Prevalence of oral soft and hard tissue lesions related to mechanical toothcleansing procedures

Alliance of oral hygiene practices and abrasion among urban and rural residents of Central India

OBJECTIVES

To attain alliance between the oral hygiene practices with prevalence of tooth abrasion among urban and rural adult population of Central India. To plan dental care services in inaccessible areas and to suggest appropriate remedial measures to prevent this avertable and self-inflicted injury of teeth in this cross-sectional study.

MATERIALS AND METHODS

A sum of 1045 adult residents both from Urban (529) and rural (516) parts of Bhopal district (Central India) was selected on a random basis. The multistage sampling technique was adopted to ascertain the sample size. In urban area the study population consisted of 240 males, 289 females and 201 males and 315 females in rural area respectively. All residents above 18 years of age from the Bhopal district were included in cross-sectional study. Assessment form comprises of questionnaire and general information on oral hygiene practices, dietary habits and medical history. Abrasion was assessed using diagnostic criteria recommended by Smith and Knight (modified). Chi- square test was used to test associations between categorical variables at 5% level of significance. Regression analysis attempted to define for risk factors causing abrasion. Literature on the prevalence of abrasion is very sparse, so attempt is made to correlate the etiological factors and recommend to prevent tooth wear.

RESULTS

Investigation of this cross-sectional study was aggregate of 1045 residences. Result shows high prevalence of abrasion 70.2%. Higher prevalence concomitant with diffident habits related to oral hygiene maintenance was recorded more among rural (76.9%) when compared to urban dwellers (63.7%). Presence of abrasion verifies statistical significance in relation to age, rural urban difference and variations in habit of oral hygiene care. Stated in the present study, avertable and self-inflicted is tooth abrasion, recurrently resulted by the reprehensible brushing method and common use of indigenous material for the maintenance of oral hygiene.

CONCLUSION

Shows significant liaisons with the presence of abrasions in relation to Urban and rural dwelling, age, material used and mode of brushing and duration of brushing. Indigenous and course material causes high amount of enamel wear and with the advancement in age abrasion tend to increase. Prevalence of abrasion does not show any gender predilection. Cultural believes, lifestyle and transition reflects in deviating presence of abrasion in populations.

Interproximal cervical lesions caused by incorrect flossing technique

This case report describes an interproximal cervical lesion caused by the incorrect use of dental floss. A 58-year-old man who was asymptomatic, presented with unusual notch-like cervical lesions. After clinical and radiographical examinations, it was concluded that the aetiology of these lesions was an incorrect flossing technique. The treatment plan included extraction of maxillary 3rd molars and re-education of the patient in oral hygiene technique.

CONCLUSION

These lesions are irreversible and often go undiagnosed; therefore, it is important for the clinician to be familiar with the clinical presentation and aetiology.

The interproximal clinical attachment level to classify gingival recessions and predict root coverage outcomes: an explorative and reliability study

BACKGROUND

The aims of this study were (i) to test the reliability of a new classification system of gingival recessions using the level of interproximal clinical attachment as an identification criterion and (ii) to explore the predictive value of the resulting classification system on the final root coverage outcomes.

MATERIAL AND METHODS

Patients showing at least one buccal gingival recession were recruited by one operator. Three recession types (RT) were identified. While class RT1 included gingival recession with no loss of interproximal attachment, class RT2 recession was associated with interproximal attachment loss less than or equal to the buccal site and class RT3 showed higher interproximal attachment loss than the buccal site. The classification was tested by two examiners blinded to the data collected by the other examiner. Intra-rater and inter-rater agreement was assessed. Furthermore, the 6-month root coverage outcomes of consecutively treated gingival recessions were retrospectively evaluated in order to explore the predictive value of the proposed classification on the final recession reduction (Rec Red).

RESULTS

The new classification system of gingival recessions was tested in a total of 116 gingival recessions (mean 3.2±1.2 mm) in 25 patients. The intra-class correlation coefficient (ICC) for inter-rater agreement was 0.86, showing an almost perfect agreement between the examiners. The RT classification was predictive of the final Rec Red (p<0.0001) at the 6-month follow-up in 109 treated gingival recessions.

CONCLUSIONS

The evaluation of interproximal clinical attachment level may be used to classify gingival recession defects and to predict the final root coverage outcomes.

Clinical study investigating abrasive effects of three toothpastes and water in an in situ model

OBJECTIVES

This in situ study compared the abrasive effect of repeated brushings (over 10 days) of a low relative abrasive dentine (RDA) toothpaste with moderate and high relative abrasive dentine (RDA) toothpastes, on human dentine in situ.

MATERIALS AND METHODS

The study design was single centre, single blind, randomized, split mouth, two period, four-treatment cross-over, in situ study in 20 healthy subjects. Subjects wore bi-lateral lower buccal appliances each fitted with four dentine sections with treatment applied with a power toothbrush, during each 10 day study period. Samples were measured at baseline, day 5 and day 10 by contact profilometry, and baseline and day 10 with non-contact profilometry.

RESULTS

Nineteen subjects were included in the efficacy analysis. Results as measured by contact and non-contact profilometry from brushing with the moderate RDA paste and high RDA paste showed significantly (p<0.0001) more abrasion to dentine than brushing with the low RDA paste or water after 10 days. Dentine loss following tooth brushing with the low RDA paste was not significantly different from brushing with water, after 10 days.

