Non-carious Cervical Lesions, an Approach of the Associated Factors in a Teaching Service Clinic.

doi:10.21203/rs.3.rs-4688481/v1

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Non-carious Cervical Lesions, an Approach of the Associated Factors in a Teaching Service Clinic.

https://doi.org/10.21203/rs.3.rs-4688481/v1

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Considering the reported prevalence and risk factors of non-carious cervical lesions (NCCLs), the present study aims to evaluate the prevalence and the factors associated with NCCLs in a Colombian higher-level institution.

Materials and Methods: An observational, analytical, cross-sectional study was done, the sample consisted of 105 patients, over 40 years of age, of both sexes. A survey was carried out with sociodemographic characteristics and factors associated with NCCL, followed by a clinical examination to record NCCLs, type of lesions and occlusal factors such as: malocclusions, coincidence of midlines and dental crowding. The statistical analysis included continuous variables, accompanied by measures of central tendency and categorical variables with absolute and relative frequencies in percentage, a multimethod regression analysis was done.

Results: NCCLs were diagnosed in 53.3% of the total respondents, with abfraction being the most prevalent type of lesion found in 39.1% of the participants. NCCL were significantly associated with tooth brushing habits, frequency of consumption of carbonated beverages and citrus fruits, and parafunctional habits. Statistical significance was found in the diagnosis of tooth sensitivity, malocclusion, bruxism, xerostomia, use of removable prosthesis, open bite, crossbite, midline coincidence and crowding. In the Multiple regression analysis, the Aggressive technique of brushing whit an OR of 9.9 (P<0.05) and tooth sensitivity OR 3.4 (P<0.05) were related whit NCCLs

Conclusions: This study showed a relatively high frequency of NCCL in subjects in the age range of 40 to 80 years.

Health sciences/Diseases

Health sciences/Diseases/Oral diseases

Tooth Diseases

Dental Abrasion

Tooth Abrasion

Tooth Erosion

Oral Health.

Non-carious cervical lesions (NCCLs) are clinically recognized as a progressive loss of dental tissue in the area of the cementoenamel junction (CEJ), which presents different extensions and characteristic shapes, affecting tissues such as enamel and dentin; and in more advanced cases, it can reach the dental pulp (1, 2, 3, 4).

According to the terminology described by the European Organization for Caries Research (ORCA) and the Cariology Research Group of the International Association for Dental Research, physiological dental wear is considered as the degree of wear caused by the natural use of the stomatognathic system throughout the lifetime. The progression rate varies among individuals, and not all worn teeth need treatment; it can be defined as pathological when it exceeds the physiological level relative to the individual's age and interferes with self-perception of well-being. (5) According to the Dental Wear Assessment System, it is pathological if it is present in moderate to extreme form in the surface of the tooth, in combination with one or more described signs and symptoms, including hypersensitivity and/or pain, functional problems (difficulty chewing and eating), deterioration of aesthetic appearance (compromised dental appearance), atypical wear for the patient's age, disintegration of dental hard tissue and restorations, threatening the integrity of the teeth, among others (5).

There are different types of risk factors, including physical, chemical, mechanical, occlusal, and a variety of non-natural agents like personal lifestyles, habits or behaviors, medical conditions, environmental exposures, or congenital characteristics that have been associated with a higher likelihood of developing NCCLs. (6). In addition, there are factors inherent to dental structure; the cervical region of the tooth is a fragile area because the proportion of enamel decreases, there is less mineral content, and a higher amount of proteins is present. Likewise, this area coincides with the fulcrum area of occlusal forces, and all of this facilitates the appearance of both caries and NCCLs. (7).

Although the etiology of NCCLs is not clear, evidence so far supports that they are considered complex and multifactorial (8, 9, 10); generally, it is much more common to find that their cause stems from the combination of different factors. (5, 9). Significant attention should be paid to this pathology because the integrity of dental tissues is compromised, leading to painful symptoms, dental sensitivity, aesthetic implications, and progression to pulp death or predisposition to unforeseen fractures. (11).

NCCLs are a health problem that has reached high prevalence and has increased significantly in the entire population as a result of the decrease in edentulism and modern lifestyle. The most affected population is the elderly population due to exposure to etiological factors over a longer period of time than younger patients (11). Likewise, and as a consequence of this, a greater number of lesions and of greater severity are expected to occur in elderly patients (12, 13, 14), so considerable care should be taken with these lesions at the time of dental care at that stage of the life cycle.

Highly variable prevalence have been reported on the literature like 9%, 35%, and 77% of NCCLs (1). The reason for these discrepancies is determined by the different evaluation and diagnostic criteria of the lesions, as well as the implementation of different study methodologies with a wide variety of test patterns such as the age of the samples, the inclusion of both sexes, the number of participants, among others. According to the National Oral Health Study (ENSAB IV) in Colombia, the presence of dental erosion is observed in prevalence of less than 10% of the population, with adults being the most affected, in contrast to the data reported in other countries (16), however, the prevalence of other types of NCCLs are not presented. Other studies carried out in the country reveal that the frequency of NCCLs was higher, one in three (1:3) people presented erosion, abrasion, and/or abfraction, with the frequency being higher in men (17). Therefore, this article aims to establish the prevalence and associated physical, chemical, mechanical, and sociodemographic factors of NCCLs in patients of a higher education institution in Colombia.

