brushing teeth and recession

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Review Article

Does tooth brushing influence thedevelopment and progression ofnon-inflammatory gingivalrecession? A systematic review

Rajapakse PS, McCracken GI, Gwynnett E, Steen ND, Guentsch A, Heasman PA. Does

tooth brushing influence the development and progression of non-inflammatorygingival recession? A systematic review. J Clin Periodontol 2007; 34: 10461061. doi:10.1111/j.1600-051X.2007.01149.x.

Abstract

Aim: The aim of this systematic review was to produce the best available evidenceand pool appropriate data to evaluate the effect of tooth brushing on the initiationand progression of non-inflammatory gingival recession.

Material and Methods: A protocol was developed a priori for the question:Do factors associated with tooth brushing predict the development and progressionof non-inflammatory gingival recession in adults? The search covered six electronicdatabases between January 1966 and July 2005. Hand searching included searchesof the Journal of Clinical Periodontology, Journal of Periodontal Research and the

Journal of Periodontology. Bibliographies of narrative reviews, conferenceproceedings and relevant texts known to the authors were also searched. Inclusion of

titles, abstracts and ultimately full texts was based on consensus between three reviewers.Results: The full texts of 29 papers were read and 18 texts were eligible for inclusion.One abstract from EuroPerio 5 reported a randomized-controlled clinical trial[Level I evidence] in which the authors concluded that the toothbrushes significantlyreduced recessions on buccal tooth surfaces over 18 months. Of the remaining 17observational studies, two concluded that there appeared to be no relationship betweentooth brushing frequency and gingival recession. Eight studies reported a positiveassociation between tooth brushing frequency and recession. Other potential riskfactors were duration of tooth brushing, brushing force, frequency of changing thetoothbrush, brush (bristle) hardness and tooth brushing technique. None of theobservational studies satisfied all the specified criteria for quality appraisal and a validappraisal of the quality of the randomized-controlled trial was not possible.

Conclusion: The data to support or refute the association between tooth brushing andgingival recession are inconclusive.

Key words: gingival recession; tooth brushing

Accepted for publication 27 August 2007

Gingival recession, exposure of the rootsurface due to apical migration of thegingival margin, affects a significantproportion of the adult population andits presence among subjects with a goodstandard of oral hygiene suggests thatthe aetiology of the condition may ofteninvolve anatomical and iatrogenic fac-tors in addition to being associated withpathology such as gingivitis andperiodontitis (Litonjua et al. 2003).

P. Sunethra Rajapakse1

,Giles I. McCracken2,

Erika Gwynnett2, Nick D. Steen2,

Arndt Guentsch3 and

Peter A. Heasman2

1University of Peradeniya, Peradeniya,

Sri Lanka; 2Newcastle University, Newcastle

upon Tyne, UK; 3Friedrich-Schiller

Universitat, Jena, Germany

Conflict of interest and source of

funding statement

This systematic review was supportedby a research grant from Philips OralHealthcare (Snoqualmie, WA, USA).The grant enabled funding for theprimary researchers post for 6months. The authors consider thatthere is no direct conflict of interestwith this collaboration, particularly

as commercially sponsored investi-gations with the primary aim ofcomparing the efficacy of differenttoothbrushes were excluded from thereview. Further, the protocol wasdesigned as an investigators ownstudy. The authors have not contribu-ted to or authored any of the papersincluded in the review.

J Clin Periodontol 2007; 34: 10461061 doi: 10.1111/j.1600-051X.2007.01149.x

1046 r 2007 The Authors. Journal compilation r 2007 Blackwell Munksgaard


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The possibility that improper toothbrushing or toothbrush trauma may beat least one contributing factor towardsthis multifactorial condition has beenrecognized for many years (Boyle1950, Miller 1950, Gorman 1967),although classical periodontal texts of

the time recognized that additional fac-tors, primarily tooth malalignment andalveolar bone thinning, may also predis-pose to non-inflammatory gingivalrecession (Glickman 1964). Positiveassociations between recession andboth increasing age (Kitchin 1941,Gorman 1967, Loe et al. 1978, 1992,Serino et al. 1994, Brown et al. 1996,Sangnes & Gjermo 1976) and good oralhygiene (OLeary et al. 1968, 1971, Loeet al. 1992, Serino et al. 1994) tend toimplicate further the significant andprimary role of tooth brushing in the

aetiology of recession, while recogniz-ing that tooth brushing itself is asso-ciated with a number of potentiallyconfounding variables such as pressure,time, bristle type and the dentifrice used.

A more exacting association betweentooth brushing variables and gingivalabrasion and erosion has been exploredin short-term clinical studies (Sangnes1976, Breitenmoser et al. 1979, Axell &Koch 1982, Niemi et al. 1984,Smukler & Landsberg 1984) and in long-itudinal, but again short-term, studies ofmanual and powered toothbrushes (Baab

& Johnson 1989, Walsh et al. 1989,Johnson & McInnes 1994, Terezhalmyet al. 1994, van der Weijden et al. 1994,Heasman et al. 1999). The extent, how-ever, to which the development of minorgingival abrasions is meaningful and rele-vant to the development of frank gingivalrecession remains unclear and controver-sial (Addy & Hunter 2003). Thus, whilefactors associated with tooth brushing arecommonly believed to be risk factors forgingival recession, the extent to whichthese factors or indeed any individualstooth brushing profile are able to predict

with confidence the development of gin-gival recession appears to be unknown.

