ADRF RESEARCH REPORT

Australian Dental Journal 1999;44:(3):176-186

Dental cervical lesions associated with occlusal erosion and attrition

F. Khan* W. G.Young* S. Shahabi* T. J. Daley*

Abstract Acid demineralization of teeth causes occlusal erosion and attrition, and shallow and wedgeshaped cervical lesions putatively involving abfraction. From 250 patients with tooth wear, 122 with cervical lesions were identified. From epoxy resin replicas of their dentitions, associations of occlusal attrition or erosion or no wear with cervical lesions were recorded at 24 tooth sites (total 2928 sites). Criteria used to discriminate occlusal attrition from erosion, and shallow from grooved, wedgeshaped or restored cervical lesions were delineated by scanning electron microscopy. A 96 per cent association was found between occlusal and cervical pathology. Shallow cervical lesions were more commonly found in association with occlusal erosion. Wedge-shaped lesions were found equally commonly in association with occlusal erosion, as with attrition. Grooved and restored cervical lesions were uncommon. Differences were appreciated in the associations within incisor, canine, premolar and molar tooth sites which related more to the sitespecificity of dental erosion than to attrition from occlusal forces. Non-carious lesions on teeth then have multifactorial aetiology and pathogenesis in which erosion and salivary protection play central roles. Dentists should primarily consider erosion in the diagnosis, prevention and treatment of tooth wear.
Key words: Abfraction, attrition, erosion, tooth wear, saliva. (Received for publication December 1997. Revised April 1998, May 1999. Accepted May 1999.)

Introduction Lesions at the cervical margins of teeth pose diagnostic and restorative problems for the dental profession. If caused by dental caries, the initial white-spot lesion may progress to infection of

*Department of Dentistr y, The University of Queensland.

