Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.

150625

Long-term Outcomes of Untreated Buccal Gingival Recessions. A Systematic

Review and Meta-Analysis
Leandro Chambrone, DDS, M.Sc., Ph.D* & Dimitris N. Tatakis, DDS, Ph.D†

*Unit of Basic Oral Investigation (UIBO), School of Dentistry, El Bosque University, Bogota, Colombia;
and School of Dentistry, Ibirapuera University (Unib), São Paulo, Brazil.
†
Division of Periodontology, The Ohio State University, College of Dentistry, Columbus, Ohio, USA.
Objective: This review aimed to (1) assess the long-term outcomes of untreated buccal gingival recession (GR) defects
and the associated reported esthetic and functional alterations, and (2) to evaluate which factors can influence the
progression/worsening of dental and periodontal tissue conditions of untreated GR defects.
Methods: Interventional and observational studies with a duration ≥24 months reporting outcomes from adult patients
with localized or multiple GR defects not treated by root coverage or gingival augmentation procedures were considered eligible
for inclusion. The MEDLINE and EMBASE databases were searched for articles published up to and including July 2015.
Random effects meta-analyses were performed comparing baseline versus most recent follow-up outcomes (i.e., number of
patients with at least one GR and number of GR).
Results: Of 378 potentially eligible papers, eight papers (reporting six studies) met inclusion criteria. Of 1647 GR
defects with baseline and follow-up information, 78.1% experienced recession depth (RD) increase during the follow-up period,
while the remaining experienced decrease or no change. Moreover, there was a 79.3% increase in the number of GR defects
among the patients followed (i.e., new GR defects). Pooled estimates (data from 4 studies) showed significantly increased odds of
recession development at long-term, regarding either number of patients (OR: 2.43; p = 0.03) or number of sites experiencing GR
(OR: 2.16; p = 0.0005).
Conclusions: Untreated recession defects in subjects with good oral hygiene have a high probability of progressing
during long-term follow-up.

KEY WORDS (MESH TERMS):

gingival recession; evidence-based dentistry; meta-analysis; tooth root; gingival recession/epidemiology; gingival
recession/physiopathology.

INTRODUCTION
The development of gingival recession (GR) is associated with “oral exposure of the root surface due to a
displacement of the gingival margin apical to the cemento-enamel junction”,1 but also with esthetic
concerns, functional impairment and other tooth-related conditions. 2-5
Different worldwide populations, whether periodontally healthy or not, demonstrate high GR
prevalence.6-8 Strong evidence indicates that root coverage procedures result in reduced recession depth
[RD] and width, clinical attachment level (CAL) gain, and keratinized tissue (KT) quality (width/thickness)
enhancements.2-5 These procedures are part of the contemporary clinical decision-making for the
management of patients presenting with GR.5
Although the predictability and effectiveness of periodontal surgical techniques used to treat GR are well
documented, the question whether to treat or not a specific recession oftentimes perplexes clinicians.9 The
question deserves attention because GR defects, when left untreated, do not improve spontaneously and may
progress to increased RD. RD progression may result in worsened esthetics and impaired function because
of increased dental hypersensitivity.2-5 What complicates the answer to the question is the lack of evidence
to suggest that GR defects per se, unlike periodontitis related CAL loss,10 will lead to eventual tooth loss in
susceptible individuals.
With respect to the long-term assessment of untreated GR, several questions remain to be answered:
there is no consensus whether these defects will continue developing and lead to RD increase; if RD
increases over time, the expected CAL loss rate is unknown; the potentially associated increase in root caries
or non-carious cervical lesion development has not been established; the related patient-centered outcomes
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Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.150625

have not been investigated. To date, no systematic review has focused on the specific topic of untreated GR
long-term outcomes.
The objectives of this review were to (1) assess the long-term (≥24 months) outcomes of untreated GR
defects and the associated reported esthetic and functional alterations, and (2) to evaluate which factors
influence the progression/worsening of dental and periodontal tissue conditions of untreated GR defects.
The following focused questions were addressed: “What are the potential anatomical changes and associated
risks for a GR defect if left untreated for a long period of time?” and “What are the factors influencing the
possible deterioration of dental and periodontal tissue conditions?”

MATERIALS & METHODS

The study protocol is registered at the National Institute for Health Research PROSPERO, International
Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/PROSPERO, registration number
CRD42015023220).11 The review text was structured in accordance with guidelines from PRISMA
(Preferred Reporting Items for Systematic Reviews and Meta-Analyses),12 the Cochrane Handbook of
Systematic Reviews of Interverstions,13 and Check Review checklist.3

Type of Studies and Participants (Inclusion Criteria)

Randomized controlled trials (RCT), controlled clinical trials (CCT) and observational studies of ≥24
months duration, with ≥10 participants, were considered eligible for inclusion. Interventional studies were
included if they reported clinical outcomes from adult (≥18 years old) patients with localized or multiple GR
defects treated by root coverage or gingival augmentation procedures. Observational trials should have
reported the clinical outcomes of patients with untreated GR. To be considered eligible for inclusion, studies
should have reported GR diagnosis based on probing/clinical measurements.

