Presence of Gingival Recession or Noncarious Cervical Lesions on Teeth under Occlusal Trauma: A Systematic Review

Drs Pedro Maria Bastião Peliz Senos Tróia1 Tobias Rauber Spuldaro1 Patrícia Alexandra Barroso da Fonseca2 Gustavo Vicentis de Oliveira Fernandes2,

 

1. Department of Dental Medicine, Universidade Católica Portuguesa, Viseu, Portugal

2. Centre for Interdisciplinary Research in Health (CIIS), Department

   of Dental Medicine, Universidade Católica Portuguesa, Viseu, Portugal

   Address for correspondence Gustavo Vicentis de Oliveira Fernandes, PhD, Quinta da Alagoa Ave., 225 – 1 DT, Viseu, 3500-606, Portugal (e-mail: gustfernandes@gmail.com).

   Eur J Gen Dent 2021;10:50–59.

   Abstract

Even though many pro- fessionals have categori- cally affirmed that there is a relation between trauma occlusal and gin- gival recession/noncar- ious cervical lesion, this systematic review found the absence of strong lit- erature to really prove it. Once defined, it allows the therapeutic focus to centre on the causal or contributing factors and preventing or reducing future recurrence.

The goal of this research was to carry out a systematic review to verify the possible influence of occlusal factors on the occurrence of gingival recession and noncarious cervical lesions. To answer the specific research question—whether gingival reces- sion or noncarious cervical lesions on teeth are present under occlusal trauma—a bibliographic search was conducted at MEDLINE/PubMed, Web of Science, and Gray Literature databases focusing on articles published, following strict inclusion cri- teria based on randomized clinical trials, controlled clinical studies, and case series, with restricted language (English) and publication date between March 2010 and March 2020, considering patients with occlusal trauma and gingival recession/non- carious cervical injuries. Questionnaires, animal or laboratory studies, case reports, and interviews were excluded. First, the title and/or abstract of the articles obtained were analyzed and, finally, a full-text reading was performed. Given the amount and diversity of the final studies, a qualitative analysis was made. Based on the established criteria, it was possible to obtain an initial 757 articles. After screening, five articles were included, and then qualitative analysis was performed. The results described in the articles were different, given the heterogeneity of the articles subjected to anal- ysis. A few studies were published in the past 10 years, suggesting that the traumatic occlusion seems to be associated with the occurrence of the noncarious cervical lesion while it is not possible to arrive at a conclusion with regard to the association of gingi- val recession and occlusal trauma.

DOI https://doi.org/ 10.1055/s-0041-1732781 ISSN 2320-4753

© 2021. European Journal of General Dentistry.

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GR and NCCL Associated with Occlusal Trauma Tróia et al. 51

Introduction

Gingival recession (GR) is defined as the migration of the marginal gingiva to an apical level, using as reference the cementoenamel junction (CEJ), exposing the root surface and involving loss of periodontal attachment apparatus.1,2 Multiple factors can be involved causing or aggravating the GR,2,3 which can be divided into three groups: anatomical factors (dehiscence of the alveolar bone and abnormal posi- tion of the teeth), physiological factors (orthodontic move- ments), and pathological factors (abrasive and traumatic brushing, intra- and perioral piercing, tooth mobility, partial denture, deficient dental restorations [mainly with subgingi– val margins], bacterial plaque, periodontal diseases, damages resulting from iatrogenesis and use of tobacco [smoking], and occlusal trauma).4-9

Occlusal trauma is characterized as an excessive masti- catory force with varying intensities, present in premature contacts or interferences, that exceeds the adaptive and repar- ative physiological capacity of the periodontal resistance.10,11 Consequently, bone resorption may occur, normally, in the tooth’s cervical region10 due to forces that are concentrated in a few points of the tooth,12,13 characterizing a pathological occlusion.14-16

Hence, occlusal disturb may increase inflammation of the periodontal structures and destruction of the collagen matrix, enhancing the osteoclasts activities,17 and causing GRs,6,10 which may cause greater susceptibility to the occurrence of root caries and root abrasion, jeopardizing esthetic, dentin hypersensitivity, reduction of keratinized tissue, and dis- harmony of the gingival margin.5,7 However, it should also be noted that the occurrence of a traumatic occlusal force depends on factors such as magnitude, direction, duration, and frequency.18 Therefore, the relation between GR and occlusal trauma needs to be clarified.