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dentine and cavitation. Problems inherent in the management of cervical lesions have recently been evaluated and reviewed.1,2 Cervical white-spot lesions of the enamel are best treated by plaque control and remineralization. Carious cavitation of cervical enamel, dentine and cementum presents significant restorative problems because the gingival margin is a site where water contamination in placing dental materials, amalgam creep, marginal leakage and recurrent caries are prone to occur. Moreover, margin-associated plaque may contribute to gingival inflammation and recession. However, plaque bacteria are not the only cause of demineralization at the cervical margin. Extrinsic acids from the diet3 and intrinsic acid from gastric reflux4 are also the aetiologic agents of many cervical lesions. They produce demineralization and erosion without bacterial pathogenesis. In fact, caries and erosion rarely occur simultaneously, because plaque micro-organisms, for example Streptococcus mutans, cease metabolism at the pH values below 4.2 that characterize erosive challenge.5 Dental erosion, but not caries, is found in lactovegetarians who are very conscious of their diet and oral hygiene.6 Dental erosion is also found in subjects with low DMFS scores who have had fluoride in the first 12 years of life.7 The hallmark symptom of the cervical lesion is dentine hypersensitivity to hot, cold, sweet and tactile stimuli due to the exposure of vital dentine produced by erosion. Clinical observations favour the possibility that extensive oral hygiene practices produce cervical lesions by abrasion.8 However, l o n g - t e rm , double-blind, human clinical studies have found that factors other than dentifrice abrasivity play important roles in this form of tooth wear.9 Through softening of the enamel and dentine, erosion decreases wear resistance to mechanical abrasion of toothbrushing immediately following an acid challenge. 10
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An interesting association between cervical lesions and occlusal attrition on the same teeth has been observed in a study of bruxism.11 A study of cervical lesions in an unselected population found that 22-23 per cent of subjects were affected by cervical lesions that were wedge-shaped and these increased in severity with age.12 Subsequently, a number of clinical studies have attempted to connect cervical lesions with occlusal pathology.13-16 The stresses of occlusal loading are believed to be transmitted as strains to the cervical area of teeth in function as a result of the elasticity of dentine. It has been proposed that the forces from tooth-to-tooth interactions, which cause wear facets on the occlusal surfaces of a tooth by attrition, develop the wedgeshaped cervical lesion on the same tooth.13 The breakdown of cervical enamel and dentine produced by this putative pathogenic mechanism has been called abfraction and has been attributed to stress corrosion.15 In engineering terms, the concept of stress corrosion identifies that corrosion advances more rapidly when material is subjected to repeated stress.15 By analogy, dental erosion could develop at a cervical site which is repetitively stressed occlusally when it is being exposed to acid. The engineering term for acid attack is corrosion,15 however it is unlikely that corrosion will be substituted for erosion in the dental literature due to its present widespread usage. A comparison among patients with tooth wear has shown that erosion is equally as common as attrition on the occlusal surfaces of the teeth of subjects with bruxism as those without.17 Studies of tooth wear in this South East Queensland