The aim of this systematic reviewwas to search for the best availableevidence to evaluate the potential roleof tooth brushing in the initiation andprogression of non-inflammatory, loca-lized gingival recession.

Material and Methods

A protocol was developed a priori fol-lowing initial discussion between all

members of the research team. Thefocused question for the review was:Do factors associated with toothbrushing predict the development andprogression of non-inflammatory gingi-val recession in adults? At the outsetof this review, no attempt was made to

separate specific variables associatedwith tooth brushing such as pressure,time spent brushing, bristle type (stiff-ness and end-shape), filament character-istics or the use of a dentifrice.

Criteria for including and excluding

studies

The protocol indicated that studies to beincluded in the review would follow thehierarchical structure: randomized clin-ical trials (RCTs) [Level I]; experimen-tal studies without randomization (CTs)

[Level II]; observational studies withcontrol groups (cohort studies, casecontrol studies) [Level II]; observationalstudies without control groups (cross-sectional studies, before-and-after stu-dies, case series) [Level III]; and casereports/expert opinion [Level IV]. Therewas some initial concern regarding thelikelihood of discovering Level I evi-dence (RCTs or CTs) that addressed thefocused question and it was decideda priori that the threshold for inclusionfor soundness of design be Level III.Inclusion criteria for the studies were

recruitment of human subjects orpatients, clinical examination to deter-mine the extent of gingival recessionand/or tooth brushing practice, an eva-luation of gingival recession and anevaluation of factors that might be asso-ciated with the development and/or pro-gression of gingival recession. Thefollowing were excluded from thereview: animal studies; studies lookingat gingival abrasion or erosion (ratherthan gingival recession); toothbrushcomparison studies; studies involvingchildren as participants; studies invol-

ving patients with periodontal diseases;commercially sponsored investigationswith the primary aim of comparing theefficacy of different toothbrushes withrespect to plaque removal and gingivitisresolution; and histological studiesincluding scanning electron microscopy.

Search strategy

The search strategy was developed withthe assistance of a senior health serviceslibrarian (E. G.) and in accordance withpublished guidance for undertaking of

systematic reviews (Khan et al. 2001).The search was unrestricted with respectto languages. The search covered sixelectronic databases for the periodbetween January 1966 and July 2005:Medline; Embase; Web of Knowledge;the Cochrane Central Register of Con-

trolled Trials; Current Contents Con-nect; and the Google Scholar searchengine. The principal root term for thesearch was toothbrush$ and the searchterms [with adjacency functions whererelevant] were: tooth brushing; dentaldevices; oral hygiene; toothbrush$.mp;toothbrush$ [adj3] pressure; tooth-brush$ [adj3] force; toothbrush$ [adj3]techniques; toothbrush$ [adj3] tooth-paste; toothbrush$ [adj3] frequency;toothbrush$ [adj3] design$; toothbrush$[adj3] texture$; toothbrush$ [adj3] bris-tle$; gingival recession; gingival [adj3]

recession; gingival [adj3] abrasion; gin-gival [adj3] trauma; and gingival [adj3]lesions, together with combinations ofthe above.

Hand searching included searches ofthe Journal of Clinical Periodonto-logy (19742005), Journal of Perio-dontal Research (19662005) and the

Journal of Periodontology (19662005),although these journals will also havebeen included in the electronic searches.Bibliographies of narrative review arti-cles and relevant texts known to theauthors, World and European Work-

shops, were also searched by hand.The abstracts of EuroPerio 5 that werepublished by the Journal of ClinicalPeriodontology as supplement 7 ofvolume 33 were searched by hand.The editors of the Journals of Perio-dontology and Journals of ClinicalPeriodontology were contacted to iden-tify whether any papers specific tothis review had been accepted forpublication.

Method of the review and validity

assessment

Titles and abstracts from the electronicsearches were managed by downloadingEndNote software. EndNote 7 was usedto search remote databases, to importthe reference data and to manage theimported references. The titles andabstracts were all in English and werescreened independently by threereviewers (P. S. R., P. A. H. and G. I.McC.). The selection criteria wereapplied to a subgroup of potentiallyrelevant studies to identify areas ofdisagreement and lack of clarity in the

Tooth brushing and gingival recession 1047

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protocol, and more specifically in theinclusion and exclusion criteria. The fulltexts of all studies reported in Englishthat potentially might have beenincluded were also reviewed by threereviewers against the stated inclusioncriteria. Full texts reported in languages

other than English were each reviewedby a single reviewer. Papers in theGerman language were reviewed, anddata were extracted by one of theauthors (A. G.). The Spanish and Greekpapers were reviewed, partly translatedand data were extracted by periodontalcolleagues in or from those countries.(Data extraction was always completedbefore a decision was made by one ofthe authors regarding whether the articleshould be included in the review.)

Inclusion of titles, abstracts and ulti-mately full texts was based initially on

consensus of full agreement between allthree reviewers. In those cases wheretwo of the three reviewers agreed oninclusion, the final decision was onlymade following discussion among thereviewers. If any missing data or informa-tion were identified, an attempt was madeto contact the author(s) of the publication.

Data were extracted from the full-textarticles using a purposely designed dataextraction form. This form recordedstudy title, authors, country in whichthe research was carried out, type ofstudy, randomization and blinding,

duration of study, objectives, clinicalmeasurements at baseline and follow-up (where appropriate), statistical find-ings and conclusions.

