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ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 142-147

Association between Gingival Thickness and Recession in Nonperiodontitis Patients


NITTE (deemed to be university), AB Shetty Memorial Institute of Dental Sciences (ABSMIDS), Department of Periodontics, Mangalore, Karnataka, India

Date of Submission09-Mar-2021
Date of Acceptance10-Nov-2021
Date of Web Publication14-Jan-2022

Correspondence Address:
Nina Shenoy
NITTE (deemed to be university), AB Shetty Memorial Institute of Dental Sciences (ABSMIDS), Department of Periodontics, Mangalore 575018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jofs.jofs_62_21

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  Abstract 


Introduction: Gingival biotype defined as a genetically determined trait describes the thickness of gingiva faciopalatally. Gingival thickness plays an important role in the development and successful treatment of mucogingival defects. Gingival recession (GR) is an undesirable condition that creates root exposure, sensitivity, and unesthetic appearance. One of the main causes proposed for GR is an overzealous toothbrushing habit. Gingival tissues can be considered as “picture framework” for restorative and aesthetic procedures. The restorative dentist must take into account the response of gingival tissues to both inflammation and restorative margins to achieve maximum desirable outcomes. Hence, the aim of this study was to determine the association between gingival thickness (GT) and GR in nonperiodontitis patients. Materials and methods: The cross-sectional study was conducted in the Department of Periodontology, Mangalore. Eighty subjects with GR of both genders aged 18 to 35 years participated in the study. GT was assessed in the maxillary and mandibular teeth using the probe transparency method. A questionnaire was utilized to determine the toothbrushing habits of the subjects. Results: Thin gingiva was more commonly found in the maxillary arch (50%) and anterior sextant (52.50%). Maxillary posterior teeth were found to be frequently affected with GR (4.49%). Comparison of GT in the anterior and posterior sextants was not statistically significant (P = 0.43). A higher prevalence of thin biotype (73.8%) was found in sites with recession. Chi-squared test was used to determine the association between GT and GR. Statistical analysis was performed using the SPSS software version 22 (IBM). Conclusion: It can be concluded that there were variations in GT with respect to dental arch and sextants. Gingiva was thinner in the maxillary arch and anterior sextant. Receded surfaces were considerably higher on the buccal surfaces of posterior teeth. Higher prevalence of thin biotype was found at sites with recession. Subjects with splaying or flattening of their toothbrush bristles had a higher mean recession depth when compared with other subjects. However, the association between GT and GR was not statistically significant.

Keywords: Gingival biotype, gingival recession (GR), gingival thickness (GT), TRAN


How to cite this article:
Sarma M, Shenoy N. Association between Gingival Thickness and Recession in Nonperiodontitis Patients. J Orofac Sci 2021;13:142-7

How to cite this URL:
Sarma M, Shenoy N. Association between Gingival Thickness and Recession in Nonperiodontitis Patients. J Orofac Sci [serial online] 2021 [cited 2022 Jan 24];13:142-7. Available from: https://www.jofs.in/text.asp?2021/13/2/142/335851




  Introduction Top


Gingival biotype defined as a genetically determined trait describes the thickness of gingiva faciopalatally.[1] Several terms such as “gingival” or “periodontal biotype” and “morphotype” or “phenotype” have been used by various authors in the past. In the most recent literature, it was referred to as periodontal phenotype that described the combination of gingival phenotype (three-dimensional gingival volume) and the buccal bone plate thickness, that is, the bone morphotype.[2]

Good periodontal health is generally related to a thick biotype that characterizes thick gingival tissue. Ample evidence indicates that thick biotype can withstand trauma and gingival recession (GR) better, encourage creeping attachment, and exhibit less inflammation clinically.[3],[4]

Thin biotype is delicate and almost translucent in appearance with a zone of attached gingiva that is quite minimal. Such gingival tissues are highly accentuated that suggests thin or minimal bone presence. They are considered to be less resistant to insults that are inflammatory or surgical in nature and are therefore more predisposed to GR.[5],[6]

One of the most prevalent functional and esthetic problems that are associated with periodontal tissues is GR.[7] It creates esthetic concerns particularly when the anterior teeth are affected. GR is characterized by root exposure due to the migration of gingival margin apically to the cementoenamel junction (CEJ). GR can either be localized that involves one tooth or a group of teeth or can be generalized throughout the mouth. Several etiologic factors for GR have been suggested in the past. Gingival morphology has also been found to play an important role in initiating GR.[8]

