fatores de risco Systematic review and meta-analysis on prevalence and risk factors for

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Journal of Dentistry 155 (2025) 105645
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0300-5712/© 2025 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Review article
Systematic review and meta-analysis on prevalence and risk factors for 
gingival recession
Felix Marschner a,* , Clemens Lechte a , Philipp Kanzow b , Valentina Hraský a, 
Wolfgang Pfister c
a Department of Preventive Dentistry, Periodontology and Cariology, University Medical Center, Robert-Koch-Str. 40, 37075, Göttingen, Germany
b Department of Restorative Dentistry, Periodontology and Endodontology, University Medicine Greifswald, Fleischmannstr. 42a, 17475, Greifswald, Germany
c Department of Hospital Hygiene, Sophien- and Hufeland-Clinic, Henry-van-de-Velde-Str. 2, 99425, Weimar, Germany
A R T I C L E I N F O
Keywords:
Gingival recession
Risk factors
Etiology
Prevalence
Meta-analysis
A B S T R A C T
Objectives: Gingival recession is a common mucogingival condition. The aim of this systematic review and meta- 
analysis was to assess the prevalence of gingival recession and identify associated risk factors in the general 
population.
Study selection: Observational studies reporting prevalence and risk factors for gingival recession published since 
2000 were included. Methodological quality was assessed using the modified Newcastle-Ottawa scale for cross- 
sectional studies. Random-effect meta-analyses were conducted for the prevalence (%) of gingival recession at 
different cut-off scores (≥1 mm, ≥3 mm, and ≥5 mm) and odds ratios (OR) of identified risk factors.
Sources: MEDLINE, Embase, Scopus, and Web of Science were systematically searched in November 2024. 
Additionally, a hand search was performed. The study was registered in PROSPERO (CRD42024516816).
Data: 21 sources, reporting on 22 studies were included in this systematic review. Most of the included studies 
represented a low risk of bias. Overall, estimated prevalence of gingival recession was 81.1 % (95 %-CI: 
73.9–86.7) for ≥1 mm, 48.4 % (95 %-CI: 39.7–57.2) for ≥3 mm, and 16.2 % (95 %-CI: 9.1–27.4) for ≥5 mm. Risk 
factors were structured into domains. Meta-analyses revealed male gender (padj.without gingival recession in the permanent 
dentition (C). The outcome included prevalence and evaluation of risk 
factors significantly associated with gingival recession (O). Observa-
tional studies published in English or German since 2000 were included 
in this systematic review (S).
Exclusion criteria included studies that involved a specific subset of 
the general population (e.g. gender-specific, such as only males or fe-
males, students, specific migrant populations, and individuals with 
specific diseases or syndromes), those with insufficient data, case re-
ports, review articles, studies reporting only prevalence, and those 
lacking relevance to risk factors. Additionally, studies without full- 
mouth examination were also excluded.
2.4. Search strategy
In November 2024 a systematic literature search was performed in 
four different electronic databases (MEDLINE via PubMed, Web of Sci-
ence, Scopus, and Embase) using the following search term ("gingival 
recession" AND ("risk factors" OR "risk indicators" OR "risk assessment" 
OR etiology OR epidemiology OR prevalence NOT implant* NOT ther-
apy)). In addition, a manual search using Google and Google Scholar (for 
grey literature) was performed, and the reference lists of included 
sources were screened. The search term was slightly adjusted to meet the 
specific requirements of each electronic database. The complete search 
terms for all electronic databases are provided in Supplemental Table 
S1.
2.5. Study selection
After the initial search, duplicate records were identified and 
removed using a reference manager (EndNote 21.2, www.endnote.com). 
The titles and abstracts were independently screened by two reviewers 
(F.M. and C.L.), who proceeded to a full-text evaluation of potentially 
relevant sources. Any disagreements between the reviewers were 
resolved through discussion. The reasons for excluding sources after the 
full-text review are detailed in Supplemental Table S2. In case of missing 
data, authors were contacted via email. After 2 weeks, a second 
reminder was sent to non-responders. If authors did not respond or if the 
required information could not be provided, the studies were excluded 
from the respective meta-analysis.