Assessment of methodological quality

The methodological quality of thepapers was assessed using separatecriteria for the Level I and LevelIII studies. Individual components ofquality were assessed rather than usingsummary scores and no attempt wasmade to blind the reviewers to names

of authors, institutions and journalswhile making the assessments. In thefirst instance, the assessment instru-ments were both piloted on papers thathad been excluded from the review. Theassessment criteria were formulated intotwo checklists for Level I and III stu-dies, respectively, and based on thequality criteria for experimental andobservational studies reported by Khanet al. (2001) (Centre for Reviews andDissemination). No attempt was madeto contact any authors of the observa-tional studies to obtain missing or addi-

tional data or for clarification of datathat may have appeared to be unclear.

Level I assessment of quality wasbased on five criteria with the overallaim of assessing methodological qual-ity, bias, internal and external validity,training and calibration of the

examiners.

Method of randomization

Randomization was considered to beadequate if it was determined using amethod of chance such as tossing a coin,a table of random numbers or a com-puter-generated sequence. Any othermethod, such as alternate assignment,was considered inadequate as was fail-ure of the authors to refer to a method ofrandomization in the text.

Allocation concealment

This was considered to be adequatewhen it was clearly stated that therandomization sequence was concealedentirely from the examiners. Partial con-cealment or attempted concealment of arandomized assignment was consideredto be inadequate and an assessment ofunclear was made if there was no men-tion of concealment.

Blinding

Blinding of examiners and participants(to protect against both performance andmeasurement bias) was assessed,although it is recognized that blindingparticipants to interventions such astooth brushing is unlikely and, depend-ing on the design of the trial, is oftenimpossible.

Completeness of follow-up

Completeness of follow-up was consid-ered to be adequate if the numbers ofparticipants were reported both at base-

line/entry and at completion of the trial,and any drop-outs were accounted forand the reasons were reported. Failure toreport these data and information led toan assignment of inadequate.

Intention-to-treat analysis

In order to protect against attrition bias,intention-to-treat was assessed as beingadequate when reported or, if it wasclear from the data analysis presentedin the paper. An assessment was madeas to whether the analysis accounted for

drop-outs and participants who were lostto follow-up.

Level III assessment of quality for theobservational studies was made inde-pendently by two reviewers (P. A. H.,G. I. McC.) according to fulfilment ofeight specific criteria (in each instance,

the assessment was made using thedichotomous response adequate/inade-quate or yes/no).

Was the cohort considered to be avalid and adequate representation ofthe wider, relevant population?

Was the population under observa-tion explicitly and adequatelydefined?

Were explicit inclusion and exclu-sion criteria adequately defined?

Was there evidence of training andcalibration of the examiners and

reproducibility testing during theobservational period?

Was, if applicable, completeness offollow-up adequately reported?

Were appropriate statistical methodsused?

Was a practical, in vivo assessment(rather than questionnaires) made oftooth brushing practice and/or fac-tors or variables associated withtooth brushing?

Was a method for measuring orassessing gingival recessionreported?

k scores and 95% confidence inter-vals (CIs) for inter-reviewer agreementwere calculated for each aspect of theassessment.

Results

Search results

The flow of articles through the reviewprocess is presented in Fig. 1. (The fullsearch strategy showing the number ofarticles retrieved by each term is given

in Appendix A.) The electronic andmanual search strategy produced 831titles and 121 abstracts were screened.The full or available texts of 29 paperswere obtained and read, and 18 textswere considered to be eligible for inclu-sion in the review. Of these 18 texts,14 were written in the English language,two in German, one in Greek and one inSpanish. The data extraction for thepapers written in German was per-formed by one researcher (A. G.).The data extraction for the remainingpapers was performed by colleagues of

1048 Rajapakse et al.



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those nationalities. One abstract fromEuroPerio 5 was included in the review.The abstract itself provided only limitedinformation, but discussion with thelead author during a poster presentationprovided sufficient evidence for the trialto be included in the review.

The reasons for excluding 11 articlesare given in the relevant section of the

bibliography to the review.

Study characteristics

The characteristics of the 18 studiesincluded in this review are shown inthe data Table 1. The earliest reportedstudy in the review was published in1976 and the most recent was reported in2006. All studies reported the number ofsubjects/participants/patients who wererecruited, and only one article failed toreport data on ages (Benz et al. 1987).

Seventeen of the articles did not reporta clinical trial that explored a null hypoth-esis using tooth brushing or any con-trolled element of tooth brushing as anintervention; none of these 17 studies,therefore, was either randomized or con-trolled. Seventeen studies were classifiedas being observational in design (LevelIII) although three studies reported clin-

ical observations that were made overdifferent time points (Paloheimo et al.1987, Kallestal & Uhlin 1992, Serinoet al. 1994). Two studies made observa-tions in groups of first- and final-yeardental students but these were separatepopulations rather than reporting data onthe same group at different time points(Checchi et al. 1999, Wilckens et al.2003). One study assessed directly toothbrushing parameters that were correlatedwith gingival recession lesions and thedesign most closely reflected a cohortstudy (Benz et al. 1987). The trial

presented as an abstract at EuroPerio 5was the only prospective, randomized,single-blind, parallel design clinical trial(Level I evidence) identified and includedin the review (Dorfer et al. 2006).

It was considered that because of theimmense heterogeneity of the studies,

their aims, design, cohorts of partici-pants and methods of recording andreporting observations, a sophisticatedlevel of data combination and analysiswas neither possible nor indicated.A meta-analysis was, therefore, notundertaken.

