J Periodont Res 2014; 49: 143–163 © 2013 John Wiley & Sons A/S.

All rights reserved Published by John Wiley & Sons Ltd

JOURNAL OF PERIODONTAL RESEARCH

doi:10.1111/jre.12094
Review Article
I. Bignozzi1, A. Crea1, D. Capri1,
Root caries: a periodontal C. Littarru2, C. Lajolo2,
D. N. Tatakis3

perspective
1
EduPERIO Periodontal Education and
Research International Organization, Rome,
Italy, 2Catholic University of Sacred Heart,
Rome, Italy and 3The Ohio State University,
Columbus, OH, USA
Bignozzi I, Crea A, Capri D, Littarru C, Lajolo C, Tatakis DN. Root caries: a
periodontal perspective. J Periodont Res 2014; 49: 143–163. © 2013 John Wiley
& Sons A/S. Published by John Wiley & Sons Ltd

Background and objective: A prevailing dental problem in the periodontal

patient is root caries. Specifically, periodontal involvement often results in root
surfaces becoming exposed and at risk for this condition. Periodontal therapy
often leads to increased gingival recession as well, and the associated increased
root caries risk may compromise the long-term success and survival of periodon-
tally treated teeth.This narrative review will address the topic of root caries in
the periodontal patient, focusing on unmet research needs.
Material and Methods: The Medline database was searched to identify items
dealing with root caries, in terms of clinical features, diagnosis, pathogenic
mechanisms and histopathology, as well as epidemiology, focusing then on the
relationship between root caries and periodontal disorders.
Results: Although there is extensive literature on root caries, consensus is lack-
ing regarding certain aspects, such as diagnostic criteria, prevalence within pop-
ulations and indisputable risk factors. Advancing age could be an aggravating
factor in susceptibility to root caries for the periodontal patient; however, defini-
tive evidence in this regard is still missing. Similarly, full awareness of the
increased risk of root caries in patients with periodontal disease or long-term
periodontal treatment appears to be still lacking. Isabella Bignozzi, DDS, PhD, EduPERIO
Periodontal Education and Research
Conclusion: Research regarding root caries in age-specific (elderly) periodontal International Organization, Rome, Via
patients is needed. Improved oral hygiene practices, locally applied preventive Germanico 99, 00192, Italy
Tel: +39 065572211
measures, good dietary habits and regular dental check-ups are crucial Fax: +39 06636208
approaches to prevent both periodontal disease progression and root caries. e-mail: i.bignozzi@tiscali.it
Periodontal patients with root exposure should follow a strict root caries pre- Key words: periodontal disease; prevention and
vention protocol, as an integral component of their periodontal maintenance control; root caries
therapy. Accepted for publication March 30, 2013

Gingival recession (GR) is defined as
“the apical migration of the gingival
margin beyond the cemento-enamel
junction” (1). This condition is inevita-
bly associated with exposed root sur-
faces and the consequently increased
risk of root caries (RC). GR is a multi-
factorial condition, with periodontal
disease and inappropriate dental
therapy being common contributing
factors (2).
The purpose of this narrative
review is to provide a periodontal per-
spective on RC in the periodontal
patient; specifically, this article will
provide an overview of the main path-
ogenic mechanisms leading to RC and
of the preventive and therapeutic
approaches to address these tooth
root lesions in periodontally involved
patients. The review focuses on: the
role of periodontal disease and ther-
apy as risk factors for tooth root
exposure and RC; the benefits and
limitations of periodontal surgical
procedures, with or without adjunc-
tive restorative treatments, as a viable
prevention and treatment strategy for
RC; and the significance of RC as a
factor complicating or reducing the
long-term prognosis of teeth treated
with resective periodontal surgery. In
addition, relevant aspects of RC in
144 Bignozzi et al.
age-specific (elderly) populations are
addressed. The review also highlights
areas of unmet research needs in
relation to RC and periodontal
involvement.
Root caries: general features
RC commonly presents as a progres-
sive lesion found on a tooth root that,
due to some degree of periodontal
attachment loss, has become exposed
to the oral environment (3,4). Sumney
et al. (3) defined RC as a cavitation
below the cemento-enamel junction
(CEJ), not including the adjacent
enamel, usually discolored, softened,
ill-defined and involving both cemen-
tum and underlying dentin. RC
lesions have been variously described
in the literature, where some authors
proposed distinctive criteria such as
location at the CEJ, position entirely
on the root surface (5), spread to
undermine the adjacent enamel (6) or
extension to more than half on the
root cementum (7).
RC lesions are most often located
on exposed root surfaces, although it
has been reported that up to 10–20%
of lesions may occur subgingivally (8).
Banting et al. (9) reported that the
most frequent RC location is close to
the gingival margin, but Ravald et al.
(10) identified the margin of previous
restorations (51%), the CEJ (25%),
and points of confluence with other
lesions (17%) as areas at risk for RC
in periodontally treated patients. Katz
et al. (6) reported that RC are found
– in descending order of frequency –
at buccal and interproximal surfaces
of mandibular posterior teeth, inter-
proximal surfaces of maxillary ante-
rior teeth, lingual and interproximal
surfaces of maxillary posterior teeth
and buccal and interproximal surfaces
of mandibular anterior teeth. In con-
trast, Heegaard et al. (11) reported
that RCs are frequently found on
labial surfaces and evenly distributed
within the dentition. Imazato et al.
(12) reported canines and first premo-
lars as the most frequently involved
teeth, while Kularatne and Ekanayake
(13) indicated instead the molars of
both arches as most frequently
involved. Regardless of possible rela-
tive differences in prevalence among
sites and tooth type, RC can affect
the entire dentition. Although RC
lesions tend to spread along the CEJ
and, in general, along the root sur-
face, more aggressive RC lesions may
progress toward the pulp similarly to
dentinal caries of the crown (14).
Investigators have based the diag-
nosis and staging of RC lesions on
location (3,8,15,16), color (17–19),
texture (6,16,20,21), cavitation (21,22)
and contour (15,23,24) of the involved
surface. Investigators have also tried
to distinguish between active and
inactive RC lesions based on charac-
teristics cited above (20,25,26). Gaen-
gler et al. (27) classified RC into three
main categories, based on clinical and
histopathological features. Specifi-
cally, depth and progression of the
lesion as well as degree of demineral-
ization were considered to distinguish
initial, stagnating and progressing
lesions.
Diagnosis of RC is based primarily
on traditional visual–tactile methods,
although some reservations have been
raised regarding the reliability and
repeatability of this RC screening
method (26). In this context, radio-
graphs and existing microbiological
tests may supplement the clinical
evaluation to increase sensitivity and
specificity of the RC diagnostic pro-
cess (28), which remains an issue.
The difficulty in rapid screening and
early detection of carious lesions is a
general concern in cariology. The
clinical detection of dental caries at
the early stages, which precede cavi-
tation, has always been a challenge.
The majority of caries detection sys-
tems proposed over the years, both
for coronal and RC, used a dichoto-
mous system (cavitation/not) that did
not measure the disease process at
different stages, but only identified
carious lesions at an advanced
stage of their natural history (29).
Recently, the International Caries
Detection and Assessment System
(ICDAS) has been developed from
the best aspects of previously pub-
lished systems to address and over-
come inconsistencies, set diagnostic
threshold and criteria, as well as reli-
ably and repeatedly identify and stage
noncavitated lesions (29). The ICDAS
visual detection codes have been pro-
ven effective for assessing enamel and
dentinal coronal caries in a reliable,
valid and reproducible manner in
both permanent and deciduous teeth
(30,31). Unfortunately, despite the
fact that ICDAS includes diagnostic
criteria and decision trees specifically
designed for RCs, data on the valid-
ity and reliability of this ICDAS sec-
tion are not yet available, because no
clinical, laboratory or epidemiological
studies have been reported to date in
this respect (32). Moreover, RC diag-
nosis may present unique clinical
issues, such as the unreliability of
color (33) and texture (28) as refer-
ence diagnostic criteria or the reduced
accessibility of the affected area to
direct view in case of interproximal
(6) or subgingival (8) lesions, espe-
cially if complicated by the presence
of prosthetic crowns (34).
As clinical examination may be not
sensitive enough to identify RC at the
very early clinical stages, several tech-
nologies have been proposed to give
the clinician the possibility to identify
subclinical, noncavitated lesions. The
use of emerging technologies aims to
anticipate the diagnostic time, allow-
ing clinicians to manage the caries
process at an earlier stage of its natu-
ral history and take preventive rather
than therapeutic measures. These
technologies range from fluorescence-
based or electrical caries monitors
(35,36) to optical coherence tomogra-
phy (37). These technologies remain
to be conclusively validated before
their use on a large scale to serve epi-
demiologic or dental practice needs.
In the context of RC diagnosis,
conclusive validation of a RC clinical
diagnostic system that is comprehen-
sive of all clinical signs, but also
rapid, feasible and repeatable, as
ICDAS has been shown to be for
coronal caries, appears to be neces-
sary. Future research should address
the in vitro and in vivo validation of
ICDAS for RCs, taking into consider-
ation intra- and inter-examiner agree-
ment, to pursue standardization in
diagnosis and staging; studies that
address the specific challenges of RC
diagnosis should be encouraged.

