Received: 8 April 2022 | Revised: 11 June 2022 | Accepted: 18 June 2022 DOI: 10.1111/odi.14289 REVIEW ARTICLE Global prevalence of gingival recession: A systematic review and meta-­analysis Vikender Singh Yadav1 | Bhumika Gumber1 | Kanika Makker1 | Vandana Gupta1 | Nitesh Tewari2 | Puneet Khanduja3 | Renu Yadav4 1 Division of Periodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India 2 Division of Pedodontics and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India 3 Public Health Consultant, MicroSave Consulting, New Delhi, India 4 Department of Prosthodontics, Surendera Dental College and Research Institute, Sri Ganganagar, India Correspondence Vikender Singh Yadav, Associate Professor, Room No. 510, 5th Floor, Division of Periodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. Email: [email protected] Abstract Objective: This systematic review and meta-­analysis aimed to estimate the global prevalence of gingival recession (GR) in the general population. Materials and Methods: Population-­based observational studies reporting the prevalence of GR and published from 1991 to 2021 were identified from five electronic databases and manual searches. Risk of bias was assessed using the Joanna Briggs Institute's Critical Appraisal Checklist for Prevalence Studies. The pooled prevalence of GR was calculated by using a random-­effect model. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to summarize the overall certainty of evidence. Results: A total of 15 studies involving 37,460 participants were included. The overall pooled prevalence was 78.16% at the minimal reported threshold values and 84.92% at ≥1 mm “cut-­off” with high heterogeneity among studies. A separate analysis for the buccal GR revealed a pooled prevalence of 75.42%. The risk of bias was found to be high for 10 and low for 5 studies. The overall certainty of the evidence was assessed to be very low. Conclusion: More than two-­thirds of the population worldwide was found to be affected by GR. Studies with standard case definition and less heterogeneity are required to accurately estimate the prevalence of GR. KEYWORDS gingival recession, meta-­analysis, prevalence, systematic review, world 1 | I NTRO D U C TI O N associated with GR have a significant impact on the treatment needs of the patients. Gingival recession (GR) is defined as the apical shift of the gingival Although GR has emerged as a public-­health problem with psy- margin in relation to the cementoenamel junction, resulting in expo- chosocial impact, it has not been given importance in oral epidemi- sure of the root surface to the oral environment (Pini Prato, 1999). GR ology. Several surveys investigating the periodontal or oral health has been known to be associated with poor aesthetics, dentinal hy- status of the population have used the Community Periodontal persensitivity, and a negative impact on the oral health-­related qual- Index of Treatment Needs (CPITN), which does not record GR. ity of life of an individual (Wagner et al., 2016; Yılmaz et al., 2020). The clinicians and researchers in periodontology have primarily GR has also been shown to be positively correlated with the devel- focused on the development of newer surgical techniques and bio- opment of root surface caries (Kularatne & Ekanayake, 2007) and materials for the coverage of the exposed root surfaces (Cosgarea non-­carious cervical lesions (Teixeira et al., 2018). These problems et al., 2022; Tavelli et al., 2020). This has resulted in patient-­related Oral Diseases. 2023;29:2993–3002. wileyonlinelibrary.com/journal/odi © 2022 Wiley Periodicals LLC. | 2993 | 2994 YADAV et al. benefits, without aiding in the public health aspects of this con- health condition); (iii) they were conference abstracts, review arti- dition. The World Workshop on the Classification of Periodontal cles, letter to editors, case reports/series, or interventional study; (iv) and Peri-­ implant Diseases and Conditions (2017) has also pro- used a self-­reported or only the visual inspection method; (v) stud- posed a treatment-­oriented classification for the GR (Cortellini & ies with duplicated data from another included study. In addition, Bissada, 2018), outlining the various clinical elements that dictate the studies that could not be retrieved even after three consecutive the surgical needs and outcomes. attempts of contacting their corresponding authors and editors of It can be envisaged that