Exclusion Criteria
Trials, case reports, or case series not fulfilling the above inclusion criteria, reviews and other types of
publications were excluded.

Outcome Measures
Primary and secondary outcomes were assessed. Primary outcome measures included RD change, KT
change, exposed root surface condition change, hypersensitivity change, KT effect on RD change, change of
esthetic assessment (by the patient). Secondary outcome measures were: CAL change; tooth loss; plaque
index (PI); gingival index; bleeding on probing (BOP); patient preference for having a GR treated or not
(split-mouth trials); percentage of patients/sites requesting/receiving periodontal plastic surgery to treat
existing GR defect over time.

Search Strategy
Comprehensive search strategies were established to identify studies for this systematic review. The
MEDLINE (via PubMed) and EMBASE databases were searched for articles published up to and including
July 2015, without language restrictions, based on the search strategy developed for MEDLINE: ((gingival
recession OR recession defect OR recession-type defect) OR (exposed root surface OR exposed root OR
gingival defect OR denuded root surface) AND (untreated OR untreated recession OR untreated gingival
recession OR undisturbed gingival recession OR non-treated recession OR recession progression)).
Reference lists of any potential articles, and OpenGrey14 database were screened for relevant
unpublished studies or papers not identified by electronic searching. Additionally, the electronic databases
of four dental journals were searched—namely, Journal of Periodontology, Journal of Clinical
Periodontology, Journal of Periodontal Research and Journal of Dental Research.

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Assessment of Validity and Data Extraction

Two independent reviewers (LC and DNT) screened the titles, abstracts, and full texts of the articles
identified. Disagreement between them was resolved through discussion until consensus was reached. When
considered necessary, it was attempted to contact the authors to resolve ambiguity. Data on the following
issues were extracted and recorded: 1) citation, publication status, and year of publication; 2) location of
trial: country and place where the patients were treated (e.g., private practice or university dental hospitals);
3) study design: RCT, CCT or type of observational study; 4) characteristics of participants and group(s); 5)
methodological characteristics of the trial; 6) outcome measures; 7) authors’ conclusions; and 8) source of
funding.

Assessment of Risk of Bias and Quality Assessment in Included Studies

Two methodological quality assessment tools were used, based on study type. For RCTs and CCTs,
methodological quality was evaluated per the Cochrane Collaboration’s tool for assessing risk of bias,13 as
subsequently adapted15-17 to permit qualification of non-randomized trials (see supplementary Appendix 1 in
online Journal of Periodontology). Concisely, the randomization and allocation methods were classified as
adequate, inadequate, unclear, or not applicable. Based on that, the bias risk of the included studies was
classified as low, unclear or high.
For observational studies, an adapted version16-19 of the Newcastle-Ottawa (NOS) scale20 was employed
(see supplementary Appendix 2 in online Journal of Periodontology). Points (stars; 14 possible total
maximum stars per study) were given for each methodological quality criterion. Studies with 11-14 stars
(≥78% of the domains satisfactorily fulfilled) were arbitrarily considered to be of high methodological
quality; studies with 8-10 stars (57-71% of domains fulfilled) were of medium quality; and studies with <8
stars (≤50% of domains fulfilled) were of low quality.

Data Synthesis
The data were pooled into evidence tables, and a descriptive summary was generated to establish the amount
of data and study dissimilarities (characteristics and results). Random effects meta-analyses were performed
using dichotomous data comparing baseline versus most recent follow-up outcomes (i.e., number of patients
with at least one GR/total number of patients and number of GR/total number of teeth or buccal sites
assessed). Results were expressed as pooled odds ratios (OR) and associated 95% confidence intervals (CIs).
The significance of discrepancies in the estimates of the treatment effects from the different trials was
assessed by means of the Cochran test for heterogeneity and the I2 statistic. Analyses were performed using
statistical analysis software.‡

RESULTS
Description of Studies

Results of the search and excluded studies. A total of 378 potentially eligible papers (97.9% in
English language) were screened and 367 were excluded following title and/or abstract assessment (Figure
1). Of the 11 papers considered for full-text screening,21-31 three29-31 were excluded because data on gingival
recession were not reported/recorded.

