans to practice in Dayton, Ohio. 27


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Material Information

Title: The Prevalence of Non-Carious Cervical Lesions in Modern and Ancient American Skulls: Lack of Evidence for an Occlusal Etiology
Physical Description: Mixed Material
Copyright Date: 2008

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THE PREVALENCE OF NON-CARIOUS CERVICAL LESIONS INT MODERN AND
ANCIENT AMERICAN SKULLS: LACK OF EVIDENCE FOR AN OCCLUSAL
ETIOLOGY














By

GAVIN M. AARON


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA


2004
















ACKNOWLEDGMENTS

I would like to thank Dr. Gregory Horning and Dr. David Hunt for helping to

coordinate this research endeavor. I would also like to thank Drs. Arthur Vernino and

Hank Towle III for their input on my research. Finally, I want to thank Dr. Misty Lenk,

my future wife, for her support, encouragement, and inspiration.





















TABLE OF CONTENTS





ACKNOWLEDGMENT S .............. .................... ii


LI ST OF T ABLE S ............. ...... .__ .............. iv..


LI ST OF FIGURE S .............. ...............v.....


AB STRAC T ................ .............. vi


CHAPTER


1 INTRODUCTION ................. ...............1.......... ......


2 METHODS AND MATERIALS .............. ...............10....


3 RE SULT S ................. ...............12.......... .....


4 DI SCUS SSION ................. ................. 19......... ....


5 CONCLUSIONS .............. ...............24....


LIST OF REFERENCES ................. ...............25........... ....


BIOGRAPHICAL SKETCH .............. ...............27....


















LIST OF TABLES


Table pg

1 Measurements for the Non-Carious Cervical Lesions .............. .....................1

2 Frequency of NCCLs per Skull ................. ......... ...............13. ...

3 Frequency of NCCLs by Tooth Type ................. ...............13........... ..

4 Opposing pairs of Teeth and Frequency of NCCLs ................. ................. .... 14

5 Comparison of Non-Carious Cervical Lesions, Occlusal Wear Score, and PDL
Score Between Modern and Ancient Skulls............... ...............15.

6 Percentage of Teeth with Non-Carious Cervical Lesions According to Occlusal
W ear S core ................. ............... 16..............



















LIST OF FIGURES


Figure pg

1 Number of NCCLs vs. Skull Type ......___ ..... ._.__....._.__ ..........1

2 Number of NCCLs vs. Occlusal Wear Score .....__.___ ..... ....__ ..........____.....16

3 Number of NCCLs vs. Race ........._.. ..... ._ __ ...............17...


4 Number of NCCLs vs. Angle' s Classification .....__.___ ........___ .........._.....1 8

5 Number of NCCLs vs. Gender ........._... .....___ ...............18..
















Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

THE PREVALENCE OF NON-CARIOUS CERVICAL LESIONS INT MODERN AND
ANCIENT AMERICAN SKULLS: LACK OF EVIDENCE FOR AN OCCLUSAL
ETIOLOGY

By

Gavin M. Aaron

May 2004

Chair: Gregory Horning
Major Department: Periodontology

The abfraction lesion is a relatively recent classification that supposedly is derived

from malocclusion. However, many studies have suggested that abfraction lesions are in

fact non-carious cervical lesions with a multi-factorial etiology. To date, no research has

compared the prevalence of abfraction lesions in populations with and without access to

toothbrushes. The purpose of this study was to examine the prevalence of non-carious

cervical lesions in modern and ancient populations.

One-hundred-and-ninety-eight modern and 100 ancient American human skulls

were examined for the presence of non-carious cervical lesions (NCCLs). The skull

specimens were a part of the collection located at the National Museum of Natural

History in Washington, D.C. The modern skulls dated back to the early to mid-twentieth

century, while the ancient skulls were derived from two Native American Indian tribes

from the eleventh and seventeenth centuries. The age, gender, race, and Angle's









classification were recorded from each skull. Teeth in each skull were examined for the

presence and dimension of NCCL, extent of occlusal wear, width of the periodontal

ligament space, distance from the cervical border of the NCCL to the alveolar crest,

presence or absence of a lingual NCCL, presence of a dental restoration, and presence of

class V caries.

A total of 6,077 teeth were examined. No NCCLs were observed in the ancient

skulls, nor were any lingual NCCLs seen in any of the skulls. Fifty-seven NCCLs were

documented in 9.6% of the modern skulls, with a prevalence rate of 1.62% of NCCLs in

the 3,524 teeth in the modern skulls. A chi-square test of association showed no

relationship between extent of occlusal wear and the presence of NCCLs (p=0.5780), and

no significance of race, gender, or pdl width and NCCLs. The angle' s class II

relationship was significantly associated with the presence of NCCLs (p<0.0001).

