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Introduction

Epidemiologic studies indicate that gingivitis of varyingseverity is nearly universal in children and adolescents.

These studies also indicate that the prevalence of destructive

forms of periodontal disease is lower in young individuals

than in adults. Gingivitis is defined as an inflammationof the

gingiva. The gingiva is all soft tissue surrounding the tooth

coronal to the crest of alveolar bone and to a varying extent

lateral to the bone, extending to the mucogingival junction.

On the other hand, the definition of periodontium includes

cementum, periodontal ligament, alveolar bone, and the

gingiva; and periodontitis includes loss of attachment of

periodontal tissues from the tooth and net loss of alveolar

bone height.

The majority of periodontal diseases can be classified as

eithergingivitis or periodontitis which occur as a resultof the

presence of bacterial plaque or calculus on supra-gingival or

sub gingival tooth surfaces. It is generally accepted that

periodontal diseases begin as gingivitis, which progresses,

onlyinsomeindividuals, toperiodontitis.

The 1999 International Workshop for a Classification of

Periodontal Diseases and Conditions classified periodontal

disease in children as follows: Dental plaque-induced

gingival diseases; aggressive periodontitis (previouslyknown as 'prepubertal' or 'early onset periodontitis'); chronic

periodontitis; periodontitis as a manifestation of a systemic

disease; and necrotizing periodontal diseases. Most of the

literature reports of severe periodontal destruction in children

are associa ted with systemic diseases such as

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Pedodontics,

Reader, Lecturer, Professor & HOD,Periodontology,

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Lecturer, Dept. of

Lecturer,Dept. ofSinhgad Dental College & Hospital, Pune - 411 041, India

vrchauhan@gmail.com

*

e-mail:

Review Article

AbstractPeriodontal diseasesareamongthemost frequent diseasesaffectingchildrenand adolescents.Theseincludegingivitis, localized or generalized

aggressive periodontitis (a.k.a., early onset periodontitis) and periodontal diseases associated with systemic disorders. The effects of

periodontal diseases observed in adults have earlier inception in life period. Gingival diseases in a child may progress to jeopardize the

periodontium in adulthood. Therefore, periodontal diseases must be prevented and diagnosed early in the life. This paper reviews the most

common periodontal diseases affecting children: chronic gingivitis (or dental plaque-induced gingival diseases) and aggressive periodontitis.

In addition, systemic diseases that affect the periodontium in young children and necrotizing periodontal diseases are addressed. The

prevalence, diagnostic characteristics, microbiology, host- related factors, and therapeutic management of each of these disease entities are

discussed.

Periodontal disease,Children,Pedodontics,Aggressive periodontitis,ChronicgingivitisKeywords:

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Journal of Dental & Allied Sciences 2012;1(1):26-29

Gingival and Periodontal Diseases in Children and Adolescents

hypophosphatasia, cyclic neutropenia, agranulocytosis,

histiocytosis X, leukocyte adhesion deficiency, Papillon-Lefvre syndrome and leukemia. Although destructive

forms of periodontal disease in infants are relatively

uncommon, children andadolescents maymanifest anyform

of periodontitis. However, it has been shown that aggressive

periodontitis may be more common in children and

adolescents, while chronic periodontitis is more frequent in

adults.

Epidemiologic surveys indicate that loss of periodontal

attachment and supporting bone at one or more sites can be

found in1% to9% of5 to11 year-olds and anywherefrom 1%

to 46% of 12 to 15 year-olds. The relatively wide variationin these prevalence figures is probably due to differences in

the populations surveyed and the criteria and the methods

usedforestablishingthediagnosisof periodontitis.

Bimstein stressed the importance of prevention, early

diagnosis and early treatment of periodontal diseases in

children and adolescents because (1) the prevalence of and

severity of periodontal diseases are high; (2) incipient

periodontal diseases in children may develop into advanced

periodontal diseases in adults; (3) there is association

between periodontal and systemic diseases; (4) patients,

families,or populationsat risk maybe identified andincludedin special prevention or treatment programs; and (5)

prevention and treatment of most periodontal diseases are

relatively simple and very effective, providing lifetime

benefits.

The aim of this paper is to review the most common

periodontal diseases affecting children: chronic gingivitis

and aggresive periodontitis. In addition, systemic diseases

that affect the periodontium and necrotizing periodontal

diseasesfoundin youngchildrenwillbe discussed.

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I) Chronic Gingivitis

II)AggressivePeriodontitis

Chronic gingivitis is the most common periodontal infection

among children, andadolescents.Thesemayinclude plaque-

induced chronic gingivitis (the most prevalent form), steroid

hormone related gingivitis, drug-influenced gingival

overgrowth, and others. The initial clinical findings in

gingivitis include redness and swelling of marginal gingiva,

and bleeding upon probing. As the condition persists, tissues

that were initially edematous may become more fibrotic.