a better understanding of the preva- respective journals through email or at the website “ResearchGate.” lence of GR, particularly in the representative population samples from varied geographic regions, will impart necessary information to the public health policy-­makers and oral healthcare providers for 2.2 | Search strategy configuring appropriate preventive and therapeutic strategies. A previous narrative review reported that GR affected more than 50% An electronic search strategy was developed for PubMed and of the population with both poor and high standards of oral hygiene adapted for Excerpta Medica (EMBASE), Latin American and (Kassab & Cohen, 2003). Systematic reviews estimating the global Caribbean Center on Health Sciences (LILACS), Scopus, and Web or regional prevalence of periodontitis have been published in past of Science databases. An initial search was conducted in different (Bouziane et al., 2020; Catunda et al., 2019; Janakiram et al., 2020), databases to find the studies published from January 1991 to April however, none of the reviews focus on the prevalence of GR till date. 28, 2021, which was further updated till December 31, 2021. MeSH Thus, the present systematic review and meta-­analysis aimed to de- terms and keywords related to “gingival recession” and “prevalence” termine the global prevalence of GR, investigate the methodological were used with Boolean operators (AND and OR) to combine the characteristics, and develop recommendations for future research. searches (Supplementary file S1). In addition, gray literature was also searched to find relevant articles through Google scholar and 2 | M ATE R I A L S A N D M E TH O DS OpenGrey repository. A manual search was performed in relevant journals, national survey websites, reference list of the included studies, and previ- This systematic review was conducted in accordance with PRISMA ous systematic or literature reviews on the epidemiology of peri- guidelines (Page et al., 2021) and the review protocol was registered odontal disease for identification of additional eligible studies (CRD42021249592) in the International Prospective Register of (Supplementary file S2). Systematic Reviews (PROSPERO). The focused research question was: “What is the prevalence of GR among the general population worldwide?” 2.1 | Eligibility criteria 2.3 | Study selection and data extraction The citations from different databases were imported to a software (Rayyan®, Qatar Computing Research Institute) for the removal of duplicates and ineligible studies. Inclusion of the studies was done The eligibility criteria were based upon the Population (P), Exposure following a two-­phase process: (a) Screening phase—­Title and ab- (E), Comparator (C), and Outcomes (O) of the research question: stract of all returned citations were screened independently by two P—­individuals of all ages and gender living in any country of the reviewers (VSY and KM) to exclude the obviously ineligible studies. world, E—­GR which has been quantitatively evaluated or classified Abstracts with unclear information and articles without abstract as per the validated criteria, C—­individuals of all ages and gender (only title) but suggesting some relation to the objective of this re- without GR, and O—­prevalence of GR. In order to provide the most view were subjected to full-­text analysis. (b) Eligibility phase: The two contemporaneous and representative estimates, only population-­ reviewers (VSY and KM) independently read the full text of the se- based (cross-­sectional or cohort) studies published in any language, lected articles to confirm or refute their inclusion based on the set which had been conducted since 1991, were considered to be eligi- eligibility criteria. Cohen's kappa (κ) test was used to evaluate search ble if they reported or provided sufficient data for determining the agreement between two reviewers (κ values—­0.92 for the screening prevalence of GR using a validated method of clinical measurement phase and 0.98 for the eligibility phase). Any disagreement between (from the cementoenamel junction to free gingival margin using a the two reviewers was resolved by discussion until a consensus is calibrated probe) at an established “cut off” score. In cohort studies, reached, otherwise the judgment of the third reviewer (NT) was the baseline data of the prevalence were used. considered as decisive. Corresponding authors of the selected