Another factor related to occlusal trauma is the presence of noncarious cervical lesions (NCCLs). Abrasion (abnormal frictional biomechanical process), erosion (mainly due to acidic dissolution), and abfraction (pathological loss of den- tal hard tissues due to biomechanical occlusal forces)19,20 zwas suggested, based in a little evidence existent, as a hypothetical component of cervical wear and could also be associated with periodontal disease.21 A study of NCCL pointed to abrasive toothpaste and traumatic brushing as the main causes of their occurrence.22 However, Lee and Eakle23 proposed that the occlusal forces with relevant cervical stress, resulting in the breaking of the enamel hydroxyapatite bonds and the consequent microfracture, chipping, and loss of structure,24 could play a major role in the NCCL etiology.

Since it was suggested, several laboratory studies of finite elements and in vivo have emerged. Bernhardt et al25 considered that this association exists, although other clini- cal researches26,27 studied individuals with a parafunctional habit of bruxism who had an even greater number of NCCL than subjects without any habit. Thereby, occlusal adjust- ments to eliminate interferences have not decreased the pro- gression of NCCL.22 Furthermore, in a 3-year follow-up study,28 it was suggested that the facets consequent of occlusal wear

was associated with a higher incidence of NCCL. Although the NCCL etiology is currently supported by the biomechanical concept of distribution of occlusal forces, there is a lack of sci- entific evidence.5 Then, it is wrong to restrict only one mech- anism responsible for the occurrence of any NCCL type.29

Observing the aforementioned facts, the aim of this sys- tematic review (SR) was identifying the relationship between GR and NCCL on teeth under occlusal trauma, providing a sci- entific answer for the existent problem.

Material and Methods

This SR was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guide- lines.30 The protocol for this study was registered on PROSPERO (CRD42020183268). The focused question for the present review was as follows: “Is there a relation between the presence of occlusal trauma and the appearance of GRs or noncarious abfraction lesions?”

Information Sources and Search Strategy

A bibliographic search was conducted using MEDLINE/ PubMed, Web of Science, and Gray Literature databases (http://opengrey.eu, http://greylit.org, http://greynet.org, https://www.oclc.org/en/oaister.html, and https://rcaap.pt) (Supplementary Table S1), to collect articles published between March 2010 until March 2020 (10 years), with English language restriction.

The used terms were “Non-carious lesions” OR “Noncarious lesions” OR “Cervical lesions” OR “Abfraction” OR “Gingival recession” OR “Gingival retraction” OR “Gum recession” OR “Gum retraction” AND “occlus” * OR “Occlusal trauma” OR “traumatic occlusion” OR “excessive occlusal force” OR “pathologic occlusion” OR “dysfunctional occlu- sion.” The research was performed combining the previ- ous terms (Supplementary Table S1), applying the filters described in Supplementary Table S2. An additional manual search was performed on the references of included articles to identify relevant publications.

Inclusion Criteria

This study was conducted based on randomized clinical trials, controlled clinical studies, and case series. The man- datory simultaneous criteria used were: clinical studies; studies published in English; publication date from March 2010 to March 2020; human studies; and articles that have the search terms in the title or abstract. Nonsimultaneous criteria were also applied, such as patients with occlusal trauma and GR (with detailed information about the type of GR); patients with occlusal trauma and noncarious cervical injuries (with detailed information about the type of noncar- ious cervical injury).

Exclusion Criteria

Clinical studies that did not fully meet the inclusion criteria, studies based on questionnaires, case reports, editorial let- ters, SRs, and meta-analysis, laboratory and animal studies, and interviews.

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52 GR and NCCL Associated with Occlusal Trauma Tróia et al.