Root caries: etiologic factors
The main etiologic factors for onset
and progression of RC are the presence
of bacteria and fermentable carbohy-
drates on the root surface (38) [Correc-
tion added on 20 May 2013, after first
online publication: Reference of
progression of RC ‘in the elderly’ was
removed]. Lactobacillus, Streptococcus
mutans and Actinomyces salivary
counts have been significantly corre-
lated with RC occurrence (39). Scan-
ning electron microscopy observations
revealed various patterns of bacterial
coaggregation in RC lesions (40), while
synergistic growth was observed in co-
cultures of Lactobacillus acidophilus
with Streptococcus mutans, Actinomy-
ces israelii with Lactobacillus acidophi-
lus and Actinomyces israelii with
Lactobacillus acidophilus and Strepto-
coccus mutans, seemingly resulting in
greater acidogenic and cariogenic
effects on the root surface (39).
Although Candida albicans has been
identified in root surface soft lesions, it
is not considered an etiologic factor in
RC onset (41–43).
Subjects with unaffected root sur-
faces show a more nonspecific micro-
flora, with greater interindividual
differences in biofilm composition,
while in patients with RC the bacterial
biofilm* of root surfaces tends to have
lower interpatient diversity, decreasing
further at affected roots (44). Although
these findings corroborate the hypoth-
esis of a plaque-specific RC etiology,
presently the microbiological agents
causing this condition have not been
conclusively identified (44). The oral
microflora is highly diversified and
may comprise up to 600 bacterial spe-
cies, many of which have not yet been
cultured (45,46). Because of their
inherent limitations, culture-dependent
identification techniques pose the risk
of limited or even misleading informa-
tion, particularly when single site anal-
ysis is performed, given the site-
specificity of microflora (44).
The use of culture-independent meth-
ods has allowed the discovery of
*Corrections added on 20 May 2013, after
first online publication: References to plaque
have been corrected to biofilm.
Root caries: a periodontal perspective
microbial species not previously identi-
fied in the oral cavity (47). Culture-
independent, open-ended approaches
comparing the biofilm of patients/sites
with or without RC are advocated. The
microbiological profile of patients with
RC with periodontal disease or sub-
jected to long-term periodontal treat-
ment should be characterized as well, to
clarify the possible impact of periodon-
tal status on root surface bacterial
biofilm and its role in RC pathogenesis.
Root caries: pathogenic
mechanism and relevant
bacterial metabolic pathways
Bacteria metabolize sugar into organic
acids, which initiate root surface
demineralization by removing calcium
and phosphate ions from surface apa-
tite crystals. For enamel, this process
takes place as the pH reaches the crit-
ical value of 5.5; however, pH 6.4 is
sufficient for cementum and dentin
demineralization, due to their lower
degree of mineralization (48). Under
normal circumstances, this loss of cal-
cium and phosphate ions is balanced
by the uptake of minerals from the
surrounding microenvironment. An
unfavorable oral environment, with
high levels of pathogenic bacteria and
rate of carbohydrate fermentation,
may alter the balance of this deminer-
alizing–remineralizing cycle in favor
of caries development.
In brief, some characteristics of
dental biofilm* have been considered
to be relevant with regard to cario-
genic potential in several studies over
the years; these include the dynamics
of pH and free calcium concentration
in the bacterial biofilm fluids after
exposure to fermentable carbohydrate
(49) and collagenase activity (50) with
consequent organic matrix degrada-
tion (51), long-lasting glycogen syn-
thetic and degradative activities at
acidic pH levels (52,53), and the abil-
ity to induce significant concentra-
tions of microbial-derived organic
acids with high dissociation constants
– such as formic and pyruvic acids –
in dentin matrix (54).
Brailsford et al. (55) suggested that
not only the ability to produce acid
from carbohydrates (acidogenicity),
145
but also the ability to survive and
grow in a low pH environment (acid-
uricity) might be a virulence determi-
nant crucial for inducing RC. The
authors proposed a dynamic model of
bacterial etiology, with a progressive
selection for a bacterial biofilm* with
significant acidogenic and aciduric
properties, that seems to include (but
is not limited to) bacteria commonly
believed to be involved, such as
S. mutans and lactobacilli.
Recently, Hashimoto et al. (56) per-
formed a pilot study in six subjects
aged 48–73 years and used 16S rRNA
sequencing analysis and anaerobic cul-
ture on blood agar plates to identify
the proportions of protein-degrading
and protein-coagulating bacteria in
plaque samples collected from RC
lesions, healthy supragingival sites and
periodontal pockets  5 mm deep. In
RC sites, a predominance of Propioni-
bacterium, Actinomyces, Streptococcus,
Lactobacillus and Bifidobacterium was
found, with evidence of prevailing pro-
tein-coagulating metabolic pathways,
and less represented protein-degrading
activities. Subgingival periodontitis
sites had the highest proportion of pro-
tein-denaturing bacterial strains, with
specific predominance of protein-
degrading ones, in agreement with pre-
vious findings (57). The authors noted
that periodontally involved root sur-
faces, exposed to oral environment and
challenged by organic acids derived
from fermentable carbohydrates are
likely to have their organic compo-
nents denatured and then degraded
through the synergistic action of pro-
tein-degrading and protein-coagulating
bacterial strains, resulting in the onset
and progression of RC (56). In this set-
ting, robust host-derived proteolytic/
collagenolytic activity (from periodon-
tally involved gingival tissues) might
play a contributory role in the RC pro-
cess in patients with periodontitis.
Although the various pathogenic
activities summarized above have been
reported in the issue-focused litera-
ture, the complete RC pathogenetic
puzzle has not yet been solved. Given
the apparent significance of proteoly-
sis as a pathogenic mechanism in RC
it appears that targeted studies, on lar-
ger patient samples, with specific
146 Bignozzi et al.

attention to protein-denaturing bacte-
rial activities, as well as their potential
association or synergism with host-
derived proteases, could be helpful in
elucidating the significance of the vari-
ous mechanisms presently implicated
in RC pathogenesis. In this context,
intervention studies targeting host-
derived proteolytic enzymes could be
of help in illuminating the contribu-
tion of periodontally involved tissues
to RC pathogenesis.
Root caries: histopathology
Root cementum and dentin are struc-
turally different from enamel and
coronal dentin and react differently
to cariogenic challenges (Table 1)
(14,28,58,59). As mentioned above,
Gaengler et al. (27) classified RC into
initial, stagnating and progressing
lesions, based on clinical and histo-
pathological features. Microstructural
observations of initial RC lesions
reveal an external layer with dentinal
tubules partly occluded by peritubular
and intratubular dentin deposition
and an underlying layer of translucent
dentin (60). Dentinal tubules appear
to be sclerosed by precipitation of cal-
cium and phosphate ions, and tubules
containing ghosts of bacteria and
fine-granular crystals may be observed
as well (61). Stagnating RC lesions
are characterized by a surface layer
with high mineral content (62),
absence of viable bacteria in dentin
tubules (59,63), impermeability to
dyes and isotopes (64) and high resis-
tance to acid and proteolytic enzymes
(65) suggesting that arrest and remin-
eralization of active lesions may
depend upon the balance between
severity of cariogenic bacterial infec-
tion of dentin and degree of active
sclerosis of dentinal tubules in areas
underlying the lesion.
Conversely, in progressing RC
lesions a superficial layer with diffuse
bacterial penetration and an intermedi-
ate area of demineralizing dentin may
be observed above the translucent den-
tin (14). Progressing lesions may be
clinically distinguished from stagnating
ones by their surface texture and color:
progressing RC lesions are commonly
characterized by a soft and yellowish
discolored surface, while in stagnating
RC lesions a hard, brown to black sur-
face may be observed (17,66). In more
advanced lesions, the surface zone and
demineralizing dentin are commonly
not well demarcated, and a massive lat-
eral spread of bacteria into intertubu-
lar dentin may be observed, with
unaffected dentinal areas becoming
continuously undermined. Notably,
the mineral content in different zones
within the lesion may vary consider-
ably, and this aspect could result in
underestimation of lesion depth (67).
Root caries: epidemiology
(prevalence, incidence and
risk indicators)
The apparent lack of unanimous con-
sensus on the criteria to diagnose RC
lesions and the variability of RC
descriptors used in the literature (28)