An observational, analytical cross-sectional study was conducted to evaluate the prevalence and etiopathogenesis of NCCLs in patients attending treatments at the Universidad del Valle clinic in the year 2023. The sample consisted of 105 patients, including male and female patients over 40 years of age who sign informed consent to participate in the study and were active patients of the clinic. Patients with cervical caries, complete edentulism, and motor or mental disabilities were excluded. This sample of 105 persons was calculated based on an estimated attendance in 2023 of around 150 patients and taking into account a prevalence of NCCLs of around 40%, with a confidence level of 95% and an estimated error alpha of 5% (0.05).

The dependent variables were abrasion, abfraction, erosion, and a variable we called NCCL, which indicates the presence or absence of any of these. The independent variables were divided into 3 subgroups: Sociodemographic characteristics (age, sex, presence of any disease, frequent medication consumption, skin color, educational level); Knowledge, habits, and practices (knows what dental wear is and its causes, type of toothbrush, brushing technique, brushing frequency, waiting time after eating to brush, pressure applied during brushing, duration of brushing, products used in brushing, frequency of consumption of carbonated beverages, citrus fruits, coffee, wine, vitamin C supplements, dental sensitivity, parafunctional habits, sports practice, perception of changes in tooth structure by the patient.); and Occlusion, symptomatology, and mental conditions (diagnosis of malocclusion, diagnosis of bruxism, feels that chews well and teeth fit, feels clenching or grinding teeth, feels tiredness or pain when chewing, frequently experiences headaches, usually feels dry mouth, constantly drinks water due to dryness sensation, wakes up with sour taste, has gastric reflux, has had or currently has orthodontic treatment, uses removable prosthesis, open bite, crossbite, midline discrepancies, crowding).

Prior to the field research, project approval code 028 − 023 was obtained from the ethics committee of Universidad del Valle, followed by a calibration using as a gold standard teachers with high experience and knowledge in the subject. The calibration had theoretical components that includes sociodemographic and clinical aspects of each NCCL and a practical component, in which a pilot test was carried out on 5 patients diagnosed with NCCLs, who were evaluated by all investigators and teachers, conducting their respective sociodemographic survey and assessment: odontogram and occlusal analysis to calculate the calibration with the clinical examination through a Kappa indicator, seeking agreement between the investigators.

The information was recorded through direct interviews using an information collection instrument and clinical assessment of the patients. Before including them in the study, they were informed about the study and sign an informed consent, followed by the interview and dental assessment, which included a clinical examination (odontogram), consisting of observing the number of teeth present in the mouth and each of their surfaces using a mirror and the WHO probe to assess NCCLs; an occlusal analysis was also carried out. These routine examinations were performed by the investigators.

The information was collected through Google Forms and the database was migrated to Microsoft Excel, the information was consolidated with its data dictionary, and the responses of the study cases to the questionnaire and clinical observation were coded. Statistical analysis was performed regarding quantitative variables expressed with measures of central tendency and variation, while categorical variables were expressed with absolute and relative frequencies in percentage. To determine differences between the clinical parameters of qualitative NCCLs, the chi-square test was used for abrasion, abfraction, and for erosion, whose prevalence is lower, Fisher's exact test was used. A multivariate analysis was conducted through logistic regression, using the statistically significant variables from the bivariate analysis for the Non-Carious Cervical Lesions variable (NCCL). The analysis was performed using Stata version 17.

An adequate kappa of agreement between the calibrators and the students of 0.86 was obtained. The presence of NCCLs was diagnosed in 53.3% of the total respondents, with abfraction being the most prevalent type of lesion, found in 39.1% of the participants. Of the 105 patients participating in this study, an average population age of around 59.15 years was obtained, with a standard deviation of 9.5, ranging from a minimum age of 40 to a maximum of 80 years.

Statistical significance analyses were conducted for each of the NCCLs and sociodemographic and clinical variables. For abrasion, abfraction, and NCCL, statistical significance tests were performed using the chi-square test, while for erosion, whose prevalence is low, Fisher's exact test was used. Statistical significance for this group of sociodemographic and clinical variables was only observed in educational level for abfraction, the dark skin color measured by the Perla Color Palette was not found in the sample. Table 1 shows this results.

