NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810

ORIGINAL ARTICLE

ETIOLOGY AND SEVERITY OF DIFFERENT GRADES OF

GINGIVAL RECESSION IN ADULT POPULATION
Bhoomika Khosya1, Devaraj CG2
1Post-graduate
Resident; 2Professor & Head, Department of Periodontology, Mahatma Gandhi Dental College & Hospital, Jaipur
Correspondence: Dr.Bhoomika khosya Email: drbhumikhosya@gmail.com

ABSTRACT
Background: Gingival recession is the most common and undesirable condition of the gingiva and its prevalence
increases with age.
Materials and methods: The study was a cross-sectional study conducted on the patients of gingival recession who
visited dental OPD. The pre-tested semi-structured questionnaire was utilized which included questions regarding
oral hygiene habits (i.e. frequency of brushing, method of brushing, type of toothbrush used, age of toothbrush).
Periodontal evaluation included Gingival score, Plaque score, Gingival recession, Clinical attachment loss and mea-
surement of width of attached gingival.
Results: Of 244 subjects 112 (45.9%) had Millers class I recession, 64 (26.2%) class II recession, 38 (15.6%) class
III recession, 30 (12.3%) class IV recession. Statistical analysis revealed that the correlation between both tooth-
brush type and brushing method with gingival recession was significantly associated (p < 0.05). The correlation
association between age, dental plaque, gingival inflammation, clinical attachment loss, width of attached gingiva and
gingival recession was found to be statistically significant (p < 0.05).
Conclusion: The most frequent affected teeth with gingival recession were the 1st and 2nd molars of maxilla fol-
lowed by mandibular incisors. Horizontal brushing method, usage of medium type toothbrush and tooth brushing
once daily were found to be more associated with gingival recession.
Keywords: Gingival Recession, molars, maxilla, mandibular incisors

INTRODUCTION tance in the aetiology of gingival recession.5 Positive

association between recession and increasing age 5,6 and
Gingival recession is the most common and undesirable
good oral hygiene 5,7 tend to implicate further the signif-
condition of the gingiva and its prevalence increases
icant and primary role of tooth brushing in the aetiology
with age. It is characterized by displacement of gingival
of recession, while recognizing that tooth brushing itself
margin apically from cement-enamel junction (CEJ) and
is associated with a number of potentially confounding
exposure of root surface to the oral environment.1,2
variables such as pressure, time, bristle type and the
Gingival recession, either localized or generalized, is one
dentifrice used.
of the clinical features of periodontal disease and is not
considered as periodontal diagnosis itself. Gingival An adequate mucogingival complex, in which the mu-
recession may be associated with the clinical problems cogingival tissues can sustain their biomorphological
such as root surface hypersensitivity, root caries, cervic- integrity and maintain an enduring attachment to the
al root abrasions, erosions, plaque retention and aesthet- teeth and the underlying soft tissue, is always essential.
ic concern. For a patient, gingival recession usually When a mucogingival problem occurs, there are basical-
creates an aesthetical problem, especially when such ly two ways in which it presents itself. First, as a close
problem affects the anterior teeth, and anxiety about disruption of the mucogingival complex resulting in
tooth loss due to progressing destruction. pocket formation. Second, as an open disruption of the
mucogingival complex resulting in gingival clefts and
The aetiology of gingival recession is multifactorial.
gingival recession.
Several factors may play a role in gingival recession
development, such as excessive or inadequate teeth Hence, there appears to be a need for further study of
brushing, destructive periodontal disease, tooth malpo- possible causative factors and severity of gingival reces-
sition), alveolar bone dehiscence, high muscle attach- sion based on Miller’s classification. Therefore, the
ment, frenum pull and occlusal trauma.3 Other causative present study aimed at assessing the aetiology and sever-
factors that have been reported are iatrogenic factors ity of different grades of gingival recession among adult
(orthodontic, or prosthetic treatment, and etc.)4 and population.
smoking. However, bacterial plaque is of equal impor-