Table 1. Comparison between coronal and root caries, adapted from Banting (28)
Coronal caries Root caries

Etiology Cariogenic bacteria (S. mutans, Lactobacilli) Cariogenic bacteria (S. mutans, Lactobacilli,
Fermentable carbohydrates Actinomyces) (39)
Fermentable carbohydrates (38)
Predisposing factors Plaque index Plaque index (80,88,89)
Frequency of carbohydrate intake Frequency of carbohydrate intake (79)
Reduced salivary flow Reduced salivary flow (90,228)
Fluoride exposure ( ) Fluoride exposure ( ) (8)
GR/CAL (69,79,94,95,97–99)
Advanced age (81,206,207)
Low socio-economic status (95)
Reduced manual dexterity (93)
Cognitive decline (229)
Surface tissue Enamel/dentin Cementum/dentin
Tissue composition Enamel: Dentin:
(by weight) 95–97% mineral 65–70% mineral
3–5% organic and water 30–35% organic and water
Dentin: Cementum
65–70% mineral 45%–55% mineral
30–35% organic and water 45–55% organic and water
Demineralization onset pH  5.5 pH  6.4 (48)
Carious process In enamel: In cementum:
Bacterial invasion followed by demineralization Bacterial invasion followed by simultaneous
demineralization and proteolysis (14,58,59)
In dentin: In dentin:
Bacterial penetration of tubules; demineralization Bacterial penetration of tubules; demineralization of
of intertubular dentin and proteolysis of organic intertubular dentin and proteolysis of organic component;
component; Sclerosis of dentin tubules, destruction of lumens and
Sclerosis of dentin tubules, destruction of lumens peritubular dentin deposition (14,28,58–60)
and peritubular dentin deposition

GR, gingival recession; CAL, clinical attachment loss.


result in subjectivity impacted esti-
mates of prevalence, incidence and
severity of RC in the studied pop-
ulations (8,68). The inclusion or
exclusion of restored root surfaces
and/or recurrent lesions in any
assessment introduce further variabil-
ity on reported prevalence rates (21).
Several population characteristics
have been investigated as putative RC
risk indicators in cross-sectional and
longitudinal studies (41,69–77); unfor-
tunately, the considerable heterogene-
ity among studies in terms of
analyzed variables (e.g. sample size,
follow-up period and analytical tech-
niques) has prevented conclusive vali-
dation of a risk model and
identification of population features
that may significantly increase the risk
of RC occurrence (78).
In general, all the identified predis-
posing conditions have to be consid-
ered risk indicators rather than actual
risk factors for RC occurrence,
because of the inability to establish
cause–effect relationships through the
available descriptive, cross-sectional
studies and the limited agreement
among reported longitudinal investi-
gations. Table 2 summarizes the
results of longitudinal studies, report-
ing the calculated incidence rates and
the variables identified as putative risk
factors for RC occurrence.
Among the numerous variables that
have been investigated over the years
as putative RC risk indicators, 30
have been shown to be significantly
associated with increased RC inci-
dence in at least one study. Specifi-
cally, RC prevalence at baseline,
number of teeth at baseline, patient
age, plaque index and salivary counts
of Lactobacillus and S. mutans are
independent variables that have been
repeatedly shown to have a positive
association with new RC occurrence
during a 1–10 year (median = 3) inci-
dence period (78).
Steele et al. (79) conducted a multi-
variate analysis on 462 patients (405
community-living; 57 institutionalized)
aged  65 years; they used the pres-
ence of primary RC as dependent var-
iable and behavioral or background
characteristics as independent vari-
ables. Based on this study, there
Root caries: a periodontal perspective
seemed to be a greater likelihood to
develop RC for patients with a higher
mean frequency of sugar intake, with
an odds ratio (OR) of 2.4, infrequent
tooth cleaning (OR = 4.7) and ineffec-
tive tooth cleaning in presence of a
partial denture (OR = 1.6). The most
relevant background risk variables
were severe (  9 mm) loss of clinical
attachment (OR = 2.4) and exposed
roots (OR = 1.05, per “vulnerable”
tooth), while having sound coronal
restorations was somehow protective
(OR = 0.94 per restored tooth). A
further stepwise multiple regression
analysis was carried out considering
as dependent variable the root caries
index for decay, calculated as the pro-
portion of all vulnerable teeth,
i.e. with some degree of exposed root
surface, being affected by active
decay. Under such analysis, the habit
of sucking sweets to relieve dry mouth
(b = 0.101, p = 0.037), living in an
institution (b = 0.172, p = 0.000) or
not attending regular dental check-
ups (b = 0.098, p = 0.002) were the
behavioral conditions associated with
RC occurrence, in addition to the pre-
viously identified variables of wearing
a partial denture and having infre-
quent personal tooth cleaning.
The potential contribution of some
sociodemographic parameters to RC
prevalence may be hypothesized but it
is not easily evaluable due to lack of
homogeneity among the relevant
studies. Several cohort studies have
revealed a wide range of incidence
rates, varying by population charac-
teristics, sample size and study length.
Despite such differences in incidence
rate, older, medically compromised or
institutionalized subjects and subjects
with advanced periodontal disease
commonly exhibit higher RC inci-
dence compared to the general adult
population (9,22,41,42,70,75,80–83).
Social, psychological and cogni-
tive status also seems to affect oral
health conditions in noninstitutional-
ized elderly subjects. Avlund et al. (84)
examined 157 independently living
subjects, aged over 80 years, and
reported substantial differences in oral
health – measured as active coronal
caries, active RC, edentulism and
regular use of dental services – in two
147
subgroups having different social class
and education. In two other studies
involving similar populations of com-
munity-dwelling individuals aged
80 years or older, cognitive decline,
reduced functional ability as well as
unsatisfactory social relations were sig-
nificantly related to higher risk of
active coronal caries and RC and, in
general, poorer oral health and infre-
quent use of dental services (85,86).
Therefore, on the basis of the avail-
able literature, the following variables
should be considered among the main
local factors involved in RC patho-
genesis: high salivary counts of patho-
genic microorganisms (41,87); high
percentage of dental surfaces harbor-
ing plaque (43,88,89); unrestored
coronal caries and RC (69,75,88); and
factors promoting plaque accumula-
tion, such as presence of restorations
(10) and reduced salivary flow (90).
The population’s systemic and behav-
ioral conditions that might play a role
in RC occurrence or progression
include advanced age (41,72–74), low
socio-economic status and educational
level (84), discontinuity in oral health
care and dental check-up (79,86),
frequency of carbohydrate intake
(91,92), impaired manual dexterity
and cognitive decline (85,93). It must
be recognized that, despite the fact
that disease prevalence is frequently
used as a rough estimate of risk, inci-
dence data from longitudinal studies
(i.e. cohort studies) may provide a
higher level of evidence and more reli-
able risk estimates.
Surprisingly, the contribution of
periodontal parameters to RC has
received limited attention. Only a few
studies (69,94,95) considered clinical
attachment loss (CAL) and/or GR
among the targeted putative risk indi-
cators. Nevertheless, considering that
GR is almost endemic in the adult
population, as well as a supposedly
necessary condition for RC occur-
rence in the majority of cases, it may
not be proper, from a methodological
point of view, to include GR as an
independent variable in a risk model
(78). However, it is undeniable that,
due to the unique spatial relationship
between root surface and marginal
periodontium, RC and periodontal
 148
Table 2. Summary of cohort longitudinal studies reporting incidence rates and risk modelling (continued)
Observation RC incidence
Sample period Population (% subjects Significant
Study size (N) (months) characteristics affected) Risk model predictors

Powell et al., 23 12  65 years old 61.9% Logistic Variables Regr Coeff (SE)
1991 (230) instituzionalized regression Gender 1.06 [0.41]
Bignozzi et al.

