Prevalence of gingival recession in university students: a systematic review

Abstract

Purpose:

This systematic review aims to comprehensively assess the prevalence, extent, severity, and distribution of gingival recession (GR) among university students. Recognizing that GR rep-resents a significant periodontal concern with aesthetic and functional consequences, this review focuses on a young demographic that is underrepresented in epidemiological surveys.

Materials and methods:

Following the PRISMA guidelines and a pre-registered protocol, a structured search strategy was designed and executed across PubMed, Web of Science, Cochrane, and EBSCO databa-ses, targeting studies published over the last 20 years. Eligibility was defined using the PICO framework: Population: university students; Intervention/Exposure: presence of GR; Comparison: absence of GR; Outcome: prevalence rates. The Joanna Briggs Institute (JBI) critical appraisal checklists were used to assess methodological quality and risk of bias across various study designs, including cross-sectional, cohort, case-control, and randomized controlled trials.

Results:

Out of 299 initially identified articles, nine met the inclusion criteria, encompassing a total of 1,619 participants. The design of the included studies revealed considerable heterogeneity in sampling, measurement methods, and reported prevalence, which ranged widely from 29.4% to 82.6%. Risk factors linked to GR included age, gender, oral hygiene practices, brushing technique and force, occlusal interferences, and anatomical factors.

Conclusion:

This systematic review demonstrates a high prevalence of gingival recession among university students, underscoring the importance of targeted preventive strategies and educational interventions in this population. Future well-designed longitudinal studies are needed to clarify causality and inform tailored prevention programs.

Introduction

Periodontal health is a crucial aspect of overall oral well-being, and any compromise to the integrity of the gingival tissues can have profound implications for an individual’s oral health. Such conditions may also raise concerns about smile aesthetics due to their so-cial impact. Gingival recession (GR) is defined as the apical displacement of the gingival margin from the cementoenamel junction (CEJ), resulting in root surface exposure (1, 2). In affected individuals, GR is often considered aesthetically undesirable and may contribute to increased sensitivity and pain, raising the risk of root caries due to greater dental plaque accumulation (2, 3, 3, 4, 5). This condition can be localized or generalized, affecting one or more tooth surfaces depending on the presence of periodontal disease (2, 6).

There are various ways to classify GR, but the classification proposed by Cairo et al. (7) is the most widely used today. This system divides recessions into type 1 (RT1), type 2 (RT2), and type 3 (RT3). RT1 describes recessions with no interproximal attachment loss and has the best prognosis. RT2 involves interproximal attachment loss that is less than or equal to the buccal attachment loss. RT3 describes cases where the interproximal attachment loss is greater than the buccal attachment loss and typically has the worst prognosis (7).

The etiology of gingival recession is considered multifactorial, with several contributing factors (2, 4, 8, 9, 10). Anatomical factors are regarded as predisposing elements and include fenestration and dehiscence of the alveolar bone, gingival biotype, tooth shape, abnormal tooth position within the arch, aberrant eruption pathways, and frenulum insertion near the cervical gingiva. These factors can result in a thinner than normal alveolar bone plate, making the tissue more susceptible to resorption.

Triggering factors, such as inflammation caused by bacterial biofilm accumulation, play a significant role in the development of GR. Additionally, traumatic toothbrushing and the type of toothbrush used are often linked to the onset and progression of localized non-inflammatory GR. Other aggravating factors include non-carious cervical lesions—such as abrasion, abfraction, erosion, attrition, and resorption—along with the use of oral piercings, occlusal trauma, tobacco use, and physiological factors like orthodontic therapy or surgical procedures.

Several studies have investigated the prevalence of GR in adults, but the findings are inconsistent. Reported prevalence rates range from 15% in a Swiss sample, to 58% in a large study of 9,689 adults in the USA, to 84.65% in France, and up to 99.75% in a rural area of Brazil (3, 9). Smaller cross-sectional studies focusing on young students have reported lower prevalence rates, such as 29.4% in Poland (11) and 39% in Italy (9), while higher rates have been observed in Chile (68.4%) (4) and Bologna (82.6%) (12).

In children and young adults, gingival recession is often linked to gingivitis, whereas in older adults it is strongly associated with periodontal disease (10). Therefore, GR frequ-ently leads to dental visits, and it is essential to identify its causes and determine appropriate treatments, as this condition affects a significant portion of young populations (8).

The protocol for this systematic review was developed in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. The target population of this study is university students. The exposure of interest is the presence of gingival recession compared to students without this condition, with the primary outcome being the prevalence of GR in this population.