Included Studies
Eight papers reporting on six studies met inclusion criteria.21-28 One study was reported in three
publications,23-25 and thus it is identified herein by one study name (Dorfman et al./Kennedy et al.). Two
studies were conducted in Italy,21,22 and one each in USA,23-25 Spain,26 Sweden,27 and the Netherlands.28
Their characteristics are summarized in Table 1. From these publications, data on 400 patients (82.6% of

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initially enrolled subjects) were available for analysis. The mean monitoring period was 8.9 years (range 5-
27 years).

Risk of Bias in Included Studies

The unique RCT included in this review23-25 was considered to be at high risk of bias because of lack of
information on randomization and allocation, lack of examiner blinding and selective reporting (exclusion of
data from defects exhibiting RD increase). Four observational studies21,22,26,27 were considered to have
medium methodological quality and one28 low (Table 2; see supplementary Appendix 3 in online Journal of
Periodontology).

Individual Studies Outcomes and Pooled Estimates

In total, 1753 buccal GR defects were assessed within the included studies. However, Schoo & Van der
Velden28 did not report on which/how many of the baseline 106 GR defects experienced RD change over
time.
Of the 1647 GR defects with both baseline and follow-up information, 78.1% (1287 defects)
experienced RD increase during the follow-up period. Also, 199 GR defects (7.2%) experienced RD
decrease and the remaining experienced no change. Moreover, at most recent follow-ups, the total number
of buccal GR defects increased to 3070, i.e., there was a 79.3% increase in the number of GR defects among
the patients followed.
Individual study findings regarding the other primary and secondary outcome variables of interest are
described bellow:
• RD change: Assessed in two studies. Agudio et al.21 reported outcomes of 73 sites with or without
attached gingiva and with or without GR, compared to 73 contralateral homologous GR sites lacking
attached gingiva that were treated with submarginal or marginal free gingival grafts (FGG). For the 55
untreated sites compared to the submarginal FGG procedure, there was 0.7 mm mean RD increase at last
follow-up; for the 18 untreated sites compared to the marginal FGG procedure, the mean RD increase RD
was 1.0 mm. Schoo & Van der Velden28 found that RD showed a slight decrease of 0.3 mm and 0.1 mm for
GR with KT ≤1 mm and KT >1 mm, respectively;
• KT change: Agudio et al.21 reported a mean KT width decrease of 0.5 mm and 0.7 mm for untreated
sites compared to submarginal and marginal FGG, respectively. Matas et al.26 showed a mean decrease of
0.18 mm. Conversely, Dorfman et al./Kennedy et al.23-25 reported 0.2 mm KT increase;
• Exposed root surface condition change: Only Agudio et al.21 reported on the exposed root surface
condition; no sites exhibited root caries, either at baseline or at follow-up.
• Hypersensitivity change: Agudio et al.21 reported a slight increase (2.74% from baseline) in the
number of sites (11 to 13) with hypersensitivity among 73 untreated sites. It was not reported whether these
same sites had experienced RD change over time.21
• Influence of KT on RD change: Only Matas et al.,26 through multiple regression analysis of the
parameters recorded at last follow-up, reported that KT was negatively associated with buccal GR
development (mean KT at follow-up was 3.48 mm); as stated above, baseline KT was not significantly
different from follow-up KT.
• Esthetic assessment change: None of the studies provided information on esthetic changes (self-
assessment by the patient);
• CAL change: From the Agudio et al.21 data, it was possible to calculate a mean CAL loss of 1.7 mm
and 2.0 mm for untreated sites compared to submarginal and marginal FGG treated sites, respectively, over
10-27 years; the CAL loss was almost exclusively due to RD changes. Schoo & Van der Velden28 reported

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an overall 0.4 mm mean CAL gain for GR with KT >1mm (p>0.05) and 0.1 mm CAL loss for GR with
KT=0 (p>0.05) over five years.
• Tooth loss: Four studies21, 23-25, 27, 28 provided no explicit information. Data reported by Agudio et
al. and Serino et al.27 indicate no loss of teeth with baseline GR. Daprile et al.22 reported no teeth lost.
21

