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Receding gums (gingival recession) refers to a loss of gum tissue resulting in an exposure in the roots of the teeth. Gum recession is a common problem in adults over the age of 40, but may also occur starting from the teens. - More from Wikipedia
Dental India
News/Discussions in the web - restoring receded gums
 (click on the description to go the article)
1.  Gingival recession: a cross-sectional clinical investigation 
2.  The prevalence and distribution of gingival recession
    among U.E. dental students with a high standard of oral hygiene.
3.  Improvement of multiple facial gingival recession by non-surgical and supportive
    periodontal therapy: a case report
4.  Gingival recession and toothbrushing in an Italian School of Dentistry: a pilot study.
5.  The tooth brush that is "too hard" is just another way of causing recession
6.  Another cause of abfraction (which is recession accompanied by a
    horizontal groove at the gumline) is bruxism
7.  SOFT bristles are the way to go.
8.  What kind of circumstances make  you recommend not doing the graft?
9.  For esthetics,color and texture changes that do not match...
10. Results from subepithelial connective tissue grafts.

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From: Larry Burnett Sent: Friday, March 16, 2001 02 31 I'd like to know if you sometimes have patients referred for grafting procedures and after seeing and talking to patient you and the patient decide he really doesn't need or want it. If so, is it difficult to handle the situation without alienating the referring dentist? From: Kelly D. Douglass, DDS, MS Sent: Thursday, March 15, 2001 18 56 I've not found it to be a problem in alienating the referring dentist.... and there have been a number of times I've recommended not doing the grafts. Generally when a patient is referred to me it is to use my expertiese and knowledge to determine what needs to be done......or not done. That's the reason they refer to me. They don't treat me like a short order cook and just tell me what to do/cook for them. - kelly d. douglass, dds, ms
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From: JB Sent: Friday, March 16, 2001 03 32 Everyone: Thanks for all the responses and advice, though I confess, I've not yet had a chance to go through it all in detail. My recession has doubtless been caused primarily from YEARS of brushing too damn hard. I'd always been told that I had "beautiful teeth" or a "nice smile", and I can distinctly remember, as a kid, thinking that brushing vigorously twice daily with my firm bristles was the proper way to maintain my dental health and appearance. I recall being almost disgusted by the perceived ineffectivness of soft-bristled brushes the few times I used them. Not until I started noticing and worrying about recession a few years ago, did I become aware through my dentist that SOFT bristles are the way to go. (Can someone please explain why they even MANUFACTURE the other firmnesses? For cleaning bathroom tiles?) I can't believe that I'm almost 37 and I heard for the first time only less than a year ago on the NBC's "Later Today" show (now-defunct, I believe) that one of the keys to dental health was brushing for 3 minutes! I now use a soft brush (though the 'soft' ones I've been using are not nearly as soft as the 'ineffectual' ones I remember from my youth), despite this, my recession is continuing. Thankfully my teeth are still straight and 'pretty', so I don't have that issue, but I'm a bit shy of smiling broadly... Anyway, forgive my rambling, but anyone have any thoughts on the following?: Whether 'soft' bristles are as soft as they used to be? Whether 'softness' varies depending on the manufacturer? Why 'mediums' and 'firms' are manufactured at all? And why people aren't better informed about proper brushing technique? Thanks. -Joel
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From: patkeat Sent: Friday, March 16, 2001 09 40 Hi Joel, why don't you purchase the Sonicare toothbrush and then you don't have to worry about whether or not you are brushing to hard. It does the job! - Janet Thanks for the recommendation -- I'll look into the Sonicare. It's just a standard electric, right? Or is there something special about this one in particular that has you recommend it specifically over other brands I've heard of (OralB, etc...). - Joel Sent: Friday, March 16, 2001 6:24 AM Subject: RE: [Periodontal] Re: Restoring Receded Gums You can tell this fellow to use an electric toothbrush (one that automatically turns off after two minutes), and let it "do it's thing". If he holds the bristles at a 45 degree angle and allows the brush to vibrate without him exerting additional pressure, he can get the thorough cleaning he wants without encouraging gum recession.- B. From: Larry Burnett Sent: Thursday, March 15, 2001 9:19 PM To: Barbara Ann Burke Subject: Fw: [Periodontal] Re: Restoring Receded Gums Here's a guy we just save from surgery by telling him to quit scrubbing his teeth so much like you.
