On the minimally invasive approach to the gingival recession.

Some aspects of pathogenesis and therapeutic approach to the gingival recession are discussed in this short communication with the example of a typical case from Russia, where excessive socket curettage after a tooth extraction resulted in a marked gingival recession. Subgingival plaque and calculus can be secondary to recession. An argument about plaque as a source of microorganisms might be plausible in case of inflammation, although various microorganisms are normal for the oral cavity. From the viewpoint of general pathology, being an atrophic condition, recession can progress due to repeated damage. On the author's opinion, calculus removal is not indicated at least for aged patients with marked gingival recession, having modest esthetic demands. Socket curettage after exodontia should be gentle. Surgical treatment of the gingival recession is beyond the scope of this communication.

Gingival recession (GR) is characterized by displacement of the gingival margin apically from the cemento-enamel junction. The prevalence of GR increases with age; according to an estimate, it varies from 8% in children up to 100% after 50 years.[1] A patient may present with symptoms including pain from exposed dentine, root caries and esthetic concerns.[234] GR should be distinguished from periodontal pocketing; however, both forms of the gingival attachment loss can be found in the same patient.[5] The consensus is that GR is not an inevitable process of ageing and is caused by cumulative effects of inflammation and trauma.[6] Among contributing factors in the literature are listed dental plaque, destructive periodontal disease, mechanical trauma including the tooth-brushing, root prominence, tooth position and other anatomical factors, margins of gingival restorations, dentures, piercing, smoking, viral infection etc.[478] Repeated root planning may render exposed root surfaces sensitive.[4] It should be commented that association of plaque and calculus with GR, although often discussed, is not readily understandable. No association between calculus and GR among adolescents was found in the literature[9] There is an opinion that calculus itself has little or no impact on gingival attachment loss.[10] An argument about plaque as a source of microorganisms might be plausible in case of inflammation, although varied micro-flora is a norm for the oral cavity; while most plaque bacteria are not described by Microbiologists as pathogens.[11] Admittedly, there are many studies confirming the association between the plaque index and GR.[51213] Relationship between plaque/calculus and GR is different among social groups:[451214] In populations with insufficient oral hygiene and access to dental care subgingival calculus is more extensive and correlates with the periodontal attachment loss,[11015] whereas in patients with adequate oral hygiene the relation of GR to periodontitis is less evident. GR without inflammation was also designated as idiopathic periodontal atrophy or involution.[16] This topic needs further elucidation by research, because removal of plaque and calculus by mechanical or ultrasonic tools causes mild, but repeated gingival trauma. From the viewpoint of general pathology, being an atrophic condition, GR can progress due to repeated damage. On the author's opinion, calculus removal is not indicated at least for older patients with marked GR, especially in cases with mobility of teeth.

The above considerations are of importance also for exodontia, where curettage of the tooth socket is a routine procedure. Note that in English-language handbooks, a gentle socket curettage is recommended;[17] while in Russia[1819] it is usually performed more intensely, with the goal of complete removal of granulation tissue.[20] In case of marked gingival atrophy and retraction [Figure 1], excessive curettage of the socket may contribute to a root denudation of neighboring teeth [Figure 2], which can result in sensitivity and pain sometimes intensive enough to make another extraction necessary. In this particular case, a man 55-year-old with marked GR underwent extraction of the tooth 16 because of pain and sensitivity of exposed roots. Vigorous socket curettage was performed in spite of the patient's protests. After the extraction, both neighboring teeth show marked GR, with increasing root sensitivity of the tooth 17. A complaint was written to the health-care authority, which was responded with the argumentation that “the treatment was performed in accordance with the diagnosis and in required volume.” It should be commented however that a method, even if practiced by the majority of practitioners, can be not in accordance with modern standards of care; and that practitioners should replace outdated methods with improved ones[21] on the basis of professional literature.[22]

Figure 1

Male patient 55-year-old. Marked gingival recession in the area of the lower incisors

Figure 2

The same patient. Secondary gingival recession; 2 days after an extraction of the tooth 16 with socket curettage

GR is usually not presented in textbooks as a separate entity; in Russian-language literature it is viewed within the scope of periodontitis, i.e., together with cases characterized by marked inflammation, formation of gingival pockets and granulation tissue, being regarded as an inflammatory condition of predominantly infectious etiology, which is obviously not the case for GR without inflammation. In conclusion, on the author's opinion, GR should be regarded as a separate entity with its own clinical presentation and indications for therapy. As in atrophy in general and in age-related atrophy in particular, the prevailing approach must be preservation and avoidance as far as reasonably possible, of traumatizing manipulations such as gingival, subgingival and socket curettage, minimization of soft-tissue damage and removal of granulation tissue, gentle handling of soft- and hard-tissues in periodontal surgery, etc.[23] The treatment of GR should be seen within the scope of minimally invasive periodontal therapy[23] and minimally invasive dentistry in general.