RCIlog 0.42 [0.15]

Ravald and 99 24 33–76 years old 50% Stepwise Variables R2 Partial correlation p-value
Birkhed, 1992 community-dwelling, multiple Baseline RC 0.18 0.43 p = 0.0002
(88) periodontally treated regression Plaque score 0.23 0.24 p = 0.0069
No. teeth 0.28 0.24 p = 0.0246
Joshi et al., 130 9–24 Middle-aged/older 50.7% Stepwise Variables Estimate (SE) OR (95% CI) p-value
1993 (89) (median = 16) community-dwelling logistic Baseline RC 0.13 [0.04] 1.14 (1.05–1.23) p = 0.004
regression No. teeth 0.97 [0.39] 2.63 (1.22–5.66) p = 0.01
Plaque score 0.99 [0.45] 2.69 (1.11–6.50) p = 0.02
Ravald et al., 27 144  46 years old 88.9% Stepwise Variables p-value
1993 (80) community-dwelling multiple Plaque score p = 0.00
periodontally treated regression Smoking p < 0.05
Scheinin et al., 96 36 47–79 years old 51% Logistic Variables OR (95% CI)
1994 (43) community-dwelling regression rDFS 12.8 [2.8–58.5]
Candida 2.8 [0.9–8.1]
Lactobacilli 8.6 [2.4–31.2]
Lawrence et al., 55 36  65 years old 29% (blacks) Logistic Variables OR (95% CI)
1995 (95) community-dwelling 39% (whites) regression Blacks:
234 blacks RPD 3.43 [1.52–7.76]
218 whites Root fragments 3.31 [1.28–8.58]
Average GR 1.75 [0.75–4.12]
P. Intermedia 2.74 [1.27–5.92]
Impact on appearance 2.24 [1.09–4.60]
Daily activities 1.67 [1.12–2.5]
Whites:
Worst GR 4.5 [1.95–10.39]
Average PD 3.81 [1.24–11.69]
Worst GR + average PD 3.35 [1.28–8.76]
Antihistamines 4 [1.45–11.07]
Calcium therapy 2.45 [1.08–5.57]
Age-related problems (> 40) 4.99 [2.17–11.47]
Employement status 3.17 [1.32–7.61]
Locker, 1996 493 36  50 years old 27.4% Logistic Variables OR p-value
(81) community-dwelling regression DFS model:
Baseline RC 2.3 p < 0.001
DS model
Age 2.5 p < 0.05
Regular check-up 1.9 p < 0.05
Baseline RC 2.2 p < 0.05
Table 2. (continued)

Observation RC incidence
Sample period Population (% subjects Significant
Study size (N) (months) characteristics affected) Risk model predictors

Lawrence et al., 702 60  65 years old 39% (blacks) Logistic NR NR

1996 (22) community-dwelling 52% (whites) regression
379 blacks
323 whites
Powell et al., 55 36  60 years old 77% Poisson Variables Regr Coeff (SE) Rel Risk (95% C) p-value
1998 (42) community-dwelling regression Bacterial countslog 0.258 [0.085] 1.29 [1.10–1.53] p = 0.002
Asian ethnicity 0.617 [0.237] 1.85 [1.16–2.95] p = 0.009
Gilbert et al., 723 24  45 years old 36% Logistic Variables OR (95% CI) Estimate (SE) p-value
2001 (75) community-dwelling regression Baseline RC 2.3 [1.4–3.7] 0.83 [0.24] p = 0.01
Baseline FS 3.6 [2.4–5.7] 1.29 [0.22] p = 0.01
No. teeth 1.9 [1.1–3.4] 0.64 [0.30] p = 0.03
No. lost teeth 1.6 [1.0–2.5] 0.46 [0.22] p = 0.04
Chalmers et al., 216 12 Older, institutionalized 62.1% (dementia) Linear Variables b (SE) F p-value
2002 (229) 103 dementia affected 44.2 (control) regression Gender (male) 0.071[0.291] 0.059 p < 0.8
113 control Dementia 0.945[0.287] 10.824 p = 0.001
Takano et al., 373 24 70 years old community- 35.9% Logistic Variables OR (95% CI) p-value
2003 (69) dwelling regression Baseline RC 3.71[2.07–6.67] p = 0.00
Prosthetic crow 2.33[1.24–4.39] p = 0.009
CAL 2.32[1.31–4.12] p = 0.004
OH habits 2.05[1.26–3.35] p = 0.004
Fure et al., 102 120 65–85 years old 12.4% Stepwise Variables Partial correlation b-coefficient
2004 (41) community-dwelling regression Lactobacilli log 0.37 2.78
No. teeth 0.45 0.85
Drugs/day 0.27 1.76
S

anchez-Garc
ıa 531 12  60 years old 21.7% Bivariate and Variables Bivariate OR Multivariate
et al., 2011 multivariate (95% CI) OR (95% CI)
(94) logistic Limitations in BDLA 2.2 [0.9–5.0] 3.1 [1.0–9.5]
regression Smoking 2.0 [1.1–3.7] 2.0 [1.0–4.1]
Self-perceived oral 1.6 [1.0–2.7] 1.4 [0.8–2.5]
health
Dental mouthwash 1.6 [1.0–2.5] 1.7 [1.0–2.8]
(no)
Mutans streptococci 1.6 [1.0–2.7] 2.1 [1.1–4.0]
(‡105 CFU⁄ ml)
DMFT index (  17) 1.6 [1.0–2.5] 1.3 [0.8–2.3]
Exposed root 5.1 [3.2–8.2] 5.4 [3.2–9.1]
surfaces (  6)
RCI  8% 1.6 [1.1–2.5] 1.8 [1.1–3.1]
CAL  4 mm 1.6 [1.0–2.5] 0.8 [0.5–1.4]
Root caries: a periodontal perspective

RCI, Root Caries Index; Regr Coeff, Regression Coefficient; SE, Standard Error; CI, Confidence Interval; RC, Root Caries; rDFS, root Decayed Filled Surface; RPD, Removable Partial
Denture; GR, Gingival recession; PD, Probing Depth; DFS, Decayed Filled Surface; DS, Decayed Surface; NR, Not Reported; Rel Risk, Relative Risk; DMFT, Decayed Missing Filled
Teeth; FS, Filled Surface; CAL, Clinical Attachment Loss; OH habits, Oral Hygiene habits; BDLA, Basic Daily Life Activity.
149
150 Bignozzi et al.

disorders often coexist, not only as
concurrent events, but also as condi-
tions linked by two-way cause–effect
relationships.
Root caries: relationship with
periodontal disorders
In the context of RC predisposing
clinical factors, particular attention
should be paid to patients with peri-
odontal diseases. CAL and GR have
been recognized as relevant predispos-
ing factors in the onset of RC, given
the increased vulnerability of exposed
root surfaces. RC is considered a
serious problem affecting the long-
term prognosis of both treated and
untreated periodontally involved teeth
(96). Epidemiologic as well as large
clinical trials agree that presence of
GR and CAL are associated with a
higher incidence of RC (79,97–99).
Fadel et al. in a recent cross-
sectional study (100) reported a high
prevalence of RC lesions and high
caries risk rates in 20% of patients
referred for periodontal treatment,
whether affected by gingivitis (mean
age 25.8), mild-to-moderate periodon-
titis (mean age 41.9), or severe peri-
odontitis (mean age 49.7); the
prevalence of root lesions (caries and/
or fillings) was 9%, 15% and 29% for
each group, respectively. However,
estimated RC risk profiles appeared
correlated with a combination of sev-
eral factors and not specifically with
periodontal disease severity. The
undeniable correlation between peri-
odontal disorders and RC incidence
rate emerged also from a RC predic-
tion model involving a population of
698 subjects aged  60 years, where
it has been shown that having
 75 years of age (OR = 1.3, CI
95% 0.8–2.0),  6 exposed roots
(OR = 5.1, CI 95%: 3.2–8.2) or
 4 mm CAL (OR = 1.6, CI 95%:
1.0–2.5) are significant risk predictors
for RC development in a 12-month
period (94).
can occur subgingivally (8), in most
cases GR might be considered a nec-
essary condition for RC development
(101,102). GR is highly prevalent in
patients with either high (2,103) or
poor (104,105) oral hygiene standard,
but presents with different characteris-
tics. Miller (106) categorized GR
defects into four classes, based on the
relation of the gingival margin to the
mucogingival junction and the degree
of interproximal CAL, highlighting
how these clinical variables concern-
ing GR are significant for root cover-
age outcomes (106).
Notably, in patients with good oral
hygiene and without signs of inflamma-
tory periodontal disease, GR is com-
monly located at buccal tooth surfaces
and putative causative factors include
traumatic tooth-brushing (107–109),
eccentric orthodontic movement (110),
tooth malposition (111), presence of
alveolar bone dehiscence (112), or high
frenal attachment (113). In this sub-
group of patients, GR defects are not
associated with interproximal CAL
and are typically classified as either
Miller I or Miller II (2,103,114)
(Fig. 1A); these types of GR defects
are much more likely to fully resolve
(i.e. to exhibit complete root coverage)
A B
C
after appropriate periodontal plastic
surgery procedures (106).
Conversely, GR that manifests as a
component of inflammatory periodon-
titis is associated with interproximal
CAL (105), and may involve buccal,
lingual and interproximal surfaces
(2,105) (Fig. 1B). This type of GR
lesion typically belongs to Miller III
or IV class (103), and is, therefore,
unlikely to be completely resolved fol-
lowing regenerative periodontal surgi-
cal intervention (106,115). Regardless
of the underlying etiology or associ-
ated attachment loss, GR lesions
predispose to several different compli-
cations, such as hypersensitivity (116),
loss of esthetic appearance (117),
tooth abrasion (118), plaque retention
(119) and RC (120). The RC preva-
lence rate in subjects with GR was
significantly higher (90%) than that
(20–40%) reported in matched reces-
sion-free subjects (120).
Root caries: relationship with
nonsurgical periodontal
therapy
The interrelationship between RC and
periodontal disease extends beyond
the pathological entities per se.

