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8932 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 Gingival in Children and Adolescents

Sulagna Pradhan1, Sushant Mohanty2, Sonu Acharya3, Mrinali Shukla1, Sonali Bhuyan1

1Post Graduate Trainee, 2Professor & Head, 3Professor, Department of Paediatric and Preventive , Institute of Dental Sciences, Siksha O Anusandhan (Deemed to be University), Bhubaneswar 751003, Odisha, India

Abstract Gingival diseases are prevalent in both children and adolescents. These diseases may or may not be associated with plaques, maybe familial in some cases, or may coexist with systemic illness. However, gingiva and receive scant attention as the primary dentition does not last for a considerable duration. As gingival diseases result in the marked breakdown of periodontal tissue, and premature affecting the nutrition and global development of a child/adolescent, precise identification and management of gingival diseases is of paramount importance. This article comprehensively discusses the nature, spectrum, and management of gingival diseases.

Keywords: Gingival diseases; children and adolescents; spectrum, and management.

Introduction reddish epithelium with mild keratinization may be misdiagnosed as . Lesser variability in the Children are more susceptible to several gingival width of the attached gingiva in the primary dentition diseases, paralleling to those observed in adults, though results in fewer mucogingival problems. The interdental vary in numerous aspects. Occasionally, natural variations papilla is broad buccolingual, and narrow mesiodistally. in the gingiva can masquerade as genuine pathology.1 The associated with the deciduous On the contrary, a manifestation of a life-threatening dentition is thicker than the permanent dentition. underlying condition is misdiagnosed as normal gingiva. Gingival sulcular depth in children varies from 1 to 2 Hence, it is crucial for dental professionals to acquire mm, which is shallower than that in adults.3 expertise and diagnostic skills to identify the diseases in 2 childhood before it turns out to be a catastrophe. Epidemiology: Previous investigations have revealed the frequent occurrence of of Anatomical Consideration: Gingiva of children various intensity in children and adolescents. These and adults differ anatomically. Gingiva of the primary investigations illustrate that the universality of severe dentition usually appears pale pink, but paler than that forms of periodontal pathologies is fewer in the younger of adults. The marginal gingiva has rich vascularity population as compared to the adults. Al Bandar and but comprises fewer connective tissues. The thinner, colleagues in 1996 evaluated a substantial number of adolescents in the United States and reported the existence of gingivitis in 82.1% of the participants. Several other studies from other parts of the world reported Corresponding Author: comparable results. Epidemiological studies indicate Dr. Sulagna Pradhan that loss of periodontal attachment and supporting bone Post Graduate Trainee, Department of Paediatric and at different locations can be recognized in 1% to 9% of 5 Preventive Dentistry, Institute of Dental Sciences, to 11year-old, 1% to 46% of 12 to 15-year-olds(juvenile Siksha O Anusandhan (Deemed to be University), periodontitis) and as low as 2.75% of 16-17-year-olds Bhubaneswar 751003, Odisha, India (). When a broad mixture of the e-mail: [email protected] population was taken into consideration, reports revealed Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 8933 a fewer universality of periodontitis among pediatric also contributory. Hence, plaque control should be and adult patients. Many investigators have proclaimed taken seriously before it culminates in pericoronal that higher plaque quantity and fewer inflammation in or leads to .11 children as compared to young individuals. However, (c) Gingivitis secondary to the orthodontic physicians recognize that the tissue destruction related to appliance: Effective brushing of the interproximal the periodontal pathologies in children and adolescents tooth is hampered during fixed appliance therapy. are generally self-healing and less prevalent compared Accumulated plaques have a subgingival shift to that in the adults.4-7 generated by the tipping movement which is virtually Classification of Gingival Diseases: out of reach of the bristles. The gingival changes occurring in the first two months of appliance A. Gingival Associated With Plaque placement is temporary and largely reversible.12 1. Without Local Contributing Factor (d) Gingivitis associated with mouth-breathing: Oral Plaque Induced Gingivitis: The presence of plaques tissue undergoes dehydration as an effect of frequent is the prime mover of this pathological entity. Dental mouth-breathing, resulting in