THE ANATOMICAL LESIONS OF CERVICAL ABRASION AND GINGIVAL RECESSION - SIDE-EFFECTS OF TOOTHBRUSHING

Abstract

The increased incidence of cervical abrasion associated with gingival abrasion or recession, encouraged us to pursue the incidence, the characteristics and factors favoring the occurrence of these lesions. The clinical study evaluated 132 patients, of which 5.63% presented cervical abrasion lesions due to an inadequate tooth-brushing, the association with gingival recession meeting in the rate of 4.22%. The cases were of both sexes, all from urban areas and the age between 16 and 40 years, on which we evaluated the location, shape, size and sensitivity of the lesions. The highest incidence of lesions was found in the canines and premolars, especially on the mandibular arch. Canines, because of the anatomical alveolar bone defects and buccal location, are more susceptible to gingival recession. In all cases, the abrasion lesions and gingival recession are in a more advanced stage at the quadrant where begins the initial placement of the brush, in the opposite area of the hand which holds the brush.

Full text

286
Dorelia Cãlin, L. Frâncu
Revista Românã de Anatomie funcþionalã ºi clinicã, macro- ºi microscopicã ºi de Antropologie
Vol. IX - Nr. 3 - 2010 ORIGINAL PAPERS
THE ANATOMICAL LESIONS OF CERVICAL ABRASION AND GINGIVAL
RECESSION  SIDE-EFFECTS OF TOOTHBRUSHING
Dorelia Cãlin1, L. Frâncu2
University of Medicine and Pharmacy Gr.T. Popa, Iaºi
1. Discipline of Cariology and Restorative Odontotherapy
2. Discipline of Anatomy
THE ANATOMICAL LESIONS OF CERVICAL ABRASION AND GINGIVAL RECESSION 
SIDE-EFFECTS OF TOOTHBRUSHING (Abstract): The increased incidence of cervical abra-
sion associated with gingival abrasion or recession, encouraged us to pursue the incidence, the
characteristics and factors favoring the occurrence of these lesions. The clinical study evaluated
132 patients, of which 5.63% presented cervical abrasion lesions due to an inadequate tooth-
brushing, the association with gingival recession meeting in the rate of 4.22%. The cases were of
both sexes, all from urban areas and the age between 16 and 40 years, on which we evaluated the
location, shape, size and sensitivity of the lesions. The highest incidence of lesions was found in
the canines and premolars, especially on the mandibular arch. Canines, because of the anatomical
alveolar bone defects and buccal location, are more susceptible to gingival recession. In all cases,
the abrasion lesions and gingival recession are in a more advanced stage at the quadrant where
begins the initial placement of the brush, in the opposite area of the hand which holds the brush.
Key words: CERVICAL ABRASION OF TOOTH, DENTAL ANATOMY, GINGIVAL ABRA-
SION, GINGIVAL RECCESION, TOOTHBRUSHING
INTRODUCTION
The natural cleaning of the teeth is insuffi-
cient because the natural physiological forces
cannot clean the oral cavity and remove all
dental plaque. The physical methods are abso-
lutely necessary to control the dental plaque.
The toothbrushing is the main mean of pre-
vention of oral cavity diseases. Because of the
many benefits it has on oral health, the adverse
effects and the damage of the hard and soft oral
tissues are usually regarded as insignificant.
Tooth cleaning devices date back thousands
years. The Chinese used chewing sticks, which
are considered primitive configurations of the
toothbrush. The toothbrush itself was used by
the Chinese in about 1000 years ago and is
believed to have been made of hogs bristle.
The toothbrush began to be used in Europe
in the late 18th century and early 19th century
but were too expensive to be used by anyone.
In the late 1930s, nylon filaments have re-
placed the natural hair and the handle was made
of plastic or wood. They have become cheaper
to reach by everyone, leading to a improved
oral health of the population.
Although manual brushing is the main way
to maintain the oral hygiene, the majority of
the people do not clean their teeth properly or
for an adequate period of time. Thus, electric
powered toothbrushes were invented in order
to overcome these barriers and to maintain a
proper oral hygiene. In the 1960s, the electric
powered toothbrushes were used especially for
patients with physical disabilities or for those
who had limited manual dexterity.
The toothbrush in combination with den-
tifrice possesses some level of abrasivity, the
reason for their use to remove deposits from
the teeth may create undesirable effects on
dental hard tissues and gingival.
In the oral cavity, four tissues can be da-
maged by the abrasive effect of toothbrushing:
the enamel, dentine, gingival tissues and al-
veolar mucosa. The most common injuries are:
epithelial abrasion, gingival recession with root
surface exposure in the oral cavity, cervical

