Periodontology 2000, Vol. 71, 2016, 228–242 © 2016 John Wiley & Sons A/S.
& Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Management and prevention of
gingival recession
G E O R G E K. M E R I J O H N
Gingival recession, in other words exposure of the
root surface caused by apical displacement of the gin-
gival margin past the cemento–enamel junction (18,
54, 91), is highly prevalent worldwide. Depending on
the population surveyed, the percentage of people
affected ranges from 30% to 100% (2, 46, 48, 56, 57,
79, 84). Its prevalence and severity increases with age
(2, 56). In the USA alone, the prevalence of recession
of ≥1 mm in persons ≥30 years of age has been
reported to be 58% and averages 22.3% teeth per per-
son (2). In both clinical practice and continuing edu-
cation, dental professionals invest substantial time
and effort on treating the esthetic zone. Clinicians are
especially frustrated when gingival recession occurs,
for example, after orthodontic tooth movement
(Fig. 1A) and/or after dental restoration margins are
properly placed in proximity to gingival tissue. Den-
tists and dental hygienists often ask, ‘How does one
avoid getting gingival recession in the first place and
then after it’s treated, how do we keep it from coming
back?’. Dental appearance, compromised by gingival
recession, is a common patient concern. However,
this awareness is often limited to those patients with
pronounced gingival display and their focus infre-
quently goes beyond the facial aspect of the anterior
dentition. Patient-driven concerns about gingival
recession are also raised if it interferes with comfort
(e.g. root sensitivity) and/or function.
In addition to esthetic concerns of the patient, an
unfavorable consequence of gingival recession is the
exposure of root surfaces to a potentially cariogenic
supragingival microbiota (Fig. 1B). In the USA, the
prevalence of root caries has been reported to be
55.9% among those ≥75 years of age (38). Of great
concern is that the group ≥65 years of age, which rep-
resented 12% of the population in 2000, is expected to
exceed 20% of the population by 2030 and root caries
is also expected to increase (38). Prevention of gingi-
val recession is essential in the primary prevention of
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PERIODONTOLOGY 2000
root caries. This alone is reason to incorporate practi-
cal protocols for managing and preventing gingival
recession into daily clinical practice.
The prudent clinician is aligned with the patient in
the desire to avoid both neglectful oversight and
inappropriate treatment. Between lies the approach
to personalized, targeted and step-by-step conserva-
tive measures for the management and prevention of
gingival recession. Therefore, the dental practitioner
must consider the esthetic and dental health con-
cerns associated with gingival recession, as well as
individual patient factors, when developing a treat-
ment strategy. Bearing in mind these various consid-
erations, the aims of this article were to: (i) illustrate
three major factors associated with increased suscep-
tibility to gingival recession; (ii) present practical con-
cepts regarding the recognition and management of
risk exposures that can be implemented in a clinical
setting; (iii) review essential data collection and
recording for monitoring patients; (iv) introduce
chairside clinical-decision-support tools designed to
help the clinician focus on triage, evaluation, plan-
ning and patient communication regarding the pre-
vention and management of gingival recession; and
(v) propose clinical decision-making criteria for when
and how to monitor gingival recession, for deciding
when a patient is a candidate for surgical evaluation
or referral to a periodontist and, if surgery is the treat-
ment of choice, what should be considered as key
surgical outcome objectives.
Gingival recession: causes and
susceptibility
The primary causes of gingival recession are plaque-
induced inflammation (79, 81) and mechanical (phys-
ical) abrasion/removal (27, 36, 41, 44, 46, 56, 76, 79,
83, 89). Occasional causes of recession include

A B
Fig. 1. Root exposure and root caries. (A) A 33-year-old
male orthodontic patient who developed gingival recession
during treatment. The patient presented with thin (deli-
cate and fragile) gingival tissue on the canine and first pre-
molar with no gingival recession before treatment. Oral
hygiene consisted of: enthusiastic use twice daily of a
power toothbrush or a large-headed medium/firm-bristle
manual toothbrush; once daily use of Waterpikâ on med-
ium pressure aimed at the gum line at the recommended
90° angle; and sporadic flossing. The first premolar
demonstrates tissue erythema and advanced recession.
