Gingival recession in school kids aged 10-15 years in Udaipur, India

Abstract

The study aimed to determine the incidence of gingival recession in the mandibular central incisor region among school children aged 10-15 years in Udaipur (India).
A sample of 1800 males and female kids were examined in a mobile dental unit. World Health Organisation (WHO) rules and standards were followed.
Gingival recession, when compared, with respect to age, mean clinical crown length, anterior crowding and frenal involvement was significant (p less than 0.00) with respect to affected teeth.

Full text

16 Journal of Indian Society of Periodontology - Vol 13, Issue 1, Jan-Apr 2009
Department of
Preventive and
Community Dentistry,
Darshan Dental College
and Hospital Udaipur,
Rajasthan – 313 001,
India
Address for
correspondence:
Dr. Anmol Mathur,
Department of Preventive
and Community Dentistry,
Darshan Dental College
and Hospital Udaipur
Rajasthan – 313 001,
India.
E-mail: dranmolmathur@
gmail.com
Submission: 30-12-08
Accepted: 11-04-09
DOI: 10.4103/0972-
124X.51889
Gingival recession in school kids aged
10-15 years in Udaipur, India
Anmol Mathur, Manish Jain, Koushal Jain, Mahima Samar,
Balasubramanya Goutham, Prabu Durai Swamy, Suhas Kulkarni
Abstract:
Aim: The study aimed to determine the incidence of gingival recession in the mandibular central incisor region
among school children aged 10-15 years in Udaipur (India). Materials and Methods: A sample of 1800 males
and female kids were examined in a mobile dental unit. World Health Organisation (WHO) rules and standards
were followed. Result: Gingival recession, when compared, with respect to age, mean clinical crown length,
anterior crowding and frenal involvement was signifi cant (p less than 0.00) with respect to affected teeth.
Key words:
Attached gingiva, children, epidemiology, gingival recession, risk factors
Original Article
INTRODUCTION
Localized gingival recession occasionally
presents a problem in children and there
is some confusion regarding the etiology and
pathogenesis of such defects. Sognnaes RF[1]
found a signiÞ cant relationship between gingival
recession and various factors like faulty tooth
brushing technique (gingival abrasion), wrong
positioning of tooth, friction from soft tissue
(gingival ablation), gingival inß ammation and
high frenum attachment. Trauma from occlusion
has also been suggested, but its mechanism of
action has never been demonstrated. Orthodontic
tooth movement in a labial direction has been
shown in monkeys to result in loss of marginal
bone and connective tissue attachment, as well
as in gingival recession.[2]
Baker and Seymour[3] have also suggested that
plaque induced inß ammation is responsible
for gingival recession. Stoner and Masdyasna[4]
found no association between calculus and
gingival recession but found that it was closely
related to the width of keratinized gingiva.
Jukka et al.[5] found the prevalence of gingival
recession more common among the girls in
the earlier age group and equally among both
with age.
Woofter[6] assumes that recession may be a
physiological process related to aging. There
is some doubt regarding diagnosis of gingival
recession[7] with certainty, before 12 years of
age, and it has been suggested that apparent
recession in the younger children was due to
more delay in the maturation of the gingivae
of adjacent paired tooth than to true recession
of the gingivae of the apparently affected
tooth. However, convincing evidence for a
physiological shift[8] of the gingival attachment
has never been presented.
Fermin A. Carranza[9] concluded that the
gradual apical shift is most probably the result
of the cumulative effect of minor pathologic
involvement and/or repeated minor direct
trauma to the gingiva.
Clinical signifi cance
Several aspects of gingival recession make it
clinically significant. Exposed root surfaces
are susceptible to caries. Wearing away of the
cementum exposed by recession leaves an
underlying dentinal surface which is extremely
sensitive, particularly to the touch. Hyperemia
of the pulp and associated symptoms may
also result from exposure of the root surface.[10]
Interproximal recession creates space in which
plaque, food and bacteria can accumulate.
MATERIALS AND METHODS
The incidence of gingival recession in the
mandibular central incisor region was examined
using the stratiÞ ed random sampling technique.
A sample of 1800 males and females were
selected from Þ ve zones in Udaipur, for a fair
sample selection. Schools from each zone: North,
South, East, West and Center were randomly
selected, equal number of boys and girls were
chosen from each school. At the onset, informed
consent for data collection was obtained from
the Principals of the school and parents of the
individuals who participated in the study. No
such study has taken place in this part of the
country till date. The period for data collection
was from November 6, 2007 to March 29, 2008.