The Einding that only modern skulls displayed NCCLs may be explained by

toothbrush use and/or acid erosion. Conversely, the ancient skulls may have incorporated

more abrasive substances into their diet and may not have had an average lifespan long

enough to develop NCCLs. Regardless, both collections included many skulls, which

showed heavy occlusal wear but failed to show any NCCLs.

From the results of this study it can be suggested that occlusal wear, likely derived

from heavy occlusal forces, is not associated with the presence of non-carious cervical

lesions. So-called abfraction lesions likely have a multifactorial etiology, rather than an

origin in occlusal stress.















CHAPTER 1
INTTRODUCTION

Non-carious cervical lesions (NCCLs) have become a controversial clinical

phenomenon in recent decades. These wedge-shaped concavities are predominantly

observed on the bucco-cervical region of teeth (Imfeld 1996, Piotrowski et al. 2001,

Boston et al. 1999), and have in recent years been termed "abfraction" lesions because of

certain evidence suggesting an origin in malocclusion.

Since then, several articles have argued for and against the abfraction classification.

Recent publications have disputed the existence of a true abfraction lesion, citing that the

lesions may be either erosive, abrasive, or multifactorial in nature (Litonjua et al. 2003a,

2003b, Piotrowski et al. 2001).

A lack of understanding of the various forms of noncarious lesions by the dental

community has lead to misdiagnosis of lesions as being abfractions (Levitch 1994, Bader

1993). Because not all clinicians have agreed on their origin, researchers have introduced

the term "non-carious cervical lesion" and/or "abfractionlike lesion" so as not to presume

the etiology of the lesions (Grippo 1991, Litonjua et al. 2003b, Piotrowski et al. 2001).

Non-carious lesions involve the irreversible loss of enamel or dentin, and may be

due to any of the following causes: attrition, erosion, resorption, abrasion, and

abfraction/malocclusion.

Attrition is the loss of tooth structure due to tooth-to-tooth forces with no

intervening foreign objects. Bruxism is a prime example of wear from attrition.









Erosion depicts the gradual etching away of tooth structure due to electrolytic or

chemical processes. Typically the pathologic loss of enamel and dentin is chronic,

localized, painless, and does not involve bacterial infiltration (Imfeld 1996). Clinically,

erosion lesions are confined to the buccal and occlusal surfaces of the mandibular

premolars and molars (Imfeld 1996).

External root resorption is the biological degradation of structures previously

produced by the body (i.e. host-mediated destruction). Resorption may be due to

cementoclastic, dentinoclastistic and/or ameloclastic activity (Imfeld 1996).

Abrasion is the wearing away of tooth structure due to abnormal mechanical

processes involving foreign objects, such as toothbrush abrasion (Imfeld 1996, Owens

and Gallien 1995, Piotrowski et al. 2001). Toothbrush abrasion may result from incorrect

brushing technique, frequency of brushing, time of brushing, force applied during

brushing, or even starting point of bashing on the arch (Addy 2000). The hardness of

the bristles and abrasiveness of the toothpaste used also make an impact on the extent of

these lesions.

Abfraction is derived from the Latin verb fra~ngere ("to break"), and defines a

wedge-shaped defect at or near the cemento-enamel junction (CEJ) of the tooth (Imfeld

1996, Piotrowski et al. 2001, Boston et al. 1999, Grippo 1991). The hypothesis that

described a new sub-class of cervical lesion that originated from tooth flexure from

occlusal loading was first introduced by Lee and Eakle in 1984. Grippo was the first to

define the term "abfraction" as a new classification of hard-tissue lesions in 1991 (Grippo

1991).









Abfractions are hypothesized to result from eccentric occlusal forces which "flex"

the tooth (Grippo 1991, 1992, Adda 2000). Their rationale for the concept of this lesion

is as follows: malocclusion due to parafunctional prematurities and hyper occlusion due

to bruxism often leads to eccentric occlusal forces, which in turn produce tensile,

compressive, and sheering stresses (Owens & Gallien 1992, Rees et al. 2003). These

stresses are focused at the CEJ, and microfractures are formed in the enamel and dentin.

Over time these microfractures propagate perpendicular to the long axis of the tooth until

enamel and dentin break away (Grippo 1992).

The enamel breaks off more easily than the dentin because of its brittleness.