Clinical gingival health on a reduced periodontium in nonperiodontitis patients can be defined as those who have some forms of GR (CAL due to traumatic causes, following crown lengthening, etc.). In such cases, clinical gingival health is characterized by <10% bleeding sites[9],[10] and probing depths (PDs) ≤3 mm.[11] Gingivitis on the other hand is distinguished by ≥10% bleeding sites[9],[10] and PD ≤3 mm.[11]

The need for proper and adequate oral hygiene is considered crucial in maintaining good oral health. However, an incorrect toothbrushing method has been proposed as the most important mechanical factor contributing to the development of GR,[12],[13],[14] especially in the buccal surfaces of posterior teeth.[12],[15],[16] Toothbrushing frequency, duration of brushing, toothbrush hardness, and force of brushing were found to be potential risk factors for development of GR.

As plenty of evidence exists establishing a relationship between GR and periodontal disease, the role of aggressive toothbrushing in the etiology of GR still remains obscure.[17]

In recent years, gingival thickness (GT) has become a subject of considerable interest for dental researchers, both from an epidemiologic and therapeutic point of view. The restorative dentist must take into account the response of gingival tissues to inflammation and restorative margins for optimizing treatment outcomes. Hence, determining the gingival tissue thickness should be considered imperative prior to periodontal procedures and placement of restorative margins.

Therefore, the aim of the present study was to determine the association between GT and GR in nonperiodontitis patients.


  Materials and Methods Top


Ethical approval for this study (ABSM/EC/79/2018) was provided by the Central Ethics Committee of AB Shetty Memorial Institute of Dental Sciences, Mangalore on October 25, 2018. An informed written consent was obtained from all the participants at the beginning of the study.

Sample size was calculated using the following formula:



where n is the sample size, α = 5%, Z1-α/2 = 1.96, d (precision) = 0.1%, P = 0.29, Q = 0.71.

A total of 80 patients were selected based on the inclusion and exclusion criteria and clinical examination was performed. Both males and females within the age group of 18 to 35 years, systemically healthy, nonperiodontitis individuals with a minimum complement of 20 natural teeth, subjects having bilateral single or multiple recession defects with ≥10% bleeding sites[9],[10] and probing pocket depth of ≤3 mm[11] were included in the study. Miller classes III and IV GR, subjects with ongoing or prior history of any dental treatment, heavy clinical pigmentation, high frenal attachments, trauma from occlusion, parafunctional habits, pregnant and lactating women, and patients under medication such as cyclosporine A, calcium channel blockers, and phenytoin were excluded.

A standard proforma consisting of the patient’s demographic details, medical and dental history were recorded. Intraoral examination of each patient was performed by a single trained dentist using mouth mirror and UNC-15 probe.

Evaluation of patient’s toothbrushing habits was made based on a questionnaire.

Clinical parameters

The following clinical parameters were systematically recorded by one trained clinician:
  1. Visible plaque index[18]: Absence or presence of visible plaque on the tooth surface after drying was scored.
  2. Gingival bleeding index[18]: Absence or presence of bleeding after gentle probing of the crevice using a William periodontal probe up to 30 seconds after probing was recorded for each teeth.
  3. Probing depth: The PD was measured using a periodontal probe on all six surfaces of a tooth (distobuccal, midbuccal, mesiobuccal, distolingual, midlingual, and mesiolingual).
  4. GR and recession depth (RD)[2]: GR was classified as per Miller classification. RD was measured in millimeters at the midbuccal aspect of a tooth with a periodontal probe, positioned between the CEJ and the gingival margin.
  5. Cementoenamel junction[19]: Classified as presence/absence of CEJ. Teeth where CEJ was undetectable, the level of CEJ of the adjacent tooth was considered.
  6. Gingival thickness[20]: GT was evaluated using the probe transparency method (TRAN), that is, a UNC-15 probe was inserted into the sulcus and the thickness was evaluated by observing the outline of the probe through the gingival tissue. Probe visible: thin (≤1 mm). Probe not visible: thick (>1 mm).
  7. Keratinized tissue width (KTW)[2]: KTW was measured in millimeters using an UNC-15 probe at the midbuccal point, from the mucogingival junction to the free gingival margin.
  8. Width of attached gingiva (WAG): WAG was determined by subtracting PD from width of keratinized gingiva.
  9. Clinical attachment level (CAL):CAL was measured from the CEJ to the base of the pocket on all the six surfaces of the tooth (distobuccal, midbuccal, mesiobuccal, distolingual, midlingual, and mesiolingual) using a William graduated periodontal probe.


