Etiology and occurrence of gingival recession - An epidemiological study

Abstract

Objectives:

Gingival recession is the term used to characterize the apical shift of the marginal gingiva from its normal position on the crown of the tooth. It is frequently observed in adult subjects. The occurrence and severity of the gingival recession present considerable differences between populations. To prevent gingival recession from occurring, it is essential to detect the underlying etiology. The aim of the present study was to determine the occurrence of gingival recession and to identify the most common factor associated with the cause of gingival recession.

Methods:

A total of 710 subjects aged between 15 years to 60 years were selected. Data were collected by an interview with the help of a proforma and then the dental examination was carried out. The presence of gingival recession was recorded using Miller's classification of gingival recession. The Silness and Loe Plaque Index, Loe and Silness gingival index, community periodontal index were recorded. The data thus obtained were subjected to statistical analysis using Chi-square test and Student's unpaired t-test.

Results:

Of 710 subjects examined, 291 (40.98%) subjects exhibited gingival recession. The frequency of gingival recession was found to increase with age. High frequency of gingival recession was seen in males (60.5%) compared to females (39.5%). Gingival recession was commonly seen in mandibular incisors (43.0%). Miller's class I gingival recession was more commonly seen. The most common cause for gingival recession was dental plaque accumulation (44.1%) followed by faulty toothbrushing (42.7%).

Conclusion:

Approximately half of the subjects examined exhibited gingival recession. The etiology of gingival recession is multifactorial, and its appearance is always the result of more than one factor acting together.

INTRODUCTION

A beautiful smile is the best ornament for the face and is the most primitive forms of human communication. The harmony of the smile is determined especially by the shape, the position and the color of the teeth.[1] People of all ages are increasingly concerned about their smile and overall appearance.

An adequate mucogingival complex, in which the mucogingival tissues can sustain their biomorphologic integrity and maintain an enduring attachment to the teeth as well as the underlying soft tissue, is always essential. When a mucogingival problem occurs, there are basically two ways in which it presents itself: (a) As a close disruption of the mucogingival complex resulting in pocket formation. (b) As an open disruption of the mucogingival complex resulting in gingival clefts and gingival recession.[2]

Gingival recession is the term used to characterize the apical shift of the marginal gingiva from its normal position on the crown of the tooth to the levels on the root surface beyond the cemento-enamel junction.[3] Although many dental conditions go unnoticed by patients, gingival recession can often be visible to patients and for which they may seek advice of a dentist. Gingival recession usually creates an esthetic problem, especially when such problem affects the anterior teeth and anxiety about tooth loss due to progression of the destruction. It may also be associated with dentine hypersensitivity, root caries, abrasion and/or cervical wear, erosion because of exposure of the root surface to the oral environment and an increase in accumulation of dental plaque.[4]

Despite the frequent observation in adult subjects, the occurrence and severity of the gingival recession presents considerable differences between study populations. A limited amount of prevalence and etiology related studies on gingival recession have been carried out in South India. Therefore, it is important to collect detailed information, to assess the tendency and epidemiology of this condition, identify the etiological factors and establish preventive measures. Hence, the aim of the present study was to determine the occurrence of gingival recession and to identify the most common factor associated with the cause of gingival recession in the patients.

MATERIALS AND METHODS

Subjects of this study were selected from the outpatients attending the Department of Periodontology, Yenepoya Dental College, Mangalore. Samples of 710 patients were examined and selected for this study. Sample size was determined after a pilot study was carried out of 151 patients. The pilot study results revealed that the prevalence of gingival recession was 35.1%. The sample size was determined using the formula n = z² pq/d². Assuming that the values obtained are z = a point on normal distribution with 95% confidence, P = prevalence from pilot study, q = 100-p, d = admissible error that is 10% of prevalence.

The study was reviewed and approved by the institutional review board of Yenepoya University, Mangalore, India. A Written informed consent was taken from every participant prior to the study and at the end of the study all the patients were treated. Patients aged between 15 and 60 years who had a minimum of 20 permanent teeth and no histories of periodontal therapy undertaken during the past 6 months were included in the study. Patients with systemic diseases were excluded from the study.

An observational study was performed to find out the most common cause and occurrence of gingival recession during May 2011 to January 2012. A random sampling technique was used to select 710 subjects of both genders aged between 15 years and 60 years from the outpatient Department of Periodontology, Yenepoya Dental College, Mangalore. Data were collected by an interview with the help of a proforma prepared for this study, and dental examination was carried out. The proforma of the study contained a detailed history of personal habits and brushing habits. Each subject was examined in a dental chair by a single, trained, and calibrated examiner using dental chair light, mouth mirror, explorer, William's periodontal probe and CPI probe. The entire mouth was examined in a uniform pattern. Presence of gingival recession was recorded using Miller's classification (1985)[5] of gingival recession. Following clinical parameters were recorded-Silness and Loe plaque index (1967),[6] Loe and Silness gingival index (1963),[7] community periodontal index (CPI) (1997).[8]

The tooth malalignment was observed by viewing the teeth from occlusal plane and position of each tooth was classified according to its relation to the regular curve of the arch either correctly positioned or outstanding (labially placed) and instanding (lingually placed) in all subjects. Diagnosis of faulty toothbrushing in this study was done by examining the facial surface of the tooth for the presence of cervical abrasion. The exposed tooth surface appeared to be free of plaque and was highly polished.[9] The upper and lower frenum was examined for the site of attachment and presence of frenal pull according to Placek et al. classification.[10] Tension test was carried out to confirm the adequacy of the width of the attached gingiva.[11] History of smoking and brushing habits (the type of brushing method, duration of brushing, frequency of brushing) was included in the questionnaire. Trauma from occlusion was assessed by checking mobility of each tooth. Fremitus test was done on both upper and lower teeth.[2] After the completion of the study, the subjects were given suitable treatment.