Table 1

Sociodemographic characteristics and non-carious cervical lesions in patients attending a teaching service clinic, 2023.
	Abrasion (n,%)		P	Abfraction (n,%)		P			P *	NCCL (n,%)
	Yes	No		Yes	No		Yes	No		Yes	No	P
Age
40–60 Years	21 (56.76%)	34 (50%)	0.5	21 (51.22%)	34 (53.12%)	0.8	3 (33.33%)	52 (54.17%)	0.3	31 (55.36%)	24 (48.98%)	0.5
60 and more	16 (43.24%)	34 (50%)	0.5	20 (48.78%)	30 (46.88%)	0.8	6 (66.67%)	44 (45.83%)	0.3	25 (44.64%)	25 (51.02%)	0.5
Sex
Male	11 (29.73%)	26 (38.242%)	0.4	14 (34.15%)	23 (35.94%)	0.9	5 (55.56%)	32 (33.33%)	0.3	20 (35.71%)	17 (34.69%)	0.9
Female	26 (70.27%)	42 (61.76%)	0.4	27 (65.85%)	41 (64.06%)	0.9	4 (44.44%)	64 (66.67%)	0.3	36 (64.29%)	32 (65.31%)	0.9
¿Do you suffer from any illness?
Yes	21 (56.76%)	32 (47.06%)	0.3	21 (51.22%)	32 (50.00%)	0.9	6 (66.67%)	47 (48.96%)	0.5	28 (50.00%)	25 (51.02%)	0.9
No	16 (43.24%)	36 (52.94%)	0.3	20 (48.7%)	32 (50.00%)	0.9	3 (33.33%)	49 (51.04%)	0.5	28 (50.00%)	24 (48.98%)	0.9
¿Do you frequently take medication?
Yes	19 (51.35%)	31 (45.59%)	0.6	19 (46.34%)	31 (48.44%)	0.8	6 (66.67%)	44 (45.83%)	0.3	25 (44.64%)	25 (51.02%)	0.5
No	18 (48.65%)	37 (54.41%)	0.6	22 (53.66%)	33 (51.56%)	0.8	3 (33.33%)	52 (54.17%)	0.3	31 (55.36%)	24 (48.98%)	0.5
Skin Color
Skin color light	23 (62.16%)	37 (54.41%)	0.4	27 (65.85%)	33 (51.56%)	0.1	7 (77.78%)	53 (55.21%)	0.3	35 (62.50%)	25 (51.02%)	0.2
Medium skin tone	14 (37.84%)	31 (45.59%)	0.4	14 (34.15%)	31 (48.44%)	0.1	2 (22.22%)	43 (44.79%)	0.3	21 (37.50%)	24 (48.98%)	0.2
Level Education
Primary education	18 (48.65%)	45 (66.18%)	0.2	20 (48.78%)	43 (67.19%)	0.007	4 (44.44%)	59 (61.46%)	0.5	29 (51.79%)	34 (69.39%)	0.1
Secondary education	14 (37.84%)	17 (25%)		19 (46.34%)	12 (18.75%)		4 (44.44%)	27 (28.12%)		21 (37.50%)	10 (20.41%)
Higher education	5 (13.51%)	6 (8.82%)		2 (4.88%)	9 (14.06%)		1 (11.11%)	10 (10.42%)		6 (10.71%)	5 (10.20%)
*Fisher's exact