CONCLUSIONS

The methodology successfully showed clear differentiation between the amount of dentine lost following toothbrushing with the low RDA paste compared to the moderate or high RDA pastes. Dentine loss following brushing with the low RDA paste showed a comparable degree of abrasion to brushing with water.

Surgical management of gingival recession: A clinical update

Gingival recession is defined as the apical migration of the junctional epithelium with exposure of root surfaces. It is a common condition seen in both dentally aware populations and those with limited access to dental care. The etiology of the condition is multifactorial but is commonly associated with underlying alveolar morphology, tooth brushing, mechanical trauma and periodontal disease. Given the high rate of gingival recession defects among the general population, it is imperative that dental practitioners have an understanding of the etiology, complications and the management of the condition. The following review describes the surgical techniques to treat gingival recession.

Use of pedicled buccal fat pad in root coverage of severe gingival recession defect

BACKGROUND

Gingival recession in its localized or generalized form is an undesirable condition resulting in root exposure. Sites exhibiting Miller Class IV gingival recession are not suitable for treatment with surgical root coverage techniques, and their prognoses are very poor with current techniques. The aim of this case report is to establish a new technique for the root coverage of severe gingival recession defects (Miller Class IV) by providing a new source of enough tissue with good blood supply using the pedicled buccal fat pad (PBFP).

METHODS

The PBFP was mobilized through an incision in the base of the buccal flap at the level of the upper second molar; the vascularized flap was secured to the buccal surface of the upper first molar tooth and premolar teeth and sutured with the wound margins.

RESULTS

A clinically significant amount of keratinized gingiva that covered the root recession defect was obtained. Epithelialization of the buccal fat pad was completed after 6 weeks, with formation of healthy-looking keratinized mucosa in the anatomic site of the keratinized gingiva.

CONCLUSIONS

The PBFP technique is simple and easy to handle. It may also be considered a novel application with promising results for the root coverage of severe gingival recession defects (Miller Class IV) that may provide a considerable amount of keratinized tissue used for root coverage of the upper posterior molar teeth.

The Evolution of Buccal Gingival Recessions in a Student Population: A 5-Year Follow-Up

BACKGROUND

Data from cross-sectional studies revealed that gingival recession commonly occurred in subjects with a good standard of oral hygiene, but very little has been reported about longitudinal changes in the presence and extent of gingival recession in a similar sample of the population. The aim of this study was to follow up on the evolution of gingival recession at buccal tooth surfaces in a student population attending the fifth year at Bologna University Dental School who had been examined in a study 5 years earlier.

METHODS

The clinical examination involved assessment of the number of buccal surfaces with plaque and buccal gingival recession. Information about toothbrushing habits (brushing technique and frequency and toothbrush bristle stiffness) was collected in an interview.

RESULTS

The number of subjects with at least one recession and the total number of recessions had increased significantly. Comparing data from the baseline and the present study, no significant differences were observed for toothbrush type and frequency of toothbrushing, whereas the use of correct brushing techniques increased to 87% of the subjects.

CONCLUSION

The percentage of affected sites increased with the level of oral hygiene education, and this increase developed despite a reduction in the frequency of dangerous toothbrushing habits.

Partial recording protocols for periodontal disease assessment in epidemiological surveys

The objective of the present study was to compare the reliability of four partial-mouth protocols for assessing shallow, moderate, and deep sites for periodontal pocket depth and clinical attachment levels. Periodontal pocket depth and clinical attachment level measurements were recorded for 156 subjects (age > 30). The four models of partial-mouth protocols compared were: Model I: all sites per tooth in the random half-mouth protocol randomly selecting one maxillary and mandibular quadrant, Model II: buccal sites in a full-mouth protocol, Model III: buccal sites in the random half-mouth protocol randomly selecting one maxillary and mandibular quadrant, Model IV: all sites per tooth using Community Periodontal Index teeth. In comparison with full mouth examination, Model I did not show significant differences for periodontal pocket depth and clinical attachment level parameters. Models II and III were different for some periodontal pocket depth means, and Model IV significantly overestimated all clinical parameters related to periodontal disease. Model I appears to be adequate to substitute for the full-mouth examination to assess the prevalence and severity of chronic periodontal disease in adults.

Tooth surface loss in adult subjects attending a university dental clinic in Trinidad

OBJECTIVES

To determine the prevalence of tooth surface loss (TSL) in a sample of subjects attending a university dental clinic in Trinidad and to investigate the relationship to tooth brushing, medical history, parafunction and dietary habits.

DESIGN

Tooth surface loss was measured clinically by the index used in the 1998 UK, Adult Dental Health Survey.

SETTING

Trinidad, West Indies.

PARTICIPANTS

Convenience sample of adult subjects attending The University of the West Indies Dental School Polyclinic, Mount Hope.

METHODS

A questionnaire was administered and tooth surface loss measured clinically.

MAIN OUTCOME MEASURES

mild, moderate and severe tooth surface loss.

RESULTS

155 subjects were examined (mean age 40.6 years) of whom 72% had some degree of TSL with the majority (52%), exhibiting mild, 16% with moderate and 4% with severe TSL. There were associations found between TSL and age (OR=3.14), reflux (OR=1.37), parafunction (OR=1.06), weekly consumption of citrus fruits (OR=1.31) and soft drinks (OR=1.78), daily consumption of alcohol (OR=1.40) and a vegetarian diet (OR=2.79).