Enamel is a very hard substance composed of inorganic crystallites, which can only be

subj ected to a relatively small amount of deformation before fracturing. Dentin on the

other hand has a greater organic component to its structure, is more resistant to

deformation, and consequently is much more resilient to the tensile and compressive

forces which can cause fracture (Owens & Gallien 1992).

Canines also play a protective role in that they reduce the amount of force

distributed to the posterior teeth during excursive movements. Naturally, occlusal

schemes where the canines are not involved in guidance offer no protection of the

posterior teeth in lateroscursive movements (Owens & Gallien 1992). Group function

occlusal schemes would involve the premolars and canines, which coincidentally are the

most common teeth demonstrating non-carious cervical lesions. Clinical research has

demonstrated that the group function occlusal scheme is more significantly associated

with abfraction lesions than canine guidance (Miller et al. 2003).









Miller and colleagues examined 61 patients displaying 309 NCCLs for excessive

brushing and occlusal interference. They also evaluated each patient's occlusal scheme

and the presence of plaque, calculus, periodontitis, wear facets, and mobility. Group

function was associated with almost three-quarters of the NCCLs, and wear facets were

associated with 94.5% of the NCCLs. In addition, balancing side prematurities were

associated with approximately 20% of the NCCLs. Interestingly, visible plaque and

calculus were found on the buccal surfaces of over 40% of the NCCLs, and 32.5% of the

NCCLs exhibited subgingival limits without signs of marginal gingival ulceration. His

study supported the notion of the abfraction lesion, which was derived from occlusal

disturbances as opposed to excessive toothbrushing (Miller et al.2003).

Computer simulations have also been developed to determine if occlusal forces

could cause non-carious cervical lesions. Finite stress analysis studies using computer

models have demonstrated that malocclusion could create microfractures in the enamel at

the CEJ (Rees 1998, Rees et al. 2003, Lee et al. 2002). These studies have shown that

that different teeth in the arch accommodate varying amounts of stress prior to reaching

their fracture point (Rees 1998, Rees et al. 2003, Lee et al. 2002). The incisor, canine,

and premolar have all been shown to manifest non-carious cervical lesions when heavy

excursive forces were directed onto the teeth; however, in all of the finite stress studies,

each tooth was evaluated individually, which failed to account for the compensating

effect of the other teeth in the arches.

A review of studies conducted by Lyons in 2001 concluded that non-carious

cervical lesions were multifactorial in nature, but conceded that occlusal loading was the

primary initiating factor (Lyons 2001).









While the much of the research on abfraction lesions has implicated malocclusion

as the primary etiology (Owens & Gallien 1995, Lee et al. 2002, Grippo 1992, Rees

1998, Rees et al. 2003), other mechanisms have been described for the formation of

abfractions (Boston et al. 1999, McCubbin 2002, Piotrowski et al. 2001).

Piotrowski in 2001 examined 103 teeth with NCCLs and 103 control teeth within a

population of U. S. veterans, and recorded each participant' s toothbrush habits, the

presence and location of NCCLs, the presence of excursive interference, plaque, and

occlusal wear on the teeth with lesions. Teeth exhibiting NCCLs had significantly more

surfaces with plaque than the control teeth; however, there were no significant

differences in wear-facet dimensions or in occlusal discrepancies between the NCCL and

control teeth. The statistical analysis suggested that toothbrush abrasion could be a

strong contributing factor, in that at least 75% of the participants reported using a firm-

bristled toothbrush and displayed improper toothbrushing technique (Pietrowski et al.

2001).

Litonjua in his review article pointed out that many of the studies advocating the

abfraction lesion were based on engineering and computer models that neglected the

influence of the periodontal attachment apparatus in absorbing the forces from occlusion.

He further noted that many of the clinical models that failed to investigate the participants

history of toothbrush abrasion and current toothbrushing technique He concluded that

the occlusal etiology for the formation of the abfraction lesion was not solidly founded,

and that abfraction lesions are likely NCCLs manifested from multiple causes (Litonjua

et al. 2003b).









Boston et al. in their case study implicated a combination of abrasion, erosion,

abfraction, linear enamel hypoplasia as the etiology of the non-carious lesions that he

observed (Boston et al. 1999). Although the patient exhibited numerous periodontally

involved teeth with wedge-shaped lesions, .a histologic examination after their extraction

lacked sufficient evidence to support malocclusion as the sole factor in the lesions

formation.

Kahn et al. in 1999 examined 122 cervical lesions in 250 patients with tooth wear.