Table 2

Knowledge, habits, practices, and non-carious cervical lesions in patients attending a teaching service clinic, 2023.
	Abrasion (n,%)		P	Abfraction (n,%)		P	Erosion (n,%)		P *	NCCL (n,%)		P
	Yes	No		Yes	No		Yes	No		Yes	No
Knowledge: Dental wear
Yes	7 (18.92%)	30 (81.08%)	0.03	6(14.63%)	5(7.81%)	0.27	2(22.22%)	9(9.38%)	0.239	8(14.29%)	3(6.12%)	0.17
No	4 (5.88%)	64 (94.12%)	0.03	35(85,37%)	59(92.19%)	0.27	7(77.78%)	87(90.62%)	0.239	48(85.71%)	46(93.88%)	0.17
Type of brush bristles
Hard bristles	12 (32.43%)	21 (30.88%)	0.42	10(24.39%)	23(35.94%)	0.37	2(22.22%)	31(32.29%)	0.79	16(28.57%)	17(34.43%)	0.66
Medium bristles	14 (37.84%)	20 (29.41%)		17(41.46%)	17(26.56%)		4(44.44%)	30(31.25%)		21(37.50%)	13(26.53%)
Soft bristles	10 (27.03%)	19 (27.94%)		10(24.39%)	19(29.69%)		3(33.33%)	26(27.08%)		15(26.79%)	14(28.57%)
does not know	1 (2.70%)	8 (11.76%)		4 (9.76%)	5(7.81%)		0(0.00%)	9(9.38%)		4(7.14%)	5(10.20%)
Brushing technique
Downward for upper teeth and upward for lower teeth	15 (40.54%)	14 (20.59%)	0.01	13(31.71%)	16(25.00%)	0.14	3(33.33%)	26(27.08%)	1.00	18(32.14%)	11(22.45%)	0.004
Horizontally	1 (2.70%)	9 (13.24%)		2(4.88%)	8(12.50%)		1(11.11%)	9(9.38%)		2(3.57%)	8(16.33%)
In circular motions	0 (0,00%)	9 (13.24%)		1(2.44%)	8(12.50%)		0(0.00%)	9(9.38%)		1(1.79%)	8(16.33%)
Use all the techniques	21 (56.76%)	36 (52.94%)		25(60.98%)	32(50.00%)		5(55.56%)	52(54.17%)		35(62.50%)	22(44.90%)
¿How many times a day do you brush?
Once a Day	0 (0.00%)	1 (1.47%)	0.16	0(0.00%)	1 (1.56%)	0.81	0(0.00%)	1(1.04%)	1.00	0(0.00%)	1(2.04%)	0.12
Twice a day	9 (24.32%)	16 (23.53%)		11(26.83%)	14(21.88%)		2(22.22%)	23(23.96%)		12(21.43%)	13(26.53%)
Three times a day	24 (64.86%)	50 (73.53%)		28(68.29%)	46(71.88%)		7(77.78%)	67(69.79%)		39(69.64%)	35(71.43%)
More tan three times a day	4 (10.81%)	1 (1.47%)		2 (4.88%)	3(4.69%)		0(0.00%)	5(5.21%)		5(8.93%)	0(0.00%)
Waiting time after eating before brushing
I don't wait	8 (21.62%)	26 (38.24%)	0.055	8(19.51%)	26(40.62%)	0.09	0(0.00%)	34(35.42%)	0.060	12(21.43%)	22(44.90%)	0.032
Less than 15 minutes	10 (27.03%)	24 (35.29%)		15(36.59%)	19 (29.69%)		4(44.44%)	30(31.25%)		18(32.14%)	16(32.65%)
More than 15 minutes	10 (27.03%)	12 (17.65%)		9(21.95%)	13(20.31%)		4(44.44%)	18(18.75%)		15(26.79%)	7(14.29%)
More than half an hour	9 (24.32%)	6 (8.82%)		9(21.95%)	6(9.38%)		1(11.11%)	14(14.58%)		11(19.64%)	4(8.16%)
Pressure applied during brushing
Light	13 (35.14%)	21 (30.88%)	0.09	9(21.95%)	25(39.06%)	0.05	0(0.00%)	34(35.42%)	0.01	15(26.79%)	19(38.78%)	0.043
Moderate	15 (40.54%)	40 (58.82%)		22(53.66%)	33(51.56%)		5(55.56%)	50(52.08%)		28(50.00%)	27(55.10%)
Aggressive	9 (24.32%)	7 (10.29%)		10(24.39%)	6(9.38%)		4(44.44%)	12(12.50%)		13(23.21%)	13(23.21%)
Dental brushing time
30 seconds	3 (8.11%)	4 (5.88%)	0.87	2(4.88%)	5(7.81%)	0.53	0(0.00%)	7(7.29%)	0.63	3(5.36%)	4(8.16%)	0.69
1 Minute	17 (45.95%)	34 (50.00%)		18(43.90%)	33(51.56%)		6(66.67%)	45(46.88%)		26(26.43%)	25(51.02%)
More tan one minute	17 (45.95%)	30 (44.12%)		21(51.22%)	26(40.62%)		3(33.33%)	44(45.83%)		27(48.21%)	20(40.82%)
Oral hygiene products
Toothpaste	31 (83.78%)	65 (95.59%)	0.04	38(92.68%)	58(90.62%)	0.71	6(66.67%)	90(93.75%)	0.029	49(87.50%)	47(95.92%)	0.12
Toothpaste and others	6 (16.22%)	3 (4.41%)	0.04	3(7.32%)	6(9.38%)	0.71	3(33.33%)	6(6.25%)	0.029	7(12.50%)	2(4.08%)	0.12
Frequency of carbonated beverage consumption
None	9 (24.32%)	13 (19.12%)	0.02	13(31.71%)	9(14.06%)	0.01	2(22.22%)	20(20.83%)	1.00	15(26.79%)	7(14.29%)	0.22