arti- Studies were excluded if (i) full-­mouth examinations were not performed; (ii) only the estimates from a specific sub-­set of the gen- cles were contacted through email to obtain any missing data before their final inclusion. eral population had been presented (e.g., gender-­specific, i.e., only Data extraction of the selected studies was performed at one males or females, students, professionals, specific migrant popula- specific time point; independently and in duplicate by the two au- tion, orthodontic patients, and persons with a specific disease or thors (VSY and KM) and was cross-­checked for accuracy by the third | 2995 YADAV et al. author (BG). The following information was extracted using a pre-­ (StataCorp. 2017. Stata Statistical Software: Release 15. College designed data collection form pilot-­tested in five studies: name of Station, TX: StataCorp LLC). first author and year of publication, country/continent, sample size, sampling method, study design, examination protocol, GR threshold value, age, gender, and prevalence. There was a high level of agree- 2.6 | Certainty of evidence ment during data extraction too (κ: 0.86–­92) and disagreements were resolved by discussion. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to determine the overall quality 2.4 | Risk of bias assessment of evidence (Atkins et al., 2004) emerging from this review. In brief, the overall certainty of evidence was assessed for each outcome, i.e., prevalence at different thresholds and in different continents. Selected studies were subjected to the methodological quality as- The effect size of the outcome, heterogeneity of the source stud- sessment by two independent reviewers (KM and BG) by using ies, and the presence of publication bias were used as the indicators the Joanna Briggs Institute (JBI) Standardized Critical Appraisal for up-­or down-­grading of the evidence. Two authors (VSY and VG) Checklist for Prevalence Studies (Munn et al., 2014). Any disagree- independently graded the outcomes (Cohen's kappa –­0.93) and the ments, if identified, were resolved through consensus or discussion third author (NT) resolved the disagreements, if any. with a third reviewer (VSY). Interrater agreement between reviewers was assessed with κ statistics (0.84–­0.92). Decisions about the scoring criteria were pre-­decided (Serni et al., 2021) with a consensus from all reviewers. Studies were categorized as low risk of bias when all the items were satisfied. If at least one of the items was not 3 | R E S U LT S 3.1 | Literature search ascertainable, the study was rated as unclear risk of bias. Alternately, if one of the items was not satisfied, the study was rated as a high The comprehensive search in different databases yielded 4200 risk of bias study. articles. After removal of duplicates and review of the title and abstracts, 104 articles potentially qualified for the full-­text evalu- 2.5 | Statistical analysis ation. Details of missing information were provided by two authors (Shah et al., 2018; Sulewska et al., 2017), however, only one study (Sulewska et al., 2017) was found eligible. A total of 13 The present review was undertaken to determine the prevalence of papers (Do et al., 2003; Ha et al., 2020; Holmgren et al., 1994; GR which is described as the percentage of the population present- Hosanguan et al., 2002; Rios et al., 2014; Romandini et al., 2020; ing with ≥1 tooth at a defined GR threshold. Heterogeneity of the se- Sarfati et al., 2010; Serrano et al., 2018; Sulewska et al., 2017; Susin lected studies was assessed through I2 statistics and was considered et al., 2004; Thomson et al., 2006; Thomson & Williams, 2002; high at a level > 75%. A p-­value of < 0.05 was considered as statisti- Zawada et al., 2012) were eligible on further omission of articles not cally significant for heterogeneity (Higgins & Green, 2011). Since the meeting the inclusion criteria (Supplementary file S3). Two papers prevalence was reported at different GR thresholds in the included (Mumghamba & Fabian, 2006; Slade et al., 2007) were included from studies, the data of the minimum “cut off” value in each study were additional searches, resulting in 15 articles to be analyzed in this sys- utilized for calculating the pooled estimates. Forest plots were gen- tematic review. A PRISMA flowchart for a detailed description of the erated to depict the pooled-­effect estimates and 95% confidence study selection process is