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Periodontal Diseases in the Child and Adolescent

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Periodontal Diseases in the Child and Adolescent J Clin Periodontol 2002; 29: 400–410 Copyright C Blackwell Munksgaard 2002 Printed in Denmark . All rights reserved ISSN 0303-6979 Tae-Ju Oh, Robert Eber and Periodontal diseases in the child Hom-Lay Wang Department of Periodontics/Prevention/ Geriatrics, School of Dentistry, University of and adolescent Michigan, Ann Arbor, MI, USA Oh T-J, Eber R, Wang H-L: Periodontal diseases in the child and adolescent. J Clin Periodontol 2002; 29: 400–410. C Blackwell Munksgaard, 2002. Abstract Background: Periodontal diseases are among the most frequent diseases affecting children and adolescents. These include gingivitis, localized or generalized aggres- sive periodontitis (a.k.a., early onset periodontitis which includes generalized or localized prepubertal periodontitis and juvenile periodontitis) and periodontal diseases associated with systemic disorders. The best approach to managing peri- odontal diseases is prevention, followed by early detection and treatment. Methods: This paper reviews the current literature concerning the most common periodontal diseases affecting children: chronic gingivitis (or dental plaque-induced gingival diseases) and early onset periodontitis (or aggressive periodontitis), in- cluding prepubertal and juvenile periodontitis. In addition, systemic diseases Key words: periodontal disease; children; that affect the periodontium and oral lesions commonly found in young children pedodontics; early onset periodontitis; are addressed. The prevalence, diagnostic characteristics, microbiology, host- aggressive periodontitis; localized juvenile periodontitis related factors, and therapeutic management of each of these disease entities are thoroughly discussed. Accepted for publication 15 May 2001 Dental clinicians must be adept at diag- The nomenclature and classification shop classification system includes a nosis and management of periodontal systems we use to describe periodontal greater variety of disease categories that disease in children and adolescents. disease have changed periodically over base the diagnosis on clinical history Periodontal diseases are not limited to the past few decades. This leads to some and findings, relying less on age of on- adults. On the contrary, periodontal confusion when one reviews past litera- set as a major criterion (Table 1). diseases are prevalent among children ture about disease prevalence, treat- This paper primarily follows the and adolescents. For example, gingivitis ment, etc. The Consensus Report of the classification of periodontal disease affects more than 70% of children older 1989 World Workshop in Clinical Peri- from the 1989 World Workshop in Clin- than seven years of age (Page & Schro- odontics used the following criteria to ical Periodontics (AAP 1989) when de- eder 1982, Stamm 1986). Bimstein distinguish various forms of peri- scribing conditions because most clini- (1991) stressed the importance of pre- odontitis: (1) age of onset; (2) rate of cians are familiar with it. For each con- vention, early diagnosis and early treat- disease progression; (3) distribution of dition, we also include the International ment of periodontal diseases in children affected sites; (4) presence or absence of Workshop in Periodontics classification and adolescents because (1) the preva- systemic medical conditions; (5) pres- (Armitage 1999) parenthetically to in- lence of and severity of periodontal dis- ence or absence of specific microbial or troduce readers to the new system and eases are high; (2) incipient periodontal host factors; and (6) response of the dis- to highlight the changes between the diseases in children may develop into ease to therapy (American Academy of two. advanced periodontal diseases in Periodontology: AAP 1989). The classi- The aim of this paper is to review the adults; (3) there is association between fication (AAP 1989) was simplified by current literature concerning the most periodontal and systemic diseases; (4) the Consensus Report of the First common periodontal diseases affecting patients, families, or populations at risk European Workshop on Periodonto- children: chronic gingivitis and early may be identified and included in logy (Attström & van der Velden 1994), onset periodontitis, including prepuber- special prevention or treatment pro- and more recently, a new classification tal and juvenile periodontitis. In ad- grams; and (5) prevention and treat- of periodontal diseases and conditions dition, systemic diseases that affect the ment of most periodontal diseases are was presented at the 1999 International periodontium and oral lesions com- relatively simple and very effective, pro- Workshop on Periodontics (Armitage monly found in young children will be viding lifetime benefits. 