Methodological quality

Level I evidence

The literature scoping identified onlyone paper that reported a RCT that

comprised Level I evidence. The studywas reported as a prospective, rando-mized, controlled, single-blind, paralleldesign clinical trial (Dorfer et al. 2006).The information available, specificallywith respect to the method of randomi-zation, allocation concealment, blindingof examiners, statistical analysis andcompleteness of follow-up, did notallow an adequate appraisal of qualityand this was therefore assigned to beunclear. There was no evidence of cali-bration of examiners or reproducibilitytesting throughout the trial period.

Repeated attempts were made to contactthe author but no response was received.Contact with the editors of the two

journals considered to be the most likelyfor publication of the data revealed nosimilar titles being in press and soaccess to a full text of the paper wasnot possible.

Level III evidence

Eleven studies were considered to haverecruited populations that, although were

adults, could not be considered to berepresentative of the general population(k 0.92, CI 0.910.99): one study excludedsubjects who were faulty brushers(Tezel et al. 2001); four studies recruitedonly small numbers of between 25 and 55subjects (Benz et al. 1987, Goutoudi et al.1997, Checchi et al. 1999, Tsami-Pandi &Komboli-Kontovazeniti 1999); and sevenstudies recruited participants from onlyyounger age groups such as dental stu-dents (Murtomaa et al. 1987, Paloheimoet al. 1987, Frentzen et al. 1989, Kallestal& Uhlin 1992, Checchi et al. 1999,

Electronic andmanual searches

Screening titlesn = 831

Screening abstractsn = 120

Screening articlesn = 2 9

Articles included inthe review

n = 1 8

Excluded titlesn = 711

Excluded abstractsn = 91

Excluded textsn = 11

Fig. 1. Flow of articles through review




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Checchietal.(1999)

Eng

lish

Unspecified

Todeterminethe

prevalenceofgingival

recessiononbuccaltooth

surfacesinadentalstudent

population

2gro

upsofdentalstudents

(271

styears;285thyears)

Observational/

cross-sectionalbut

withobservations

at2timepoints

z

C

linicalexamination.Data

c

ollectionontooth

b

rushingbehaviour

Thefinalyearstudentshad38%ofrecessions

42mmcompared

with15%withfirstyear

students.Horizonta

l,verticalorrotarytooth

brushingtechniques(simple)wereassociated

with2.22moreGR

lesionswhencompared

withBassorrollte

chniques(complex)

(p5

0.013).Eacha

dditionalepisodeoftooth

brushingperdayis

associatedwith11.07

lesionsofGR(R2

5

0.23,p5

0.016)

Tsami-Pandi&Komboli-

Kontovazeniti(1999)

Gree

k

Unspecified

Tocorrelatetheseverityof

gingivalrecessionwith

aetiologicalfactors

32su

bjectswithanterior

sites

ofgingivalrecession

(2738years)

Observational/

cross-sectionalz

C

linicalexamination

Themostsignificantfactorsidentified(in

orderofimportance)asbeingassociatedwith

GRwere:age(po

0.001),smoking

(p5

0.005)andfre

quencyoftoothbrushing

(p5

0.064).There

appearedtobeno

significantassociationbetweenothertooth

brushingfactorsan

dGR:Hardnessofthe

bristles(p5

0.470),strengthoftoothbrushing

(p5

0.250)anddurationofbrushing

(p5

0.392)

Arowojolu(2000)

Eng

lish

Unspecified

Todetermineprevalenceof

gingivalrecessionandto

associatewithaetiological

factors

491consecutivepatients

referredtouniversity

perio

dontalclinic(1882

years

)

Observational/

cross-sectionalz

H

ealthinterviews.Clinical

e

xamination

GRincreaseswith

thenumberofepisodesof

toothbrushing/day:

Frequency

Percentageof

subjects

1/day

26.1%

2/day

40.0%

(po0.001)

Subjectswhoaccentuatedhorizontalscrub

motion(usingachewingstick)had

significantlymoreGR(29.4%)thanthose

usingatoothbrush

(22.2%).Subjectsusing

bothhadalmosttw

icetheincidenceofGR

(57.8%)(p5

0.004

)

Tezeletal.(2001)

Eng

lish

Unspecified

Toassessrelationship

betweengingivalrecession

andtoothbrushingfreq-

uency,technique,duration

andhandednessofsubject

110subjectswithgingival

reces

sion(2045years)

Observational/

cross-sectionalz

C

linicalexamination.

O

bservationoftooth

b

rushinghabits

GRincreasessignifi

cantlywithtoothbrushing

frequencyandduration.Forexamplesforleft-

handedsubjects:

MeanGR(mm) Mal

es

Females

o

1min.

1.4

1.2

4

3min.

2.6

2.8

(po0.05)

1/day

1.4

1.3

4

3/day

2.8

2.9

(po0.05)

Significantlygreate

rGRinthosewhouseda

horizontaltoothbrushingtechnique(means

2.7mm)compared

withthosewhouseda

verticaltechnique(mean1.6mm)(po0.05)

Ta

ble1.

(Con

td.)