Matas et al.26 reported one tooth lost (from 1100 teeth at baseline; reason for loss not reported).
• PI, gingival index and BOP: Agudio et al.21 reported all sites being BOP-negative at baseline and
follow-up. At last follow-up, Daprile et al.22 found significantly less plaque-positive buccal surfaces and
non-significantly less plaque-positive buccal GR surfaces. Dorfman et al./Kennedy et al.23-25 reported
significant PI and gingival index reduction. Matas et al.26 reported significant PI increase overall and BOP
increase at GR sites.
• Patient preference for having a GR treated or not: No study provided specific information. Patients
reported greater discomfort during toothbrushing in untreated sites;21 this statement alone cannot be
considered an indication of preference for having GR defects treated.
• Percentage of patients/sites requesting/receiving periodontal plastic surgery to treat existing
recession over time: Dorfman et al./Kennedy et al.23-25 reported that three control group GR defects (21.6%)
were directed to treatment because additional RD ≥2 mm occurred.
Four sets of meta-analyses were performed (Figures 2 and 3). The meta-analyses revealed significantly
increased odds of GR development, in terms of the number of patients (OR: 2.43; 95% CI: 1.09, 5.42; p =
0.03, I2 = 40%) (Figure 2.1) or the number of sites experiencing GR (OR: 2.16; 95% CI: 1.40, 3.33; p =
0.0005, I2 = 91%) (Figure 3.1). Both pooled estimates identified a high degree of heterogeneity. Visual
inspection of generated forest plots suggested that this outcome could be associated with the results of
Mattas et al.26 Thus, two ancillary analyses were conducted without the data from that study,26 and both
resulted in no significant heterogeneity (Figures 2.2 and 3.2).

DISCUSSION
Summary of Main Results
This systematic review identified limited but consistent evidence that untreated buccal GR defects in
subjects with good oral hygiene are highly likely (78% of defects) to progress, experiencing RD increase
during long-term follow-up. Four studies (67% of included studies) showed RD increase after a minimum
follow-up period of five years (Table 1). In general, the pre-existing amount of KT seems to influence the
development and progression of GR during follow-up, with sites lacking KT seemingly more susceptible to
further CAL loss. These findings are supported by both the individual studies’ outcomes and by the pooled
estimates. Overall, during the long-term follow-up of untreated buccal GR, there was 143% chance of
increase in the number of patients presenting GR (OR=2.43) as well as 116% chance of increase in the
number of sites with GR (OR=2.16).

Quality of the Evidence

None of the included studies was judged to be of “high methodological quality” or at “low risk of bias”,
based on the criteria used. The sole included RCT23-25 was designed >35 years ago, when specific guidelines
(e.g., CONSORT Statement)32 for RCT design were not available. The included observational studies
recruited convenience patient populations, which may not reflect the overall community. One can
reasonably assume that most participants were well informed on up-to-date concepts and the importance of
oral hygiene.
A substantial degree of heterogeneity was detected in both sets of meta-analyses (Figs. 2 and 3),
associated with Matas et al.26 results, where participants (dentists) did not receive maintenance care by the
investigators during the study. One could argue whether dentists are representative of the general population

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with regards to oral health; interestingly, plaque control levels deteriorated among the participating dentists
during the 10-year study.26
One study28 did not record data important for this review, specifically, the number of defects
experiencing RD increase. Only one study21 presented statistical analysis adjusted for potential confounders
that could have influenced the final outcomes.
Regarding quality of the reported evidence, it is important to highlight that the purpose of evaluating
“risk of bias/quality of studies” is to identify whether the most important methodological points and primary
outcome measures of interest were reported as clearly and comprehensively as possible and not to “grade”
studies.15-17 The possible qualitative limitations of the included studies did not seem sufficient per se to
decrease or underestimate the strength of the reported outcomes.

Potential Biases in the Review Process

The specific inclusion criteria applied in this review were chosen because of clinical relevance (rarity of GR
in children/adolescents), to allow “a follow-up long enough for the outcome to occur” (GR development or
increase),3 and to decrease heterogeneity. These criteria might have precluded review of other potentially
relevant data that could have helped answer focused questions of this review. Nevertheless, the inherent
challenges with pursuing (funding, continuity in personnel) and completing (participant drop-out) long-term
studies accentuate the significance of the data gathered in this review.
There are additional points to consider when assessing potential biases in the review process. It is highly
likely that all studies did not assess the same type of GR defects or follow the same maintenance protocol.
Inclusion of highly motivated patients with regular high oral hygiene standards might select for populations
more prone to GR development. Although such potential confounders could limit achievement of definitive
conclusions, the consistency of the evidence obtained suggests that they had limited, if any, impact on the
overall outcomes.

Agreements and Disagreements With Other Studies or Reviews

There is a limited base of evidence of relevant clinical studies addressing the specific topic. It has been
argued that a minimum band of keratinized tissue (≥2 mm) may be important to prevent GR
development/progression.33 Chambrone & Tatakis5 recently reviewed root coverage procedure outcomes
and reported that increase in KT thickness (“biotype modification”) can prevent GR recurrence at long-term.
Kim & Neiva34 recently concluded that gingival augmentation procedures to increase KT width might
“prevent the development and progression of GR” and that they should be used based “on the particular
clinical situation and the patient’s oral hygiene competence”. In this context it is noteworthy that 67% of
patients in the Agudio et al.21 study reported greater comfort level when toothbrushing on the treated sites,
compared to untreated sites, a finding reasonably attributable to the postoperative KT quality changes. The
low incidence of RD increase over time reported in some studies26 might be related to baseline KT quality.

