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Original Article

Etiology and occurrence of gingival

recession ‑ An epidemiological study
Sarpangala Mythri, Suryanarayan Maiya Arunkumar,1 Shashikanth Hegde,1
Shanker Kashyap Rajesh,1 Mohamed Munaz,2 Devasya Ashwin3

Department of Abstract:
Periodontology, Kannur Objectives: Gingival recession is the term used to characterize the apical shift of the marginal gingiva from its
Dental College, Kannur, normal position on the crown of the tooth. It is frequently observed in adult subjects. The occurrence and severity
Kerala, 1Department of the gingival recession present considerable differences between populations. To prevent gingival recession
of Periodontology, from occurring, it is essential to detect the underlying etiology. The aim of the present study was to determine the
Yenepoya Dental occurrence of gingival recession and to identify the most common factor associated with the cause of gingival
recession. Methods: A total of 710 subjects aged between 15 years to 60 years were selected. Data were collected
College, Mangalore,
by an interview with the help of a proforma and then the dental examination was carried out. The presence of
3
Department of gingival recession was recorded using Miller’s classification of gingival recession. The Silness and Loe Plaque
Pedodontics, Kannur Index, Loe and Silness gingival index, community periodontal index were recorded. The data thus obtained were
Dental College, Kannur, subjected to statistical analysis using Chi‑square test and Student’s unpaired t‑test. Results: Of 710 subjects
Kerala, 2Department examined, 291 (40.98%) subjects exhibited gingival recession. The frequency of gingival recession was found to
of Periodontology, increase with age. High frequency of gingival recession was seen in males (60.5%) compared to females (39.5%).
Rangoonwala College Gingival recession was commonly seen in mandibular incisors (43.0%). Miller’s class I gingival recession was
of Dental Science, more commonly seen. The most common cause for gingival recession was dental plaque accumulation (44.1%)
followed by faulty toothbrushing (42.7%). Conclusion: Approximately half of the subjects examined exhibited
Pune, Maharashtra,
gingival recession. The etiology of gingival recession is multifactorial, and its appearance is always the result of
India more than one factor acting together.
Key words:
Dental plaque, epidemiology, etiology, gingival recession, prevalence

