Management and prevention of gingival recession

Authors

  • George K. Merijohn


Abstract

Gingival recession is highly prevalent worldwide. It increases the risk for root caries and can interfere with patient comfort, function and esthetics. Progressive gingival recession also increases the risk of tooth loss secondary to clinical attachment loss. Although mitigating the causes of gingival recession decreases its incidence and severity, implementing practical management and prevention strategies in the clinical setting can be challenging. Identification of susceptible patients and evaluating them for the presence of modifiable risk exposures are essential first steps in developing action plans for appropriate interventions. This article reviews these steps and introduces chairside tools that can help in the selection of interventions designed to reduce the risk of future gingival recession and may also facilitate patient communication. Practical decision-making criteria are proposed for when and how to monitor gingival recession, for deciding when a patient is a candidate for surgical evaluation or referral to a periodontist, and, if surgery is the treatment of choice, what should be considered as key surgical outcome objectives.

Gingival recession, in other words exposure of the root surface caused by apical displacement of the gingival margin past the cemento–enamel junction [18, 54, 91], is highly prevalent worldwide. Depending on the population surveyed, the percentage of people affected ranges from 30% to 100% [2, 46, 48, 56, 57, 79, 84]. Its prevalence and severity increases with age [2, 56]. In the USA alone, the prevalence of recession of ≥1 mm in persons ≥30 years of age has been reported to be 58% and averages 22.3% teeth per person [2]. In both clinical practice and continuing education, dental professionals invest substantial time and effort on treating the esthetic zone. Clinicians are especially frustrated when gingival recession occurs, for example, after orthodontic tooth movement (Fig. 1A) and/or after dental restoration margins are properly placed in proximity to gingival tissue. Dentists and dental hygienists often ask, ‘How does one avoid getting gingival recession in the first place and then after it's treated, how do we keep it from coming back?’. Dental appearance, compromised by gingival recession, is a common patient concern. However, this awareness is often limited to those patients with pronounced gingival display and their focus infrequently goes beyond the facial aspect of the anterior dentition. Patient-driven concerns about gingival recession are also raised if it interferes with comfort (e.g. root sensitivity) and/or function.

Figure 1.

Root exposure and root caries. (A) A 33-year-old male orthodontic patient who developed gingival recession during treatment. The patient presented with thin (delicate and fragile) gingival tissue on the canine and first premolar with no gingival recession before treatment. Oral hygiene consisted of: enthusiastic use twice daily of a power toothbrush or a large-headed medium/firm-bristle manual toothbrush; once daily use of Waterpik® on medium pressure aimed at the gum line at the recommended 90° angle; and sporadic flossing. The first premolar demonstrates tissue erythema and advanced recession. The canine demonstrates moderate recession with potentially early-stage/reversible root decay. (B) A 56-year-old female patient with progressive gingival recession and clinically detectable root caries. Note the thin gingival tissue and presenting mucogingival conditions (see Fig. 2). The patient reported that she is a tobacco user, flosses four to five times per week and uses a power toothbrush and/or a manual medium/firm-bristle toothbrush with over-the-counter fluoridated toothpaste twice daily. She periodically used tooth-whitening strips. Previous periodontal treatment consisted of routine adult prophylaxis two to three times per year, oral hygiene instruction, typical dietary counseling and infrequent in-office fluoride application.

In addition to esthetic concerns of the patient, an unfavorable consequence of gingival recession is the exposure of root surfaces to a potentially cariogenic supragingival microbiota (Fig. 1B). In the USA, the prevalence of root caries has been reported to be 55.9% among those ≥75 years of age [38]. Of great concern is that the group ≥65 years of age, which represented 12% of the population in 2000, is expected to exceed 20% of the population by 2030 and root caries is also expected to increase [38]. Prevention of gingival recession is essential in the primary prevention of root caries. This alone is reason to incorporate practical protocols for managing and preventing gingival recession into daily clinical practice.

