Case Report
Improvement of Multiple Facial Gingival Recession
by Non-Surgical and Supportive Periodontal Therapy:
A Case Report
Kazunari Ando,* Koichi Ito,† and Seidai Murai
We report a case of multiple facial gingival reces-
sion which was improved by non-surgical and sup-
portive periodontal therapy. The patient, a
28-year-old Japanese woman, presented for treat-
ment of multiple facial gingival recession ranging
from 1 to 4 mm on teeth 5 through 12 and 19
through 30. Periodontal plastic surgery to cover the
exposed multiple root surfaces was suggested.
However, because of emotional problems, the patient
did not wish to undergo the procedures and instead
accepted non-surgical periodontal therapy including
oral hygiene instruction, scaling, and root planing.
The exposed root sites were monitored at periodic
maintenance visits, and gradual improvement
through a coronal increase of the gingival margin
was noted. The possible etiologic factors and healing
process associated with this case are discussed. J
Periodontol 1999;70:909-913.
KEY WORDS
Dental plaque/prevention and control; gingival
recession/therapy; periodontal diseases/therapy;
planing; scaling; toothbrushing/adverse effects.
* Previously, Department of Periodontology, Nihon University School of
Dentistry, Tokyo, Japan; currently, private practice, Chiba prefecture.
† Department of Periodontology, Nihon University School of Dentistry.
J Perlodontol • August 1999
†
Gingival recession has been defined as location of
the gingival margin apical to the cemento-enamel
junction (CEJ).1 Localized and generalized gingival
recession frequently occurs in patients with incipient
as well as advanced periodontal disease.2-4 Gingival
recession is also often found at facial tooth surfaces in
individuals who are otherwise periodontally healthy.2,5
Three different types of gingival recession have been
suggested: 1) mechanical factors, predominantly
toothbrushing trauma; 2) localized plaque-induced
inflammatory lesions; and 3) generalized forms of
destructive periodontal disease.6
Several types of periodontal plastic surgery using
both soft tissue grafting and guided tissue regeneration
have been reported to improve gingival recession and
to cover single/multiple exposed root surfaces.7 In a
review, Michaelides and Wilson8 reported that free gin-
gival grafting was the most desirable technique for root
coverage because it is a single-stage procedure that
can employ readily available donor tissue.
Lindhe and Nyman 9 examined changes in the posi-
tion of the gingival margin following the apically reposi-
tioned flap procedure with osseous surgery. Following
active treatment, all patients were recalled once every
3 to 6 months for maintenance care. After 10 to 11
years of maintenance, a small degree of coronal
regrowth (approximately 1 mm) of the soft tissue mar-
gin had occurred, and no recession was observed in
these patients maintained on a careful prophylaxis pro-
gram. Andlin-Sobocki et al.10 reported that 25 out of
35 recessions with an initial depth of 0.5 to 3.0 mm in
children healed spontaneously following improvement
of oral hygiene standards. Therefore, surgical proce-
dures for treatment of gingival recession in the devel-
oping dentition may not be necessary and should be
postponed until the growth is complete.
Generally, periodontal plastic surgery for coverage
of facial exposed single/multiple roots using not only
soft tissue grafting but also guided tissue regeneration
(GTR) has been employed, and the results have
become predictable.
The present report describes a case of multiple
facial gingival recession ranging from 1 to 4 mm on
teeth 5 through 12 and 19 through 30 in which
improvement was noted after non-surgical and sup-
portive periodontal therapy.
909
 Case Report
CASE REPORT
In April 1993, a 28-year-old Japanese woman visited
the Department of Periodontology, Nihon University
Dental Hospital, Tokyo, for treatment of multiple facial
gingival recession with esthetic problems. Her medical
history revealed no documented systemic problems
except for exaggerated nervousness about dental
treatment. She did not smoke or drink alcoholic bever-
ages and her family history was non-contributory.