Probing depths may increase if significant hypertrophy or

hyperplasia of thegingiva occurs.Although themicrobiology

of this disease has not been completely characterized,

increased subgingival levels of

, and

have been found in experimental gingivitis in children when

compared to gingivitis in adults. These species maytherefore

be important in its etiologyand pathogenesis.

Matsson performed a 21-day experimental gingivitis study

comparing 6 children, aged 4 to 5 years, with 6 dental

students, aged 23 to 29 years. They found that the children

developed gingivitis less readily than the adults. After 21

days without plaque removal, the children had less gingival

exudate and a lower percentage of bleeding sites than the

adults. Also, the children had a smaller increase in gingival

crevicular leukocytes than the adults in response to plaque

accumulation. The study hypothesized that children may

havea different vascularresponsethanadults.

Steroid hormone-related gingivitis is associated withelevatedsexhormone levels. Increasedlevels of estrogenand

progesteroneduring pregnancy, during puberty, or in patients

medicated with oral contraceptives have been reported to

result in increased gingival vascularity and inflammation.

Removal of local factors is the key to the management of

steroid hormone-related gingivitis; however, it is often

necessary to surgically excise unresolved gingival

overgrowth. Drug-influenced gingival enlargement has been

observed in patients taking cyclosporin, phenytoin and

calcium channel blockers, with higher prevalence in

children.

The primary features of aggressive periodontitis include a

history of rapid attachment and bone loss with familial

aggregation. Secondary features include phagocyte

abnormalities and a hyperresponsive macrophage

phenotype. Aggressive periodontitis can be localized or

generalized. Localized aggressive periodontitis (LAgP)

patients have interproximal attachment loss on at least two

permanent first molars and incisors, with attachment loss on

no more than two teeth other than first molars and incisors.

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Actinomyces sp.,

Capnocytophaga sp., Leptotrichia sp. Selenomonas sp.

Generalized aggressive periodontitis(GAgP) patientsexhibit

generalized interproximal attachment loss including at least

three teeth that are not first molars and incisors. LAgP

occurs in children and adolescents without clinical evidence

of systemic disease and is characterized by the severe loss of

alveolar bone around permanent teeth. Reported estimates of

the prevalence of LAgP in geographically diverse adolescent

populationsrange from0.1% to 15%.

Bacteria of probable etiologic importance include highly

virulent strains of in

combination with like species. A variety of

functional defects have been reported in neutrophils from

patients with LAgP. These include anomalies of chemotaxis,

phagocytosis, bactericidal activity, superoxide production,

Fc RIIIB (CD16) expression, leukotriene B4 generation and

Ca2+-channelandsecond messengeractivation.

GAgP, often considered to be a disease of adolescents and

young adults, can begin at any age and often affects the entire

dentition. Individuals withGAgPexhibit marked periodontal

inflammation and have heavy accumulations of plaque and

calculus. Subgingival sites from affected teeth harbor high

percentages of non-motile, facultatively anaerobic, Gram-

negative rods including .

Neutrophils from patients with GAgP frequently exhibit

suppressed chemotaxis as observed in LAgP with a

concomitant reduction in GP-110. This suggests a

relationship between the two variants of aggressive

periodontitis. Alterations in immunologic factors such asimmunoglobulins are known to be present in aggressive

periodontitis.

Successful treatment of aggressive periodontitis depends on

early diagnosis, directing therapy against the infecting

microorganisms and providing an environment for healing

that is free of infection. The majority of reports suggest that

the use of antibiotics is usually beneficial in the treatment of

LAgP. Metronidazole in combination with amoxicillin has

also been utilized, especially where tetracyline-resistant

are present. In GAgP patients who

have failed to respond to standard periodontal therapy,laboratory tests of plaque samples may identify periodontal

pathogens that are resistant to antibiotics typically used to

treat periodontitis. It has been suggested that follow-up

tests after additional antibiotic or other therapy is provided

may be helpful in confirming elimination of targeted

pathogenicorganisms.

Chronic periodontitis is most prevalent in adults, but can

occur in children and adolescents. It can be localized (less

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Actinobacillus actinomycetemcomitans

Bacteroides

Porphyromonas gingivalis

A.

actinomycetemcomitans

III)Chronic Periodontitis

Journal of Dental & Allied Sciences 2012;1(1):26-29

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than 30% of the dentition affected) or generalized (greater

than 30% of the dentition affected) and is characterized by a

slow tomoderate rate ofprogression that mayinclude periods

of rapid destruction. Furthermore, the severity of disease can

be mild (1 to 2 mm clinical attachment loss), moderate (3 to 4

mm clinical attachment loss), or severe ( 5 mm clinical

attachment loss).Childrenand young adultswith this form of

disease were previously studied along with patients having

localizedaggressive periodontitisand generalized aggressive

periodontitis. Therefore, published data are lacking for this

group.