The prudent clinician is aligned with the patient in the desire to avoid both neglectful oversight and inappropriate treatment. Between lies the approach to personalized, targeted and step-by-step conservative measures for the management and prevention of gingival recession. Therefore, the dental practitioner must consider the esthetic and dental health concerns associated with gingival recession, as well as individual patient factors, when developing a treatment strategy. Bearing in mind these various considerations, the aims of this article were to: (i) illustrate three major factors associated with increased susceptibility to gingival recession; (ii) present practical concepts regarding the recognition and management of risk exposures that can be implemented in a clinical setting; (iii) review essential data collection and recording for monitoring patients; (iv) introduce chairside clinical-decision-support tools designed to help the clinician focus on triage, evaluation, planning and patient communication regarding the prevention and management of gingival recession; and (v) propose clinical decision-making criteria for when and how to monitor gingival recession, for deciding when a patient is a candidate for surgical evaluation or referral to a periodontist and, if surgery is the treatment of choice, what should be considered as key surgical outcome objectives.

Gingival recession: causes and susceptibility

The primary causes of gingival recession are plaque-induced inflammation [79, 81] and mechanical (physical) abrasion/removal [27, 36, 41, 44, 46, 56, 76, 79, 83, 89]. Occasional causes of recession include thermal and chemical injury [41, 76]. Mitigating these causes in susceptible patients will decrease the incidence and severity of gingival recession. Three major factors are associated with increased susceptibility to gingival recession: (i) thin gingival tissue; (ii) mucogingival conditions; and/or (iii) a positive history of progressive gingival recession and/or inflammatory periodontal disease(s) in teeth presenting with either or both of the first two factors.

Relative to its clinical appearance, gingival tissue can be broadly categorized as thick, average or thin. Thick gingival tissue appears densely fibrous and noticeably keratinized, whereas thin gingival tissue [1, 12, 22, 50, 67, 77] appears more translucent with less obvious keratinization, as depicted in Fig. 2, an example of a visual guide to enhance chairside patient communication. When describing gingival tissues to patients, it is helpful to refer to thick tissue as protective and durable and thin tissue as fragile and delicate. It is important to note that not all teeth will necessarily develop gingival recession solely as a result of thin gingival tissue (Fig. 3).

Figure 2.

Gingival recession chairside visual guide.

Figure 3.

Conservatively managed and nonsurgically treated thin gingival tissue (mandibular left canine tooth): a 17-year follow-up. (A) A 39-year-old male patient on a 4-month recall interval in 1993 presenting with thin gingival tissue, narrow band of keratinized tissue and probing depth extending beyond the mucogingival junction. Treatment consisted of: coronal scaling with hand instruments and coronal polishing; and subgingival hand instrumentation with curettes for removal of biofilm, plaque and any clinically detectable calculus. Personal oral hygiene consisted of: twice daily nonforceful sulcular/Bass brushing technique with a soft-bristled, narrow-headed manual toothbrush and over-the-counter fluoridated toothpaste; flossing once daily with lightly waxed or nonwaxed dental floss; tooth pick use (blunted and softened tip) once weekly; and use of an end-tufted brush for buccal cervical plaque removal. The patient was instructed to use a magnified lighted mirror when performing procedures. The patient had an acceptable level of skill and reasonable compliance with the recommended oral hygiene procedures. (B) The same tooth in 2010: relatively unchanged thin gingival tissue, 17 years later, is observed.

Mucogingival conditions (Fig. 2) are defined as deviations from the normal anatomic relationship between the gingival margin and the mucogingival junction [42]. The most common mucogingival conditions are: gingival/soft-tissue recession [42]; the absence or reduction of keratinized tissue; and/or probing depths extending beyond the mucogingival junction [5]. In the section, Parameter on Mucogingival Conditions of the Parameters of Care, the American Academy of Periodontology identifies reduced keratinized tissue as a mucogingival condition but does not specify numerical criteria for what constitutes a clinically important reduction [5]. Teeth with less than 2 mm of keratinized tissue have been studied in the literature. Lang & Lőe [52] demonstrated that although tooth surfaces may be kept free of clinically detectable plaque, areas with <2 mm of keratinized gingiva tended to remain inflamed. However, other clinicians have evaluated sites with <2 mm of keratinized tissue and concluded that these sites do not necessarily develop gingival recession solely as a result of a narrow width or band of keratinized tissue [28, 29, 31, 32, 47, 49, 65]. It is therefore important to emphasize that surgical therapy is not warranted based solely on the presence of thin gingival tissue, gingival recession, probing depths extending beyond the mucogingival junction and/or the absence or reduction of keratinized tissue [31, 32, 54, 60, 63].