Although the patient had undergone treatment and
prophylaxis for dental caries, she had not received
orthodontic treatment or periodontal surgery. Her
occlusion was within normal limits.
In general, slight to moderate inflammation was
noted around almost the entire gingival margin.
Probing depth (PD) ranged from 1 to 5 mm and was
particularly severe (4 to 5 mm) in the molar areas.
Gingival recession (Miller type I defects11) ranging
from 1 to 4 mm was found on facial teeth 5 through
12 and 19 through 30 (Fig. 1). Slight lingual gingival
recession was also seen on teeth 23, 25, 26, and 28 (1
mm) and 27 (2 mm). The width of the attached gin-
giva was shallow and was particularly inadequate (<1
mm) or lacking on facial teeth 5, 6, 11, 19 through 22,
and 27. Radiographic examination revealed that the
bone level was within normal limits. There was no
abnormal tooth mobility. The plaque control record
(PCR)12 was 58%. Periodontal treatment planning
including periodontal plastic surgery for the gingival
recession was explained to the patient. However,
because of emotional problems, she declined the
surgery. Therefore, non-surgical therapy, including oral
hygiene instruction, scaling and root planing, was
employed initially for the entire mouth, with the inten-
tion of making a final decision about surgery after
reevaluation. About 1 year before presentation, the
patient had consulted a general dentist about treat-
ment for the gingival recession. At that time, the den-
tist had suggested that her toothbrushing method was
inappropriate, and instructed her in a scrubbing
method using a manual toothbrush. We changed her
toothbrush from hard (company unknown) to ultra-
soft,? but the method was not altered. The patient was
given overall instruction in oral hygiene techniques.
The dental plaque was stained with a disclosing solu-
tions and she was given instruction by a dental
hygienist to use a correct scrubbing method with an
ultra-soft toothbrush and unwaxed dental floss.||
Six sessions of scaling and root planing using ultra-
sonic and hand scalers were performed for the entire
mouth. After the initial treatment, PCR was still rela-
tively high (approximately 33%), and again the
910 Improvement of Gingival Recession by Non-Surgical Therapy
patient’s toothbrushing technique was reviewed. We
changed her toothbrush from ultra-soft to medium.¶
The patient was also recalled at 1-month intervals and
reinstructed on toothbrushing and flossing, as well as
given professional tooth cleaning including scaling,
root planing, and polishing using a rubber cup with
paste# on the exposed root surfaces. After the addi-
tional treatment, PCR was decreased to less than 20%.
Again, the details of periodontal plastic surgery and the
need to minimize the root exposure were explained.
However, the patient still felt uneasy about the prospect
of surgery. Therefore, she opted for supportive peri-
odontal therapy with recall every 2 to 3 months.
The gingival inflammation and recession gradually
improved; however, slight inflammation was still noted
on the anterior teeth. The gingival margins showed
coronal regrowth after 2 years (Fig. 2). PD ranged
from 2 to 3 mm on the teeth that had shown gingival
recession at the initial examination. Gingival recession
ranging from 1 to 2 mm was still noted on teeth 5
through 11 and 19 through 30, and PCR was 19%.
Further improvement was observed thereafter, and
partial or full coverage of the exposed roots was noted
during the 4-year period of periodontal supportive
therapy (Fig. 3). A clinically healthy gingiva was
noted, and the PD was shallow, ranging from 1 to 3
mm; PCR was 17%.
DISCUSSION
The main treatment indications for gingival recession
are esthetic considerations, dentin hypersensitivity,
and management of root caries and cervical abra-
sions. In addition, changing the topography of the
marginal gingiva to facilitate plaque removal should
be considered.
Several surgical procedures have been reported for
the treatment of teeth showing single or multiple gingi-
val recession. However, it seems that there has been
no report of successful root coverage at multiple sites
resulting from non-surgical therapy. In the present
case, after non-surgical periodontal therapy including
scaling, root planing, proper oral hygiene instruction,
and periodic supportive periodontal therapy, the multi-
ple facial gingival recession improved, and a healthy
gingival margin was almost fully obtained.