These may include insulin dependent diabetes mellitus

(IDDM), Papillon-Lefe`vre syndrome, hypophosphatasia,

neutropenia, Chediak-Higashi syndrome, leukemias,

histiocytosis X, acrodynia, acquired immunodeficiency

syndrome (AIDS), Down syndrome, and leukocyte adhesiondeficiency. Cianciola et al. studied the association between

juvenile diabetes and periodontal diseases in young

children. Children were found to have overt periodontitis

often localized to first molars and incisors, although

periodontitis was also found in a generalized pattern.

A ff ec t e d s ub g i ng iv a l s i t e s h a r bo r e d

and Oral

manifestations of leukemias in children are gingival

hemorrhage, petechiae, lymphadenopathy, gingival

hyperplasia or hypertrophy, andgingivalpallor.

Children with AIDS may develop an atypical form of acutenecrotizing ulcerative gingivitis (ANUG) however, no

reports of prepubertal pediatric AIDS patients presenting

with alveolar bone loss exist. Due to a defective immune

system, rampant and precocious periodontal disease is

prevalent among children with down syndrome. In Down's

syndrome, the amount of periodontal destruction has been

shown to be positively correlated with the severity of the

neutrophil chemotaxis defect.

Periodontitis as a manifestation of systemic disease in

children isa rare disease that oftenbeginsbetween thetimeof

eruption of the primary teeth up to the age of 4 or 5. Thedisease occurs in localized and generalized forms. In the

localized form, affected sites exhibit rapid bone loss and

minimal gingival inflammation. In the generalized form,

there is rapid bone loss around nearly all teeth and marked

gingival inflammation. Neutrophils from some children with

a clinical diagnosis of periodontitis as a manifestation of

systemic disease have abnormalities in a cell surface

glycoprotein (LFA-1, leukocyte functional antigen 1, also

known as CD11, and Mac-1). The neutrophils in these

patients having LAD (leukocyte adhesion deficiency) are

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IV)Periodontitis as manifestation of systemic diseases

A. actinomycetemcomitans Capnocytophaga sp.

likelyto have a decreasedability to move from thecirculation

to sites of inflammation and infection. Affected sites harbor

elevated percentages of putative periodontal pathogens such

as

, and .

Treatment of periodontitis as a manifestation of systemic

disease in children is similar to the treatmentof localized and

generalized aggressive periodontitis in the permanent

dentition and has been reported to include surgical or non-

surgicalmechanical debridement andantimicrobial therapy.

The two most significant findings used in the diagnosis of

necrotizing periodontal diseases (NPD) are the presence of

interproximal necrosis and ulceration and the rapid onset of

gingival pain. Patients with NPD can often be febrile.

Necrotizing ulcerative periodontitis sites harbor high levels

of and , and invasion of the tissues

by has been shown to occur.

Factors that predispose children to NPD include viral

infections (including HIV), malnutrition, emotional stress,

lack of sleep, and a variety of systemic diseases. Treatment

involves mechanical debridement, oral hygiene instruction,

and careful follow-up. Debridement with ultrasonics has

been shown to be particularly effective and results in a rapid

decreaseinsymptoms.If thepatient is febrile,antibioticsmay

be an important adjunct to therapy. Metronidazole and

penicillinhave been suggestedas drugs of choice.

Periodontal diseases are among the most frequent diseases

affecting children and adolescents. Dental clinicians must be

aware of the prevalence, diagnostic characteristics,

microbiology, host-related factors, and therapeutic

management ofeach of thesedisease entities.It iswell known

that the primary etiology of periodontal diseases is bacterial

plaque. However, patients affected by early onset

periodontitis (or aggressive periodontitis) often present with

impaired immune function, mainly neutrophil dysfunction.

Therefore, it is important when managing periodontal

diseases in young individuals, the dentist should rule outsystemic diseases that canaffect host defense mechanisms. It

is believed that the best approach to manage periodontal

diseases is prevention, followed by early detection and

treatment. To achieve this, profound knowledge about

periodonticsand pedodontics as well as intimateperiodontal-

pedodontics interactionsare essential.

A. actinomycetemcomitans, Prevotella intermedia,

Eikenella corrodens Capnocytophaga sputigena

spirochetes P. intermedia

spirochetes

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V) Necrotizing periodontaldiseases

Conclusion

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