Nevertheless, the clinician must consider when and if gingival recession is an indicator of progressive loss of periodontal support and future recession. For example, Serino et al. [81] reported that teeth with a positive history of progressive gingival recession have increased susceptibility to additional apical displacement of the soft-tissue margin. They also noted that loss of proximal periodontal support was associated with gingival recession at the buccal surface. Yoneyama et al. [94] determined that the major feature of the progression of destructive periodontal disease with age was gingival recession. Sarfati et al. [79] found that gingival bleeding was significantly associated with the severity of gingival recession and concluded that the inflammatory reaction to dental biofilms is the predominant biologic feature shared by gingival recession and periodontitis. Albandar & Kingman [2] suggested that gingival recession occurs primarily as a consequence of periodontal diseases and aggressive use of mechanical oral hygiene measures. A positive history of inflammatory periodontal disease (e.g. plaque-induced gingivitis and localized chronic periodontitis) can be considered an important factor associated with gingival recession, especially for teeth with thin gingival tissues and/or mucogingival conditions. Although mitigating the causes of gingival recession in susceptible patients will decrease its incidence and severity, implementing practical management and prevention strategies in a clinical setting can be challenging [46, 50, 89, 94]. Of prime importance in implementing such prevention and treatment strategies is an understanding of the current knowledge of factors associated with the risk of initiation and progression of gingival recession.

The susceptible patient and factors that increase gingival recession risk

Studies have reported several contributing factors and conditions commonly associated with gingival recession and/or increasing recession [8, 46, 55, 57, 76, 77, 79]. Exposure to such factors and conditions can make susceptible patients particularly vulnerable to gingival recession [4]. Although definitive causality and magnitude-of-effect hierarchy have yet to be determined for the contributing factors and conditions associated with gingival recession, there is some evidence upon which to base recommendations for its management and prevention. Presently, clinicians can recommend simple lifestyle interventions and consider various dental procedures that are capable of reducing the risk of inflammation and/or mechanical injury for tissues susceptible to gingival recession. Some contributing factors and conditions are readily modifiable (e.g. dental plaque, forceful brushing and tobacco use), whereas others are not (e.g. age, gender and history of progressive gingival recession). The term ‘modifiable conditions’ is used in this article for those contributing factors and conditions commonly associated with gingival recession that lend themselves to modification through conventional interventions in a clinical setting. These modifiable conditions are listed in Table 1. Increasing patient awareness about gingival recession susceptibility and modifiable conditions is an indispensable first step for an effective management and prevention program. In addition to being examined and advised about findings by their dentists and dental hygienists, independent self-discovery by patients is often a strong motivator for adopting preventive-oriented lifestyle choices and accepting treatment interventions appropriate for managing and preventing dental problems.

Table 1. Susceptibility factors and modifiable conditionsThumbnail image of

Online knowledge resources can serve as a practical means to increase awareness and decrease confusion about dental conditions. My Gum Recession Analyzer and Gum Recession FAQ (www.gumtest.com) are two examples of evidence-based online resources (Fig. 4). My Gum Recession Analyzer is a self-screening tool that features those gingival recession susceptibility factors and modifiable conditions from Table 1 that more readily lend themselves to patient self-discovery. It is designed to help the individual: (i) discover if she/he has gum recession; (ii) determine her/his susceptibility to gum recession; and (iii) identify exposure to any of eight common, but modifiable, risks associated with gum recession. Gum Recession FAQ addresses frequently asked questions about gingival recession. Anecdotal evidence suggests that use of appropriate online knowledge resources can improve and streamline patient communications and consultations.

