by Lynne H. Slim RDH, BSDH, MSDH
OK, I’ll admit it: I’m not always good at dressing for success. I enjoy following designer trends in women’s apparel, but when it comes to dressing myself, I need help. I recently entered a design boutique called “Sassy Ladies,” and, frustrated, I searched the racks for that new look.
Sensing my frustration, a store employee whisked me around the entire store and helped me figure out what flattered my not-so-perfect figure. I left the boutique thoroughly satisfied and couldn’t wait to get home to model my clothes for my four miniature dachshunds. They know what looks good on me!
As I review various topics for the Periodontal Therapy column, I offer assistance to those dental hygienists who are not comfortable searching the literature. It’s incredibly time-consuming and rather tedious to wade through the online muck. My nerdy nature finds it fascinating and challenging too. When writing about a certain topic, I search using multiple online databases. In private practice, I appraise and incorporate evidence into clinical decision-making. Searching for evidence (like growing older) isn’t for sissies!
The rumor mill in dentistry is always alive and well. I’ve heard dental hygienists and dentists say that power toothbrushes do and don’t cause gingival recession. In an attempt to put this particular rumor to rest, at least temporarily, let’s look at the literature on this topic.
In searching the literature, I look for higher levels of evidence than animal/ laboratory studies, case reports/case-controlled studies, or cohort studies. The highest levels of evidence include randomized controlled trials, meta-analyses, and systematic reviews.
The etiology of gingival recession is multifactorial and is common in patients with good oral hygiene.1 Often, it involves anatomical and iatrogenic factors in addition to pathology such as gingivitis and periodontitis.1 Gingival recession associated with chronic periodontitis tends to be generalized and presents with significant destruction of the interdental tissues.2
Other contributing factors may include toothbrushing technique, toothbrush trauma, tooth malalignment, alveolar bone thinning, cervical class V lesions, and orthodontic treatment.1,2 Increasing age and even good oral hygiene have been associated with gingival recession. Toothbrushing alone is associated with a number of confounding variables such as pressure, time, bristle type, and dentifrice used.1
I was very pleased overall with my search (in spite of the eye strain) and here’s what I found: a 2007 systematic review and a 2009 longitudinal randomized clinical trial.
When systematic reviews are carried out, a protocol is developed and explains how the authors decided to conduct the review. In this instance, 29 papers on this topic were obtained and read and 18 articles were included in the review. Out of these 18 reports, 17 were observational studies of poor quality but consistent in implicating one or more of a range of etiological factors for gingival recession such as duration and frequency of toothbrushing, hardness of bristles, technique, brushing force, and frequency of changing a toothbrush.1
The authors concluded that the data to refute the association between toothbrushing and gingival recession is inconclusive. But they also mentioned that there was limited evidence from one randomized, controlled, clinical trial to suggest that toothbrushing with either a manual or powered toothbrush with standardized toothbrushing technique may reduce the severity of gingival recession in noninflammatory lesions.1
Let’s move on to 2009 and the longitudinal (12 month) study by McCracken et al.2 The purpose of this longitudinal, single blind, randomized study was to evaluate the effects of manual and powered toothbrushes on early (incipient) lesions of gingival recession. The test group was randomized to use a Philips Sonicare Elite powered toothbrush, and the control group was randomized to use an Oral-B 35 manual toothbrush. Both groups brushed with Colgate Total toothpaste. Subjects using the powered toothbrush received manufacturer’s instructions for use, including brushing twice daily for two minutes. Those subjects using the manual toothbrush were instructed in crevicular (sulcular) toothbrushing technique twice daily for two minutes.
The research data suggest that for subjects with incipient lesions of gingival recession, changing from a manual to a Philips Sonicare Elite powered toothbrush did not increase the risk of further recession over a 12-month period. The authors also indicated that there are many other aspects of research that should be explored such as using powered toothbrushes of different designs, recruiting subjects with varying degrees of recession, and extending the period of observation beyond 12 months. Additionally, there were no differences between the groups in the width of clinical keratinized gingival attachment level, probing depth, and bleeding on probing.
Based on the above evidence, can we now feel more confident in telling our patients that powered toothbrushes do not contribute to gingival recession? What I now feel comfortable saying to my patients is this: There is some limited evidence that powered toothbrushes do not contribute to gingival recession, especially if you already have some. I’d also say that gingival recession is multifactorial and list some of the contributing factors including the possibility that a patient did not have adequate technique instruction with a powered toothbrush. I will remind my patients who use powered and manual toothbrushes that I will track their recession on a routine basis during their recare exams. If we spend time teaching patients how to prevent gingival recession based on known risk factors that can be controlled, many patients should benefit from this evidence-based advice.
Being armed with the appropriate information is like being dressed for success.
- 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: 1046–1061.
- McCracken GI, Heasman L, Stacey F, Swan M, Steen N, de Jager M, Heasman PA. The impact of powered and manual toothbrushing on incipient gingival recession. J Clin Periodontol 2009; 36: 950–957.
Lynne Slim, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.