Very occasionally (maximum 3 times a month)	20 (54.05%)	41 (60.29%)		17(41.46%)	44(68.75%)		6(66.67%)	55(57.29%)		28(50.00%)	33(67.35%)
Once a week	1 (2.70%)	12 (17.65%)		4(9.76%)	9(14.06%)		1(11.11%)	12(12.50%)		6(10.71%)	7(14.29%)
Two or more times per week	4 (10.81%)	1 (1.47%)		4(9.76%)	1(1.56%)		0(0.00%)	5(5.21%)		4(7.14%)	1(2.04%)
Diary	3 (8.11%)	1 (1.47%)		3(7.32%)	1(1.56%)		0(0.00%)	4(4.17%)		3(5.36%)	1(2.04%)
Frequency of consumption of citrus fruits
None	3 (8.11%)	1 (1.47%)	0.002	1(2.44%)	3(4.69%)	0.003	0(0.00%)	4(4.17%)	0.001	3(5.36%)	1(2.04%)	0.003
Very occasionally (maximum 3 times a month)	7 (18.92%)	15 (22.06%)		10(24.39%)	12(18.75%)		2(22.22%)	20(20.83%)		13(23.21%)	9(18.37%)
Once a week	5 (13.51%)	30 (44.12%)		9(21.95%)	26(40.62%)		0(0.00%)	35(36.46%)		12(21.43%)	23(46.94%)
Two or more times per week	14 (37.84%)	19 (27.94%)		11(26.83%)	22(34.38%)		2(22.22%)	31(32.29%)		17(30.36%)	16(32.65%)
Diary	8 (21.62%)	3 ( 4.41%)		10(24.39%)	1(1.56%)		5(55.56%)	6(6.25%)		11(19.64%)	0(0.00%)
Frequency of coffee consumption
None	5 (13.51%)	3 (4.41%)	0.14	3(7.32%)	5(7.81%)	0.87	2(22.22%)	6(6.25%)	0.502	6(10.71%)	2(4.08%)	0.19
Very occasionally (maximum 3 times a month)	2 (5.41%)	3 (4.41%)		2(4.88%)	3(4.69%)		0(0.00%)	5(5.21%)		3(5.36%)	2(4.08%)
Once a week	1 (2.70%)	2 (2.94%)		2(4.88%)	1(1.56%)		0(0.00%)	3(3.12%)		3(5.36%)	0(0.00%)
Two or more times per week	3 (8.11%)	18(26.47%)		7(17.07%)	14(21.88%)		1(11.11%)	20(20.83%)		8(14.29%)	13(23.21%)
Diary	26 (70.27%)	42 (61.76%)		27(65.85%)	41(64.06%)		6(66.67%)	62(64.58%)		36(64.29%)	32(65.31%)
Frequency of wine consumption
None	30 (81.08%)	58(85.29%)	0.82	36(87.80%)	52(81.25%)	0.55	8(88.89%)	80(83.33%)	0.12	46(82.14%)	42(85.71%)	0.85
Very occasionally (maximum 3 times a month)	6 (16.22%)	9 (13.24%)		4(9.76%)	11(17.19%)		0 (0.00%)	15(15.62%)		9(16.07%)	6(12.24%)
Once a week	1 (2.70%)	1 (1.47%)		1(2.44%)	1(1.56%)		1(11.11%)	1(1.04%)		1(1.79%)	1(2.04%)
Frequency of vitamina C consumption
None	23 (62.16%)	41(60.29%)	0.45	27(65.85%)	37(57.81%)	0.64	6(66.67%)	58(60.42%)	1.00	35(62.50%)	29(59.18%)	0.78
Very occasionally (maximum 3 times a month)	10(27.03%)	24(35.29%)		11(26.83%)	23(35.94%)		3(33.33%)	31(32.29%)		17(30.36%)	17(34.69%)
Once a week	2(5.41%)	1 (1.47%)		1(2.44%)	2(3.12%)		0 (0.00%)	3(3.12%)		2(3.57%)	1(2.04%)
Two or more times per week	1(2.70%)	0 (0.00%)		1(2.44%)	0(0.00%)		0 (0.00%)	1(1.04%)		1(1.79%)	0(0.00%)
Diary	1(2.70%)	2(2.94%)		1(2.44%)	2(3.12%)		0 (0.00%)	3(3.12%)		1(1.79%)	2(4.08%)
Tooth sensitivity
Yes	14(37.84%)	14 (20.59%)	0.056	15(36.59%)	13(20.31%)	0.066	2(22.22%)	26(27.08%)	0.55	21(37.50%)	7(14.29%)	0.007
No	23 (62.16%)	54 (79.41%)	0.056	26(63.41%)	51(79.69%)	0.066	7(77.78%)	70(72.92%)	0.55	35(62.50%)	42(85.71%)	0.007
Parafunctional habits
Yes	8 (21.62%)	3 (4.41%)	0.006	7(17.07%)	4(6.25%)	0.077	1(11.11%)	10(10.42%)	0.65	10(17.86%)	1(2.04%)	0.008
No	29 (78.38%)	65(95.59%)	0.006	34(82.93%)	60(93.75%)	0.077	8(88.89%)	86(89.58%)	0.65	46(82.14%)	48(97.96%)	0.008
Engages in sports
Yes	9(24.32%)	15(22.06%)	0.79	9(21.95%)	15(23.44%)	0.86	2(22.22%)	22(22.92%)	0.66	12(21.43%)	12(24.49%)	0.71
No	28(75.68%)	53(77.94%)	0.79	32(78.05%)	49(76.56%)	0.86	7(77.78%)	74(77.08%)	0.66	44(78.57%)	37(75.51%)	0.71
¿Have you noticed any changes in the structure, shape, or color of your teeth?
Yes	7 (18.92%)	12(17.65%)	0.87	10(24.39%)	9(14.06%)	0.18	2(22.22%)	17(17.71%)	0.51	12(21.43%)	7(14.29%)	0.34
no	30(81.08%)	56(82.35%)	0.87	31(75.61%)	55(85.94%)	0.18	7(77.78%)	79(82.29%)	0.51	44(78.57%)	42(85.71%)	0.34
*Fisher's exact

