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The non-carious dental cervical lesion and associated risk factors

An observational, cross-sectional and multi-centre epidemiological study


PROTOCOL

Table of contents
TABLE OF CONTENTS ................................................................................................................. 1
1.
GLOSSARY .......................................................................................................................... 2
2.
INTRODUCTION ................................................................................................................ 2
3.
AIMS OF THE STUDY ......................................................................................................... 3
3.1. PRINCIPAL AIM ................................................................................................................. 3
3.2. SECONDARY AIM .............................................................................................................. 4
4.
EXPERIMENTAL DESIGN AND METHODOLOGY .................................................... 4
4.1. TYPE OF STUDY .................................................................................................................. 4
4.2. SELECTION OF GENERAL DENTISTS........................................................................... 5
4.3. SELECTION OF PATIENTS .............................................................................................. 5
4.4. NUMBER OF SUBJECTS NECESSARY ........................................................................... 5
4.5. SAMPLING METHODS ....................................................................................................... 5
4.6. CALIBRATON OF EXAMINERS ........................................................................
5
5.
INFORMATION TO BE COLLECTED ............................................................................. 6
6.
ORIGIN AND TYPE OF CATEGORICAL DATA TO BE COLLECTED .................... 6
6.1. DOCUMENTS TO BE COMPLETED ............................................................................... 6
7.
DATA MANAGEMENT ....................................................................................................... 7
7.1. STATISTICAL ANALYSIS ................................................................................................ 7
8.
ETHICAL CONSIDERATIONS ......................................................................................... 8
9.
BUDGET ................................................................................................................................. 9
10. TIMETABLE.......................................................................................................................... 9
11. SCIENTIFIC COUNCIL ...................................................................................................... 9
12. NATIONAL INSTITUTIONS.. .9
12. REFERENCES ...................... ...10

The non-carious dental cervical lesion and associated risk factors An observational, cross-sectional and multi-centre epidemiological study: 2010-2011

1. Glossary
BEWE
GDP
SD
BU
NCCL
OR

Basic Erosive Wear Examination


General Dental Practitioners
Sentinel Dentist
Bristol University
Non-Carious Dental Cervical Lesion
Odds ratio

2. Introduction
All teeth are exposed to attrition by virtue of being in an environment which wears the teeth and may result
in cervical wear lesions. To different degrees, all dental surfaces are at risk of wear due to conditions
inherent in the oral environment, and it is generally agreed that their aetiology is multifactorial. Different
cervical lesion morphologies have been described corresponding to particular principal or even sole causes,
so that cervical lesions may be identified and quantified in epidemiological studies.
Non-carious cervical lesions progress constantly. Their high prevalence may be attributed to several factors
of which the most important are linked to oral hygiene practices and dietary habits; to these may be added
stress and its effects on the occlusion, and increases in population longevity.
Cervical wear lesions typically present for one of three reasons. The patient may well present
spontaneously because of hypersensitivity associated with the lesion or because of unaesthetic appearance,
or the condition may be detected at a routine dental examination, without the patient being aware of a
problem.
Clinical identification of the lesion will determine the diagnosis and govern the therapeutic decision.
Identification of aetiological factors will determine the prognosis of the lesion and suggest the treatment
plan. The latter should most definitely include preventing the aggravation of the symptoms and the lesions,
to facilitate the ultimate success of any restorative treatment.
Non-carious cervical lesions are generally linked to a combination of three basic mechanisms:
Mechanical Mechanisms: Abrasion of enamel, due to forceful brushing. This well recognised
mechanism may be accompanied by superficial gingival inflammation and gingival recession.
Mechanical mechanisms underlie also the loss of tissue due to flexion of the dental crown under
mechanical masticatory forces. Repeated flexion may lead to localised sub-surface tissue loss as pieces
of the tissue fracture off. Details of this mechanism for tissue loss remain controversial.
Chemical mechanisms: Erosion of dental calcified tissue under the influence of acids can occur; the
acids may be of dietary origin, or come from pharmaceutical products, or be linked to certain work
environments. Gastroesophageal reflux, which may affect up to 60% of people during their lives, may
also lead to erosions.
The multifactorial origin of these lesions makes it difficult to define exactly their aetiology. The difficulty
may be explained partly by the very wide differences in prevalence reported by different studies.
Today, it is nevertheless possible to narrow down the aetiology of non-carious cervical lesions by
identifying and analysing certain potential causal factors. These determining factors may be gleaned from:
- Questionnaires competed by affected persons covering hygiene habits, dietary habits and any
pathology or medication that could modify the pH of the oral environment or affect the buffering
capacity of saliva.
- Clinical records which provide information from ordinal indices on tooth wear, periodontal health
and the occlusion.