Study

Language

Funding

Aim

Sa

mplecharacteristics

(agerange)

Hierarchal

assignmentleveln

Assessments

Datapresentation

withspecificreferenceto

toothbrushingfactors




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Carrenoetal.(2002)

Span

ish

Unspecified

Toassociatethepresence

ofplaqueandcalculus,and

toothbrushingbehaviour

withgingivalrecession

150p

atientsattending

unive

rsitymedical/dental

unit(1867years)

Observational/

cross-sectionalz

C

linicalexamination.Data

collectionoftoothbrushing

b

ehaviouratinterview

83.3%ofcohortde

monstratedGR.50.4%of

subjectsusedahard-bristledtoothbrushand

hadsignificantlym

oreteethwithGRthan

thosewhousedeith

ersoft(20.8%)ormedium

(28.8%)brushes(p

5

0.0001).Therewere

significantlymoreteethwithGRinasub-

groupusingahoriz

ontaltooth-brushing

techniquecomparedwiththoseusinga

circularorsweepin

gmovement(p5

0.0001)

Wilckensetal.(2003)

Eng

lish

Unspecified

Tocomparetheprevalence

ofgingivalrecessionin

first-andfinal-yeardental

students

80de

ntalstudents(401st

years

;405thyears)

Observational/

cross-sectionalz

C

linicalexamination.

Interview

IndependentpredictionsofGR:age

(p5

0.0003),tooth-brushingtechnique

(p5

0.0001)andfr

equencyofchanging

toothbrush(p5

0.0

03).Constructionofa

bivariatemodelstrategyimplicationtooth

brushingtechnique

asasignificant

contributingfactor

(p5

0.001)

Kozlowskaetal.(2005)

Eng

lish

Unspecified

Toinvestigatetheinfluence

oforalhygienepracticeson

gingivalrecession

455m

edicalstudents

(1832years)

Observational/

cross-sectionalz

T

oothbrushingandtooth

b

rushingparameters

recordedbyquestionnaire

IncidenceofGR29.4%.Factorssignificantly

associatedwithGR

:

Frequencyoftoo

thbrushing(po0.001)

Hardnessofbristles(po0.05)

Frequencyofchangingtoothbrush

(po0.0001)

Forceoftoothbrushing(po0.001)

Theseindependent

variableshadasignificant

effectonGRasthedependentvariable

(F5

33.556,

R2

5

0.041)

nLevelsassignedtoevidencebasedonsoun

dnessofdesign.

wExperimentalstudies:RCTsandCTswithoutrandomization.

zObservationalstudieswithoutcontrolgroups(cross-sectionalstudies,before-and-afterstudies,caseseries).

GR,gingivalrecession;RCT,randomizedclinicaltrial.

Ta

ble1.

(Con

td.)

Study

Language

Funding

Aim

Samplecharacteristics

(agerange)

Hierarchal

assignment

leveln

Assessments

Datapresentationw

ithspecificreferenceto

toothbrushingfactors




9/16

Wilckens et al. 2003, Kozlowska et al.2005).

The population under observation

was described in all studies (k

0.95,95% CI 0.920.99) but explicit inclu-sion/exclusion criteria were described inonly two studies (with one of thesereferring the reader to a previous pub-lication) (Khocht et al. 1993, Serinoet al. 1994) (k 0.86, 95% CI 0.820.99).Completeness to follow-up was not rele-vant in 14 studies (k 0.90, 95% CI 0.880.99). Baseline and follow-up data werereported in three studies (Benz et al.1987, Kallestal & Uhlin 1992, Serinoet al. 1994) and Kallestal & Uhlin(1992) were the only authors to report

full reasons for drop-outs. The statisticalaspects of 14 studies appeared to beappropriate although this element of thestudy was either unreported or unclear inthree studies (Sangnes & Gjermo 1976,Benz et al. 1987, Frentzen et al. 1989)(k 0.60, 95% CI 0.661.0). A practical, invivo assessment of tooth brushing factorsor variables was only described in twostudies (Benz et al. 1987, Goutoudi et al.1997) (k 0.99, 95% CI 0.990.99). Withrespect to the assessment and, or valida-tion of the measurement of gingivalrecession, five studies used a classifica-

tion system (Benz et al. 1987, Paloheimoet al. 1987, Frentzen et al. 1989, Goutoudiet al. 1997, Carreno et al. 2002), sixstudies relied on an observation of reces-sion being present (Sangnes & Gjermo1976, Murtomaa et al. 1987, Vehkalahtiet al. 1989, Khocht et al. 1993, Tsami-Pandi & Komboli-Kontovazeniti 1999,Arowojolu 2000), three studies reportedthe use of a periodontal probe in makingthe assessment (Kallestal & Uhlin 1992,Serino et al. 1994, Tezel et al. 2001) andthe method was unclear or unreported inthree studies (Checchi et al. 1999,

Wilckens et al. 2003, Kozlowska et al.2005) (k 0.58, 95% CI 0.621.00).Calibration and training of examiners

was not reported in the majority (12) ofstudies. Five studies reported that theclinical measurements had been madeby one examiner (Murtomaa et al. 1987,Paloheimo et al. 1987, Kallestal & Uhlin1992, Khocht et al. 1993, Goutoudi et al.1997). Goutoudi et al. reported 95.65%reproducibility for the single examinermeasuring within 1 mm for gingivalrecession. Arowojolu (2000) reportedthat calibration of examiners was under-taken 23 weeks before clinical observa-tions were made, but no data werepublished. Serino et al. (1994) reported

that three examiners had been trained andcalibrated but did not report on the meth-ods. Reproducibility testing for within1 mm of attachment level measurementsand probing depths were reported asbeing 100% and 97%, respectively.None of the observational studies fulfilledall eight of the pre-specified qualityassessment criteria.