Study Selection and Quality Assessment

After the bibliographic search, two independent research- ers (P.M.B.P.S.T. and T.R.S.) proceeded to filter relevant arti- cles that fitted the study by analyzing the title and abstract for study selection. Any disagreement between the review- ers was discussed with a third author (G.V.O.F.). Cohen’s kappa test was performed to assess the reviewers’ agree- ment. Assessment of risk of bias and study quality of the included studies were performed independently by two reviewers (P.M.B.P.S.T. and G.V.O.F.), where the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement was applied. It featured 18 items that were answered with one of four options: 1—yes, 2—no, 3— cannot answer, and 4—not applicable. Only items with option 1 generated the score. Therefore, each article could obtain a score between 0 (no criteria fulfilled) and 18 (all criteria fulfilled).

The data collected using the STROBE statement was rated in a total of 18 points, among the 22 topics, as low quality (scored 0–6 out of a total of 18 points), as moderate quality (7–12), or as high quality (13–18). The ratings obtained were verified by a third reviewer (T.R.S.) and any discrepancy was resolved by discussion with another reviewer (P.A.B.F.).

Data Extraction

Reviewers extracted the data independently from the selected articles for further analysis using data extraction tables, which included the following parameters: author(s), year of publication, study design, main goal, the number of participants, systemic condition, exclusion criteria, and occlusal assessment method. All values and details were reported.

Results

Study Selection, Characteristics, and Description/Quality Assessment and Heterogeneity

The study selection is described in the flow diagram (►Fig. 1). A total of 757 articles were obtained, of which 83 were duplicate, thus resulting in 674 final articles from MEDLINE/PubMed (n = 371), Web of Science (n = 294), and Gray Literature (n = 9). After reading the title and abstract of these articles, 19 articles were chosen to be read full text, PubMed (n = 12), Web of Science (n = 6), and Gray Literature (n = 1). Afterward, 14 were excluded with justifi- cation described in ►Table 1, the remaining 5 articles were chosen for inclusion (1 case–control and 4 cross-sectional studies). The agreement value between examiners was respectively 90.61 and 92.4%.

A summary was made about the articles included in this study (►Table 2), containing the journal, the year of publi- cation, the type of study, objective, inserted and excluded patients, and method used for assessing occlusal trauma. However, ►Table 3 refers to the detailed results relevant to this study and the conclusions of each article.

A fact that was verified in all five included studies was the detailed description of the occlusal factors and its assessment method. The factors analyzed were different in each study,

 

Fig. 1 Articles selection flow diagram based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

integrating the panoply of analyzed factors were the fol- lowing: prematurity in centric relation and excursive move- ments,31 prematurity at maximum intercuspation and on the nonwork side,32,33 guides and occlusal contacts,34 and inter- ferences in centric relation, maximum intercuspation, and excursive movements.35 The articular-paper used (Accufilm II, Parkell, Edgewood, New York, United States) for evaluation was the same in four of the five articles,31-33,35 contrasting with the only study34 in which it was used a distinct type of articular-paper (Bausch Arti-Check, Bausch Articulating Papersn Inc., Nashua, New Hampshire, United States).

Four articles31,32,34,35 described the method used in the NCCL and GR diagnosis although heterogeneity has been observed, and only one article33 did not describe the method applied. Teixeira et al,31 Yoshizaki et al,32 and Brandini et al35 developed all analyses with only one examiner, while in Alvarez-Arenal et al study,34 six researchers (one of each university included) performed the diagnosis. It is also worth mentioning that Smith and Knight Dental Wear Classification36 were used to classify NCCL.

Teixeira et al31 classified the lesions according to their morphology (concave or wedge shapes) and the depth (superficial: 0–0.9 mm, medium: 1.0–1.9 mm, deep:

> 2.0 mm), for which, impressions with an elastomeric mate- rial was used and, for GRs, Miller’s classification was applied. Yoshizaki et al32 and Brandini et al35 studies described that any discrepancy resulting from tooth structure loss at the level of the CEJ, not resulting from caries, was considered as NCCL. Despite these similarities, it is important to note that a classification regarding the lesions form was performed by Yoshizaki et al.32

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GR and NCCL Associated with Occlusal Trauma Tróia et al. 53