The non-carious dental cervical lesion and associated risk factors An observational, cross-sectional and multi-centre epidemiological study: 2010-2011

Few representative studies have examined the relationship between non-carious cervical lesions and
periodontal disease in subjects presenting with clinical loss of attachment. An observational clinical
epidemiological study would thus seem to be an appropriate public health response, for the following
reasons:
- Oral hygiene practices, and particularly brushing techniques, are key components in the
maintenance of good periodontal health. On the other hand, poorly applied, it is well established
that these factors can generate inflammation and gingival recession, frequently concomitant with
damage to calcified dental tissues.
- Periodontal conditions lead to cervical and radicular exposure (with clinical loss of attachment),
illustrating the aggressiveness of the oral environment and the damage due to brushing, to the
cement and the dentine which are 7 to 9 times less resistant than enamel.
- The consequences of these lesions, at the tooth-periodontal tissue interface, manifest themselves
functionally by dentinal-pulpal hypersensitivity and aesthetically when the lesions are on the
anterior teeth. These functional and aesthetic problems necessitate either restorative treatment or
periodontal plastic surgery.
Dentinal hypersensitivity is one of the first symptoms to appear after cervical wear lesions occur. It occurs
during the initial phases of an attack leading to cervical lesions. Epidemiological reports agree on an
approximate prevalence in adult populations of 10% to 20%. In this connection, dentinal hypersensitivity,
apart from having an impact on quality of life, seems to be the fundamental predictive risk factor for early
detection of non-carious cervical lesions and preventive interventions for these conditions.
If risk factors for non-carious cervical lesions have hitherto been poorly studied, better knowledge of these
conditions would allow the establishment of preventive measures that seek to reduce the incidence of this
condition and to diminish its impact, given that the condition has functional, aesthetic and painful
consequences that impact on the quality of life of adult sufferers. We are proposing to conduct a study,
using general dental practitioners, to identify risk factors for non-carious cervical lesions as diagnosed in
dental practice. Apart from the risk factors for acquiring non-carious cervical lesions, we hope to answer
questions about methods of management for the lesions, how is prevention organised, which preventive
strategy for which risk factors?
3. Aims of the study
3.1. Principal Aim
To research the risk factors associated with the occurrence of a non-carious cervical lesion in people aged
18-35 years included seen in general dentistry in Europe including Finland, France, Spain, Italy, Latvia,
Estonia, United Kingdom. *
Factors to be researched:
1.
Clinical loss of attachment
2.
Oral hygiene
3.
Dietary habits
4.
Tobacco and alcohol use
5.
Medical predispositions
6.
Life events during the preceding 12 months

* Turkey is inside the project as an associate partner. It performs the same study as methodological criteria, but the analysis, because of
technical constraints identified in a development phase of the protocol, will be delayed. The Czech Republic is also an associate member. The
methodology used in CZ is type CATI interview (by phone) including 700 adults. Only the questionnaire ESCARCEL project is used, no
clinical collection is performed.

The non-carious dental cervical lesion and associated risk factors An observational, cross-sectional and multi-centre epidemiological study: 2010-2011

3.2. Secondary aims


To record the prevalence of non-carious dental cervical lesions in a population of young adults
attending a general dentist for consultation in Europe including Finland, France, Spain, Italy,
Latvia, Estonia, United Kingdom (West South England; Bristol area);
To record the prevalence of dentinal hypersensitivity in a population of young adults attending a
general dentist for consultation in Europe including Finland, France, Spain, Italy, Latvia, Lithuania,
United Kingdom;
To analyse the relationship between subjective impressions of the dentition and clinical indices.