In patients maintaining high standards of oral
hygiene, loss of attachment and gingival recession are
‡ GUM 222, John O. Butler Co., Chicago, IL.
§ Prospec, GC, Tokyo, Japan.
|| Dr. Bass, John O. Butler Co.
¶ GUM 211, John O. Butler Co.
# CCS Prophy Paste RDA 40, CCS Clean Chemical Sweden AB, Borlänge,
Sweden.
Volume 70 • Number 8
 Case Report

Figure 1.
Slight to moderate inflammation is noted around almost the entire gingival margin. Multiple facial gingival recession ranging from 1 to 4 mm is evident on
teeth 5 through 12 and 19 through 30.

Figure 2.
After 2 years, gingival inflammation and recession have gradually improved. Gingival margins have regrown in a coronal direction, although slight recession
ranging from 1 to 2 mm is still evident.

Figure 3.
Further improvement has continued, and partial or full coverage of the exposed root surfaces is observed 4 years later. A healthy gingiva has been
established, and the patient’s esthetic problems have been resolved.

J Perlodontol • August 1999 Ando, Ito, Murai 911

 Case Report
found at predominantly facial surfaces,13,14 and are
frequently associated with the presence of a wedge-
shaped defect in the crevicular area of one or several
teeth.2 Facial recession seems to be more common
and more advanced at single-rooted teeth than at
molars.15 Toothbrushing trauma and tooth malposition
are the factors most frequently associated with gingi-
val recession. 16,17 In addition, Khocht et al.18 showed
that recession could be related to the use of hard
toothbrushes.
Therefore, the major causative factors in the devel-
opment of gingival recession are plaque-induced peri-
odontal inflammation and trauma caused by
toothbrushing. Control of these factors will, in most
cases, prevent further progression of gingival reces-
sion. At the initial examination, the patient was given
overall instruction in oral hygiene techniques. During
the initial therapy, the dental plaque was stained with a
disclosing solution, and the patient was given instruc-
tion by a dental hygienist to use a scrubbing method
with a medium toothbrush, directing as little apical
pressure as possible on the gingival margin.
Appropriate sequencing and an adequate time and
frequency (at least twice daily) of toothbrushing with a
small quantity of dentifrice were special concerns for
establishing the goal of effective plaque control. In
addition, the patient was told to use dental floss for
interdental cleaning. The patient’s oral hygiene
instructions were repeated and the techniques were
checked and reviewed at each scaling and root plan-
ing session; these procedures were continued during
the supportive periodontal therapy.
At the initial visit, PCR was 58%, and this gradually
decreased to 17%. Therefore, the patient was consid-
ered to be well motivated. At first, we selected an
ultra-soft toothbrush for plaque control instruction, but
PCR remained relatively high (approximately 33%).
After the initial therapy, we therefore changed the bris-
tle hardness from ultra-soft to medium. The question
of the most desirable toothbrush bristle hardness is not
settled. Although a short-headed brush with straight-
cut, round-ended, soft-to-medium nylon bristles
arranged in 3 or 4 rows of tufts is recommended for
routine patients, selection of a proper toothbrush and
an adequate toothbrushing method should be based
on PCR and improvement of the gingival condition. 19
An increased apico-coronal height of the marginal gin-
giva is found following non-surgical and supportive
periodontal therapy. This may be explained by several
events taking place during the healing and maturation
of the marginal gingiva. Formation of granulation tis-
sue from the periodontal ligament tissue will create
912 Improvement of Gingival Recession by Non-Surgical Therapy
connective tissue similar to that of the gingiva, with the
potential to induce keratinization of the covering
epithelium.20,21 This creeping attachment involves
postoperative migration of the gingival marginal tissue
in a coronal direction, partially or totally covering a
previously denuded root. The gingival tissue becomes
firmly attached to the root surface, and probing does
not reveal any sulcular depth. Creeping attachment
may occur on a previously denuded root surface sev-
eral months after grafting.22
Extensive root planing or grinding, in order to
reduce the convexity of the root and to minimize the
mesio-distal avascular recipient bed in free graft pro-
cedures, has been suggested.23 It might be speculated
that non-surgical periodontal therapy consisting of
periodic scaling, root planing, and root surface polish-
ing creates the right conditions (plaque-free and flat
root surfaces) for easy regrowth of marginal tissue sur-
rounding the gingiva.
