aetiology and management of gingival recession and sensitivity

definition of recession

location of the gingival margin apical to the cemento-enamel junction resulting in exposure of the root surface

label the diagram

what is the incidence of recession

canines and premolars are most commonly affected

labial and buccal surface most commonly affected

what classification of recession is used

Miller 1985

what is class 1 recession

marginal tissue recession not extending to the mucogingival junction

no loss of interdental bone or soft tissue

what is class 2 recession

marginal tissue recession extends to or beyond the mucogingival junction

no loss of interdental bone or soft tissue

class 3 recession

marginal tissue recession extends to or beyond the mucogingival junction

loss of interdental bone or soft tissue is apical to the CEJ but coronal to the apical extent of the marginal tissue recession

class 4 recession

marginal tissue recession extends to or beyond the mucogingival junction

loss of interdental bone extends to a level apical to the extent of the marginal tissue recession

what is the pathogenesis of recession

1 - plaque induced inflammation of the connective tissues

2 - trauma induced inflammation of the connective tissues

3 - connective tissue destruction

4 - proliferation of the epithelium from both sides

5 - interconnecting cord of epithelium is formed between oral and pocket epithelium

6 - subsidence of the epithelium surface

what 3 factors contribute to pathological bone disease

• periodontal disease

• periodontal treatment - pt will initially present with not alot of recession with non surgical tx then recession and sensitivity

• smoking

calculus and smoking

smoking is a main cause of periodontal disease as well as unstable diabetes

smoking modifies recession

« darker gingivae so can tell sub calculus

what can cause trauma to the gingivae

tooth brushing

fictitious injury e..g fingernail picking

malocclusion e.g. class 2 div 2 with a traumatic overbite

poorly designed partial denture

chemical trauma e.g. cocaine

lip/tongue stud

what are some local plaque retentive factors

calculus

subgingival restorative margins

high muscle attachments

frenal pulls - frenulum close to teeth so hard for pt to brush

overhanging restorations

label this diagram

what is the link between restorations and the biological width

restorations invading the biological width can cause gingival recession (initially causes gingival inflammation then long term is recession

if restoration margin invades biological width, it will cause chronic inflammation, gingivitis, periodontitis, and subsequently recession (only place in necessary)

describe orthodontic tooth movement

excessive proclination especially when fixed appliances have or are being used - can cause recession

name some anatomical features that can also cause recession

thin gingival tissue

bone dehiscence

fenestration

what are the complications of gingival recession

• pain from exposed dentine - sensitivity

• root caries

• tooth abrasion

• plaque retention and gingival inflammation

• aesthetic concerns

what is the management of recession

monitor, measure, photograph, models

management of the aetiological factors

management of the consequences

first…

prescription from the dentist should be obtained

history and examination to identify the aetiological factors

what can be used to monitor

what is involved in the management of aetiological factors

• advise on an atraumatic brushing technique

• advice relating to traumatic habits

• advice on smoking cessation

• plaque control and OHI

• remove all local factors e.g. scaling, overhang removal

• dentist needs to correct deficient partial denture design

• margins of restorations need to be placed supragingival where possible

what are the consequences that need to be managed

dentine hypersensitivity

root caries

aesthetics

mucogingival surgery

how can dentine hypersensitivity be managed

give dietery advice e.g. control of acid in the diet

antisensitivity dentrifices

fluoride mouthwash

professionally applied products - fluoride varnish, dentine bonding agents

restorations e.g. GIC, etched composite

what are the ideal agents of a desensitising agent

• easily applied

• non irritant to the pulp

• painless on application

• consistently effective

• rapid in action

• effective for a long period

• non staining

what agents can we use

fluoride

potassium salts

strontium

colgate sensitive pro relief desensitising paste

dentine bonding agents

fluoride

fluoride occludes the dentinal tubules

• duraphat, 22,600 ppm F

• Gel Kam, 0.4% stannous fluoride and 1000ppm fluoride

• mouthwash, fluoriguard 2,500ppm

potassium salts

potassium has a direct desensitising effect on the pulpal nerve fibres

• sensodyne F, potassium nitrate 5.0%

• colgate sensitive, potassium citrate 5.5%

strontium

strontium blocks or occludes dentinal tubules

• sensodyne mint, strontium acetate 8.0%

colgate sensitive pro-relief desensitising paste

tubules occluded by a calcium rich layer created by the interaction of arginine and calcium carbonate

• based on the amino acid arginine and calcium carbonate

• available as a toothpaste and polishing paste used by the professional

dentine bonding agents

block or occlude dentinal tubules

• seal and protect

• routine restorative bonding agents

placing resin which physically blocks the tubules and stops movement of fluid in dentine tubules

how can we manage root caries

• diet advice

• fluoride application

• restoration

what could the dentist consider for aesthetics

gingival veneers to cover exposed root surfaces and hide the spaces interdentally

what is mucogingival surgery

root coverage using pedicle grafts

free grafts

guided tissue regeneration

pedicle graft

maintain their connection with the donor site after placement at the recipient site

lateral or coronary repositioned

free graft

completely deprived of their connection with the donor area

e.g. dissected from palate and used elsewhere