population have suggested that patient dehydration reduces salivary protection against dental erosion18 and that erosion is of greater importance in the aetiology of tooth wear in these patients than bruxism.17 This suggests that acid demineralization is not only the primary cause of cupped lesions of erosion but also of attritional wear facet development on occlusal enamel softened by acids, in a site-specific manner. Hypothetically, the observable associations between occlusal and cervical pathology are primarily a result of site-specific dental erosion. In contrast, the abfraction hypothesis emphasises that the forces which cause wear facets on occlusal surfaces are transmitted as strains to cervical sites, there causing wedge-shaped lesions to evolve by stress corrosion. The aims of this study were to describe the incidence and site-specificity of various types of cervical lesion and their associations with occlusal attrition indicative of shearing forces on the tooth, or with occlusal erosion indicative of extrinsic or intrinsic acid aetiology. A further aim was to contribute to better diagnosis, management and treatment of cervical lesions on teeth, because the
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prevention and treatment of cervical lesions must address causes as well as mechanisms by which cervical lesions evolve. Materials and methods From the records of 250 patients referred to the Tooth Wear Clinic at The University of Queensland, School of Dentistry, 122 subjects (81 male, 41 female; mean age 33.46 years, range 14-70 years; 86 per cent right-handed) were selected because of the presence of one or more dental cervical lesions. Impressions were taken from the dentition of each patient at first presentation, using polyvinylsiloxane material. Clear epoxy-resin models were poured from the impressions. Wear on occlusal surfaces of the models was characterized and scored using scanning electron microscopy (SEM) cri t e ri a previously described. 7 Briefly, two different patterns of microwear were discriminated on the occluding surfaces of teeth worn into dentine. In general, attrition (Pattern A tooth wear) was characterized by planar enamel wear and shallow dentine wear, often contoured asymmetrically in the direction of relative tooth-to-tooth movement, and with equivalent facets being found on all opposing teeth. Erosional tooth tissue loss (Pattern B) was characterized by sharp and chipped enamel edges and deeply cupped dentine loss on incisal or occlusal surfaces. The enamel/dentine interfaces were symmetrical around the lesion. Type-specimens of teeth showing associations of occlusal wear and different types of cervical lesions were prepared for SEM. Replicas for SEM were washed using 70 per cent alcohol/30 per cent detergent. An ultraviolet light-cured adhesive was used to mount the replicas onto SEM stubs. These were then sputter-coated with gold for a period of 320 seconds at a plasma current level of between 15 and 19 mA and vacuum pressure of 0.1 Torr. These specimens were examined using the scanning electron microscope, generally at 10 magnification. The maxillary and mandibular models were viewed under a stereoscopic light microscope at 1 6 - 40 magnificat i o n . T h e associations of occlusal wear patterns with the cervical lesion categories were recorded for 24 tooth sites per subject,without reference to the subjects identifying clinical information. The tooth sites recorded were the central incisors, canines, premolars and first molars in the maxilla (Mx) and mandible (Md).Two cervical sites were discriminated on first molars, above the mesial and above the distal roots. Clinical observations have noted that cervical lesions may be