INTRODUCTION gingival recession can often be visible to patients

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DOI:
A beautiful smile is the best ornament for
the face and is the most primitive forms
of human communication. The harmony of the
10.4103/0972-124X.156881 smile is determined especially by the shape, the
Quick Response Code: position and the color of the teeth.[1] People of all
ages are increasingly concerned about their smile
and overall appearance.
An adequate mucogingival complex, in which
the mucogingival tissues can sustain their
biomorphologic integrity and maintain an
enduring attachment to the teeth as well as
the underlying soft tissue, is always essential.
When a mucogingival problem occurs, there are
basically two ways in which it presents itself: (a)
As a close disruption of the mucogingival
complex resulting in pocket formation. (b)
Address for As an open disruption of the mucogingival
correspondence: complex resulting in gingival clefts and gingival
Dr. Sarpangala Mythri, recession.[2]
Kannur Dental College,
Kannur ‑ 670 612, Gingival recession is the term used to characterize
Kerala, India.
the apical shift of the marginal gingiva from
E‑mail: dr.my3perio@
gmail.com its normal position on the crown of the tooth
to the levels on the root surface beyond the
Submission: 25‑03‑2014 cemento‑enamel junction. [3] Although many
Accepted: 19-03-2015 dental conditions go unnoticed by patients,
© 2015 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow 671
and for which they may seek advice of a dentist.
Gingival recession usually creates an esthetic
problem, especially when such problem affects
the anterior teeth and anxiety about tooth loss
due to progression of the destruction. It may also
be associated with dentine hypersensitivity, root
caries, abrasion and/or cervical wear, erosion
because of exposure of the root surface to the oral
environment and an increase in accumulation of
dental plaque.[4]
Despite the frequent observation in adult subjects,
the occurrence and severity of the gingival
recession presents considerable differences
between study populations. A limited amount of
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License, which allows others to remix, tweak, and build upon
the work non‑commercially, as long as the author is credited
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For reprints contact: reprints@medknow.com
How to cite this article: Mythri S, Arunkumar
SM, Hegde S, Rajesh SK, Munaz M, Ashwin D.
Etiology and occurrence of gingival recession - An
epidemiological study. J Indian Soc Periodontol
2015;19:671-5.
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Mythri, et al.: Etiology and occurrence of gingival recession
prevalence and etiology related studies on gingival recession
have been carried out in South India. Therefore, it is important
to collect detailed information, to assess the tendency and
epidemiology of this condition, identify the etiological factors
and establish preventive measures. Hence, the aim of the
present study was to determine the occurrence of gingival
recession and to identify the most common factor associated
with the cause of gingival recession in the patients.
MATERIALS AND METHODS
Subjects of this study were selected from the outpatients
attending the Department of Periodontology, Yenepoya Dental
College, Mangalore. Samples of 710 patients were examined
and selected for this study. Sample size was determined after
a pilot study was carried out of 151 patients. The pilot study
results revealed that the prevalence of gingival recession was
35.1%. The sample size was determined using the formula
n = z2 pq/d2. Assuming that the values obtained are z = a point
on normal distribution with 95% confidence, P = prevalence
from pilot study, q = 100‑p, d = admissible error that is 10%
of prevalence.
The study was reviewed and approved by the institutional
review board of Yenepoya University, Mangalore, India.
A Written informed consent was taken from every participant
prior to the study and at the end of the study all the patients
were treated. Patients aged between 15 and 60 years who had a
minimum of 20 permanent teeth and no histories of periodontal
therapy undertaken during the past 6 months were included
in the study. Patients with systemic diseases were excluded
from the study.
An observational study was performed to find out the most
common cause and occurrence of gingival recession during May
2011 to January 2012. A random sampling technique was used
to select 710 subjects of both genders aged between 15 years and
60 years from the outpatient Department of Periodontology,
Yenepoya Dental College, Mangalore. Data were collected by
an interview with the help of a proforma prepared for this
study, and dental examination was carried out. The proforma
of the study contained a detailed history of personal habits
and brushing habits. Each subject was examined in a dental
chair by a single, trained, and calibrated examiner using dental
chair light, mouth mirror, explorer, William’s periodontal
probe and CPI probe. The entire mouth was examined in a
uniform pattern. Presence of gingival recession was recorded
using Miller’s classification  (1985)[5] of gingival recession.
Following clinical parameters were recorded‑Silness and Loe
plaque index (1967),[6] Loe and Silness gingival index (1963),[7]
community periodontal index (CPI) (1997).[8]
The tooth malalignment was observed by viewing the teeth
from occlusal plane and position of each tooth was classified
according to its relation to the regular curve of the arch either
correctly positioned or outstanding (labially placed) and
instanding (lingually placed) in all subjects. Diagnosis of faulty
toothbrushing in this study was done by examining the facial
surface of the tooth for the presence of cervical abrasion. The
exposed tooth surface appeared to be free of plaque and was
highly polished.[9] The upper and lower frenum was examined
for the site of attachment and presence of frenal pull according
672 Journal of Indian Society of Periodontology - Vol 19, Issue 6, Nov-Dec 2015
to Placek et al. classification.[10] Tension test was carried out to
confirm the adequacy of the width of the attached gingiva.[11]
History of smoking and brushing habits (the type of brushing
method, duration of brushing, frequency of brushing)
was included in the questionnaire. Trauma from occlusion was
assessed by checking mobility of each tooth. Fremitus test was
done on both upper and lower teeth.[2] After the completion of
the study, the subjects were given suitable treatment.
The data obtained were subjected to statistical analysis using
Chi‑square test and Students unpaired t‑test. The results were
tabulated using SPSS version 17 software.(Chicago).
RESULTS
Occurrence of gingival recession
Of 710 subjects, 291 (40.98%) had gingival recession. In total,
1152 teeth had gingival recession [Table 1].
In age group 15–25 years, the gingival recession was
26.9% (n = 78); age group 25–35 years, it was 41.5% (n = 113);
age group 35–45 years, it was 66.1% (n  =  74); and in age
group 45–60 years, it was 70.3% (n = 26). It shows that as age
increases there is increase in gingival recession which was of
statistical significance (P < 0.001) [Figure 1].
Males were mostly affected by gingival recession 60.5%
compared to females 39.5% which was of statistical
significance  [Figure  2]. Gingival recession was commonly
seen in mandibular incisors (43.0%) followed by maxillary
molar (13.2%), mandibular premolar (12.2%), maxillary incisor
and premolar  (8.9%), mandibular molar  (4.9%), maxillary
canine (4.6%), mandibular canine (4.3%) [Figure 3]. Recession
was commonly observed in the mandibular arch (66%) than
maxillary arch (34%) [Figure 4].
The most commonly seen was Miller’s class I (59.5%) followed
by class II (35.3%), class III (2.7%) and class IV (2.5%)
[Figure 5]. According to CPI, in recession group, 63.6% of
subjects had score 3 compared to without recession group
subjects.
Probable etiologic factor causing gingival recession
When the etiologic factors causing gingival recession were
examined in 1152 teeth of 710 subjects, the most common factor
was found to be dental plaque accumulation (44.1%) followed
by faulty toothbrushing (42.7%), habits such as smoking and
use of smokeless tobacco (7.1%), malocclusion (4.6%), high
frenal attachment (0.4%) and others like inadequate attached
gingiva, occlusal trauma (1%) [Figure 6].
The mean plaque index was 1.35 in subjects without gingival
recession compared to 1.96 in subjects with gingival recession.
It was statistically significant in recession group compared to
without recession group (P < 0.001).
Table 1: Occurrence of gingival recession
Group Number of subjects Percentage
Without recession 419 59.02
With recession 291 40.98
Total 710 100
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Mythri, et al.: Etiology and occurrence of gingival recession