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The Anatomical Lesions of Cervical Abrasion and Gingival Recession
abrasion of cementum and dentine.
The aim of our study is to continue the
previous research (1) on the effects of incorrect
tooth brushing, with inadequate products, on
the soft and hard oral tissues.
MATERIALS AND METHODS
Our study included the assessment of the
dentition and of the effects of toothbrusing on
the hard and soft oral tissues in 132 pacients in
the dental office of discipline of Cariology and
Restorative Odontotherapy of University of Medi-
cine ºi Pharmacy Gr. T. Popa Iaºi.
The selected patients for the clinical study
were of both sexes and between 16 and 72
years old. They were from both rural and urban
areas. All the patients hadnt presented associa-
ted diseases of oral mucosa and general diseases.
The selected cases were presented dental
and gingival lesions caused by toothbrushing
assessed after a systematic and accurate dental
history. The assessment of the lesions was made
after the removing of the debris, dental plaque
from the surface of the lesions, using the mirror
and dental probe. We aimed to detect if there
are present concomitant cervical lesions and
gingival lesions or gingival recession in the same
individual and the topography of the lesions.
RESULTS AND DISCUSSIONS
The study of our personal casuistry allowed
us to detect eight cases of cervical abrasion
caused by toothbrushing which represents 5.63%.
The both sexes were interested, three cases
were found in male persons and five in female
persons, all the cases were in people from
urban areas.
At six of the eight cases, the cervical lesions
of abrasion were accompanied by gingival re-
cession (75%), which represents 4.22% of all
examined patients. The gingival recession was
located most frequently at the cervical abrasion
lesions of the mandibullary and maxillary ca-
nines (8 teeth), then the premolars (5 teeth)
and incisors (1 tooth). In one patient were
revealed lesions of type I gingival abrasion.
In all cases, the abrasion lesions and gin-
gival recession are in a more advanced stage at
the quadrant where begins the initial placement
of the brush, in the opposite area of the hand
which holds the brush.
We will present the lesional characteristics
aspects in the detected cases.
Case no 1: C.D., 38 years, presents type I
gingival lesion, a patch-like surface defect cau-
sed by toothbrushing at 22 tooth (fig. 1) and
type I gingival lesion, a ribbon-like surface
defect and gingival recession localized to 33
caused by the abnormal position in the dental
arch (fig. 2).
Case no 2: F.L., 40 years. Canine ectopia
(33) with cervical abrasion caused by tooth-
brushing, V shape lesion, with a hard surface
at palpation with a dental probe. The lesion
appeared 12 years ago and remained stationary
by changing the habits of brushing and the use
of a toothpaste without abrasive particles. The
buccal location in the dental arch makes it more
susceptible to gingival recession. Light sensi-
tivity is present in the air stream from the
dental unit. 33 canine presents gingival re-
cession (fig. 3).
Case no 3: M.A., 24 years, makes an aggres-
sive toothbrushing 4-5 times per day. Canine
ectopia (23), gingival recession, 24, 34 pre-
Fig. 1. Case no 1. C.D., 38 years.
Fig. 2. Case no 1. C.D., 38 years.