Observations

The single RCT identified in the review

recruited 109 healthy subjects who wererandomized to one of two experimentalinterventions: twice-daily tooth brushingfor 2 min. using either a powered or amanual toothbrush (Dorfer et al. 2006).The inclusion criterion was for the subjectsto have at least one buccal site of visiblerecession. Over an 18-month follow-upperiod, the authors reported statisticallysignificant mean (SE) reductions in gingi-val recession from 1.58(0.65) to0.68(0.76) mm for the powered toothbrushgroup and from 1.28(0.43) to0.54(0.62)mm in the manual toothbrush

group. The authors concluded that thetoothbrushes significantly reduced reces-sions on buccal tooth surfaces over the

18-month period.A summary of the main outcomes madein each of the 17 observational studies ispresented in Table 1. Further, the studieshave been grouped according to obser-vations of association between toothbrushing factors and gingival recession(Table 2). Only the cohort study involvedan intervention in which subjects used acomputer-assisted toothbrush to recordtooth brushing parameters, namely time,frequency and force.

Of the 17 articles, only two concludedthat there appeared to be no association

between tooth brushing frequency andgingival recession (Murtomaa et al.1987, Kallestal & Uhlin 1992), andindeed Kallestal & Uhlin (1992)observed no association between anytooth brushing factors and gingivalrecession. This conclusion was basedon perceived low validity of subjectinterviews and observations made inthe clinic that may not be representativeof tooth brushing habits at home. Eightstudies reported an association betweentooth brushing frequency and recession(Sangnes & Gjermo 1976, Vehkalahti

et al. 1989, Khocht et al. 1993, Checchiet al. 1999, Tsami-Pandi & Komboli-Kontovazeniti 1999, Arowojolu 2000,Tezel et al. 2001, Kozlowska et al.2005). Vehkalahti et al. (1989) reporteda significant increased odds ratio of 2.1for the likelihood of developing gingivalrecession in those subjects who brushmore than once a day over less frequentbrushers. The duration of tooth brushingwas implicated in only one study inwhich both males and females whobrushed for43 min. had approximatelytwice the mean severity of gingival

Table 2. Studies grouped by observation of significant associations between tooth brushing factors and gingival recession

Tooth brushing frequency Tooth brushingtechnique

Bristle hardness Frequency ofchanging tooth

brush

Tooth brushingforce

Duration oftooth brushing

Vehkalahti et al. (1989) Paloheimo et al.(1987)

Khocht et al. (1993) Paloheimo et al.(1987)

Benz et al. (1987) Tezel et al. (2001)

Khocht et al. (1993) Checchi et al. (1999) Goutoudi et al.

(1997)

Wilckens et al.

(2003)

Kozlowska et al.

(2005)Checchi et al. (1999) Arowojolu (2000) Carreno et al. (2002) Kozlowska et al.

(2005)Tsami-Pandi & Komboli-Kontovazeniti (1999)

Tezel et al. (2001) Kozlowska et al.(2005)

Arowojolu (2000) Carreno et al. (2002)Tezel et al. (2001) Wilckens et al. (2003)Kozlowska et al. (2005)




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recession as did those subjects whobrushed for o1 min. (Tezel et al.2001). Tooth brushing force was impli-cated in two studies (Benz et al. 1987,Kozlowska et al. 2005), although only thestudy of Benz et al. (1987) was designedscientifically to analyse tooth brushing

force using hardware specifically for thepurpose. Kozlowska et al. (2005) con-cluded that force was significantly asso-ciated with gingival recession although itappears that force was categorized asheavy, medium and weakusing only a questionnaire survey. Anassociation with higher standards of oralhygiene was implicated in three studies(Sangnes & Gjermo 1976, Paloheimo etal. 1987, Kozlowska et al. 2005)although this outcome can only beregarded as a surrogate measure of toothbrushing parameters. Other factors sug-

gested as being causal in the develop-ment of gingival recession werehardness of the brush or toothbrushbristles (Khocht et al. 1993, Goutoudiet al. 1997, Carreno et al. 2002,Kozlowska et al. 2005) and the fre-quency of changing the toothbrush(Paloheimo et al. 1987, Wilckens et al.2003, Kozlowska et al. 2005).

Only the study of Serino et al. (1994)was generally inconclusive in that toothbrushing was implicated indirectly as anaetiological factor for gingival reces-sion. Buccal attachment loss was identi-

fied in younger subjects with both a highstandard of oral hygiene and no historyof periodontitis and toothbrush traumawas identified only as a possible con-tributory factor.

Discussion

The search uncovered predominantlyobservational (cross-sectional) studies,which, by design, are unable to determinecausation between the risk factor and out-come. The evidence gathered to answer

the focused question was evaluated only asbeing of low or modest quality and unfor-tunately, the limited information availablefrom the single randomized-controlled trialmeant that a confident appraisal of qualitywas not possible.