inflammation of the plaque usually builds up more briskly in the 8-12 years gingiva and halitosis. This should be addressed age group compared to the adults. However, gingivitis with appropriate , moisturizing the in the pediatric population is typically less severe than tissues, use of the oral screen to protect the tissue in adults with the same plaque level. Inflammation during sleep, planning a comprehensive treatment is generally restricted to the marginal gingiva with protocol with orthodontics, and otolaryngology insignificant depletion of bone or connective tissue consultations.13 attachment in the majority of the cases. Red, linear (e) Other elements: Excessive and , inflammation accompanied by underlying chronic nasal blockage, partially exfoliated, loose deciduous, changes including swelling, augmented vascularity, and malaligned tooth, chipped off sharp edges of partly . Bleeding and deep pockets are not common cavitated and decayed teeth can usually lead to findings in children. The greatest intensity of gingival gingival inflammation.14 inflammation exists in patients aged 14-16-year. Aggressive plaque control is recommended along with B. Gingival Diseases and Systemic Factors: 8,9 or as per the condition. 1. Effect of Endocrine Alterations 2. With Local Contributing Factor (a) gingivitis: Pubertal gingivitis or steroid hormone-associated gingivitis is described as (a) Eruption cyst and hematoma: Erupting teeth aggravation of gingivitis by pre-pubertal and are frequently related to a variety of dentigerous pubertal alterations in sex hormone levels. This can cyst known as eruption cyst. These cysts have be justified by estrogen and progesterone upsurge circumscribed swellings and are usually translucent in the gingival tissues leading to vasodilatation and fluctuant. The presence of blood in the cystic and proliferation and increased susceptibility cavities imparts a purple/deep-blue discoloration to to inflammation. The interrelationship between the circumscribed swelling, described as eruption elevated levels of the gonadotrophic hormones and hematoma.10 pubertal gingivitis is noticeable from the fact that (b) Eruption gingivitis: Emergence of primary teeth gingival inflammation peaks prior in girls (10-13 into the oral cavity is often associated with gingival years) than in boys (13-15 years). According to in inflammation. Malalignment of the erupting teeth vivo evidence, P. intermedius is associated with the and/or neglected oral hygiene may exaggerate the elevated levels of plasma estrogen and progesterone, inflammation. However, optimal occlusion of the suggesting that P. intermedius thrives on these tooth subsides the inflammation. It may reappear in hormones for nutrients. It is markedly distinguished the 6-7 years of age group when the permanent teeth by conspicuous inflammation, bluish-red set to erupt. This develops, as the coronal contour of appearances, swelling, and overgrowth, prominent the tooth provides limited protection to the gingival bulbous interproximal papillae of anterior segments margin during the initial stage of an active eruption. which are precipitated from local irritating factors Additionally, frequent gingival food impingement is 8934 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 that would normally evoke a relatively benign C. Effect of Medications: Drug-induced gingival gingival reaction. Management of puberty gingivitis overgrowth: Gingival hyperplasia is an established should be targeted towards professional prophylaxis, side effect of several medications which include elimination of all local irritants, restoration of (anti-convulsant), cyclosporine carious teeth, and nutritional monitoring to ensure (immunodepressant), , , and a sufficient nutritional status. Occasionally, the ( and anti- fibrotic transformation of the gingival swelling hypertensive). Gingival hyperplasia was described warrants timely surgical .15 in 30% of patients receiving cyclosporin (Seymour & Heasman 1992), 50% of patients receiving 2. Gingivitis Associated with : phenytoin (Hassell 1981), and 15% of patients are malignant diseases resulted from the receiving the above-mentioned calcium channel proliferation of the WBC-precursors. Leukemia blockers (Lederman et al. 1984, Pernu et al. 1989, may have an acute or a chronic presentation and Seymour et al. 1994). The look normal during may be associated with one of the WBC precursors the neonatal period but start to enlarge with the such as granulocytes (myeloid), lymphocytes, or eruption of the primary teeth. This pattern of gingival monocytes. Acute leukemias are prevalent under hyperplasia typically starts as a nodular bulge in the the age group of 19-years. Acute lymphoblastic interdental papillae before growing extensively to leukemia is common in the first decade of life. intrude the marginal gingival and