CONCLUSIONS

Tooth surface loss in this Trinidadian population group appears to be common. Data supports an association between TSL and age, reflux parafunction and certain dietary patterns.

A critical review of non-carious cervical (wear) lesions and the role of abfraction, erosion, and abrasion

The terms 'abfraction' and 'abrasion' describe the cause of lesions found along the cervical margins of teeth. Erosion, abrasion, and attrition have all been associated with their formation. Early research suggested that the cause of the V-shaped lesion was excessive horizontal toothbrushing. Abfraction is another possible etiology and involves occlusal stress, producing cervical cracks that predispose the surface to erosion and abrasion. This article critically reviews the literature on abrasion, erosion, and abrasion, and abfraction. The references were obtained by a MEDLINE search in March, 2005, and from this, hand searches were undertaken. From the literature, there is little evidence, apart from laboratory studies, to indicate that abfraction exists other than as a hypothetical component of cervical wear.

Epidemiological evaluation of the multifactorial aetiology of abfractions

The purpose of this study was to determine risk indicators for the aetiology of abfractions (cervical wedge-shaped defects) on teeth using dental and medical variables obtained in a population-based sample of the cross-sectional epidemiological 'Study of Health in Pomerania' (SHIP). Medical history, dental, and sociodemographic parameters of 2707 representatively selected subjects 20-59 years of age with more than four natural teeth were checked for associations with the occurrence of abfractions using a two-level logistic regression model on a tooth and a subject level. The estimated prevalence of developing abfractions generally increased with age. The following independent variables were associated with the occurrence of abfractions: buccal recession of the gingiva, odds ratio (OR) = 6.7; occlusal wear facets of scores 1, 2 and 3, OR = 1.5, 1.9, 1.9; tilted teeth, OR = 1.4; inlays, OR = 1.6; toothbrushing behaviour, OR = 1.9 to 2.0 (two and three times a day versus once a day). First premolars had the highest estimated risk for developing abfractions, followed by the second premolars. Maxillary and mandibular teeth behaved similarly in terms of abfractions, with the exception of mandibular canines, which had a much lower estimated risk of incurring abfractions than did maxillary canines. The results of this analysis indicated that abfractions are associated with occlusal factors, like occlusal wear, inlay restorations, altered tooth position and tooth brushing behaviour. This study delivers further evidence for a multifactorial aetiology of abfractions.

Periodontal bone loss associated with an improper flossing technique: a case report

PURPOSE

This article documents a case in which soft tissue and bone damage was associated with a long-standing habit of improper flossing.

CASE DESCRIPTION

A 33-year-old patient with excellent oral hygiene presented with gingival clefting and an unusual pattern of moderate angular bone loss at several sites. Previous radiographs suggested that some bony lesions had been present for more than 13 years. Examination revealed no evidence that the osseous defects were related to chronic periodontitis or occlusal trauma. The focus of treatment for these chronic injuries was teaching the patient an atraumatic flossing technique.

CONCLUSION

As the lesions had gone undiagnosed for many years, this case underscores the need to look for clinical signs of floss-induced damage during periodic examinations.

Treatment of Gingival Recession: Comparison of Two Techniques of Subepithelial Connective Tissue Graft

BACKGROUND

The increasing interest in esthetics and the subsequent need to solve related problems such as hypersensitivity and root caries have favored the development of many surgical procedures that permit the coverage of exposed roots. This clinical study was conducted to examine the coverage of gingival recession defects, where two different subepithelial connective tissue graft (SCTG) techniques (Langer and Langer and modified tunnel) were used.

METHODS

Thirty one patients (21 females and 10 males), each contributing Miller Class I and II gingival recessions, were selected. Recession defects were randomly treated by using the Langer and Langer technique (17 patients) or the modified tunnel technique (14 patients). Vertical recession, probing depth (PD), and attachment level were assessed at baseline and 6 months postoperatively.

RESULTS

Six months after the surgery, a significant reduction in recession depth was noticed in both groups. There was also a decrease of PD and attachment level for both groups, but not statistically significant. In comparison, at 6 months, statically significant differences were found between the tunnel and Langer and Langer techniques for root coverage and attachment gain. The percentage of root coverage was 96.4% and 75.5% in the tunnel and Langer and Langer groups, respectively.

CONCLUSIONS

The present study suggests that the use of SCTG in combination with a tunnel procedure may result in an increased amount of root coverage and clinical attachment gain compared to the Langer and Langer technique. Further comparative studies are necessary to understand the periodontal healing generated by the tunnel procedure and Langer and Langer technique.

Coverage of localized gingival recessions: comparison of micro- and macrosurgical techniques

BACKGROUND

In the presence of a thin and narrow zone of gingival tissue root recessions caused by trauma or inflammatory reactions seem to be a common feature of the buccal tissue morphology. The surgical coverage is mainly indicated for aesthetic reasons and may be accomplished with pedicled flaps in conjunction with or without the use of connective tissue grafts.

AIM

The purpose of the present study was to evaluate the degree of vascularization of connective tissue grafts by applying a microsurgical approach. In addition, the clinical outcome was followed for 1 year.