Figure 4.

Online gingival recession self-screening.

Encouraging patients to perform self-screening and increase personal awareness augments the clinician's efforts in determining which patients are most susceptible to gingival recession. Patients can access online knowledge resources at their convenience from smart phones or computer tablets/personal computers. Clinicians utilize online self-screening tools in a variety of ways based on personal preferences. For example, patients can be instructed to use online tools outside the practice setting before appointments, in the practice reception room or in the dental operatory during appointments such as examinations and hygiene maintenance visits. It is beyond the scope of this paper to review online self-screening tools in detail. These can be evaluated online by the clinician for applicability in her/his individual practice setting.

Decreasing the susceptible patients’ exposure to modifiable conditions will decrease future risk for gingival recession and increase the likelihood of its long-term prevention. However, developing patient-centered treatment plans for the management and prevention of gingival recession necessitates that the clinician first examines the patient for key susceptibility factors and modifiable conditions (Table 1). Positive findings need to be documented and all essential data recorded for long-term tracking and monitoring. In the busy practice setting, having a practical and efficient means to do so can improve workflow and decision making.

Essential data collection and recording

The surest way to under-treat or over-treat gingival recession is through inadequate records.

Evaluation of a patient's periodontal status requires obtaining relevant medical and dental histories and conducting thorough clinical and radiographic examinations with evaluation of extra-oral and intraoral structures [5]. Traditional clinical assessments and procedures remain the foundation upon which periodontal diagnoses are made [35]. The Parameter on Comprehensive Periodontal Examination, developed by the American Academy of Periodontology, states that all relevant clinical findings should be documented in the patient's record [5]. See Fig. 5 for recommendations regarding where to document, in the patient record, the susceptibility factors and modifiable conditions associated with gingival recession.

Figure 5.

Documenting susceptibility factors and modifiable conditions. MH/DH, Medical History/Dental History

To establish a baseline and to track changes effectively over time, all measurable and/or detectable essential clinical findings (see Fig. 5) are recorded on the periodontal examination record. A comprehensive periodontal examination should be performed for all new patients and repeated at appropriate periodic intervals based on the needs of the individual patient. Figure 6 is an example of a periodontal examination record that facilitates documentation and recording of the comprehensive periodontal examination parameters, gingival recession susceptibility factors and measurable/detectable gingival recession contributing factors and conditions.

Figure 6.

Example of a periodontal examination record.

Periodontal evaluation and data recording during dental hygiene/maintenance appointments can be very challenging, especially for adult patients with a relatively full complement of teeth and/or implants. Within the allotted time it is not always possible to perform and record a comprehensive periodontal examination, in addition to performing other essential tasks, such as: medical and dental health history update; review of radiographs; head and neck examination; appliance checks; caries and restoration check; scaling/root planing as needed; coronal polishing; oral hygiene review and instruction/training; lifestyle assessment and recommendations; and fluoride application (if needed) [5]. One must also consider the time it takes to greet and exit the patient, as well as to perform operatory disinfection and chairside set up. Nevertheless, a thorough periodontal evaluation is a critical component of the dental hygiene/maintenance appointment [5]. A practical approach is to evaluate the patient for the key periodontal parameters and then document, on the periodontal maintenance record, only those significant negative changes relative to the most recent comprehensive data on the periodontal examination record. Figure 7 is an example of a periodontal maintenance record that simplifies documentation and recording and is compatible with the periodontal examination record example in Fig. 6. Regardless of the recording systems used, examination and documentation are the important first steps for patient-centered clinical decision making. After the data are gathered, use of chairside tools designed to help the clinician focus on triage, planning, communication and education can facilitate the development of interventions for the management and prevention of gingival recession.

Figure 7.

Example of a periodontal maintenance record.