4. Study plan and methods of


4.1 Type of study
The study is a cross-sectional observational epidemiological study that will take place in Finland, France,
Spain, Italy, Latvia, Estonia, United Kingdom. Turkey is involved as associate partner. The study
participants are to be ambulatory persons aged 18-35 years included who consult a general dentist
belonging to the Sentinel network. The standardised clinical examination will take place in connection
with a routine check-up in the practice of a private or public dental practitioner. This examination will
serve to divide participants into two groups: those who present with positive findings on examination and
those who present with negative findings at the clinical examination. Persons who provide informed
consent to participate will be asked to complete a self-administered questionnaire.
Included in the study:

For every person to be included, the general dentist will


Explain the study to the participant
Provide him with a letter offering information
Request his consent
Provide the participant with a self-administered questionnaire
Help the participant to complete the dentist questionnaire which covers clinical information and
antecedent factors for the condition.
The dentist will complete a register of patients affected by non-carious dental cervical lesions seen in
consultation and will indicate whether each person was included or not in the study.
Sentinel dentists will be requested not to modify their usual management practices for patients. This
study should not change the dentistpatient relationship. The dentists will remain free to decide their
treatment options and follow-up procedures and no out-of-the-ordinary treatment or examination is linked
to this study.
4.2 Selection of general dentists
General dentists of the Sentinel network will be invited to participate in the study. They will receive an
invitation letter. The selection of those who will participate (n=20 maximum) will be based on an invitation
to participate, a balanced territorial distribution and a regional distribution balancing urban, suburban and
rural dentists. Calibrated and trained examiners will have completed a 11/2-day training on use the clinical
index to conducting the study including inter and intra examiner reproducibility assessments.
The number of GDP was respectively 10 in Estonia, Finland and Latvia, 15 in France, 17 in Italy, 20 in
Spain. The epidemiological and national GDP of France, Italy, Latvia and Estonia have already participated
in European EGOHID (www.egohid.eu) in 2008-2009 and have already gained quality experience in this
field. It is important to understand that, although the ultimate vision of the second phase of the EGOHID
project was to have teams of trained sentinel dentists working in primary care collecting comprehensive
oral health information on representative quota samples of patients of specific age and socioeconomic
groups passing through their practices.
In each member state, a local coordinator was appointed and set a target of recruiting 10 to 20 dentists to be
trained in the methodology.
Only UK opted to use national epidemiologists (2).

The non-carious dental cervical lesion and associated risk factors An observational, cross-sectional and multi-centre epidemiological study: 2010-2011

4.3 Selection of participants


Inclusion criteria for participants
o Patients of either sex, ambulatory, who consult a general dentist
o Aged 1835 years, inclusive
o Having a good understanding of the national language
o Understands and is willing, able and likely to comply with all study procedures and restrictions
o Who accept the form of the study and who sign a declaration of informed consent
o Who are of good health (in the opinion of the GDP) without clinical abnormality nor abnormal
medical history
Exclusion criteria
o Persons incapable of responding to the questions
o Persons having pathology haemophilia, using anti-coagulants (including plaque anti-aggregants);
o Persons using fixed maxillary or mandibular orthodontic appliances;
o Persons who had used antalgic (pain relieving) drugs or had used a topical analgesic in the preceding
24 hours;
o Persons who required antibiotic cover (following infectious endocarditis, using prosthetic cardiac
valves);
o An employee of the study site or their immediate family member.
4.4 Number of participants necessary
The required number of participants is based on the principal objective, the evaluation of risk factors
associated with the occurrence of non-carious cervical lesions. With two controls for each case of noncarious cervical lesion, an expected odds ratio of 2, a risk of 5% and a power of 80%, the required number
of participants in Finland, Estonia, Spain (Region of Andalusia), UK (Bristol and Metropolitan West of
South England) would be 332. The estimated error margin of 5% (incomplete questionnaires) brings the
required number of participants to 350. In France, Italy, the required numbers of participants were 700.
4.5 Sampling method
The sampling method chosen to achieve the aims of the study is the method of quotas on site. It comprises
four-stage stratification with age, sex, profession and region** (based on the last national census in each
country). The number of participants included for each Sentinel general dentist depends (1) of the
relative weight of the regional population to which the centre belongs and (2) to the activity profile
(number of consultations) of each Sentinel general dentist.
4.6. Calibration of Examiners
The chief objective of calibration process was to develop a comprehensive instrument to allow for the
collection of NCCL oral health epidemiological data throughout the countries of the European Union
together with additional documentation to support training, assessment, and comparability. The format of
this instrument was to be a full standard clinical assessment form, adaptable and usable at local, national,
and European level encompassing a BEWE index, Hypersensibility index, Schiff Index, Loss of
attachment, Pocket deeph index, Bleeding index recommended by ESCARCEL.
Training was organised on behalf of an European coordinator (DB) and national coordinators identfied in
each country. In order to make the best possible use of a total of one days face-to-face training (two halfday sessions), participating dentists will received detailed information and training booklet to use at their
practices in advance of training (See booklet in annex)
The recommendations for training the GDP are:
1. One half day of slide presentations and discussions of the LA, BEWE and Schiff codes and
protocol for examination. Information should be done via an e-session.
2. At least one half day of examiner training which will include examination of a set of subjects
providing balanced numbers of tooth surfaces with LA Score, BEWE codes 0-3 and Schiff codes.
The examination findings of all examiners should be reviewed to identify differences in
interpretation. Examinations are to be repeated until agreement is reached among the examiners.