Using epoxy resin replicas of their dentitions and scanning electron microscopy,

associations of occlusal attrition, erosion, and occlusal wear with cervical lesions were

recorded. They concluded that acid demineralization of teeth causes occlusal erosion

and attrition, and causes shallow and wedge-shaped cervical lesions. Moreover, Kahn

concluded that non-carious lesions have a multifactorial etiology in which erosion and

salivary protection play central roles (Kahn et al. 1999).

Indeed "abfraction", abrasive, and erosive lesions do have similarities which could

lead to misdiagnosis. All three lesions can be located on the buccal surfaces of the

canines and premolars. However, the effects of erosion can be observed in many other

places in the dentition, namely the occlusal surfaces of teeth (Imfeld 1996). In addition,

"abfraction" lesions have been described as displaying sharp margins along their borders,

while most erosion and abrasion lesions exhibit a rounder margin (Piotrowski et al.

2001).

This difference in appearance has been explained by the rationale that the surface

of erosive lesions are hypomineralized and consequently are less resistant to abrasive

forces from toothbrushing and eating (Imfeld 1996, Lambrechts et al. 1996). The acid










degradation, in turn, makes the tooth more susceptible to toothbrush abrasion and/or

abfraction lesions (McCubbin 2002).

Abrasion lesions from overzealous toothbrushing have been well established in

periodontal literature, and their clinical features are very similar to abfraction lesions

(Addy et al. 2003, Litonjua et al. 2003a, Gorman 1967). Like "abfractions", these lesions

are located on the buccal tooth surface along the cemento-enamel junction, are non-

carious in nature, and are found in similar teeth in the arch (Addy et al. 2003, Litonjua et

al. 2003a).

The distinction between the diagnoses of abfraction versus erosive and abrasive

lesions is important because the treatment of the phenomena are different.

The primary treatment of an abfraction lesion involves an occlusal adjustment and

possible restoration of the tooth (Imfeld 1996, Grippo 1992). Restorative therapy is

recommended particularly if the tooth is susceptible to a fracture or pulp exposure in the

near future. Glass ionomers are a popular choice because of the fluoride-releasing

capacity; however, microfilled composite resin with a low modulus of elasticity is

another viable option (Lambrechts et al. 1996). The low modulus of elasticity allows the

restoration to absorb occlusal forces without transferring them to the surrounding tooth

structure. According to one author, the most beneficial treatment for abfraction lesions is

an occlusal adjustment and nightguard fabrication to eliminate or at least reduce the

suspected occlusal etiology (Lambrechts et al. 1996).

The treatment of abrasion lesion, on the other hand, centers on the modification of

oral hygiene techniques and may involve the placement of a gingival graft (Litonjua et al.

2003a, Sullivan and Atkins 1968). Recommended treatment of erosive lesions includes










changes in dietary or behavior patterns, application of desensitization products, and

intensive fluoride therapy (Lambrechts et al. 1996, Owens & Gallien 1995).

A maj ority of the current research into non-carious cervical lesions has been

conducted on human subj ects, which is beneficial because an inquiry into the patients'

dietary and hygiene habits can be obtained, and parafunctional habits can also be

accurately measured and reproduced.

Unfortunately, current studies have failed to include a patient population which

does not incorporate toothbrush use. Toothbrush use is a significant factor because it can

lead to non-carious cervical lesions, and possibly contribute to the formation of non-

carious cervical lesions.

In order to best eliminate the impact of oral hygiene factors on the formation on

abfraction lesions, a modern group of subj ects with access to toothbrushes and dentifrices

was compared to a pre-modern group with no access to toothbrushes. In this regard, the

suggested primary etiologic factor of "abfraction" lesions occlusion can be more

fairly isolated.

In this study, two groups of American skulls were examined for the presence and

extent of non-carious cervical lesions and occlusal wear. However, only one of the two

groups had access to modern oral hygiene devices. Theoretically by eliminating

toothbrush use, any non-carious cervical lesions observed in the pre-modern skulls can be

more confidently attributed to occlusal factors. Comparing the prevalence of non-carious

cervical lesions in the two groups hopefully will increase the understanding of the non-

carious cervical lesion and its etiology.







9


The purpose of this study was to document the prevalence of non-carious cervical

lesions in modern and ancient American human skulls.















CHAPTER 2
METHODS AND MATERIALS

This study was conducted at the Natural Museum of Natural History in Washington

D.C. Two hundred modern American human skulls from the early to mid-twentieth

century and 100 ancient American Indian skulls from the eleventh and seventeenth

century were evaluated. The modern skulls were a part of the Terry anatomic collection,

which consisted of 1,760 skeletons consisted of persons who donated their bodies to

science or were unclaimed after death. The ancient skulls in this investigation were

excavated from American Indian burial mounds from Northern Illinois (11th century) and

from South Dakota (17th century). The gender, race, and Angle's classification were

recorded from each skull specimen. The age at the time of death was only collected from

the modern skulls because the age was not available for the ancient skulls.