Materials and methods

Ethical statement

This project was reviewed and approved by the Institutional Review Board of the Instituto Universitário de Ciências da Saúde (CE/IUCS/CESPU-23/23).

Study protocol

The protocol for this systematic review was developed in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. The eligibility criteria were structured using the PICO framework as follows: P (Population): University students, I (Intervention / Exposure): Presence of gingival recession, C (Comparison): Students without gingival recession, O (Outcome): Prevalence of gingival recession among university students. This review aims to answer the following question: What is the prevalence of gingival recession among university students?

Research strategy

A comprehensive search was conducted in the Web of Science, Cochrane, PubMed, and EBSCO databases for all relevant literature published in the last 20 years. The following MeSH terms were used: [(gingival recession) AND (student) OR (gingival recession) AND (student) AND (prevalence) OR (gingival recession) AND (student) AND (epidemiology)].

Eligibility criteria

Inclusion criteria: Studies published in English, Spanish, or Portuguese that investigated the prevalence of gingival recession in university students. Exclusion criteria: Studies involving animals, non-university populations, studies lacking clear outcome measures, on-going studies, or review articles not written in English, Spanish, or Portuguese.

Study selection and data collection

Articles were screened based on the eligibility criteria, beginning with a review of the title and abstract. Full texts of potentially relevant articles were then assessed to deter-mine whether they met the inclusion criteria. Relevant data from each included study were extracted and organized in a results table, detailing the study design, objectives, study population (including sample size and mean age or age range), and findings.

Results

Database search

A total of 299 records were initially identified through database searches. After removing 102 duplicates, 197 articles remained for abstract screening, of which 126 were excluded. The full texts of the remaining 71 articles were then reviewed in detail. Following the application of the inclusion and exclusion criteria, 49 studies were deemed potentially eligible. However, 40 of these were excluded due to differences in study population, resulting in a final inclusion of 9 studies. Figure 1 illustrates the detailed article selection process.

Figure 1.

Flow diagram of study selection process.

Characterization of the sample for the quality of the study

The quality assessments are presented in Table 1 for cross-sectional studies, Table 2 for case-control studies,Table 3 for randomized controlled trials, and Table 4 for cohort studies. Overall, the methodological quality of the included studies, based on the appraisal criteria and the number of positive responses, is generally high for four studies (4, 5, 8, 13). However, three studies (9, 14, 15) were rated as providing moderate evidence, while two studies (12, 16) were considered to be of lower quality.

Table 1.

Joanna Briggs Institute critical appraisal checklist for analytical cross-sectional studies.

Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies.	1. Were the Criteria for Inclusion in the Sample Clearly Defined?	2. Were the Study Subjects and the Setting Described in Detail?	3. Was the Exposure Measured in a Valid and Reliable Way?	4. Were Objective, Standard Criteria Used for Measurement of the Condition?	5. Were Confounding Factors Identified?	6. Were Strategies to Deal with Confounding Factors Stated?	7. Were the Outcomes Measured in a Valid and Reliable Way?	8. Was Appropriate Statistical Analysis Used?
Krishna Prasad et al. (16) 2013	N	N	UN	Y	N	N	UN	UN
Souza et al. (8)2019	Y	Y	Y	Y	Y	Y	Y	Y
Amaro-Rivera et al.(4), 2020	Y	Y	Y	Y	Y	Y	Y	Y
Vignoletti et al.(9) 2020	N	UN	Y	Y	Y	Y	Y	Y
Domenico et al. (14), 2022	N	Y	Y	Y	Y	UN	Y	Y
Kozlowska et al. (12), 2005	N	UN	UN	Y	UN	UN	UN	Y

Table 2.

Joanna Briggs Institute critical appraisal checklist for case control studies.

Joanna Briggs Institute Critical Appraisal Checklist for Case Control Studies.	1. Were the Groups Comparable other than the Presence of Disease in Cases or the Absence of Disease in Controls?	2. Were Cases and Controls Matched Appropriately?	3. Were the Same Criteria Used for Identification of Cases and Controls?	4. Was Exposure Measured in a Standard, Valid, and Reliable Way?	5. Was Exposure Measured in the Same Way for Cases and Controls?	6.Were Confounding Factors Identified?	7.Were Strategies to Deal with Confounding Factors Stated?	8. Were Outcomes Assessed in a Standard, Valid, and Reliable Way for Cases and Controls?	9. Was the Exposure Period of Interest Long Enough to be Meaningful?	10. Was Appropriate Statistical Analysis Used?
Gürbüz et al. (5), 2023	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y

Table 3.