The position of the gingival margin is considered
normal if it approximates the CEJ. Gingival recession
can take place, and some dentitions are more prone
than others to this process. A thin, highly scalloped
gingival margin, associated with a tapered crown,
recedes more frequently than the thick, flat gingival
architecture that envelopes a square tooth crown.24 It
was speculated that the present patient had thin,
highly scalloped gingival tissue associated with a
tapered crown, and that inappropriate toothbrushing
with a medium-hard brush caused the multiple facial
gingival recession. Also, PCR was 58% at the initial
examination, and the presence of inflammation had
led to increased probing depth and attachment loss.
Vigorous toothbrushing pressure had then created
multiple facial exposed roots.
There was no clear indication of the patient’s gingi-
val condition in childhood. However, slight to moder-
ate gingival inflammation and a relatively high PCR
were noted at the initial visit. Therefore, it may be
speculated that she had chronic gingivitis since child-
hood and had developed periodontitis with multiple
gingival recession. Maynard25 stated from his clinical
experience that if gingival recession is properly diag-
nosed and detected early in pediatric patients, treat-
ment by gingival grafting should be initiated to prevent
more advanced periodontal disease. It is much easier
to use a graft procedure prior to loss of attachment
and gingival recession than to try to repair a defect
after it has developed.
In this case, gradual improvement through a coro-
nal increase of the gingival margin was achieved
under conditions of multiple gingival recession without
Volume 70 • Number 8

the use of a grafting procedure. A review of the litera-
ture revealed that cases like this one are rare.
Although there is a possibility of improving multiple
gingival recession with a non-surgical procedure, there
is still uncertainty about root coverage without the use
of grafting. At present, it might be safer to carry out
proper periodontal plastic surgery to improve multiple
facial gingival recession, especially when associated
with esthetic problems.
CONCLUSION
Multiple facial gingival recession (Miller type I defects)
was followed, without periodontal plastic surgery, over
a 4-year period. An inappropriate brushing method
with an excessively hard toothbrush appeared to be
the main etiologic factor and this was changed. No
precipitating factors, such as tooth malposition, high
frenum attachment, or a shallow vestibule, were identi-
fied. The final outcome was a coronally positioned gin-
gival margin, which was equal in height, or slightly
(approximately 1 mm) lower than the CEJ. A clini-
cally healthy gingiva and good oral hygiene have been
established and maintained. The marginal gingiva in
relatively young individuals may have the potential of
continuous regrowth. Daily home care by the patient
and supportive periodontal therapy might have played
an important role in maintaining this improvement.
ACKNOWLEDGMENTS
The authors with to thank Dr. David B. Douglas for his
assistance in manuscript preparation.
REFERENCES
1. The American Academy of Periodontology. Glossary of
Periodontal Terms, 3rd ed. Chicago: The American
Academy of Periodontology; 1992:41.
2. Sagnes G, Gjermo P. Prevalence of oral soft and hard
tissue lesions related to mechanical tooth cleaning
procedures. Community Dent Oral Epidemiol 1976;
4:77-83.
3. Ånerud KE, Robertson PB, Löe H, Ånerud Å, Boysen H,
Patters MR. Periodontal disease in three young adult
populations. J Periodont Res 1983;18:655-668.
4. Okamoto H, Yoneyama T, Lindhe J, Haffajee AD,
Socransky SS. Methods of evaluating periodontal
disease data in epidemiological research. J Clin
Periodontol 1988;15:430-439.