Patient education and treatment planning

After recording all clinical measures, patient history and other relevant findings, patient education and treatment planning are the next steps in the management of gingival recession. Treatment algorithms and patient presentation tools can be particularly beneficial in this critical stage of patient management. An example of such a tool that can be employed is presented in Table 2 (Gingival Recession Checklist). This checklist is a quick reference chairside guide for the clinician and is to be used in the dental examination/treatment operatory. The companion Gingival Recession Chairside Visual Guide (Fig. 2), on its reverse side, can serve both as a reference for the clinician and a visual communication tool for use with patients.

Table 2. The gingival recession checklistThumbnail image of

These chairside clinical-decision-support tools are like other chairside tools in that they help busy clinicians focus on triage, evaluation, planning and patient communication [60, 61, 63, 64, 66, 68]. They can be used to facilitate the development of interventions for the prevention and management of gingival recession. Specifically, these chairside tools help support the clinician in: (i) identification of patients who are susceptible to gingival recession; (ii) assessment of key modifiable conditions associated with gingival recession; (iii) development of targeted and personalized treatment/action plans for the prevention and management of gingival recession; and (iv) communication with patients at the point of care, which can help increase patient awareness, develop preventive behaviors and boost treatment acceptance.

Evidence supports the use of checklists in clinical settings to improve the quality of care and to reduce errors and complications [40, 80]. The World Health Organization developed its validated Surgical Safety Checklist, a 19-item tool created by the World Health Organization in association with the Harvard School of Public Health, modeling it after in-flight safety checklists used by the airline industry [34, 92]. Clinical examination and procedural checklists have been introduced and recommended for use in dental practice [21, 72]. Like other checklists and visual guides, these tools are designed to be used in conjunction with examination, decision-making or treatment-planning appointments, including dental hygiene/maintenance appointments [61, 63]. This type of checklist and visual guide can also be used for clinical staff training, calibration and ongoing chairside support in facilitating patient communication.

This sample checklist presented in Table 2 is comprised of four sequential steps: (A) determine whether the patient is susceptible to gingival recession; (B) evaluate the patient for the presence of any gingival recession modifiable conditions listed on the Checklist; (C) develop a treatment plan to address each positive Checklist finding; and (D) review the visual guide (Fig. 2) and checklist (Table 2) findings with the patient. For every positive finding on the Checklist, a tailored and personalized treatment/action plan is developed to address it. Interventions should be patient-centered and focused on clinically relevant outcomes [6, 62, 64, 66, 68, 78]. Whenever clinically reasonable, interventions should be instituted in a step-by-step approach, starting first with the most effective conservative measures. As a chairside clinical-decision-support tool, this checklist example is designed to be simple and easy to use [63]. Like any safety checklist, it is not intended to be 100% all-inclusive: clinicians might find that there are exceptions.

Using the gingival recession checklist and visual guide in the practice setting

It is beyond the scope of this paper to provide an in-depth review of the numerous therapeutic approaches available to clinicians for the management of every modifiable condition listed on the checklist (Table 2). Select conditions are presented below.

Poor metabolic control of diabetes

Greater gingival inflammation is seen in adults with type 2 diabetes than in nondiabetic controls, with the highest level of inflammation occurring in subjects with poor glycemic control [23, 59]. Significantly greater gingival bleeding is seen in patients with poorly controlled diabetes than in either subjects with well-controlled diabetes or nondiabetic controls [30, 59]. Importantly, increased periodontal destruction is associated with poorer glycemic control [58]. As both plaque-induced gingivitis and/or periodontitis and poor glycemic control are modifiable risk exposures for gingival recession [10, 44, 79, 81, 84, 94], for diabetic patients who are susceptible to gingival recession, appropriate metabolic control coupled with improved plaque control will decrease the risk of gingival recession.