shown in Figure 1. intervals (CI) for each study using a random-­effect model. Pooled prevalence was also calculated for the buccal GR and at different GR thresholds reported in the selected studies. The subgroup analyses 3.2 | Study characteristics were performed for the minimum reported GR threshold, continents, and risk of bias to determine the possible sources of heterogeneity. A total of 37,460 participants had been examined in 15 studies. The Meta-­regression was done to investigate the relationship between median number of participants was 882 (range: 169–­10,676). According the prevalence of GR with the sample size and the year of study. to the decade of publication, one study was from the first decade Sensitivity analysis was conducted to confirm the robustness of the (1990–­ 2000) (Holmgren et al., 1994), eight studies were from the meta-­analysis results by step-­by-­step exclusion of each study or re- second decade (2001–­2010) (Do et al., 2003; Hosanguan et al., 2002; moval of the specific datasets. Publication bias was quantitively as- Mumghamba & Fabian, 2006; Sarfati et al., 2010; Slade et al., 2007; sessed on a Doi plot using Luis-­Furuya-­Kanamori (LFK) index, which Susin et al., 2004; Thomson et al., 2006; Thomson & Williams, 2002), has a greater power to detect asymmetry than the funnel plot with and six from the third decade (2011–­ 2020) (Ha et al., 2020; Rios Begg's and Egger's tests (Furuya-­Kanamori et al., 2018). LFK index et al., 2014; Romandini et al., 2020; Serrano et al., 2018; Sulewska of <1 indicates symmetry, 1–­2 indicates minor asymmetry and >2 et al., 2017; Zawada et al., 2012). Regarding the distribution as per indicates major asymmetry. Data were analyzed by using STATA® the continents, 4 studies had reported the prevalence data from 2996 | YADAV et al. F I G U R E 1 PRISMA flow diagram of study selection process. Adapted from PRISMA 2020 Australia (Thomson & Williams, 2002; Thomson et al., 2006; Slade estimated potential risk of bias was low for five (Ha et al., 2020; Rios et al., 2007; Ha et al., 2020), three each from Asia (Do et al., 2003; et al., 2014; Serrano et al., 2018; Slade et al., 2007; Susin et al., 2004) Holmgren et al., 1994; Hosanguan et al., 2002), Europe (Sarfati and high for 10 studies (Do et al., 2003; Holmgren et al., 1994; et al., 2010; Sulewska et al., 2017; Zawada et al., 2012), and South Hosanguan et al., 2002; Mumghamba & Fabian, 2006; Romandini America (Rios et al., 2014; Serrano et al., 2018; Susin et al., 2004), et al., 2020; Sarfati et al., 2010; Sulewska et al., 2017; Thomson and one each from Africa (Mumghamba & Fabian, 2006) and North et al., 2006; Thomson & Williams, 2002; Zawada et al., 2012). Main America (Romandini et al., 2020). All studies were published in the causes of bias in studies were identified in reporting of statistical English language except one in Polish (Zawada et al., 2012) which was analysis, response rate, examiner's calibration, sample size estima- translated to English through a website (https://www.onlinedoctransl tion, and sampling method. ator.com/en/translationform). The minimal threshold for reporting the prevalence of GR was ≥1 mm in ten studies (Hosanguan et al., 2002; Rios et al., 2014; Romandini et al., 2020; Sarfati et al., 2010; Serrano 3.4 | Pooled estimates et al., 2018; Sulewska et al., 2017; Susin et al., 2004; Thomson et al., 2006; Thomson & Williams, 2002; Zawada et al., 2012), ≥2 mm Using a random-­ effect model, the pooled prevalence of GR at in three studies (Do et al., 2003; Ha et al., 2020; Slade et al., 2007), ≥1 mm was found to be 84.92% (95% CI: 75.88–­92.15; I2 = 99.64%; and ≥3.5 mm (Mumghamba & Fabian, 2006) and ≥4 mm (Holmgren p < 0.001) from 10 studies, while it was 78.16% (95% CI 68.37–­86.57; et al., 1994) in one study each. The prevalence of GR from the included I2 = 99.76%; p < 0.001) when the prevalence reported at the minimum studies ranged from 48-­99.7%. Sample size in three (Mumghamba & threshold levels were pooled from all the included studies (Figure 2). Fabian, 2006; Sulewska et al., 2017; Thomson & Williams, 2002) of 15 When analyzed as per the continents, North America had the included studies was below the calculated sample size of 263 (assum- highest prevalence (91.63%; 95% CI: 91.08–­92.14) followed by ing a prevalence of 78% and a precision of 0.05). Main characteristics South America (88.01%; 95% CI: 64.20–­99.59), Africa (86.07%; of the included studies are shown in Table S1 (Supplementary file S4). 