Joel JSM-820, Tokyo, Japan. Leitz, Wetzlar,Germany. 177

DEJ C1 DEJ

C1

Fig.1. The buccal aspects of a mandibular right first molar (46) and second premolar (45),which show the association of occlusal erosion and the shallow cervical lesion. Cupped lesions of erosion (B) are evident on the mesiobuccal cusp of 46 and the buccal cusp of 45. The cervical lesions (C1) show shallow exposure of dentine with a gradual slope into the enamel at the dento-enamel junctions (DEJ). [Bar=1 mm].

F F

C1

Fig. 2. The buccal aspects of a mandibular right first molar (46) which shows the association of occlusal erosion and a shallow cervical lesion (C1) above the mesial root. The decision that the occlusal wear was erosion was based on the deep cupped lesions (B) found on the buccal and lingual cusps of this tooth and on tooth 45. However, wear facets (F) in enamel are apparent on the buccal slopes of the buccal cusps of both 46 and 45 which can be attributed to attrition of the enamel softened by demineralization.The linear defect over the distal root was interpreted as a wedge-shaped defect although it appears to be a distal extension of the shallow defect over the mesial root. [Bar=1mm].

more common over the mesial than over the distal buccal roots of molars, and that this may relate to differential stresses at these sites. For each of these tooth sites in each dentition, cervical lesions were classified as: C1 (the shallow cervical lesion), Cg (the grooved cervical lesion), Cw (the wedge-shaped
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lesion), Cr (the cervical restoration), or Co (no cervical lesion). In this study, a total of 2928 tooth sites were recorded. The associations between occlusal wear pattern (A or B) or no wear into dentine (O) and the cervical lesion were recorded for each site. Restored teeth were included, since occlusal
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B LE TE F DEJ PD

Cw HD R

Cw

Fig. 4. A mandibular right first premolar showing the definitive wedge-shaped cervical lesion (Cw) with a horizontal floor in dentine (HD) perpendicular to the vertical axis of the tooth and a planar dentine face (PD) which extends coronally at an acute angle from the inner edge of the wedge. This occlusal surface is worn by attrition, as it shows the shallow enamel to dentine interface of the leading edge (LE) and the hollowed out dentine-to-enamel interface on the trailing edge (TE). [Bar=1 mm]. Fig. 3. A mandibular right first premolar showing a wedge-shaped lesion (Cw) in the dentine. The coronal aspect of this lesion has features of the shallow cervical lesion at the dentino-enamel junction (DEJ). However, a restoration (R) comprises the radicular aspect. Although a facet is apparent on enamel of the distobuccal aspect of buccal cusp (F arr ow ) , the cusp tip has a cupped lesion (B arrow) from which occlusal erosion was inferred. [Bar=1 mm].