2.6. Data extraction
The data extraction from the included studies was independently 
carried out by two reviewers (F.M. and C.L.) using a pre-tested spread-
sheet. If available, extracted information included study characteristics 
(i.e. authors, year of publication, country, continent, recruitment and 
sampling method), number of participants, age range, inclusion and 
exclusion criteria, reference level and minimum cut-off for assessment of 
gingival recession, prevalence (at the following cut-off scores: ≥1 mm, 
≥3 mm, ≥5 mm), reported risk factors, and results of the statistical 
analysis (significant vs. non-significant risk factors vs. not reported) for 
each assessed risk factor. Risk factors for gingival recession were cate-
gorized into following seven domains: socio-demographics, socio-eco-
nomics, general health conditions, general health behaviors, dental 
health behaviors, dental health conditions, and periodontal health 
conditions. To enable quantitative synthesis, the absolute numbers of 
participants with and without gingival recession were extracted for each 
reported risk factor. In case of studies reporting on multiple cut-off 
scores, the proportion of patients with gingival recession was based on 
the highest cut-off score.
2.7. Data synthesis and meta-analyses
To determine the prevalence (%) of gingival recession, meta-analyses 
were performed for the following cut-off scores, which were the most 
commonly reported: ≥1 mm, ≥3 mm, and ≥5 mm. Additionally, 
multivariable meta-regression analysis was performed to investigate the 
relationship between the prevalence of gingival recession, geographic 
location of study (continents), and the year of publication.
Identified risk factors and their respective significance in each study 
were visually presented in a heatmap, similar to the approach used in 
previous studies [22,23]. Additionally, meta-analyses of odds ratios 
(ORs) were conducted for each risk factor domain. Within each domain, 
individual risk factors reported uniformly as dichotomous variables 
were categorized into subgroups, and pooled-effect estimates were 
calculated for each subgroup.
Statistical analysis was conducted using the software R (www.r-pr 
oject.org, version 4.4.1) along with the packages “meta” (version 
8.0–1) and “metafor” (version 4.6–0). Statistical heterogeneity was 
evaluated using Cochran’s Q test and I2 statistics [24]. Due to high 
heterogeneity being present throughout all analyses (p-values of 
Cochran’s Q testrecession at the cut-off score of ≥1 mm [11–14,29–35,37–40,
42–46], while 11 sources were included in the meta-analysis based on a 
cut-off at ≥3 mm [11–14,31,32,36,37,40,42–44], and 7 sources in the 
meta-analysis using a cut-off score of ≥5 mm [11,14,31,32,37,40,42,
43]. The overall estimated prevalence of gingival recession in the per-
manent dentition in the general population was stratified by cut-off 
scores, with values of 81.1 % (95 %-CI: 73.9–86.7) for ≥1 mm 
(Fig. 2), 48.4 % (95 %-CI: 39.7–57.2) for ≥3 mm (Fig. 3), and 16.2 % (95 
%-CI: 9.1–27.4) for ≥5 mm (Fig. 4). There was no indication of relevant 
publication bias based on the statistical and graphical analyses (Sup-
plemental Figure S1).
Meta-regression showed a significant impact of geographic location 
on the prevalence of gingival recession at all cut-off scores. For a cut-off 
score of ≥1 mm, studies from South America reported a significantly 
higher prevalence compared to Europe (p = 0.032). For ≥3 mm, studies 
from Asia showed a significantly lower prevalence (p = 0.002). At a cut- 
off score of ≥5 mm, both North America and South America exhibited 
significantly higher prevalence rates than Europe (pJournal of Dentistry 155 (2025) 105645
5
Table 1 (continued )
Study and country Recruitment (sampling method) Number of 
participants (% 
males) 
Age 
range 
(year) 
Inclusion (I)/exclusion (E) criteria Reference level and 
minimum cut-off score
Cairo’s classification 
[21]
Abdulhamed and Mousa 2023, 
Iraq
Khanzad teaching center for oral 
health Erbil city (NR)
989 (29.6) 18–55 (I): Systemically healthy patients, 
Participants with a minimum of 20 remaining 
teeth; (E): patients with orthodontic 
appliances, teeth with restoration, smokers, 
periodontal therapy in the last 6 months
Distance ≥ 1 mm from 
the CEJ to the FGM, 
Miller’s classification 
[20]
Strauss et al. 2023, Chile First Chilean National Examination 
Survey (probability sampling 
method)
1456 (44.1) 33–74 (I): Age between 33 and 74 years; (E): 
edentulous individuals
Distance ≥ 1 mm from 
the CEJ to the FGM, 
Cairo’s classification 
[21]
West et al. 2024, Germany, 
Ireland, Italy, Portugal, 
Spain, Switzerland, UK
Patients from private dental 
practice, and university hospital 
dental schools (probability 
sampling method)
3517 (43.6) 18–89 (I): Age ≥ 30 years, minimum 10 teeth not 
including teeth with crowns or bridges; (E): 
orthodontic appliances, pregnancy, 
antibiotic prophylaxis for dental procedures, 
bleeding disorders, taking anticoagulants, 
taking pain medication in the last 24 h
Distance ≥ 1 mm from 
the CEJ to the FGM
NR, not reported; USA, United States of America; UK, United Kingdom; CEJ, cemento-enamel junction; FGM, free gingival margin; NPASES I, First National Periodontal 
and Systemic Examination Survey; NHANES, National Health and Nutrition Examination Survey.