Clinicians should routinely communicate with diabetic patients regarding personal glycemic control targets and current status. Patients may be more familiar with their average glucose (eAG) than they are with glycated hemoglobin percentage (A1C) values. Websites, including www.diabetes.org, provide simple conversion calculators for converting glycated hemoglobin to average glucose. A simple reference conversion table kept in the dental operatory will save time and improve communication efficiency. If there is concern regarding the patient's glycemic control, the dentist should fax the physician and request the last 2 years of glycated hemoglobin values.

For patients with good glycemic control, routine dental therapy can be planned accordingly. For patients with poor glycemic control, anecdotal evidence suggests that clinicians should consider the following approach: refer to a physician for further evaluation and care; consult with a physician regarding glycemic control and oral conditions; treat dental infections using conservative therapies, such as scaling and root planing, root canal therapy and/or restoration of cavitated carious lesions; and delay elective therapies, such as gingival grafting or dental implant placement surgery.

The field of screening and assessment of blood glucose levels continues to evolve, and dental professionals can participate by offering in-office finger-stick testing. Dental clinicians should give guidance, in the form of consultation and reference material, supporting the key healthy lifestyle choices for managing diabetes. These include seeing a physician, undergoing regular physical activity, limiting consumption of sugar-sweetened beverages, eating a healthy diet, managing periodontal disease and controlling modifiable conditions associated with gingival recession (Table 2).

Tobacco use, including smokeless tobacco

Tobacco use is an important gingival recession risk factor [8, 39, 43, 79, 84]. Studies demonstrate that users of smokeless tobacco tend to have more severe gingival recession and clinical attachment loss, and a greater proportion of sites with higher values of the same, compared with never users [8]. Smoking has a long-term chronic negative effect on many important aspects of the inflammatory and immune responses, including alterations in the vasculature and on neutrophil function. In addition, nicotine and other tobacco compounds have detrimental effects on fibroblast function, including proliferation, adhesion to root surfaces and cytotoxicity [69], which may, in turn, adversely affect treatments for gingival recession.

Indirect evidence suggests that a significant reversal of periodontitis risk might be achievable within 10 years after quitting smoking [33]. Dental professionals are in a unique position to help tobacco users who present for dental care by providing assistance to help them stop smoking or using other tobacco products [16]. As such, this has become part of the responsibility of all oral health professionals [75], and tobacco users should be encouraged to quit as part of their overall periodontal management [20]. Clinicians should routinely check with tobacco-using patients and actively provide ongoing encouragement, support and positive reinforcement for tobacco-use cessation. Although some clinicians may feel that managing in-office smoke-cessation programs may be impractical and/or cost-prohibitive, it takes little time and effort to provide tobacco-using patients with an up-to-date list of appropriate local tobacco-cessation programs and online resources. A more detailed description of the benefits of structured tobacco-cessation programs for dental practitioners is presented in another article in this volume of Periodontology 2000.

Other modifiable conditions associated with the major pathogenic mechanisms of gingival recession

The Gingival Recession Checklist (Table 2) and the Gingival Recession Chairside Visual Guide (Fig. 2) are examples of practical chairside support tools that illustrate, to patients, the modifiable conditions commonly associated with gingival recession that she or he can personally control. Especially with patients susceptible to gingival recession, mitigating modifiable conditions will probably improve the chances for better management and prevention of gingival recession. Such conditions include clinically detectable plaque, damaging oral hygiene methods (such as forceful toothbrushing), damaging oral habits (such as picking teeth with sharp objects), damaging eating habits (such as patients with lower incisors that have thin, delicate tissues, who habitually bite into foods such as very hard fruit and thick crusty bread) and oral jewelry in proximity to gingival tissues.

Using the checklist during treatment/procedure planning can also help guide clinicians toward procedure options that can potentially decrease the risk of damage to tissues (e.g. avoiding mechanical tissue abrasion/removal; preventing chemical and/or thermal injury). This can help improve the odds of providing better management and preventing gingival recession. In addition to the conditions already discussed other modifiable local dental conditions should also be considered in treatment planning for gingival recession. Three of the modifiable conditions listed in Table 2 are discussed below.