labial tissues. The Factors that have been suggested in the etiology are mouth is predominantly affected in the anterior side, radioactive rays and chemical damage, inherited but occasionally it affects the incisal and occlusal risk factors (for example, Down’s syndrome), surfaces of the teeth. Histological hallmarks of immune-compromised state, and viral ailment. this condition include epithelial acanthosis, higher Gingiva appears as swollen, glazed, and purplish- fibroblast quantity, and enhanced collagen synthesis. deep-red in color accompanying hemorrhage. The Mechanical and chemical plaque control method swelling may emerge as a scattered expansion of are essential for the improvement of oral hygiene. the gingival mucosa, and overgrown augmentation Besides, professional scaling and root planning are of the marginal gingiva, or a distinct lump like warranted to eliminate the local contributing factors. interdental papillary mass. The texture is reasonably On occasions, gingivectomy and gingivoplasty are firm, but there is a propensity towards friability recommended so that the patient can be esthetically and bleeding, either involuntarily or on trivial sound which ultimately enhances the hygiene. provocation. Indolence, restlessness, painful throat, Patients’ physiciansshould be consulted to discuss pyrexia, recurrent dermatological manifestations, the drug side effects so that other safe therapeutic purpura, cervical , splenomegaly, avenues can be explored at the earliest.17 hepatomegaly, and petechiae are common signs.16-18 B. Non-Plaque Induced Gingival Diseases 3. Associated with Nutritional Deficiency (a) Gingivitis associated with nutritional deficiency: Bacterial Several lines of evidence indicate an association (a) Acute necrotizing ulcerative gingivitis (ANUG): of hypervitaminosis and mineral deficiencies with ANUG is also recognized as Trench mouth or periodontal diseases. Scurvy, which emerges due Vincent’s disease and is caused by Borrelia to hypovitaminosis-C culminates in the reduction vincentii. ANUG has a greater prevalence in of collagen synthesis or the production of abnormal developing countries than in developed countries, ones. Oral scurvy manifests with painful gingival and children are more frequently affected compared swelling, edematous and spongy gingiva, and to adults. India has up to 2/3rd of the cases affecting hemorrhage, either spontaneously or with a slight the children in the first decade of life. ANUG is provocation. A combination of vitamin C deficiency described by punched-out crater-like ulcers in and poor oral hygiene contributes to a painful version interproximal gingiva coated with a grayish-white of gingivitis known as scorbutic gingivitis. It has pseudo-membrane, which may expand to encompass additional signs that include ulcerative gingivitis, marginalgingiva. It sometimes presents with deep malodor, the fast formation of the periodontal pockets as a result of extensive gingival necrosis pocket, and tooth damage. and crestal alveolar bone destruction.Patients Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 8935 commonly report excruciating pain, a distinctive Congenital Anomalies: metallic taste, spontaneous gingival bleeding, and halitosis. Low-grade , swollen lymph nodes, (a) Congenital (Gingival Granular Cell restlessness, myalgia, loss of appetite are the ): It is an uncommon gingival tumor of frequent accompanying symptoms. Simultaneous unknown histogenesis that grows commonly in local and systemic therapy is required to manage newborns, especially on the maxillary alveolar ANUG. The initial step should be professional ridge. On presentation, the area of concern (gum along with the debridement pad) typically is firm, pink, smooth swelling of the of necrotic tissue.Patientsare encouraged to gingival, and usually seen as gingival hyperplasia. maintain a proper diet andoral hygiene. Oxidizing Considerably large-seized growths may elevate the (e.g., ) mayserve to upper . The teeth which have not emerged into improvemicrobial stability. Five-day therapy with the oral cavity are typically unaltered and can be 15 penicillin or erythromycin is usually recommended. visualized in MRI. can be administered for the speedy (b) Congenital Gum Synechiae: This rare malformation recovery of symptoms.12-15 is identified by innate adherence between various parts of the oral apparatus. It leads to trouble in Viral breathing soon after birth. Prompt treatment is (a) Acute herpetic gingivostomatitis: This self- advocated involving the excision of alveolar bands. limiting disease occurs due to virus If left untreated, it may result in TMJ ankylosis, (HSV-1) . Pediatric patients younger than restricted jaw movement and overall growth may 6-7 years are chiefly affected. It is characterized by also be interrupted (restricted feeding).16 a scattered, reddish, and