95% CI: 80.50–­ 9 0.54), Europe (78.36%; 95% CI: 68.03–­ 87.15), and Asia (76.13%; 95% CI: 37.80–­98.80) while Australia had the 3.3 | Risk of bias least prevalence (63.42%; 95% CI: 56.08–­70.45) (Supplementary file S6). Pooled prevalence of GR according to risk of bias of the included Each study was assessed in the different domains of JBI Checklist for studies was 76.30% (95% CI: 60.95–­88.75) for low and 79.07% (95% Prevalence Studies. A detailed description of the results of the risk of CI: 68.30–­88.10) for the high risk of bias studies (Supplementary bias assessment is shown in Supplementary file S5. In summary, the file S7). | 2997 YADAV et al. F I G U R E 2 Forest plot of prevalence of gingival recession stratified by the threshold values (reported at minimum “cut off” score in a study) 3.5 | Meta-­regression size were omitted from the pooled analysis, the overall prevalence was 76% (95% CI: 66–­85) which did not differ significantly from the Meta-­regression showed no significant differences in the trend of previous pooled prevalence. These results indicated the stability and prevalence of GR with the year of publication (coefficient: 0.424; reliability of the performed analysis. 95% CI: −0.779 –­ 1.629; p-­value: 0.460) and sample size of study (coefficient: -­0.0001; 95% CI: −0.0030 –­ 0.0025; p-­value: 0.836) (Supplementary file S8). 3.6 | Sensitivity analysis 3.7 | Publication bias The Doi plot could be interpreted as asymmetrical favoring studies that reported higher prevalence as shown in Supplementary file S10. LFK index with a value of 1.42 also suggests minor asymmetry (LFK The leave-­one-­out study sensitivity analysis showed that overall index exceeds ±1 but within ±2) which concurred with an a priori pooled prevalence was not driven by any single study (Supplementary concern about positive publication bias, i.e., studies reporting more file S9). When the studies with a smaller than the calculated sample prevalence of GR are more likely to be published. | 2998 YADAV et al. 3.8 | Grading Riley et al., 2011). Given the prevalence rates of GR from the past Since all the studies included in the meta-­analysis were observa- view suggested that a future (new) study would observe a preva- tional, the baseline grading of overall evidence was considered low lence of GR as low as 44% and also the possibility of affecting the as per the GRADE handbook (Schumemann et al., 2013). Due to the whole (100%) population examined. 20 years' studies at ≥1 mm “cut off,” a 95% PI estimation in this re- substantial heterogeneity among the studies that could not be fully It should be emphasized that the strict eligibility criteria were explained and the detection of publication bias, the GRADE's cer- imposed for the inclusion of studies, so that, the results of our re- tainty of evidence was considered very low for the overall outcome view could truly reflect the prevalence estimates of the population and the subgroup outcomes (Supplementary file S11). in general. For instance, the samples representing a specific group of population or originating from the participants attending the 4 | DISCUSSION hospital settings were excluded to avoid the chances of selection bias and overestimation of the prevalence (Mansfield et al., 2016; Valesan et al., 2021). In addition, data generated from partial mouth Although several studies from different parts of the world have re- examinations (index teeth or half mouth design) may lead to the un- ported the prevalence of GR, the data from these epidemiological derestimation of the GR prevalence (Hunt & Fann, 1991; Thomson & studies have never been systematically reviewed and compiled to Williams, 2002) and were thus not included in this review. Despite the strict inclusion criteria, a large heterogeneity determine the overall prevalence of GR. The present systematic re2 view with meta-­analysis is the first to provide an estimate of the (I = 99.76%) was observed which in fact is common for the meta-­ pooled global prevalence of GR among the general population. The analysis of prevalence studies, particularly among the general pooled analysis of the included studies revealed that GR is a highly populations (Mansfield et al., 2016; Shafiee et al., 2017; Teixeira prevalent condition affecting 78% of the population worldwide, with et al., 2020; Zhang et al., 2020). variations in geographical