The following inclusion criteria were employed:

1. The estimated age of the individual at his/her time of death must have been at least
40 years old.

2. At least 10 teeth must have been intact.

3. Intact but fractured teeth were not included in the data collection.

A non-carious cervical lesion was defined as:

Any lesion located at the cemento-enamel junction of the tooth, which extended

axially at least .5mm into the dentin without signs of previous dental caries.

The teeth still intact in the skulls were examined for the following:

1. Presence of a non-carious cervical lesion on the buccal and lingual tooth surfaces.
The circumferential border of any lesions detected were classified as having either










sharp or round margins. The height, width, and depth was measured to the nearest
half-millimeter using a UNC-15 probe.

2. Presence of caries. Lesions were considered carious if they displayed elliptical as
opposed to wedge-shaped defects, were black in appearance, exhibited enamel
undercuts, or were soft and "leathery" upon probing with a UNC-15 probe. The
height, width, and depth was measured to the nearest half-millimeter using a UNC-
15 probe.

3. Presence of restorations. Any artificially created restoration was recorded,
including amalgam and gold foil restorations and crowns.

4. Distance from the cervical border of the lesion to the alveolar crest. The distance
was measured to the nearest .5mm using a UNC-15 probe.

5. Extent of occlusal wear. The occlusal wear was visually classified according to a
four-point scale:

1 = very minimal to no occlusal wear

2 = occlusal wear is confined to the enamel

3 = occlusal wear extents into the dentin

4 = occlusal wear extents into the dentin involving all cusps and
the central fossa, thereby giving a "table top" appearance

6. Extent of pdl width. No radiographs were taken. The pdl width was measured
using a UNC-15 probe and was classified according a three-point scale:

1 = pdl width < .5mm

2 = pdl width > .5mm and I 1mm

3 = pdl width > Imm

The data was analyzed using descriptive statistical analysis (means, averages, etc.),

chi-square tests, Mantel-Haenszel chi-square tests, and logistical regression analysis.















CHAPTER 3
RESULTS

Out of 300 specimens, 2 modern skulls were not included because of incomplete

collection of data. A total of 6,077 teeth in 298 skulls were examined.

The distribution was as follows for the modern skulls: 59 White males, 57 Black

males, 20 White females, 60 Black females, and 2 Asian males. The average age was 53

years old (range: 40-87 years, standard deviation: 11.3 years). 39 restorations and 50

class V carious lesions were observed. 101 class I, 34 class II, and 52 class III Angle

malocclusions were observed.

Out of 3,524 teeth in the modern skulls, 57 NCCLs were observed with a

prevalence of 1.62%. For the NCCLs, the average width was 4.01mm (range: 2-8mm,

sd: 1.54mm), the average height was 1.92mm (range: 1-5mm, sd: 0.69mm), and the

average depth was 0.73mm (range: 0.5-1.5mm, sd: 0.34mm). The average distance

from the NCCL to the alveolar crest was 2.75mm (range: 2-6mm, sd: 1.15mm), and in 4

teeth (canines) the distance was not recorded because a buccal dehiscence exposed the

roots almost to the apices. The average occlusal wear score was 2.49 (range: 1-4, sd:

0.57), and the average pdl score was 1.26 (range: 1-3, sd: 0.25). See Table 1.

Table 1: Measurements for the Non-Carious Cervical Lesions
Standard
Parameters Averae Range Deviation
Width (mm) 4.01 2-8 1.54
Height (mm) 1.92 1-5 0.69
Depth (mm) 0.73 0.5-1.5 0.34
Distance to Crest (mm) 2.75 2-6 1.15













Of the 3,524 teeth in the modern skulls, 9.6% percent exhibited NCCLs. No lingual

NCCLs were observed. The amount of NCCLs per skull ranged from 0 to 10, with the

majority having only one lesion. The distribution of the lesions is shown in Table 2.

Table 2: Frequency of NCCLs per Skull
# of Skulls # of NCCLs Percentage
179 0 90.4
8 1 4.04
5 2 2.53
2 3 1.01
1 5 0.51
1 6 0.51
1 7 0.51
1 10 0.51
When each tooth type was taken into consideration, the data showed that the

canines, premolars, and molars were the most susceptible to developing a NCCL.