1999). The 1999 International Work- addressed. Periodontal diseases in children 401 Table 1. Classifications of periodontitis brushes and antibacterial mouthrinses The 1989 World Workshop in Clinical Periodontics may be useful adjuncts to standard I. Adult periodontitis toothbrushing and flossing for children II. Early-onset periodontitis who are physically challenged, such as A. Prepubertal periodontitis (generalized, localized) children with Downs syndrome, and for B. Juvenile periodontitis (generalized, localized) children undergoing orthodontic care C. Rapidly progressive periodontitis (Trombelli et al. 1995, Grossman & III. Periodontitis associated with systemic disease Proskin 1997, Boyd 1989). IV. Necrotizing ulcerative periodontitis Steroid hormone-related gingivitis is V. Refractory periodontitis associated with elevated sex hormone The 1994 First European Workshop on Periodontology levels that amplify clinical inflamma- I. Early onset periodontitis tory changes of gingivitis (Suzuki II. Adult periodontitis 1988). Increased levels of estrogen and III. Necrotizing periodontitis progesterone during pregnancy (Löe The 1999 International Workshop on Periodontology 1965), during puberty, or in patients I. Gingival diseases medicated with oral contraceptives II. Chronic periodontitis (Kalkwarf 1978) have been reported to III. Aggressive periodontitis IV. Periodontitis as a manifestation of systemic diseases result in increased gingival vascularity V. Necrotizing periodontal diseases and inflammation. Removal of local VI. Abscesses of the periodontium factors is the key to the management of VII. Periodontitis associated with endodontic lesions steroid hormone-related gingivitis; VIII. Developmental or acquired deformities and conditions however, it is often necessary to surgic- ally excise unresolved gingival over- growth. Drug-influenced gingival enlargement increase in gingival activity from early has been observed in patients taking (I). Chronic Gingivitis (Dental Plaque- childhood to adult age. Previously, cyclosporin, phenytoin and calcium induced Gingival Diseases) Matsson (1978) performed a 21-day ex- channel blockers, with higher preva- Chronic gingivitis is the most common perimental gingivitis study comparing 6 lence in children (Mariotti 1999, Seym- periodontal infection among children, children, aged 4 to 5 years, with 6 den- our et al. 2000). Gingival enlargement and adolescents. These may include tal students, aged 23 to 29 years. They was reported in 30% of patients taking plaque-induced chronic gingivitis (the found that the children developed gin- cyclosporin (Seymour & Heasman most prevalent form), steroid hormone givitis less readily than the adults. After 1992), 50% of patients taking phenytoin related gingivitis, drug-influenced gin- 21 days without plaque removal, the (Hassell 1981), and 15% of patients tak- gival overgrowth, and others. It is char- children had less gingival exudate and ing calcium channel blockers such as acterized by inflammation of the mar- a lower percentage of bleeding sites nifedipine (Lederman et al. 1984), vera- ginal gingiva without detectable loss of than the adults. Also, the children had pamil (Pernu et al. 1989), and amlodipi- bone or connective tissue attachment. a smaller increase in gingival crevicular ne (Seymour et al. 1994). Gingival en- The initial clinical findings in gingivitis leukocytes than the adults in response largement starts in the interdental pa- include redness and swelling of mar- to plaque accumulation. The study pilla region and spreads to involve the ginal gingiva, and bleeding upon prob- hypothesized that children may have a marginal gingiva. In severe cases the en- ing. As the condition persists, tissues different vascular response than adults. larged gingiva may cover the incisal and that were initially edematous may be- Gingivitis does not always progress occlusal surfaces of the teeth (Chapple come more fibrotic. Gingival margins, to periodontitis, but periodontitis is 1996). Histologically, the overgrowth is normally knife-edged in contour, may preceded by gingivitis. According to fibroepithelial in nature, with epithelial become rolled, and interdental papillae Marshall-Day et al. (1955), gingivitis acanthosis, increased numbers of may become bulbous and enlarged. without evidence of bone loss was con- fibroblasts and increased collagen pro- Probing depths may increase if signifi- fined to a younger age group, and bone duction. The severity of gingival en- cant hypertrophy or hyperplasia of the loss without gingival alterations was largement is closely related to the level gingiva occurs. rarely found. of plaque control, and therefore reduc- Histologically, ulceration of the sul- Plaque-induced chronic gingivitis is tions in dental plaque can limit the se- cular epithelium and inflammatory cell
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