AUTHORS’ CONCLUSIONS
Based on both the individual studies’ outcomes and the pooled estimates, it can be concluded that untreated
buccal GR defects in subjects with good oral hygiene are highly likely to experience RD increase during
long-term follow-up. Limited evidence suggests that presence of KT and/or greater KT width decrease the
likelihood of RD increase/new GR development. Limited evidence also suggests that existing or progressing
GR does not lead to tooth loss.

Implications for Practice

The findings allow practitioners to provide patients with GR defects germane information on the potential
long-term outcomes of such defects. Marginal keratinized tissue quality should be considered when
establishing patient treatment plans.

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Implications for Research

Long-term case-control studies and national level longitudinal epidemiological studies assessing GR
progression/development are needed to further support the findings reported herein. Such future
investigations should include appraisal of exposed root condition and patient-centered outcomes.

ACKNOWLEDGEMENTS
This study was supported by the Division of Periodontology, College of Dentistry, The Ohio State University. The authors report
no conflict of interest related to this study.

CONFLICT OF INTEREST:
The authors report no conflict of interest related to this study.

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Periodontology; 2001;53.
2. Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA. Root coverage procedures for the
treatment of localized recession-type defects: a Cochrane systematic review. J Periodontol 2010; 81:452–478.
3. Chambrone L, Faggion Jr CM, Pannuti CM, Chambrone LA. Evidence-based periodontal plastic surgery: an assessment of
quality of systematic reviews in the treatment of recession-type defects. J Clin Periodontol 2010; 37:1110–1118.
4. Chambrone L, Pannuti CM, Tu Y-K, Chambrone LA. Evidence-based periodontal plastic surgery. II. An individual data
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5. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: a systematic review from the AAP Regeneration
Workshop. J Periodontol 2015; 86(2 Suppl):S8–S51.
6. Richmond S, Chestnutt I, Shennan J, Brown R. The relationship of medical and dental factors to perceived general and dental
health. Community Dent Oral Epidemiol 2007; 35:89–97.
7. Susin C, Haas AN, Oppermann RV, Haugejorden O, Albandar JM. Gingival recession: epidemiology and risk indicators in a
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a birth cohort. J Periodontol 2006; 77:947–954.
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2015; 59:981-996.
10. Löe H, Anerud A, Boysen H, Morrison E. Natural history of periodontal disease in man. Rapid, moderate and no loss of
attachment in Sri Lankan laborers 14 to 46 years of age. J Clin Periodontol. 1986;13:431-445.
11. National Institute for Health Research PROSPERO, International Prospective Register of Systematic Reviews.
http://www.crd.york.ac.uk/PROSPERO
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reporting items for systematic reviews and meta-analyses: the PRISMA Statement. J Clin Epidemiol 2009; 62:1006-1012.
13. Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0. Cochrane Collaboration.
http://community.cochrane.org/handbook Updated March 2011. Accessed on January 7, 2016.
14. OpenGrey. System for Information on Grey Literature in Europe. http://www.opengrey.eu. Accessed on August 1, 2015.
15. Chambrone L, Chambrone LA, Lima LA. Effects of occlusal overload on peri-implant tissue health: a systematic review of
animal model studies. J Periodontol 2010; 81:1367-1378.
16. Chambrone L, Mandia Jr J, Shibli JA, Romito GA, Abrahao M. Dental implants installed in irradiated jaws: A systematic
review. J Dent Res 2013; 92 (Suppl. 2): 119S-130S.
17. Chambrone L, Preshaw PM, Ferreira JD, Rodrigues JA, Cassoni A, Shibli JA. Effects of tobacco smoking on the survival rate
of dental implants placed in areas of maxillary sinus floor augmentation: a systematic review. Clin Oral Impl Res 2014; 25:
408–416.