Joanna Briggs Institute critical appraisal checklist for randomized controlled trials.

Joanna Briggs Institute Critical Appraisal Checklist for Randomized Controlled Trials.	1. Was True Randomization Used for Assignment of Participants to Treatment Groups?	2. Was Allocation to Treatment Groups Concealed?	3. Were Treatment Groups Similar at the Baseline?	4. Were Participants Blind to Treatment Assignment?	5. Were Those Delivering Treatment Blind to Treatment Assignment?	6. Were Outcomes Assessors Blind to Treatment Assignment?	7. Were Treatment Groups Treated Identically Other than the Intervention of Interest?	8. Was Follow up Complete and If Not, Were Differences between Groups in Terms of Their Follow up Adequately Described and Analyzed?	9. Were Participants Analyzed in the Groups to Which They Were Randomized?	10. Were Outcomes Measured in the Same Way for Treatment Groups?	11. Were Outcomes Measured in a Reliable Way?	12. Was Appropriate Statistical Analysis Used?	13. Was the Trial Design Appropriate, and any Deviations from the Standard RCT Design (Individual Randomization, Parallel Groups) Accounted for in the Conduct and Analysis of the Trial?
Cifcibasi et al. (15), 2014	Y	Y	Y	UN	Y	Y	Y	N	N	Y	UN	Y	Y

Table 4.

Joanna Briggs Institute critical appraisal checklist for randomized controlled trials.

Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies.	1. Were the Two Groups Similar and Recruited from the Same Population?	2. Were the Exposures Measured Similarly to Assign People to both Exposed and Unexposed Groups?	3. Was the Exposure Measured in a Valid and Reliable Way?	4. Were Confounding Factors Identified?	5. Were Strategies to Deal with Confounding Factors Stated?	6. Were the Groups/Participants Free of the Outcome at the Start of the Study (or at the Moment of Exposure)?	7. Were the Outcomes Measured in a Valid and Reliable Way?	8. Was the Follow up Time Reported and Sufficient to Be Long Enough for Outcomes to Occur?	9. Was Follow up Complete, and If Not, Were the Reasons to Loss to Follow up Described and Explored?	10. Were Strategies to Address Incomplete Follow up Utilized?	11. Was Appropriate Statistical Analysis Used?
Daprile et al.(13) 2007	Y	Y	UN	Y	UN	Y	Y	Y	Y	UN	Y

Characteristics of the included studies

We collected data on the general characteristics of all eligible studies included in this systematic review, such as the study population (including sample size and average age), study design, objectives, and results Table 5)).

Table 5.

The main characteristics of the included studies.

Author, year	Title	Population	Study type	Aim of the study	Conclusions	Results
Daprile et al. (13), 2007	The evolution of buccal gingival recessions in a student population: a 5-year follow-up	10 males and 13 females, aged 23–25 years	Cohort	To evaluate changes in buccal gingival recessions over a 5-year period in dental students.	The percentage of affected sites increased despite improved oral hygiene education.	The number of subjects with at least one recession increased significantly over time.
Krishna Prasad et al. (16), 2013	The influence of occlusal trauma on gingival recession and gingival clefts	50 subjects with gingival recession and 10 with gingival clefts	Cross-sectional	To assess occlusal contact patterns and their relationship with gingival lesions.	Occlusal interferences may contribute to gingival recession and clefts.	Gingival recession was more frequent in group function occlusion than canine guidance.
Cifcibasi et al. (15), 2014	Comparison of manual toothbrushes with different bristle designs	40 dental students (25 females, 15 males; 21–25 years)	Randomized controlled trial	To compare plaque control efficacy and gingival recession outcomes.	Bristle design had little impact on gingival recession when soft bristles were used.	Both toothbrush designs significantly reduced plaque and gingival index scores.
Souza et al. (8), 2019	Prevalence of gingival recession in Brazilian dental students	80 dental students aged 18–35 years	Cross-sectional	To evaluate prevalence of gingival recession and dentine hypersensitivity.	Gingival recession was highly prevalent among students.	62.5% of students had at least one gingival recession, mainly on buccal surfaces.
Amaro-Rivera et al. (4), 2020	Prevalence and risk indicators of gingival recessions in Chilean students	310 students (53.5% women)	Cross-sectional	To identify prevalence and risk indicators of gingival recession.	High prevalence of gingival recession was observed.	At least one gingival recession was present in 68.4% of students.
Vignoletti et al. (9), 2020	Prevalence and risk indicators of gingival recessions in Italian students	264 dentistry and dental hygiene students	Cross-sectional	To assess prevalence, severity, and associated risk indicators.	Low prevalence of gingival recessions was observed.	Age and smoking were associated with extent and severity of recession.
Domenico et al. (14), 2022	Prevalence and periodontal conditions of developmental grooves	251 students (mean age 22.9 ± 4.7 years)	Cross-sectional	To evaluate prevalence of developmental grooves and periodontal effects.	Radicular grooves increased the risk of gingival inflammation.	Presence of grooves was significantly associated with plaque and bleeding on probing.
Gürbüz et al. (5), 2023	Evaluation of mid-buccal gingival recessions and occlusal interferences	149 dental students aged 18–25 years	Case-control	To assess relationships between occlusal interferences and gingival recessions.	Occlusal interferences may influence presence and severity of recessions.	Multiple occlusal and periodontal factors were associated with recession severity.
Kozlowska et al. (12), 2005	The oral cavity hygiene as a factor in gingival recession prophylaxis	455 university students aged 18–32 years	Cross-sectional	To evaluate hygiene-related factors associated with gingival recession.	Improper brushing habits were associated with increased recession.	Gingival recession was detected in 134 out of 455 subjects.