Table 1 Articles excluded from the study, authors, and the reason for exclusion

Title	Authors	Exclusion motive
Secondary trauma from occlusion and periodontitis	Mark Branschofsky, Thomas Bieler, Ralf Schafer, Thomas F Flemming, Herman Lang	Factors associated with NCCL/GR are not included in the research strategy
Clinical evaluation of the association of noncarious cervical lesions, parafunc- tional habits, and TMD diagnosis	Daniela Atili Brandini, Sônia Regina Panzarini, Igor Mariotto Benete, Carolina Lunardelli Trevisan	Factors associated with NCCL/GR are not included in the research strategy
Factors influencing the progression of noncarious cervical lesions: A 5-year prospective clinical evaluation	Kanchan Sawlani, Nathaniel C. Lawson, John O. Burgess, Jack E. Lemons, Keith E. Kindernecht, Daniel A. Givan, Lance Ramp	Factors associated with NCCL/GR are not included in the research strategy
Noncarious cervical lesions (NCCLs) in a random sampling community popula- tion and the association of NCCLs with occlusive wear	J. Yang, D. Cai, F. Wang, D. He, L. Ma, Y. Jin, K. Que	Factors associated with NCCL/GR are not included in the research strategy
The role of occlusal loading in the patho- genesis of noncarious cervical lesions	John R. Antonelli, Timothy L. Hottel, Robert Brandt, Mark Scarbecz, Tejas Patel	Factors associated with NCCL/GR are not included in the research strategy
Association of noncarious cervical lesions with oral hygiene habits and dynamic occlusal parameters	Satheesh B. Haralur, Abdulrahman Saad Alqahtani, Mohammed Shaya AlMazni, Mohammad Khalid Alqahtani	Factors associated with NCCL/GR are not included in the research strategy
New insights in the link between maloc- clusion and periodontal disease	Olaf Bernhardt, Karl-Fiedrich Krey, Amro Daboul, Henry Volzke, Stefan Kindler, Thomas Kocher, Christian Schwahn	Factors associated with NCCL/GR are not included in the research strategy
Relationship between self-reported brux- ism and periodontal status: Findings from a cross-sectional study	João Botelho, Vanessa Machado, Luís Proença, João Rua, Leonardo Martins, Ricardo Alves, Maria Alzira Cavacas, Daniele Manfredini, José João Mendes	Factors associated with NCCL/GR are not included in the research strategy
Noncarious cervical lesions: why on the facial? A theory	W. Dan Sneed	No assessment for etiology of NCCL
Erosive tooth wear and wedge-shaped defects in 1996 and 2006: cross- sectional surveys of Swiss army recruits	Adrian Lussi, Matthias Strub, Ernst Schurch, Markus Schaffner, Walter Burgen, Thomas Jaeggi	No assessment for etiology of NCCL
Abfraction, abrasion, biocorrosion, and the enigma of noncarious cervical lesions: a 20-year perspective	John O. Grippo, Marvin Simring, Thomas A. Coleman	No assessment for etiology of NCCL
Biomechanics of noncarious cervical lesions	G. Beresescu, L.C. Brezeanu	Laboratorial study
Effects of occlusal loads in the genesis of noncarious cervical lesions – a finite element study	Andreea Stanusi, Veronica Mercut, Monica Scrieciu, Mihaela Sanda Popescu, Monica Mihaela Craitoiu Iacob, Luminita Daguci, Stefan Castravete, Daniela Doina Vintila, Mihaela Vatu	Laboratorial study
The role of occlusal factors in the pres- ence of noncarious cervical lesions in young people: a case-control study	A. Alvarez-Arenal, L. Alvarez-Menendez, I. Gonzales-Gonzalez, E. Jiménez-Castellanos, M Garcia-Gonzalez, H deLlanos-Lanchares	Same data/patients used in two differ- ent articles

Abbreviations: GR, gingival recession; NCCL, noncarious cervical lesion; TMD, temporomandibular disorder.

The quality assessment of all studies included was consid- ered high, considering them as low risk of bias (►Fig. 2), with the following results: Teixeira et al,31 Alvarez-Arenal et al,34 and Brandini et al35 with score of 16, and Yoshizaki et al32 and Figueiredo et al33 with score of 15.