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18. Chambrone L, Foz AM, Guglielmetti MR, Pannuti CM, Artese HPC, Feres M, Romito GA. Periodontitis and chronic kidney
disease: a systematic review of the association of diseases and the effect of periodontal treatment on estimated glomerular
filtration rate. J Clin Periodontol 2013; 40: 443–456.
19. Chambrone L, Shibli JA, Mercurio CE, Cardoso B, Preshaw PM. Efficacy of standard (SLA) and modified sandblasted and
acid-etched (SLActive) dental implants in promoting immediate and/or early occlusal loading protocols: a systematic review
of prospective studies. Clin Oral Impl Res 2015; 26:459-470.
20. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for
assessing the quality of nonrandomised studies in meta-analyses. University of Ottawa, 2001. Available at
http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm (Accessed on January 7, 2016).
21. Agudio G, Nieri M, Rotundo R, Franceschi D, Cortellini P, Pini Prato GP. Periodontal conditions of sites treated with
gingival-augmentation surgery compared to untreated contralateral homologous sites: a 10- to 27-year long-term study. J
Periodontol 2009;80:1399-1405.
22. Daprile G, Gatto MR, Checchi L. The evolution of buccal gingival recessions in a student population: a 5-year follow-up. J
Periodontol 2007;78: 611-614.
23. Dorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of free autogenous gingival grafts. A four year report. J
Periodontol 1982; 53: 349-352.
24. Dorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of free autogenous gingival grafts. J Clin Periodontol 1980; 7:
316-324.
25. Kennedy JE, Bird WC, Palcanis KG, Dorfman HS. A longitudinal evaluation of varying widths of attached gingiva. J Clin
Periodontol 1985: 12:667-675.
26. Matas F, Sentıs J, Mendieta C. Ten-year longitudinal study of gingival recession in dentists. J Clin Periodontol 2011;
38:1091-1098.
27. Serino G. Wennstrom J. Lindhe J and Eneroth L: The prevalence and distribution of gingival recession in subjects with a high
standard of oral hygiene. J Clin Periodontol 1994; 21: 57-63.
28. Schoo WH, van der Velden U. Marginal soft tissue recessions with and without attached gingiva. A five-year longitudinal
study. J Periodontal Res 1985; 20:209-211.
29. Salkin LM, Freedman AL, Stein MD, Bassiouny MA. A longitudinal study of untreated mucogingival defects. J Periodontol
1987; 58:164-166.
30. Freedman AL, Salkin LM, Stein MD, Green K. A 10-year longitudinal study of untreated mucogingival defects. J
Periodontol 1992; 63:71-72.
31. Freedman AL, Green K, Salkin LM, Stein MD, Mellado JR. An 18-year longitudinal study of untreated mucogingival
defects. J Periodontol 1999; 70:1174-1176.
32. Schulz KF, Altman DG, Moher D, for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting
parallel group randomised trials. J Clin Epidemiol 2010; 63:834-840.
33. Lang NP, Löe H. The relationship between the width of keratinized tissue and gingival health. J Periodontol 1972; 43:623-
627.
34. Kim DM, Neiva R. Periodontal soft tissue non–root coverage procedures: A systematic review from the AAP regeneration
workshop. J Periodontol 2015;86 (Suppl):S56-S72.

Contact author: Dr. Dimitris N. Tatakis, Division of Periodontology, College of Dentistry, The Ohio State
University, 305 West 12th Avenue, Columbus, OH 43210. Tel. 614-292-0371; Fax. 614-292-4612; Email:
tatakis.1@osu.edu
Submitted October 21, 2015; accepted for publication January 21, 2016.

Figure 1.
Flow chart of manuscripts screened through the review process.

Figure 2.
Forest plot of random-effects meta-analyses. Outcome: number of patients with at least one buccal gingival recession. M-H,
Mantel-Haenszel; CI, confidence interval; t, Kendall tau; z, z-test.

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Figure 3.
Forest plot of random-effects meta-analyses. Outcome: number of buccal sites with gingival recession. M-H, Mantel-Haenszel;
CI, confidence interval; t, Kendall tau; z, z-test.