restorations did not obscure occlusal pathology and cervical restorations were mainly found adjacent to teeth with non-carious cervical lesions, implying common aetiology. The few teeth with full coverage of occlusal and/or buccal surfaces were excluded.As only a few of the subjects studied showed lingual or palatal cervical lesions of the above types, the results refer to facial or buccal-cervical sites only. The results were recorded by data spread sheet, analysed and, where appropriate, subjected to chi-squared analysis. Results Ultrastructure The ultrastructural appearance of a shallow cervical lesion (C1) is illustrated in Fig. 1. These lesions generally extended from the gingival margin of the buccal surface, one-third coronally as a shallow exposure of dentine with a gradual transition to enamel at the dentino-enamel junctions.The dentine was not grooved or angular as in the wedge-shaped defect. The surrounding enamel did not show accentuation of Hunter-Schreger bands in the
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enamel or of perichymata. Extensions of shallow cervical lesions were sometimes found which appeared to develop into linear, wedge-shaped lesions (Fig. 2). Sometimes, wedge-shaped lesions were found associated with restorations in the dentine of lesions which otherwise were shallow (Fig. 3). The definitive wedge-shaped lesion (Cw) was characterized by a horizontal cervical floor at right angles to the vertical axis of the tooth and a planar face at an acute angle to the horizontal floor, which extended toward the coronal extent of the lesion (Fig. 4). Wedge-shaped lesions were often found on adjacent teeth (Fig. 5). Cervical grooved lesions (Cg) were characterized by multiple grooves in the dentine, parallel to one another and horizontal to the vertical axis of the tooth (Fig. 6). In the peripheral adjacent enamel, the Hunter-Schreger banding was often accentuated as superficial furrows in the enamel. Wear pattern frequency Non-carious cervical lesions were generally found where either erosion or attrition was present on incisal or occlusal surfaces (96.2 per cent of tooth sites with non-carious cervical lesions). Conversely, in the absence of occlusal wear, very few cervical lesions of any type were found (3.8 per cent of sites). Figure 7 shows the frequencies of associations of wear patterns for all tooth sites. The shallow lesion
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PD HD Cw

Fig. 5. Wedge-shaped cervical lesions on adjacent mandibular incisors, associated with incisal attrition. Wear facets on lower incisor teeth do not show marked asymetrical wear on the flat shallow facets (F) but well-defined margins indicate attrition.The horizontal floor of the lesions have an almost subgingival margin and extend deeply into the dentine (HD) from where the planar dentine face (PD) extends incisally. [Bar=1mm].

Cg Cg

Fig. 6. Maxillary central incisors with marked cervical grooved lesions in dentine (Cg).These were associated with erosion, which had ablated most of the enamel (E) of the incisal edge and the palatal aspects of these teeth (not shown). [Bar=1mm].

was the most common cervical lesion found, and was found most commonly in association with occlusal erosion (BC1). However, it was also commonly found in association with occlusal attrition (AC1). The next most commonly found cervical lesion was wedge-shaped. Of these, 49 per cent were found associated with occlusal attrition (ACw) and 46 per cent were found associated with occlusal erosion (BCw). Fifteen sites (5.2 per cent) affected by wedge lesions were not associated with any occlusal wear
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(OCw). Cervical restorations were more common in association with attrition (ACr), than with occlusal erosion (BCr).The grooved lesion was least commonly found, and was only found if attrition or erosion were present occlusally. Cervical lesions were more likely to be absent on teeth affected occlusally by attrition (991 sites) than on teeth affected by erosion (458 sites). Figure 8 shows the relative frequencies of the associations found in the mandible and maxilla of right and left central incisors. In both jaws, incisal
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Fig.7. Frequencies of associations between occlusal attrition (A) or erosion (B) or no wear (O) and the shallow cervical lesion (C1),the grooved lesion (Cg), the wedge-shaped lesion (Cw), the restored cervical lesion (Cr) and the absence of a cervical lesion (Co) on maxillary and mandibular teeth from 2928 tooth sites. Cervical wear was rarely found in the absence of occlusal wear (O).The most common combination was occlusal erosion with shallow cervical lesions (BC1), which were also commonly found with occlusal attrition (AC1).The wedge-shaped lesion(Cw) was almost equally associated with attrition as with erosion.

8a

8b

Fig.8 . Frequencies of incisal attrition (A) or erosion (B) or no wear (O) associated with cervical lesions on (a) right and (b) left central incisors. The greatest numbers of shallow facial cervical lesions were found associated with incisal erosion on maxillary (Mx) incisors (BC1). Despite the high frequency of mandibular (Md) incisal attrition, wedge-shaped lesions, as illustrated in Fig. 5, were not common on lo wer incisors.