288
Dorelia Cãlin, L. Frâncu
sents gingival recession caused by inappro-
priate toothbrushing and buccal location in the
dental arch. Light sensitivity is present.
Case no 4: L.A., 23 years, toothbrushing
manually performed 2-3 times per day. Cer-
vical abrasion lesion at 43 accompanied by
gingival recession (fig. 4)
Case no 5: N.L., 24 years, makes unex-
pected toothbrushing associated with an exces-
sive consumption of carbonated drinks. Cervical
lesions are located bilaterally in the canine and
premolars at enamel-cement junction. Gingival
recession is accompanying the abrasion lesions
(fig. 5).
Case no 6: M.V.,16 years, cervical abra-
sion caused by brushing the 33 tooth (canine
ectopia) and 34. V-shaped lesions, with hard
surface at palpation with the probe, is not colored
and is not covered by plaque. Gingival recession
is marked by the 33 position anomaly (fig. 6).
The clinical study of the casuistry that stayed
at our disposal allowed the description of the
lesions caused by toothbrushing, both on the
dental hard tissues (enamel and dentine), as
well as on the soft tissues.
The effects of toothbrushing on the
enamel and dentine
As you noted from the above description,
the abrasion caused by toothbrushing is usually
located at the cervical area on the facial sur-
faces of teeth prominent in the arch. Usually,
the lesions are initiated by horizontal brushing
with a brush with hard bristles.
Abrasion occurs only in the presence of
gingival recession, also caused by the brushing
technique and the cemento-enamel junction be-
comes exposed in the oral cavity.
Sagnes and Gjemo (1979) observed con-
comitant dental and gingival lesions in the same
individual that indicates a common etiology of
these lesions (2).
The effects of the toothbrushing on the
gingiva
The clinical studies confirm the occurrence
of the gingival lesions in patients with strict
oral cavity hygiene (too long and too frequent
toothbrushing). The gingival recession is located
on the buccal surfaces of the teeth, more pro-
nounced in the cervical region of canines and
premolars and more frequently in the maxilla.
The gingival abrasion has two topographical
forms inflammation of the gingival margin and
the inflammation of the protruding areas on the
gingiva remote from the gingival margin. These
forms described in the literature may be accom-
panied by ulceration (3).
Wolfram (4) suggested that the depth of the
gingival sulcus can be related to the mechanical
trauma caused by toothbrushing.
Bass (5) noted that a inappropiate use of a
toothbrush could cause gingival recession. He
concluded that toothbrushes with soft bristles
can cause less trauma to the gingival tissue
Fig. 3. Case no 2. F.L., 40 years.
Fig. 4. Case no 4. L.A., 23 years.
Fig. 5. Case no 5. N.L., 24 years.

289
The Anatomical Lesions of Cervical Abrasion and Gingival Recession
compared to those with hard bristles and recom-
mended that each filament tip should be end-
-rounded to minimize tissue trauma.
Since 1953 the researches of the Stahl (6)
shows that toothbrusing increases the kerati-
nisation degree of the gingiva, natural hair
brushes are more traumatic compared to those
of nylon. More recently, demonstrated that the
toothbrushing is a traumatic procedure for the
periodontal tissues. The soft tissue trauma may
lead to gingival abrasion (7) and to gingival
recession (8, 9).
The gingival recession is localized on the
facial surfaces of the teeth and is attributed to
an improper toothrushing technique (7). The
lesions are more pronounced in the cervical
areas of the incisors, canines and premolars
(2). The lesions are more common in the ma-
xilla compared with the mandible. Subjects
with a thin gingival tissue are more susceptible
to gingival recession compared to those with a
thick gingival tissue (10).
The gingival recession is more frequent in
people that cleans their teeth with hard bristle
toothbrush. It occurs more often in older people
but is not related to the physiological effect of
ageing, but shows that the toothbrusing was
made for a longer period of time (11). The
increase of the frequency of the gingival recession
as a result of an aggressive toothbrushing can
lead in time to an increased incidence of the
root surface caries.
Gillette and van House (3) have described a
classification of the lesions which result from
improper oral hygiene measures. This classi-
fication is based upon source of injury, site of
occurence and potential side-effects. Thus, the
gingival lesions caused by toothbrushing are
classified in three groups:
Laceration which is an acute mechanical
trauma
Gingival recession
Hyperkeratinization and hyperplasia, the last
two being characteristic of chronic lesions.
Sandholm (1982) (7) used scanning electron
microscopy to describe these lesions and des-
cribed 3 types:
Type I- erosion of the epithelial surface at
the gingival margin with the appearance of
a ribbon or patch-like surface defect or a
diffuse border at the gingiva-tooth interface
caused by bleeding or oozing of tissue fluid
from the eroded areas;
Type II- epithelial, surface flap rolled up
leaving the underlying tissue uncovered;
Type III- rupture or fenestration of the sur-
face epithelium in the middle of the promi-
nent but healthy gingival area.
Breitenmoser (1979) (12) found that the use
of a disclosing agent such as that used for dental
plaque may result in an excellent staining of these
lesions and they could be easily distinguished
from normal gingiva. The small lesions of abra-
sion are not visible on clinical evaluation (13).
Several factors must be considered in the
etiopathogenesis of the cervical abrasion le-
sions and gingival recession which can be sys-
tematized as:
 Individual factors: such as inappropriate
toothbrushing technique, the frequency
of toothbrushing, the force used during
brushing;
 Factors related to the material: the use of a
hard bristle toothbrush, the quality of the
toothbrush, the dentifrice abrasiveness;
 The position of the teeth in the arch.
The force used during toothbrushing
Numerous clinical and experimental studies
support the assumption that the use of an ex-
cessive force during toothbrushing is respon-
sible in part for the trauma caused to the soft
and hard dental tissues (14).
Previously, numerous studies have evaluated
the force during toothbrushing and showed sig-
nificant variations in force magnitude (15, 16).
Differences appear to be related to toothbru-
shing technique, toothbrush design,research me-
thods.
McLey ºi Zahradnik (1994) (17) investigating
the force used during the power toothbrushing
compared with the manual toothbrushing de-
monstrated that the force used during manual
brushing is significantly higher compared with
that of the electric brush. Van der Weijden
(1996) (18) obtained similar results. The re-
sults of these studies may be relevant in terms
of maintaininig the long-term integrity of oral
soft and hard tissues exposed to various brushing
devices.
An inadequate toothbrushing is the main
factor responsible for a repetitive gingival
trauma leading to tissue distruction and gingival
recession.

