Gingival Recession and Root Caries in the Ageing Population

J Clin Periodontol 2017; 44 (Suppl. 18): S178–S193 doi: 10.1111/jcpe.12676

Peter A. Heasman1, Mark Ritchie2, Gingival recession and root Abisola Asuni2, Erika Gavillet3, Janne L. Simonsen4 and Bente Nyvad5 1School of Dental Sciences, Newcastle caries in the ageing population: University, Newcastle upon Tyne, UK; 2Dental Hospital, Newcastle upon Tyne, UK; 3Faculty of Medical Sciences, Newcastle a critical evaluation of treatments University, Newcastle upon Tyne, UK; 4Faculty of Health, Aarhus University, Aarhus C, Denmark; 5Department of Dentistry and Oral Health, Aarhus University, Aarhus C, Heasman PA, Ritchie M, Asuni A, Gavillet E, Simonsen JL, Nyvad B. Gingival Denmark recession and root caries in the ageing population: a critical evaluation of treatments. J Clin Periodontol 2017; 44 (Suppl. 18): S178–S193. doi: 10.1111/ A paper submitted for the 13th European Workshop in Periodontology, 6–8 November jcpe.12676. 2016, Parador at La Granja de San Abstract Ildefonso, Segovia and in consideration for publication in The Journal of Clinical Aim: To review evidence for the treatments of gingival recession and root caries Periodontology. in older populations. Materials & Methods: A systematic approach was adopted to identify reviews and articles to allow us to evaluate the treatments for gingival recession and root caries. Searches were performed in PubMed, Medline and Embase, the Cochrane trials register and bibliographies of European and World Workshops. Observations: Gingival recession: We identified no articles that focussed specifically on older populations. Conversely, no evidence suggested that Miller class I and II lesions should be managed differently in older patients when compared to younger cohorts. Six systematic reviews included older patients and suggested that connective tissue grafts are the treatment of choice, alone or in combination with enamel matrix derivative. Root caries can be controlled at the population level by daily brushing with fluoride-containing toothpastes, whilst active decay may be inactivated using professional application of fluoride varnishes/solutions or self- applied high-fluoride toothpaste. Active root caries lesions that cannot be cleaned properly by the patient may be restored by minimally invasive techniques. Key words: ageing population; atraumatic restorative treatment; gingival recession; Conclusions: Gingival recession and root caries will become more prevalent as operative treatment; periodontal surgery; patients retain their teeth for longer. Whilst surgical (gingival recession) and non- prevention; root caries operative approaches (root caries) currently appear to be favoured, more evidence is needed to identify the most appropriate strategies for older people. Accepted for publication 27 October 2016

a significant proportion of the Brown et al. 1996) but should not Historical Perspective adult population. The presence of necessarily be seen as a conse- Gingival recession, exposure of the gingival recession amongst subjects quence of ageing (Khocht et al. root surface due to apical migra- with a good standard of oral 1993). Getting long in the tooth is a tion of the gingival margin, affects hygiene suggests that the aetiology patient-related observation that is complex and multifactorial most likely reflects generalized loss (Joshipura et al. 1994) and involves of attachment as a result of the Conflict of interest and source of anatomical and iatrogenic factors cumulative exposure to multiple funding statement as well as being associated with causal exposures over many decades The authors have stated explicitly gingivitis and periodontitis (Baker (Needleman 2015), and there is that there are no conflict of interests & Spedding 2002, Litonjua et al. growing evidence to support the in connection with this article. 2005). relationship between age and loss The authors received no specific, external source of funding for the The prevalence of gingival reces- of attachment as being age-associ- sion increases with age (Kitchen ated rather than being a conse- preparation of this review, nor was it € supported by a grant award. 1941, Sangnes & Gjermo 1976, Loe quence of ageing (Page & Beck et al. 1978, 1992, Serino et al. 1994, 1997).

The classical studies of Ainamo fillings) were included (Fejerskov plateaus around 60% and then & Talari (1976) and Ainamo et al. et al. 1991). Similarly, the intra-oral reduces in later life as, presumably, (1981) established that, in the distribution of root caries differs those teeth most severely affected by absence of periodontal disease, the between studies. Mandibular molars caries or periodontal disease are lost. width of attached gingiva increases and premolars seem to be the most The percentage of people with loss with age between 23 and 65 years frequently affected, followed by of attachment, however, increases which is most likely due to teeth maxillary canines and incisors (Katz through middle age to later life. moving occlusally (Ainamo & Talari et al. 1982, Wallace et al. 1988, Although gingival recession itself 1976, Locker et al. 1998). Further, a Fejerskov et al. 1991). Only a few was not reported, the percentage of detailed study of the NHANES I studies have considered the activity people with any exposed roots, the data deriving incidence from preva- status of root caries lesions. In two mean number of teeth/person with lence data supports the hypothesis studies (Fejerskov et al. 1991, exposed roots and the percentage of that when excellent plaque control is Ekstrand et al. 2013), the mean all teeth with exposed roots all maintained, age may be seen to cor- number of active lesions per patient increase with age showing that, relate with, rather than be a true was 2.7 and 2.6, respectively, and regardless of the cause, gingival determinant of, attachment loss almost all individuals experienced recession is an increasing problem (Abdellatif & Burt 1987, Burt 1994). one or more surfaces with inactive with increasing age. Similar data for Such a hypothesis fits comfortably lesions. root caries demonstrate that the per- with the observation that over time, So although the modelling of lon- centage of people with active decay attachment loss at buccal sites may gitudinal change of incidence with and the mean number of teeth/per- also cumulate as a consequence of time suggests that recession and sub- son with active decay also increase toothbrushing trauma (Papapanou sequently root caries are not age throughout the decades. Further, the et al. 1991). changes (Abdellatif & Burt 1987, subset of individuals with any All exposed root surfaces run a Burt 1994), cross-sectional data con- exposed roots in their mouths show risk of developing root caries. The tinue to tell us that loss of attach- a steady increase in the overall num- root caries prevalence has been ment, the risk of root caries and ber of teeth with exposed roots and reported to vary significantly across root caries itself are all more preva- the mean number of teeth with populations. This could be due to lent in older cohorts of dentate indi- active decay up to around 50– differences in diagnostic criteria, viduals. For example, data from the 60 years of age, and the data then treatment patterns, lifestyle and age. UK Adult Dental Health Survey remain constant until the ninth dec- Because of the cumulative nature of (2009) showing percentage of pock- ade (Table 1) (White et al. 2011). caries, the root caries prevalence ets, loss of attachment, risk of root These data must be considered increases with age, ranging from caries (exposed surfaces) and root against the prevalence of risk factors 26% amongst 50- to 64-year-olds caries are presented in Table 1 which are likely to impact upon peri- (Kirkegaard et al. 1986) to 65–93% (White et al. 2011). Clinical exami- odontal disease and caries, in the in 60- to 79-year-olds (Salonen et al. nations of 6469 people living at population under observation. So, 1989, Fure & Zickert 1990). One home comprise the largest ever epi- for example, in the overall UK pop- study of 60- to 80-year-old Danes demiological survey of adult dental ulation and across all age groups, recorded a 100% root caries preva- health in the United Kingdom and 20% of adults were current smokers, lence with 70% of the individuals show that amongst dentate adults, 65% had visible plaque deposits and having eight or more surfaces the percentage of pockets >4mm 15% had a poor diet represented by affected when all scores (lesions and gradually increases up to middle age, a high carbohydrate intake.