MATERIAL AND METHODS

The study population consisted of 10 patients with bilateral Class I and II recessions at maxillary canines. In split-mouth design, the defects were randomly selected for recession coverage either by a microsurgical (test) or macrosurgical (control) approach. Immediately after the surgical procedures, and after 3 and 7 days of healing, fluorescent angiograms were performed to evaluate graft vascularization. In addition, the clinical parameters were assessed before the surgical intervention, and 1, 3, 6 and 12 months postoperatively.

RESULTS

The results of the angiographic evaluation at test sites revealed a vascularization of 8.9+/-1.9% immediately after the procedure. After 3 days and after 7 days, the vascularization rose to 53.3+/-10.5% and 84.8+/-13.5%, respectively. The corresponding vascularization at control sites were 7.95+/-1.8%/44.5+/-5.7% and 64.0+/-12.3%, respectively. All the differences between test and control sites were statistically significant. The clinical measurements revealed a mean recession coverage of 99.4+/-1.7% for the test and 90.8+/-12.1% for the control sites after the first month of healing. Again, this difference was statistically significant. The percentage of root coverage both test and control sites remained stable during the first year at 98% and 90%, respectively.

CONCLUSIONS

The present controlled clinical study has demonstrated that in root surface coverage, a microsurgical approach substantially improved the vascularization of the grafts and the percentages of root coverage compared with applying a conventional macroscopic approach.

Brushing with and without dentifrice on gingival abrasion

OBJECTIVES

This study was designed to evaluate two factors possibly influencing incidence of gingival abrasion during toothbrushing: (1) the abrasiveness of a dentifrice and (2) the possible influence of feedback of oral sensory perception.

MATERIAL AND METHODS

For this purpose, two separate, single blind, randomized clinical experiments were performed. The two groups of subjects were requested not to brush their teeth 48 h, prior to the experiments. After staining with disclosing solution gingival abrasion sites were recorded as small (< or =5 mm) and large (>5 mm), both before and after brushing. The dentifrice experiment was a split-mouth design, including 36 subjects, brushing their teeth in two randomly selected contra-lateral quadrants, either with or without dentifrice, whereas the remaining two quadrants were brushed, using the alternative choice. The sensory perception feedback experiment was a full-mouth design, including 43 subjects and two separate brushing exercises with use of dentifrice. The first brushing-exercise was performed by a dental hygienist, excluding the feedback of oral sensory perception of the brusher. After a 4 weeks period of familiarization to the manual toothbrush, subjects brushed themselves in the same random order as the hygienist, using a fresh brush, thus including oral sensory perception.

RESULTS

In the dentifrice experiment, the increment of small abrasion sites was 5.86 for brushing with and 5.75 without dentifrice. There was no statistically significant difference between brushing with and without dentifrice. Both with and without dentifrice, more small abrasions were found vestibular, (3.78 and 4.22, respectively) as compared with lingual (2.22 and 1.42, respectively) (p=0.027, p<0.001). In the sensory perception feedback experiment, the increment in small gingival abrasion sites was larger for the subjects brushing themselves (8.86) as compared with the professional brushing (2.94, p <0.0001). Subjects caused more abrasion on the vestibular surfaces (6.28) as compared with the lingual (0.60, p=0.0001), where the professional did not show this difference (vestibular: 1.88, lingual: 1.30, p=0. 1388).

CONCLUSIONS

No statistically significant difference in the incidence of gingival abrasion was found between brushing with dentifrice or without dentifrice. Neither did oral sensory perception seem to affect the incidence of gingival abrasion.

Traumatic Lesions of the Gingiva: A Case Series

BACKGROUND

The most recent classification of periodontal diseases includes a new section on traumatic gingival lesions. Traumatic lesions of the gingiva are thought to be highly prevalent, yet the periodontal literature contains few references on the topic. The purpose of this article is to present a broad spectrum of traumatic gingival lesions of iatrogenic, accidental, and factitious origin.

METHODS

Twelve clinical cases were selected to document chemical (due to aspirin, snuff, and peroxide), physical (due to malocclusion, flossing, removable partial denture, oral piercing, and self-inflicted trauma), and thermal (due to overheated ultrasonic scaler, hot food, and ice) injury to the gingiva.

RESULTS

Chemical, physical, and thermal gingival injuries of iatrogenic, accidental, or factitious origin can have a variety of presentations with overlapping clinical features. Although the appearance and associated symptoms of a gingival lesion may be suggestive of a particular traumatic etiology, useful or confirmatory diagnostic information is often discovered through careful history-taking. The management of gingival injuries typically requires elimination of the insult and symptomatic therapy. If permanent gingival defects resulted from the injury, periodontal plastic surgery may be necessary.

CONCLUSIONS

A variety of chemical, physical, and thermal injuries may involve the gingiva. Accidental and iatrogenic injuries are often acute and self-limiting, while factitious injuries tend to be more chronic in nature.

