Management & Prevention of Gingival Recession GK_MgmtPrevGinRec_Sem... · gingival/soft tissue recession; probing depths extending beyond the MGJ; absence or narrow band (< 2mm) of

Management & Prevention

of Gingival Recession

Workbook

George K. Merijohn, DDS San Francisco, California

______________________________________________________________________________ Assistant Clinical Professor, UCSF School of Dentistry, Dept. of Orofacial Sciences, Postgraduate Periodontology Affiliate Associate Professor, University of Washington School of Dentistry, Postdoctoral Periodontics

www.merijohn.com

©2015 George K. Merijohn, DDS All rights reserved Page 2

Table of Contents 1 Gingival Recession Today 3

2 Who is Susceptible? 3

3 What Causes It? 4

4 What Increases the Risk? 4

5 Essential Data Collection & Recording 5

6 Gingival Recession Interventions Work Session 7

7 When to Monitor and When to Consider Surgery 10

References 12 Gingival Recession Checklist and Chairside Visual Guide Gingival Recession Chairside Visual Guide

17 Each course participant may print one copy of the workbook for personal use.


1. Gingival Recession Today

Gingival/soft tissue recession: The exposure of the root surface due to __________________

of the gingival/soft tissue margin past the cementoenamel junction (CEJ)18,53,91

Worldwide prevalence: % - % 2,45,47,55,56,79,84

Prevalence and severity increases with _______.2,55

United States: Prevalence of ≥1 mm recession in persons 30 years and older is _____%, and

averaged _______% teeth per person.2

Gingival recession in dental students and dentists 56:_______________________________

Gingival recession: Important to patients when it interferes with ______________________,

________________, or increases the risk of tooth loss due to _______________________ or

______________________.59

Prevalence of root caries experience in the U.S. has been reported to be ______% among

those aged 75+ years.37

Age group 65 and older (12% in 2000) is increasing and expected to exceed ______% by

2030 and ___________ is expected to increase along with it.37

2. Who is Susceptible?

Three major factors are associated with increased susceptibility to gingival recession, whether presenting independently or in combination: 59

1. Thin (delicate, fragile) Gingival Tissue 1,12,22,49,67,77

2. Mucogingival Conditions 5,41

Gingival/soft tissue recession Probe depth extends beyond the mucogingival junction Absence or narrow band (<2mm) of keratinized tissue

3. Positive History: Progressive gingival recession 81

Inflammatory periodontal disease(s) (e.g., plaque-induced gingivitis, localized chronic periodontitis) is a particularly important factor associated with gingival recession 2,79,81,94 especially for teeth with #1 &/or #2 above 59


3. What Causes It?

Major causes of gingival recession: __________________________________ 79,81 and

mechanical (physical) abrasion/removal (e.g., _______________ oral hygiene practices or

_________________ dental procedures).27,35,40,43,45,55,76,79,83,89

Occasional causes:___________ and _____________ injury.40,76

4. What Increases the Risk?

Studies have reported several contributing factors and conditions commonly associated with

gingival recession and/or increasing recession. 8,45,54,56,76,77,79 Exposure to such factors and

conditions can make susceptible teeth particularly vulnerable to gingival recession.

Modifiable Conditions: Those common risk exposures associated with gingival recession that

lend themselves to ____________________ through conventional interventional therapy in the

clinical setting (Table 1). Table 1.Modifiable Conditions Associated with Gingival Recession

Clinical Tip: Decreasing the susceptible patients' exposure to modifiable conditions will decrease future risk for gingival recession and increase the likelihood of its long-term prevention.


Identifying which patients are more ____________________ to gingival recession and which risk

exposures are __________________ in the clinical setting are essential first steps in developing

an action plan for the management and prevention of gingival recession.

5. Essential Data Collection and Recording

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

Evaluation of the patient’s periodontal status requires obtaining a relevant medical and dental history and conducting a thorough clinical and radiographic examination with evaluation of extraoral and intraoral structures.5 The Parameter on Comprehensive Periodontal Examination developed by the American Academy of Periodontology states that all relevant clinical findings should be documented in the patients record.5

See Table 2 for recommendations regarding where to document in the patient record the susceptibility factors and modifiable conditions associated with gingival recession. 59 Table 2. Documenting Susceptibility Factors and Modifiable Conditions59

Clinical & Risk Management Tip: In order to establish a baseline and to most effectively track changes over time, all measurable/detectable essential clinical findings are recorded in the periodontal examination record. A comprehensive periodontal examination should be performed for all new patients and at appropriate periodic intervals based on the needs of the individual patient. 4,5


See Figure 1 for an example of a comprehensive periodontal examination record that provides for data collection and recording for gingival recession susceptibility and modifiable risk factors. Figure 1. Periodontal Examination Record Example

www.perioaccess.com Q: How is periodontal charting data practically managed during dental hygiene/maintenance visits? A: Given the typical time allotment for dental hygiene appointments, for an adult patient with a relatively full complement of teeth and/or implants it is not always possible to perform and record a comprehensive periodontal examination in addition to performing other required assessments including: 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).4,5 One must also consider the time it takes to greet and exit the patient as well as to perform operatory tear-down/disinfection and chairside set up. However, comprehensive periodontal evaluation [assessment) is a critically important component of the dental hygiene/maintenance appointment.5 A practical approach is to record on the periodontal maintenance record (see example in Figure 2), only significant negative changes comparing present findings to the most recent data on the periodontal examination record. (Figure 1). Q: Is comprehensive periodontal data recording/charting required at every hygiene visit?