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From: Kelly D. Douglass, DDS, MS Sent: Friday, March 16, 2001 03 36 What kind of circumstances make you recommend not doing the graft? If there is adequate keratinized tissue with restorations adjacent to the margin....if there is no restoration adjacent to the marginal tissue, none planned, good oral hygiene and no recession..... if recession is not progressing.....if patient is able to provide adequate oral hygiene to the area without pain or trauma to non-keratinized tissue. Exceptions to the above is if the patient is concerned with the esthetics of the recession and would like the area repaired. kelly d. douglass, dds, ms From: David Sent: Friday, March 16, 2001 04 40 Dear Kelly, I feel grafts are generally unnecessary, unless for prosthetics or orthodontics. For esthetics, I've seen results that look terrible because of color and texture changes that do not match. - David DiBenedetto From: Larry Burnett Sent: Friday, March 16, 2001 05 48 Generally when a patient is referred to me it is to use my expertiese and knowledge to determine what needs to be done......or not done. That's the reason they refer to me. They don't treat me like a short order cook and just tell me what to do/cook for them. kelly d. douglass, dds, ms
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From: JB Sent: Friday, March 16, 2001 08 45 Another cause of abfraction (which is recession accompanied by a horizontal groove at the gumline) is bruxism. As far as recession, often it is caused by frenum pull or teeth that are positioned to the buccal. If that is the cause, then the facial gingiva must be reinforced by a graft or it may continue to recede regardless of the patient's habits... Meg, I appreciate your response, but... bruxism? frenum pull? buccal? facial gingiva? I have no idea what any of this means. - joel From: JB Sent: Friday, March 16, 2001 09 00 For esthetics, I've seen results that look terrible because of color and texture changes that do not match... This is what I'm afraid of, especially given that my interest in the grafting surgery is primarily cosmetic to begin with. Are there any sites you can recommend on the 'net where I can find some 'before' and 'after' photos that might give me a sense of the kind of results I might expect from the grafting procedure? And where do the take the tissue from to begin with? The upper palate? And is there a lot of post-surgery soreness in the donor area? - Joel From: Kelly D. Douglass, DDS, MS Sent: Friday, March 16, 2001 09 30 Then you've not seen results from subepithelial connective tissue grafts. They have absolute perfect color to the adjacent tissue and the contour/texture simply blends into the existing tissue. We are not talking about "free gingival grafts"....those things that look like tire patches. I've done many that if you'd not seen the before photos you'd never know they ever had any recession.....nor that they ever had a surgical procedure done. Sorry....nope, I don't remember you from sci.med.dentistry......I guess I block bad places out. :-) From: Larry Burnett Sent: Friday, March 16, 2001 10 18 I agree with Kelly on this. You can get a graft that will look fine. If it were my I would make it clear to the surgeon that you are doing it for esthetic reasons only and that you will be extremely disappointed if it doesn't look great. - Larry From: Kelly D. Douglass, DDS, MS Sent: Friday, March 16, 2001 10 20 BTW...I have a pretty heavy cosmetic portion to my periodontal practice..... I do a lot of esthetic surgery for root coverage and esthetic crown lengthening. I don't really have a grasp as to how prevalent esthetics and cosmetics are in the average periodontal practice. Please follow Larry's suggestion and let the periodontist know what you are expecting....then he/she can decide if it is something they can provide or refer on to someone who will.