Table 1. Presence of loss of attachment, active root caries and risk of root caries in UK dentate adults by age (data from Adult Dental Health Survey UK 2009). The data were collected following clinical examination of 6469 adults in UK domestic households 16–24 25–34 35–44 45–54 55–64 65–74 75–84 85 and All over

Amongst dentate adults Percentage of pockets ≥4mm 193643526160614745 Percentage of people with LOA ≥ 4mm 6167767266 Percentage of people with LOA ≥ 6mm 1822253021 Percentage of people with any exposed (vulnerable) root surfacea 31 53 72 88 95 96 98 97 73 Mean number of teeth with exposed (vulnerable) roots 2.1 3.9 6.4 9.4 11.1 11.8 10.7 10.9 7.3 Percentage of all teeth with exposed (vulnerable) roots 7 14 23 36 48 56 62 78 29 Percentage of people with roots with activeb decay 1 3 4 8 11 10 20 17 7 Mean number of teeth with activeb root decay 0.0 0.1 0.1 0.2 0.3 0.2 0.4 0.3 0.2 Amongst those with exposed (vulnerable) roots Mean number of teeth with exposed (vulnerable) roots 6.9 7.4 8.9 10.7 11.7 12.3 10.9 11.2 10.1 Mean number of teeth with activeb root decay 0.1 0.2 0.1 0.2 0.3 0.2 0.4 0.3 0.2 aAn exposed (vulnerable) surface is anywhere the gingiva has receded, and the root surface may be in any condition (sound, decayed, ﬁlled or worn). bActive decay, not including hard arrested decay.

The observation that the preva- relevant research articles that would respective online databases of these lence of gingival recession increases inform our statement: journals (Accepted Articles, Ahead of with age is certainly not specific to i Review previous systematic (in- Print and Early View) were also the United Kingdom and has been cluding Cochrane) reviews (2002– searched for relevant publications observed in other populations, for 2016) to identify those which that might be “in press” for paper example: the NHANES III data (US versions. – included patients from an ageing 1988 1994) show such a pattern population and from which a clin- Adjustments were made using whilst also reporting that the severity ical evaluation could be made subject headings appropriate to each of gingival recession increases with (essentially a systematic review of database and keyword terms and age (Albander & Kingman 1999); systematic reviews); truncators used as appropriate. Lim- and the NPASES I cross-sectional its of “human” were applied in both ii Undertake our own systematic + data (France) used a multivariate search for original articles evaluat- databases and “45 ” in Medline. linear regression model to show that ing the treatment of gingival reces- This limit is not in use in Embase, age can be considered a risk factor sion specifically in an ageing so all documents were retained in for both the extent and severity of population. the search results. The two sets were gingival recession (Sarfati et al. combined and deduplicated. 2010). Geriatric patients in nursing Criteria for including studies Search strategy for treatment of gingival homes may suffer particularly high recession Types of studies root caries rates (Vigild 1989, Wyatt 2002, Simunkovic et al. 2005, Ferro The search strategy was developed in Studies to be included in the review et al. 2008) with a substantial pro- accordance with basic search criteria would be randomized clinical trials portion of active lesions (Guivante- for systematic reviews (Khan et al. (RCTs) [level I] and controlled clini- Nabet et al. 1998) suggesting an 2011). Medline and Embase were cal trials (CCTs) [level II] and extraordinary treatment need. Cogni- searched from 1946 and 1974 respec- excluding pilot and feasibility stud- tive, medical and functional impair- tively and both to March 2016. ies. Inclusion criteria for the studies ment plays a significant role in the Search terms were selected using the were as follows: recruitment of severe deterioration of oral hygiene following descriptors: “gingival reces- human subjects or patients; clinical and the associated increase in coro- sion” OR “gingival recession/therapy” examination to determine the extent nal and root caries in these groups OR “gingival recession/surgery” OR of gingival recession on natural (Chalmers et al. 2002, Ellefsen et al. “guided tissue regeneration” OR teeth; clinical examination to deter- 2008, Chen et al. 2013). Although “membranes, barrier” OR “tooth mine post-treatment root coverage; gingival recession and root caries root/surgery” OR “grafts, connective and parallel-group design with a fol- may not be true age changes, there tissue” OR “graft, gingival” OR low-up of at least 12 months. is clear evidence that both conditions “gingiva-transplantation” OR “gin- Types of participants show increased prevalence through- givoplasty–method” OR “connective- out life (Table 1). tissue-transplantation.” Subjects/patients included were those The objective of this review there- The Cochrane Oral Health aged 55 years or older. fore was to critically evaluate and Group specialist trials register was Types of interventions compare treatments of gingival also searched using the following: recession and root caries in older “Gingival-recession” OR “Gingival Conservative or surgical treatment patients. recession” OR “Guided-tissue-regen- of localized or generalized gingival eration” OR “Guided tissue regener- recession. ation” OR “GTR” OR Materials and Methods ((“resorbable” OR “non-resorbable”) AND “barrier membrane*”) OR The review process Gingival recession (“connective tissue” AND (“graft*” Titles and abstracts from the elec- The authors adopted the PRISMA OR “transplant*”)) OR “free gingi- tronic searches were managed by Statement (checklist) and flow dia- val graft” OR “coronally advanced downloading to EndNote software. gram. A protocol was developed a flap*” OR “gingiva* transplant*” EndNote x7 0.2 was used to search priori following initial discussion OR “gingivoplasty” OR “periodon- remote databases, to import the ref- between members of the research tal surg*” OR “root* surg*” (modi- erence data and to manage the team. The objective statement for fied from Roccuzzo et al. 2002a,b). imported references. The titles and this part of the review was “a critical The searches were restricted to abstracts were all in English and evaluation of treatments for gingival titles, abstracts and papers in Eng- were screened by two reviewers (AA recession in the ageing population.” lish. Bibliographies of review articles, and MR). Disagreement following At the outset, we assumed that relevant texts and World and Euro- the review of titles was resolved by the literature associated with the pean Workshops were also screened. consensus following reading by a treatment of gingival recession, In addition, manual hand searches third reviewer (PAH); disagreement either localized or generalized, in the were performed of the Journal of following the review of abstracts older population would be sparse, so Clinical Periodontology, the Journal was also resolved by discussion with we adopted a structured approach to of Periodontology, the Journal of a third reviewer (PAH) to moderate identify systematic reviews and Periodontal Research and the if necessary. The full texts of all © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Gingival recession and root caries S181 studies reported in English that Observations potentially might have been included were also reviewed by the same two Gingival recession reviewers against the stated inclu- Treatment of gingival recession sion criteria. Data extraction was specifically in an ageing cohort of completed before a decision was patients made regarding whether the article should be included in the review. If The flow of articles through this any missing data or information aspect of the review is shown in was identified, an attempt was made Fig. 1. Three thousand six hundred to contact the author(s) of the pub- and forty-two titles and abstracts lication. were screened and produced 96 articles for which the full text was read. Twenty-eight papers were included: Root Caries 27 describing systematic reviews and one original research article. In two Search strategy for treatment of root instances, two papers described the caries same systematic review (Clauser It was decided to adopt a search et al. 2003, Pagliaro et al. 2003, strategy aiming at non-operative and Chambrone et al. 2009c, 2010a,b), operative treatments of root caries. so only 25 different systematic Search terms were selected using the reviews were read. No research following descriptors: ((“Root car- paper fulfilled all the inclusion crite- ies” OR “Root surface caries”) ria as none focussed entirely on the AND (“Dental Care for Aged” OR older population defined for this “Geriatric Dentistry” OR older OR part of the review as those over the Fig. 1. Flow of articles through the elderly OR elder). age of 55 years. The patient popula- search (based on the PRISMA checklist). For the search strategy aiming at tion described by Castellanos et al. non-operative treatments, the (2006) combined a mean age of – descriptors were combined with 42.5 years with a range of 28 conclusion was that whilst the coro- (“chlorhexidine OR “mouth 71 years suggesting that a high pro- nally positioned flap was an effective hygiene” OR “oral hygiene” OR flu- portion of the cohort will have been procedure for covering single reces- oride). Searches were performed in over 55 years of age. (The authors sion defects, the addition of EMD PubMed on 7 October 2016. Two were contacted for the detailed data, significantly improves root coverage hundred and twenty-nine papers but no response was forthcoming.) (Castellanos et al. 2006). were identified, including 32 reviews For the systematic reviews, only six Overview of the 25 systematic reviews and 12 systematic reviews. Only one included studies with participants review included a quantitative meta- over 55 years were identified Details of the 25 systematic reviews analysis of current non-operative (Pagliaro et al. 2003, Cairo et al. identified in the search and published interventions for root caries (Wier- 2008, Chambrone et al. 2008, 2009c, between 2002 and 2016 are shown in ichs & Meyer-Lueckel 2015). 2012, Chambrone & Tatakis 2015) Table 2. The reporting of defect type For the search strategy aiming at (Table 2). was unclear in two reviews (Al-Ham- operative treatment of root caries, dan et al. 2003, Clauser et al. 2003,/ Overview of Castellanos et al. (2006) the descriptors were combined with Pagliaro et al. 2003), whilst the (“Dental Atraumatic Restorative This article fulfilled all of the inclu- remaining 23 all reported on Miller Treatment” OR “atraumatic restora- sion criteria with the exception that type I and II defects. Six reviews tive treatment” OR “ART restora- it did not focus exclusively on the included type III defects (Oates et al. tions” OR “ART technique” OR older population. The clinical trial 2003, Hwang & Wang 2006, ART OR “Dental Restoration, Per- reported on 22 patients with single Hofmanner€ et al. 2012, Cairo et al. manent” OR “Permanent Dental Miller class I or II defects and ran- 2014, Graziani et al. 2014, Cham- Restoration” OR “Permanent Dental dom assignment of two surgical brone & Tatakis 2015), and one Restorations” OR “Dental Restora- treatments: coronally positioned flap review included patients with type IV tion, Permanent”[Mesh] OR amal- with enamel matrix derivative defects (Chambrone & Tatakis 2015). gam OR “composite resin” OR (EMD) (test group) versus coronally All reviews included either random- “glass ionomer cement” OR “glass positioned flap alone (control ized controlled and/or controlled tri- ionomer cements”). Searches were group). The 12-month data showed als with the number of articles performed in PubMed on 26 Octo- a significant reduction in vertical ranging from 6 to 94. Regarding clin- ber 2016 and identified 144 papers, recession for those in the test group ical outcomes, the majority of 17 of which were reviews. Only one compared to those in the control reviews concluded that connective review adopted a systematic group (2.32 1.03 mm and tissue grafts are significantly better at approach, but the material was 1.41 0.57 mm respectively was achieving root coverage than compa- insufficient to perform a meta-analy- equivalent to root coverage of rable procedures (and particularly sis (Amer & Kolker 2013). 88.6% versus 62.2%). The guided tissue regeneration) (Clauser

© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Table 2. Twenty-seven systematic reviews (published as 25 articles between 2002 and 2016) evaluating surgical treatment strategies for lesions of gingival recession. Highlighted reviews pro- S182 vided information regarding the ages of the participants included in the articles/reviews Study (year) Focussed question/objectives Gingival Types of studies Number of Meta- Consideration Principal conclusions

recession: articles included analysis of older al. et Heasman Single/ in review cohorts? Multiple Classiﬁcation

Roccuzzo et al. In patients with buccal GR, Single RCT 30 YES NO • All surgical procedures produced (2002a,b)a what is the effect of PPS Miller I, II CCT a significant improvement in GR on root coverage and Case series and CTG were statistically signifi- attachment gain? (>6 months) cantly superior to GTR Al-Hamdan • To define the clinical Single RCT 40 NO NO • GTR resulted in 55% CRC com- et al. (2003) outcomes of GTR-based Multiple Comparative pared to 41% for conventional procedures in achieving Unclear Case controls microgingival surgery. CRC for GR lesions. Case reports • The respective % means (sd) root • To compare the out- coverage for the 2 procedures comes with these follow- were: 81% versus 74% ing conventional mucogingival surgery Clauser et al. To find evidence to guide Unclear RCT 65 3 separate 22 studies • CTG performed better than GTR (2003) decision-making in CCT meta- included in obtaining complete root cover- Pagliaro et al. planning root coverage Case studies analysis participants age (2003) b comparing >55 years • Irrespective of surgical procedure, various complete root coverage © surgical approaches 100% as initial GR 07Jh ie osAS ulse yJh ie osLtd Sons & Wiley John by Published A/S. Sons & Wiley John 2017 techniques depth decreases Oates et al. What is the effect of surgical Unclear RCT 32 YES NO • Autogenous CTG was signifi- (2003) therapy for root coverage Miller I, II, cantly better than GTR in terms in patients with GR III of achieving root coverage compared with other • Lack of standardization of treatment modalities? patient-orientated outcomes Gapski et al. In patients with GR and/or Unclear RCT 8 YES NO • Tentative conclusion that ADM- (2005) lacking KG, is there a Miller I, II based mucogingival surgery can benefit in treating the be used to successfully repair GR patient with ADM defects compared to traditional treatment modalities? Hwang & Wang To collect and summarize Single RCT 15 NO NO • A critical threshold flap thickness (2006) clinical data from root Multiple Cohort studies may exist for root coverage suc- coverage studies analysing Miller I, II, Case control cess but the heterogeneity of the flap thickness in a III Case series data and studies compromise firm systematic fashion conclusions Cheng et al. To assess the efficiency of Single RCT 18 NO NO • At 12 months, root coverage was (2007) EMD and root Multiple CT significantly improved (84%) conditioning on root Miller I, II when EMD was used with a coverage with coronally coronally positioned flap when positioned flap in terms of compared to CPF alone (54%) GR depth and root coverage % © Table 2. (continued) 07Jh ie osAS ulse yJh ie osLtd Sons & Wiley John by Published A/S. Sons & Wiley John 2017 Study (year) Focussed question/objectives Gingival Types of studies Number of Meta- Consideration Principal conclusions recession: articles included analysis of older Single/ in review cohorts? Multiple Classification