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MATERIALS AND METHOD Statistical analysis: Data was collected and related
clinical parameters were calculated. The Pearson corre-
The study was conducted on the patients who visited
lation was used to analyze correlation between gingival
Department of Periodontology in Mahatma Gandhi
recession and clinical parameters using the statistical
Dental College, Jaipur. The study consisted of partici-
package of SPSS 16.0 version. A P value less than 5%
pants who had gingival recession. All examinations were
(P<0.05) was considered to be statistically significant.
performed by the author of the article. Questionnaire
and clinical parameters were recorded for each subject.
An intraoral examination was also performed by a single
RESULT
investigator to decrease subjective error. All the subjects
were examined in artificial light, with the use of the Gingival recession was observed in 101 females (41.4%)
probe, mirror. and 143 males (58.6%). Of 244 subjects 112 (45.9%)
had Millers class I recession, 64 (26.2%) class II reces-
Questionnaire: A pre-tested semi-structured question-
sion, 38 (15.6%) class III recession, 30 (12.3%) class
naire was prepared and the data of the all the partici-
IV recession. The most frequent affected teeth with
pants were filled before undergoing clinical examina-
gingival recession were molars followed by the incisors.
tion. The questionnaire included questions regarding
(Table 1)
oral hygiene habits (i.e. frequency of brushing, method
of brushing, type of toothbrush used, age of tooth-
brush) and also about treatment of recession.
Table 1: Distribution of Grades of gingival reces-
Inclusion criteria: Inclusion criteria were Patient hav- sion by tooth type (n=244)
ing minimum of 20 teeth present; minimum of 2 teeth
Type of Grades of gingival recession
with gingival recession; and clinical attachment loss of
Teeth Class I Class II Class III Class IV
more then ≥2mm
Anterior 39 22 18 16
Exclusion criteria: Those patients were excluded who Premolars 31 18 9 4
were having Recession in Third molars; Pregnant Molars 42 24 11 10
/lactating women; who have visited dentist/had under- Total 112 64 38 30
gone any dental treatment in last 6 months; and with
systemic disease.
Table 2 Oral hygiene aid used by studied sample
Clinical examination: The subjects in the study were
Oral hygiene aid Frequency (%)
clinically examined for periodontal conditions. Peri-
Aid to clean teeth Brush 110 (45.1)
odontal evaluation included Gingival score, Plaque Finger 53 (21.7)
score, Gingival recession, Clinical attachment loss and Neem twig 81 (33.2)
measurement of width of attached gingiva. Presence or Method of Brushing Horizontal 199 (81.6)
absence of supragingival plaque was recorded after Vertical 34 (13.9)
applying disclosing agent on tooth. The area was then Circular 11 (4.5)
evaluated by assessing the plaque and calculus accumu- Material used Paste 91 (37.3)
lation on each tooth. In cases that CEJ was covered by Powder 68 (27.9)
calculus or hidden by restoration or loss due to caries Unknown 85 (34.8)
Frequency of brushing Twice 236 (96.7)
or wear lesions, the location of such junction was esti-
One 8 (3.3)
mated on the basis of adjacent teeth. Plaque was Type of bristle Medium bristle 81 (33.2)
scored in a range of 0-3 using the plaque index of Sil- Soft bristle 31 (12.7)
ness and Löe8(PLI). Gingival score was assessed using Unknown 132 (54.1)
the gingival index of Löe and Silness (GI). Gingival
recession was classified according to Miller’s classifica- Aid used to clean teeth, type of tooth brush used and
tion(1985)9. Gingival recession was measured from horizontal brushing method and usage of medium type
cement-enamel junction (CEJ) to gingival margin using of toothbrush were found to be more injurious to gin-
a William’s probe in the midbuccal surfaces of all teeth. giva leading to gingival recession and poor oral hygiene
Width of attached gingiva was measured from base of (Table 2). Statistical analysis revealed that the correla-
pocket to mucogingival junction. Then, the tooth mal- tion between both toothbrush type and brushing me-
alignment was observed by viewing the teeth from thod with gingival recession was significantly associated.
occlusal Plane. The position of each tooth was classified (P < 0.001)
in all participants according to its relation to the regular
curve of the arch as either correctly, labially or lingually Dental plaque, gingival inflammation and clinical at-
positioned. tachment loss appeared to be the most frequent precipi-
tating aetiological factors (Fig.3). The correlation associ-
Ethics: All participants were informed about the study ation between dental plaque, gingival inflammation,
procedure to which they would be submitted and those clinical attachment loss and gingival recession was
participants who gave their voluntary informed consent found to be statistically significant. (Table 3)
were included in the study.

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80 Also the present study showed that patients who ap-

67.6 68.6
70 plied horizontal method (81.6%) of tooth brushing had
more gingival recession than those who used vertical
% of Participants

60
50 (13.9%) or circular methods (4.5%). The same finding
40 was recorded for patients who used medium bristle
30
25.8 toothbrushes and brushed their teeth once daily. Similar
17.8 findings made in previous studies reported that too
20 13.6
10
6.6 vigorous, forceful and excessive use of medium bristle
toothbrushes in horizontal direction could cause abra-
0
sions of the gingiva. Those studies showed that gingival
1.0-0.9