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Greetings Kelly, Nice to hear from you. We can all benefit by having you share your ideas with us. I hope you can find time for more posts. I'd like to know if you sometimes have patients referred for grafting procedures and after seeing and talking to patient you and the patient decide he really doesn't need or want it. If so, is it difficult to handle the situation without alienating the referring dentist? A couple of quick studies to address common causes of recession. Of course poor plaque control is another very common etiologic factor. But sometimes this results in well intentioned coaching from hygienists and dentists causing the patient to overbrush and cause more recession. The tooth brush that is "too hard" is just another way of causing recession by overzealous brushing without being as overzealous as is necessary with a soft brush. Bur I would still include that as "overbrushing" - Larry From: Kelly D. Douglass, DDS, MS Sent: Wednesday, March 14, 2001 7:49 PM Subject: Re: [Periodontal] Re: Restoring Receded Gums I'm also not sure you have any scientific research to show that the "most common reason" for recession is "trying to clean their teeth too hard." kelly d. douglass, dds, ms
   Gingival recession: a cross-sectional clinical investigation.  TOP 
Gingival recession: a cross-sectional clinical investigation. Goutoudi P, Koidis PT, Konstantinidis A Department of Preventive Dentistry and Periodontology, School of Dentistry, Aristotle University of Thessaloniki, Greece. In this cross-sectional study, risk and potentially causative factors of gingival recession were examined and their relationship to apical migration of the gingival margin evaluated. Thirty eight patients (18-60 years), displaying one or more sites with gingival recession but without any significant periodontal disease participated. A total of 28 parameters were evaluated in both 'test' teeth (50 teeth with gingival recession) and 'control' teeth (50 contralateral teeth). The results revealed that gingival margin recession was associated with both high inflammatory and plaque scores, with decreased widths of keratinized and attached gingiva and with the subjects' toothbrush bristle hardness. PMID: 9487812
   The prevalence and distribution of gingival recession among U.E. students with a high standard of oral hygiene.  TOP 
3: J Philipp Dent Assoc 1995 Dec-1996 Feb;47(3):27-48 Related Articles, Books, LinkOut The prevalence and distribution of gingival recession among U.E. dental students with a high standard of oral hygiene. Carlos MC, Muyco MM, Caliwag MC, Fajardo JA, Uy HG The aims of this study were to evaluate the prevalence and the distribution of the attachment loss and gingival recession at facial tooth surfaces in a population sample with a high standard of oral hygiene, at the same time, to determine the occurrence of gingival recession. An additional aim was to study the relationship between attachment loss and gingival recession and its relation to its etiologic factors. The subject sample comprised of 100 male and female dental students in the University of the East between the ages of 18 and 26 with a minimum of 25 natural teeth, no advance periodontitis or history of periodontal surgery were examined, gingival recession was scored as present whenever the free gingival margin was apical to the c.e.i. and root surface was exposed. The clinical examination involved assessment of gingivitis, probing depth, probing attachment and gingival recessions. The results of the combined cross-sectional and longitudinal analysis performed in the study demonstrated among 100 U.E. dental students with a high standard of oral hygiene showed that: 1) Facial gingival recessions was a frequent finding due to the compensatory and remodelling process caused by loss of approximal periodontal attachment; 2) Prevalence and distribution of gingival recessions is independent with the presence of attachment loss; 3) Facial gingival recessions can exist with or without attachment loss and teeth without gingival recessions may or may not present attachment loss; 4) And presence of gingival recessions in patients with a high standard of oral hygiene can either be attributed to orthodontic treatment or wrong toothbrushing technique, too much strength exerted in brushing, overbrushing, and usage of hard toothbrush bristles.
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Jones writes I have seen psuedo-pocketing occur on both connective and free gingival grafts but they can be easily corrected with CO2 lasers. Actually, sometimes, if the rugae from the palatal donor tissue transfer to the graft site, we use the laser to "smooth" out the wrinkles and recontour the graft site. Mr. Jones, we have a little problem with pocketing and ugliness here but I can easily correct it by running out and getting a $25,000 Co2 laser. That wouldn't be easy for me :) - Larry Burnett Kelly replies I've probably averaged 1-2 connective tissue grafts per week over the last 5-6 years and have never had a single incidence of psuedo-pocketing from this procedure Sent: Friday, April 13, 2001 10:29 AM Subject: Re: [Periodontal] Re: Restoring Receded Gums Meg says: Current information indicates that the toothpaste when brushing causes abrasion; nylon bristles alone don't do the damage. Larry replies: That's interesting but this patient wants to know about gingival recession, not enamel abrasion
