Advance Your Understanding of Gingival Recession

Oral health professionals rely on myriad classification and management strategies when diagnosing and treating patients with gingival recession, and sale reps can benefit from a basic understanding of these approaches.

Gingival recession is a common clinical condition, presenting in at least one or more tooth surfaces in 23% of U.S. adults between the ages of 30 and 90.1 This condition is associated with exposure of the root surface due to a displacement of the gingival margin apical to the cementoenamel junction.2 The presentation of gingival recession is variable. This article will summarize the deformities and conditions that oral health professionals may encounter in clinical practice, including gingival/mucosal tissue recession, lack of keratinized gingiva and decreased vestibular depth.

FIGURES 1A THROUGH 1C. Progression of gingival recession without treatment; these images were taken on (A) November 17, 2015, (B) February 2, 2016, and (C) April 13, 2016. JESSICA SCULLY, DDS

But how does gingival recession start in the first place? This is an important question for clinicians, as the underlying cause must be discovered for the condition to truly be treated. And it’s helpful for sales reps to know the steps necessary to complete such analysis and diagnosis when assisting oral health professionals with product recommendations.

Sales professionals should know that the etiology of gingival recession is multifactorial and can be categorized into predisposing factors and precipitating factors (Table 1).3 Although predisposing factors are mainly linked to anatomical factors — such as presence of underlying bone and thickness of the gingival biotype — inflammation can also be implicated. Additional anatomical predisposing factors include frenal pull and a lack of adequate keratinized gingiva.4 Important to note is that, when left untreated, gingival recession has a high probability of progressing — even in the presence of optimal home care.5 Figures 1A through 1C demonstrate the progression of gingival recession without treatment.

FIGURE 2. Signs of aggressive toothbrushing are visible. KIRAN ARORA, DDS

PRECIPITATING FACTORS

Although lack of oral hygiene and subsequent inflammation are precipitating factors in gingival recession, patients’ overzealous oral hygiene can also negatively impact the gingiva. The results of traumatic toothbrushing most commonly present as recession (Figure 2). In evaluating the effect of brushing, the factors that positively correlated with gingival recession include frequency, duration, using a horizontal or scrub method, bristle hardness and frequency of changing a toothbrush.6 Generalized remodeling of the gingival tissue as a result of periodontal disease and/or tooth extraction is also a factor. Other precipitating factors include tobacco chewing and oral piercings. Orthodontic therapy has long been debated as a precipitating factor, but a systematic review suggests the incidence of gingival recession is <10% in patients undergoing orthodontic treatment.7 When gingival recession is noted with orthodontic therapy, it tends to be treatable if identified early.3

ESTHETICS AT PLAY

Sales reps should know there are many indications for treatment of gingival recession, but esthetics is a major driving factor.8 According to a literature review that analyzed and identified factors that influence the decision to treat gingival recession, the other primary indications for treatment of gingival recession include classification of recession defect; hypersensitivity; progression of defect; and restorative or orthodontic needs.3

Classification of Recession Defect — Miller9 classified gingival recession based on severity. When a clinician classifies a patient having Miller’s class I or II recession, it means the patient has good predictability in terms of root coverage (Figure 3, page 32). Minimal coverage is expected in the case of a Miller’s class III or IV defect. Grafting is attempted in all classifications of Millers recession. Any treatment of Millers Class III and Class IV recession is completed with a goal of increasing the zone of keratinized gingiva and or to increase the thickness since root coverage is unpredictable.

Hypersensitivity — Aside from esthetics, hypersensitivity is the chief complaint of patients. Hypersensitivity has been shown to be significantly reduced following root coverage procedures.3,10 Some cases of hypersensitivity may require additional treatment, though clinicians generally explore nonsurgical treatment options before considering surgical root coverage. Sales reps should know and offer product formulations and options for non-surgical treatment of hypersensitivity resulting from gingival recession.

Progression of Defect — Recession that progresses without surgical intervention usually requires surgical treatment to regain lost attachment and halt further progression.

Restorative or Orthodontic Needs — It is suggested that oral health professionals maintain a band of keratinized gingiva around restorations with intracrevicular margins to achieve healthier tissue.11 While orthodontic treatment does not cause permanent damage to the periodontium, the risk for recession is high among patients with a thin gingival biotype. Clinicians often recommend gingival augmentation to patients who present with areas of thin gingival biotype or when orthodontic therapy is expected to move the tooth outside the alveolar housing.11

Furthermore, orthodontic practices should closely monitor patients for signs of recession, as surgical intervention may be required before, during or after treatment — especially among patients who present with a high plaque score. Areas featuring a lack of keratinized gingiva can be difficult to clean, leading to biofilm accumulation.4,11 This accumulation promotes inflammation that could potentially cause the recession to progress. Dental teams should educate patients about the need for optimal oral hygiene, and clinicians should consider treatment to increase the zone of keratinized gingiva.