1.0-1.9

2.0-3.0

0.1-1.0

1.1-2.0

2.1-3.0
recession was correlated with frequency, duration, and
technique of tooth brushing (especially horizontal scrub
Plaque index Gingival Index
technique).15,16
Studies reported that frequency and hardness of tooth-
brushes,15,17,8 duration and technique of tooth brushing
Figure 3: Plaque index and Gingival index of sam-
(especially horizontal scrub technique)16,19and trauma
ple studied
from tooth brushing 2,15,18-20-22 were associated with
gingival recession. In other studies, the use of excessive
brushing force has been shown to be a major cause of
Table 4: Association between Plaque index, Gin- gingival abrasion22 and the frequency of tooth brush
gival index, CAL and Width of attached gingiva changing had significant influence on the number of
with Gingival recession sites with gingival recession. A study by Mumghamba et
Clinical parameters Gingival Recession al.23 showed that tooth cleaning practices were not
r Value P value significantly associated with gingival recession while no
Age 0.81 0.001 significant differences were observed for toothbrush
Plaque index 0.45 0.001 type and frequency of tooth brushing. A systematic
Gingival index 0.41 0.001 review by Rajapakse et al.19 showed that only 2 out of
Clinical attachment loss 0.24 0.001 17 studies concluded that there appeared to be no rela-
Width of attached gingival 0.06 0.34 tionship between tooth brushing frequency and gingival
recession while 8 studies reported a positive association
between tooth brushing frequency and gingival reces-
DISCUSSION sion. Other potential risk factors were duration of tooth
brushing, brushing force, and frequency of changing the
The present study included 244 subject, 143 (58.6%) tooth brush, brush hardness and tooth brush technique.
males and 101 (41.4%) females who showed gingival
recession. This finding is in agreement with the findings Regarding dental plaque, gingival inflammation and
in a study conducted by Hosanguan C et al 10 which also pocket depth, this study showed significant association
showed males exhibited greater levels of recession than with gingival recession (P value 0.01). They suggested
females (P < 0.001). The findings of our study differ that localized inflammatory process causes the break-
from another study done by Kozlowska et al.11 which down of connective tissue. Proliferation of epithelial
showed 74% of females and 28% of males showed cells into the connective tissue brings about a subsi-
gingival recession, respectively. In the present study, the dence of the epithelial surface which is manifested clini-
most frequent affected teeth with gingival recession cally as gingival recession. Some studies showed that
were the maxillary 1st and 2nd molars followed by the gingival recession was associated with a high level of
mandibular incisors. Checchi et al.12 showed that ca- dental plaque and calculus and gingival bleeding on
nines of both jaws were the most frequent teeth af- probing17,18,23,24. Similarly, the results of a study by Gou-
fected by gingival recession. Muller et al.13 found that toudi et al.25 revealed that gingival margin recession was
1st and 2nd molars of both jaws were the most fre- associated with both high inflammatory and plaque
quently teeth affected by gingival recession. However, scores. One study26 showed a negative correlation be-
Murray14 showed that the most frequent teeth with tween dental plaque on the buccal tooth aspect and
gingival recession were mandibular incisors followed by gingival recession. The majority of the patients of the
1st maxillary molars, 1st mandibular molars, premolars present study (67.16%) showed subgingival calculus
of both jaws, 2nd maxillary molars, 2nd mandibular while only 32.84% showed supra-gingival calculus.
molars and canines. These differences could be attri- Those findings (although the difference was not statisti-
buted to several factors such as the heterogeneity sam- cally significant) were in agreement with other studies
ples, the difference in attitude of the samples to the which reported that calculus plays an important role in
value of oral hygiene and the need for a regular dental the etiology of gingival recession. Those stu-
follow-up, the different criteria used by several examin- dies20,21,27,28,29 showed that the presence of supra- gin-
ers (clinical examination-questionnaire) in order to gival calculus had the most significant association with
collect data, and the origin of the sample collected (den- localized and generalized gingival recession.
tal hospital, private practice, etc.).

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It is important to highlight that the aim of the present 11. Kozlowska M, Wawrzyn-Sobczak K, Karczewsk JK, Stokowska
study was not only to find out the aetiological factors of W. The oral cavity hygiene as the basic element of the gingival
recession prophylaxis. Rocz Akad Med Bialymst 2005; 50(Suppl
gingival recession but to review the association between 1): 234-7.
these factors and gingival recession. It is also apparent
12. Checchi L, Daprile G, Gatto MR, Pelliccioni GA.Gingival
that aetiological factors vary across countries and cul- recession and toothbrushing in an Italian School of Dentistry: a
tures and must be taken into consideration when look- pilot study. J Clin Periodontol 1999; 26(5): 276-80.
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sion. According to the present study, factors causing smokers and non-smokers with minimal periodontal disease. J
gingival recession were tooth brushing method, type of Clin Periodontol 2002; 29(2): 129-36.
toothbrush, frequency of tooth brushing, oral hygiene, 14. Murray JJ. Gingival recession in tooth types in high fluoride and
gingival inflammation. low fluoride areas. J Periodontal Res 1973; 8(4): 243-51.
15. Khocht A, Simon G, Person P, Denepitiya JL. Gingival reces-
sion in relation to history of hard toothbrush use. J Periodontol
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16. Tezel A, Canakci V, Cicek Y, Demir T. Evaluation of gingival
Majority of the participants showed Miller’s class I recession in left- and right-handed adults. Int J Neurosci 2001;
gingival recession and its overall prevalence was greater 110(3-4): 135-46.
in males than in females. The most frequent affected 17. Drisko C. Oral hygiene and periodontal considerations in
teeth with gingival recession were the 1st and 2nd mo- preventing and managing dentine hypersensitivity. Int Dental J
lars of maxilla followed by mandibular incisors. Hori- 2007; 57(S6): 399-410.
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more associated with gingival recession. The correlation 94
association between dental plaque, gingival inflamma- 19. Rajapakse PS, McCracken GI, Gwynnett E, Steen ND,
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development and progression of noninflammatory gingival re-
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21. .Banihashemrad SA, Fatemi K, Najafi MH. Effect of Smoking
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