Root caries: relationship with

gingival recession
As discussed above, despite the fact
that a small proportion of RC lesions
Fig. 1. (A) Patient with good oral hygiene and multiple deep Miller I and Miller II gingi-
val recession defects. (B) Severe Miller III and Miller IV gingival recession defects in a
patient with periodontitis. (C) Severe periodontitis treated by osseous surgery (left panel);
the resulting gingival recession is evident at the 1 wk postoperative visit (right panel).

Periodontal therapy alone may lead
to GR and thus to an increased vul-
nerability of the root surface to caries.
While the crucial role of subgingival
mechanical debridement (scaling and
root planing) in the treatment of peri-
odontitis is undisputed (121), the
occurrence of GR development or
increase following mechanical instru-
mentation has been widely reported
(122–124). GR development or pro-
gression following scaling and root
planing, especially for initially shallow
or moderately deep probing depths
(125), is particularly evident in
patients with thin gingiva (126).
Cause-related periodontal therapy,
through ultrasonic or hand instru-
mentation, acts on the root surface by
removing or exposing cementum and
dentin; these tissues are characterized
by a lower degree of mineralization,
limited amount of fluoride and poorer
caries resistance than enamel (48).
Furthermore, repeated professional
oral hygiene procedures may lead to
an imbalance of normal competitive
microflora, promoting the growth of
cariogenic bacterial colonies on the
root surface (127).
Ravald et al. (10,80,128,129) studied
longitudinally the incidence of RC and
the main reasons for tooth loss in a
population of periodontally treated
patients at four (128), eight (10), 12
(80) and 14 (129) years of maintenance
periodontal therapy. The mean age of
patients was 52  10.6 years (range
30–78) at baseline and 64  8.3 years
(range 49–91) at the final examination.
During the first 4 years of follow-up,
approximately two-thirds of patients
developed RC lesions. This incidence
of new RC lesions was confirmed
during all observation periods, exhibit-
ing a certain degree of clustering in
some patients and sporadic or
recurrent correlation with advanced
age (10,80,128,129), salivary counts of
S. mutans and Lactobacilli
(10,80,128,129), plaque score (10,80),
dietary habits (10), previous RC experi-
ence (10,128), low saliva secretion rates
(128) and smoking habit (80,129). In
these studies, patients with ongoing
periodontal problems were more preva-
lent (49%) than patients with RC alone
(3%), and recurrence of periodontal
Root caries: a periodontal perspective
breakdown was the main cause of tooth
loss during the period of observation.
However, a combination of periodon-
tal problems and RC was evident in
20% of the considered population, and
RC lesions alone accounted for 13% of
failing teeth (129). It should be empha-
sized that subgingival mechanical
debridement is indicated, and must be
performed, only in pathologically
involved periodontal sites; subgingival
instrumentation performed on physio-
logic crevices, with shallow probing
depth values and absence of bleeding
on probing, may result in iatrogenic
CAL and GR, which could promote
long-term RC occurrence.
The nonsurgical therapy of peri-
odontitis may include systemic and/or
local chemotherapeutic agents that
target either the pathogenic biofilm or
host-derived catabolic processes (130–
133). Although most of the chemo-
therapeutic drug studies are of short
duration, which precludes consider-
ation of RC development, even stud-
ies of sufficient duration (  12 mo)
have not included RC assessment
(134–137). Therefore, the potential
impact of periodontal chemotherapeu-
tics to RC incidence or prevention
remains to be investigated.
Root caries: relationship with
surgical periodontal therapy
Although surgical pocket elimination
remains an important component of
periodontal treatment, it can be antic-
ipated that periodontal surgery, espe-
cially when incorporating resective
procedures, will have an even greater
impact than nonsurgical therapy in
promoting increased RC incidence.
Kaldahl et al. (138,139) followed 82
patients with chronic periodontitis
(initial mean age 43.5 years) treated
by either coronal scaling, root plan-
ing, modified Widman surgery, or
osseous resection surgery in a four-
quadrant split-mouth design, evaluat-
ing probing depth, CAL and GR after
2 (138) and 7 (139) years of mainte-
nance therapy. In general, osseous
resective surgery produced both the
greatest probing depth decrease and
the greatest amount of GR compared
with other therapies, showing the
151
worst probing depth/GR ratio in sites
of medium (5–6 mm) and shallow
(1–4 mm) probing depth. Even
though it is important to emphasize
that sites treated by resective surgery
seem to have the least incidence of
breakdown during long-term follow-
up (139), it is fair to point out that
the potential significant amount of
GR resulting from this surgical
approach (Fig. 1C) may constitute a
limit of the obvious and generally
recognized clinical benefit of osseous
surgery in certain cases.
In this context, when surgical inter-
vention is deemed necessary, an alter-
native to osseous surgery, such as
open flap debridement, may be con-
sidered to gain access to the affected
root surfaces without drastically
changing the periodontal tissue archi-
tectural relationships, thus minimizing
post-surgical GR occurrence. Further-
more, as two determining factors for
the prognosis of surgically treated
sites are the quality of the patient’s
postoperative plaque control and the
frequency of maintenance care
appointments (140,141), patients who
have difficulty in maintaining a high
standard of self-performed daily oral
hygiene and/or regular attendance for
dental check-ups are not the best can-
didates for resective periodontal sur-
gery (or any periodontal surgical
therapy, for that matter).
Other site-specific putative
predisposing factors;
noncarious cervical lesions
In sites affected by GR, it is not
uncommon to observe an associated
noncarious cervical lesion (NCCL) on
the exposed root surface. NCCL is
defined as the wear of tooth substance
along the gingival margin of the
tooth, due to mechanical abrasion,
erosion or abfraction. The different
underlying etiologies result in NCCL
with diverse clinical characteristics.
Dental abrasion is frequently asso-
ciated with repeated mechanical
trauma from compulsive, excessive
toothbrushing and use of abrasive
toothpaste or hard toothbrush. The
frequency and duration of tooth-
brushing, force applied and structure
152 Bignozzi et al.