Participants

Heterogeneity was observed across all the studies. In three studies,37-39 the participants were patients from the ser- vices of each institution; in one,40 the population was stu- dents; and, in the another,41 the population was patients, students, and employees of the institution. All studies were conducted in dental clinics at educational institu- tions (4 in Brazil31-33,35 and 1 in Spain34). Besides, three stud- ies31,32,35 detailed the number of teeth analyzed and the age

was considered a possible etiological factor by three out of five studies31,32,35 which had a reduced average rating between 39 and 41 years, and in two31,35 there was a positive associa- tion between the increased prevalence of NCCL and age. Only Yoshizaki et al32 found a higher prevalence of NCCL in the group of patients aged 31 to 50 years and not in the group corresponding with more advanced age (> 50 years). Only Teixeira et al31 observed an association between age and GR.

Occlusal Factors and Characteristics

After analysis of the different occlusal factors was conducted, the report of its influence on the occurrence of the injury was transversal to all the five studies. In two,32,33 it was found that prematurity at maximum intercuspation and on the nonwork side were factors associated with the occurrence of

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Tróia et al.

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Table 2 Brief description of included articles in the study

Article	Journal/IF	Year	Country/ Language	Study type	Main goal	Patients sys- temic condition	Number of participants	Not include	O.T. evaluation method
Teixeira et al, 2018	Journal of Dentistry, 3.28	2018	Brazil/English	Cross- sectional	Evaluate the risk factors associ- ated with NCCL, cervical dentin	> 18 years old and present at	Initial – 185 patients	Patients with: -Any missing teeth (except	Evaluation of prematurity in centric relation and in
					hypersensitivity (CDH), and	least one of the	Male/Female =	3rd molars);	excursive movements with
					GR, besides to the relationship	three changes,	0.68/1	-Analgesic medication or any	articular paper (Accufilm II)
					between them in a specific Brazilian population	alone or in combination	Age average: 41.9	other that hides sensitivity; -Teeth under orthodontic,
								endodontic treatment, with
								marginal restorations, with
								marginal infiltration, pulpitis,
								caries, or fractures
Yoshizaki et al, 2017	Journal of Oral Rehabilitation, 2.341	2017	Brazil/English	Cross- sectional	Evaluate the clinical characteris- tics and factors associated with NCCLs and dentin hypersensitiv-	> 18 years old and good sys- temic health	Initial – 118 patients; Male – 50;	Patients with: -Less than 4 teeth; -Analgesic, tranquilizer or	Evaluation of prematurity in centric relation and in excursive movements with
					ity (DH), as well as the distinct entities		Female – 68	mood-changing medication; -Teeth with endodontic treat-	articular paper (Accufilm II)
								ment, crown, orthodontic
								treatment, prosthetic abut-
								ment teeth, with marginal
								restorations that interfere
								with evaluation (only for HD)
Alvarez-	Journal of Oral	2019	Spain/English	Case–control	1 – Evaluate, by means of uni-	No reference is	Initial – 280	Patients that:	Assessment of guides and
Arenal	Rehabilitation,				variate and multivariate logistic	made	patients	-Were subjected to orthodon-	occlusal contacts with 40
et al, 2019	2.341				regression analysis, whether		Male – 106	tic treatment	µm articular paper (Bausch
					occlusal factors, brushing fac-		Female – 174	-Have dental prostheses of	Arti-Check)
					tors, and consumption of acidic			any type of teeth under study
					foods and drinks are signifi-			-Has restorations / caries in
					cantly associated with NCCLs			the cervical region of the
					2 – Show the intensity of any			teeth under study
					association
					3 – Formulate a predictive model
Brandini	Journal of	2012	Brazil/English	Cross-	Assess the potential relationship	No reference is	Initial – 111	Patients with:	Assessment of prematuri-
et al, 2012	Prosthetic Dentistry, 2.787			sectional	between occlusal factors and the occurrence of NCCL	made	patients Male – 30 Female – 81	-Incomplete dentition (not necessarily 3rd molars) -Caries or cervical restorations	ties and interferences in centric relation, maxi- mum intercuspation, and
							Functional		excursive movements with
							occlusion analysis		articular paper (Accufilm II)
							– 46 patients (with
							NCCL)
Figueiredo	Revista	2015	Brazil/English	Cross-	Observe the occlusal aspects of	No reference is	Initial – 88 patients	Patients with:	Assessment of inter-
et al, 2015	Gaúcha de Odontologia, 0.033			sectional	patients with and without NCCL and identify their risk factors	made	Male – 36,64% Female – 63,36%	-Periodontal disease – Orthodontic, endodontic and occlusal treatment	ferences at maximum intercuspation and at the nonworking side with
								-Pregnant women	articular paper (Accufilm II)
								-Serious witchcraft
								-Opening mouth limitation

Abbreviations: GR, gingival recession; IF, impact factor; NCCL, noncarious cervical lesion.