Figure 2: Occurrence of gingival recession according to gender

Figure 1: Occurrence of gingival recession according to age

Figure 3: Occurrence of gingival recession according to the type of teeth Figure 4: Occurrence of gingival recession according to the type of arch

Figure 5: Occurrence of gingival recession according to Millers class of gingival
recession
Horizontal type of brushing was followed by 64.9% of
subjects with recession (P < 0.001). About 46.4% of subjects
with recession brushed for > 3 min (P < 0.001). About 62.2%
of subjects with recession brushed twice daily (P < 0.001) The
type of brushing method, duration of brushing, frequency of
brushing are statistically significant in subjects with recession
compared to subjects without recession.
Figure 6: Etiology of gingival recession in percentage
co‑relations between two or more findings. Various suppositions
regarding cause and effect have been based upon these
co‑relations. However, correlations are not a means of showing
cause and effect but only a means of showing a relationship.[2]
The exact nature of the relationship remains to be determined in
the future studies. The present study was designed to determine
the occurrence and probable etiology of gingival recession
among 710 individuals in the age group between 15 and 60 years.

DISCUSSION Of the 710 subjects examined for the study, 291  (40.98%)
subjects showed gingival recession. Similar results were seen
Epidemiology is a useful means of establishing a need for in previous studies.[12‑16] Whereas a higher prevalence of (>50%)
treatment or for preventive intervention. It often deals with gingival recession was seen in other studies.[17‑24] A recent study