9a

9b

Fig. 9. On (a) right and (b) left canines, no cervical lesions were found in the absence of incisal wear (O). However, most canine teeth had incisal attrition (A) without cervical lesions (ACo).The shallow cervical lesion was most commonly found on mandibular (Md) canines with incisal attrition (AC1). Wedge-shaped lesions were more common on left canines than right canines with incisal attrition (ACw). The few mandibular canines with incisal erosion showed relatively few cervical lesions.
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10a

10b

Fig. 10. On (a) right and (b) left first premolars, cervical lesions were infrequent in the absence of occlusal wear (O). On mandibular (Md) first premolars, more cervical lesions were found than on mandibular canines. The most common cervical lesion found on maxillary (Mx) premolars was the shallow cervical lesion associated with occlusal erosion (BC1). Wedge lesions were found with approximately equal frequenc y associated with both occlusal attrition and erosion and were more common on the left side.

11a

11b

Fig. 11. On (a) right and (b) left second premolars, more cervical lesions associated with occlusal erosion were found in the mandible (Md) than on mandibular first premolars (compare with Fig. 10). However, in association with occlusal erosion, more shallow cervical lesions were found on the right than on the left and more wedge lesions were found on the left than the right.

12a

12b

Fig. 12. Associations of occlusal wear types on (a) right and (b) left first molars. More mandibular (Md) cervical lesions of both types were found in association with erosion than with attrition occlusally. Handedness appears to influence numbers of wedge lesions found on left maxillary (Mx) teeth with attrition and on left mandibular teeth with erosion.
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attrition was most commonly encountered without a cervical lesion.This finding was more common in the mandible than the maxilla. In contrast, incisal erosion was much more common on maxillary incisors than mandibular incisors, and was commonly associated with shallow cervical lesions (BC1). Smaller numbers of shallow cervical lesions were found in association with incisal attrition (AC1). Grooved, wedged and restored lesions were common but were equally distributed on both the right and left sides. Of the total number of mandibular incisor tooth sites surveyed (244) only six were found to have wedgeshaped lesions. Of note in these data is the virtual absence of cervical lesions of any type when incisal wear was absent (OCo). The most remarkable difference between the incisor and canine data was the increased frequency of shallow cervical lesions found on mandibular canines with incisal attrition (Fig. 9, AC1).This was a much more common association than incisal erosion combined with the shallow cervical lesion (BC1), on the mandibular canines. The maxillary canines were sites of wedge-shaped lesions, p a rticularly in association with attrition (ACw). Moreover, this association was more common on the left side. Two differences were noticed between the canine and first premolar data.Firstly, more cervical lesions of all types were found on mandibular first premolars than on mandibular canines. Particularly, wedgeshaped lesions were more common on first premolars than on canines (Fig. 10). Secondly, more first premolars than canines were unaffected by occlusal wear, particularly in the maxilla. The emergence of these differences was accentuated following comparisons of the second premolar and the canine data (Fig. 9, 11). Compared with the mandibular canines, the mandibular second premolars were found to have more cervical lesions of all types associated with occlusal erosion. Considerably more maxillary second premolars than canines were unaffected by occlusal wear and unaffected at the cervix (Fig. 9, 11). The incidence and the most favoured site for wedge lesions associated with erosion (BCw) changed from the canines, where they were equally commonly found in the mandible and maxilla, to higher incidences in the mandibular premolars. Differences in handedness were also apparent in that more wedge lesions were found on the left than the right. There appeared to be no consistent association between either attrition or erosion occlusally with the cervical wedge lesion in the canine or premolar data. Figure 12 illustrates the frequencies of the association of lesions on molar teeth. Although the shallow cervical and wedge lesions were found slightly more commonly above the mandibular mesial root than above the distal root (data not
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shown), these data were combined for presentation. Two overall trends were apparent. F i rs t l y, a reduction in the number of sites in both jaws affected by attrition was evident when compared with the more anterior teeth. Secondly, fewer maxillary molar sites were affected by erosion than were mandibular sites. The trends found in the premolar compared with the canine data were accentuated in the molar data (Fig. 12) in the following three respects. Firstly, more cervical lesions of shallow and wedge types were found on mandibular molars than on maxillary molars. Secondly, fewer cervical lesions of all types were found associated with occlusal attrition, but more were found associated with erosion on mandibular molars.Thirdly, maxillary molar sites were relatively unaffected by occlusal wear and cervical lesions when compared with mandibular sites. Discussion Decision making in the dental diagnosis, management and treatment of cervical lesions needs to consider factors that influence salivary protection of the teeth against caries and erosion (Fig. 13). Clinical parameters of plaque, enamel and dentine demineralization and infection discriminate carious from non-carious lesions. However, shallow, wedgeshaped and grooved non-carious lesions, associated with either cupped lesions or flat wear facets, do not discriminate reliably between teeth affected by extrinsic or intrinsic acids and teeth affected by abrasion or occlusal stress. When tooth tissue loss is the cupped lesion on incisal edges, or on cusp apices, the aetiology can be inferred to be dental erosion. However, differences of aetiology or pathogenesis cannot be inferred from the different morphologies of the shallow, wedge-shaped or grooved cervical lesions. This study found that cervical lesions of all types (96 per cent), occurred on teeth with occlusal attrition or erosion. Conversely, in the absence of occlusal tooth tissue loss, very few (4 per cent) had cervical lesions. Thus, a very strong association was found between occlusal and cervical pathology. If the primary aetiology of tissue loss on a tooth was erosion, then the shallow cervical lesion should be found most commonly and on teeth affected by occlusal erosion, and uncommonly at sites where saliva protects the teeth from acid attack most effectively. The shallow lesion was the most common cervical lesion found and was most commonly associated with occlusal erosion. In the maxilla, shallow facial cervical lesions of the incisor, canine and first premolar teeth were most commonly associated with incisal (and palatal) erosion. In the mandible, facial cervical lesions were relatively
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Fig.13. Paradigm for decision making in the diagnosis,management and treatment of cervical lesions on teeth.