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Journal of Periodontology; Copyright 2016
Table 1 –
Characteristics of included studies
STUDY DESIGN PARTICIPANTS & METHODS
Dorfman et Prospective 32 patients (of 92 originally
al./Kennedy splitmouth enrolled) with bilateral sites of
et al. 1980- design, treated inadequate attached gingiva were
198523-25 GR versus non included in the study
treated control
sites, 6 years’
followup
Test sites were treated with
SRP+FGG whereas control sites
with SRP alone
Patients’ age and gender not
reported
Number of smokers not reported
Each patient contributed with a
pair of sites (test and control)
To be included in control group,
site should not present a GR with
RD >1 mm
Patients were recalled at 3- to 6-
month intervals (or less if
needed) for periodontal
maintenance; 10 patients did not
participate in maintenance phase
for an average of 61 months
Schoo & Prospective, 25 patients were included in the
Van der fullmouth study
Velden assessment of 18-67 years of age
198528 untreated GR, 5 Number of smokers not reported
years’ follow- Assessment of 106 buccal sites
up with localized GR and PPD ≤3
mm, divided into two groups:
KT ≤1 mm: 52 teeth
KT >1 mm: 54 teeth
DOI: 10.1902/jop.2016.150625
UNTREATED GROUP OUTCOMES
14 buccal GR present at baseline – 3
(21.4%) were removed from the control
group because of additional GR ≥2 mm,
and no additional GR nor subsequent
loss of attachment were found to have
occurred over the 6-year follow-up
period for the remaining 10 GR
Significant improvement in the oral
hygiene of control sites:
Plaque Index at baseline: 1.1±0.09
Plaque Index at 6 years: 0.3±0.08
The 10 patients not participating in
maintenance phase had significant
increase in average RD during the
follow-up period
The number of GR sites showing
increase/decrease in RD was not reported
KT ≤1 mm – RD change: -0.3±0.9 mm
CAL change: -0.1±0.9 mm
PD change: 0.2±0.6 mm
KT >1 mm – RD change: -0.1±1.0 mm
CAL change: -0.4±0.9 mm
10
AUTHORS’ MAIN CONCLUSIONS NOTES
“The findings demonstrate that it is University-based (USA)
possible to maintain periodontal
health and attachment through
control of gingival inflammation
despite the absence of attached
gingiva.”
This study was supported by the
Medical Research Service of the
Veterans Administration VAMC,
Richmond, Virginia.
“On the average, a small amount of University-based (The Netherlands)
loss of attachment was found in the
KT >1 mm group, but not in the KT No information on financial support
≤1 mm group. If the object of a
surgical intervention is to prevent
further loss of attachment at teeth
with gingival recessions, it seems
impossible to decide that such a
procedure is indicated based merely
Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.150625

Patients did not undergo regular PD change: 0.4±0.6 mm on the presence (or absence) of a
oral hygiene control or repeated certain minimum width of attached
hygiene instruction, but only gingiva.”
upon the request of the patient
Serino et al. Prospective, 225 patients were included in the 1373 buccal GR at baseline (26.56% of “The observations made in the Community-based (Sweden)
199427 fullmouth study teeth), and 2532 buccal GR at 12 years present study show that teeth with
assessment of follow-up (52.34% of teeth) - 25.76% recession should be considered as
untreated GR, increase in the number of sites with GR susceptible for additional apical
12 years’ 18-65 years of age Additional RD increase was not reported displacement of the soft tissue The study was supported by grants
follow-up for 173 (3.34%) GR present at baseline; margin” from the Swedish Medical Research
however, information on the decrease of Council, the Public Dental Service.
RD for any of these defects was not County of Varmland, Sweden and
reported either the Colgate-Palmolive Co.,
Number of smokers not reported Of the total sites with a baseline Piscataway, NJ, USA.
recession, 1200 (87.39%) experienced an
increase in GR
High standard of oral hygiene Of the total of sites without a baseline
(<30% dental plaque and <10% recession (3795), 1332 (35.09%)
bleeding on probing) presented a GR at end of the follow-up
period
Participating patients had to be Multiple regression analysis showed that
regular dental attendees (at least buccal GR was related to approximal
once/year) at the community periodontal breakdown and negatively
dental clinics. During follow-up associated with buccal site gingival
period, preventive and therapeutic inflammation
measures were delivered
according to community clinic
dentist decisions
3rd molars were excluded
Daprile et Prospective, 23 dental students (of 27 initially 28 buccal GR at baseline distributed “The number of subjects with at University-based (Italy)
al. 200722 fullmouth enrolled) were included in the within 11 students (47.82%), and 64 least one recession and the
assessment of study buccal GR at 5-year follow-up within 19 percentage of affected sites
untreated GR, 5 students (82.60%) - 34.78% increase in increased with the level of oral
years’ follow- the number of students with GR, and hygiene education, and these
up 128.57% increase in the number of sites increases developed despite a
with GR reduction in the most dangerous
10 males and 13 females (23-25 Of the total sites with a baseline toothbrushing habits” No information on financial support
years of age) recession, 6 (21.42%) experienced an
increase in GR, and 6 improved.