Fig. 2. Random effects estimates of gingival recession prevalence (%, cut-off: ≥1 mm) and 95 % confidence intervals. Studies from different continents are shown as 
subgroups with their pooled effect estimates (diamonds). CI, confidence interval.
F. Marschner et al. 
Journal of Dentistry 155 (2025) 105645
6
The mapping of risk factors showed high variability in the assessment of 
these factors. Socio-demographic factors, such as age and gender were 
reported in all included studies. Besides these, smoking (76.2 % of the 
studies), dental plaque (61.9 % of the studies), tooth brushing frequency 
and education (both 57.1 % of the studies), and gingivitis (52.4 % of the 
studies) were the most often investigated potential risk factors.
Except for general health conditions, all domains were included in 
meta-analyses. In total, seven meta-analyses were conducted, and 23 
risk factors were entered as subgroups of the respective domains. Studies 
included in meta-analyses for each specific risk factor are shown in 
Fig. 5. Table 3 presents the ORs with their 95 % confidence interval (CIs) 
for each included risk factor as well as the pooled effect estimates in the 
meta-analyses and summary of findings. Male gender (padj.(p-value0.999 1.05 
(0.78–1.42)
484 per 
1000
12 more per 1000 (61 
fewer to 87 more)
General health conditions ​ ​ ​ ​ ​ ​ ​ ​
General health conditions -‡ – – – – – – –
Body mass index -† – – – – – – –
Snoring -‡ – – – – – – –
Diabetes mellitus -‡ – – – – – – –
Chemotherapy/radiotherapy -‡ - – – – – – –
Medication intake -‡ – – – – – – –
General health behaviors ​ ​ ​ ​ ​ ​ ​ ​
Smoking (5) (yes vs. no) 2120/ 
11,040 
(19.2)
818/1797 
(45.5)
0.999 1.44 
(0.41–5.11)
640 per 
1000
79 more per 1000 (218 
fewer to 261 more)
Toothbrushing technique (2) (horizontal vs. vertical) 139/223 
(62.3)
750/1582 
(47.4)
0.443 >0.999 0.67 
(0.24–1.85)
623 per 
1000
98 fewer per 1000 (339 
fewer to 131 more)
Type of toothbrush (2) (hard vs. soft) 35/86 
(40.7)
343/958 
(35.8)
0.018 0.212 0.55 
(0.33–0.90)
407 per 
1000
133 fewer per 1000 
(25–222 fewer)
Interapproximal cleaning (2) (yes vs. no) 158/272 
(58.1)
555/1699 
(32.7)
0.112 0.9 0.36 
(0.10–1.27)
581 per 
1000
248 fewer per 1000 
(459 fewer to 57 more)
Type of dentifrice -‡ – – – – – – –
Last dental visit (1) (regular vs. irregular/none) 61/212 
(28.8)
174/811 
(21.5)
0.025 0.271 0.68 
(0.48–0.95)
288 per 
1000
72 fewer per 1000 
(10–125 fewer)
Dental health conditions ​ ​ ​ ​ ​ ​ ​ ​
Number of teeth -† ​ ​ ​ ​ ​ ​ ​
​ ​ ​ ​ ​ ​ ​ ​ ​
Previous orthodontic 
treatment (3)
(yes vs. no) 99/520 
(19.0)
67/910 
(7.4)
0.98 >0.999 1.01 
(0.40–2.55)
190 per 
1000
2 more per 1000 (104 
fewer to 184 more)
Tooth wear -‡ – – – – – – –
Malocclusion (1) (yes vs. no) 19/63 
(30.2)
358/926 
(38.7)
0.181 >0.999 1.46 
(0.84–2.54)
302 per 
1000
85 more per 1000 (35 
fewer to 222 more)
Hypersensitivity -‡ – – – – – – –
Non-carious cervical lesions -‡ – – – – – – –
Periodontal health conditions ​ ​ ​ ​ ​ ​ ​ ​
Supragingival calculus (2) (yes vs. no) 174/276 
(63.0)
1020/1736 
(58.8)
0.010 0.134 2.76 
(1.28–5.95)
630 per 
1000
195 more per 1000 
(55–280 more)
Biotype (1) (thin vs. thick) 18/48 
(37.5)
16/56 
(28.6)
0.334 >0.999 0.67 
(0.29–1.52)
375 per 
1000
88 fewer per 1000 (227 
fewer to 102 more)
Gingivitis (GBI/ FMBS/ GI) 
(3)
(yes vs. no) 739/947 
(77.9)
992/1801 
(55.1)
0.174 >0.999 1.49 
(0.84–2.64)
779 per 
1000
61 more per 1000 (31 
fewer to 124 more)
(continued on next page)