uncommon on incisors, canines and first premolars and lingual erosion was very rare, despite the incidence of incisal attrition and cupped lesions. Erosion of the lingual surfaces of the mandibular incisors is rare and has only been found in two per cent of all patients in this study. These marked differences in anterior tooth site-specificity can be explained by the following aspects of salivary physiology. The maxillary anterior teeth are readily dried by mouth breathing and, due to the absence of glands on the anterior hard palate, their incisal and palatal surfaces are relatively unprotected against acid attack.The facial cervical aspects of these teeth are nearest to the labial minor salivary glands, but as these lack bicarbonate buffer in their mucus, facial aspects also may be relatively unprotected.19 In contrast, the mandibular anterior teeth are virtually always protected lingually by the buffering action of submandibular saliva.20 Moreover, circulation of saliva from the submandibular gland into the anterior mandibular vestibular sulcus affords protection to the mandibular facial cervical region. On second premolars and molars, buccally more shallow cervical lesions were found associated with occlusal erosion in the mandible than in the maxilla. Several studies have documented that occlusal erosion affects posterior mandibular more than maxillary teeth.7,17,21,22 Parotid salivary flow may account for the relative protection of all maxillary posterior tooth sites.21 Although, why the mandibular
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premolars and first molars are less protected from occlusal erosion and from associated buccal cervical lesions is less clear. Overall, the association of shallow cervical lesions with occlusal cupping relates best to the site-specificity of salivary protection against the acids that cause dental erosion. Although fewer in number, grooved, wedgeshaped and restored cervical lesions were found in similar locations in association with occlusal erosion as were shallow cervical lesions. Ultrastructural observations suggest that wedge-shaped lesions may later develop from shallow ones (Fig. 2-4). Wedgeshaped lesions were not found at sites considered to be protected by saliva. If the aetiology of wedgeshaped lesions was occlusal stress transmitted as strain to cervical enamel and dentine,13 they would be found more commonly on teeth with occlusal attrition than erosion. Moreover, because occlusal wear facets occur reciprocally on opposing maxillary and mandibular teeth, wedge-shaped lesions should be equally distributed between the mandible and maxilla. Neither of these extrapolations from the abfraction hypothesis were sustained by the present data. Elsewhere, the assumption that occlusal attrition in this present population is due solely to excessive occlusal force has been questioned.17 Because attritional wear is exacerbated by acid demineralization of enamel, severe attrition when found in young patients is commonly due to erosive factors in the diet.23 Erosion from industrial acids has repeatedly been associated with severe attritional tooth wear.24,25
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Thus there is evidence that acid demineralization predisposes to severe attrition and that the two mechanisms often act in tandem to cause tooth tissue loss. At the cervical margin, the effects of acid demineralization may be amplified secondarily by cervical strains as postulated in the explanation of abfraction as stress corrosion.15 However there may be other explanations for the angular junction of the wear planes of the definitive wedge-shaped lesion (Fig. 4, 5).The differences found in the distribution of wedge-shaped lesions in anterior sites between right and left sides suggest that toothbrush abrasion, dependent on handedness, may exacerbate the formation of this lesion. Grooved lesions were found most commonly associated with occlusal erosion, less so with attrition (Fig. 7). Though relatively few in number compared with other cervical lesions, they were more common on the maxilla and frequently absent from the mandible except in the canine and second premolar sites (Fig. 9, 11). The grooved lesion was not present unless there was also occlusal erosion or attrition on the teeth.This suggests again that the primary aetiology is acid softening of cervical enamel, but the ultrastructure of the grooved cervical lesion, with furrowing of the dentine and accentuated HunterSchreger bands or perichymata, suggests that abrasion by toothbrushing also contributes to the grooves. The numbers of this lesion found showed no influence of handedness. A new paradigm for the examination, diagnosis and treatment planning of the non-carious cervical lesion therefore emerges (Fig. 13). The explanation for the association between occlusal and cervical pathologies lies in emphasizing that acid challenge to enamel and dentine makes the teeth more susceptible to attrition and abrasion as well as to erosion. The perception that occlusal attrition and the wedge-shaped lesion principally result from stresses and strains on the tooth should be questioned.The unique shape of the wedge lesion may reflect cervical stress on particular teeth, when they are repeatedly challenged by acid, and hence their pathogenesis may involve stress corrosion. Alternatively, both the wedged and the grooved lesion are lesions accentuated perhaps by toothbrushing. Conclusions There is a very strong association between occlusal and cervical pathology. The site-specificity of salivary protection offers the best explanation for the locations in which occlusal erosion and the shallow cervical lesion are associated. It also offers the best explanation for the locations of the wedge-shaped lesion associated with occlusal erosion.The hypothesis that the wedge-shaped lesion is primarily due to occlusal forces, which also cause attrition, is not