11
Journal of Periodontology; Copyright 2016
Information on smoking status
not reported Students with
orthodontic treatment excluded
Good standard of oral hygiene
Students were considered to have
received oral “hygiene instruction
in accordance with the most up-
to-date scientific trends” during
their dental education
638 teeth examined at baseline
and follow-up; 3rd molars and
teeth with restorations next to
gingival margin were excluded
Agudio et Retrospective 55 patients (of a patient pool of
al. 200921 splitmouth 105) with 73 GR lacking attached
design, treated gingiva treated with gingival
GR versus non grafts (test group), and 73
treated control contralateral homologous sites,
sites, 10 to 27 with or without GR (control
years’ follow- group), and with or without
up (mean 15.3 attached gingiva were included in
years) the study
19 males and 36 females (18-56
years of age)
6 smokers
High oral hygiene level (full-
mouth plaque/bleeding score
<20%)
Each patient contributed at least
one pair of sites (test and control)
Patients were recalled every 4
months for periodontal
maintenance during follow-up
period
DOI: 10.1902/jop.2016.150625
No teeth lost during follow-up
Significant improvement in oral hygiene
of buccal surfaces between baseline and
last examination (p=0.001)
44 buccal GR present at baseline “Untreated sites showed a tendency Practice-based (Italy)
(60.27% of sites), and 59 buccal GR ≥ 10 for apical displacement of the
years follow-up (80.82% of sites) - gingival margin with an increase of
20.55% increase in the number of sites the existing recessions and the
with GR development of new recessions in
some of the previously healthy
sites”
Of the 44 sites with a baseline recession, No information on financial support
35 (79.54%) experienced an increase in
RD and none improved
Of 73 untreated sites, 11 showed
hypersensitivity at baseline, whereas 13
at the end of the follow-up period
The 73 untreated GR were separated in
two “subgroups”, one containing 55 GR
that was compared to submarginal FGG
and the other 18 GR compared to
marginal FGG
No GR sites exhibited BOP or root
caries, either at baseline or at follow-up.
49 patients reported being less
comfortable when toothbrushing the
untreated sites, compared to the
contralateral treated sites
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Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.150625

Single rooted teeth (76.7%

mandibular); teeth with prosthetic
crowns or restorations were
excluded
Matas et al. Prospective, 40 dentists (of 60 originally 188 buccal GR present at baseline and “In dentists, after 10 years, mean University and practice-based
201126 fullmouth enrolled) were included in the 242 buccal GR present at follow-up number of gingival recession per (Spain)
assessment of study examination – 28.72% increase in the person and mean recession height
untreated GR, number of sites with GR increased whereas plaque control
10 years’ decreased”
follow-up Full-mouth measurements of GR 54 of the newly developed buccal GR “The prevalence and clinical This study was supported by the
were ≥2 mm parameters of gingival recession in authors and by institutional funds
24 males and 16 females (mean Of the 188 buccal sites with a baseline dentists showed different patterns in
age of 33.95 years at follow-up recession, 113 (60.1%) had decreased the two examinations. The first
examination) RD, 32 (17.0%) did not change and 43 pattern was most likely related to a
(22.9%) had increased RD 10 years later. high standard of oral hygiene and
15% of the sample formed by 1100 teeth at baseline the second to a significant increase
smokers at followup examination in plaque accumulation”
(20% at baseline)
15 participants had undergone 1099 at follow-up
orthodontic therapy at baseline (1
more underwent orthodontic
therapy during follow-up period)
6 participants (15%) had received Tooth level multiple regression analysis
periodontal therapy of some kind using data from the 2nd examination
(1 gingival grafting, 3 occasional showed that PPD was associated with
SRP, and two were under regular buccal GR while KT was negatively
periodontal maintenance) at associated with the development of
baseline; no changes during buccal GR
follow-up period
No information provided on
maintenance care during follow-
up period.
Dental implants, 3rd molars and
teeth with orthodontic bands or
prosthetic crowns were excluded
CAL – clinical attachment level; FGG – free gingival grafts; GR – gingival recession; KT – keratinized tissue; PPD – periodontal probing depth; RD – recession depth; SRP – scaling and root
planing

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Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.150625

Table 2 –
Methodological quality of included observational studies
Study Selection Comparability Outcomes Statistics Study Quality
Schoo & Van der
**** - ** * Low
Velden (1985)28
Serino et al.
****** * * ** Medium
(1994)27
Daprile et al.
***** - ** ** Medium
(2007)22
Agudio et al.
**** ** * ** Medium
(2009)21
Matas et al.
***** - *** ** Medium
(2011)26
Assessment based on an adapted version16-19 of the Newcastle-Ottawa (NOS) scale.20 Overall study quality was categorized as
“high” (11-14 total stars), “medium” (8-10 stars), or “low” (0-7 stars).
‡
Review Manager, Version 5.3, Nordic Cochrane Centre, Copenhagen, Denmark

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 Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.150625
Identification and Screening

Potentially relevant publications

identified and screened for retrieval: Publications excluded on basis of
MEDLINE, EMBASE, and title and abstract (n=367)
handsearching/reference lists (n=378)

Full-text article screening of potentially

Excluded publications, not fulfilling
relevant publications for the review
inclusion criteria (n=3)
(n=11)
Eligibility

Articles included in review/qualitative

synthesis (n=8)
One study was reported in 3 articles
(total studies included: n=6)
Included

Articles (studies) included in meta-

analyses/quantitative synthesis (n=4)

15
Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.150625

21

22

26

21

22

16
Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.150625

21

22

26
27

21

22

27

17