The canine demonstrates moderate recession with poten-
thermal and chemical injury (41, 76). Mitigating these
causes in susceptible patients will decrease the inci-
dence and severity of gingival recession. Three major
factors are associated with increased susceptibility to
gingival recession: (i) thin gingival tissue; (ii)
mucogingival conditions; and/or (iii) a positive his-
tory of progressive gingival recession and/or inflam-
matory periodontal disease(s) in teeth presenting
with either or both of the first two factors.
Relative to its clinical appearance, gingival tissue
can be broadly categorized as thick, average or thin.
Thick gingival tissue appears densely fibrous and
noticeably keratinized, whereas thin gingival tissue (1,
12, 22, 50, 67, 77) appears more translucent with less
obvious keratinization, as depicted in Fig. 2, an exam-
ple of a visual guide to enhance chairside patient
communication. When describing gingival tissues to
patients, it is helpful to refer to thick tissue as protec-
tive and durable and thin tissue as fragile and deli-
cate. It is important to note that not all teeth will
necessarily develop gingival recession solely as a
result of thin gingival tissue (Fig. 3).
Mucogingival conditions (Fig. 2) are defined as
deviations from the normal anatomic relationship
between the gingival margin and the mucogingival
junction (42). The most common mucogingival con-
ditions are: gingival/soft-tissue recession (42); the
absence or reduction of keratinized tissue; and/or
probing depths extending beyond the mucogingival
junction (5). In the section, Parameter on Mucogingi-
val Conditions of the Parameters of Care, the Ameri-
can Academy of Periodontology identifies reduced
keratinized tissue as a mucogingival condition but
does not specify numerical criteria for what consti-
Management & prevention of gingival recession
tially early-stage/reversible root decay. (B) A 56-year-old
female patient with progressive gingival recession and clin-
ically detectable root caries. Note the thin gingival tissue
and presenting mucogingival conditions (see Fig. 2). The
patient reported that she is a tobacco user, flosses four to
five times per week and uses a power toothbrush and/or a
manual medium/firm-bristle toothbrush with over-the-
counter fluoridated toothpaste twice daily. She periodically
used tooth-whitening strips. Previous periodontal treat-
ment consisted of routine adult prophylaxis two to three
times per year, oral hygiene instruction, typical dietary
counseling and infrequent in-office fluoride application.
tutes a clinically important reduction (5). Teeth with
less than 2 mm of keratinized tissue have been
studied in the literature. Lang & Lo } e (52) demon-
strated that although tooth surfaces may be kept
free of clinically detectable plaque, areas with
<2 mm of keratinized gingiva tended to remain
inflamed. However, other clinicians have evaluated
sites with <2 mm of keratinized tissue and con-
cluded that these sites do not necessarily develop
gingival recession solely as a result of a narrow
width or band of keratinized tissue (28, 29, 31, 32,
47, 49, 65). It is therefore important to emphasize
that surgical therapy is not warranted based solely
on the presence of thin gingival tissue, gingival
recession, probing depths extending beyond the
mucogingival junction and/or the absence or reduc-
tion of keratinized tissue (31, 32, 54, 60, 63).
Nevertheless, the clinician must consider when
and if gingival recession is an indicator of progres-
sive loss of periodontal support and future reces-
sion. For example, Serino et al. (81) reported that
teeth with a positive history of progressive gingival
recession have increased susceptibility to additional
apical displacement of the soft-tissue margin. They
also noted that loss of proximal periodontal support
was associated with gingival recession at the buccal
surface. Yoneyama et al. (94) determined that the
major feature of the progression of destructive peri-
odontal disease with age was gingival recession. Sar-
fati et al. (79) found that gingival bleeding was
significantly associated with the severity of gingival
recession and concluded that the inflammatory
reaction to dental biofilms is the predominant
biologic feature shared by gingival recession and
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Merijohn
periodontitis. Albandar & Kingman (2) suggested
that gingival recession occurs primarily as a conse-
quence of periodontal diseases and aggressive use
of mechanical oral hygiene measures. A positive his-
tory of inflammatory periodontal disease (e.g. pla-
que-induced gingivitis and localized chronic
periodontitis) can be considered an important fac-
tor associated with gingival recession, especially for
teeth with thin gingival tissues and/or mucogingival
230
Fig. 2. Gingival recession chairside
visual guide.
conditions. Although mitigating the causes of gingi-
val recession in susceptible patients will decrease its
incidence and severity, implementing practical
management and prevention strategies in a clinical
setting can be challenging (46, 50, 89, 94). Of prime
importance in implementing such prevention and
treatment strategies is an understanding of the cur-
rent knowledge of factors associated with the risk of
initiation and progression of gingival recession.