Effects of occlusal load on cervical lesions

Toothbrush abrasion has been considered to cause cervical lesions. However, some investigators have proposed that occlusal loading factors direct tensile stresses at the cervical area, resulting in wedge-shaped abfraction defects. The purpose of this study is to investigate the role of axial and non-axial load on the development of cervical lesions. Matched paired premolars, extracted for orthodontic purposes, were used in a custom-fabricated toothbrushing apparatus. A periodontal sulcus width of 0b1 mm with 1 mm gingival recession was simulated with denture base resin. In phase 1, eight matched premolar pairs were subjected to 80 h (1b4 million strokes) of brushing and 300 g of toothbrush force. Toothpaste slurry was applied continuously through the toothbrush. One specimen in each pair was subjected to 250 h and 45 kg of continuous axial load, while the other unloaded tooth served as a negative control. In phase 2, 10 matched premolar pairs were subjected to the same conditions; however, the experimental teeth were subjected to 250 h and 45 kg of intermittent non-axial load, directed at a 45 degrees angle to the buccal cusp. Rubber impressions were made of the cervical lesions, then trimmed, weighed, and compared to determine the amount of tooth material lost. When teeth were loaded axially, there was significantly less tooth material loss (P < 0b02); however, when teeth were loaded non-axially, there was no significant difference (P =0b80) when compared with controls. Optical and scanning electron microscopy did not reveal any significant differences in the morphology between pairs. Our data suggest that the application of occlusal load may not necessarily play a significant role in the progression of cervical tooth wear commonly referred to as abfraction.

The prevalence of non-carious cervical lesions in permanent dentition

A non-carious cervical lesion (NCCL) is the loss of hard dental tissue on the neck of the tooth, most frequently located on the vestibular plane. Causal agents are diverse and mutually interrelated. In the present study all vestibular NCCL were observed and recorded by the tooth wear index (TWI). The aim of the study was to determine the prevalence and severity of NCCL. For this purpose, 18555 teeth from the permanent dentition were examined in a population from the city of Rijeka, Croatia. Subjects were divided into six age groups. The teeth with most NCCL were the lower premolars, which also had the largest percentage of higher index levels, indicating the greater severity of the lesions. The most frequent index level was 1, and the prevalence and severity of the lesions increased with age.

A survey of the correspondence between abrasions and tooth brushing habits in Erzurum, Turkey

AIM

To determine whether there is a correlation between dental abrasions and the frequency and technique of tooth brushing, as well as to examine the prevalence of dental abrasion according to age and gender.

MATERIALS AND METHODS

This study was carried out on 428 adults (242 female, 186 male) 20 years of age and older, who attended the Department of Operative Dentistry, Department of Oral Diagnosis and Oral Radiology Faculty of Dentistry, Atatürk University.

RESULTS

The study revealed a statistically significant relationship between abrasive lesions and age groups as well as between abrasive lesions and gender. A statistically significant difference was determined between abrasions and tooth brushing frequency, while there was no statistically significant relation between abrasions and tooth brushing technique (p>0.05).

CONCLUSION

The prevalence of tooth brushing abrasions increases with age, and lesions are seen more frequently in males than in females. Also, tooth brushing technique is not important to the presence of abrasions, but increased tooth brushing frequency results in an increase in the number of abrasions.

Association between level of education and oral health status in 35-, 50-, 65- and 75-year-olds

AIM

The aim of the present study was to evaluate the association between educational level and dental disease, treatment needs and oral hygiene habits.

MATERIAL AND METHODS

Randomized samples of 35-, 50-, 65- and 75-year-olds, classified according to the educational level: [low (LE): elementary school or higher (HE)], were identified. In 1091 subjects, a number of characteristics such as (i) number of teeth, (ii) periodontal attachment levels (PAL), (iii) caries and (iv) occlusal function were recorded. Educational level, oral hygiene and dietary habits were self-reported. Non-parametric variables were analyzed by chi2, Mann-Whitney U-Wilcoxon's rank sum tests, and parametric variables by Student's t-test (level of significance 95%). A two-way anova was performed on decayed, missing and filled surfaces to investigate the interaction between age and educational level. All statistical procedures were performed in the SPSS statistical package.

RESULTS

The number of remaining teeth was similar for LE and HE in the 35-year olds (25.8 versus 26.6), but in the older age groups LE had significantly a larger number of missing teeth. The LE groups (except in 65-year olds) exhibited significantly more PAL loss. LE had significantly fewer healthy gingival units in all but the 75-year age group. In all age groups, LE had fewer intact tooth surfaces and a significantly poorer occlusal function. The frequency of tooth cleaning measures and dietary habits did not differ between LE and HE.

CONCLUSION

Educational level was shown to influence the oral conditions and should be considered in assessing risk, and in planning appropriate preventive measures.

Toothbrushing and gingival recession

AIM

To review the hypothesis that toothbrushing leads to gingival recession. Gingival recession develops due to anatomical and pathological factors. The prevalence of recession is dependent on the age and characteristic of the population because it usually presents in individuals with periodontal disease or those who practise zealous or improper oral hygiene methods. Gingival trauma and gingival abrasion from toothbrushing is thought to progress directly to gingival recession. Case studies documenting recession from toothbrush trauma are speculative. Short-term studies suggest that gingival trauma and gingival abrasion may result from toothbrushing, but the direct relationship between traumatic home care and gingival recession is inconclusive. Long-term studies remain elusive or do not support the development of recession following toothbrushing. Nevertheless, tooth abrasion may be an integral part in the aetiology of recession. Toothbrush abrasion also may cause wear at the cemento-enamel junction resulting in the destruction of the supporting periodontium leading to recession.

Six-month comparison of powered versus manual toothbrushing for safety and efficacy in the absence of professional instruction in mechanical plaque control

BACKGROUND

Reports suggest powered toothbrushing may provide some clinical benefit over manual tooth-brushing, but most studies have been of short duration with subjects trained in toothbrush use. The aim was to determine if the oscillating-rotating powered brush (PB) could safely provide clinical benefits over and above a manual brush (M) in subjects with no formal instruction or experience in powered brush use.