of dental tissues influence the degree face (Fig. 2A). Dental erosion is tooth erosion lesions appear as not well-
of tooth wear in each individual structure dissolution without bacterial demarcated, hard and quite smooth
(142). Root surface abrasion lesions involvement, due to intrinsic (e.g. gas- areas (Fig. 2B). Abfraction lesions
appear as well-demarcated cervical tro-esophageal reflux) or extrinsic appear to be the consequence of tooth
concavities, usually more broad than (e.g. acidic foods such as fruit juices) bending and strain, possibly due to
deep, showing a hard and smooth sur- acid sources (143). Root surface eccentric occlusal forces (144). They
commonly present as deep, narrow,
v-shaped notches on the facial aspect
A B of the cervical area (Fig. 2C).
Recent clinical and experimental
findings suggest that it is the synergis-
tic action of the various processes
cited above, with mechanical causes
such as abrasion and abfraction being
potentiated by chemical dental ero-
sion, which results in tooth structure
wear, as opposed to the action of a
single damaging mechanism (145).
C NCCLs have the potential to evolve
and in later stages result in dentin
hypersensitivity (146), severe loss of
tooth structure integrity and pulpal
involvement (Fig. 2D). More impor-
tantly, for the context of the present
topic, NCCLs may be complicated by
superimposed RCs (147) (Fig. 2E).
It is widely recognized that NCCL
and RC are distinct nosologic entities,
D E and risk models generally do not con-
sider NCCL as a predisposing factor
for RC (78). Nevertheless, these two
pathological conditions share some
clinical features (such as progressive
impaired structural integrity of cervi-
cal dental hard tissues), pathogenic
factors (such as cavitation from inter-
mittent demineralization processes
(148) and long-term consequences, as
F mentioned above; these shared traits
establish a conceptual link between
NCCL and RC. In this context, it is
reasonable to postulate that the pres-
ence of NCCL, i.e. concave area near
the gingival margin, may promote
bacterial biofilm* accumulation on
tissues with decreased microstructural
resistance and thus result in RC
development (149).
Fig 2. (A) Patient with multiple noncarious cervical lesions, likely due to mechanical
trauma from horizontal toothbrushing (abrasion lesions). (B) Gingival recession defects
Specifically focusing on dental
associated with noncarious cervical lesions apparently due to erosion from acidic foods erosion, long-term high intake of
and drinks. (C) Noncarious cervical lesions probably related to occlusal imbalance (abfrac- acidic drinks or foods has been shown
tions). Frontal view (left panel) and lateral view (right panel); note the wear facets on to reduce surface hardness of enamel
canines and premolars. (D) Advanced noncarious cervical lesion resulting in pulpal expo- and dentin (150). Frequent exposure to
sure (endodontically treated left central incisor) in elderly patient; note the good level of erosive substances, in the presence of
oral hygiene and superimposed inactive carious lesion. (E) Carious cervical lesion superim- good oral hygiene, results primarily in
posed on noncarious cervical lesion. (F) Multiple restored noncarious cervical lesions and dental erosion without caries. Hard tis-
coexisting buccal and interproximal root caries, under conditions of suboptimal oral sue loss after acid exposure and imme-
hygiene, in an elderly patient. diate toothbrushing is significantly

greater than acid erosion alone
(151,152) and, paradoxically, it would
be advisable to avoid toothbrushing
for at least 30 min after an erosive
attack to protect dentin (153). Never-
theless, in a patient who presents with
multiple NCCLs a decline in self-
performed oral hygiene standard can
quickly lead to the onset of deep RC
lesions superimposed on the previous
inactive ones (154) (Fig. 2F).
Root caries: preventive and
therapeutic considerations
From a clinical standpoint, there is
general agreement in the literature
that deep cervical lesions, regardless
of their carious or noncarious nature,
require a full understanding of their
etiology; this will allow the clinician
to provide the patient with appropri-
ate information on lifestyle changes
and adoption of preventive measures
(145), as well as proper restorative
treatment to preclude further damage
(154).
Preventive measures
Proper preventive measures should be
taken based on the estimated level of
risk for the individual patient. In gen-
eral, all modifiable behaviors that
have been implicated, as outlined
above, in the multifactorial model of
pathogenesis should be addressed, to
the extent possible. Particularly, pre-
vention of RC, similar to coronal car-
ies, is based on modification of
harmful dietary habits, inhibition of
demineralization, promotion of remin-
eralization and reduction of the cario-
genic dental biofilm (155).
The high consumption of low molec-
ular weight carbohydrates, especially in
industrialized countries, appears to be
strongly implicated in the observed
high caries prevalence, as organic acids
resulting from the anaerobic metabo-
lism of fermentable dietary sugars is
the main cause of demineralization and
cavity development (91). Accordingly,
patient education regarding diet, i.e.
avoiding high-sugar containing foods
and snacks and limiting the frequency
of sugar intake, should be an essential
component of a caries prevention
Root caries: a periodontal perspective
program (91). Nevertheless, sugar
restriction may be a difficult goal to
achieve for most individuals (156), con-
sidering that sweet taste may be
responsible for addictive-like behaviors
(157). A possible support strategy to
address this concern is to replace fer-
mentable carbohydrates with noncario-
genic sugar alcohols such as sorbitol or
xylitol, to decrease sugar intake and
thus reduce caries risk (158). The
replacement of sugar with xylitol was
able to produce a substantial (85%)
decrease in caries incidence in an adult
Finnish population during a 2-year
observation period (159).
Furthermore, when polyol sweeten-
ers are delivered in the form of chew-
ing gum, the chewing action in itself
and the resulting salivary flow stimu-
lation may provide further protective
effects (160). Accordingly, xylitol and
sorbitol in chewing gum or candies
were able to significantly reduce RC
incidence in a geriatric patient popu-
lation sample over a 6–30 month per-
iod (161). Although the widespread
adoption of a xylitol regimen for
caries prevention appears to be non-
sustainable, because of low cost-effec-
tiveness (160), this prevention strategy
remains viable when applied to high-
risk populations such as disabled,
elderly and most frail individuals
(155).
Fluorides are widely recognized to
be a key factor in the prevention and
control of dental caries, through
inhibition of demineralization and
enhancement of remineralization.
Topical fluoride treatments may be
indicated, especially in patients with
reduced salivary flow or impaired self-
performed oral hygiene ability (162),
but higher fluoride concentrations
seem to be required for remineraliza-
tion of RC in comparison with coro-
nal caries (163). There are several
options available, such as daily
5000 ppm sodium fluoride toothpaste
or 0.025–0.1% fluoride mouth rinses,
neutral 1.2% sodium fluoride gel (in a
5-min tray), as well as sodium fluoride
or silver diamine fluoride varnishes
applied on to the exposed root sur-
faces three to four times a year;
finally, fluoride tablets, chewing gum,
toothpick and flossing have been
153
proposed, although their use may be
questioned due to unfavorable cost–
benefit ratio (164).
Griffin et al. (165), analyzing thro-
ugh a systematic review with meta-
analysis the effectiveness of various
forms of fluorides in preventing caries
in adults, reported that any form of
fluoride administration (self- and pro-
fessional application or water fluori-
dation) results in a RC prevented
fraction of 22% per year. There is
some evidence (166) of a synergistic
effect of amorphous calcium phos-
phate and casein amorphous calcium
phosphate complexes with fluoride,
through the induction of a favorable
chemical gradient of calcium and
phosphorous at the tooth surface able
to induce remineralization and
reduced incidence of RC even in
patients at particular risk (167).
Recently, encouraging in vitro
results have been obtained testing a
proanthocyanidin-rich grape extract, a
widely available naturally occurring
plant metabolite, in reducing root
dentin demineralization during a
pH cycling artificial caries protocol
(168,169). Based on the principle that
proper mineralization of a collagen-
based tissue (i.e. root dentin) strictly
depends on structure and stability of
its extracellular organic matrix, the
mechanism of action hypothesized for
a proanthocyanidin-rich grape extract
in inhibiting RC relies on increased
collagen cross-links and reduced enzy-
matic degradation of the root collagen
matrix (168). A synergistic effect with
fluoride has been speculated, but fur-
ther studies are needed to deepen the
knowledge about this promising natu-
ral agent.
Moreover, as already underlined, it
is essential to motivate the patient to
perform satisfactory oral hygiene rou-
tines and attend regular dental check-
ups, as a good standard of oral hygiene
is a necessary condition in any caries
prevention program, but especially
when addressing RC prevention (170)
in the periodontal patient. Focusing on
patients with a history of periodontal
disease and therapy, typically exhibit-
ing generalized CAL and numerous
tooth surfaces with GR, the resulting
anatomical complications must be
154 Bignozzi et al.
considered a nonmodifiable risk factor;
however, the patient’s motivation to
achieve a high standard of oral hygiene,
along with close monitoring of at-risk
sites, integrated with the patient’s peri-
odontal maintenance program, may be
useful in preventing RC occurrence
(171). Antimicrobial agents, such as
chlorhexidine, have been investigated
as additional tools in reducing cario-
genic oral biofilm (172), but – specifi-
cally considering RC prevention – the
current lack of evidence on long-term
clinical outcomes and ascertained side
effects makes chlorhexidine devoid of
any added clinical benefit compared to
conventional and well-established
preventive measures, i.e. diet modifica-
tion, fluoride delivery and improved
oral hygiene (173). In patients with
impaired salivary gland function, due
to aging, radiotherapy, diseases or
medications, the administration of sali-
vary substitutes to buffer the acidic
environment and inhibit adhesion and
growth of bacteria might also be of
help (174,175).
The general preventive measures
considered above are useful and effec-
tive in preventing RC by reducing the
impact of risk factors throughout the
oral cavity. In addition to general pre-
vention, it is possible to implement
site-specific measures that, from a
periodontal standpoint, could repre-
sent an important clinical strategy to
prevent and arrest RC (176–178).
Whenever possible, the ideal site-
specific approach to RC prevention in
GR cases, with or without initial RC
or NCCL, is the restitutio ad integrum
of the root–periodontium complex
(102). Complete root coverage will
significantly diminish, if not eliminate,
the possibility of RC development
and progression for the specific site.
State of the art of root coverage peri-
odontal techniques have been the sub-
ject of several clinical trials (179–183)
and systematic reviews (184–186).
Although great progress has been
made in the surgical treatment of GR,
and the available techniques show
excellent results (185,186), it must be
emphasized that most, if not all, of
the published studies have not consid-
ered specifically the patient with a his-
tory of inflammatory periodontal
involvement. Therefore, clinical stud-
ies focusing on the periodontal man-
agement of GR in this class of
patients are warranted. Given the pro-
gressing aging of the population, such
studies will be particularly applicable
to periodontal practice.
Restorative therapeutic approaches
The potential consequences of both
RC and NCCL, e.g. dental pulp and/
or marginal periodontal tissue involve-
ment, hypersensitivity and compro-
mised aesthetics, demand a timely and
comprehensive therapeutic approach
for each lesion. Such a site-specific
approach may include the use of res-
torations (Fig. 3). Glass ionomer,
resin-modified glass ionomer, resin
composite, fluoride-containing resin
composite or compomer restorations
may be recommended based on indi-
vidual patient risk (187). In this con-
text, it should be emphasized that
unique aspects of the tooth cervical
area, i.e. less than ideal characteristics
as adhesion substrate (188), concentra-
tion of biomechanical stress (189),
spatial relationship with the marginal
periodontium and difficulties in access
and field isolation, may render chal-
lenging the achievement of perfect
marginal seal and long-term success of
composite restorations used to treat
RC. However, as restorative issues are
not the focus of this review, the reader
is referred to specific sources on this
topic (154,190).
Periodontal therapeutic approaches
Deep RC may occur, involving deep
layers of dentin and/or affecting the
root at a more apical level than the
cervical area or the marginal gingiva.
In such cases, the maximum apical
extension of RC should be carefully
considered to achieve complete
removal of the decayed tissue and
proper cavity restoration. RC that
extends below the gingival margin
may impinge on the biologic width
and interfere with the gingival attach-
ment apparatus (191).
A deeply placed restorative margin,
violating the biologic width, will
result in loss of periodontal support
(192). Tal et al. (193) considered in a
beagle dog model class V cavities pre-
pared so that the apical margin was
in close spatial relationship with the
alveolar crest (test) and other cavities
not exceeding the CEJ (control). All
cavities were restored and, at 1 year
following treatment, GR and bone
loss were significantly greater at test
sites in comparison with controls.
More recently, G€ unay et al. (194)
reported increased inflammatory
parameters and periodontal attach-
ment loss at prosthetic restorative
margins placed in proximity of the
bone crest, i.e. within the biologic
width. There is general agreement in
recommending that when RC extends
below the gingival margin the restora-
tion must be preceded by, or be part
of, a crown lengthening procedure
(Fig. 4) to re-establish a proper bio-
logic width apical to the proposed res-
toration margin (195).
Root caries: a risk factor for
tooth loss after periodontal
therapy
From a periodontal perspective RC is
significant not only because periodon-
tal disease (attachment loss) and ther-
apy lead to conditions (i.e. GR) that
favor RC development, as outlined in
the previous paragraphs, but also
because RC can be a leading factor
compromising the long-term outcomes
of definitive periodontal therapy. Lon-
gitudinal studies have shown that in
cases of advanced periodontal disease,
where resective therapeutic approaches
(such as osseous surgery combined
with root amputation, hemisection or
tunneling procedures) have been
employed, it is not uncommon for the
initially successful therapeutic out-
come to be compromised long-term,
primarily because of complications
other than periodontal ones, and espe-
cially because of RC (196). In this
regard, several authors reported RC
occurrence to account for 7.9% (202)
to 25% (203), and up to 50% (204) of
the nonsalvageable complications
leading to tooth extraction.
The frequency of periodontally
involved teeth treated by resective sur-
gery and subsequently condemned