A B
Fig. 3. Conservatively managed and nonsurgically treated
thin gingival tissue (mandibular left canine tooth): a 17-
year follow-up. (A) A 39-year-old male patient on a 4-
month recall interval in 1993 presenting with thin gingival
tissue, narrow band of keratinized tissue and probing
depth extending beyond the mucogingival junction. Treat-
ment consisted of: coronal scaling with hand instruments
and coronal polishing; and subgingival hand instrumenta-
tion with curettes for removal of biofilm, plaque and any
clinically detectable calculus. Personal oral hygiene con-
sisted of: twice daily nonforceful sulcular/Bass brushing
technique with a soft-bristled, narrow-headed manual
toothbrush and over-the-counter fluoridated toothpaste;
flossing once daily with lightly waxed or nonwaxed dental
floss; tooth pick use (blunted and softened tip) once
weekly; and use of an end-tufted brush for buccal cervical
plaque removal. The patient was instructed to use a mag-
nified lighted mirror when performing procedures. The
patient had an acceptable level of skill and reasonable
compliance with the recommended oral hygiene proce-
dures. (B) The same tooth in 2010: relatively unchanged
thin gingival tissue, 17 years later, is observed.
The susceptible patient and factors
that increase gingival recession risk
Studies have reported several contributing factors
and conditions commonly associated with gingival
recession and/or increasing recession (8, 46, 55, 57,
76, 77, 79). Exposure to such factors and conditions
can make susceptible patients particularly vulnera-
ble to gingival recession (4). Although definitive
causality and magnitude-of-effect hierarchy have
yet to be determined for the contributing factors
and conditions associated with gingival recession,
there is some evidence upon which to base recom-
mendations for its management and prevention.
Presently, clinicians can recommend simple lifestyle
interventions and consider various dental proce-
dures that are capable of reducing the risk of
inflammation and/or mechanical injury for tissues
susceptible to gingival recession. Some contributing
factors and conditions are readily modifiable (e.g.
Management & prevention of gingival recession
dental plaque, forceful brushing and tobacco use),
whereas others are not (e.g. age, gender and history
of progressive gingival recession). The term ‘modifi-
able conditions’ is used in this article for those con-
tributing factors and conditions commonly
associated with gingival recession that lend them-
selves to modification through conventional inter-
ventions in a clinical setting. These modifiable
conditions are listed in Table 1. Increasing patient
awareness about gingival recession susceptibility
and modifiable conditions is an indispensable first
step for an effective management and prevention
program. In addition to being examined and
advised about findings by their dentists and dental
hygienists, independent self-discovery by patients is
often a strong motivator for adopting preventive-
oriented lifestyle choices and accepting treatment
interventions appropriate for managing and pre-
venting dental problems.
Online knowledge resources can serve as a practical
means to increase awareness and decrease confusion
about dental conditions. My Gum Recession Analyzer
and Gum Recession FAQ (www.gumtest.com) are two
examples of evidence-based online resources (Fig. 4).
My Gum Recession Analyzer is a self-screening tool that
features those gingival recession susceptibility factors
and modifiable conditions from Table 1 that more
readily lend themselves to patient self-discovery. It is
designed to help the individual: (i) discover if she/he
has gum recession; (ii) determine her/his susceptibility
to gum recession; and (iii) identify exposure to any of
eight common, but modifiable, risks associated with
gum recession. Gum Recession FAQ addresses fre-
quently asked questions about gingival recession.
Anecdotal evidence suggests that use of appropriate
online knowledge resources can improve and stream-
line patient communications and consultations.
Encouraging patients to perform self-screening and
increase personal awareness augments the clinician’s
Fig. 4. Online gingival recession self-screening.
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Merijohn

Table 1. Susceptibility factors and modifiable conditions

efforts in determining which patients are most Essential data collection and
susceptible to gingival recession. Patients can access
recording
online knowledge resources at their convenience from
smart phones or computer tablets/personal computers.
