ETD

• carious cervical lesions
• class V lesions
• literature review
• non-carious cervical lesions (NCCLs)

Class V lesions develop in the gingival third of facial or lingual tooth surfaces and may be carious (biofilm-mediated) or non-carious cervical lesions (NCCLs). Carious cervical lesions occur through plaque biofilm and acid demineralization, while NCCLs arise from multifactorial, non-bacterial mechanisms, notably abrasion, biocorrosion/erosion, and abfraction. Clinical evidence indicates these factors often act synergistically. Abrasion results from improper brushing and abrasive habits, erosion from intrinsic and extrinsic acids, and abfraction from occlusal stress causing microfractures at the cervical margin though there clinical evidence is highly controversial. Epidemiological studies show NCCLs are highly prevalent, with nearly half of adults affected, and prevalence increases with age.
Diagnosis and examination require a detailed history of habits, diet, and occlusion, combined with thorough inspection under proper illumination. Clinically, root caries appear soft, yellowish to brown, often near gingival margins, while NCCLs are hard, glossy, wedge- or saucer-shaped, and often associated with dentin hypersensitivity. Distinguishing features of abrasion, erosion, and abfraction aid diagnosis.
The decision to monitor or restore is nuanced. Active caries clearly require intervention, but non-carious lesions may be managed by preventive strategies unless progression, sensitivity, aesthetics, or structural compromise suggest otherwise. Over-restoration risks initiating the “re-restoration cycle,” causing cumulative tooth loss. Guidelines recommend conservative monitoring when lesions are shallow, nonsensitive, and stable, with documentation and reassessment over time.
Non-restorative management emphasizes preventive measures. Fluoride therapy remains central, with high-fluoride toothpastes, gels, and varnishes shown to enhance remineralization and slow progression. Other methods include strontium, arginine/calcium carbonate, NovaMin (bioactive glass), and CPP-ACP complexes, though evidence for long-term superiority over fluoride alone is mixed. Emerging biomimetic agents such as amelogenin peptide hydrogels are giving promising results. Desensitizing agents like potassium nitrate, oxalates, resin-based sealants, and lasers help alleviate hypersensitivity, though no gold-standard exists. Occlusal splints may be useful when occlusal stress is suspected, though evidence for occlusal adjustment remains inconclusive and highly debated.
Restorative management is indicated in cases of cavitated or progressing caries, persistent hypersensitivity, compromised structure, subgingival margins, prosthetic abutment needs, or aesthetic concerns. Successful outcomes rely on careful isolation and moisture control, often with rubber dams or retraction cords, though improper use may cause gingival damage or compromise bonding if hemostatic agents contaminate dentin.
Cavity and surface preparation should be conservative. While minimal intervention without mechanical retention is possible, some evidence suggests retention grooves enhance longevity. Surface roughening of sclerotic dentin improves bonding, and beveling enamel increases surface area and esthetic blending. However, evidence supporting beveling remains limited, though no harm is reported.
Material selection requires balancing aesthetics, durability, and biocompatibility. Glass ionomer cements (GICs): chemically bond to dentin, release fluoride, and show better retention than composites but poor wear resistance. Resin-modified GICs (RMGICs): improve strength, moisture tolerance, and aesthetics, with variable long-term outcomes. Compomers: combine features of GIC and composites, offering some fluoride release but prone to discoloration. Resin composites: most aesthetic and durable when bonding is optimized, though technique-sensitive. A sandwich technique combining GIC and composite may provide advantages.
Adhesion strategies are critical. Sclerotic dentin poses bonding challenges due to tubule occlusion and hypermineralization, but roughening and extended etching times (30s) improve outcomes. Selective enamel etching enhances marginal integrity. Both etch-and-rinse and self-etch/universal adhesives perform acceptably, with longevity depending more on operator technique than system type. Universal adhesives with functional monomers (e.g., 10-MDP) allow versatile application.
Composite placement can use flowable, packable, or layered approaches. Flowable resins adapt well to irregularities and small increments, while packable composites provide strength. A combination—flowable lining with packable overlay—balances adaptability and durability. Oblique layering minimizes shrinkage stress. Finishing and polishing are essential to prevent plaque retention, gingival irritation, and caries recurrence. Techniques minimizing excess material are preferred.
Periodontal considerations are integral, particularly with lesions extending subgingivally or associated with recession. Improper isolation or finishing can exacerbate gingival inflammation, while over-contoured restorations may impair plaque control. In severe cases, surgical approaches such as gingival retraction or crown lengthening may be required for access and longevity. Non-carious cervical lesions (NCCLs) are frequently associated with gingival recession and in some cases may require periodontal surgery. Factors such as traumatic toothbrushing, occlusal overload, and thin periodontal phenotype predispose the gingiva to both NCCLs and recession.
In conclusion, Class V lesion management requires tailored, multifactorial decision-making, integrating caries activity, lesion type, patient risk factors, and esthetic demands. Conservative monitoring is preferred for stable lesions, while preventive and restorative strategies must be tailored carefully to avoid overtreatment and preserve tooth and periodontal health.