Cairo et al. What is the clinical benefit Single RCT 27 YES 11 Studies • CTG or EMD in conjunction (2008)a of adding to CAF: CTG; Multiple included with CAF enhances the likeli- BM; EMD; ADM; PRP; or Miller I, II participants hood of CRC in Miller I and II HF-DDS? >55 years lesions Chambrone Can subepithelial CTGs be Single RCT 23 NO 10 studies • CTGs provide significant root et al. (2008) considered the Gold Multiple included coverage and comparisons to Standard procedure in the Miller I, II participants other surgical procedures allow it treatment of GR-type >55 years to be considered as the defects? “Gold Standard” of interventions • Very few data consider patient- reported outcome measures. Chambrone Does tobacco smoking Single CCT 6 YES 1 study • CTGs provide significantly et al. (2009a) influence outcome measures Multiple Case series included greater root coverage for non- achieved by root coverage Miller I, II participants smokers compared to smokers procedures? >55 years (27–80% versus 0–25%) • Noticeable variation in root coverage between studies and procedures Chambrone To evaluate different root Multiple RCT 4 NO No study • CAF alone or in combination et al. (2009b) coverage procedures in the Miller I, II CCT included any with CTG led to improvements in treatment of multiple Case series participant GR depths: recession-type defects over 48 years • Patients’ needs should be care- fully evaluated to ensure their complaints can be addressed. Chambrone To evaluate the effectiveness Single RCT 24 YES 10 studies • Significantly greater reduction in igvlrcsinadro caries root and recession Gingival et al. of different root coverage Multiple included GR for CTG when compared to (2009c, 2010a, procedures in the treatment Miller I, II participants GTR with restorable membranes b)b of recession-type defects >55 years • Limited data exist on patients’ opinions and preferences for treatment Ko & Lu (2010) To assess the effectiveness of Unclear RCT 18 YES NO • CTG is significantly more effec- CTG and GTR in treating Miller I, II CCT tive than GTR in achieving root patients with GR Cohort study coverage of Miller I, II lesions Case report after 12 months. Chambrone Which recession-, patient- Single RCT 22 YES 9 studies • CTG and EMD were superior in et al. (2012) and/or procedure-related Multiple included achieving CRC when compared factors can influence CRC? Miller I, II participants to CAF alone. >55 years. • The use of root modification did not affect CRC. • MG + EMD should be considered a second choice procedure. S183 S184

Table 2. (continued) Study (year) Focussed question/objectives Gingival Types of studies Number of Meta- Consideration Principal conclusions recession: articles included analysis of older al. et Heasman Single/ in review cohorts? Multiple Classiﬁcation

Oliveira & Does root surface bio- Unclear RCT 6 NO NO • CTG and CAF produced a high Muncinelli modification have an effect Miller I, II rate of success in terms of root (2012) before root coverage coverage procedures? • Root surface bio-modification protocols (ND:YAG, citric acid, EDTA) yielded no additional benefits Hofmanner€ et al. What is the predictability of Multiple RCT 16 NO No • CAF or MCAF with or without (2012) PPS in achieving complete Miller class CTG will give predictable root root coverage of GR I, II, III coverage that can be maintained lesions? over 5 years. MCAT is a valued technique for Miller class III lesions Koop et al. Is the additional use of Unclear RCT 6 YES NO • EMD + CAF produced signifi- (2012) EMD more effective than Miller I, II CCT cantly more CRC compared with control treatments for the CAF alone.

07Jh ie osAS ulse yJh ie osLtd Sons & Wiley John by Published A/S. Sons & Wiley John 2017 when comparing CAF + EMD versus CAF + CTG. Oliveira & Does root surface bio- Single RCT 6 NO • No method of root surface bio- Muncinelli modification have any Multiple modification (citric acid, EDTA, (2012) positive or negative effect Miller class Nd:YAG, Er:YAG) produced when used before root I, II any additional root coverage coverage procedures? when compared to PPS procedure alone Buti et al. (2013) What is the best approach to Miller class RCT 31 YES • CAF + CTG is the most effec- obtain GR reductions and I, II tive procedure for root coverage root coverage? of Miller I and II lesions Cairo et al. What is the clinical Single RCT 53 YES NO • CAF + CTG achieved the best (2014)a efficiency of PPS procedure Unclear clinical outcome for single GR in the treatment localized Miller I, II, defects with or without interden- GR with or without III tal CAL interdental CAL? • EMD improves the efficiency of CAF Graziani et al. In subjects affected by Multiple RCT 9 YES NO • In addition to the traditional (2014) multiple recessions, which Miller I, II, CAF approach, the use of CTG, PPS procedure is most III flap modifications and tunnel effective in terms of % root procedures may improve clinical coverage and CRC? results. © 07Jh ie osAS ulse yJh ie osLtd Sons & Wiley John by Published A/S. Sons & Wiley John 2017

Table 2. (continued) Study (year) Focussed question/objectives Gingival Types of studies Number of Meta- Consideration Principal conclusions recession: articles included analysis of older Single/ in review cohorts? Multiple Classiﬁcation

Chambrone & • What is the efficiency/ef- Unclear SRs 94 YES 33 studies • All root coverage procedures pro- Tatakis (2015) fectiveness of root cover- Miller I, II, RCT included vide significant reductions in GR age procedures by III, IV CCT participants for Miller I, II defects degree of GR? Case series >55 years • CTG provides the best outcome • What are the risks from Case reports regarding root coverage and the patients’ perspective? increase in the keratinized tissue • Limited data from case reports suggest that class IV defects may be improved but may not deliver the expected aesthetic outcome • Class III defects may significantly benefit from CTG-based procedures and EMG + CAF, ADM + CAF, and GTR + CAF may be used as graft substitutes. Karam et al. Does the use of root surface Single RCT 6 NO 1 study • The use of root surface modifiers (2015) modifiers improve clinical Multiple included (citric acid, EDTA, Nd:YAG, outcomes in GR lesions Miller class participants EMD) is not justified as an treated with CTG? I, II >55 years adjunct to PPS to treat GR Luo et al. (2015) Do platelet concentrates Single RCT 9 YES 1 study • The use of platelet concentrate affect the outcome of Multiple included as an adjunct to grafting proce- caries root and recession Gingival regenerative procedures for Miller class participants dures led to a significant addi- the treatment of GR? I, II >55 years tional reduction in GR of 0.34 mm Moraschini & What are the effects of PRF Unclear RCT 7 YES • PRF membranes did not improve dos Santos membranes on the Miller class Prospective CT the root coverage of GR defects Porto Barboza treatment of GR? I, II when compared to CAF alone (2016)

ADMG, acellular dermal matrix graft; BM, barrier membrane; CAF, coronally advanced flap; CAL, clinical attachment loss; CCT, controlled clinical trial; CPF, coronally positioned flap; CRC, complete root coverage; CTG, connective tissue graft; EDTA, ethylenediaminetetraacetic acid; EMD, enamel matrix derivative; Er:YAG, erbium:yttrium–aluminium–garnet; GR, gingival recession; GTR, guided tissue regeneration; HF, human fibroblast-derived dermal substitute; KG, keratinized gingiva; MG, matrix graft; MCAF, modified coronally advanced flap; MCAT, modified coronally advanced tunnel; Nd:YAG, neodymium-doped yttrium aluminium garnet; PPS, periodontal plastic surgery; PRF, platelet-rich fibrin; PRP, platelet-rich plasma; RCT, randomized controlled clinical trial; SR, systematic review. aSystematic reviews published as Proceedings of previous European Workshops (2002, 2008, 2014). bSystematic review data published as two articles. S185 S186 Heasman et al.