Subgingival restorations

Clinicians should determine if the physical characteristics (e.g. rough surfaces or margin–tooth surface discrepancies) of subgingival restorations provide protected habitats for microorganisms that can lead to biofilm-induced or plaque-induced inflammation. If appropriate oral hygiene and periodontal treatment do not mitigate the inflammatory response, clinicians can recontour and polish these restorations or replace them with new restorations designed to decrease risk exposures.

Oral appliances

In considering the role of fixed or removable orthodontic appliances/retainers, removable prostheses, mouth guards and occlusal guards, clinicians should evaluate whether these appliances impinge on gingival tissue or if they are too close to the fragile soft tissue. In addition, clinicians should determine whether oral appliances contribute to tissue inflammation or mechanical tissue irritation/injury and whether these devices should be modified or replaced with new ones that mitigate these risk exposures.

Orthodontic tooth movement in patients susceptible to gingival recession

Contradictory statements can be found in the literature regarding orthodontic tooth movement as a risk factor for gingival recession. Some studies conclude that it is not a relevant risk factor [3, 25, 85], whereas others demonstrate an increased risk [9, 11, 45, 50, 77, 82, 90, 93]. It has been suggested that a better understanding of the relationship between orthodontic tooth movement and gingival recession will be gleaned from prospective, randomized controlled trials that include assessment of periodontal parameters before, during and after treatment [45, 53, 77].

However, with our present understanding it can be considered that orthodontic treatment in general and its retention phase may be considered as risk factors, especially for the development of labial gingival recession [50, 77]. Therefore, patients susceptible to gingival recession will be more so during or after orthodontic treatment, especially if they present with modifiable conditions (Table 2) that are not addressed before, during and after treatment. For example, patients who use forceful toothbrushing methods on thin (delicate and fragile) facial gingival tissue have a greater risk for gingival recession if orthodontic treatment facially proclines these teeth.

Prudent interdisciplinary dental teams can determine whether prospective orthodontic patients are susceptible to gingival recession, consider adjusting tooth-movement plans and outcomes, and recommend appropriate interventional periodontal therapy – especially for teeth at increased risk for gingival recession. Even with such measures, susceptible patients should be informed about gingival recession risks before treatment begins.

Clinical decision making: just monitor or a candidate for surgical evaluation?

One of the more critically important and frequently asked questions about gingival recession is, ‘Can we monitor it or do we need to consider surgery?’. Therefore, are there practical criteria the clinician can use to help guide the clinical decision-making process?

All patients susceptible to gingival recession should have ongoing careful monitoring as part of their overall case management. Monitoring is an active ongoing process that engages both clinician and patient. It is particularly important at clinical decision-making points (e.g. examination/evaluation appointments, patient consultations/treatment plan presentations and dental hygiene appointments). The checklist and visual guide examples illustrated in this paper are useful chairside tools that can facilitate the process. The desired goal is that all positive checklist items (Table 2) are reviewed with patients during appropriate appointments until there are no more positive checklist findings. Susceptible patients, including those who have had or will have surgical interventions for gingival recession defects, should have individualized treatment/procedure plans developed that address all modifiable conditions. Although individual patient circumstances may determine otherwise, practical clinical criteria are proposed below as general guidance to support clinicians in making appropriate clinical decisions regarding patients presenting with gingival/soft-tissue recession; probing depths extending beyond the mucogingival junction; absence or narrow band (<2 mm) of keratinized tissue; and/or thin (delicate and fragile) gingival tissue [4, 60, 63]. These major clinical decisions can be grouped into three broad categories:

  • When to monitor a patient without surgical evaluation.
  • When is the patient a candidate for surgical intervention?
  • When should the patient be referred to a periodontal specialist?

When to monitor gingival recession without surgical evaluation

It is proposed that clinicians can monitor gingival recession without surgical evaluation in such patients when all of the following criteria are met: (i) no documented evidence of progressive gingival recession; (ii) clinical attachment loss (probing depth plus gingival recession) ≤5 mm; (iii) gingival recession <2 mm; and (iv) all of the above and the teeth in question will not have subgingival restorations, orthodontic tooth movement, oral appliances that can or will be in contact with the tissue or dental therapy that is potentially damaging to thin gingival tissue (Table 2).