GR and NCCL Associated with Occlusal Trauma Tróia et al. 55

Table 3 Description of included articles in the study (results and conclusion)

Article	Relevant results to the study	Conclusion
Brandini et al, 2012	46 patients with NCCL (171 teeth with lesions) Of 1,296 teeth examined: NCCL: 171 Teeth with NCCL and maxillary position when occlusal trauma occurs: MIP: n = 61; p-value ≤ 0.001 Centric relation: n = 59; p-value ≤ 0.001 Working side: n = 80; p-value ≤ 0.001 Nonworking side: n = 24; p-value ≤ 0.001 Protrusion: n = 14; p-value = 0.002	Although the etiology of NCCL is multifactorial, the results of this study indicate that the direction and intensity of forces applied to teeth are important contributions to the occur- rence of NCCL
Figueiredo et al, 2015	Descriptive and inferential statistics: Interferences in maximum intercuspation (Present): Not NCCL (F) – 1; Yes NCCL (%) – 1.1; Reference values (F) – 45**; Reference values (%) – 51.1% Interferences on the nonworking side (Present): Not NCCL (F) – 5; Yes NCCL (%) – 5.7; Reference values (F) – 28**; Reference values (%) – 31.8% Relative risk of developing NCCL: Higher number of NCCL (OR): Interferences in maximum intercuspation – 26,640*; Interferences on the nonworking side -3,789*; Presence of NCCL (95% CI): Interferences in MIP – 8.289–85.61; Interferences on the nonworking side – 1.521–9.438; Presence of NCCL (OR): Interferences in MIP -100.385*; Interferences on the nonworking side – 4.667%; 95% CI: Interferences in MIP – 12.45–809.0; Interferences on the nonwork- ing side – 1.570–13.87 NCCL – 280	Occlusal interference in maximum intercuspation and on the nonworking side are risk factors for a greater num- ber of injuries and their development
Yoshizaki et al, 2017	80 patients with NCCL Of 2,902 teeth examined: Poisson analysis of the association between independent variables and the presence of NCCL: Premature contacts: MIP: Adjusted prevalence ratio = 3.68; 95% CI = 2.43–5.59; p-value ≤ 0.0001 Nonworking side: Adjusted prevalence ratio = 2.76; 95% CI = 1.27–5.99; p-value ≤ 0.010	Factors associated with NCCL were Age; Presence of interferences at max- imum intercuspation and on the nonworking side; Consumption of wine and alcoholic beverages NCCL – 1,308 GR – 1,334 NCCL, GR, and CDH – 479 NCCL – Mean = 7.42; SE = 0.42; p-value = 0.008 GR – Mean = 7.68; SE = 0.54; p-value = 0.008 NCCL – Estimate = 2.999; 95% CI = 0.774–5.223; p-value = 0.009 GR – Estimate = 3.956; 95% CI = 1.072–6.840; p-value = 0.007
Teixeira et al, 2018	163 patients with NCCL 110 patients with RG Of 5,180 teeth examined: Bivariate analysis: Premature contacts (Yes): Multivariate analysis: Premature contacts (Yes):	Confirms, within limitations, that NCCL and GR increase with age; NCCL, CDH, and GR have a positive correlation; Lesion depth and morphology contribute to different levels of recession; Age, gender, gastric diseases, and occlusal trauma were relevant fac- tors for the occurrence of NCCL, CDH, and GR
Alvarez-Arenal et al, 2019	Univariate logistic regression: Protrusive interferences (Yes): Total – 59; OR – 1.82; 95% CI – 1.11–2.99; p-value – 0.018 Right laterally interferences (Working side): Total – 19; OR – 1.21; 95% CI – 0.59–2.43; p-value – 0.598 Right laterally interferences (Nonworking side): Total – 34; OR – 1.96; 95% CI – 1.06–3.65; p-value – 0.033 Right laterally interferences (Both sides): Total – 17; OR – 2.40; 95% CI – 1.01–5.71; p-value – 0.048 Left laterally interferences (Working side): Total – 16; OR – 1.18; 95% CI – 0.56–2.51; p-value – 0.661 Left laterally interferences (Nonworking side): Total – 38; OR – 1.82; 95% CI – 1.02–3.31; p-value – 0.043 Left laterally interferences (Both sides): Total – 16; OR – 2.23; 95% CI – 0.93–5.36; p-value – 0.072	NCCL probably have a multifactorial etiology; The risk factors contained in this predictive model are not enough to explain the presence of NCCL; Protrusive and nonworking side interferences are significant for the occurrence of NCCL, in univariate or isolated analysis, but not in multi- variate analysis