Evidence from this one randomized-controlled trial was identified andalthough this was published initially asan abstract, further information wasforthcoming from the authors throughpersonal communication and discussion.The aim of the study was to observe thechange in severity of buccal gingival

recession, originally, over a 12-monthperiod, in otherwise healthy subjectsusing either a powered (D17U, Oral BLaboratories) or a manual toothbrush(an ADA reference toothbrush). Thestudy was supported and funded byOral B Laboratories. The 18-month fol-

low-up data were presented in theabstract and revealed that both tooth-brushes reduced significantly the extentof buccal attachment loss and that thiseffect was apparent even at sites ofrelatively pronounced gingival reces-sion. Unfortunately, the authors did notrespond to later questions (by e-mail)regarding reasons for drop-outs (thusevaluating attrition bias) nor did theygive reasons or present a hypothesis asto why the mean gingival recessiondecreased in each group over the18 months of the study. These observa-

tions were in conflict with the generalevidence and conclusions that could bedrawn from the 17 observational stu-dies; that is, that one or more of a rangeof factors associated with tooth brushingis likely to be causative (rather thanreparative) for non-inflammatory lesionsof gingival recession. One confoundingelement that may compromise a rando-mized-controlled trial, however, is theHawthorne effect, which may contributeto performance bias (which may alsohave been influenced by the single-blindnature of the design). Thus, for example,

with the knowledge that they are parti-cipating in a clinical trial, the subjectsmay have made a significant effort toimprove their standard of plaque con-trol, irrespective of the treatment groupto which they had been randomized.Similarly, in this particular trial, theoral hygiene advice may have correcteda previously damaging tooth brushingtechnique. This, together with the reso-lution of even a minimal degree ofgingival inflammation, may haveencouraged an element of creeping buc-cal attachment that is more usually seen

after mucogingival surgery, and cer-tainly the magnitude of the meanchanges observed (approximately0.70.9 mm) would be consistent withsuch an effect (Bernimoulin et al. 1975,Kennedy et al. 1985). This, however, ishypothesis, and it is equally possiblethat there may have been an elementof measurement bias in a study in whichthere was no control group that did notreceive an intervention. On a moregeneral point, however, evidencefrom systematic reviews has identifiedconflicting results from observational

studies and randomized-controlledtrials (Kunz & Oxman 1998), and it hasbeen suggested that selection bias or selec-tion by prognosis may compromise thevalue of observational studies that aredesigned to evaluate therapy or treatment(Vandenbroucke 2004). Further, it may

be argued that tooth brushing is a lifestylebehaviour rather than a treatment andagain, because of selection bias or otherconfounding factors and selections ofusual care, will be notoriously difficultto study with observational studies.

The evidence from the 17 observa-tional studies was of poor quality butnevertheless was relatively consistent inimplicating one or more of a range oftooth brushing factors that are likely tobe aetiological for gingival recession:duration and frequency of tooth brush-ing, tooth brushing force, hardness of

the bristles, tooth brushing techniqueand the frequency of changing a tooth-brush. None of these studies (by defini-tion) involved introducing, or evenmodifying an intervention that wouldimpact on tooth brushing behaviourand therefore gingival recession.Further, the proposed link between thestandard of oral hygiene and gingivalrecession (Sangnes & Gjermo 1976,Paloheimo et al. 1987) must, however,be considered with some caution asplaque control is essentially a surrogatemeasure for tooth brushing and specific

tooth brushing parameters were notobserved directly.There were three studies in the review

that were of a longitudinal nature(Paloheimo et al. 1987, Kallestal &Uhlin 1992, Serino et al. 1994) but thesewere classified as being observationalstudies as they involved recordingsbeing made over different time pointsrather than including an interventionwith follow-up, as would be the casein a randomized-controlled clinical trial.

A further observation that should beconsidered when drawing conclusions

from these data is the characteristics ofthe subjects who were recruited. Themajority (10) of the studies in this reviewrecruited patients or regular dental atten-ders whose ages ranged between 16 and82 years. Gingival recession is reported asbeing positively associated with increasingage (Serino et al. 1994, Tsami-Pandi &Komboli-Kontovazeniti 1999, Arowojolu2000, Wilckens et al. 2003), suggestingthat future longitudinal studies addressingthe role of tooth brushing in gingivalrecession will need to consider age as apotential confounding factor.




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We acknowledge that the quality ofthe database that was formulated fromthe 17 observational/cross-sectionalstudies compromises significantly theconfidence with which we are able tomake conclusions and recommenda-tions. These observational studies were

not of an association between an out-come (gingival recession) and changesin one characteristic of the intervention(tooth brushing) but rather observationsof individuals and groups where little orno attempt had been made to standardizepotential confounding factors such asage, tissue biotype and previous ortho-dontic treatment.

There is, however, a view that studiesof risk factors (for whatever condition)should not be randomized in design,primarily because they relate to inherenthuman characteristics and because

exposing participants to unnecessaryrisk is unethical (Lipsett & Campleman1999, Stroup et al. 2000). The argumentof an issue embedded in clinical andresearch ethics is not within the scopeof this review although even high-qualityobservational studies with clear state-ments of hypothesis, standardization ofdesign, heterogeneity of populations,quality control, description of outcomesand statistics may enable a more robustapproach that allows meta-analysis of theoutcome data and then greater confidencecan be afforded to the conclusions.

This is the first published systematicreview that has explored the associationbetween tooth brushing and gingivalrecession and we recognize that thereare limitations to the project. Theabsence of randomized-controlled clin-ical trials does not necessarily compro-mise the quality of data available,although making firm conclusions aboutthe effect of an intervention (toothbrushing) is more difficult when:

the variables associated with theintervention are not controlled;

other confounding aetiological fac-tors are uncontrolled;

there are no control groups in thetrial and with particular reference togingival recession; and

there are too few long-term studies.

The potential for performance bias inthe single RCT has already been dis-cussed and it is further recognized thatobservational studies (17/18 in thisreview) are vulnerable to selectionbias, inherent when adjustments cannot

be made for unmeasured confoundingvariables (Khan et al. 2001).

