Gingival recession is a common condition, affecting patients with a good understanding of the importance of oral healthcare as well as those who visit the dentist less often. The condition is multifactorial, and causes include periodontal disease, a thin periodontal phenotype, or mechanical trauma, as well as the ageing process.
Gingival recession can also be affected by problems with systemic health. The blood supply to gingiva consists of an intricate web of arteries that originate from the carotid artery, the health of which is affected by conditions like diabetes, obesity and high blood pressure, as well as by the ageing process and smoking.
Approaches to treatment
Left untreated, gingival recession can reduce resistance against pathogenic stimuli such as cariogenic bacteria, and compromised plaque control can lead to bone resorption, tooth mobility and tooth loss. Treatment approaches will vary depending on the severity of the condition, as well as the causes and any underlying conditions affecting the patient’s periodontal health.
Non-surgical treatment options for gingival recession defects include establishing regular hygiene appointments and educating the patient to help ensure optimal plaque control. Gingival recession, and other periodontal problems can be associated with subgingival restorations and removal of overhanging restorative material might be required. Where there is pain and sensitivity due to exposed dental tubules, a desensitising agent such as calcium sodium phosphosilicate, arginine and calcium carbonate, and strontium can help reduce exposure and relieve pain.
Surgical treatment
Free gingival graft (FGG) is a relatively simple procedure and has the advantage that multiple teeth can be treated at the same time. FGG is considered a predictable treatment and can be used in the anterior mandibular region unlike some other approaches, creating a band of keratinised tissue that can resist recession with a reasonable percentage of root coverage. Potential disadvantages associated with the procedure include postoperative discomfort, two surgical sites and a risk of haemorrhage at the donor site.
A subepithelial connective tissue graft (SCTG) is a procedure where tissue from the palate is removed and placed under thin gingival tissue. The coronally advanced flap (CAF) with SCTG has a high success rate and achieves a more harmonious colour matching with the surrounding tissue than FGG. However, there is a risk of graft necrosis in the anterior mandibular area due to a less plentiful blood supply. Where it is not possible to harvest a connective tissue graft from the patient’s own palate, acellular dermal matrices, collagen matrices, and/or enamel matrix derivatives can be successful alternatives.
Various methods and modifications of the pedicle flap procedure have also been developed to minimise operative complications. These include the lateral repositioned flap, the double papilla flap, and tunnelling technique. The latter is a procedure without coronal displacement of the mucogingival junction, and there is minimal damage to the blood supply and a diminished risk of excessive scar tissue formation.
Overall, clinical studies indicate that the CAF and tunnelling procedures combined with SCTG is considered the most predictable surgical treatment option for gingival recession.
Healing progression
The first week after a gingival graft is a critical time, where the graft can appear to have failed. A clinician not familiar with the healing of a FGG might mistake the pallor and odour as a dead and/or failed graft. Educating patients on this phase of the healing process is important for reassurance.
As well as tissue discolouration, gingival surgery can result in postoperative bleeding, pain, swelling, and bruising. In most cases, postoperative pain can be managed with short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. Cold pack application, periodontal dressing, or surgical stents may also help with pain control after surgery. Pre-emptive analgesia may reduce discomfort in the most painful few hours post-surgery.
Antibiotics are generally not necessary after gingival flap surgery, pedicle flap surgery, or connective tissue and free gingival graft surgery. Postoperative infections following periodontal surgery are rare, occurring only two per cent of the time. Generally, smokers or patients with diabetes are considered to have a higher risk for postoperative infections.
Oral hygiene
A dental professional will spot the early signs of gingival recession on a daily basis and offer patients advice and support on adjusting their oral homecare routines to prevent the condition from advancing wherever possible.
Flexi interdental brushes from Tandex, with the addition of Prevent Gel are ideal for supporting the oral care of all patients, including those at risk of gingival recession. The Flexi interdental brushes keep gingiva conditioned, while removing plaque-producing biofilm. Prevent Gel adds the antibacterial effects of 0.12 per cent chlorhexidine protection, and with 900 ppm fluoride, it helps reduce sensitivity.
Though common, gingival recession can lead to serious consequences for patients. Ensuring they have the tools to optimise their gingival health can reduce the risk of complications. Oral hygiene can help prevent the need for surgery, as well as to optimise outcomes in cases where surgery is indicated.
References available on request.
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