METHODS

This 6-month, single-masked, parallel design, randomized clinical trial compared the PB with an American Dental Association (ADA)-accepted soft-bristle manual brush in a non-flossing gingivitis population (n = 157). Subjects were given written instructions but no demonstration on toothbrush use at baseline. Efficacy was assessed by changes in gingival inflammation, plaque, calculus, and stain, while changes in clinical attachment levels and recession measurements provided safety data. A prophylaxis was provided after baseline assessment. The 6-month plaque index (PI) was recorded immediately post-brushing after covert timing of the subjects, and correlation analyses were run to assess the relationship of brushing time to PI. Paired t tests, analysis of variance (ANOVA), and analysis of covariance (ANCOVA) were used to assess within and between treatment group differences for PB (n = 76) versus M groups (n = 81).

RESULTS

Measures of inflammation showed a statistically significant drop for both brushes at 3 and 6 months. Mean overnight full-mouth PI scores were significantly lower at 3 months for the PB (1.57) compared to the M group (1.80), P = 0.0013. Immediate post-brushing PI at 6 months was also significantly lower for the PB (1.10) versus M (1.39) (P= 0.0025). There was an overall negative correlation for PI and brushing time (r = -0.377, P= 0.0001). Mean calculus index (CI) scores were lower for the PB at 3 (P= 0.0304) and 6 months (P = 0.0078), while no significant differences in stain were observable. Clinical attachment level and recession measurements showed no significant between-group changes from baseline for either brush on canine teeth or on teeth with recession at baseline.

CONCLUSION

The oscillating-rotating toothbrush safely provides clinical benefits in plaque and calculus reduction over a manual brush even in subjects with no formal oral hygiene instruction.

Evaluation of gingival recession in left- and right-handed adults

Recession is the exposure of the root surface by an apical shift in the position of the gingiva. Several factors have been implicated in the etiology of gingival recession. The aim of this study was to assess the relationship between gingival recession and the hand, right or left, duration, frequency, and technique of tooth brushing in left- and right-handed adults in Erzurum, Turkey. Fifty five left-handed (35 female and 20 male) and 55 right-handed (35 female and 25 male) subjects were included in the study. The left and right hand positions of the subjects were determined by using Oldfield's Edinburg Inventory Index, and they were divided into two groups as left-handed and right-handed. The amount of gingival recession and localization, oral hygiene situations, gingival bleeding, toothbrushing duration, frequency, and techniques of subjects were evaluated. The relationship between the amount of gingival recession and localization and the subjects' hand, duration, frequency and technique of tooth brushing were examined. The data were evaluated with variance analysis and student's t test. The oral hygiene situations in right- and left-handed subjects were determined. On comparing the left-handed subjects with the right-handed ones, it was observed that the left-handed subjects had better oral hygiene than the right-handed. But, this case was not statistically significant (p > .05). In both right-handed and left-handed subjects, women had better oral hygiene than men (p < .01). The rate of gingival recession was found more in the left-handed than in the right-handed (p < .05). In the right-handed subjects, gingival recession was found in the premolar and canine regions of upper right and lower right jaw. A similar result was also observed in the left-handed subjects, because gingival recession was seen on their upper left and lower left jaw. Incisive teeth were affected at the same rate in the left-handed and right-handed. The gingival recession was seen more in maxillary jaw than in mandibular jaw in both groups. A statistically significant relationship between gingival recession and frequency duration, and technique of tooth brushing was found. While the greatest amount of gingival recession was found in horizontal scrub technique, gingival recession increased with increasing tooth brushing duration and frequency. The relationship between gingival recession and hand using in tooth brushing was determined.

Gingival recession-its significance and management

OBJECTIVES

To review the prevalence and current concepts of the mechanisms and aetiology of gingival recession and present the principles of assessment and management of the patient with gingival recession.

DATA AND SOURCES

The literature was searched for review and original research papers relating prevalence, mechanisms, aetiology, assessment, and treatment of gingival recession using Medline and manual tracing of references cited in key papers otherwise not elicited.

STUDY SELECTION

Studies with gingival recession as focus and pertinent to key aspects of review.

RESULTS

Gingival recession is a common condition and its extent and prevalence increase with age. Many factors including trauma and periodontal disease have a role in its aetiology. The patient may develop signs and symptoms including pain from exposed dentine, root caries and aesthetic concerns. Management of gingival recession requires thorough patient assessment, identification of aetiological factors, and recording and monitoring of the extent and severity of the condition. Treatment should be directed at prevention of further progression and the control of symptoms and disease. The patient's aesthetic concerns should be appreciated. Surgical treatment of recession may be indicated to cover exposed root surfaces. Many surgical techniques have been described with varied reported clinical effectiveness.

CONCLUSIONS

Gingival recession should be thoroughly assessed and evaluated in order to offer the most suitable management.

Pocket elimination surgery with simultaneous connective tissue graft. A case report with 3-year follow-up

BACKGROUND, AIMS

The purpose of the present case report was to present 2 ways of treating recession in a periodontal patient combined with regular pocket elimination surgery. The techniques used enabled the operator to reduce the number of surgical sessions and clinically evaluate the 3-year coverage of gingival recessions using a subpedicle connective tissue graft.