5. Murtomaa H, Meurman JH, Rytomaa I, Turtola L.
Periodontal status in university students. J Clin
Periodontol 1987;14:462-465.
6. Lindhe J, Karring T, Lang NP. Clinical Periodontology
and Implant Dentistry, 3rd ed. Copenhagen:
Munksgaard; 1997:569-591.
7. Miller PD, Craddock RD. Surgical advances in the
coverage of exposed roots. Curr Opin Periodontol
1996;3:103-108.
J Periodontol • August 1999
Case Report
8. Michaelides PL, Wilson SG. An autogenous graft
technique. Int J Periodontics Restorative Dent 1994;
14:113-125.
9. Lindhe J, Nyman S. Alterations of the position of the
marginal soft tissue following periodontal surgery. J
Clin Periodontol 1980;7:525-530.
10. Andlin-Sobocki A, Marcusson A, Persson M. Three-
year observation on gingival recession in mandibular
incisions in children. J Clin Periodontol 1991;18:155-
159.
11. Miller PD. A classification of marginal tissue recession.
Int J Periodontics Restorative Dent 1985;5(2):8-13.
12. O’Leary TJ, Drake RB, Naylor JE. The plaque control
record. J Periodontol 1972;43:38.
13. Löe H, Ånerud Å, Boysen H. The natural history of
periodontal disease in man: Prevalence, severity, extent
of gingival recession. J Periodontol 1992;63:489-495.
14. Serino G, Wennström JL, Lindhe J, Eneroth L. The
prevalence and distribution of gingival recession in
subjects with high standard of oral hygiene. J Clin
Periodontol 1994;21:57-63.
15. Yoneyama T, Okamoto H, Lindhe J, Socransky SS,
Haffajee AD. Probing depth, attachment loss and
gingival recession. Findings from a clinical examination
in Ushiku, Japan. J Clin Periodontol 1988;15:581-591.
16. Gorman WJ. Prevalence and aetiology of gingival
recession. J Periodontol 1967;38:316-322.
17. Vekalahti M. Occurrence of gingival recession in adults.
J Periodontol 1989;60:599-603.
18. Khocht A, Simon G, Person P, Denepitiya JL. Gingival
recession in relation to history of hard toothbrush use. J
Periodontol 1993;64:900-905.
19. Carranza FA Jr. Glickman’s Clinical Periodontology, 7th
ed. Philadelphia: WB Saunders Co.; 1990:684-687.
20. Karring T, Ostergaard E, Löe H. Conservation of tissue
specificity after heterotopic transplantation of gingival
and alveolar mucosa. J Periodont Res 1971;6:282-293.
21. Lundberg M, Wennström JL. Development of gingiva
following surgical exposure of a facially positioned
unerupted incisor. J Periodontol 1988;59:652-655.
22. Goldman H, Schluger S, Fox L, Cohen DW. Periodontal
Therapy, 3rd ed. St. Louis: The CV Mosby Company;
1964:560.
23. Miller PD. Root coverage using a free soft tissue
autograft following citric acid application. III. A
successful and predictable procedure in areas of deep-
wide recession. Int J Periodontics Restorative Dent
1985;5(2):15-37.
24. Schluger S, Youdelis R, Page RC, Johnson RH.
Periodontal Diseases, 2nd ed. Philadelphia: Lea &
Febiger;1990:294.
25. Maynard JG Jr. The rationale for mucogingival therapy
in the child and adolescent. Int J Periodontics
Restorative Dent 1987;7(1):36-51.
Send reprint requests to: Dr. Koichi Ito, Department of
Periodontology, Nihon University School of Dentistry, 1-8-
13, Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8310,
Japan. Fax: 0081-3-3219-8349; e-mail: ito-k@dent.nihon-
u.ac.jp
Accepted for publication October 26, 1998.
Ando, Ito, Murai 913