The non-carious dental cervical lesion and associated risk factors An observational, cross-sectional and multi-centre epidemiological study: 2010-2011

This exercise should be conducted by a senior examiner. Part of the exercise may involve using
extracted teeth; however, the training exercise must include examining live subjects
3. 1/2 days of reliability assessment using live subjects presenting with non carious cervical with
severity ranging between 0 and 3 (BEWE). At least 15 patients should be examined per examiner
and the senior examiner
A senior examiner is a dentist with experience in using the BEWE, has high degree (Kappa = 0.75+) of
intra-examiner reliability, and has been calibrated and is reliable with another experienced BEWE
examiner. In some studies, a senior examiner may work concurrently with the other examiners to reach a
final decision. The term senior examiner (DB, AN) is used to refer to the standard which will be used to
compare with the findings of the examiners in a study.

3 types of calibration 1 days seminars were organized:


Type 1: Training dentists sentinel by the European coordinator of the project (DB) in France, Italy, Spain,
Latvia (Kappa> 75)
Type 2: Training Coordinator Finnish national epidemiologist by the European coordinator (Kappa> 75),
followed by formation of Finnish and Estonian GDP (Kappa> 75)
Type 3: Formation of two national epidemiologists by the European coordinator of the project (Kappa> 75)
in UK.
Country

Training

No.
of
Dentists

Estonia*

AN

10

France*

DB

15

Italy*

DB LO

17

Latvia*

DB/ES

10

Finland

AN

10

UK

DB

Spain

DB

20

Turkey

DB

10

Total

94

Training format:
(C) Conventional workshop using PowerPoint and discussion over clinical cases;
(E) Formation of national officers using training and standardisation toolkits;
(D) Formation of national epidemiologists
Training days: (DB) Denis Bourgeois; (LO) Livia Ottolenghi (AN) Annamari Nihtila; (ES) Egita Senekola.
*: Egohid Team (WWW.egohid.eu)
The agenda of the calibration session include 8 sections :
Section 1 Introduction
Section 2: Basic Erosive Wear Examination
Test calibration
Evaluation
Section 3: Hypersentivity, Schiff Index
Section 4 Periodontal Health Assessment
Test calibration

The non-carious dental cervical lesion and associated risk factors An observational, cross-sectional and multi-centre epidemiological study: 2010-2011

Evaluation
Section 5 Euro Oral Health Erosion Clinical Form
Section 6 Questionnaire
Section 7: Practical organisations
Section 8: Conclusions
The trained dentists then returned to their own practices and recruited patients for inclusion in the study
from their patients who had pre-existing appointments for dental examinations. National coordinator was in
charge to control the sampling plan and the evolution of the type and nature of patients included according
to the evolution of the quota. A hot line was initiated to assist GDP if necessary.