The surest way to under-treat or over-treat gingival
Clinicians utilize online self-screening tools in a variety
recession is through inadequate records.
of ways based on personal preferences. For example,
Evaluation of a patient’s periodontal status requires
patients can be instructed to use online tools outside
obtaining relevant medical and dental histories and
the practice setting before appointments, in the prac-
conducting thorough clinical and radiographic exam-
tice reception room or in the dental operatory during
inations with evaluation of extra-oral and intraoral
appointments such as examinations and hygiene
structures (5). Traditional clinical assessments and
maintenance visits. It is beyond the scope of this
procedures remain the foundation upon which peri-
paper to review online self-screening tools in detail.
odontal diagnoses are made (35). The Parameter on
These can be evaluated online by the clinician for
Comprehensive Periodontal Examination, developed
applicability in her/his individual practice setting.
by the American Academy of Periodontology, states
Decreasing the susceptible patients’ exposure to
that all relevant clinical findings should be docu-
modifiable conditions will decrease future risk for
mented in the patient’s record (5). See Fig. 5 for rec-
gingival recession and increase the likelihood of its
ommendations regarding where to document, in the
long-term prevention. However, developing patient-
patient record, the susceptibility factors and modifi-
centered treatment plans for the management and
able conditions associated with gingival recession.
prevention of gingival recession necessitates that the
To establish a baseline and to track changes effec-
clinician first examines the patient for key susceptibil-
tively over time, all measurable and/or detectable
ity factors and modifiable conditions (Table 1). Posi-
essential clinical findings (see Fig. 5) are recorded on
tive findings need to be documented and all essential
the periodontal examination record. A comprehen-
data recorded for long-term tracking and monitoring.
sive periodontal examination should be performed
In the busy practice setting, having a practical and
for all new patients and repeated at appropriate peri-
efficient means to do so can improve workflow and
odic intervals based on the needs of the individual
decision making.

232

Fig. 5. Documenting susceptibility factors and modifiable conditions.
MH/DH, Medical History/Dental History
patient. Figure 6 is an example of a periodontal
examination record that facilitates documentation
and recording of the comprehensive periodontal
examination parameters, gingival recession suscepti-
bility factors and measurable/detectable gingival
recession contributing factors and conditions.
Periodontal evaluation and data recording during
dental hygiene/maintenance appointments can be
very challenging, especially for adult patients with a
relatively full complement of teeth and/or implants.
Within the allotted time it is not always possible to
perform and record a comprehensive periodontal
examination, in addition to performing other essen-
tial tasks, such as: medical and dental health history
update; review of radiographs; head and neck exami-
nation; appliance checks; caries and restoration
check; scaling/root planing as needed; coronal pol-
ishing; oral hygiene review and instruction/training;
lifestyle assessment and recommendations; and
Management & prevention of gingival recession
fluoride application (if needed) (5). One must also
consider the time it takes to greet and exit the patient,
as well as to perform operatory disinfection and
chairside set up. Nevertheless, a thorough periodon-
tal evaluation is a critical component of the dental
hygiene/maintenance appointment (5). A practical
approach is to evaluate the patient for the key peri-
odontal parameters and then document, on the peri-
odontal maintenance record, only those significant
negative changes relative to the most recent compre-
hensive data on the periodontal examination record.
Figure 7 is an example of a periodontal maintenance
record that simplifies documentation and recording
and is compatible with the periodontal examination
record example in Fig. 6. Regardless of the recording
systems used, examination and documentation are
the important first steps for patient-centered clinical
decision making. After the data are gathered, use of
chairside tools designed to help the clinician focus on
233
Merijohn
Fig. 6. Example of a periodontal examination record.
triage, planning, communication and education can
facilitate the development of interventions for the
management and prevention of gingival recession.
Patient education and treatment
planning
After recording all clinical measures, patient history
and other relevant findings, patient education and
treatment planning are the next steps in the man-
agement of gingival recession. Treatment algo-
rithms and patient presentation tools can be
particularly beneficial in this critical stage of patient
management. An example of such a tool that can
be employed is presented in Table 2 (Gingival
Recession Checklist). This checklist is a quick refer-
ence chairside guide for the clinician and is to be
used in the dental examination/treatment opera-
tory. The companion Gingival Recession Chairside
Visual Guide (Fig. 2), on its reverse side, can serve
234
both as a reference for the clinician and a visual
communication tool for use with patients.
