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Inconclusive evidence for tooth brushing-gingival recession link

John Gunsolley DDS, MS .


Systematic Review Conclusion

Inconclusive data neither support nor refute the association between tooth brushing and gingival recession.

Critical Summary Assessment

Only weak evidence supports an association between tooth brushing and gingival buccal recession. There is no evidence to support a causal relationship.

Evidence Quality Rating

Limited Evidence

Structured Abstract

Clinical Questions:

Do factors associated with tooth brushing predict the development and progression of non-inflammatory gingival recession in adults?

Review Methods:

A search of MEDLINE, Embase, and 4 other electronic databases plus hand searching of 3 journals yielded 831 “hits.” After screening, a full text review of 29 of these reports resulted in the inclusion of 18 studies in 3 different languages. Of those 18 studies, 17 were observational and 1 was a randomized controlled trial (RCT) reported in abstract form only.

Main Results:

Eighteen studies met the inclusion criteria of the authors. One randomized clinical trial was identified. That report, published only as an abstract, provided limited evidence that a rotary toothbrush significantly reduced buccal gingival recession. The remaining 17 studies were observational. Eight studies reported a positive association between tooth brushing frequency and recession; six reported an association with tooth brushing technique, four with bristle hardness, three with the frequency of changing tooth brushes, two with tooth brushing force and one with duration of tooth brushing. Two of the observational studies using limited young patient samples reported no relationship between non-inflammatory gingival recession and factors associated with toothbrushing.


The data to support or refute the association between tooth brushing and gingival recession are inconclusive.

Source of Funding:

Philips Oral Healthcare, Snoqualmie WA.


Importance and Context:

There is a belief among some dentists that buccal recession is related to inappropriate toothbrushing. Nonscientific literature and Internet-available information ( help foster this belief: The authors of this systematic review sought to determine if there was evidence to support this belief.

Strengths and Weaknesses of the Systematic Review:

The authors of the review followed an appropriate approach in their search and evaluation of the literature based on the stated inclusion and exclusion criteria. The rigor of the search strategy suggests that the review found all the existing studies related to the broadly stated question but the lack of focus of the question resulted in some studies that were not consistent in toothbrushing factors and/or in the description of gingival recession. To provide information on those studies that had consistent elements, the authors provided tables describing the relationship between toothbrushing factors and gingival recession, but did not evaluate the data further. The review would have been strengthened if they had evaluated this data further.

Strengths and Weaknesses of the Evidence:

The authors appropriately judged the studies to be of low quality. Of the 18 total studies, 17 were observational. One study, a randomized clinical trial evaluating powered toothbrushes, was published only as an abstract. Thus, the existing literature provides very weak evidence.

Implications for Dental Practice:

This review identified, at best, weak evidence from observational studies supporting the belief that buccal recession is related to inappropriate toothbrushing factors. Thus, the evidence from this systematic review suggests that there may be a potential benefit in guiding patients away from inappropriate toothbrushing practices. It is also important to note that in contrast to common beliefs, a cause-effect relationship between improper toothbrushing factors and buccal gingival recession could not be firmly established based on current evidence. More studies are needed to determine what factors are related to gingival recession.

Critical Summary Publication Date:


These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association © 2019