However, tooth type by itself was not a significant predictor of NCCL formation

(p=0.0429). The distribution of NCCLs for each tooth is shown in Table 3.

Table 3: Frequency of NCCLs by Tooth Type
Tooth # # of Teeth # of NCCLs Percentae
1 78 0 0
2 116 0 0
3 108 3 2.78
4 117 1 0.85
5 119 2 1.68
6 131 3 2.29
7 73 1 1.37
8 59 0 0
9 56 0 0
10 69 1 1.45
11 121 1 0.83
12 128 1 0.78
13 115 0 0
14 118 1 0.85
15 114 0 0
16 69 0 0









Table 3 contd.
Tooth # # of Teeth # of NCCLs Percentage
17 92 0 0
18 114 1 0.88
19 94 1 1.06
20 140 1 0.71
21 163 5 3.07
22 161 4 2.48
23 135 3 2.22
24 135 1 0.74
25 121 0 0
26 136 0 0
27 150 4 2.67
28 168 8 4.76
29 136 3 2.21
30 99 4 4.04
31 133 3 2.26
32 81 0 0



When pairs of opposing teeth were analyzed, the teeth on the right side of the skull

exhibited more NCCLs. Certain pairs of teeth were significantly associated with NCCLs.

(p=0.007). Table 4 shows the trends in teeth pairing and NCCLs.

Table 4: Opposing. pairs of Teeth and Frequency of NCCLs
Teeth # of Teeth # of NCCLs Percentage of
Pair NCCLs
1 8 32 159 0 0
2 &31 249 3 1.2
3 & 30 207 7 3.38
4 & 29 253 4 1.58
5 & 28 287 10 3.48
6 & 27 284 7 2.49
7 & 26 209 1 0.48
8 8 25 180 0 0
9 & 24 191 1 0.52
10 & 23 204 4 1.96
11 & 22 282 5 1.77
12 & 21 291 6 2.06
13 & 20 255 1 0.39
14 & 19 212 2 0.94
15 &18 228 1 0.44
16& 17 161 0 0












For the ancient skulls the distribution was 26 Northern Illinois males, 24 Northern

Illinois females, 25 South Dakota males, and 25 South Dakota females. The age of death

of each specimen was not available. Four carious lesions were observed. Thirty-three

class I, 6 class II, and 60 class III Angle's malocclusions were observed.

No NCCLs were present. The average occlusal wear score was 3.32 (range: 1-4, sd:

0.57), and the average pdl score was 1.28 (range: 1-3, sd: 0.25). See Table 5 and figure 1.

Table 5: Comparison of Non-Carious Cervical Lesions, Occlusal Wear Score, and PDL
Score Between Modern and Ancient Skulls
Skulls Parameters Total # Average (mm) Range (mm) SD (mm)
Modern # of NCCLs 57
Occlusal Wear Score 2.49 1-4 1.26
PDL Score 1.26 1-3 0.25
Ancient # of NCCLs 0
Occlusal Wear Score 3.32 1-4 0.57
PDL Score 1.28 1-3 0.25


ANrrDr d Leamas








Stil Type


Figure 1. Number of NCCLs vs. Skull Type

The proceeding chi-square and statistical regression analyses are only for the

modern skulls.









Of all of the teeth with no occlusal wear (OW score = 1), 4 (1.76%) had NCCLs.

In teeth with moderate occlusal wear (OW score = 2), 26 (1.41%) had NCCLs. Of the

teeth with severe occlusal wear (OW score = 3), 19 (1.63%) had NCCLs. Finally, 3

(0.72%) of the teeth with very severe occlusal wear (OW score = 4) had NCCLs. The

association between occlusal wear and NCCL formation was not significant (p=0.4492).

Table 6 and figure 2 visualize these findings.

Table 6: Percentage of Teeth with Non-Carious Cervical Lesions According to Occlusal
Wear Score
Occlusal Wear # of Teeth # of NNCLs % of Teeth w/
Score NCCL

1 (no wear) 2741.76
1840 26
2 (mild wear) 1.41
3 (moderate 1167 19
wear) 1.63
4 (severe wear) 1 0.72


12 3 4

oslus w soare



Figure 2. Number of NCCLs vs. Occlusal Wear Score

A Mantel-Haenszel chi-square test of association determined that no significant

trend existed between increasing or decreasing occlusal wear scores and NCCL formation

(p = 0.0243).