These chairside clinical-decision-support tools are
like other chairside tools in that they help busy clini-
cians focus on triage, evaluation, planning and
patient communication (60, 61, 63, 64, 66, 68). They
can be used to facilitate the development of interven-
tions for the prevention and management of gingival
recession. Specifically, these chairside tools help sup-
port the clinician in: (i) identification of patients who
are susceptible to gingival recession; (ii) assessment
of key modifiable conditions associated with gingival
recession; (iii) development of targeted and personal-
ized treatment/action plans for the prevention and
management of gingival recession; and (iv) communi-
cation with patients at the point of care, which can
help increase patient awareness, develop preventive
behaviors and boost treatment acceptance.
Evidence supports the use of checklists in clinical
settings to improve the quality of care and to reduce
errors and complications (40, 80). The World Health

Fig. 7. Example of a periodontal maintenance record.
Organization developed its validated Surgical Safety
Checklist, a 19-item tool created by the World Health
Organization in association with the Harvard School
of Public Health, modeling it after in-flight safety
checklists used by the airline industry (34, 92). Clini-
cal examination and procedural checklists have been
introduced and recommended for use in dental prac-
tice (21, 72). Like other checklists and visual guides,
these tools are designed to be used in conjunction
with examination, decision-making or treatment-
planning appointments, including dental hygiene/
maintenance appointments (61, 63). This type of
checklist and visual guide can also be used for clinical
staff training, calibration and ongoing chairside
support in facilitating patient communication.
This sample checklist presented in Table 2 is com-
prised of four sequential steps: (A) determine whether
the patient is susceptible to gingival recession; (B)
evaluate the patient for the presence of any gingival
recession modifiable conditions listed on the Check-
list; (C) develop a treatment plan to address each pos-
itive Checklist finding; and (D) review the visual guide
(Fig. 2) and checklist (Table 2) findings with the
Management & prevention of gingival recession
patient. For every positive finding on the Checklist, a
tailored and personalized treatment/action plan is
developed to address it. Interventions should be
patient-centered and focused on clinically relevant
outcomes (6, 62, 64, 66, 68, 78). Whenever clinically
reasonable, interventions should be instituted in a
step-by-step approach, starting first with the most
effective conservative measures. As a chairside clini-
cal-decision-support tool, this checklist example is
designed to be simple and easy to use (63). Like
any safety checklist, it is not intended to be 100%
all-inclusive: clinicians might find that there are
exceptions.
Using the gingival recession
checklist and visual guide in the
practice setting
It is beyond the scope of this paper to provide an in-
depth review of the numerous therapeutic
approaches available to clinicians for the manage-
ment of every modifiable condition listed on the
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Merijohn
Table 2. The gingival recession checklist
checklist (Table 2). Select conditions are presented
below.
Poor metabolic control of diabetes
Greater gingival inflammation is seen in adults with
type 2 diabetes than in nondiabetic controls, with the
236
highest level of inflammation occurring in subjects
with poor glycemic control (23, 59). Significantly
greater gingival bleeding is seen in patients with
poorly controlled diabetes than in either subjects with
well-controlled diabetes or nondiabetic controls (30,
59). Importantly, increased periodontal destruction is
associated with poorer glycemic control (58). As both

plaque-induced gingivitis and/or periodontitis and
poor glycemic control are modifiable risk exposures
for gingival recession (10, 44, 79, 81, 84, 94), for dia-
betic patients who are susceptible to gingival reces-
sion, appropriate metabolic control coupled with
improved plaque control will decrease the risk of gin-
gival recession.
Clinicians should routinely communicate with dia-
betic patients regarding personal glycemic control
targets and current status. Patients may be more
familiar with their average glucose (eAG) than they
are with glycated hemoglobin percentage (A1C) val-
ues. Websites, including www.diabetes.org, provide
simple conversion calculators for converting glycated
hemoglobin to average glucose. A simple reference
conversion table kept in the dental operatory will save
time and improve communication efficiency. If there
is concern regarding the patient’s glycemic control,
the dentist should fax the physician and request the
last 2 years of glycated hemoglobin values.
