Is toothbrushing associated with gingival recession?

Regular toothbrushing with fluoride toothpaste has clear benefits for oral health. However, the possibility that incorrect toothbrushing can be a contributory factor for adverse effects such as gingival recession and non-carious cervical lesions (NCCLs) has been noted since the 1950s. The aim of this review was to assess whether traumatic toothbrushing contributes to increased prevalence of non-inflammatory gingival recession or increased prevalence of NCCLs.

Methods

Searches were conducted in Medline, Embase, Web of Knowledge/ Science (including current contents connect) and the Cochrane Oral Health Group Trials Register. In addition hand searching of the Journal of Clinical Periodontology, the Journal of Periodontology, the Journal of Periodontal Research and IADR abstracts was carried out. Studies involving clinical examinations to assess extent of gingival recession and or NCCLs and factors that may ne associated with their development were considered. Two reviewers independently abstracted data and methodological quality assessment was undertaken.

Results

19 studies (5 RCTs, 1 case control, 13 cross-sectional) involving a total of 4227 patients were included.
2 RCTS (159 patients) contributed to a meta-analysis that showed that subjects who used manual toothbrushes had greater gingival recession after 12 months when compared to those using powered toothbrushes (mean difference 0.20 mm; 95%CI 0.05– 0.34 mm)
13 cross-sectional studies identified; toothbrushing frequency; a horizontal or scrub toothbrushing method; bristle hardness; toothbrushing duration and the frequency of changing a toothbrush as the most frequent toothbrushing factors associated with gingival recession.
The principal toothbrushing factors associated with NCCLs were toothbrushing method and frequency.

Conclusions

The authors concluded:

The data to support or refute the association between toothbrushing and gingival recession and NCCLs are of variable quality.

Comments

This review has adopted a good methodological approach and this research group had previously reviewed the evidence for toothbrushing as a causative factor in the development and progression of non-inflammatory gingival recession (Rajapakse et al. 2007). At that time they concluded that there were insufficient, good quality data to support or refute the association. This new review included the potential role of toothbrushing in NCCLs and while they were able to include some new RCTs the overall quality of the available studies is variable. The one meta-analysis they were able to conduct only included 2 studies and did show a small benefit in favour of powered toothbrushes, but, as the authors note themselves a mean difference of 0.2mm is unlikely to be of clinical significance and could change markedly if larger high quality trials were conducted to assess this issue.