Terms to Learn

Gingival recession: Associated with oral exposure of the root surface due to a displacement of the gingival margin; noted primarily on the left maxillary canine and premolars, as well as the mandibular canines.
Cementoenamel junction: Visible anatomical border on a tooth.
Vestibular depth: Measurement of gingival tissue in the mandibular anterior region of the oral cavity.
Multifactorial: Resulting from more than one cause or influence.
Predisposing factors: To give a partiality or tendency to beforehand consideration of outside factors.
Precipitating factors: Factors that cause or trigger a reaction/response.
Gingival biotype: Thickness of the gingival tissue.
Inflammation: Redness, swelling or bleeding in the gums caused by bacterial proliferation.
Frenal pull: A force exterted by the frenum (the membrane located on the underside of the tongue) in either the maxillary or mandibular arch.
Periodontium: Specialized tissues that help support teeth by surrounding them.


DENTAL IMPLANTS

Expanding on early successes in osseointegration, the focus in implantology today is shifting to more esthetic outcomes.12 Oral health professionals are charged with ensuring that dental implants and implant restorations in the esthetic zone closely mimic natural tooth structure and exhibit a soft-tissue profile that offers the appearance of a natural tooth. Successful implants in the esthetic zone are made possible through preservation of the soft tissue or soft-tissue augmentation procedures and also help maintain the soft tissue health of dental implants.

FIGURE 3. Miller’s Class II gingival recession is visible on this patient. TANNER BROCK, DDS

CONCLUSION

Prompt diagnosis of gingival recession is critical to early intervention and successful outcomes. Although not every case of recession warrants treatment, clinicians are charged with evaluating etiology and factors that indicate the need for a therapeutic solution. And sales reps should be ready to offer product recommendations that will assist in the indicated next step.

Bonus Web Content

The author thanks Kiran Arora, DDS, Jessica Scully, DDS, and Tanner Brock, DDS, for supplying the images.

The article is adapted from one previously published in Decisions in Dentistry.

References

  1. Albandar JM, Kingman A. Gingival recession, gingival bleeding, and dental calculus in adults 30 years of age and older in the United States, 1988–1994. J Periodontol. 1999;70:30–43.
  2. American Academy of Periodontology. Glossary of Periodontal Terms. Available at: 184.106.75.105/sites/default/files/files/PDFs/Clinical%20Resources/GlossaryOfPeriodontalTerms2001Edition.pdf. Accessed December 19, 2017.
  3. Chan HL, Chun YH, MacEachern M, Oates TW. Does gingival recession require surgical treatment? Dent Clin North Am. 2015;59:981–996.
  4. Lang NP, Löe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol. 1972;43:623–627.
  5. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: a systematic review from the AAP Regeneration Workshop. J Periodontol. 2015;86(Suppl 2):S8–S51.
  6. Heasman PA, Holliday R, Bryant A, Preshaw PM. Evidence for the occurence of gingival recession and non-carious cervical lesions as a consequence of toothbrushing. J Clin Periodotontol. 2015;42(Suppl 16):S237–S255.
  7. Joss-Vassalli I, Grebenstein C, Topouzelis N, Sculean A, Kastros C. Orthodontics therapy and gingival recession: a systematic review. Orthod Craniofac Res. 2010;13:127–141.
  8. Cairo F, Pagliaro U, Buti J, et al. Root coverage procedures improve patient aesthetics. A systematic review and Bayesian meta-analysis. J Clin Periodontol. 2016;43:965–975.
  9. Miller PD Jr. Root coverage using the free soft tissue autograft following citric acid application. III. A successful and predictable procedure in areas of deep-wide recession. Int J Periodontics Restorative Dent. 1985;5:14–37.
  10. Douglas de Oliveira DW, Oliveira-Ferreira F, Flecha OD, Gonçalves PF. Is surgical root coverage effective for the treatment of cervical dentin hypersensitivity? A systematic review. J Periodontol. 2013;84:295–306.
  11. Kim DM, Neiva R. Periodontal soft tissue non-root coverage procedures: a systematic review from the AAP Regeneration Workshop. J Periodontol. 2015;86(Suppl 2):S56–S72.
  12. Azar DE. Dental implant uncovering techniques with emphasis on increasing keratinized mucosa. Compend Contin Educ Dent. 2015;36:290–292,294,296–297.

Featured Image by YURI_ARCURS/DIGITALVISION/GETTY IMAGES

From MENTOR. February 2018;9(2): 28-32.

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