The data obtained were subjected to statistical analysis using Chi-square test and Students unpaired t-test. The results were tabulated using SPSS version 17 software.(Chicago).

RESULTS

Occurrence of gingival recession

Of 710 subjects, 291 (40.98%) had gingival recession. In total, 1152 teeth had gingival recession [Table 1].

Table 1.

Occurrence of gingival recession

In age group 15–25 years, the gingival recession was 26.9% (n = 78); age group 25–35 years, it was 41.5% (n = 113); age group 35–45 years, it was 66.1% (n = 74); and in age group 45–60 years, it was 70.3% (n = 26). It shows that as age increases there is increase in gingival recession which was of statistical significance (P < 0.001) [Figure 1].

Figure 1.

Occurrence of gingival recession according to age

Males were mostly affected by gingival recession 60.5% compared to females 39.5% which was of statistical significance [Figure 2]. Gingival recession was commonly seen in mandibular incisors (43.0%) followed by maxillary molar (13.2%), mandibular premolar (12.2%), maxillary incisor and premolar (8.9%), mandibular molar (4.9%), maxillary canine (4.6%), mandibular canine (4.3%) [Figure 3]. Recession was commonly observed in the mandibular arch (66%) than maxillary arch (34%) [Figure 4].

Figure 2.

Occurrence of gingival recession according to gender

Figure 3.

Occurrence of gingival recession according to the type of teeth

Figure 4.

Occurrence of gingival recession according to the type of arch

The most commonly seen was Miller's class I (59.5%) followed by class II (35.3%), class III (2.7%) and class IV (2.5%) [Figure 5]. According to CPI, in recession group, 63.6% of subjects had score 3 compared to without recession group subjects.

Figure 5.

Occurrence of gingival recession according to Millers class of gingival recession

Probable etiologic factor causing gingival recession

When the etiologic factors causing gingival recession were examined in 1152 teeth of 710 subjects, the most common factor was found to be dental plaque accumulation (44.1%) followed by faulty toothbrushing (42.7%), habits such as smoking and use of smokeless tobacco (7.1%), malocclusion (4.6%), high frenal attachment (0.4%) and others like inadequate attached gingiva, occlusal trauma (1%) [Figure 6].

Figure 6.

Etiology of gingival recession in percentage

The mean plaque index was 1.35 in subjects without gingival recession compared to 1.96 in subjects with gingival recession. It was statistically significant in recession group compared to without recession group (P < 0.001).

Horizontal type of brushing was followed by 64.9% of subjects with recession (P < 0.001). About 46.4% of subjects with recession brushed for > 3 min (P < 0.001). About 62.2% of subjects with recession brushed twice daily (P < 0.001) The type of brushing method, duration of brushing, frequency of brushing are statistically significant in subjects with recession compared to subjects without recession.

DISCUSSION

Epidemiology is a useful means of establishing a need for treatment or for preventive intervention. It often deals with co-relations between two or more findings. Various suppositions regarding cause and effect have been based upon these co-relations. However, correlations are not a means of showing cause and effect but only a means of showing a relationship.[2] The exact nature of the relationship remains to be determined in the future studies. The present study was designed to determine the occurrence and probable etiology of gingival recession among 710 individuals in the age group between 15 and 60 years.

Of the 710 subjects examined for the study, 291 (40.98%) subjects showed gingival recession. Similar results were seen in previous studies.[12,13,14,15,16] Whereas a higher prevalence of (>50%) gingival recession was seen in other studies.[17,18,19,20,21,22,23,24] A recent study conducted in Greece showed an overall prevalence of 63.9%.[25] On the contrary, a study by Mathur et al.[4] showed a lesser prevalence of gingival recession (18%). This might be due to the very young age group (10–15 years) of subjects in the study.

In the present study, frequency of gingival recession was found to increase with age. In younger age group (15–25 years), the gingival recession was 26.9%; and in older age group (45–60 years), it was 70.27%. Investigators have found that in most of the studies, the frequency of recession was 100% for older age group.[13,18,21] This relationship between the occurrence of gingival recession and age may be because of the longer period of exposure to the agents that cause gingival recession; associated with intrinsic changes in the organism, both local and systemic, besides the cumulative effects of the lesion itself. According to Loe et al.,[3] destruction of periodontal tissues progresses steadily over time. The occurrence of gingival recession in young patients is usually localized and seems to comprise isolated etiologic factors. On the other hand, a more generalized distribution, as observed among older subjects, might indicate the associated and cumulative effect of several factors such as previous periodontal disease associated with toothbrushing trauma.