Abbreviations: CDH, cervical dentin hypersensitivity; CI, confidence interval; GR, gingival recession; MIP, maximum intercuspation position; NCCL, noncarious cervical lesion; OR, odds ratio; SE, standard error.

*p < 0.05

**p < 0.01

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56 GR and NCCL Associated with Occlusal Trauma Tróia et al.

Fig. 2 Quality of assessment; Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

NCCL. As for the study developed by Alvarez-Arenal et al,34 interferences during protrusive movements and on the non- work side were statistically significant when the univariate analysis was conducted, but not in the multivariate analy- sis. Brandini et al35 also concluded, more generally, that the direction and intensity of forces, due to occlusal trauma, is an important factor for the occurrence of NCCL. Teixeira et al31 were not objective in the conclusion, reporting several factors, including occlusal trauma, associated with the

development of both NCCL and GR, not specifying whether it was related to both or just one of the types of injuries, although it was verified in both, with presence of statistical significances (p < 0.05).

The occlusal scheme with the development of NCCL was studied only by Brandini et al.35 A positive association was obtained between the occurrence of NCCL and the presence of group function during left (63%) and right (54%) laterality movements.

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GR and NCCL Associated with Occlusal Trauma Tróia et al. 57

NCCL and GR Location and Etiology

The analysis of the role of occlusal trauma as an etiological factor in the presence of NCCL31-35 and GR31 was performed in all the studies. NCCL location was not performed by one study, Alvarez-Arenal et al.34 The GR preferential location also was not studied by Teixeira et al,31 although it was the only study that focused on the relationship between occlusal trauma and the occurrence of GR.

After analysis, it was concluded in three articles31,32,35 that NCCLs were more prevalent in the maxillary premolars. Yoshizaki et al32 had 57% of incidence in premolars, while Brandini et al35 detailed this issue, affirming more presence in first premolars (23.1% of the total NCCL on the right side and 20% at maxillary on the left side). Teixeira et al31 and Figueiredo et al33 concluded that this type of lesions appeared exponentially in maxillary premolars.

Nonocclusal Factors Causing NCCL and GR Abrasive/traumatic brushing,31,32,34 extrinsic or intrinsic31 acid activity,31,32,34 and parafunctional habits31,33,34 were reported in the articles and included as etiological causal factor of NCCL and GR. The abrasive/traumatic brushing had contra- dictory results and did not present a statistical significance,31,32 but it can be considered a contributing factor. Only one study34 considered it as a risk factor for NCCL.

Another variable reported was the acidic activity and its influence on the development of NCCL. It is worth to be noted that a positive correlation associated with the presence of gastroesophageal diseases but not significant (p > 0.05). Similarly, a relationship was found between the consumption of alcoholic beverages and consumption of exogenous acid with the occurrence of NCCL.

Parafunctional habits have been suggested as a factor that can play a major role in the development of NCCL.37,38 A positive correlation between the existence of parafunc- tional habits and NCCL occurrence was observed in two studies.33,34 On the other hand, one study31 did not verify sta- tistically significant correlation between occlusal parafunc- tion and NCCL/GR.