Table 3. Overview Quality and Assessment Questionnaire (OQAQ) applied to systematic reviews on root coverage procedures. (Adopted and modiﬁed from Chambrone et al. 2010a,b) Pagliaro et al. Chambrone Cairo et al. Chambrone Chambrone Chambrone & (2003) et al. (2008) (2008) et al. (2009c) et al. (2012) Tatakis (2015)

1. Were the search methods reported? Yes Yes Yes Yes Yes Yes 2. Was the search comprehensive? No Yes Yes Yes Yes Yes 3. Were the inclusion criteria reported? Yes Yes Partially Yes Yes Yes 4. Was selection bias avoided? No Yes Yes Yes Yes Yes 5. Were the validity criteria reported? Partially Yes Yes Yes Yes Yes 6. Was validity assessed appropriately? No Yes Yes Yes Yes Yes 7. Were the methods used to combine Yes (no Yes Yes Yes Yes Yes studies reported? meta-analysis) 8. Were the findings combined Unclear Yes Yes Yes Yes Yes appropriately? 9. Were the conclusions supported Yes Yes Yes Yes Yes Yes by the reported data? 10. What was the overall scientific 276777 quality of the overview? (1–7) et al. 2003, Oates et al. 2003, OQAQ indicating a high level of following GTR and CTG proce- Pagliaro et al. 2003, Cairo et al. quality assurance (Table 3). Only dures. 2008, Chambrone et al. 2008, 2009a, one review included studies that In a more generalized conclusion, b,c, 2010a,b, Ko & Lu 2010, Cham- recruited participants with type III Chambrone & Tatakis (2015) brone et al. 2012, Oliveira & Munci- and IV defects, and none of the reported that patients considered all nelli 2012, Hofmanner€ et al. 2012, reviews reported a clear, objective of a wide range of root coverage Buti et al. 2013, Cairo et al. 2014, assessment of outcome aesthetics nor procedures to be safe and effective Graziani et al. 2014, Chambrone & considered the cost-effectiveness of but with a preference for procedures Tatakis 2015). The benefit of root the interventions. that involve only one surgical site. conditioning was somewhat more All six reviews concluded in The lack of an evidence base for equivocal with three reviews conclud- favour of connective tissue grafts the management of gingival recession ing that there was no benefit of any (CTGs) as the treatment of choice in older patients makes it impossible one of a range of procedures (citric (Clauser et al. 2003/Pagliaro et al. to critically evaluate interventions acid, EDTA, Nd:YAG, Er:YAG, 2003, Chambrone et al. 2008, 2009c, specifically in this cohort. It is rea- EMD) (Chambrone et al. 2012, Oli- 2010a,b, Chambrone & Tatakis sonable to assume, however, that veira & Muncinelli 2012, Karam 2015), and whilst there are limited conclusions regarding periodontal et al. 2015) and a further three data to suggest that EMD may be a plastic procedures in younger popula- reviews concluding that EMD did useful biomaterial in current peri- tions or in those cohorts that include improve root coverage when com- odontal plastic surgery (Chambrone a minority group of older patients pared to surgical procedures alone et al. 2012), further studies are nec- can also be applied with some confi- (Cheng et al. 2007, Cairo et al. 2008, essary to definitively evaluate indica- dence to the older group in general. Koop et al. 2012). tions for treatment and associated Consequently, the six reviews that clinical benefits (Cairo et al. 2014). are consistent in promoting CTGs as Overview of the six systematic reviews Three reviews reported patient- the “Gold Standard” for the manage- with participants over 55 years related outcome measures (Cham- ment of localized and generalized, Of the 25 reviews included, six brone et al. 2008, 2009c, Chambrone Miller class I and II defects should reported more than a third of the & Tatakis 2015). Chambrone et al. not be overlooked. Gingival recession included studies as recruiting partici- (2008) identified two articles where in older cohorts may, of course, not pants over 55 years of age: 34% the patients were completely satisfied be restricted to Miller class I and II (Clauser et al. 2003, Pagliaro et al. with the clinical result independent defects and the prevalence of class III 2003), 35% (Chambrone & Tatakis of the surgical technique used (Bou- and IV defects, and a more general- 2015), 41% (Cairo et al. 2008), 41% chard et al. 1994, Rosetti et al. ized pattern of gingival recession (Chambrone et al. 2012), 42% 2000). A further trial reported should encourage not only surgical (Chambrone et al. 2009c) and 43% greater patient satisfaction with acel- (where indicated) but also more con- (Chambrone et al. 2008). The quality lular dermal matrix grafts when servative approaches to management of the reviews was assessed using the compared to connective tissue grafts such as reassurance, placement of Overview Quality and Assessment (Aichelmann-Reidy et al. 2001). pink and/or white restorations, posi- Questionnaire (OQAQ) (Oxman & Chambrone et al. (2009c) also tioning of margins of full coronal Guyatt 1991, Shea et al. 2007). Five reported the observations made by restorations and gingival veneers. of the six reviews scored an overall Bouchard et al. (1994) as well as This would then provide the opportu- 6/7 (Cairo et al. 2008) or 7/7 (Cham- those of Rosetti et al. (2000) who nity to critically evaluate the inter- brone et al. 2008, 2009c, 2012, found that all patients were equally ventions across a much broader Chambrone & Tatakis 2015) on the satisfied with the aesthetic outcome profile of criteria apart from the © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Gingival recession and root caries S187 attainment of complete (or partial) surface zone, the mineral content of of root caries (Nyvad & Fejerskov root coverage. Indeed, it may be con- which may be higher than that of 1986), modern classification methods jectured that aesthetics, particularly sound unexposed tissue (Selvig are now recommending a distinction of single, localized lesions, may not 1969). Experimental studies in vivo of lesions into active and inactive be of much relevance or importance have shown that topical treatments stages (Fejerskov et al. 1991, to older subjects; had this been the with fluoride may enhance mineral Ekstrand et al. 2008). Briefly, the case, then intervention would have precipitation in root surfaces (Fur- typical active lesions are soft on gen- been sought much earlier assuming seth 1970). On the contrary, peri- tle probing and show a yellowish or they were of a long-standing nature. odontal surgery and aggressive light brown colour without obvious Further, the pattern of gingival reces- mechanical debridement may break cavitation. The inactive or slowly sion in older patients may well be dif- or remove the surface layer (Jepsen progressing lesions may present a ferent to that in younger patients, et al. 2004) and expose the underly- leathery or hard darkly discoloured perhaps as a consequence of peri- ing dentinal tubules, leading to surface, even if the lesion has odontal disease, periodontal treat- hypersensitivity and possibly biofilm reached the stage of cavitation ment or a heavily restored dentition accumulation and caries. What the (Nyvad & Fejerskov 1982). Such with multiple restorations at or below periodontist may see as a successful classification is now commonly used the gingival margin. Such presenta- treatment could thus be counterpro- in clinical trials of root caries. tions may not be manageable by peri- ductive for the cariologist, who odontal plastic surgery and more praises preservation of the root sur- Non-operative treatments conservative measures indicated. face! Fortunately, when the patient Patient-reported opinions are is able to carry out an adequate Most of our knowledge about the infrequently reported on clinical out- daily hygiene with fluoride tooth- effects of non-operative treatment of comes following surgery (Cham- paste, a new hypermineralized sur- root caries originates from narrative brone et al. 2008, Graziani et al. face layer may develop within a few reviews. Many reviews describe a 2014) when clearly their views of months after overinstrumentation of broad variety of treatments without