5. Information to be collected
The general dentists will recruit sequentially patients who agree to participate corresponding to the
eligibility criteria. The study is a cross-sectional observational epidemiological study taking place in (1)
metropolitan West of South England; (2) region of Bristol, England; (3) France, Italy, Latvia, Estonia at
national level; (4) region of Andalusia of Spain; (5) region of Helsinki in Finland.
Inclusion in the study: For every included participant, the general dentist should:
o Explain the study to the participant;
o Give the letter of information to the participant;
o Obtain his informed consent;
o Provide the participant with the self-completed questionnaire;
o Complete with the participant the dentist questionnaire which covers the participants clinical and
socio-demographic data.
The standardised clinical examination and interview will take place in connection with a routine check-up
in the practice of a private or public dental practitioner. The Sentinel general dentists will be requested
not to modify their treatment practices for these patients. This study must not modify the dentistpatient
relationship; the dentists remain free to choose the treatment of their choice and their follow-up. No out-ofthe-ordinary treatment or examination will be linked to this study
6. Origins and type of categorical data to be collected
The general dentists will recruit sequentially patients who agree to participate in accordance with to the
eligibility criteria and their willingness to participate and to complete the self-administered questionnaire.
6.1 Documents to be completed
When the participant is initially admitted to the study, the general dentist should complete a register
comprising: the participants initials; the age, sex, date of examination, included in the study (yes/no),
reason for exclusion. Once admitted to the study, the self administered questionnaire completed by the
patient and the clinical questionnaire will be provided; these will not include the participants name but
rather an identifying number made up of the dentists number and a sequence number for the participant.
The patientgeneral dentist questionnaire, completed by the dentist, will comprise:
Criteria of eligibility:
o Verification of the inclusion/exclusion criteria; age; date of consultation; socio-demographic data for
the patient; age, sex, professional activity, study level achieved, location.
Clinical data about non-carious cervical lesions:
o Evaluated using the Basic Erosive Wear Examination BEWE- Index on an ordinal scale ranging
from 0 to 3 (0=no erosive wear, 3=Wear with tissue loss on more than 50% of the surface);
o Localisation of the lesion (coronal, root surface or crown-root junction).
Clinical data about dentinal hypersensitivity:
o Evaluated by the Schiff index (ordinal scale, 0=no sensitivity, 3=continuous painful sensitivity on
stimulus) and on the dentinal hypersensitivity index (binary, 0 = yes, 1=no on stimulus).

The non-carious dental cervical lesion and associated risk factors An observational, cross-sectional and multi-centre epidemiological study: 2010-2011

Clinical data about periodontal conditions evaluated by (1) loss of attachment (mm); (2) depth of
periodontal pockets, and (3) presence or absence of gingival bleeding.
All information to collect data are involved in the booklet attached: Booklets Escarcel

The participants self-administered questionnaire, completed before the consultation, will include:
o Data on the participants oral hygiene practices;
o The participants Oral Health Related Quality of Life: this scale is a measurement tool comprising
questions; responses are made on a 4 point scale;
o Data on the participants perception of dentinal sensitivity: intensity, duration, origin.
o Data on the evaluation of risk factors associated with non-carious cervical lesions (tobacco,
medication, diet).
o Data on the evaluation of risk factors associated with non-carious cervical lesions: seeking aid in the
dental care system; health associated preventive behaviours (weight, size)
7. Data management
The data arising from the dentist questionnaire, completed by the dentist, will be recorded on a paper
form provided to the dentists at the commencement of the study. These paper forms will be returned to the
Sentinel network using a pre-paid reply envelope. The information from these forms will be entered on
computer using the EPIDATA programme and will form the database. The paper forms will be archived
with the other documents of this study.
The data arising from the patient self-completed questionnaire, on paper, will be returned to the
Sentinel network by the dentist using a pre-paid reply envelope by the general dentist. The information
from these forms will be entered on computer using the EPIDATA programme and added to the data base.
The paper forms will be archived with the other documents of this study. Responses to the patient-D and
patient self reported questionnaires in the data base will be identified by the sequence number and no
names will be recorded against the data item in the electronic file so created. At the end of the study, a
report with statistical tables and conclusions will be prepared for analysis and consideration of the findings
by the scientific council and those responsible for the project. A scientific report will be written. The data
will remain the property of the promoter of the study; all information published will be anonymous. Apart
from the report and the scientific publication, no sharing of the data is anticipated. The final report will be
published online on the internet site of the Sentinels network after the work has been published in medical
and scientific journals. Internet access to the information will be free to all.
7.1. Statistical analysis
The questionnaire data will be double entered to identify data entry errors and checked for logical
coherence. Analysis will be conducted using the R programme. All questionnaire items will be analysed.
Missing data will be flagged. The qualitative variables will be described and compared using the Chisquare test or Fishers Exact test if the former test is inappropriate. Quantitative variables will be described
and compared using the Wilcoxon test.
The analysis will be undertaken in two stages: a univariate analysis followed by a multivariate analysis.
The univariate analysis will estimate crude odds ratios, measuring separately the strength of association
between the disease and each of the exposure factors, without taking account of other potential
confounding factors. An odds ratio of 1.0 signifies the absence of an association. An odds ration
significantly greater than 1.0 implies that the exposure factor is a risk factor for the condition (disease)
while an odd ration significantly lower than 1.0 suggests that the exposure factor is a preventive factor for
the condition.