distribution. Structural diversities such as It could be attributed to the variations in the sampling char- ethnicity, race, culture, socio-­economic status, distribution of dental acteristics, differences in the studied age groups, disparities in services, and the residential place (rural or urban) of the screened the distribution of the risk factors and confounders (Dye, 2012). population could have resulted in this non-­homogenous distribution Methodological variations such as the types of probes used, differ- across the continents and within the same countries of a continent. ences in the cut-­offs/threshold points to report the prevalence of This review was designed to investigate the prevalence of GR GR and probing locations could have also potentially contributed to without any age limitation. Among the included studies, the precise the heterogeneity between studies and made it difficult to compare overlap of the age groups was not observed. Regarding the gender the results (Irfan et al., 2001). A high degree of heterogeneity simi- distribution, most of the studies did not report the necessary details lar to present study has also been observed in previous prevalence of the participants. It limited us from performing a subgroup analy- systematic reviews (Bouziane et al., 2020; Pentapati et al., 2019) due sis and presenting the pooled prevalence estimates in different age to the geographic variations, changes in diagnostic criteria, and the groups and genders. However, the results of individual studies re- methodological features. flected a higher prevalence of GR with an increase in age, and males being predominantly affected. The thresholds of the severity of GR may influence the prevalence reported in a population. To explore this further, we extracted Considering the fact that most of the included studies were pub- and pooled the prevalence provided at different threshold values in lished in the past two decades, the overall prevalence of GR at ≥1 mm different studies. Expectedly, an inverse relationship was found, that threshold remained almost unchanged from 2001–­2010 (84.77%; is, a higher “cut-­off” value was associated with a low prevalence rate 95% CI: 75.06–­92.43) to 2011–­2020 (85.07%; 95% CI: 63.39–­95.80) (Supplementary file S13). It also implies that reporting the prevalence as shown in Supplementary file S12. The observed marginal differ- rate without a pertinent GR threshold value is of little significance ence could be attributed to the variations in the sampling methods and such studies were therefore not included in this review. Most of and the geographical distribution of the studies. Prediction interval the studies reported the prevalence at a minimal threshold of ≥1 mm (PI) is a method to estimate the range within which the prevalence and ranged from ≥1 to ≥4 mm. A pooled prevalence of 84.92% at a estimates of any future study will fall. It is based on the effect size GR threshold of ≥1 mm was found in the present study. These re- of the studies included in the meta-­analysis. In other words, PI re- sults are, however, in contrast to those reported in a literature re- flects the dispersion of the true effect sizes in any new study rather view by Kassab and Cohen (2003) where they found that more than than only quantifying the precision of the average effect size as in CI 50% of the population has one or more sites with GR of ≥1 mm. This (Spineli & Pandis, 2020). Furthermore, PI presents the heterogene- discrepancy in prevalence outcomes could be attributed to the fact ity on the same scale as the original effect size measure in contrast that the results of the present review are contrastingly derived from 2 2 to τ or I (IntHout et al., 2016). For these reasons, the inclusion of the inclusion of studies mostly published after 2003 (n = 12) and by PI in a random-­effect meta-­analysis makes the results more mean- systematically synthesizing the prevalence data. The global pooled ingful for the researchers. It is therefore recommended to routinely prevalence was found to be 78% while considering the prevalence report the PI alongside CI and heterogeneity (IntHout et al., 2016; reported at a minimal GR threshold value given in a study, though it | 2999 YADAV et al. may not depict an accurate estimation. Furthermore, the number of prevalence of GR (≥1 mm) according to new classification system i.e. sites examined for each tooth varied from 1 to 6 and it seems likely recession types (RT) (Cairo et al., 2011) at both participant level (RT1–­ to have influenced the prevalence. 