Discussion

The role of occlusal trauma in the etiology of GR and NCCL is a topic of clinical relevance in dentistry. However, it remains a controversial subject due to the reduced current scientific evidence that supports its true relation.

Studies Quality

It is noteworthy that, from the elected studies, all are in the middle of the pyramid of quality of scientific evi- dence.42 STROBE Statement was used to assess the quality and risk of bias, which all achieved a high-quality classifica- tion. Despite, Alvarez-Arenal et al study34 presented a some- what compromising detail of the quality of the study.

Study Design, Population Characteristics, and Etiology Regarding patients age, three studies31,32,35 had a reduced aver- age age (39–41 years). So, the premise that the prevalence of

NCCLs and GR increases with age becomes limited consid- ering this aspect, particularly in the Brandini et al study.35 Yoshizaki et al32 found a higher prevalence in patients aged 31 to 50 years, and another study34 had no conclusion regard- ing age. Only Teixeira et al31 reported an association between age and GR, also it was the only study included to evaluate GR. It was suggested by two studies31,32 that age is an etiolog- ical factor due to the longer exposure to which an older indi- vidual is subjected, corroborating the information available in the study developed by Borcic et al.42

For clinical diagnosis performed, if single or six uncali- brated examiners, there was a risk of bias and imprecision of the studies may increase, jeopardizing also the reproducibil- ity. Also, no laboratory study was included in this SR, given the inherent limitations of finite element analysis (based on computer models, not completely representing teeth in vivo; most of the studies regarding NCCLs use two-dimensional models).39-41

It is safe to say that NCCL occurred preferentially in upper premolars, which revealed to be in agreement with other previous studies.19,35,42,43 This prevalence is verified probably due to the lower capacity to absorb lateral forces observed in premolars when compared with canines, leading to cervical tension and a consequent occurrence of NCCL.44

Three studies31,33,34 tested this etiological factor (para- functional habits) and in two33,34 had a positive correlation with NCCL occurrence, despite being low.33 On the other hand, Teixeira et al31 could not verify a significant correla- tion with NCCL or GR, suggesting it as an enhancer of tooth loss at a cervical level, when compared with physiological forces37,38 since the magnitude of forces during this type of habit greatly exceed loads during normal activity.31

The acidic activity was another factor analyzed by three articles31,32,34 with no unanimous results, and was considered a contributing factor for the occurrence of NCCL but not GR. Also, the role that abrasive/traumatic brushing played in the development of both NCCL and GR, three studies31,32,34 considered it, nevertheless, in this SR the data verified was not enough to draw any conclusions about this topic. Regarding brushing, it is important to state that two studies45,46 described the existence of NCCL in populations that did not have brushing habits, in concordance with Teixeira et al31 and an in vitro study,47 which has shown that the presence of this factor is not enough for the development of these NCCLs. On the other hand, Morigami et al48 reported higher occurrence of this lesion in the left hemi-arch in right-handed patients, suggesting the influence of the brushing method on the eti- ology of NCCL.

Then, the evidences presented here are in concordance

with Fan and Caton5 study and are weak and not feasible to conclude occlusal trauma causes periodontal alterations. Conversely, a case report published by Ustun et al7 affirmed, in a patient Angle Class III malocclusion and with deep bite, that the severe GR was occasioned by the traumatic occlusion, which is in agreement with Jati et al49 who demonstrated bone dehiscence and V-shaped recession due to occlusal trauma. Therefore, Campos et al,50 in an experimental study,

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58 GR and NCCL Associated with Occlusal Trauma Tróia et al.

concluded that occlusal trauma promoted bone resorption after 14 days of analyses, while it did not cause GR.

Within the limitation of this SR, it can be concluded that few studies were published in the past 10 years, high- lighting that NCCL and GR present a multifactorial etiology. However, the traumatic occlusion with consequent exacer- bated forces to which the teeth are subjected seem to be associated with the occurrence of NCCL. No conclusions regarding the association of GR with the presence of occlu- sal trauma were possible to be done. The few published studies showed a high degree of heterogeneity, which sug- gests new well-designed randomized controlled clinical studies on the subject.

Conflict of Interest

The authors declare no conflicts of interest with this study.

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