Figure 2. Periodontal Maintenance Record Example

www.perioaccess.com 6. Gingival Recession Interventions Work Session

Gingival Recession Checklist and Visual Guide is a practical chairside support tool that illustrates to the patient the gingival recession modifiable conditions that she or he can personally control. Especially with patients susceptible to gingival recession, mitigating these conditions will improve the chances for better management and prevention of gingival recession.59 Gingival Recession Checklist is especially helpful to the clinician when developing treatment plans. Its use during treatment/procedure planning can help guide the clinician toward options that can potentially decrease the risk of damage to tissues (e.g., mechanical abrasion/removal, inflammation, chemical, or thermal injury). This can help improve the odds of providing better management and prevention of gingival recession.59

Clinical Management/Treatment Plan Options Work Session: (Overview of 10 of the 14 Modifiable Conditions on Gingival Recession Checklist)

Poor metabolic control of diabetes


Tobacco use including smokeless

Damaging oral hygiene methods contributing to inflammation/tissue injury

Damaging oral habits/eating habits contributing to inflammation/tissue injury

Bleeding on probing/inflammatory periodontal disease(s) (e.g., plaque-induced gingivitis, chronic periodontitis)

Clinically significant root sensitivity leading to avoidance of oral hygiene procedures


Subgingival restorations contributing to inflammation despite effective oral hygiene and appropriate periodontal treatment

Oral appliances contributing to inflammation/tissue injury (e.g., oral jewelry, fixed orthodontic appliances, removable appliances)

Panned dental therapy that can cause inflammation or physical injury to the gingival tissues

Example: Potentially traumatic subgingival instrumentation:

Planned orthodontic tooth movement

Orthodontic treatment in general and the following retention phase are considered risk factors especially for the development of labial gingival recession.49,77 Use the Gingival Recession Checklist before, during and after orthodontic treatment. Patients susceptible to gingival recession will be more so during or after orthodontic treatment, especially if they present with modifiable conditions that are not addressed before, during, and after treatment. The prudent inter-disciplinary dental team will:

1. Determine whether the prospective orthodontic patient is susceptible to gingival recession

2. Consider adjusting tooth movement plans and outcomes 3. Recommend appropriate interventional periodontal therapy-especially for teeth at

increased risk for gingival recession


7. When to Monitor and When to Consider Surgery 59

When to Monitor Gingival Recession Although individual patient circumstances may dictate otherwise, for patients presenting with: gingival/soft tissue recession; probing depths extending beyond the MGJ; absence or narrow band (< 2mm) of keratinized tissue; and/or thin (delicate, fragile) gingival tissue, it is proposed that the clinician can monitor gingival recession without surgical evaluation when all of the following criteria are met:4,59,60,63

No documented evidence of______________________ gingival recession Clinical attachment loss (probing depth plus gingival recession) is _______ mm

________ mm of gingival recession

All of the above and none of the following are planned involving the teeth in question Subgingival restorations Orthodontic tooth movement Oral appliances (e.g., oral jewelry, removable dental appliances) that can or will be in

contact with the tissue Potentially damaging dental therapy such as those treatments or procedures that can

cause inflammation or physical injury to the gingival tissues

When the Patient is a Candidate for Surgical Evaluation Although individual patient circumstances may determine otherwise, for patients presenting with: gingival/soft tissue recession; probing depths extending beyond the MGJ; absence or narrow band (< 2mm) of keratinized tissue; and/or thin (delicate, fragile) gingival tissue, it is proposed that the patient is a candidate for surgical evaluation when at least one of the following criteria are met: 4,59,60,63

Documented evidence of_____________________ gingival recession

___________________gingival inflammation despite appropriate therapeutic interventions and

also present with clinical attachment loss ______mm and/or gingival recession ______mm

____________________ gingival inflammation despite appropriate therapeutic interventions and

the inflammation is associated with:

Clinical Tips: Not all teeth presenting with thin gingival tissue, probing depth extending to or beyond the MGJ, &/or absence or narrow band of keratinized tissue will demonstrate gingival recession Surgical therapy is not warranted based solely on the presence of thin gingival tissue, probing depths extending beyond the MGJ, &/or absence or reduction of keratinized tissue. Lindhe J, Allen E, Maynard G Jr, Bruno J, Miller PD, Holbrook T, Wennstrőm J, Pini Prato G, Takei H. Consensus report. Mucogingival Therapy. Ann Periodontol 1996; 1: 702-706.


___________ vestibular depth that restricts access for effective oral hygiene

___________ position that compromises effective oral hygiene

Tissue _____________ (cleft/fissure, etc.)

Any of the above and any of the following are planned for the teeth in question Subgingival restorations Orthodontic tooth movement Oral appliances that contact the tissue Potentially damaging dental therapy (see above)

When to Refer the Patient to the Periodontal Specialist59

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, a referral to the periodontist is appropriate when: 59

The______________________ prefers referral

The dentist ____________________ referral is in the best interest of the patient

The dentist determines she/he does not possess sufficient knowledge, skills, and/or

experience to provide the patient with the necessary __________ _________ objectives

The dentist determines that clinical__________________ dictates additional input into the

case

Situations that increase clinical uncertainty include: some medically complex patients; advanced-severe gingival recession defects; multi-tooth involvement; and/or recession risks that cannot be readily modified. 59 According to The Principles and Code of Professional Conduct of the American Dental Association,

patients should receive treatment from those licensed dentists who keep current; have the

appropriate surgical training; and possess the requisite _______________, _____________, and

______________________.6

Every clinician must __________________________ whether they have the knowledge, skills, and

experience to monitor or plan/perform surgery on the patient for the management of gingival

recession defects.59


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Management & Prevention of Gingival Recession GK_MgmtPrevGinRec_Sem... · gingival/soft tissue recession; probing depths extending beyond the MGJ; absence or narrow band (< 2mm) of