Statistical analysis

The data were processed and analyzed using the IBM Statistical Packages for Social Sciences (SPSS software version 22, IBM). Shapiro–Wilk test was used to test for normality of the data. Chi-squared test was used to assess the association between GT and GR, and Kruskal–Wallis test was used for comparison between RD and toothbrushing habits. P < 0.05 was considered to be statistically significant.


  Results Top


Eighty subjects between the age of 18 to 35 years were included in the study. The obtained data were tabulated and subjected to statistical analysis.

The study consisted of 43 (53.8%) females and 37 (46.3%) males with GR.

Mean values of periodontal parameters in the study population are summarized in [Table 1].
Table 1 Mean values of periodontal parameters

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  Discussion Top


Different biotypes behave differently when exposed to inflammatory processes, Trauma, or surgical insults, which can dictate the treatment outcome of various dental procedures. The determination of GT prior to surgical procedures is thus pertinent in the field of clinical periodontics.

The present day youth are highly concerned about their aesthetic appearance. The presence of GR can create root exposure and compromise aesthetics especially in the anterior region. One of the main causes proposed for GR is an overzealous toothbrushing habit.[12],[13],[14]

Hence, this cross-sectional study was designed to determine the association between GT and GR in 80 nonperiodontitis patients between 18 and 35 years of age. Subjects with prior history or ongoing dental treatment were excluded from the study to focus attention on GR that was unrelated to any periodontal disease or orthodontic tooth movement.

The GT is said to vary according to age, gender, and dental arch.[21]

Thin gingiva is usually found in older age groups. It also varies among individuals as well as in different areas of the mouth within the same subject.[22] The study population comprised of 53% females and 46% males with a mean GR depth of 2.21 ± 0.78 mm [Table 1]. No significant gender-based difference in the distribution of GT was noted [Table 2]. This could be due to the inclusion of younger patient population for the study. Other studies have found a higher prevalence of thin gingiva in females.[23],[24]
Table 2 Gender wise distribution of study participants based on gingival thickness

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Comparison of GT in the maxillary and mandibular dental arches and sextants indicated thinner gingiva in the maxillary anterior sextant. However, it was not statistically significant [Table 3] and [Table 4]. Similarly incisors (42.5%) and premolars (41.25%) had thinner gingiva compared to the molars [Table 5]. Lee et al.[25] and Eger et al.[26] reported a higher prevalence of thin gingiva in the anterior and premolar region, respectively.
Table 3 Arch-wise distribution (DA) of study participants based on gingival thickness

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Table 4 Sextant-wise distribution of study participants based on gingival thickness

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Table 5 Teeth-wise distribution of study participants based on gingival thickness

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Various factors such as tooth form,[27] position of tooth in the arch, and genetic traits[28] could influence the form of tissue around a tooth. Olsson and Lindhe[27] reported that teeth that is tapered are usually associated with thin gingiva, whereas wide and square crown forms are associated with gingiva that is thick. The heterogeneity in the GT may be due to the fact that gingival architecture varies considerably with tooth morphology.

The prevalence of GR was higher on the buccal surfaces of maxillary posteriors followed by mandibular posteriors when compared with anterior teeth [Figure 1]. Kassab and Cohen,[12] Serino et al.,[15] and Checchi et al.[16] stated that recession on the buccal surfaces were a common finding in subjects who maintained a good standard of oral hygiene. Similarly, other cross-sectional studies[29],[30] have reported buccal GR to be more common in molars and premolars in subjects less than 40 years of age, thereby supporting the finding in our study.
Figure 1 Maxillary posterior teeth were frequently affected with Gingival recession (4.49%).