[Downloaded free from http://www.jisponline.com on Friday, August 30, 2019, IP: 223.228.182.178]

Journal of Indian Society of Periodontology - Vol 13, Issue 1, Jan-Apr 2009 17
A dental examination was carried out in a mobile dental
unit. “Interchangeable plane mouth mirrors and Williams
periodontal probe no.0”was used to measure the clinical
crown length of the affected and adjacent teeth. The following
information was recorded:
Clinical crown length was measured for affected and adjacent
teeth, using Williams’s periodontal probe. Measurements
were made at the labial midline from the gingival crest to the
incisal surface. Gingival inß ammation was recorded on the
labial aspect of mandibular incisor using the gingival index
of Loe and Sillness.[11]
For anterior crowding, the position of each mandibular central
incisor was classiÞ ed according its relation to the regular curve
of the arch as described by Stoner and Mazdyasma[12] where
0=correctly positioned or instanding, 1=when the tooth was
labially placed or absent.
Frenal involvement in the affected and adjacent teeth was
recorded according to the classiÞ cation of Powell and Mc
Entery.[13] Accodingly, 0= No Frenal involvement, 1= Frenal
insertion close to the gingival margin but no retraction of
gingiva, 2= Narrow Frenal insertion with retraction of gingiva,
3= Broad Frenal insertion with retction of gingiva.
In data collection, methods and standards recommended by
WHO, 1997, have been followed. The response rate to this
study was 82%. Other relevant information was also recorded.
The Ethical clearance for this study was taken from the ethical
committee of "Darshan Dental College".
Exclusion criteria: Of the 1800 students, 324 had gingival
recession in the mandibular central incisor region. The
remaining 1236 students were excluded as they did not have
gingival recession; 172 were absent or not co-operating, 68 did
not have mandibular central incisors.
The agreement (Kappa Statistics) for diagnosis of gingival
recession and there supporting criterias was determined
(Field Team v/s Expert) and inter examiner variability by a
group of four people is 91.2% 2 days prior to the examination.
Statistical analysis was carried out using Chi-squared test for
the signiÞ cance of apparent association between Recession and
Recorded variables.
RESULTS
Gingival recession was observed in 324 (18%) of 1800 male
and female pupils.
Table 1 and Graph 1 shows the mean and standard deviation of
clinical crown length of the affected and adjacent lower central
incisor teeth by age groups. There was a signiÞ cant difference
in the clinical crown length of teeth with gingival recession
between the various age groups (P<.000).
Table 2 and Graph 2 shows that gingival inß ammation was less
frequent on teeth with gingival recession than for the adjacent
teeth without recession (x²=1.133(a), df 3, p=.769).
Data collected for all pupils were statistically analyzed and
revealed signiÞ cant differences in gingival recession by age
(x²=89.665, df=15, P=.000) [Table 3 and Graph 3].
Gingival score of 1 was most frequent in relation to the adjacent
teeth and formed 57.4% of the total no. of adjacent teeth. While
the gingival score of 3 is equal in both affected and adjacent
teeth constituting 2.5% of the total of there respective teeth.