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Meg says: As far as recession, often it is caused by frenum pull or teeth that are positioned to the buccal. If that is the cause, then the facial gingiva must be reinforced by a graft or it may continue to recede regardless of the patient's habits. I work with a periodontist and she often will get root coverage with a connective tissue graft that looks great and does not probe >2 mm. Sent: Thursday, March 15, 2001 09 36 Subject: Re: [Periodontal] Re: Restoring Receded Gums Agreed...current grafting techniques utilizing connective tissue have shown excellent results. Another type of graft that may be performed is a pedical graft in which adjacent tissue is released and sutured into position over the concerned area. There are a few individuals who are also utilizing a material called Emdogain with the connective grafting procedure to aid in tissue attachment, Emdogain is a porcine derivative material that stimulates guided tissue regeneration. Of course root coverage is limited by the height of the immediate papillae and gingival tissues; therefore, if there is a fair amount of bone loss present, root coverage may not be attained. Free gingival grafts normally don't provide adequate root coverage for this type of procedure but it will create a more healthy site of attached gingivae. Another product I have seen is the allograft material...donor tissue, but I have seen mixed results. Personally, I say go with your own tissue bank :) Things to consider as possible etiologies for recession may be tooth positioning (lingual tipping), frenum involvement, minimal or lack of attached gingivae, prominent roots (cuspids), bruxism, oral habits (smokeless tobacco), brushing habits and orthodontic treatment to name a few. In regards as to whether the procedure is cosmetic or preventative, I think we should consider the oral health of the patient. As Dr. Larry stated, without actually completing an examination this is hard to establish. Personally, I think that if an individual has a high risk for caries, has dry mouth symptoms and or poor home care, then this procedure could be invaluable in decreasing future root caries activity. The healing time for these procedures really varies from patient to patient. Typically, the donor sites from the palate tend to heal faster due to the fact that the excision is deep rather than wide which allows for complete closure with suturing whereas the free gingival graft is wide and shallow and would then leave an open site that tends to heal slower and be more uncomfortable to the individual...if you ever had a bad pizza burn on the roof of your mouth than you know what this feels like. Sometimes, a surgical stent can be fabricated prior to the surgical visit to help alleviate some of this discomfort. The graft sites themselves tend to heal a little slower if it is a connective tissue graft, while a free gingival graft tends to heal much faster. There may be localized swelling at the graft site as well. I have seen psuedo-pocketing occur on both connective and free gingival grafts but they can be easily corrected with CO2 lasers. Actually, sometimes, if the rugae from the palatal donor tissue transfer to the graft site, we use the laser to "smooth" out the wrinkles and recontour the graft site. Anyway, I hope this helps. Plenty of things to discuss with your periodontist at your next appointment I am sure. Good luck! S. Valdez -Dental Hygiene Student....former periodontal assistant Now.....back to studying for my national board exams....March 27th!!!
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Larry replies: No matter what the cause of the recession, the cause of the recession must be removed in order for the recession to halt. A gingival graft will never stop the recession, nor is it intended to. There is no evidence anywhere I know of that suggests gingival recession is a cause of further recession if it is not covered over with a graft. If a frenum pull is the cause (doubtfull) placing a graft will not stop further recession unless the frenum causing the problem is removed. If the recession is caused by teeth moving labial or buccal, the recession will continue as long as the teeth continue to drift in that direction. A graft will not stop it. When recession occurs, you identify the cause and stop it. Then the patient can decide if the recession that has occurred requires a graft to make him look better. To tell a patient they need a graft to stop the recession is an example of confusing esthetic dentistry with therapeutic treatment and misinforming the patient. This patient assumed or had heard that a gingival graft was in some way needed to maintain his oral health. I say it isn't, but if you have some literature suggesting that it is, I and he would certainly be interested in hearing about it. I also include the myth that a certain amount of keratinized gingiva is necessary. I'm glad you brought this up because many patients are sold gingival grafts with the idea that it is needed for their health. The first study is to suggest "try the easy way first: The second one is to suggest finding one of these causes, stop the habit that is causing it and the recession will no longer continue. Now if the recession happens to be on a 19 year old female who wants to pose for adds in a dental magazine, a nice graft could be the perfect treatment after the recession is halted. PS. If anyone would like to know if your patient's recession is continuing over time, simply take an alginate impression at one appointment and then continue to compare those models with the patients gingival margin as the years go by. I'll bet you will end up suggesting a lot less grafting procedures. - Larry