METHODS

Surgery consisted of pocket elimination procedures to treat adult periodontitis as a way to harvest connective tissue to be placed in the areas of recession. The grafted tissue was covered by the primary flap or left uncovered in a pouch, according to 2 different techniques described in the literature.

RESULTS

In this case, we observed that, with this approach, we were successful in reducing the number of surgical session as well as achieving objective and subjective goals of therapy in treated areas.

Self-preventive oral behavior in an Italian university student population

BACKGROUND/AIM

The aim of this study was to assess the oral hygiene attitude and the professional preventive examination compliance in Italian university students.

METHOD

A sample of 202 students attending the University of Bologna was randomly selected and interviewed about their preventive oral health attitude and compliance. All students reported using toothpaste and most of them (92.1%) brushed their teeth at least 2x a day using artificial, medium stiffness bristles. The toothbrush was generally (81.6%) replaced within 3 months. Few subjects (14.9%) said they used dental floss daily or utilized other devices. A majority of subjects (59.9%) had a dental examination within the year previous to the interview. Cluster analysis was performed.

RESULTS

4 groups were identified with homogeneous oral hygiene behavior and compliance toward professional preventive examination. Only one cluster, representing 33.6% of the sample, showed consistent frequency and modalities of oral hygiene habits. The other clusters seemed to be defective with interproximal cleaning procedures and compliance toward professional preventive care. Since the sample was characterized by a young, urbanized, homogeneous group with a high educational level and frequently from an upper middle class social status, the analysis probably gives a supra-estimation of the positive behavior.

CONCLUSION

It is rational to suppose that strategies to promote dental service utilization, patients' compliance and a professional style oriented toward prevention may be useful to improve the oral health condition in the young adult Italian population.

Periodontal status of mandibular incisors after pronounced orthodontic advancement during adolescence: a follow-up evaluation

The purpose of this study was to analyze whether pronounced orthodontic advancement of the mandibular incisors during Class II correction in the mixed dentition results in gingival recession. Through mandibular superimposition of the pretreatment and posttreatment cephalograms of 67 Class II patients who were treated with reverse headgear to the mandibular dentition, 45 patients with a minimum of a 1-mm advancement of the cementoenamel junction (CEJ; mean, 2.18 +/- 0.87) and a minimum of a 2-mm advancement of the incisal edge (mean, 3.87 +/- 1.34) were identified. Using the same protocol in Class II patients, 30 individuals who finished treatment at a similar time and age, but without reverse headgear and with no advancement of the CEJ (mean -0.43, SD 0.53) and a maximum of 1-mm advancement of the incisal edge (mean -0.26, SD 1.15) were identified. Before treatment, the mandibular incisors were more retruded, relative to the line from point A to pogonion and relative to the mandibular plane in the patients with pronounced advancement than in those with no advancement of the mandibular incisors; no differences were found at the time of appliance removal. A total of 30 patients with pronounced advancement and 21 patients with no advancement could meet for a follow-up examination a mean period of 7.83 years (SD, 4.44) and 9.38 years (SD, 4.39) after treatment, respectively. Clinical examinations at the time of follow-up revealed no differences in the amount of recession, the width of attached gingiva, the length of supracrestal connective tissue attachment, the probing pocket depth, and gingival bleeding index or visible plaque index of the mandibular incisors between the patients in the 2 groups. An examination of color slides demonstrated no differences in the number of mandibular incisors that developed recession from before treatment to after treatment and from after treatment to follow-up. Measurement of mandibular incisor crown height on the study models demonstrated no difference in the increase in clinical crown height from after treatment to follow-up between the patients in the 2 groups. It was concluded that pronounced advancement of the mandibular incisors may be performed in adolescent patients with dentoalveolar retrusion without increasing the risk of recession.

Coronally positioned flap procedures with or without a bioabsorbable membrane in the treatment of human gingival recession

BACKGROUND

A variety of surgical techniques have been used to cover recession type defects. New data have indicated that the outcome of coronally positioned flap procedures may be augmented by supporting the flap with a membrane.

METHODS

The present study aimed at comparing the clinical outcome following treatment of localized gingival recessions by a coronally positioned flap procedure alone, or combined with a bioabsorbable membrane. Twenty patients with buccal bilateral Miller Class I or Class II gingival recessions in cuspids or premolars participated in the study. The split-mouth design, randomized selection of site treatment, and blind evaluation provided 20 sites in a membrane group and 20 sites in a non-membrane group for examination at baseline, and at 3 months and 6 months postoperatively. Clinical variables included the apical extent of the gingival recession, the width of the recession defect measured at the cemento-enamel junction (CEJ), and the width of keratinized tissue at the recession site as well as probing depth and attachment level.

RESULTS

Both treatments resulted in a significant gain (P <0.0001) of root coverage, amounting to an average of 2.3 mm in the membrane group and 2.5 mm in the non-membrane group at the 6-month evaluation. There was no significant difference between the treatments. Similarly, a significant gain of clinical attachment level was seen in the membrane (1.3 mm; P <0.001) as well as in the non-membrane (1.5 mm; P <0.0001) group, but without a significant difference between the groups. The reduction of the recession width from baseline to 6 months was significantly greater (P <0.01) for the non-membrane (2.3 mm) than for the membrane (1.4 mm) group. Probing depth changes were small and not significant for either of the treatments. When patients were grouped as smokers (8) and non-smokers (12), no significant differences were revealed for any of the response variables. Overall, among the 20 membrane sites, one showed no change while the remaining 19 gained root coverage at the 6-month examination. Five sites obtained coverage to the CEJ. Among the non-membrane sites, all gained root coverage at 6 months and 10 sites showed complete coverage to the CEJ.