glazed appearance of the Traumatic Lesion: gums and the neighboring tissues. Varying grades of swelling, spontaneous gingival bleeding, disjunct (a) It occurs accidentally in our daily practice and the spheroidal gray vesicles that eventually burst and inflammation or swelling lasts only for a transient develop into ulcers with an erythematous, raised, period. Factitious gingivitis (Gingivitis artefecta) nimbus like edge and a depressed yellowish or is a self-inflicting injury of gingival that could be grayish-white central part are also recognized.18 habitual, accidental, or psychological. Soft tissue injury by bitting unknowingly, faulty brushing Fungal techniques, idiopathic trauma, tissue laceration (a) Acute candidiasis (Thrush, Candidiasis): It while replacing orthodontic components, chewing arises due to the overgrowth of the fungus Candida abrasive foodcan result ina mucogingival recession albicans. Children frequently develop acute or local inflammatory reaction. Management candidiasis after prolonged local therapy. includes removal of irritation source, habit, The appear as elevated, furry, white patches, rectification, and wound dressing. Psychological or which can be taken out easily to produce bleeding psychiatric consultation may be beneficial in severe 17,18 of the underlying surface. For infants and very cases. young children, daily administration of Nystatin Gingival Diseases Due to Heredity: suspension (1 ml, 4 times/d) is recommended. (a) Hereditary Gingival fibromatosis (HGF): Clotrimazole suspension is also highly effective. This benign condition is marked by a gradually (b) Linear gingival (LGE): It is clinically progressive . The commonest described by a reddish, linear band of 2-3mm width variety, HGF, is usually familial and has an on the marginal gingiva presentedas petechiae-like autosomal dominant mode of transmission. Another or disperse erythematous changes on the attached rare type has been referred to as elephantiasis gingiva gingiva which may be associated with profuse or hereditary hyperplasia of the gums. It manifests hemorrhage. It might be limited to less than two asnon-hemorrhagic, firm, leathery which advances teeth but it is frequently a generalized gingival slowly upon eruption of permanent dentition pathology.13-15 involving attached, marginal and interdental gingiva. This may be complicated by esthetic or 8936 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 functional issues such as a malaligned tooth, delayed strawberry gingivitis. retention of primary teeth, and delayed eruption of (f) Kindlers syndrome: This condition is characterized a permanent successor. Removal of hyperplastic by the presence of poikiloderma, cutaneous neonatal tissues by conventional gingivectomy may be a bullae, acral atrophy, and photosensitivity. Oral treatment modality. lesions similar to can also : Although it is a very unusual be part of the manifesting symptoms. Traditional condition, it is manifested as a grayish-blue-black non-surgical periodontal management can be useful appearance on the (typically on the lower for treating gingival manifestation.18-20 gums) due to the accidental diffusion of dental amalgam into the soft tissues. Occasionally, it is misdiagnosed as Conclusion . Gingival diseases have a wide prevalence and these can affect all the age groups. However, the common Gingival Findings Associated with Systemic myth is that gingival diseases affect only adults. Disorders: Through this review, we reinforce that gingival diseases (a) Infectious mononucleosis: Epstein-Barr virus can be troublesome in children as well. Inadequate (EBV) is the causative organism and it primarily awareness about any involving the affects children and young individuals. Patients gingiva in toddlers and young ones would jeopardize the chiefly complain of fever, sore throat, and enlarged periodontium in grown-up individuals. As prevention lymph nodes, but malaise, fatigue, headache is also is better than cure, it is important to streamline patient present. The abnormal findings include gingival education, and parent counseling to have regular bleeding, palatal petechiae, ulceration of the gingiva, pedodontic gingival assessment to maintain a healthy and buccal mucosa (White, 1998). oral cavity in childhood. (b) Chickenpox: Varicella-zoster is the reason of Funding: Nil chickenpox primarily affects individuals who are less than 15 years old. Although the location of Conflict of Interest: Nil lesions in the oral cavity is variable, , gingiva, Ethical Approval: Approved. and buccal mucosa are commonly affected.18-20 (c) : The causative pathogen of herpangina References is the Coxsackie group A virus. It characterized 1. McDonald Ralph E, Avery David R, Dean Jeffrey by plentiful small vesicles that further form small A. 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