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Ample evidence suggests that thin gingiva is more predisposed to recession than gingiva that is thick.[20],[31] Even though the comparison of GT with recession revealed a higher prevalence of thin gingiva (73.8%) in sites with recession [Table 6], the findings were not statistically significant (P > 0.05) [Table 7]. These findings are not in accordance with a variety of other studies in the literature.[20],[31]
Table 6 Prevalence of biotype in sites with recession

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Table 7 Association between gingival thickness and gingival recession

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Nevertheless, the influence of confounding factors such as racial and genetic factors that can influence GT cannot be ruled out.

A detailed questionnaire on brushing habits was recorded [Table 8]. A majority of the subjects (77.5%) brushed their teeth in horizontal direction and 83.8% noticed splaying of their toothbrush bristles. Mean RD was higher in subjects with splayed or flattened bristles (2.29 ± 0.75), which was highly significant statistically (P = 0.01) [Table 9]. Wear of the bristles is often indicated by their splaying or flattening. Vigorous toothbrushing supplemented by thin gingiva could be the main factor responsible for recession. Overzealous brushing is hypothesized to increase the risk of tissue damage and predispose the tissues to localized recession.[13]
Table 8 Distribution of study participants based on questionnaire responses

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Table 9 Comparison of recession depth based on splaying or flattening of toothbrush bristles

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Although the prevalence of thin gingiva was more in the maxillary anterior sextant, the recession observed was more prevalent in the maxillary molar and premolar regions. As most confounding factors responsible for recession were excluded, it can be concluded that faulty toothbrushing techniques could be responsible for the observations in this study.

There were several limitations in this study. The study was cross-sectional, observational in nature. Tooth morphology that can greatly affect the gingival architecture was not taken into consideration. The questionnaire used to ascertain the toothbrushing habits of the individuals was highly subjective.


  Conclusion Top


Within the limitations of the study, it can be concluded gingival biotype varies according to dental arch and sextants. Thinner gingiva was found more frequently in the maxillary arch and anterior sextant. Receded surfaces were considerably higher on the buccal surfaces of maxillary posteriors. The prevalence of thin biotype was higher in teeth exhibiting GR. However, there was no significant association between GT and GR.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kao RT, Fagan MC, Conte GJ. Thick vs. Thin gingival biotypes: a key determinant in treatment planning for dental implants. J Calif Dent Assoc 2008;36:193-8.  Back to cited text no. 1
    
2.
Jepsen S, Caton JG, Albandar JM et al. Periodontal manifestations of systemic diseases and developmental and acquired conditions: consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Clin Periodontol 2018;45:S219-29.  Back to cited text no. 2
    
3.
Kois JC. Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent 2004;25:895-900.  Back to cited text no. 3
    
4.
Chung DM, Oh TJ, Shotwell JL, Misch CE, Wang HL. Significance of keratinized mucosa in maintenance of dental implants with different surfaces. J Periodontol 2006;77:1410-20.  Back to cited text no. 4
    
5.
Weisgold AS. Contours of the full crown restoration. Alpha Omegan 1977;70:77-89.  Back to cited text no. 5
    
6.
Baldi C, Pini-Prato G, Pagliaro U et al. Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. J Periodontol 1999;70:1077-84.  Back to cited text no. 6
    
7.
The American Academy of Periodontology. Glossary of Periodontal Terms. 4th ed. Chicago IL: The American Academy of Periodontology; 2001. p. 44.  Back to cited text no. 7
    
8.
Mamta S, Chaubey KK, Madan E, Thakur RK, Agarwal MC, Joshi N. Correlation between gingival biotype and occurrence of gingival recession. Saudi J Oral Dent Res 2016;1:119-23.  Back to cited text no. 8
    
9.
Trombelli L, Farina R, Silva CO, Tatakis DN. Plaque-induced gingivitis: case definition and diagnostic considerations. J Periodontol 2018; 89(Suppl 1):S46-73.  Back to cited text no. 9
    
10.
Ramseier C, Mirra D, Schutz C et al. Bleeding on probing as it relates to smoking status in patients enrolled in supportive periodontal therapy for at least 5 years. J Clin Periodontol 2015;42:150-9.  Back to cited text no. 10
    
11.
Chapple IL, Mealey BL, Van Dyke TE et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Periodontol 2018;89:S74-84.  Back to cited text no. 11
    