F. Marschner et al. 
Journal of Dentistry 155 (2025) 105645
9
recession based on a cut-off score at ≥5 mm, indicating that larger 
studies tend to report lower prevalence rates. Thereby, results from 
smaller studies should be interpreted with caution, and further research 
should employ an adequate sample size.
This systematic review revealed a total of 46 potential risk factors for 
gingival recession that were assessed in observational studies. Socio- 
demographic factors like age and gender, and dental health conditions 
and periodontal health conditions were most often, but not consistently, 
assessed. Meta-analyses of potential risk factors were performed for 
dichotomous risk factors reported in a uniform way (e.g. consistent cut- 
offs and/or groups). As main limitation of the present study several 
other variables (e.g. age, bleeding on probing) could not be included due 
to their inconsistent reporting and lack of raw datasets. Unfortunately, 
meta-analysis for the domain of general health conditions was also not 
possible due to a lack of sufficient data. Consequently, the domains 
general health conditions, general health behaviors, and dental health 
conditions are underrepresented in our meta-analyses and need to be 
further assessed in future studies. On the other hand, methodological 
strengths of this systematic review include a systematic search across 
four databases, the application of the GRADE framework to assess the 
quality of evidence for each outcome (prevalence and domains), and the 
systematic mapping of nearly all potential risk factors for gingival 
recession reported in observational studies conducted since 2000.
We found that male gender, general health behaviors such as 
smoking and alcohol consumption, dental plaque, the presence of a high 
frenulum, occlusal trauma, periodontitis, and a history of periodontal 
treatment are significantly associated with gingival recession. These 
results are consistent with the findings of recent studies, which identify 
male gender, smoking, and periodontitis as key risk factors for gingival 
recession [10,51–53]. Periodontal conditions are highly prevalent in 
males [54,55] who also tend to exhibit less favorable health behaviors 
such as poor oral hygiene [55], higher rates of smoking [55,56], and 
alcohol consumption [55,57]. These behavioral patterns likely explain 
the observed association between male gender and gingival recession, 
which can be attributed to the multifactorial etiological causes of peri-
odontal diseases that contributeto clinical attachment loss and the 
progression of circular gingival recessions [58]. It is important to 
consider that these risk factors may interact with each other and 
potentially confound the results.
Furthermore, smoking is a well-established risk factor for gingival 
recession [3,10]. Patients should be supported through structured 
smoking cessation programs, including both individual counseling ses-
sions and group programs [59,60], as well as the use of nicotine 
replacement therapies [61,62]. Alongside smoking cessation, alcohol 
cessation should also be a key focus of patient education, as alcohol 
consumption disrupts the balance of the oral microbiota and promotes 
inflammation [63].
Also, dental plaque has been identified as a significant factor in the 
development of gingival recession in several clinical studies [51,52], 
closely associated with attachment loss. The organized microorganisms 
Table 3 (continued )
Risk factors (studies 
included in meta-analysis) 
Included in meta-analysis Summary of findings
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Without With P-value Padj.- 
value 
OR (95% CI) Risk 
without 
Risk with
Dental plaque (PI/ FMPS) (3) (a lot vs. few) 617/790 
(78.1)
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	Systematic review and meta-analysis on prevalence and risk factors for gingival recession
	1 Introduction
	2 Materials and methods
	2.1 Protocol
	2.2 Research question
	2.3 Eligibility criteria
	2.4 Search strategy
	2.5 Study selection
	2.6 Data extraction
	2.7 Data synthesis and meta-analyses
	2.8 Quality assessment
	2.9 Evidence assessment
	3 Results
	3.1 Study characteristics
	3.2 Quality assessment of included sources
	3.3 Prevalence of gingival recession
	3.4 Risk factors for gingival recession
	3.5 Assessment of evidence
	4 Discussion
	5 Conclusions
	Statement of ethics
	Funding sources
	CRediT authorship contribution statement
	Declaration of competing interest
	Supplementary materials
	References