For patients with good glycemic control, routine
dental therapy can be planned accordingly. For
patients with poor glycemic control, anecdotal evi-
dence suggests that clinicians should consider the fol-
lowing approach: refer to a physician for further
evaluation and care; consult with a physician regard-
ing glycemic control and oral conditions; treat dental
infections using conservative therapies, such as scal-
ing and root planing, root canal therapy and/or
restoration of cavitated carious lesions; and delay
elective therapies, such as gingival grafting or dental
implant placement surgery.
The field of screening and assessment of blood glu-
cose levels continues to evolve, and dental profes-
sionals can participate by offering in-office finger-
stick testing. Dental clinicians should give guidance,
in the form of consultation and reference material,
supporting the key healthy lifestyle choices for
managing diabetes. These include seeing a physician,
undergoing regular physical activity, limiting con-
sumption of sugar-sweetened beverages, eating a
healthy diet, managing periodontal disease and con-
trolling modifiable conditions associated with gingi-
val recession (Table 2).
Tobacco use, including smokeless
tobacco
Tobacco use is an important gingival recession risk
factor (8, 39, 43, 79, 84). Studies demonstrate that
users of smokeless tobacco tend to have more severe
gingival recession and clinical attachment loss, and a
greater proportion of sites with higher values of the
Management & prevention of gingival recession
same, compared with never users (8). Smoking has a
long-term chronic negative effect on many important
aspects of the inflammatory and immune responses,
including alterations in the vasculature and on neu-
trophil function. In addition, nicotine and other
tobacco compounds have detrimental effects on
fibroblast function, including proliferation, adhesion
to root surfaces and cytotoxicity (69), which may,
in turn, adversely affect treatments for gingival
recession.
Indirect evidence suggests that a significant rever-
sal of periodontitis risk might be achievable within
10 years after quitting smoking (33). Dental profes-
sionals are in a unique position to help tobacco users
who present for dental care by providing assistance
to help them stop smoking or using other tobacco
products (16). As such, this has become part of the
responsibility of all oral health professionals (75), and
tobacco users should be encouraged to quit as part of
their overall periodontal management (20). Clinicians
should routinely check with tobacco-using patients
and actively provide ongoing encouragement, sup-
port and positive reinforcement for tobacco-use ces-
sation. Although some clinicians may feel that
managing in-office smoke-cessation programs may
be impractical and/or cost-prohibitive, it takes little
time and effort to provide tobacco-using patients
with an up-to-date list of appropriate local tobacco-
cessation programs and online resources. A more
detailed description of the benefits of structured
tobacco-cessation programs for dental practitioners
is presented in another article in this volume of Peri-
odontology 2000.
Other modifiable conditions associated
with the major pathogenic mechanisms
of gingival recession
The Gingival Recession Checklist (Table 2) and the
Gingival Recession Chairside Visual Guide (Fig. 2) are
examples of practical chairside support tools that
illustrate, to patients, the modifiable conditions com-
monly associated with gingival recession that she or
he can personally control. Especially with patients
susceptible to gingival recession, mitigating modifi-
able conditions will probably improve the chances for
better management and prevention of gingival reces-
sion. Such conditions include clinically detectable
plaque, damaging oral hygiene methods (such as
forceful toothbrushing), damaging oral habits (such
as picking teeth with sharp objects), damaging eating
habits (such as patients with lower incisors that have
thin, delicate tissues, who habitually bite into foods
237
Merijohn
such as very hard fruit and thick crusty bread) and
oral jewelry in proximity to gingival tissues.
Using the checklist during treatment/procedure
planning can also help guide clinicians toward proce-
dure options that can potentially decrease the risk of
damage to tissues (e.g. avoiding mechanical tissue
abrasion/removal; preventing chemical and/or ther-
mal injury). This can help improve the odds of pro-
viding better management and preventing gingival
recession. In addition to the conditions already dis-
cussed other modifiable local dental conditions
should also be considered in treatment planning for
gingival recession. Three of the modifiable conditions
listed in Table 2 are discussed below.
Subgingival restorations
Clinicians should determine if the physical character-
istics (e.g. rough surfaces or margin–tooth surface dis-
crepancies) of subgingival restorations provide
protected habitats for microorganisms that can lead
to biofilm-induced or plaque-induced inflammation.