Table 3

Occlusion, symptomatology, medical conditions, and non-carious cervical lesions in patients attending a teaching service clinic, 2023.
	Abrasion (n,%)		P	Abfraction (n,%)		P	Erosion (n,%)		P*	NCCL (n,%)		P
	Yes	No		Yes	No		Yes	No		Yes	No
Diagnosis: Malocclusion
Yes	10 (27.03%)	7 (10.29%)	0.07	9 (21.95%)	8 (12.5%)	0.03	4 (44.44%)	13 (13.54%)	0.07	12 (21.43%)	5 (10.20%)	0.13
No	14 (37.84%)	28 (41.18%)		10 (24.39%)	32 (50%)		2 (22.22%)	40 (41.67%)		18 (32.14%)	24 (48.98%)
Dont Know	13 (35.14%)	33 (48.53%)		22 (53.66%)	24 (37.5%)		3 (33.33%)	43 (44.79%)		26 (46.43%)	20 (40.82%)
Diagnosis: Bruxism
Yes	10 (27.03%)	4 (5.88%)	0.00	10 (24.39%)	4 (6.25%)	0.02	4 (44.44%)	10 (10.42%)	0.03	11 (19.64%)	3 (6.12%)	0.07
No	23 (62.16%)	33 (48.53%)		19 (46.34%)	37 (57.81%)		3 (33.33%)	53 (55.21%)		30 (53.57%)	26 (53.06%)
Dont Know	4 (10.81%)	31 (45.59%)		12 (29.27%)	23 (35.94%)		2 (22.22%)	33 (34.38%)		15 (26.79%)	20 (40.82%)
¿Do you feel that you chew well and that when you close your mouth, your teeth fit together?
Yes	23 (62.16%)	38 (55.88%)	0.53	24 (58.81%)	37 (57.81%)	0.94	6 (66.67%)	55 (57.29%)	0.73	33 (58.93%)	28 (57.14%)	0.85
No	14 (37.84%)	30 (44.12%)	0.53	17 (41.46%)	27 (42.19%)	0.94	3 (33.33%)	41 (42.71%)	0.73	23 (41.07%)	21 (42.86%)	0.85
¿Do you feel that you clench or grind your teeth during the day or at night?
Yes	12 (32.43%)	8 (11.76%)	0.01	11 (26.83%)	9 (14.06%)	0.10	3 (33.33%)	17 (17.71%)	0.36	13 (23.21%)	7 (14.29%)	0.24
No	25 (67.57%)	60 (88.24%)	0.01	30 (73.17%)	55 (85.94%)	0.10	6 (66.67%)	79 (82.29%)	0.36	43 (76.79%)	42 (85.71%)	0.24
¿Do you feel tiredness or pain when chewing?
Yes	9 (24.32%)	10 (14.71%)	0.22	11 (26.83%)	8 (12.50%)	0.06	3 (33.33%)	16 (16.67%)	0.20	13 (23.21%)	6 (12.24%)	0.14
No	28 (75.68%)	58 (85.29%)	0.22	30 (73.17%)	56 (87.50%)	0.06	6 (66.67%)	80 (83.33%)	0.20	43 (76.79%)	43 (87.76%)	0.14
¿Do you have frequent headaches?
Yes	7 (18.92%)	5 (7.35%)	0.07	4 (9.76%)	8 (12.50%)	0.66	0 (0%)	12 (12.50%)	0.59	7 (12.50%)	5 (10.20%)	0.71
No	30 (81.08%)	63 (92.65%)	0.07	37 (90.24%)	56 (87.50%)	0.66	9 (100%)	84 (87.50%)	0.59	49 (87.50%)	44 (89.80%)	0.71
¿Do you usually feel your mouth dry?
Yes	19 (51.35%)	5 (7.35%)	0.00	16 (39.02%)	8 (12.50%)	0.00	3 (33.33%)	21 (21.88%)	0.42	20 (35.71%)	4 (8.16%)	0.00
No	18 (48.65%)	63 (92.65%)	0.00	25 (60.98%)	56 (87.50%)	0.00	6 (66.67%)	75 (78.12%)	0.42	36 (64.29%)	45 (91.84%)	0.00
¿Do you constantly drink water due to the sensation of dryness in your mouth?
Yes	20 (54.05%)	11 (16.18%)	0.00	16 (39.02%)	15 (23.44%)	0.08	4 (44.44%)	27 (28.12%)	0.44	23 (41.07%)	8 (16.33%)	0.00
No	17 (45.95%)	57 (83.82%)	0.00	25 (60.98%)	49 (76.56%)	0.08	5 (55.56%)	69 (71.88%)	0.44	33 (58.93%)	41 (83.67%)	0.00
¿Do you wake up with a sour taste in your mouth?
Yes	6 (16.22%)	8 (11.76%)	0.52	8 (19.51%)	6 (9.38%)	0.13	0 (0%)	14 (14.58%)	0.60	9 (16.07%)	5 (10.20%)	0.37
No	31 (83.78%)	60 (88.24%)	0.52	33 (80.49%)	58 (90.62%)	0.13	9 (100%)	82 (85.40%)	0.60	47 (83.93%)	44 (89.80%)	0.37
¿Do you have gastric reflux?
Yes	8 (21.62%)	11 (16.18%)	0.47	8 (19.51%)	11 (17.19%)	0.76	1 (11.11%)	18 (18.75%)	1.00	10 (17.86%)	9 (18.37%)	0.94
No	29 (78.38%)	57 (83.82%)	0.47	33 (80.49%)	53 (82.81%)	0.76	8 (88.89%)	78 (81.25%)	1.00	46 (82.14%)	40 (81.90%)	0.94
¿Do you have or have you had orthodontic treatment?
Yes	9 (24.32%)	6 (8.82%)	0.03	6 (14.63%)	9 (14.06%)	0.93	1 (11.11%)	14 (14.58%)	1.00	10 (17.86%)	5 (10.20%)	0.26
No	28 (75.68%)	62 (91.18%)	0.03	35 (85.37%)	55 (85.94%)	0.93	8 (88.89%)	82 (85.40%)	1.00	46 (82.14%)	44 (89.80%)	0.26
¿Do you use removable dentures?
Yes	4 (10.81%)	9 (13.43%)	0.69	2 (5%)	11 (17.19%)	0.06	0 (0%)	13 (13.68%)	0.59	4 (7.27%)	9 (18.37%)	0.08
No	33 (89.19%)	58 (86.57%)	0.69	38 (95%)	53 (82.81%)	0.06	9 (100%)	82 (86.32%)	0.59	51 (92.73%)	40 (81.63%)	0.08
Open bite
Yes	3 (8.11%)	1 (1.47%)	0.09	3 (7.32%)	1 (1.56%)	0.13	0 (0%)	4 (4.17%)	1.00	4 (7.14%)	0 (0%)	0.05
No	34 (91.89%)	67 (98.53%)	0.09	38 (92.68%)	63 (98.44%)	0.13	9 (100%)	92 (95.83%)	1.00	52 (92.86%)	49 (100%)	0.05
Crossbite
Yes	4 (10.81%)	1 (1.47%)	0.03	3 (7.32%)	2 (3.12%)	0.32	1 (11.11%)	4 (4.17%)	0.36	5 (8.93%)	0 (0%)	0.03
No	33 (89.19%)	67 (98.53%)	0.03	38 (92.68%)	62 (96.88%)	0.32	8 (88.89%)	92 (95.83%)	0.36	51 (91.07%)	49 (100%)	0.03
Midline coincidence
Yes	20 (54.05%)	42 (61.76%)	0.09	21 (51.22%)	41 (64.06%)	0.29	4 (44.44%)	58 (60.42%)	0.05	29 (51.79%)	33 (67.35%)	0.03
No	13 (35.14%)	12 (17.65%)		13 (31.71%)	12 (18.75%)		5 (55.56%)	20 (20.83%)		19 (33.93%)	6 (12.24%)
No Reference	4 (10.81%)	14 (20.59%)		7 (17.07%)	11 (17.19%)		0 (0%)	18 (18.75%)		8 (14.29%)	10 (20.41%)
Crowding
Yes	6 (16.22%)	5 (7.35%)	0.15	9 (21.95%)	2 (3.12%)	0.00	1 (11.11%)	10 (10.42%)	1.00	10 (17.86%)	1 (2.04%)	0.00
No	31 (83.78%)	63 (92.65%)	0.15	32 (78.05%)	62 (96.88%)	0.00	8 (88.89%)	86 (89.58%)	1.00	46 (82.14%)	48 (97.96%)	0.00
*Fisher's exact