A B
C D
E F
G H
Fig. 3. Root caries occurrence in patient with periodontitis treated with resective surgery
and root amputation; clinical view at baseline (A) and at 3 mo (B), 2 years (C), 3 years
(D) and 6 years (E, F) postoperatively. Recommended restorative procedure was per-
formed (G, H) following the long-awaited patient consent.
because of RC suggests that patients
with periodontitis who are candidates
for osseous surgery must undergo a
stringent assessment for all endodon-
tics, prosthetic and periodontal prog-
nostic factors before implementing
such a treatment approach (197).
Ultimately, the level of patient com-
pliance and feasibility of an adequate
maintenance program, in conjunction
with an individualized caries preven-
tion protocol during follow-up, will
allow the patient who received resec-
tive periodontal therapy to remain
Root caries: a periodontal perspective
free of RC and retain the function
of his/her periodontally treated denti-
tion.
Root caries and periodontal
issues in the elderly
Longer life expectancy and decreased
edentulism result in an ever-increasing
number of elderly patients retaining
their natural dentition in advanced age
and being in need of special dental ser-
vices (198). Aging is associated with
changes, such as reduced manual
155
dexterity and altered oral anatomical
structures, which can hinder the
performance of proper oral hygiene.
Senescence is also associated with
reduced salivary flow, because of age-
related structural salivary gland
changes (199,200) or functional impair
ment induced by various systemic dis-
orders and medications. Hyposaliva-
tion is a debilitating condition that can
potentially induce difficulty in chewing
and speaking, as well as taste loss, dys-
phagia, and increased incidence of den-
tal caries and soft tissue pathologies
(201,202). Furthermore, other factors
can also contribute to deficiencies in
the structural integrity of teeth in
elderly people through an incremental
effect over the years: dietary acid
exposure, oral parafunctional habits,
occlusal trauma, attrition, abrasion
from toothpastes or powders, erosion
by alteration of oral pH due to medi-
cations or gastro-esophageal reflux
(145).
Consistently, the prevalence of RC
in adults has been shown to progres-
sively increase with age (203–205).
The 1988–1991 NHANES III national
survey (203) provided evidence for
RC prevalence among nearly 6726
people; 55.9% of patients aged
 75 years had one or more RC
lesions, with severity being age-
dependent. The NHANES III study
established that, past the age of
34 years, the expected probability for
a person of having one or more
decayed or filled root surface will be
20–22% less than his age. This means
that for a person aged 65 years, a 43–
45% probability of having one or
more RC may be assumed.
More recently, different prevalence
rates in the elderly have been reported
in the literature, ranging from 28.4%
to 96.5% (12,13,206–210). This wide
range of RC prevalence probably
reflects the highly diverse ethnic, cul-
tural and social background of the
populations examined in the afore-
mentioned studies; such differences
are likely to represent different dietary
habits, standards of oral hygiene, and
other relevant parameters, such as
availability of water fluoridation,
community-dwelling or institutional-
ized subjects, and urban or rural
156 Bignozzi et al.
A B
C D
Fig. 4. Root caries under fixed dental prosthesis; note the extension of the carious lesion
apical to the gingival margin. Clinical view at initial presentation (A), during crown
lengthening surgery (B), intraoperative restoration application (C), and 3 mo postopera-
tively (D).
inhabitants. Nevertheless, it is clear
that RC in the elderly is a problem
with a global impact. In older adults
it is not unusual to find RC, espe-
cially at the margin of previous pros-
thetic restorations, which often extend
below the gingival margin.
Increased RC susceptibility of the
elderly may be due to age-specific
behavioral and socio-demographic
characteristics, as mentioned above.
However, from a clinical point of view,
the main local factor that may be asso-
ciated with increased RC prevalence is
root surfaces becoming exposed simply
due to aging or progressive periodontal
disease (41,69). Coherently, in peri-
odontal patients the estimated RC risk
profile appears correlated with a
number of predisposing factors but
as reported above, the prevalence
increases with the amount of CAL and
with advancing age (108). A correlation
with advanced age recurs also in stud-
ies, including periodontally involved
patients receiving long-term supportive
periodontal therapy (10,80,128,129). In
this regard, the cumulative effect over
time of repeated professional root
instrumentation procedures should be
considered.
With respect to resective periodontal
surgery, age per se is not a contraindica-
tion for this approach, which – when
used in older adults – seems to provide
clinical outcomes similar to those
obtained in younger patients (140).
However, careful consideration con-
cerning the advisability of performing
resective surgery in the elderly patient is
necessary (211). Considering the docu-
mented increased RC risk with advanc-
ing age (41,69,80) and greater GR
(79,97,99), the overall therapeutic
advantage of radical surgical pocket
elimination should be carefully weighed
in the context of the overall dental
health management of the older adult.
As previously mentioned, furcation-
involved molars treated with flap sur-
gery and root resection are prone to
the development of a series of compli-
cations, including RC (197,212,213).
It is reasonable to assume that in
elderly populations the coexistence of
several predisposing factors, such as
hyposalivation or impaired manual
dexterity may result in increased post-
operative RC incidence; nevertheless,
targeted studies on age-specific popu-
lations, which may corroborate this
assumption, are still lacking (196).
Similarly, knowledge on some other
issues regarding RC in the elderly is
still scarce. Current models of RC
microbiological etiology are based
mainly on studies of young and mid-
dle-aged adults. Bacterial species other
than those commonly found have been
isolated in RC lesions of elderly
patients (214), suggesting that the
putative RC etiologic agents in older
adults belong to microbial communi-
ties more complex than previously
presumed (44,87). Recently Preza
et al. (215), using an rRNA-based,
culture-independent, microarray tech-
nique in a sample of 41 patients aged
70 or older, did not find specific
strains to be consistently associated
with RC, suggesting the possibility of
a certain degree of intersubject vari-
ability regarding RC bacterial etiology
in this age-specific setting and the need
for additional research. Moreover,
although the caries process is endemic
in the elderly and more than 50% of
all individuals retaining their dentition
after age 65 have at least one RC
lesion (205,216,217), clustering has
been observed so that only a third of
the older adults account for the
majority of RC cases (218–220); the
latter observation suggests the possible
contribution of yet unknown genetic
factors (90). Specifically focusing on
patients with periodontitis, the inte-
nse protein-degrading activity found
at RC-affected and periodontally
involved sites may suggest the possi-
bility of a special role for protein-
degrading and protein-coagulating
bacterial strains in the onset and pro-
gression of RC (56). This putative
pathogenic mechanism deserves fur-
ther investigation, with special empha-
sis on the elderly.
Other special issues of RC in the
aging patient should be considered as
well. RC diagnosis in elderly people
may be complicated by the necessity to
perform examinations under nonideal
clinical settings (221) and the reduced
ability to maintain a good standard of
oral hygiene, resulting in greater bac-
terial biofilm accumulation [Correction
added on 20 May 2013, after first
online publication: The phrase ‘result-
ing in greater plaque deposits’ has been
corrected to ‘resulting in greater bac-
terial biofilm accumulation’.] on the
root surfaces (222). Such diagnostic
difficulties lessen the reliability of the
reported epidemiological data in the