The non-carious dental cervical lesion and associated risk factors An observational, cross-sectional and multi-centre epidemiological study: 2010-2011

Multivariate analysis allows all the risk factors to be taken into account by simultaneously adjusting for
their effects. The standard analytical method for case control studies is multiple logistic regression analysis.
This method allows adjusted odds ratios (and their associated confidence intervals) to be estimated for each
exposure factor.
Odds ratios for risk factors associated with the different questionnaire items (dentinal sensitivity, erosion,
periodontal conditions, quality of life scales and dietary variables will be calculated in accordance with the
advice of the scientific committee.

8. Ethical Considerations
The refusal of the patient to participate in a study must never interfere with the physician-patient
relationship.
The design and performance of the study should be should be transmitted to a specially appointed
independent committee for consideration, comment and guidance in accordance with national
legislation. The protocol has been approved by the National Ethics Committee in each country.
9. Budget
Co-funding for this research study will be provided by GlaxoSmithKline Consumer Healthcare in the
context of an agreement for observational research with University Lyon1-EZUS, France.
10. Scientific Council
Pr. Denis Bourgeois, University Lyon1, France, European coordinator
Pr David Bartlett, Kings College University, London, United Kingdom
Pr. A. Lussi, University of Berne, Switzerland
Pr. Mariano Sanz, Computense University of Madrid, Spain
Pr. Ph. Bouchard, University Paris VII, France
Pr. N. West, University of Bristol, United Kingdom
11. National Institutions
Italy: University di Roma Sapienza
France: French Union for Oral Health UFSBD United Kingdom: University Bristol
United Kingdom : Kingstons College, London
Spain: University of Grenada
Turkey: National Dental Association; University of Ankara
Finland : Public Health National Service, Espoo
CZ: TNS Sofress
Estonia: National Dental Association
Latvia: University of Riga

12. Timetable
Stage 1: March-April 2010 Meeting of the scientific committee and finalisation of the protocol and
questionnaires; Stage 2: October-November 2010 Recruitment of the general dentists; Stage 3: January
2011; Launching of the study; June 2011: Termination of the study
13. References
1. Addy M. Dentine hypersensitivity: new perspectives on an old problem. Int Dent J 2002; 52:
367-375.

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2. Miller N, Penaud J, Ambrosini P, Bisson-Boutelliez C, Brianon S. Analysis of etiologic


factors and periodontal conditions involved with 309 abfractions. J Clin Periodontol. 2003;
30:828-32.
3. Mayhew RB, Jessee SA, Martin RE. Association of occlusal, periodontal, and dietary factors
with the presence of non-carious cervical dental lesions. Am J Dent. 1998; 11:29-32.
4. Berg-Beckhoff G, Kutschmann M, Bardehle D. Methodological considerations concerning the
development of oral dental erosion indexes: literature survey, validity and reliability. Clin Oral
Investig. 2008; 12 Suppl 1:S51-58.
5. Bartlett DW, Shah P. A critical review of non-carious cervical (wear) lesions and the role of
abfraction, erosion, and abrasion. J Dent Res. 2006; 85:306-312.
6. Bartlett DW, Palmer I, Shah P. An audit of study casts used to monitor tooth wear in general
practice. Br Dent J. 2005; 13;199:143-145
7. Bartlett DW, Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE): a new scoring
system for scientific and clinical needs. Clin Oral Invest 2008; 12 (suppl 1): S65-S68.
8. Bartlett DW, Evans DF, Smith BG. The relationship between gastro-oesophageal reflux and
dental-erosion. J Oral Rehabil 1996; 23: 289-297.
9. Bardsley PF. The evolution of tooth wears indices. Clin Oral Invest 2008; 12(suppl 1): S15S19.
10. Bardsley PF, Taylor S, Milosevic A. Epidemiological studies of tooth wear and dental erosion
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11. Pegoraro LF, Scolaro JM, Conti PC, Telles D, Pegoraro TA. Non-carious cervical lesions in
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12. Lussi A, Schaffner M. Progression and risk factors for denral erosion and wedge-shaped
defects over 6-year period. Caries Res. 2000; 321-330
13. Lussi A, Hellwig E. Erosive potential of oral care products. Caries Res 2001; 35:52-56.
14. Zero T, Lussi A. Erosion chemical and biological factors of importance to the dental
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The non-carious dental cervical lesion and associated risk factors An observational, cross-sectional and multi-centre epidemiological study: 2010-2011

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