In other analysis, statistical significance was obtained in knowledge of dental wear, brushing technique, waiting time after eating to brush, pressure applied during brushing, oral hygiene products, frequency of carbonated beverages and citrus fruits, dental sensitivity, and parafunctional habits.

Statistical significance was observed in the diagnosis of malocclusion, bruxism, fatigue or pain when chewing, frequent headaches, xerostomia, use of removable prosthesis, open bite, crossbite, midline discrepancies, and crowding. None of the patients experienced constant vomiting, scissor bite, or eating disorders. Mental health or musical instruments did not generate a sufficient sample size for analysis, developmental defects of enamel were not included. Molar and canine class were two variables that did not generate significance due to the large number of non-references. The Spee curve and Wilson curve also had many data points without reference.

In the analysis of NCCL by tooth, Premolars were the most prevalent dental group, with tooth 34 being the most affected at 30.48%, followed by canines and molars; lower teeth were the most associated with this condition as shown in Table 4.

Table 4

Prevalence of NCCLs by tooth in patients attending a teaching service clinic, 2023.
Diente	LCNC Presente (n,%)	LCNC Ausente (n,%)
11	6(5.7%)	99 (94.3%)
12	5(4.8%)	100(95.2%)
13	14(13.3%)	91(86.7%)
14	21(20.0%)	84(80.0%)
15	14(13.3%)	91(86.7%)
16	11(10.5%)	94(89.5%)
17	4(3.8%)	101(96.2%)
21	4(3.8%)	101(96.2%)
22	6(5.7%)	99 (94.3%)
23	18(17.1%)	87(82.9%)
24	18(17.1%)	87(82.9%)
25	8(7.6%)	97(92.4%)
26	6(5.7%)	99 (94.3%)
27	1(0.95%)	104(99.1%)
31	5 (4.76%)	100 (95.24%)
32	4 (3.81%)	101 (96.19%)
33	15 (14.29%)	90 (85.71%)
34	32 (30.48%)	73 (69.52%)
35	19 (18.10%)	86 (81.90%)
36	5 (4.76%)	100 (95.24%)
37	3 (2.86%)	102 (97.14%)
47	1 (0.95%)	104 (99.05%)
46	2 (1.90%)	103 (98.10%)
45	18 (17.14%)	87 (82.86%)
44	25 (23.81%)	80 (76.19%)
43	15 (14.29%)	90 (85.71%)
42	7 (6.67%)	98 (93.33%)
41	5 (4.76%)	100 (95.24%)

In the multivariate analysis, it was established that a horizontal brushing technique and aggressive brushing maintain significant relationships with NCCLs. Table 5 shows this relation.

Table 5

Multivariate Analysis for NCCLs in patients attending a teaching service clinic, 2023.
NCCLS	OR	P	[95% conf. interval]
Brushing technique
Downward for upper teeth and upward for lower teeth	1.0
Horizontally	0.2	0.01	0.001–0.411
In circular motions	0.11	0.06	0.011–1.124
Use all the techniques	0.74	0.6	0.252–2.216
Pressure applied during brushing
Light	1.0
Moderate	0.97	0.9	0.351–2.717
Aggressive	9.9	0.04	1.006–97.577
Frequency of consumption of citrus fruits
None	1.0
Very occasionally (maximum 3 times a month)	0.54	0.64	0.040–7.386
Once a week	0.44	0.52	0.036–5.482
Two or more times per week	0.39	0.45	0.032–4.719
Tooth sensitivity
No
Yes	3.49	0.053	0.985–12.38

The prevalence of NCCLs shows that at least 1 out of every 2 patients attending a teaching service clinic presents NCCLs, an aspect that must be analyzed and established in the context of the educational environment. These lesions are becoming more common in practice, likely as a result of demographic and epidemiological transitions and conditions of an aging population (18).

Studies related to the etiology and factors associated with the causes of NCCLs are still not entirely conclusive, so it is suggested to continue working and researching on this topic, as there is a high degree of discrepancy. Recent studies suggest that the prevalence of NCCLs ranges from 9%, 35%, and 77%. This percentage are similar to those found in this article, however, there are different prevalence’s depending on the condition, further approaches are required that specifically investigate each of the NCCLs. New methodologies and ways of understanding oral health problems and factors are crucial, as well as unifying diagnostic forms in the discipline; understanding oral health problems in a more holistic way is key (19).