A high frequency of gingival recession was seen in males (60.5%) compared to females (39.5%). These results were comparable to the study by some authors.[2,20,22,26] Ainamo et al.[19] on the other hand found that gingival recession was equally common in both the genders in 17 years age group. In our study, mandibular incisors (n = 495) had the highest prevalence of gingival recession when compared to other teeth. These findings were in confirmation with the previous studies.[2,3,13,19,20,26,27,28] Recessions may be found in teeth that are prominently positioned that is, the alveolar bone is thin or absent, and the gingival tissue is thin in these areas. Areas with deficient keratinized mucosa have been demonstrated to be more susceptible to gingival recession, especially due to the smaller amount of connective tissue available in the area. This leads to localized inflammatory reactions, which are triggered by different processes that affect the entire extension of the tissue, ultimately leading to gingival recession. This might be one of the most common reasons for the occurrence of gingival recession in the mandibular anterior teeth. But the findings in the few other studies showed that the gingival recession is more in maxillary first molar.[9,13,25] This may be due to the angulations of the root in the bone, which has got an influence on recession and is often observed in maxillary molars area.

In this study, Miller's class I type of recession was more commonly seen. This was in comparable with studies by Dodwad[2] Marini et al.[23] and Almeida et al.[13] In our study, it was also seen that Millers class I recession was more common due to the presence of plaque and Millers class II recession was due to faulty toothbrushing. It should be stressed that the distribution pattern of gingival recessions has been related to different etiologic factors. Gingival recessions on the mandibular incisors have been primarily associated with poor oral hygiene,[12] whereas those on the premolars would be originated by traumatic toothbrushing.[29] Concerning the maxillary first molars, some authors believe the cause would be traumatic toothbrushing,[9] while others state that it would be the outcome of poor oral hygiene, demonstrated by the presence of dental plaque and calculus.

The CPI of the subjects of two groups was also recorded. In recession group, 63.6% of subjects had score 3 and 99.7% had loss of attachment more than 3 mm. The severity of periodontal disease can be quantified with measurements of the pocket depth and by loss of supporting structures around tooth, which is indexed clinically as attachment loss. Hence, to know the severity of the loss of attachment in recession group, this index was recorded.

The present study intends to evaluate the probable etiological factors associated with gingival recession. Studies by Dodwad,[2] Bindu and Cheru[21] Chrysanthakopoulos[25] have found the etiology of gingival recession to be multifactorial like faulty toothbrushing, tooth malposition, lack of function, frenal pull, habits, poor oral hygiene, etc., with one type being associated with the other. In our study, the most common factor associated with gingival recession was seen to be plaque followed by faulty toothbrushing and this similar result has been found by several other authors as well.[12,13,15,24,25] Localized inflammatory process due to plaque causes the breakdown of connective tissue and proliferation of the epithelium into the site of connective tissue destruction. Proliferation of epithelial cells into the connective tissue brings about a subsidence of the epithelial surface, which is manifested clinically as gingival recession.

In the present study, subjects using horizontal method of toothbrushing showed the second common associated factor of gingival recession than those following either vertical or circular methods (11.78%). Previous studies have reported similar observations. Vigorous and forceful use of hard and medium stiff-bristled brushes in a horizontal direction can cause minor lacerations, contusions or abrasions of the gingiva with the resultant cleavage detachment or atrophy of the same as well as resorption of the underlying alveolar plate which lead to gingival recession.[20,29,30] Vehkalahti et al.[20] in their study have reported a significantly increased odds ratio of 2.1 for the likelihood of developing gingival recession in those subjects who brush more than once a day over less frequent brushers. The duration of toothbrushing was implicated in a study by Tezel et al.[31] in which both males and females who brushed for >3 min had approximately twice the mean severity of gingival recession than those subjects who brushed for < 1 min. In a systematic review, it was concluded that toothbrushing factors that had been associated with the development and progression of gingival recession were duration and frequency of brushing, technique, brushing force, frequency of changing toothbrushes and hardness of the bristles.[32] On the contrary, Bindu and Cheru[21] found malalignment of teeth to be the most common etiologic factor associated with recession. Manchala et al.[26] and Banihashemrad et al.[33] found gingival recession more common in smokers.

In this study, it was also found that severe gingivitis was seen in recession group compared to moderate gingivitis in the other group. This might be due to the presence of plaque in the recession group.

CONCLUSION

Approximately, half of the subjects examined exhibited gingival recession. The information gathered would probably help in evolving long-term strategies to prevent the occurrence of mucogingival defects and enable us to predict the rate of success of therapeutic measures. In addition to the ones mentioned in this study, there are few more implicating factors such as gingival biotype, chemical trauma, lack of function in the initiation of gingival recession that have not been considered here. The etiology of gingival recession is multifactorial, and its appearance is always the result of more than one factor acting together. At the community level, adequate awareness and education in oral hygiene maintenance should prove to be fruitful in long run.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.