If appropriate oral hygiene and periodontal treatment
do not mitigate the inflammatory response, clinicians
can recontour and polish these restorations or
replace them with new restorations designed to
decrease risk exposures.
Oral appliances
In considering the role of fixed or removable
orthodontic appliances/retainers, removable prosthe-
ses, mouth guards and occlusal guards, clinicians
should evaluate whether these appliances impinge on
gingival tissue or if they are too close to the fragile soft
tissue. In addition, clinicians should determine
whether oral appliances contribute to tissue inflam-
mation or mechanical tissue irritation/injury and
whether these devices should be modified or replaced
with new ones that mitigate these risk exposures.
Orthodontic tooth movement in patients susceptible
to gingival recession
Contradictory statements can be found in the liter-
ature regarding orthodontic tooth movement as a
risk factor for gingival recession. Some studies con-
clude that it is not a relevant risk factor (3, 25, 85),
whereas others demonstrate an increased risk (9,
11, 45, 50, 77, 82, 90, 93). It has been suggested
that a better understanding of the relationship
between orthodontic tooth movement and gingival
recession will be gleaned from prospective, ran-
domized controlled trials that include assessment
of periodontal parameters before, during and after
treatment (45, 53, 77).
238
However, with our present understanding it can be
considered that orthodontic treatment in general and
its retention phase may be considered as risk factors,
especially for the development of labial gingival
recession (50, 77). Therefore, patients susceptible to
gingival recession will be more so during or after
orthodontic treatment, especially if they present with
modifiable conditions (Table 2) that are not
addressed before, during and after treatment. For
example, patients who use forceful toothbrushing
methods on thin (delicate and fragile) facial gingival
tissue have a greater risk for gingival recession if
orthodontic treatment facially proclines these teeth.
Prudent interdisciplinary dental teams can deter-
mine whether prospective orthodontic patients are
susceptible to gingival recession, consider adjusting
tooth-movement plans and outcomes, and recom-
mend appropriate interventional periodontal therapy
– especially for teeth at increased risk for gingival
recession. Even with such measures, susceptible
patients should be informed about gingival recession
risks before treatment begins.
Clinical decision making: just
monitor or a candidate for surgical
evaluation?
One of the more critically important and fre-
quently asked questions about gingival recession
is, ‘Can we monitor it or do we need to consider
surgery?’. Therefore, are there practical criteria the
clinician can use to help guide the clinical deci-
sion-making process?
All patients susceptible to gingival recession should
have ongoing careful monitoring as part of their over-
all case management. Monitoring is an active ongoing
process that engages both clinician and patient. It is
particularly important at clinical decision-making
points (e.g. examination/evaluation appointments,
patient consultations/treatment plan presentations
and dental hygiene appointments). The checklist and
visual guide examples illustrated in this paper are
useful chairside tools that can facilitate the process.
The desired goal is that all positive checklist items
(Table 2) are reviewed with patients during appropri-
ate appointments until there are no more positive
checklist findings. Susceptible patients, including
those who have had or will have surgical interven-
tions for gingival recession defects, should have indi-
vidualized treatment/procedure plans developed that
address all modifiable conditions. Although individ-
ual patient circumstances may determine otherwise,

practical clinical criteria are proposed below as gen-
eral guidance to support clinicians in making appro-
priate clinical decisions regarding patients presenting
with gingival/soft-tissue recession; probing depths
extending beyond the mucogingival junction;
absence or narrow band (<2 mm) of keratinized tis-
sue; and/or thin (delicate and fragile) gingival tissue
(4, 60, 63). These major clinical decisions can be
grouped into three broad categories:
 When to monitor a patient without surgical evalu-
ation.
 When is the patient a candidate for surgical inter-
vention?
 When should the patient be referred to a peri-
odontal specialist?
When to monitor gingival recession
without surgical evaluation
It is proposed that clinicians can monitor gingival
recession without surgical evaluation in such patients
when all of the following criteria are met: (i) no docu-
mented evidence of progressive gingival recession; (ii)
clinical attachment loss (probing depth plus gingival
recession) ≤5 mm; (iii) gingival recession <2 mm; and
(iv) all of the above and the teeth in question will not
have subgingival restorations, orthodontic tooth
movement, oral appliances that can or will be in con-
tact with the tissue or dental therapy that is poten-
tially damaging to thin gingival tissue (Table 2).