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sustainable. Rather, the primary aetiology of this lesion is acid demineralization at sites relatively unprotected by saliva, possibly involving stress corrosion as a pathogenic mechanism or possibly involving abrasion correlated with handedness. Acknowledgements The dentists who referred patients to the Tooth Wear Clinic at The University of Queensland Dental School for differential diagnosis and management are thanked for their vigilance. Informed consent was obtained from patients for use of their records and study models for this project in acordance with NHMRC Ethical Guidelines. The Australian Dental Research Foundation Inc. is acknowledged for its support of Mr Farid Khan by a Student Scholarship and of the project by an ADRF grant. Mr Don Gowanlock of the Centre for Microscopy and Microanalysis, The University of Queensland, is thanked for his assistance with scanning electron microscopy. Mr Ian Johnston of Wrigley Co. Pty Ltd Australia is thanked for continued support of these studies. References
1. Heymann HO, Sturdevant JR, Bayne S,Wilder AD, Sluder TB. Examining tooth flexure on cervical restorations: a two year clinical study. J Am Dent Assoc 1991;122:41-47. 2. Heymann HO, Bayne SC. Current concepts on dentin bonding: focussing on dentinal adhesion factors. J Am Dent Assoc 1993;124:27-35. 3. Zero DT. Etiology of dental erosion extrinsic factors. Eur J Oral Sci 1996;104:162-177. 4. Scheutel P. Etiology of dental erosion intrinsic factors. Eur J Oral Sci 1996;104:178-190. 5. Meurman JH, Cate JM. Pathogenesis and modifying factors of dental erosion. Eur J Oral Sci 1996;104:199-206. 6. Linkosalo E, Markkanen S. Dental erosion in relation to lactovegetarians. Scand J Dent Res 1989;93:436-441. 7. Teo C,Young WG,Daley TJ,Sauer H.Prior fluoridation in childhood affects dental caries and tooth wear in a South-east Queensland population.Aust Dent J 1997;42:92-102. 8. Levitch LC,Bader JD, Shugars DA,Heymann HO. Non-carious cervical lesions. J Dent 1994;22:195-207. 9. Volpe AR, Mooney R, Zumbrunnen S, Stahl D, Goldman HM. A long term clinical study evaluating the effect of two dentifrices on oral tissues. J Periodontol 1975;46:113-118. 10. Kelly MP, Smith BGH.The effect of remineralizing solutions on tooth wear in vitro. J Dent 1988;16:147-149. 11. Xhonga FA.Bruxism and its effects on the teeth. J Oral Rehabil 1997;4:65-76. 12. Bergstrm J, Eliasson S. Cervical abrasion in relation to toothbrushing and periodontal health. Scand J Dent Res 1988;96:405-412. 13. Lee WC, Eakle WS. Possible role of tensile stress in the etiology of cervical erosive lesions of teeth. J Prosthet Dent 1984; 52:374-379. 14. Bevenius J, LEstrange P, Karlsson S, Carlsson GE. Idiopathic cervical lesions: in vivo investigation by oral microendoscopy and scanning electron microscopy. A pilot study. J Oral Rehabil 1993;20:1-9. 15. Grippo JO, Simring M. Dental erosion revisited. J Am Dent Assoc 1995;126:619-630. 16. Spranger H. Investigation into the genesis of angular lesions at the cervical region of the teeth. Quintessence Int 1995;26:149154.
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17. Khan F, Young WG, Daley TJ. Dental erosion and bruxism. A tooth wear analysis from South East Queensland. Aust Dent J 1998;43:117-127. 18. Young WG. Diet and nutrition for oral health:advice for patients with tooth wear. Aust Dent Assoc News Bulletin 1995;Jul:8-10. 19. Dawes C. Salivary flow rate and composition. In: Edgar WM, OMullane DM, eds. Saliva and oral health. 2nd edn. London: British Dental Association, 1996:40. 20. Dawes C. Physiological factors affecting salivary flow rate, oral sugar clearance and the sensation of dry mouth in man. J Dent Res 1987;66:648-653. 21. Eccles JD.Tooth surface loss from abrasion, attrition and erosion. Dent Update 1982;9:373-381. 22. Jrvinen VK, Rytomaa I, Heinonen OP. Risk factors in dental erosion.J Dent Res 1991;70:942-947.

23. Eccles JD, Jenkins WG. Dental erosion and diet. J Dent 1974;2:153-159. 24. Bruggen Cate HJ ten. Dental erosion in industry. Brit J Industr Med 1968;25:249-266. 25. Petersen PE, Gormsen C. Oral conditions among German battery factory workers. Community Dent Oral Epidemiol 1991;19:104-106.

Address for correspondence/reprints: Associate Professor W. G.Young, Oral Biology and Pathology, The University of Queensland, Queensland 4072.

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