   Improvement of multiple facial gingival recession by non-surgical and supportive periodontal therapy: a case report.  TOP 
Improvement of multiple facial gingival recession by non-surgical and supportive periodontal therapy: a case report. - Ando K, I to K, Murai S Department of Periodontology, Nihon University School of Dentistry, Tokyo, Japan. We report a case of multiple facial gingival recession which was improved by non-surgical and supportive periodontal therapy. The patient, a 28-year-old Japanese woman, presented for treatment of multiple facial gingival recession ranging from 1 to 4 mm on teeth 5 through 12 and 19 through 30. Periodontal plastic surgery to cover the exposed multiple root surfaces was suggested. However, because of emotional problems, the patient did not wish to undergo the procedures and instead accepted non-surgical periodontal therapy including oral hygiene instruction, scaling, and root planing. The exposed root sites were monitored at periodic maintenance visits, and gradual improvement through a coronal increase of the gingival margin was noted. The possible etiologic factors and healing process associated with this case are discussed. PMID: 10476900
   Gingival recession and toothbrushing in an Italian School of Dentistry: a pilot study.  TOP 
2: J Clin Periodontol 1999 May;26(5):276-80 Related Articles, Books, LinkOut Gingival recession and toothbrushing in an Italian School of Dentistry: a pilot study. Checchi L, Daprile G, Gatto MR, Pelliccioni GA School of Dentistry, University of Bologna, Italy. lchecchi@alma.unibo.it The aim of this pilot study was to evaluate the prevalence of gingival recession at buccal tooth surfaces in a student population of Bologna University Dental School. A total of 55 subjects, attending the 1st and 5th year of the course were examined. The clinical examination involved assessment of plaque, calculus, width of keratinized gingiva, buccal probing depth and buccal gingival recession. Information about toothbrushing behavior was collected in an interview. The multiple regression analysis showed that level of education (p=0.002), toothbrushing technique (p=0.013) and toothbrushing frequency (p=0.016) are significant contributors to gingival recession. Notwithstanding the limits of a preliminary study, a higher prevalence of buccal recession is observed in the final year students, which have also a significantly lower % of buccal surfaces with calculus (p=0.014). In addition, it clearly appears that there is the necessity to investigate other factors connected with toothbrushing (pressure, time, toothpaste quantity) in order to provide an oral hygiene education without undesired effects. PMID: 10355616
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Kelly writes Not only will root coverage grafting improve the ability of one to keep an area clean by leveling the gingival margin and adding keratinized tissue which is much kinder to oral hygiene than non-keratinized tissue.....but there is actually histological research to show cementum and bone growth on the root surface where a connective tissue graft has been done. I've not seen a single report where proper connective tissue grafting has created a "gum pocket" as you describe. I'm also not sure you have any scientific research to show that the "most common reason" for recession is "trying to clean their teeth too hard." From: JB Sent: Wednesday, March 14, 2001 1:47 PM Subject: [Periodontal] Re: Restoring Receded Gums Thanks for the quick response. Yes, my concerns are primarily cosmetic, but I suppose from a dental health standpoint, the procedure probably does help protect the teeth as well, no? Also, I imagine the procedure is not inexpensive, although I know the cost must vary significantly depending on the extent of the grafting done. I guess I'd have to go in for a consultation to get a quote... Joel Larry Replies: It would really be rare for that procedure to add anything as far as dental health is concerned. You should understand that the most common reason for recession is a person trying to hard to clean their teeth and literally scrubbing too hard with the toothbrush over time. If you recognize this as the cause, just stop scrubbing and make sure recession is not continuing. As long as recession does not continue, it will only be a matter of appearance you should base your decision on. Perhaps you can avoid that expensive surgery. Also the graft itself may create a gum pocket where one never existed before. So if the appearance doesn't bother you, save yourself some money and trouble. Please understand, I haven't seen your mouth and their could be some unusual circumstance which would call for a different opinion. Any one else have any thoughts about this? - Larry Burnett Are you having it done for appearance, or is there some other reason for the grafting procedure? - Larry From: JB Sent: Wednesday, March 14, 2001 11:44 AM Subject: [Periodontal] Restoring Receded Gums I have some advanced gum recession, and am interested in having some grafting done. Is there anyone on this board who has had this procedure? I'm interested in getting a sense of the healing process, ultimate cosmetic effect, etc. Thanks. JB
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