When is a patient a candidate for surgical
evaluation?
It is proposed that a patient presenting with the con-
ditions noted above is a candidate for surgical evalua-
tion when at least one of the following criteria are
met: (i) documented evidence of progressive gingival
recession; (ii) persistent gingival inflammation (e.g.
bleeding on probing, swelling, edema, redness and/or
tenderness) despite appropriate therapeutic interven-
tions, in combination with clinical attachment loss
>5 mm and/or gingival recession ≥2 mm; and/or (iii)
persistent gingival inflammation despite appropriate
therapeutic interventions and association of the
inflammation with shallow vestibular depth that
restricts access for effective oral hygiene, frenum
position that compromises effective oral hygiene
and/or tissue deformities (e.g. clefts or fissures). The
patient is also a candidate for surgical evaluation if
found positive for any of the above three criteria and
any of the following are planned for the teeth in ques-
tion: (i) subgingival restorations; (ii) orthodontic
Management & prevention of gingival recession
tooth movement; (iii) oral appliances that contact the
tissue; and/or (iv) potentially damaging dental ther-
apy (Table 2).
If surgery is the treatment of choice, treatment
should be directed to achieve key surgical outcome
objectives. The minimum required outcome of a sur-
gical procedure for problematic gingival recession is
cessation of further recession. This necessitates the
correction/improvement of presenting problematic
tissue factors/conditions (5), including: thin gingival
tissue; probing depths extending beyond the
mucogingival junction; absence or narrow band of
keratinized tissue; shallow vestibular depth problem;
frenum position problem; and/or tissue deformities
(e.g. clefts or fissures). When root coverage is a surgi-
cal treatment goal, the selected approach should also
correct for all of the above presenting problematic tis-
sue factors/conditions. Otherwise, after a root-cover-
age procedure the tooth can remain susceptible to
progressive gingival recession.
When should a patient be referred to a
periodontal specialist?
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, referral to a
periodontist is appropriate when one or more of
the following criteria are met: (i) the patient prefers
referral; (ii) the dentist decides that she/he does
not possess sufficient knowledge, skills and/or
experience to provide the patient with the neces-
sary surgical outcome objectives; (iii) the dentist
decides that referral is in the best interest of the
patient; and/or (iv) the dentist decides that clinical
uncertainty dictates additional input into the case.
Situations that increase clinical uncertainty include:
some medically complex patients; advanced-severe
gingival recession defects; multitooth involvement;
and/or recession risk that cannot be readily modi-
fied. According to the Principles of Ethics and Code
of Professional Conduct of the American Dental
Association, “All dentists. . . have the obligation of
keeping their knowledge and skill current.” With
respect to consultation and referral, “Dentists shall
be obliged to seek consultation, if possible, when-
ever the welfare of patients will be safeguarded or
advanced by utilizing those who have special skills,
knowledge, and experience.” (7). Every clinician
must self-determine whether they have the knowl-
edge, skills and experience to monitor or plan/per-
form surgery on patients for the management of
gingival recession defects.
239
Merijohn
Concluding remarks
Gingival recession is highly prevalent worldwide. It
increases the risk for root caries and can interfere
with patient comfort, function and esthetics. Progres-
sive gingival recession also increases the risk of tooth
loss secondary to clinical attachment loss. Although
mitigating the causes of gingival recession decreases
its incidence and severity, implementing practical
management and prevention strategies in a clinical
setting can be challenging. Identification of suscepti-
ble patients and evaluating them for the presence of
modifiable risk exposures are essential first steps in
developing action plans for appropriate interven-
tions. This paper reviews these steps and introduces
chairside tools that can help in the selection of
interventions designed to reduce the risk of future
gingival recession and also facilitate patient com-
munication. Practical decision-making criteria are
proposed for the following: when and how to monitor
gingival recession; when is a patient a candidate for
surgical evaluation or referral to a periodontist; and,
if surgery is the treatment of choice, what should be
considered as key surgical outcome objectives.
Acknowledgments
The author acknowledges Gary Armitage for his
invaluable advice and guidance throughout the
preparation of this manuscript. Figures 1–7 and
Tables 1 and 2 have been previously published and
are reproduced with permission.
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