their initial clinical status would be root surfaces (Selvig 1969). due consideration of their relative invaluable to help inform the selec- Scaling and root planing could be clinical significance (Leake 2001, tion of the appropriate treatment even more problematic in the pres- Rodrigues et al. 2011, Walls & regimen. Similarly, aesthetic evalua- ence of root caries. Root caries Meurman 2012, Gluzman et al. tions of outcomes by independent lesions present a subsurface type of 2013, Bignozzi et al. 2014). This observers are seldom reported, a cru- mineral loss, similar to enamel caries could mislead practitioners to think cial oversight as aesthetic considera- lesions. However, if the surface layer that a palette of preventive methods tions such as tissue thickness, colour of the lesion is damaged due to vig- applied simultaneously might result match, scarring and misalignment of orous probing or mechanical in better outcomes than a single the mucogingival margin cannot be debridement, the body of the carious effective treatment. Only one system- determined by recording the extent lesion may develop into an uncleans- atic review has conducted a quanti- of root surface coverage alone able cavity requiring restoration. tative meta-analysis of current non- (Cairo et al. 2009, Graziani et al. Anyone who has performed a filling operative interventions of root caries 2014). Further, we found no evi- on a root surface knows the difficul- (Wierichs & Meyer-Lueckel 2015). dence that any treatment for gingival ties encountered with such treat- The authors concluded that regular recession, surgical or conservative, ment. Therefore, from a cariological use of dentifrices containing has been evaluated from the position point of view, the surface integrity 5000 ppm fluoride and quarterly of health economics; cost-minimiza- of root caries lesions should be pre- professionally applied chlorhexidine tion, cost-effectiveness, cost-utility served by non-operative treatments. (CHX) or silver diamine fluoride and cost-benefit analyses would all Root caries lesions may occur on (SDF) seem to be efficacious in be relevant and applicable to the all exposed root surfaces but are reducing the initiation and progres- management of gingival recession mainly found in biofilm retention sion of root caries. Yet, the authors (Vernazza et al. 2012) and particu- sites, such as along the cemento- toned down their conclusions due to larly so in older cohorts. enamel junction, in mesial and distal the low numbers of clinical trials for concavities, and along margins of each of the explored methods, the Treatment of root caries restorations. Such sites may not high risk of bias within studies, and always be the sites most frequently the limiting grade of evidence. There Management of root surfaces from a checked by the periodontist, who are no recent publications that could cariological perspective mainly focusses on sites next to the justify a new meta-analysis. There- Root surfaces differ from enamel gingival margin. Diagnosis of root fore, the following presents a critical surfaces by a lower mineral content caries is difficult because of impaired re-digestion of existing data with the and a higher amount of organic visibility, and the diagnosis must be aim to obtain a clearer picture of material. Because of the smaller size performed cautiously without force- potential knowledge gaps. of the apatite crystals, root surfaces ful poking into the tissue. Formerly, Fluoride are highly receptive to mineral root caries lesions were predomi- uptake in the oral environment. This nantly classified according to their Brushing the teeth with fluoride explains why exposed root surfaces severity (Billings et al. 1985). How- toothpaste is a strong recommenda- usually present a hypermineralized ever, recognizing the dynamic nature tion for caries control. Daily © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd S188 Heasman et al. brushing with fluoride toothpaste residents who had their teeth brushed root caries (Kidd et al. 2015), and confers a 24% reduction in caries by the nursing staff twice a day. any topical fluoride treatment could over 2–3 years in children and ado- After 8 months, lesion arrest (“re- facilitate hypermineralization of the lescents compared to placebo (Mar- hardening”) was more prevalent in surface layer during root caries inho et al. 2003), and a similar effect the high-F group. As there were no arrest (Nyvad et al. 1997). Although has been estimated for enamel and differences in plaque conditions originally developed for controlling root surfaces in adults (Griffin et al. between the two groups at the end of cavities in children, SDF has also 2007). Interestingly, the prevented the study, the authors ascribed differ- been tested for the prevention of fraction of community water fluori- ences in the outcome to the higher root caries in functionally indepen- dation or rinsing with a fluoride solu- fluoride content (Ekstrand et al. dent adults. Tan et al. (2010) com- tion on root caries could be in the 2013). In the other study, home- pared the effect of annual same order of magnitude as brushing bound 75+-year-olds were assigned application of 38% SDF in conjunc- with fluoridated toothpaste (Twet- to one of three groups. Participants tion with individualized oral hygiene man et al. 2004, Wyatt & MacEntee in group 1 brushed their teeth with (OHI) with 3-monthly applications 2004, Griffin et al. 2007). This might 1450-ppm-fluoride toothpaste, and of 1% chlorhexidine varnish and indicate that mechanical oral hygiene once a month, a dental hygienist OHI, 3-monthly applications of 5% does not matter. Yet, cross-sectional brushed the teeth with the same NaF varnish and OHI, or OHI studies have shown that the strongest toothpaste and applied 5% F varnish alone. All participants were recom- factor explaining the presence of root (23,000 ppm F) to active root caries mended to use fluoridated toothpaste caries, with control for other factors, lesions. Participants in groups 2 and for daily cleaning of the teeth. At was oral hygiene (DePaola et al. 3 received 5000- and 1450-ppm-F the end of the 3-year trial, all the 1989, Vehkalahti et al. 1997). Prop- toothpaste, respectively, and brushed therapeutic interventions were more erly designed experimental in situ twice daily. At the end of the study, effective in preventing new root car- studies have suggested that only half the root caries status of the partici- ies lesions than giving oral hygiene of the treatment effect of brushing pants in groups 1 and 2 had instruction alone. No one interven- with fluoride toothpaste could be improved significantly compared tion (38% SDF, 1% chlorhexidine ascribed to fluoride, and the other with group 3. Interestingly, partici- varnish or 5% NaF varnish) was sig- half was due to a cleaning effect pants in group 2 brushing with the nificantly superior to the other. The (Dijkman et al. 1990). These obser- high-F paste did not fare better than authors did not report on lesion vations imply that the quality of oral participants in group 1 using a low-F arrest, but subsequent studies found hygiene might play a significant role paste and receiving monthly profes- that annual SDF treatment may also for the outcome of interventions with sional cleaning and fluoride varnish promote lesion arrest (Zhang et al. fluoride. The design of future inter- application. These results imply that 2013, Li et al. 2016). Nevertheless, vention studies with fluoride should brushing with high-F toothpaste these premature studies do not pro- therefore allow for a distinction should not necessarily be considered vide evidence to support that SDF between the fluoride component and “best practice” for root caries con- treatment should be preferable in the mode of application. trol. It should also be noted that in root caries control. In recent years, research has both of the above studies, profes- Proponents of SDF treatment focussed on boosting fluoride con- sional dental cleaning was applied in often ignore the potential harmful