When is a patient a candidate for surgical evaluation?

It is proposed that a patient presenting with the conditions noted above is a candidate for surgical evaluation when at least one of the following criteria are met: (i) documented evidence of progressive gingival recession; (ii) persistent gingival inflammation (e.g. bleeding on probing, swelling, edema, redness and/or tenderness) despite appropriate therapeutic interventions, in combination with clinical attachment loss >5 mm and/or gingival recession ≥2 mm; and/or (iii) persistent gingival inflammation despite appropriate therapeutic interventions and association of the inflammation with shallow vestibular depth that restricts access for effective oral hygiene, frenum position that compromises effective oral hygiene and/or tissue deformities (e.g. clefts or fissures). The patient is also a candidate for surgical evaluation if found positive for any of the above three criteria and any of the following are planned for the teeth in question: (i) subgingival restorations; (ii) orthodontic tooth movement; (iii) oral appliances that contact the tissue; and/or (iv) potentially damaging dental therapy (Table 2).

If surgery is the treatment of choice, treatment should be directed to achieve key surgical outcome objectives. The minimum required outcome of a surgical procedure for problematic gingival recession is cessation of further recession. This necessitates the correction/improvement of presenting problematic tissue factors/conditions [5], including: thin gingival tissue; probing depths extending beyond the mucogingival junction; absence or narrow band of keratinized tissue; shallow vestibular depth problem; frenum position problem; and/or tissue deformities (e.g. clefts or fissures). When root coverage is a surgical treatment goal, the selected approach should also correct for all of the above presenting problematic tissue factors/conditions. Otherwise, after a root-coverage procedure the tooth can remain susceptible to progressive gingival recession.

When should a patient be referred to a periodontal specialist?

Although there is no single, specific clinical tipping point that can be used as a guideline for all patients in deciding when to do so, referral to a periodontist is appropriate when one or more of the following criteria are met: (i) the patient prefers referral; (ii) the dentist decides that she/he does not possess sufficient knowledge, skills and/or experience to provide the patient with the necessary surgical outcome objectives; (iii) the dentist decides that referral is in the best interest of the patient; and/or (iv) the dentist decides that clinical uncertainty dictates additional input into the case. Situations that increase clinical uncertainty include: some medically complex patients; advanced-severe gingival recession defects; multitooth involvement; and/or recession risk that cannot be readily modified. According to the Principles of Ethics and Code of Professional Conduct of the American Dental Association, “All dentists… have the obligation of keeping their knowledge and skill current.” With respect to consultation and referral, “Dentists shall be obliged to seek consultation, if possible, whenever the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience.” [7]. Every clinician must self-determine whether they have the knowledge, skills and experience to monitor or plan/perform surgery on patients for the management of gingival recession defects.

Concluding remarks

Gingival recession is highly prevalent worldwide. It increases the risk for root caries and can interfere with patient comfort, function and esthetics. Progressive gingival recession also increases the risk of tooth loss secondary to clinical attachment loss. Although mitigating the causes of gingival recession decreases its incidence and severity, implementing practical management and prevention strategies in a clinical setting can be challenging. Identification of susceptible patients and evaluating them for the presence of modifiable risk exposures are essential first steps in developing action plans for appropriate interventions. This paper reviews these steps and introduces chairside tools that can help in the selection of interventions designed to reduce the risk of future gingival recession and also facilitate patient communication. Practical decision-making criteria are proposed for the following: when and how to monitor gingival recession; when is a patient a candidate for surgical evaluation or referral to a periodontist; and, if surgery is the treatment of choice, what should be considered as key surgical outcome objectives.

Acknowledgments

The author acknowledges Gary Armitage for his invaluable advice and guidance throughout the preparation of this manuscript. Figures 1–7 and Tables 1 and 2 have been previously published and are reproduced with permission.

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