Sociodemographic factors studied such as age, sex, race, presence of diseases, or medication consumption did not show statistical significance. However, in the case of educational level and lack of knowledge about dental wear and its causes, a statistically significant difference was found. This could be an influential factor that is less associated or studied in other research, so it is important to highlight it.

Habits related to oral hygiene such as brushing technique, pressure applied during brushing, waiting time after eating to brush, and type of products used for dental brushing were notably relevant due to their statistically significant difference in relation to the presence of NCCLs. However, no significance was found in factors such as frequency and duration of dental brushing, and stiffness of the toothbrush. In relation to these results, a study was found that analyzed the interaction between the abrasiveness level of toothpaste and the stiffness of the toothbrush, which demonstrated that the stiffness of the toothbrush was irrelevant when used with less abrasive toothpaste. However, a greater volume loss of dentin was observed with medium and hard toothbrushes when used with medium and high abrasiveness toothpaste (20). The habits described by the patients have an important relation whit the presence of NCCLs.

The demineralization process of dentin and enamel due to the frequency of consumption of carbonated beverages and citrus fruits can be explained by the low pH of these substances. In this research, a statistically significant difference was found between the frequency of consumption of carbonated beverages and citrus fruits and the presence of NCCLs. This is a factor that has been studied in other research and it is reported that carbonated beverages not only affect dental tissue but also affect the longevity of composite resin restorations (21).

The diagnosis of malocclusion was significant in this study for abrasion, abfraction, and erosion, as occlusal forces generated by chewing and parafunctions are concentrated in the cervical area. This was very similar to results of other research which agree that NCCLs are related to occlusion (22, 23). The diagnosis of bruxism was also significant for all evaluated NCCLs due to the damaging forces it produces; these results agree with other research that supports this relationship (24, 25). Emphasis is placed on the importance of educating patients about these diagnoses since in this research, the majority were unaware of these terms.

Xerostomia was significant for abrasion, abfraction, and NCCL but not for erosion, possibly due to the limited sample size in that NCCL; in contrast, other authors find an association where saliva is considered as a biological modifying factor that can impact the development and progression of erosive lesions (26–28). The use of removable prosthesis was related to abfraction and NCCL; this agrees with other studies regarding the relationship of NCCLs since retainer adjustment can generate excessive friction on the cervical area (29, 30). Open bite and crossbite were related to abrasion and NCCLs; midline discrepancies were related to abrasion, erosion, and NCCLs; crowding was related to abfraction and NCCLs; however, no studies were found that have evaluated this relationship, so it is suggested to include this variables in future studies. In our study, the most affected dental group was premolars, which is similar to other authors who agree that the most affected group are premolars and molars (31, 32).

The multi linear regression analysis shows a significant relation in the way of doing the hygiene as brushing technique and pressure in the gums, the sensitivity and the consumption of citrus fruit, these findings have been reported previously, in other studies an OR of 1.52 (1.17–1.99) whit p ≤ 0.01 have been reported for harmful tooth brushing habits (33), the sensitivity and the citrus consumption have also significant relations whit NCCLs (34).

The limitations of the study included the sample size in general; larger samples could be very interesting, in addition to the low prevalence of erosion, a complete sample of periodontal evaluation is required, this process is important in order to address the relationship of NCCLs with periodontal aspect. The results of the present study indicated a relatively high frequency of non-carious cervical lesions in subjects aged 40 to 80 years.

In addition, it is important to work on consolidating the knowledge of the causes and factors associated with NCCLs from the dental professional, as they are responsible for health education and as transmitters of the necessary information for instructing patients susceptible to this condition and for selecting the appropriate treatment.

LCNCs are a condition that can be prevented under the direction of oral health educators, an aspect that must be specifically nested in the education process of dentists. This article demonstrates that there is a quantitative and risk relationship between aspects of oral hygiene, practices and diet with the appearance of these lesions in the oral cavity. Further research requires follow-up of participants and the inclusion of larger sample sizes. Another aspect is the inclusion of qualitative methodologies that could generate new hypotheses.

CONFLICT OF INTEREST

The authors of the article do not declare any conflict of interest.

AUTHOR CONTRIBUTION STATEMENT

The conceptualization of the theme was carried out by Harold David Goyes, Jhoana Daniela Perez, Maria Cristina Arango and Bruno Gutiérrez Quiceno. The design and methodology was prepared by Bruno Gutiérrez Quiceno and Maria Cristina Arango. Data collection was carried out by Harold David Goyes and Jhoana Daniela Perez. Data analysis was carried out by Bruno Gutiérrez Quiceno. The writing and preparation of the draft was carried out by Harold David Goyes, Jhoana Daniela Perez, Maria Cristina Arango and Bruno Gutiérrez Quiceno. The supervision and final review of the document was carried out Harold David Goyes, Jhoana Daniela Perez, Maria Cristina Arango and Bruno Gutiérrez Quiceno.

ACKNOWLEDGEMENTS

To the patients, the teachers, the adult clinic and the primary health care clinic; in general to the Universidad del Valle for the support in collecting the information.

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Non-carious Cervical Lesions, an Approach of the Associated Factors in a Teaching Service Clinic.

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