centrations in toothpaste for at least one of the experimental arms. side effects. In addition to blackening improved control of root caries. This Indeed, when adults were using 5000- of carious dentin, an effect of purely development was possibly triggered ppm-F paste for 6 months on their cosmetic concern, SDF treatment by early clinical studies of DePaola own, without professional plaque causes mildly painful chemical burns (1993) showing that professional control, root caries arrest varied of the oral mucosa (see illustration by application of 12,000 ppm NaF gel widely across individuals (Srinivasan Deutsch 2016) that may last for up to to active non-cavitated root caries et al. 2014). Further studies of longer 48 h (Rosenblatt et al. 2009). The lesions every four months over a duration including crossover design European Union classifies silver year was successful in arresting root are therefore required to confirm the nitrate as both corrosive and danger- caries. More recently, four short- potential superiority of high-F tooth- ous for the environment, and SDF term clinical trials of 6- to 8-month pastes compared with other topical has not yet been cleared by the US duration (Baysan et al. 2001, fluoride interventions for root caries. Food and Drug administration (Fung Ekstrand et al. 2008, 2013, Srini- et al. 2013). To circumvent this prob- Fluoride derivatives vasan et al. 2014) have concluded lem, Deutsch (2016) developed an that root caries progression might be Ammonia-based 28% SDF was pro- alternative topical fluoride strategy halved by exchanging a conventional moted as an alternative treatment to for treating root caries lesions using a toothpaste (1100, 1350, 1450 ppm F) halt and prevent the development of combination of aqueous 40% AgF with a 5000-ppm-F toothpaste new dentin caries (Rosenblatt et al. and 10% SnF2. It was stated that the (Wierichs & Meyer-Lueckel 2015). 2009). The philosophy behind SDF advantage of AgF and SnF2 over In particular, the studies by is based on the antimicrobial effect SDF is that AgF + SnF2 does not Ekstrand and co-workers are of of silver and the formation of a cause gingival irritation. The method interest. In one study, 1450- or 5000- “sclerotic coating” at the surface of was applied on a 3- to 4-monthly ppm-fluoride toothpastes were tested carious dentin. Bacterial killing is, basis to arrest multiple active root in elderly disabled nursing home however, not a long-lasting cure for caries lesions in frail elderly without © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Gingival recession and root caries S189 causing discomfort, and it was sug- addition to poor dental hygiene, root surface and may be used in gested that the approach might be hyposalivation and frequent sugar minimally invasive approaches such particularly useful when treating cog- intake are risk factors that stimulate as the ART technique (Frencken nitively impaired elderly who may acidification of the dental biofilm 2014). In ART, only hand instru- not have the ability to comply with (Takahashi & Nyvad 2011). Any car- ments are used to remove soft cari- conventional dental treatment. ies treatment must therefore start by ous dentine. Comparative studies Deutsch (2016) also advocated that identification of individual risk fac- have shown that the survival of root AgF + SnF2 could be used as an tors which should be modified caries restorations using this tech- alternative to excavation prior to according to individual needs (Nyvad nique is similar to the traditional placing atraumatic restorative treat- & Kidd 2015). There is no standard approach using rotary instruments ment (ART) restorations. Further cure for caries. Caries control is a for excavation (Lo et al. 2006). The testing of the effect of these methods matter of establishing the right bal- low-technology approach of ART in physically and cognitively debili- ance between major risk factors such may be particularly useful and cost- tated patients is clearly warranted. as plaque control, sugar exposure effective for outreach dental services and fluoride. Particularly, it should such as in homebound and institu- Chlorhexidine be appreciated that although fluoride tionalized elderly with physical or One systematic review has evaluated is important, fluoride alone cannot cognitive disorders (Da Mata et al. the effect of chlorhexidine varnish be expected to stop root caries as 2014, Gonzales & Zuluaga 2016). on root caries incidence and activity long as the dental biofilm is produc- Further clinical trials are needed to (Slot et al. 2011). Evaluation of data ing high amounts of acids. explore the benefits of these treat- provided no conclusive evidence that ments for the vulnerable elderly. regular application of chlorhexidine Operative treatment varnish to root surfaces is effective Trends and Future Perspectives for caries control in patients receiv- Operative treatment of root caries ing regular professional tooth clean- should be avoided as far as possible. Although trend and projection data ing. Slot et al. (2011) proposed that This is because of the relatively poor for the prevalence of either localized in the absence of regular profes- prognosis of restorations. Studies in or generalized gingival recession in sional interventions, chlorhexidine elderly patients have shown that the older age groups are not readily varnish might have a beneficial effect survival of root caries restorations is identifiable, it is reasonable to use in special care patients. However, about 90% and 65% after 1 and the retention of teeth as a broad but other authors found that the evi- 2 years, respectively (Hu et al. 2005, nevertheless indicative surrogate dence was too weak to support this Lo et al. 2006, Gil-Montoya et al. marker for the prevalence of gingival conclusion (Twetman 2004, Duane 2014). No studies have evaluated the recession and subsequently root car- 2011). Likewise, regular mouthrins- longevity of restorations for more ies. The national surveys of Adult ing with 0.12% chlorhexidine solu- than 2 years. Irrespective of the Dental Health in the United King- tion did not have an effect on the restorative material applied (glass dom have been undertaken every preservation of enamel and root sur- ionomer or composite resin), the 10 years (1988, 1998 and 2009) since faces in older adults (Wyatt & majority of fillings fail because of 1978, and trends indicate clearly that MacEntee 2004, Wyatt et al. 2007). dislodgement (Levy and Jensen 1990, there is a decline in the rate of tooth Hu et al. 2005), possibly because of loss with each decade (Fuller et al. Dental hygiene difficulty in achieving adequate 2011). The percentage of dentate A few reviews stress the overriding moisture control. Another problem UK adults in all age groups, and importance of dental hygiene in root in the elderly may be associated with particularly those over 55 years, is caries control (Fejerskov 1994, Big- decreased ability to cooperate result- increasing significantly over the dec- nozzi et al. 2014, Wierichs & Meyer- ing in poor visibility and access to ades (Steele et al. 2000, Fuller et al. Lueckel 2015). In their systematic the caries lesion. Therefore, it is 2011), and future projections using review, Wierichs & Meyer-Lueckel always recommended to consider the data of 1988 and 1998 predicted (2015) observed that several trials whether an active root caries lesion that approximately 43% of adults reported improved oral hygiene for might be managed non-operatively over the age of 85 in 2008 would all participating patients, even in the rather than operatively. Operative retain at least one natural tooth control groups, emphasizing the sig- treatment is purely symptomatic and (Steele et al. 2000). The actual figure nificance of dental cleaning in the does not deal with the patient’s car- was 53% (Fuller et al. 2011) indicat- management of root caries (Nyvad & ies problem (Nyvad & Fejerskov ing that the retention of natural Fejerskov 1986, Emilson et al. 1993). 