Discussion

Gingival recession, defined as the downward movement of the gingival margin leading to root surface exposure, is a prevalent oral health concern with implications for both aesthetics and periodontal health. While numerous studies have investigated its prevalence in various populations, there remains a lack of research specifically focused on its occurrence among university students. Understanding the prevalence, extent, severity, distribution, and related risk or predisposing factors in this demographic is essential for informing targeted oral health interventions and promoting effective prevention strategies. In this review, we aim to synthesize the available evidence regarding the prevalence of gingival recession among university students and discuss its implications for oral health promotion in this population. Our review identified a total of nine studies that met the inclusion criteria.

Prevalence

The lowest prevalence was reported in a cross-sectional study by Kozlowska et al. (12), which assessed the impact of specific hygiene factors on the development of gingival recession and dental plaque in 455 students at the Medical University of Bialystok (aged 18–32 years). They found a prevalence of 29.4%, similar to the 39% reported by Vignoletti et al. (9) in a comparable study involving 251 students aged 19–50 years from the School of Dentistry and Dental Hygiene in Milan. Their study aimed to assess the prevalence, extent, severity, distribution, and patient perception of gingival recession, as well as to identify potential risk factors. This relatively low prevalence contrasts with findings from other studies. For example, De Souza et al. (8) reported that at least one site of gingival recession was present in 62.5% of a sample of 80 dental students at a Brazilian university (aged 18–35 years). Similarly, Amaro-Rivera et al. (4) found a prevalence of 68.4% in a sample of 310 students from Valdivia (aged 16–21 years).

The highest rates were reported by Daprile et al. (13), who followed the progression of gingival recession in dental students at Bologna University Dental School over five years. They found a baseline prevalence of 47.8%, which increased to 82.6% after five years. This trend is consistent with Gürbüz et al. (5), who reported 47% prevalence of mid-buccal gingival recession in 149 dental students at Gazi University. Their longitudinal data also suggest a strong correlation between improved oral hygiene training and an increase in detected recessions among dental students. Minor differences between studies may be attributed to variations in the age range of participants and sample sizes.

Extent and severity

Another important aspect reported in the studies is the severity of recession at both the patient and site levels (9, 12). De Souza et al. (8) reported that 96.25% of sites were classified as Miller Class I, with only 0.1% as Class II and none as Class III. These results are consistent with Amaro-Rivera et al. (4), who found similar distributions (97.7% Class I, 1.4% Class II, 0.9% Class III). Severe recession depths (>4 mm) were found in only 1% of individuals assessed by Vignoletti et al. (9), while 14% presented with 3 mm depths and half of the sample (50%) had shallow recessions of about 1 mm. Consistently, Gürbüz et al. (5) reported similar patterns, with 61.4% of sites at 1 mm and 5.6% at 3 mm; no sites with 4 mm recessions were found in their sample. These findings likely reflect the younger age of the study populations.