age-specific populations and, more
importantly, may result in inadequate
patient care.
As regards prevention, a good stan-
dard of oral hygiene may be a chal-
lenge for the elderly, because of
physical and mental disabilities.
Changes in dietary habits and gravita-
tion towards softer foods rich in sim-
ple sugars – typical of the elderly
population – may complicate further
prevention efforts. Therefore, elderly
patients need to receive adequate
motivation and support for the neces-
sary changes in diet, with particular
emphasis on the frequency of ferment-
able carbohydrate ingestion and the
possible replacement with noncario-
genic sweeteners (161). Moreover,
instructions to maintain the best pos-
sible plaque control using electric or
manual toothbrush, floss, interdental
brush and adjuvants such as chlorhex-
idine and fluoride mouthwashes, and
fluoride or anti-plaque dentifrices
(223) should be provided, especially in
elderly patients with a history of peri-
odontal involvement. Unfortunately,
other age-specific socio-demographic
characteristics, such as institutionali-
zation, lower socio-economic status
and age-related cognitive decline, may
severely impair effective patient com-
munication or essentially curtail the
patient’s ability to comply with peri-
odontal maintenance.
In conclusion, advanced age, peri-
odontitis and RC are a triad of condi-
tions frequently interrelated. The
recent epidemiological data indicating
that moderate or severe periodontitis
affects 64% of adults aged  65 years
in the United States (224) underscores
the relevance of periodontal disease for
the older adult. Therefore, future stud-
ies on RC in periodontally involved
elderly populations are needed to bet-
ter understand epidemiologic, diagnos-
tic, preventive and therapeutic aspects
predominantly or uniquely relevant to
this patient subgroup.
Root caries and periodontal
disease: need for greater
awareness
Although the evidence linking peri-
odontal disease to RC development is
Root caries: a periodontal perspective
well established, it appears that impli-
cations of the interrelationship
between these two clinical entities have
not been routinely considered in the
course of RC investigations. Despite
the fact that GR and, in general, peri-
odontal attachment loss are biological
factors essential for RC onset and pro-
gression, often these variables are not
investigated in the proposed risk mod-
els (78). The inclusion of these param-
eters in future investigations should
help determine further the significance
of the periodontal component in RC
pathophysiology.
Despite the recognition of the signif-
icance of RC prevention protocols as
integral parts of a periodontal mainte-
nance program (80,225), it appears
that RC prevention is commonly not
given due weight and importance dur-
ing periodontal supportive therapy
(226). Given that high patient compli-
ance with periodontal maintenance has
been shown to result in protection
from further attachment loss and the
onset of new RC (227), a fact that
underscores again the interrelationship
between the two conditions, it is evi-
dent that periodontists, hygienists or
other oral healthcare providers respon-
sible for periodontal maintenance, can
play a key role in RC prevention.
Specifically emerging from this
review, future research should assess
provider awareness about the impact
of RC as a risk factor for further
tooth loss in periodontally compro-
mised patients of advanced age, with
the inevitable consequences of edentu-
lism and reduced quality of life. Clini-
cal studies regarding the effect of
specific RC prevention protocols –
possibly based on targeted check-ups,
dietary advice, improved oral hygiene
techniques supplemented by topical
fluoride therapy – long-term results of
periodontal maintenance care and rate
of tooth loss would help improve the
oral care of older patients and should
help increase awareness of the signifi-
cance of RC in this growing segment
of the population.
Conclusions
This review highlighted the need for
careful consideration of the potential
157
role of RC in compromising the long-
term survival of the dentition of peri-
odontal patients. RC appears to be
an underestimated clinical problem,
despite its high prevalence and contri-
bution to tooth loss in this patient
population. The exposure of root sur-
faces to the oral environment due to
aging, i.e. progressive GR, makes
them prone to carious involvement.
The risk of RC in patients with a his-
tory of periodontitis and resective sur-
gery, especially in multi-rooted teeth,
is of particular concern. Therefore,
general preventive measures such as
noncariogenic diet and fluoride appli-
cation together with plaque control,
must be regarded as mandatory com-
ponents of any periodontal mainte-
nance program. Careful assessment of
each individual case is needed to out-
line a patient-centered comprehensive
preventive and therapeutic approach
for RC lesions. The high prevalence
of periodontitis in older adults,
increasing life expectancy and decreas-
ing edentulism of the population, and
apparent coexistence of RC with
advanced age and periodontitis, col-
lectively suggest that RC could
become an increasingly frequent chal-
lenge for periodontal care providers.
From this standpoint, future studies
are needed to address special diagnos-
tic, preventive and therapeutic mea-
sures to best meet the needs of the
elderly periodontal patient.
Acknowledgements
We gratefully acknowledge Dr Luca
Landi and Dr Takuichi Sato for the
scientific material provided.
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