2015). Only when the patient cannot teeth in the oldest age groups, at Yet, intensive professional plaque clean an active (cavitated) root caries least in the United Kingdom, is far control programmes in special care lesion properly is an operative inter- exceeding expectation. Further, the patients (Johnson & Almqvist 2003) vention required. percentage of adults in the United and periodontal patients (Ravald & In recent years, high-viscosity Kingdom, over the age of 55 years, Birkhed 1992, Emilson et al. 1993) glass-ionomer cements have been the and retaining at least 21 natural have shown differing effects on root preferred mode of restoring root car- teeth has increased by approximately caries. This may not be surprising. ies lesions in the elderly (Amer & 10% each decade from 30% in 1978 Root caries is a multifactorial condi- Kolker 2013). These materials bene- to 63% in 2009. Over the same per- tion that relies on several factors. In fit from binding chemically to the iod, the mean number of natural © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd S190 Heasman et al. teeth/individual has risen from 16 to Adult Dental Health Survey UK. (2009) Sum- Recommendations for Clinical 21.2 (Fuller et al. 2011); if the trend mary report and thematic series. Available at: Practice http://content.digital.nhs.uk/catalogue/PUB01086 continues, by around 2030, 80% of Accessed 30.09.16. adults over 55 years in the United 1 There is no evidence to suggest Aichelmann-Reidy, M. E., Yukna, R. A., Evans, Kingdom will have at least 21 natu- that periodontal surgical proce- G. H., Nasr, H. F. & Mayer, E. T. (2001) Clin- ral teeth, with a mean number of ical evaluation of acellular allograft dermis for dures to manage gingival reces- the treatment of human gingival recession. approximately 25. The implication sions in younger age groups are Journal of Periodontology 72, 998–1005. for the prevalence of gingival reces- not equally successful and should Ainamo, A., Ainamo, J. & Poikkeus, R. (1981) sion and root caries is clear. be used for older patients in older Continuous widening of the band of attached It follows from the above that gingiva from 23 to 65 years of age. Journal of cohorts, and particularly those 16 – there is no easy cure for root caries. Periodontal Research , 595 599. with Miller class I and II lesions. Ainamo, J. & Talari, A. (1976) The increase with Current methods involving fluorides 2 Root caries lesion development age of the width of attached gingiva. Journal of may at best reduce the progression can be controlled at the popula- Periodontal Research 11, 182–188. Albander, J. M. & Kingman, A. (1999) Gingival of root caries by about 50%. We are tion level by brushing the teeth gradually learning more about the recession, gingival bleeding, and dental calculus twice a day with conventional flu- in adults 30 years of age and older in the Uni- pathogenic processes in root caries, oride toothpaste (1000–1500 ppm ted States, 1988–1994. Journal of Periodontol- especially the biochemical processes F). ogy 70,30–43. Al-Hamdan, K., Eber, R., Sarment, D., Kowal- that occur in the dentin organic 3 Active root caries lesions can be con- materials as a result of demineraliza- ski, C. & Wang, H.-L. (2003) Guided tissue verted into inactive lesions by twice- regeneration-based root coverage: meta-analy- tion (Takahashi & Nyvad 2016). It is daily brushing with conventional sis. Journal of Periodontology 74, 1520–1533. hypothesized that as bacterial acids fluoride toothpaste (1000–1500 ppm Amer, R. S. & Kolker, J. L. (2013) Restoration demineralize and expose the organic F), combined with professional appli- of root surface caries in vulnerable elderly matrix, host-derived proteases from patients: a review of the literature. Special Care cationsof5%NaFvarnishor2% in Dentistry 33, 141–149. saliva and dentin itself (matrix met- NaF solution 3–4 times a year. Alter- Baker, P. & Spedding, C. (2002) The aetiology of alloproteinases and cathepsins) natively, lesion arrest might be gingival recession. Dental Update 29,59–62. become activated to promote the ini- Baysan, A., Lynch, E., Ellwood, R., Davies, R., obtained by brushing lesions twice a Petersson, L. & Borsboom, P. (2001) Reversal tial degradation of the dentin matrix. day with high-F toothpaste Novel strategies based on protection of primary root caries using dentifrices contain- (5000 ppm F). ing 5,000 and 1,100 ppm fluoride. Caries of the dentin matrix by protease 4 Fluoride interventions should be Research 35,41–46. inhibitors might potentially improve combined with meticulous dental Bignozzi, I., Crea, A., Capri, D., Littarru, C., Lajolo, C. & Tatakis, D. N. (2014) Root caries: therapies for root caries in the future hygiene and sugar control to opti- (for review, see Takahashi & Nyvad a periodontal perspective. Journal of Periodon- mize the caries-controlling effect. tal Research 49, 143–163. 2016). Such strategies are urgently If proper dental hygiene cannot be Billings, R. J., Brown, L. R. & Kaster, A. G. needed as our populations are grow- performed, for example in the (1985) Contemporary treatment strategies for root surface dental caries. Gerodontics 1,20–27. ing older with an increasing number elderly medically compromised of teeth at risk of root caries. Bouchard, P., Etienne, D., Ouhayoun, J. P. & patient, daily use of a fluoridated Nilveus, R. (1994) Subepithelial connective tis- mouthrinse may help in control- sue grafts in the treatment of gingival reces- Recommendations for Future ling root caries lesion develop- sions. A comparative study of 2 procedures. Journal of Periodontology 65, 929–936. Research ment. Chlorhexidine has no Brown, L. J., Brunelle, J. A. & Kingman, A. (1996) additional effect in combination Periodontal status in the United States, 1998– 1 The epidemiological profile and with regular use of fluoride. 1991: prevalence, extent and demographic varia- clinical presentation of gingival 5 Active root caries lesions that can- tion. Journal of Dental Research 75, 672–683. not be cleaned properly by the Burt, B. A. (1994) Periodontitis and aging: recession in older groups should reviewing recent evidence. Journal of the Ameri- be investigated. patient should be restored by min- can Dental Association 125, 273–279. 2 Further clinical trials are necessary imally invasive techniques using Buti, J., Baccini, M., Niera, M., LaMarca, M. & before any firm conclusions can be glass-ionomer cements. Pini-Prato, G. P. (2013) Bayesian network meta- analysis of root coverage procedures: ranking drawn regarding the most appro- efficacy and identification of best treatment. priate treatment options, surgical Journal of Clinical Periodontology 40, 372–386. or conservative, for older patients Cairo, F., Nieri, M. & Pagliaro, U. (2014) Effi- with gingival recession. Such stud- Acknowledgements cacy of periodontal plastic surgery procedures ies should include independent aes- in the treatment of localised facial gingival The authors would like to thank recession. A systematic review. Journal of Clini- thetic observations, patient-centred Ninah Patterson for her valuable cal Periodontology 41(Suppl. 15), S44–S62. opinions and health economic assistance and attention to detail in Cairo, F., Pagliaro, U. & Nieri, M. 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Clinical Relevance caries in older patients necessitates a Practical implications: Surgical Scientific rationale for the study: different approach to that under- management for Miller I and II Gingival recession and root caries taken for younger cohorts. defects achieves predictable root become prevalent as patients retain Principal findings: Connective tissue coverage. Where root caries has their teeth throughout their lives. grafts achieve substantial root cover- already developed, the integrity of A systematic approach was war- age of localized lesions in patients of the root should be preserved by ranted to ascertain whether the all ages. Root caries may be controlled non-operative treatments using management of recession and root without operative interventions. topical fluorides.