Having considered carefully the evi-dence from this review, the limited num-ber of included studies and the qualityof the data permit us to make only threeconclusions within the limit of the protocol

and the focused question. We have also,however, evaluated the conclusions madeby the authors of the included papers andhave noted the identification of significantgaps in this area of clinical research.

Conclusions

Based on the studies included in thisreview, we conclude that:

The data to support or refute theassociation between tooth brushingand gingival recession areinconclusive.

Tooth brushing factors that havebeen associated with the develop-ment and progression of gingivalrecession are duration and frequencyof brushing, technique, brushingforce, frequency of changing tooth-brushes and hardness of the bristles.

There is limited evidence from onerandomized, controlled, clinical trialto suggest that tooth brushing witheither a powered or a manual tooth-brush and with standardized instruc-tions in tooth brushing technique mayreduce the severity of gingival reces-sion of non-inflammatory lesions.

Recommendation for research

The review failed to identify a ran-domized, controlled, clinical trialthat was designed specifically toevaluate the effect of one or moretooth brushing factors in the devel-opment and progression of gingivalrecession while controlling for con-

founding factors. Such a study, or anobservational study of high quality,will almost certainly contribute bet-ter evidence to substantiate theobservation that tooth brushing fac-tors are contributory, rather than justassociated with non-inflammatorygingival recession.

A prospective randomized-con-trolled clinical trial would need toevaluate a factor or factors asso-ciated with tooth brushing (forexample force) while controllingfor the remaining factors such as

time, method, type of brush, dura-tion and bristle hardness. More thanone variable could be assessed byusing multiple parallel groups. Poten-tial confounding factors such ascrowding and a history of orthodontictreatment need to be controlled. Target

sites of incipient gingival recessioncould be monitored over a period of12 years and specific exit criterianeed to be adopted to maintain anethical approach to the concept ofexposing patients to increased risk ofdeterioration. Compliance with factorssuch as time of brushing and forcewould be a challenge but not insur-mountable as current technology, par-ticularly for powered toothbrushes,allows for standardization of such fac-tors as well as individual data monitor-ing using data logger technology.

Recommendations for clinical practice

The duration and frequency of toothbrushing have been implicated mostoften as being causal for gingivalrecession but the available evidencedoes not confirm or refute that theseare indeed the most important aetio-logical factors. While any level ofuncertainty remains, it is importantto assess tooth brushing duration and

frequency on an individual patientbasis, and a more complete profileof tooth brushing should include asassessment of tooth brushing techni-que, bristle hardness and frequency ofchanging the toothbrush.

There is limited evidence to suggestthat effective tooth brushing usingeither a conventional manual or apowered toothbrush may help toresolve buccal attachment loss. Untilthe evidence for these findings isreproduced, it is recommended thatclinicians continue to reassure patients

with established gingival recessionthat these lesions may be stabilizedbut not necessarily resolved by mod-ifying tooth brushing behaviour.

Acknowledgements

The authors would like to thank GwenForster and Lyndsey Dvaz for theirassistance in preparing the manuscriptand Mariano Sanz for his invaluablehelp in translating and extracting datafrom Spanish articles.




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Address:Prof. Peter Heasman

School of Dental Sciences

University of Newcastle upon Tyne

Framlington Place

Newcastle upon Tyne

NE2 4BW

UK

E-mail: [email protected]

Clinical RelevanceScientific rationale for the study:Anecdotal evidence, case reportsand reviews suggest an associationbetween tooth brushing and thedevelopment of gingival recession.This suggested that there was aneed for a review to evaluate thequality of evidence more carefully.

Principal findings: The majority ofthe evidence from cross-sectionalstudies suggests that tooth brushingand tooth brushing habits are asso-ciated with the development of gin-gival recession although it is unclearwhich factors are causative. Evi-dence from one RCT indicates thattooth brushing with manual and pow-

ered brushes may, under certain cir-cumstances, reduce lesions of buccalgingival recession.Practical implications: Cliniciansmust, however, remain vigilant tothe possibility that tooth brushingmay contribute to gingival recession.




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Table A1. Table depicting the selection strategy comprising a free text electronic search of sequences and giving the number of articles retrieved byeach search term or combination of terms

Database Search number Search term Results

Medline 1 Tooth brushing 41591966July 2005 2 Dental devices/home care 11543 Oral hygiene 71544 Toothbrush$.mp 47415 Combined 1 or 2 or 3 or 4 11,3086 Toothbrush$ [adj3] pressure 137 Toothbrush$ [adj3] force 298 Toothbrush$ [adj3] techniques 549 Toothbrush$ [adj3] toothpaste 113

10 Toothbrush$ [adj3] frequency 16311 Toothbrush$ [adj3] design$ 11512 Toothbrush$ [adj3] texture$ 513 Toothbrush$ [adj3] bristle$ 18114 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 61415 5 or 14 11,30816 Gingival recession 1396

17 Gingival [adj3] recession 171518 Gingival [adj3] abrasion 3519 Gingival [adj3] trauma 3120 Gingival [adj3] lesions 34221 17 or 18 or 19 or 20 208322 16 or 21 208323 15 and 22 223

Embase Identical run 65Web of Science Identical run 52Current contents Identical run 34Cochrane reviews Identical run 45Google scholar Advance

searchTooth brushing with gingival recession and/or

gingival abrasion/gingival trauma/gingival lesions294

Hand search 118Total 831

Appendix A


r 2007 Th A th J l il ti r 2007 Bl k ll M k d

brushing teeth and recession

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