There was a signiÞ cant correlation between the teeth in the
dental arch and the occurrence of gingival recession (x²=21.920,
Table 1: Mean and standard deviation of clinical crown
length, affected and adjacent mandibular central incisor
teeth by age group
Age Students Affected Adjacent
X`± SD* X ± SD
10 38 8.2 9 ±`0.89 8.18`± 1.09
11 34 8.71`± 0.84 8.06`± 1.10
12 48 8.81 ±`0.97 8.25`± 1.02
13 60 8.50 ±`1.13 8.18`± 1.13
14 70 8.71 ± 0.97 8.66`± 1.01
15 74 8.69 ± 1.02 8.49`± 0.86
X± SD = Mean standard deviation; t = 3.522, P = 0.000 (by ‘t’ test)
Table 2: Association of gingival infl ammation, anterior
crowding and frenal involvement with affected and
adjacent tooth
Variable score Affected tooth Adjacent tooth Chi-square
n % n %
Gingival 0 88 27.2 84 25.9 C.S=1.133
Infl amm 1 174 53.7 186 57.4 DF=3
2 54 16.7 46 14.2 P=0.769
3 8 2.5 8 2.5 -
Anterior C.S=21.920
Crowdin 0 282 87 234 72.2 DF=1
1 42 13 90 27.8 P=0.000
Frenal 0 244 75.3 278 85.8 C.S=18.46
INVOL. 1 68 21 46 14.2 DF=2
2 12 3.7 0 0 P=0.000
Mathur, et al.: Gingival recession in Indian school children
Table 3: Distribution of gingival infl ammation, anterior crowding and frenal involvement by age
Age Infl ammation score Anterior crowding score Frenal involvement score
0 1 2,3 0 1 0 1 2,3
N % N % N % N % N % N % N % N %
10 30 17.44 36 10 10 8.62 64 12.40 12 9.09 68 13.02 8 7.01 0 0
11 24 13.95 40 11.11 4 3.44 48 9.30 20 15.15 64 12.26 4 3.50 0 0
12 14 8.13 62 17.22 20 17.24 80 15.50 16 12.12 76 14.55 20 17.54 0 0
13 28 16.27 74 20.55 18 15.51 90 17.44 30 22.72 102 19.54 16 14.03 2 16.66
14 32 18.60 62 17.22 46 39.65 112 21.70 28 21.21 88 16.85 48 42.10 4 33.33
15 44 25.58 86 23.88 18 15.51 122 23.64 26 19.69 124 23.75 18 15.78 6 50
Chi-square X2=89.665, df=10, P=0.000 X2=7.536, df=5, P=0.184 X2=51.286, df=10, P=0.000
[Downloaded free from http://www.jisponline.com on Friday, August 30, 2019, IP: 223.228.182.178]

18 Journal of Indian Society of Periodontology - Vol 13, Issue 1, Jan-Apr 2009
df=1, P=.000). No signiÞ cant difference in tooth position of
teeth with gingival recession by age was observed (x²=7.536,
df=5, P=.184)
A signiÞ cant association between frenal involvement and
gingival recession was found (x²=18.460(a), df=2, P=.000). The
majority of the affected and adjacent teeth (80.6%) were not
affected by frenal insertion, however narrow frenal insertion
was not found in relation to the adjacent teeth. Broad frenal
insertion was completely absent during the study.
There was also a signiÞ cant changes in frenal involvement
on teeth with gingival recession by age (x²=51.286(a), df=10,
P=.000).
Other relevant information
Calculus deposits were not related to the occurrence of gingival
recession and were present in 68 children. Recent Apthous
Ulceration was noted in 23 cases. Thin, almost transparent
tissue was observed over the unaffected adjacent teeth in a
number of subjects and is presumably associated with active
soft tissue remodeling. Several students seemed concerned
to prevent the gingival recession. Among them, 52 students
have gone through the reparative treatment and proper
plaque control programme. This study shows that rural school
students are more prone to recession compared to students in
urban areas. It was also seen that more number of boys than
girls had recession in each respective age groups.
DISCUSSION
The results of this study show that the higher percentage
of teeth with gingival recession is frequently associated
with clinical crown length, arch relationship and frenum
involvement while gingival inß ammation is less signiÞ cant. It
appears from this study that gingival recession of mandibular
central incisor at age 10-15 years is less affected by gingival
inß ammation (p greater than 0.76) but with the increase in age
gingival inß ammation get signiÞ cant (p less than 0.00). We
can prove our result with the help of different study models
about, effects of aging on progression of periodontal disease. A
comparison of developing gingivitis between young and older
individuals demonstrated a greater inß ammatory response in
older subjects.[14-17] This effect must be because older individuals
are more prone to poor oral hygiene habits like tobacco chewing
and cigarette smoking.
Our observation is in partial accordance with the results
presented by Sognnaes RF[1] as he found a significant
relationship between gingival recession and various factors like
faulty tooth brushing technique, tooth malposition, gingival
ablation and high frenal attachment which is in accordance to
our results but it also included gingival inß ammation as a major
criteria for gingival recession which is in partial acceptance
with this study.
According to our study, gingival recession of mandibular
central incisor can manifest itself as early as 10 years of age
which is in accordance with Powell and Mcenetry[13] and ParÞ tt
Mathur, et al.: Gingival recession in Indian school children
Graph 1:
Showing mean difference of crown length between affected and adjacent
teeth of age group ranging 10-15 years
Graph 2: Showing mean difference of gingival infl ammation between affected and
adjacent teeth of age group ranging from 10-15 years
Graph 3: Showing mean difference of arch relationship between affected and
adjacent teeth of age group ranging from 10-15 years
[Downloaded free from http://www.jisponline.com on Friday, August 30, 2019, IP: 223.228.182.178]

Journal of Indian Society of Periodontology - Vol 13, Issue 1, Jan-Apr 2009 19
and Major.[18] when tested in the similar age groups with this
study.