12.
Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220-5.  Back to cited text no. 12
    
13.
Khocht A, Simon G, Person P, Denepitiya JL. Gingival recession in relation to history of hard toothbrush use. J Periodontol 1993;64:900-5.  Back to cited text no. 13
    
14.
Sarfati A, Bourgeois D, Katsahian S, Mora F, Bouchard P. Risk assessment for buccal gingival recession defects in an adult population. J Periodontol 2010;81:1419-25.  Back to cited text no. 14
    
15.
Serino G, Wennstrom J, Lindhe J, Eneroth L. The prevalence and the distribution of gingival recession in subjects with a high standard of oral hygiene. J Clin Periodontol 1994;21:57-63.  Back to cited text no. 15
    
16.
Checchi L, Daprile G, Gatto MRA, Pelliccioni GA. Gingival recession and toothbrushing in an Italian School of Dentistry: a pilot study. J Clin Periodontol 1999;26:276-80.  Back to cited text no. 16
    
17.
Rajapakse PS, McCracken GI, Gwynnett E, Steen ND, Guentsch A, Heasman PA. Does tooth brushing influence the development and progression of non‐inflammatory gingival recession? A systematic review. J Clin Periodontol 2007;34:1046-61.  Back to cited text no. 17
    
18.
Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975:25:229-35.  Back to cited text no. 18
    
19.
Pini-Prato G, Franceschi D, Cairo F, Nieri M, Rotundo R. Classification of dental surface defects in areas of gingival recession. J Periodontol 2010;81:885-90.  Back to cited text no. 19
    
20.
Kan JY, Morimoto T, Rungcharassaeng K, Roe P, Smith DH. Gingival biotype assessment in the esthetic zone: visual versus direct measurement. Int J Periodontics Restorative Dent 20101;30:237-43.  Back to cited text no. 20
    
21.
Vandana KL, Savitha B. Thickness of gingiva in association with age, gender and dental arch location. J Clin Periodontol 2005;32:828-30.  Back to cited text no. 21
    
22.
Agarwal V, Mehrotra N, Vijay V. Gingival biotype assessment: variations in gingival thickness with regard to age, gender, and arch location. Indian J Dental Sci 2017;9:12-5.  Back to cited text no. 22
    
23.
Bhat V, Shetty S. Prevalence of different gingival biotypes in individuals with varying forms of maxillary central incisors: a survey. J Dent Implant 2013;3:116-21.  Back to cited text no. 23
  [Full text]  
24.
Zawawi KH, Al-harthi SM, Al-zahrani MS. Prevalence of gingival biotype and its relationship to dental malocclusion. Saudi Med J 2012;33:671-5.  Back to cited text no. 24
    
25.
Lee SA, Kim AC, Prusa LA Jr, Kao RT. Characterization of dental anatomy and gingival biotype in Asian populations. J Calif Dent Assoc 2013;41:31–3, 36-9.  Back to cited text no. 25
    
26.
Eger T, Müller HP, Heinecke A. Ultrasonic determination of gingival thickness: subject variation and influence of tooth type and clinical features. J Clin Periodontol 1996;23:839-45.  Back to cited text no. 26
    
27.
Olsson M, Lindhe J. Periodontal characteristics in individuals with varying form of the upper central incisors. J Clin Periodontol 1991;18:78-82.  Back to cited text no. 27
    
28.
Malhotra R, Grover V, Bhardwaj A, Mohindra K. Analysis of the gingival biotype based on the measurement of the dentopapillary complex. J Indian Soc Periodontol 2014;18:43-7.  Back to cited text no. 28
[PUBMED]  [Full text]  
29.
O’Leary TJ, Drake RB, Crump PP, Allen MF. The incidence of recession in young males. A further study. J Periodontol 1971;5:264-7.  Back to cited text no. 29
    
30.
Bjorn AL, Andersson U, Olsson A. Gingival recession in 15-year-old pupils. Swed Dent J 1981;5:141-6.  Back to cited text no. 30
    
31.
De Rouck T, Eghbali R, Collys K, De Bruyn H, Cosyn J. The gingival biotype revisited: transparency of the periodontal probe through the gingival margin as a method to discriminate thin from thick gingiva. J Clin Periodontol 2009;36:428-33.  Back to cited text no. 31
    


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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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