290
Dorelia Cãlin, L. Frâncu
Dentifrice abrasiveness
Depends on the toothpaste properties. They
contain many ingredients, but the most com-
mon are detergents and abrasives which can
cause loss of tooth substance.
Beyeler ºi Mooser (1960) (19), during a
study of patients with a so called perfect
hygiene, showed that the cervical abrasion and
gingival lesions can be caused by the abrasive
components of the dentifrices. In addition, the
amount of applied dentifrice may increase its
abrasive potential (20), and the cervical abra-
sion is closely linked to the use of undiluted
toothpaste that is places in the same area of the
oral cavity (21). It is useful to advise patients
to use decreased quantities of dentifrice and
begin brushing on the occlusal surfaces in order
to dilute the toothpaste. Also, it is recom-
mended to alternate the initial placement of the
paste between quadrants in order to distribute
the abrasive effect.
The end of the bristles
Since 1948, Bass recommended that each
filament should be end-rounded to minimiye
tissue trauma. Studies that assessed the effect
of the end of the bristles on the gingival surface
(12), showed that manual brushes with pointed
bristles produce greater gingival lesions com-
pared with end-rounded bristles.
Force control during brushing
Lately, manual and electric toothbrushes
manufacturers have introduced designs which
sould limit the force used to reduce the chance
of hard and soft dental tissue damage (22).
CONCLUSIONS
1. The toothbrushing is the main mean of pre-
vention of oral cavity diseases, but oral hygiene
products should be evaluated for safety.
2. Cervical abrasion lesions and gingival lesions
have a common and multifactorial etiology.
3. There are many predisposing factors: ana-
tomical, physiological and pathological
which potentiate the effects of an inadequate
brushing.
4. The abrasive effect of toothbrushing can
damage four tissues in the oral cavity: the
enamel, dentine, gingival tissue and alveolar
mucosa.
5. Both conditions are developing in a long
period of time and in incipient forms are
difficult to detect clinically.
6. Cervical abrasion occurs in 5.63% of all
examined patients, while the association with
gingival recession accurs in a proportion of
4.22%.
7. These associated lesions occurs more
frequently on canines and premolars, on
teeth with abnormal position, the mandi-
bullary arch is more frequently interested.
8. The abrasion lesions and gingival recession
are in a more advanced stage at the quadrant
where begins the initial placement of the
brush, in the opposite area of the hand which
holds the brush.
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