Distribution

Most studies reported a higher prevalence of gingival recession in the lower jaw. Amaro-Rivera et al. (4) observed the highest frequency at the lower premolars (47.7%), a pattern also seen by De Souza et al. (8), who found 37.35% at the same sites. These results align with findings from Kozlowska et al. (12) and Daprile et al. (13). In contrast, Gürbüz et al. (5) found a higher prevalence on the mandibular canines and incisors (62%). Moreover, Vignoletti et al. (9) reported higher prevalence in the maxilla (60%), with the first premolars being the most affected. Regarding the most affected surface, the buccal surface was consistently the most reported in studies by Kozlowska et al. (12) and De Souza et al. (8). Variations in hygiene habits or anatomical differences may explain these discrepancies.

Perception

The perception of gingival recession was investigated by Vignoletti et al. (9) using a patient questionnaire. They found that 36% of subjects were unaware of the condition, while 64% recognized it. Of those aware, 24% were concerned about aesthetics, 16% reported air sensitivity, and 11% reported both. Of the 63 patients who noticed the condition, only 24 sought treatment. Similarly, De Souza et al. (8) found that 28% of students reported air sen-sitivity, with mild pain being most common.

Risk indicators

Age has frequently been analyzed as a potential risk factor. Vignoletti et al. (9) and Kozlowska et al. (12) found a significant correlation between age and GR prevalence, whereas Cifcibasi et al. (15), who compared different toothbrush designs, found no such correlation. Sex was another factor noted in multiple studies. Kozlowska et al. (12) reported a hig-her incidence of GR among women (34.74%) than men, which contrasts with Gürbüz et al. (5), who found a significant association between male gender and the extent or presence of gingival recession. Smoking was considered only by Vignoletti et al. (9), who noted it as a potential factor contributing to increased recession, though few smokers were included in the other studies. Full-mouth bleeding score (FMBS) was examined by Gürbüz et al. (5), who found that it increased both the presence and extent of GR, similar to Vignoletti et al. (9), who observed a link between bleeding on probing (BOP) and severity. Both studies also concluded that non-carious cervical lesions (NCCLs) and low keratinized tissue width (KTW) strongly influence the severity or presence of recession. Brushing technique and habits can also have a significant impact on GR. Kozlowska et al. (12) found that brushing pressure, technique, toothbrush hardness, and frequency of brush replacement were all significantly associated with an increased number of recessions. Gürbüz et al. (5) found that poor brushing frequency increased the extent of lesions, with infrequent brushing increasing the likelihood of mid-buccal gingival recessions (mbGR) by 7.5 times. Amaro-Rivera et al. (4) reported that 89.18% of participants who brushed once a day or less, and had low interproximal hygiene habits, showed signs of GR; notably, 40.3% were unaware of their toothbrush hardness. Cifcibasi et al. (15) compared criss-cross and flat-trim bristle designs, concluding that brush design had little effect on GR but that the criss-cross bristles were slightly more effective at reducing inflammation. Occlusal factors also play a role. Krishna Prasad et al. (15 examined the influence of occlusal trauma on GR and gingival clefts in 60 dental students, finding that clefts were more frequent in the maxillary posterior region. Occlusal interferences—such as protrusive, mediotrusive, and laterotrusive contacts—were linked to GR, particularly in subjects with group function occlusion and without mutually protected occlusion. Gürbüz et al. (5) confirmed similar correlations between occlusal interferences and mbGR in molars and premo-lars. Di Domenico et al. (14) investigated developmental grooves, concluding that radicular grooves retain plaque six times more and double the likelihood of inflammation, acting as significant risk factors for recession development. Socioeconomic factors were addressed by Amaro-Rivera et al. (4), who found that students attending public institutions had a higher prevalence of GR, likely due to reduced access to education and professional care. Finally, the influence of knowledge and training was demonstrated by Daprile et al. (13), whose five-year follow-up of dental students showed that improved oral hygiene education (e.g., increased use of the Bass technique) correlated with a rise in GR prevalence from 47.8% to 82.6%, suggesting that greater awareness and technique mastery can paradoxically increase detection and reporting of GR.

Conclusion

This systematic review provides valuable insights into the prevalence of gingival recession among university students. Through the comprehensive analysis of these nine studies, a wide range of reported prevalence rates was identified. While some studies reported relatively low prevalence, others indicated significantly higher rates of GR in this population. The majority of the studies demonstrated that demographic factors such as higher age, lower socioeconomic status, female gender, and poor oral hygiene behaviors are associated with an increased prevalence of gingival recession among students. This population represents an important target group for oral health promotion and preventive interventions. Implementing targeted educational programs, promoting regular dental care, and encouraging effective oral hygiene practices can help reduce the incidence of this condition and improve oral health outcomes among university students.