Our observation is in agreement with the results presented
by Volchansky and Jones[7] which demonstrated that gingival
height did not stabilize in the central incisor region before
the age of 12 years. In our study we mentioned that gingival
height did not stabilize i.e leading to recession in earlier age
group (10-15 years).
HOLLIST[19] reported that children usually started to use the
chewing stick (Miswak) as a traditional habit between the
age of seven and 10 year and he also reported that unsuitably
varying length of miswak will easily traumatize the periodontia
leading to recession in earlier age group in accordance with
us. We noticed recession of quite dramatic proportions even
in the six year age group well before the eruption of lateral
incisors, suggesting that even where crowding might become
complicating factor at a later date, the disuse destruction was
already established prior to the manifestation of crowding.
A study of Salwa and Mohammad Farouk[20] recorded a
prevalence of gingival recession in the mandibular central
incisor region of 9.88% in a group of 1336 children aged
10-15 years. As per this study the prevalence rate of gingival
recession increases to 18% in a group of 1800 children having
age 10-15 years, it means the trend of gingival recession has
been increased in the same age group.
In this study tooth malposition is one of the major criteria for
gingival recession. Similar type of study was done by Anna
Andlin Sobocki.[21] He examined 38 children aged 7-12 years
with a gap of two years to determine whether facial/lingual
tooth position changes were related to alteration of the width of
attached and keratinized gingival and the clinical crown height.
The result showed that signiÞ cant alteration in the width
of attached and keratinized gingiva took place when teeth
changed position in labial or lingual direction. The changes in
gingival widths could, to some extent be coupled to changes
in clinical crown height. In teeth moving lingually gingival
width increased and clinical crown height decreased. In teeth
moving facially, the gingival width decreased, and the facial
gingival sometimes receded. However, in our study, anterior
crowding is more signiÞ cant in relation to adjacent teeth, not
having gingival recession.
Clinical crown height is an objective measure of the position
of gingival margin which could be used in determining
the “normal position” of the gingival margin according to
Volchansky and Cleaton Jones,[7] the aim of this study was to do
a systematic review of published clinical crown heights in the
human permanent dentition to compare the measurements and
to see if the clear trend with age exists. There is a statistically
signiÞ cant increase in clinical crown height of central and
lateral incisors with age that slows down as age increases.
Similarly, in our study signiÞ cant increase in clinical crown
height of central and lateral incisors with age is seen as the
age increases, age is in signiÞ cant association with gingival
recession (P=0.00).
This study favours the results presented by Elifuraha et al.[22]
that the risk factors for gingival recession were identiÞ ed as
Mathur, et al.: Gingival recession in Indian school children
male sex, lower educational status, presence of plaque and
gingival inß ammation, but did not match with the results of
Cahen et al.,[23] as per whose result sex has a signiÞ cant inß uence
on caries indices but not on plaque, calculus or gingival indices.
The finding of Sobocki et al.[21] that gingival recession in
mandibular incisors in young children often improves over
time suggests that preventive or reparative treatment in
this part of the developing dentition may not be necessary.
Decisions regarding such treatment should be postponed until
any spontaneous improvement has taken place.
According to the Raymer et al.,[24] the self assessment approaches
can be effective in improving the long term periodontal health
status of teenagers. As with much of dental epidemiology
the value of cross sectional surveys in the study of gingival
recession is limited. Longitudnal studies are required so that
effects of resolution of gingival inß ammation and of relief of
crowding may be followed under conditions of a controlled
clinical trial. Only in this way the complex instructions
inß uencing gingival recession may be unraveled.
ACKNOWLEDGMENTS
We thank Dr. H.R. Dayakara, Principal and H.O.D Prosthodontics,
Dr. K.T. Chandreshekar, Vice Principal H.O.D Periodontology and
Dr. B.R. Ranwa, Statistician.
REFERENCES
1. Sognnaes RF. Periodontal significance of intraoral friction
ablation. J West Soc Periodontal Abstr 1977;25:112-21.
2. Steiner GG, Person JK, Ainamo J. Changes of the marginal
periodontium as a result of labial tooth movement in monkeys.
J Periodontal 1981;52:314-20.