CONCLUSIONS

The coronally positioned flap operation offers a predictable, simple, and convenient approach as a root coverage procedure in Miller Class I and Class II recession defects. Combining this technique with the placement of a bioabsorbable membrane does not seem to improve the results following surgical treatment of such defects.

Improvement of multiple facial gingival recession by non-surgical and supportive periodontal therapy: a case report

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.

The aetiology of the non-carious cervical lesion

Erosion and abrasion have been widely reported as causes of non-carious cervical lesions (NCCL). However, more recently, tooth flexure has been implicated in the formation of these lesions generating renewed interest in the pathogenesis of the non-carious loss of cervical tooth substance. This paper considers the causes of erosion and abrasion, related to modern lifestyles, and reviews the literature concerning tooth flexure as a cause of NCCL. A description of different types of NCCL is given, as an aid to determining the aetiology, yet at the same time accepting that the causation and pathogenesis of NCCL is probably multi-factorial resulting in many different clinical presentations. Consideration is given to the indications for treatment of NCCL and to the selection of materials for restoring such defects.

Aspectos clínicos da etiologia da hipersensibilidade dentinária cervical

Esta pesquisa visa o estudo dos aspectos clínicos da hipersensibilidade dentinária cervical (HSDC). Um total de 32 pacientes com sintomas de HSDC foram examinados para identificar sua etiologia, sendo avaliados clinicamente 97 dentes. Com base na anamnese e exames clínicos efetuados, classificamos as lesões de acordo com suas principais características em: abrasão, erosão ou abfração. Os seguintes fatores puderam ser associados ao desencadeamento da HSDC: melhor e constante higienização, tratamento periodontal, consumo de alimentos ácidos e trauma oclusal. Concluímos que as lesões pequenas e radiculares estão mais associadas à HSDC, sendo os pré-molares os dentes mais afetados. Alguns hábitos alimentares e de higienização, bem como situações oclusais não-harmônicas e o tratamento periodontal, foram os fatores que predispõem os elementos dentais à HSDC, e os pré-molares, neste estudo, os dentes mais acometidos por esses fatores. Concluímos que as lesões por abrasão foram aquelas que mais manifestaram HSDC.

Irritant contact stomatitis: a review of the condition

Several different types of interactions are possible between a chemical, a mixture of chemicals, and associated extrinsic factors (i.e., mechanical irritation) in the oral mucosa. These interactions can be broadly classified as irritative or allergenic in nature. In each case, the pathology usually includes mucosal inflammation. The information compiled and reviewed in this article suggests that, given the broad definition of surface lesions/mucosal abnormalities, there may be a continuum of irritation that can be termed "irritant contact stomatitis." This may be due to the fact that the mouth is lined with highly vascular mucosa that turns over rapidly compared to the skin, and may or may not be covered by keratin. Some regions in the mouth are uniquely sensitive to irritants because they can penetrate through the tissue easily. Key factors involved in the potential development of irritation are: inherent irritation potential of the agent, amount of exposure (concentration, duration, and frequency), ability to penetrate the tissue, and inherent reactivity of the subject as well as other extrinsic factors. Irritation leading to oral mucosal alterations is a common occurrence caused by a wide variety of exposures and insults to the oral cavity. Various irritants such as foods, chemicals, friction, thermal/mechanical injury, metals, spices, and oral care products have been documented to cause irritant reactions in susceptible individuals, particularly if used under exaggerated exposure conditions. It is important to note that most irritation in the oral cavity tends to reverse quickly when the causative agent is removed. Oral irritation is a commonly occurring phenomenon. Thus, it is important that the clinician be aware of the clinical manifestations and etiology of the condition.

Gingival recession and its association with calculus in subjects deprived of prophylactic dental care

This paper describes the prevalence and severity of gingival recession in Tanzanian adults covering the age range from 20 to 64 years. In addition, it attempts to assess the relationship between the degree of gingival recession and the presence and amount of calculus. In the 20-34 years age group recession occurred in > or = 32% of the buccal, > or = 25% of the lingual, and > or = 13% of the approximal surfaces. These %s increased to > or = 64%, > or = 52%, and > or = 48%, respectively, in the 45-64 years age group. In the 20-34 years age group, lingual surfaces of mandibular incisors and canines followed by buccal surfaces of these teeth were the sites most severely affected with gingival recession. With increasing age, all sites became gradually more severely affected, particularly the buccal and lingual surfaces of the maxillary first molar. The lingual surfaces of mandibular incisors exhibited on an average 1.3 mm, 2.4 mm and 3.2 mm recession in the 20-34 years, 35-44 years and 45-64 years age group, respectively. Most of the correlation coefficients between gingival recession and calculus at the individual tooth surface in three age groups were statistically significant. The highest correlation coefficients (0.50-0.67) were found in the youngest (20-34 years) age group at the lingual surfaces of the mandibular incisors, canine and first premolar and at the buccal surfaces of the mandibular incisors. Based on these findings, the working hypothesis is advanced that longstanding calculus is an important determinant in the onset of gingival recession at sites exhibiting pronounced recession at a young age in populations deprived of prophylactic dental care.