12.37%, RT2–­88.81%, RT3–­54.99%) and tooth level (RT1–­0.85%, GRs affecting the buccal surfaces of the teeth are of particular RT2–­24.49%, RT3–­8.25%). Although none of the included studies relevance from both patient's and clinician's perspectives. Increased has explicitly provided the numerical data to relate the periodontitis aesthetic demands from the patients in the past few years have in- with the GR, a higher prevalence of GR attributed to loss of attach- cited the clinicians to develop and/or modify several surgical tech- ment primarily due to destructive periodontal disease per se peri- niques for the treatment of buccal recession defects (Cairo, 2017). odontitis was suggested by two authors (Sarfati et al., 2010; Zawada It becomes prudent to identify the prevalence of these defects and et al., 2012). Moreover, four of the included studies (Hosanguan therefore a separate meta-­analysis was performed to determine the et al., 2002; Rios et al., 2014; Susin et al., 2004; Zawada et al., 2012) pooled prevalence. All the buccal sites (mesio-­buccal, mid-­buccal, found a positive significant association of GR with dental calculus, and disto-­buccal) examined in different studies were assimilated a predisposing factor for chronic inflammatory periodontal disease. to buccal estimates for the analysis. A high pooled prevalence of In this context, Susin et al. (2004) concluded that population-­based 75.42% (95% CI: 59.24–­88.57) at the minimal reported threshold programs aimed at the prevention of periodontal disease may reduce from seven studies and 86.17% (95% CI: 66.38–­97.96) at ≥1 mm from the prevalence of GR. four studies was observed (Supplementary file S14). Considering the Given the limited number of studies with high heterogeneity consequences of untreated buccal recessions (worsening of aesthet- between them, the pooled prevalence estimates of GR should be ics, dentinal hypersensitivity, and increase in recession depth in the inferred with caution for the world population. There is a scarcity long-­term) (Chambrone & Tatakis, 2016) and their negative impact on of population-­based prevalence studies addressing GR from several a person's quality of life, these figures may be of concern. However, countries, even from the world's top ten most populous ones (except it is worth mentioning that most of GRs are often asymptomatic United States and Brazil). Hence, the pooled prevalence data may (without aesthetic or functional impairment) and people are largely not be representative of many countries or regions which poten- unaware of this condition. This observation has been confirmed in tially limits the generalizability of the findings of this study. It em- a private practice-­based study (Nieri et al., 2013) where 80% of the phasizes the need for well-­designed population-­based prevalence examined patients were affected with at least one GR. However, studies from several countries to estimate the global burden of GR. 92% of the recessions were asymptomatic and/or not perceived by Moreover, the actual pooled GR prevalence could have been overes- the patients, and only 11% of patients requested treatment for their timated due to the inclusion of data from the older age groups since 7% recessions. Extrapolating these findings to the high prevalence the occurrence of GR seems to increase with age (Löe et al., 1992; of GR as observed in present SR, it may be inferred that GR itself Thomson et al., 2006). These limitations make it difficult to have a is not a disease condition and the real need for treatment could be clear judgment about the general prevalence rates. very low. Furthermore, it should also be highlighted that most of the Nevertheless, there are considerable strengths in the present exposed root surfaces (RT2/RT3 or Miller class III/IV, i.e., with inter- systematic review and meta-­analysis. Since we implemented strict proximal attachment loss) occur due to the tissue destruction from inclusion criteria from the outset of our review in an attempt to min- periodontitis and are not amenable for complete root coverage to imize the heterogeneity and ensure some comparability between meet patients' expectations after treatment. the studies, it allowed us to include only the limited studies, primar- Traumatic toothbrushing may be a contributing factor to the de- ily