The effect of race was insignificant. Anglo-Americans and African-Americans

exhibited approximately the same amount of teeth with NCCLs. Asian skulls had almost

half as many NCCLs.The number of African-American teeth displaying NCCLs was 19

(0.83%); the number of Anglo-American teeth displaying NCCLs was 21 (1.61%); and

the number of Asian-American teeth displaying NCCLs was 12 (28.57%). These

findings are visualized in Figure 3.



25-





of NCCLs







Black White Asi an

Race

Figure 3. Number of NCCLs vs. Race

Skulls with Angle's class I occlusion had 10 (0.50%) of teeth with NCCLs; Thirty

(5.12%) of the teeth in skulls with Angle's class II occlusion showed NCCLs; and 9

(0.97%) of the teeth in skulls with Angle' s class III occlusion showed NCCLs. The

Angle' s class II occlusion was significantly related to the rate of NCCLs (p < 0.0001).

See figure 4.


















# of NCCLs 2-







I II Ill

Angles Classification

Figure 4. Number ofNCCLs vs. Angle's Classification

When gender was taken into account, males and females exhibited similar number

of teeth with NCCLs Twenty-seven (1.18%) of the males' teeth displayed NCCLs, while

25 (1.84%) of the females' teeth displayed NCCLs. This was not statistically significant

(p = .1045). See figure 5.









# of NCCLs 15


Male Female


Gender


Figure 5. Number of NCCLs vs. Gender















CHAPTER 4
DISCUSSION

Most of the skulls did not have all of their teeth intact, and several teeth had

fractured crowns. Teeth that were partially fractured were later excluded from the

results. Many skulls had teeth which were glued into the socket, and some of the teeth

were glued out of the plane of occlusion. Occasionally, the crania were sagitally split. In

most of the cases however, the teeth in the two halves of the skull could be accurately

articulated, thereby allowing the Angle's classification to be recorded. Because teeth that

were glued into the sockets were not differentiated from teeth that were not glued, the pdl

width was not extensively incorporated into the results and discussion.

Because previous studies focused primarily on only those teeth displaying non-

carious lesions, the 1.62% prevalence of NCCLs in the modern skulls is without

comparison. Out of 6,077 teeth, no lingual NCCLs were observed. There is no previous

research citing lingual NCCLs, which implies that NCCLs occur only on the buccal

surfaces of teeth or that lingual NCCLs are extremely rare.

Both modern and ancient skull collections demonstrated advanced occlusal wear;

however, only the modern skulls displayed NCCLs. In addition, the average occlusal

wear score for the modern skulls was less than the average occlusal wear score for the

ancient skulls. Regardless, in both collections there were numerous teeth which exhibited

heavy occlusal wear but failed to show any NCCLs. Perhaps the studies advocating the

notion of the abfraction lesion are focusing too much on those teeth with lesions, and are










not taking into consideration all of other teeth which display malocclusion without NCCL

formation.

Why would only the modern skulls exhibit non-carious cervical lesions despite

having a lower overall amount of occlusal wear? This discrepancy may be explained by

unique factors found in each of the two populations.

The NCCLs in the modern skulls may have been facilitated by overzealous

toothbrushing. Improper toothbrushing technique could form non-carious cervical lesions

independent of the extent of occlusal wear.

On the other hand, the Native Americans may have developed advanced occlusal

wear without necessarily exerting heavy occlusal forces. According to anthropologists,

the diet of the Native Americans was largely meats, grains, and vegetables, which likely

were not adequately cleansed of dirt and debris. Incorporating a more abrasive diet

would have lead to an increased level of occlusal wear.

The advanced occlusal wear in the ancient skulls may also have been due to

bruxism. Perhaps the Native American muscles of mastication may have been

hypertrophied compared to modern Americans from eating less tender food. Or, Native

Americans may have bruxed their teeth because of the greater stress level associated with

survival. Many of the ancient skulls displayed full arch "table-top" occlusal wear.

Usually, "table-top" occlusal wear in modern Americans is attributed to bruxism. If the

Native Americans had an etiology of bruxism for their advanced occlusal wear, then they

should have displayed abfraction lesions according to current dental concepts.

Perhaps the Native Americans would have developed non-carious cervical lesions,

but they did not live long enough on average to manifest these lesions clinically. The









main disadvantage of working with ancient skulls is the lack of demographic and cultural

information that is helpful in formulating theories. Without the age at the time of death

of each of the skull specimens, the age factor can only be speculative at best.

Based on the finding that only the modem American skulls displayed NCCLs, one

could hypothesize that non-carious cervical lesions are a modern phenomenon. In other

words, non-carious cervical lesions including abfraction lesions are a product of the

modern lifestyle.