3. Baker DL, Seymour GJ. The possible pathogenesis of gingival
recession. J Clin Periodontol 1976;3:208-19.
4. Stoner JE, Masdyasana S. Gingival recession in the lower incisor
region of 15 year old subjects. J Periodontol 1981;51:74-6.
5. Ainoma J, Palohiemo L. Gingival recession in school children at
7,12 and 17 years of age in Espoo, Finland. Community Dent Oral
Epidemiol 1986;15:283-6
6. Woofter C. The prevalence and etiology of gingival recession.
Periodontal Abstr 1969;17:45-50.
7. Volchansky A, Cleaton-Jones P. The position of the gingival
margin as expressed by clinician crown height in children aged
6-16 years. J Dent 1976;3:116-22.
8. Loe H. The structure and physiology of the dentogingival junction.
In: Miles AE, editor. Structure and Chemical Organization Of
Teeth. Vol 2. New York: Academic Press; 1967.
9. Fermin A. Carranza JR. Clinical features of gingivitis. Clin
Periodontol 2006;10:369.
10. Merritt AA. Hyperemia of the dental pulp caused by gingival
recession. J Periodontal 1933;4:30.
11. Loe H, Silness J. Periodontal disease in pregnancy: I: Prevalence
and severity. Acta Odontol Scand 1963;21:533-51.
12. Stoner JE, Mazdyasna S. Gingival recession in the lower incisor
region of 15 year old subjects. J Periodontal 1980;51:74-6.
13. Powell RN, McEniery TM. Disparities in gingival height in
mandibular central incisor region of children aged 6-12 years.
Community Dent Oral Epidemiol 1981;9:32-6.
14. Berglundh T, Lindhe J, Sterrett JD. Clinical and structural
characteristics of periodontal tissues in young and old dogs. J
Clin Periodontal 1991;18:616-23.
[Downloaded free from http://www.jisponline.com on Friday, August 30, 2019, IP: 223.228.182.178]

20 Journal of Indian Society of Periodontology - Vol 13, Issue 1, Jan-Apr 2009
15. Fransson C, Berglundh T, Lindhe J. The effect of age on the
development of gingivitis. J Clin Periodontal 1996;23:379-85.
16. Fransson C, Mooney J, Kinane DF, Berglundh T. Differences in
the inß ammatory response in young and old human subjects
during the course of experimental gingivitis. J Clin Periodontal
1999;26:453-60.
17. Holm-Pederson P, Agerbaek N, Theilade E. Experimental
gingivitis in young and elderly individuals. J Clin Periodontal
1975;2:14.
18. ParÞ tt G.J, Mjor IA. A clinical evaluation of local gingival recession
in children. J Dent Child 1964;31:257-62.
19. Hollist NO. The technique and use of chewing stick.
Odontostomatol Trop 1981;4:171-4.
20. Younes SA, El Angbawi MF. Gingival recession in the mandibular
central incisor region of Saudi school children aged 10-15 years.
Community Dent Oral Epidemiol 1983;11:246-9.
21. Andlin-Sobocki A, Marcusson A, Persson M. 3 Year observations
on gingival recession in mandibular incisors in children. J Clin
Periodontol 1991;18:155-9.
22. Elifuraha GS, Mumghamba, Makkanen HA, Honkala E.
Risk factors for periodontal diseases in llala, Tanzania. J Clin
Periodontol 1995;22:347-54.
23. Cahen PM, Caubet AM, Rebillet R, Frank RM. Oral conditions
in a population of young adults in Strasbourg. Community Dent
Oral Epidemiol 1977;5:40-5.
24. Nowjack-Raymer R, Ainamo J, Suomi JD, Kingman A,
Driscoll WS, Brown LJ. Improved periodontal status through
self assessment: A 2 year longitudinal study in teenagers. J Clin
Periodontol 1995;22:603-8.
Source of Support: Nil, Confl ict of Interest: None declared.
Mathur, et al.: Gingival recession in Indian school children
Author Help: Reference checking facility
The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks
the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal.
• The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a
single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference.
• Example of a correct style
Sheahan P, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy.
Otolaryngol Head Neck Surg 2002;127:294-8.
• Only the references from journals indexed in PubMed will be checked.
• Enter each reference in new line, without a serial number.
• Add up to a maximum of 15 references at a time.
• If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct
article in PubMed will be given.
• If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to
possible articles in PubMed will be given.
[Downloaded free from http://www.jisponline.com on Friday, August 30, 2019, IP: 223.228.182.178]