Cervical Caries—Treatment Options Based Upon Etiology of the Lesion
Howard E. Strassler, DMD
With patients now keeping their teeth over their lifetime, there has been an increased challenge to treatment plan and restore Class V cervical carious lesions. These lesions can be located solely in enamel or, many times after gingival recession, initiate on the root surfaces. The choice of restorative options is often not an easy one to make because the etiology of these lesions affects the durability and clinical success of the restorative materials used. This article will focus on the placement of direct restorative materials, even though there are times when the use of full-coverage crown restorations may be necessary.
Cervical carious lesions occur in the esthetic zone and those areas of the mouth where the restoration will not be visible. For direct placement restorations, the nonesthetic option to restore Class V lesions is dental amalgam. For lesions in the esthetic zone, options include adhesive composite resins, conventional and resin modified glass ionomers, flowable composite resins, and compomers. How does one choose from among these options?
In recent years, increased attention has been placed on the role of carbonated beverages, sports drinks, and their high sugar content in their combined chemical erosive effect on dentin. For the patient in Figure 1, the habit of drinking 4 to 6 bottles of a national brand carbonated beverage per day, combined with poor oral hygiene, contributed to the presence of anterior maxillary Class V carious lesions. When the etiology of Class V lesions in the esthetic zone is due to poor patient oral hygiene and a high sugar diet, oral hygiene instruction and dietary counseling are important after restorative treatment.
Also, adolescents undergoing orthodontic treatment are at risk for Class V lesions. For them, the use of prescription strength fluorides—combined with a mechanical toothbrush—can prevent carious lesions around bonded brackets, especially in the cervical region.
When the above factors are present—orthodontic brackets, high sugar diet, and poor oral hygiene—the treatment for these cervical lesions should be the use of an adhesive composite resin.
The presence of xerostomia has been on the increase. Combined with gingival recession and exposed root surfaces, with xerostomia, teeth are at a greater risk of Class V carious lesions. Currently more than 400 medications can cause dry mouth. These medications include antihypertensives, antidepressants, analgesics, tranquilizers, diuretics, and antihistamines. Patients undergoing cancer therapy are susceptible to xerostomia. Chemotherapeutic medications can affect both the flow and composition of saliva. Also, head and neck radiation can temporarily or permanently damage the salivary glands. After radiation, the protective ability of the saliva is also impacted by a decrease in the immunoglobulin in the saliva.
Other conditions can also cause a decrease in salivary flow. Patients with endocrine disorders, depression, anxiety and stress, and nutritional deficiencies may exhibit symptoms of dry mouth. Sjorgren’s syndrome, an autoimmune disease, causes both dry mouth and dry eyes. Trauma to the head and neck area due to accidents or surgery can cause nerve damage that affects salivary flow.1
When Class V cervical lesions are due to xerostomia, the choice of restorative materials depends upon the location of the lesions. Lesions in the esthetic zone are best treated with glass ionomer restoratives. In some cases, if the lesions are subgingival, it may be necessary to lay a miniflap to expose the pathology prior to restoration. The use of specialized gingival retraction retainers with a dental dam will afford the greatest chance for success with these restorations.2
Glass ionomers are a unique restorative. They are self-adhesive due to ionic bonding to the tooth structure. Also, glass ionomers are referred to as a “smart” restorative material that not only releases fluoride to the surrounding tooth structure, but also has a semi-permeable surface that allows the calcium and phosphate ions present in saliva to pass through the restorative material and combine with the fluoride to produce remineralization of the enamel as a fluorapatite. Another unique characteristic of a glass ionomer is that it provides a high burst of fluoride for remineralization, as well as a prolonged fluoride release over time.3
One aspect of counseling for patients who have cervical carious lesions with xerostomia as a contributing etiology is the recommendation for the use of prescription strength fluorides. These fluorides, combined with fluoride mouthrinses and over-the-counter fluoride toothpastes, can enhance the glass ionomer restorations by recharging the glass ionomer with new fluoride ions every day. Also, the patient should be provided with a strategy to combat dry mouth through the use of oral lubricants and artificial saliva. In some cases, a prescription drug (e.g., pilocarpine [Salagen] 5 mg, 4 times a day) can be prescribed. For the patient in Figure 2, the use of an antidepressant and poor oral hygiene contributed to multiple Class V lesions that were restored with a resin-modified glass ionomer cement.
While much of today’s focus is on the use of esthetic materials, when the cervical carious lesions are in the nonesthetic zone, the linguals of the posterior teeth, or the facial surfaces of second molars, the choice of dental amalgam provides the patient with long-lasting restorations. Dental amalgam can be placed in a compromised field that might be difficult to isolate due to salivary or bleeding contamination.
Conclusion
There is no single solution for treatment planning and restoring Class V carious lesions.A thorough evaluation of etiology of the cervical caries provides a sound basis for good treatment decisions and patient counseling to avoid the recurrence of these lesions.
References
1. Atkinson JC, Grisius M, Massey W. Salivary hypofunction and xerostomia: diagnosis and treatment. Dent Clin North Am. 2005;49(2):309-26.
2. Starr CB. Class 5 restorations. In: Summitt JB, Robbins JW, Schwartz RS, eds; Fundamentals of Operative Dentistry. 2nd ed. Chicago: Quintessence Pub. Co.; 2001: 386-400.
3. Xu X, Burgess JO. Compressive strength, fluoride release and recharge of fluoride-releasing materials. Biomaterials. 2003;24(14):2451-61.
About the Author
Howard E. Strassler, DMD
Professor and Director of Operative Dentistry
Department of Endodontics, Prosthodontics and Operative Dentistry
University of Maryland Dental School
Baltimore, Maryland