One obvious facet of the modern lifestyle is an increased awareness about personal

oral hygiene. With the advent of the modem toothbrush and dentifrice, people were more

likely to brush their teeth in order to remove plaque. However, improper toothbrushing

technique has been known to create abrasive lesions at the buccal surfaces of the CEJs of

teeth. Just as the current population displays a proportion of toothbrush abrasion, so

would the mid-20th century population representing the skulls.

Another phenomenon of modern society is the mass availability and consumption

of sugar into the diet. Compared to the ancient populations, modem society certainly has

incorporated more food products with a higher sugar content on a regular basis. While

too much sugar can lead to dental caries, a sugar consumption below the caries threshold

could lead to hypomineralization of the enamel. The hypomineralized enamel would in

turn be more susceptible to abrasion from toothbrushing or to the forces that lead to

abfraction lesions. This theory however, is minimally supported by publications and

would need more dedicated research to access its validity.

The more accepted notion is that occlusal factors are responsible for the non-

carious cervical lesions exhibited in modern society. The question arises as to whether









the ancient Native Americans had such different occlusion from modern Americans that

NCCLs failed to form. There has been no research to suggest that occlusal patterns and

forces have spontaneously increased in complexity in the last thousand years, so the idea

that abnormal or excessive occlusal forces are unique to modem society is unfounded.

The x-factor in discussing occlusal schemes and abfraction lesions in this study is

race. It is possible that the Anglo-Americans, the African-Americans, the Sino-

Americans, and the Native Americans all had different dento-skeletal relationships from

one another. As the results demonstrated, those modem skulls with an Angle's class II

dental relationship where much more susceptible to forming NCCLs than either class I or

class III. Moreover, the Anglo-Americans as an independent variable were significantly

associated with the proclivity to form NCCLs. Compared to African-Americans and

Sino-Americans, Anglo-Americans have a stronger genetic predisposition towards the

class II phenotype because of their Northemn European ancestry Perhaps those of

Northern European decent have a stronger susceptibility to forming non-carious cervical

lesions.

Of course, a small proportion of the ancient skulls had an Angle's class II dental

relationship and did not have any NCCLs. Although the Angle's relationship may play a

part in abfraction susceptibility, the argument still circles back to occlusion because the

Angle's classification ultimately affects the dental occlusion.

The periodontal ligament is a biologic structure which physiologically absorbs the

forces from occlusion to an extent. In health, the periodontal ligament is approximately

20 microns wide. Widening of the periodontal ligament is thought to be derived from

heavy occlusal forces. This study hoped to include the variations in the periodontal










ligament width to help determine the extent of occlusal forces upon each tooth.

Unfortunately, many of the teeth were glued back into their respective tooth sockets, so

the parameter of periodontal ligament width was not included in the results of this study.

The results of the paper do not eliminate occlusal forces from contributing to the

formation of non-carious cervical lesions. The correlation drawn can only describe an

association and cannot assign causality. What the results of this research demonstrate

however is that factors that lead to occlusal wear are probably not justified to create a

specific subclass of non-carious cervical lesions, namely the abfraction lesion.

The next step for future research on this controversy would be to examine a live

human population that has no access to toothbrushes or dental care. The participants

would also be examined for maladaptive occlusal forces and occlusal prematurities.

Then perhaps a cause-effect relationship relating to the formation of "abfraction" or other

non-carious cervical lesions could be more confidently supported.















CHAPTER 5
CONCLUSIONS

6,077 teeth in 298 skulls (198 modern, 100 ancient) were examined for non-carious

cervical lesions. Of the 3,524 modern teeth, 1.62% or 57 teeth exhibited NCCLs. None

of the teeth in the ancient skulls demonstrated NCCLs. One-hundred percent of the

NCCLs were located on the buccal surfaces, whereas 0% were found on the lingual

surfaces. Occlusal wear was not significantly associated with the presence ofNCCLs,

nor was any trend of an increasing or decreasing amount of occlusal wear associated with

the presence ofNCCLs. Neither race nor gender were significantly associated with the

presence ofNCCLs. Finally, the Angle's class II relationship was shown to significantly

associated with the presence of NCCLs.

Occlusal wear, derived from factors affecting the occlusion, are not likely to be

causative of NCCLs.
















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BIOGRAPHICAL SKETCH

Dr. Gavin M. Aaron received his undergraduate degree in psychology from the

University of Virginia. He received his doctoral degree in dental surgery from Virginia

Commonwealth University. After completing his matriculation at the University of

Florida periodontology residency, he plans to practice in Dayton, Ohio.