the surveys. Furthermore, the review was rigorously conducted velopment and progression of this multifactorial condition, although while following the best practices of evidence-­based medicine—­ the evidence to prove this association is largely circumstantial developing and registering an a priori protocol, conducting a compre- (Heasman et al., 2015). Among the studies included in this review, hensive search in different databases without language restriction, three (Rios et al., 2014; Serrano et al., 2018; Zawada et al., 2012) assessing the risk of bias with a validated tool, and performing all found a higher prevalence of GR in individuals reporting lower fre- the steps in duplicate to minimize individual bias. Quantitative as- quency of toothbrushing while two studies (Hosanguan et al., 2002; sessment of the publication bias using Doi plot, reporting the PI and Mumghamba & Fabian, 2006) could not elucidate the relationship the use of GRADE approach to assess the final evidence were some between toothbrushing and GR. Additionally, Rios et al. (2014) re- other strengths of this study. ported lower chances of having GR in participants using circular rather than the horizontal movement of toothbrushing. The overall grading of the final evidence was judged very low which reinforces the need for more robust protocols to report the Stratification of GR prevalence according to classification sys- prevalence of GR. Based on our observations from the present sys- tems was not identified in majority of the studies. In this regard, tematic review, a universally accepted case definition and protocol Zawada et al. (2012) reported the prevalence of GR at tooth level to record GR in future epidemiological studies are suggested to min- based on Miller classes (Miller, 1985) (Class I—­45.5%, Class II—­1.1%, imize the heterogeneity and maintain the comparability across the Class III—­47.7%, Class IV—­5.6%). Sarfati et al. (2010) found that studies. Such a definition implies to the severity "cut-­offs", number Miller class I and II GRs represented the majority (no data provided) of sites examined per tooth, extent of the oral cavity examined and of their sample. Only one study (Romandini et al., 2020) reported the the type of instrument used. Additional domains such as extent, | 3000 YADAV et al. severity, and presence of buccal recessions should also be considered. Furthermore, a uniform stratification in age groups and reporting gender-­wise prevalence is suggested. 5 | CO N C LU S I O N Within the limitations of the included studies, GR was found to affect more than three-­fourths of the population worldwide. Such prevalence estimates do not indicate the prompt need for treatment. Nevertheless, the results of present review can help in developing a better understanding of the burden of this condition and can be used for addressing its public health aspects. The recommendations arising from this review can assist in improving the quality and reporting of the prevalence studies related to GR. AU T H O R C O N T R I B U T I O N S Vikender Singh Yadav: Conceptualization; data curation; formal analysis; project administration; resources; validation; writing –­original draft; writing –­review and editing. Bhumika Gumber: Data curation; formal analysis; software; validation; writing –­review and editing. Kanika Makker: Data curation; formal analysis; methodology; supervision; writing –­review and editing. Vandana Gupta: Data curation; formal analysis; validation; writing –­review and editing. Nitesh Tewari: Conceptualization; methodology; resources; supervision; visualization; writing –­ review and editing. Puneet Khanduja: Data curation; formal analysis; methodology; resources; software; visualization; writing –­ review and editing. Renu Yadav: Data curation; formal analysis; methodology; validation; writing –­review and editing. AC K N OW L E D G M E N T S None. C O N FL I C T O F I N T E R E S T The authors do not have any financial interest to disclose. 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How to cite this article: Yadav, V. S., Gumber, B., Makker, K., Gupta, V., Tewari, N., Khanduja, P., & Yadav, R. (2023). Global prevalence of gingival recession: A systematic review and meta-­analysis. Oral Diseases, 29, 2993–3002. https://doi. org/10.1111/odi.14289 Copyright of Oral Diseases is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
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