Journal of Indian Society of Periodontology - Vol 19, Issue 6, Nov-Dec 2015 673
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Mythri, et al.: Etiology and occurrence of gingival recession
conducted in Greece showed an overall prevalence of 63.9%.[25]
On the contrary, a study by Mathur et  al.[4] showed a lesser
prevalence of gingival recession (18%).This might be due to the
very young age group (10–15 years) of subjects in the study.
In the present study, frequency of gingival recession was found
to increase with age. In younger age group (15–25 years), the
gingival recession was 26.9%; and in older age group (45–
60 years), it was 70.27%. Investigators have found that in most
of the studies, the frequency of recession was 100% for older
age group.[13,18,21] This relationship between the occurrence of
gingival recession and age may be because of the longer period
of exposure to the agents that cause gingival recession; associated
with intrinsic changes in the organism, both local and systemic,
besides the cumulative effects of the lesion itself. According to
Loe et al.,[3] destruction of periodontal tissues progresses steadily
over time. The occurrence of gingival recession in young patients
is usually localized and seems to comprise isolated etiologic
factors. On the other hand, a more generalized distribution, as
observed among older subjects, might indicate the associated
and cumulative effect of several factors such as previous
periodontal disease associated with toothbrushing trauma.
A high frequency of gingival recession was seen in males (60.5%)
compared to females (39.5%). These results were comparable to
the study by some authors.[2,20,22,26] Ainamo et al.[19] on the other
hand found that gingival recession was equally common in both
the genders in 17 years age group. In our study, mandibular
incisors (n = 495) had the highest prevalence of gingival
recession when compared to other teeth. These findings were in
confirmation with the previous studies.[2,3,13,19,20,26-28] Recessions
may be found in teeth that are prominently positioned that is,
the alveolar bone is thin or absent, and the gingival tissue is
thin in these areas. Areas with deficient keratinized mucosa
have been demonstrated to be more susceptible to gingival
recession, especially due to the smaller amount of connective
tissue available in the area. This leads to localized inflammatory
reactions, which are triggered by different processes that affect
the entire extension of the tissue, ultimately leading to gingival
recession. This might be one of the most common reasons for
the occurrence of gingival recession in the mandibular anterior
teeth. But the findings in the few other studies showed that the
gingival recession is more in maxillary first molar.[9,13,25] This
may be due to the angulations of the root in the bone, which
has got an influence on recession and is often observed in
maxillary molars area.
In this study, Miller’s class I type of recession was more
commonly seen. This was in comparable with studies by
Dodwad[2] Marini et al.[23] and Almeida et al.[13] In our study, it
was also seen that Millers class I recession was more common
due to the presence of plaque and Millers class II recession
was due to faulty toothbrushing. It should be stressed that
the distribution pattern of gingival recessions has been
related to different etiologic factors. Gingival recessions on
the mandibular incisors have been primarily associated with
poor oral hygiene,[12] whereas those on the premolars would
be originated by traumatic toothbrushing.[29] Concerning the
maxillary first molars, some authors believe the cause would
be traumatic toothbrushing,[9] while others state that it would
be the outcome of poor oral hygiene, demonstrated by the
presence of dental plaque and calculus.
674 Journal of Indian Society of Periodontology - Vol 19, Issue 6, Nov-Dec 2015
The CPI of the subjects of two groups was also recorded. In
recession group, 63.6% of subjects had score 3 and 99.7% had
loss of attachment more than 3 mm. The severity of periodontal
disease can be quantified with measurements of the pocket
depth and by loss of supporting structures around tooth,
which is indexed clinically as attachment loss. Hence, to know
the severity of the loss of attachment in recession group, this
index was recorded.
The present study intends to evaluate the probable etiological
factors associated with gingival recession. Studies by
Dodwad,[2] Bindu and Cheru[21] Chrysanthakopoulos[25] have
found the etiology of gingival recession to be multifactorial
like faulty toothbrushing, tooth malposition, lack of function,
frenal pull, habits, poor oral hygiene, etc., with one type being
associated with the other. In our study, the most common
factor associated with gingival recession was seen to be plaque
followed by faulty toothbrushing and this similar result has
been found by several other authors as well.[12,13,15,24,25] Localized
inflammatory process due to plaque causes the breakdown of
connective tissue and proliferation of the epithelium into the
site of connective tissue destruction. Proliferation of epithelial
cells into the connective tissue brings about a subsidence of the
epithelial surface, which is manifested clinically as gingival
recession.
In the present study, subjects using horizontal method of
toothbrushing showed the second common associated factor
of gingival recession than those following either vertical or
circular methods  (11.78%). Previous studies have reported
similar observations. Vigorous and forceful use of hard and
medium stiff‑bristled brushes in a horizontal direction can
cause minor lacerations, contusions or abrasions of the gingiva
with the resultant cleavage detachment or atrophy of the same
as well as resorption of the underlying alveolar plate which
lead to gingival recession.[20,29,30] Vehkalahti et al.[20] in their study
have reported a significantly increased odds ratio of 2.1 for the
likelihood of developing gingival recession in those subjects
who brush more than once a day over less frequent brushers.
The duration of toothbrushing was implicated in a study by
Tezel et al.[31] in which both males and females who brushed
for >3 min had approximately twice the mean severity of
gingival recession than those subjects who brushed for < 1 min.
In a systematic review, it was concluded that toothbrushing
factors that had been associated with the development and
progression of gingival recession were duration and frequency
of brushing, technique, brushing force, frequency of changing
toothbrushes and hardness of the bristles.[32] On the contrary,
Bindu and Cheru[21] found malalignment of teeth to be the most
common etiologic factor associated with recession. Manchala
et al.[26] and Banihashemrad et al.[33] found gingival recession
more common in smokers.
In this study, it was also found that severe gingivitis was seen
in recession group compared to moderate gingivitis in the
other group. This might be due to the presence of plaque in
the recession group.
CONCLUSION
Approximately, half of the subjects examined exhibited
gingival recession. The information gathered would probably
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Mythri, et al.: Etiology and occurrence of gingival recession
help in evolving long‑term strategies to prevent the occurrence
of mucogingival defects and enable us to predict the rate
of success of therapeutic measures. In addition to the ones
mentioned in this study, there are few more implicating
factors such as gingival biotype, chemical trauma, lack of
function in the initiation of gingival recession that have not
been considered here. The etiology of gingival recession
is multifactorial, and its appearance is always the result of
more than one factor acting together. At the community level,
adequate awareness and education in oral hygiene maintenance
should prove to be fruitful in long run.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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