This document provides an overview of gingival and periodontal diseases in children. It begins with an introduction stating that many periodontal diseases originate during childhood, so early detection and treatment are important. It then covers topics such as the normal periodontium in children, classifications of gingival diseases including gingivitis, acute gingival diseases like herpetic gingivostomatitis, and gingival enlargement. It also discusses periodontitis, specifically aggressive periodontitis which can occur in adolescents, as well as systemic diseases associated with periodontal problems. The conclusion emphasizes that early detection and treatment of periodontal issues in children can prevent more advanced diseases and also identify underlying systemic conditions.
3. Introduction
• Periodontal diseases peak their destructive stages in
the middle age , but many of them have their
inception during childhood.
• The early detection and early treatment are
important from a preventive aspect since, the
prevention of most periodontal diseases are
relatively simple and very effective, providing lifetime
benefits.
3
5. • The clinical and radiographic images of gingiva
and periodontium in children and adolescent
differ from those seen in adults, owing to the
significant changes taking place during growth
and development.
• The periodontium during childhood and puberty
is in constant state of change owing to the
exfoliation and eruption of teeth.
• This makes a general description of the normal
periodontium difficult because it varies with age
of the patient. (Baer and Benjamin, 1974)
5
6. 6
Features Children Adults
Gingival colour More reddish Coral pink
contour Free gingival margin-
rounded
Gingival margin-
knife edge
Consistency Flabby due to less CT
density and lack of
organized collagen fiber
bundles
Firm and resilient
Surface texture Stippling absent in
infancy.
`Mostly seen by age of 6
yrs
Stippling present
7. 7
feaatures Children Adults
Interdental area Saddle shaped gingiva Papillary gingiva
Gingival sulcus Newly erupted teeth
sulcus depth is greater
than deciduous
predecessor
1-2mm
Attached gingiva Width increases with
age and concomitant
decrease in sulcus
depth
Greater in adults
12. Gingivitis
• Dental plaque induced gingival inflammation is
the most common form of gingivitis.
• It is characterized by inflammation of gingival
tissues without loss of attachment or bone.
• Local factors contributing to gingivitis in
children
• Crowded teeth
• Orthodontic appliances
12
13. • Gingivitis associated with poor oral hygiene is
usually classified as
• Initial lesion
• Early lesion
• Moderate lesion
• Advanced lesion
13
14. 14
stage Initial stage Early stage Established
stage
Time (days) 2-4 4-7 14-21
Blood vessels Vascular
dilatation
Vascular
proliferation
Vascular
proliferation,
Blood stasis
Junctional &
Sulcular epi.
Infiltration
by PMNs
Same as stage
1,
Same but
more
advanced
Predominant
immune cells
PMNs Lymphocytes Plasma cells
Collagen Perivascular
loss
Increased
loss
Continuous
loss
Clinical
findings
Gingival fluid
flow
Erythema,
Bleeding on
probing
Changes in
color, texture,
size
Stages of gingivitis
17. Primary herpetic gingivostomatitis
• Caused by Herpes simplex virus type 1
• Age-Children younger than 6 yrs, but also may be
seen in adolescents and adults.
• Primary infection is asymptomatic
• Location- lesions mainly involve hard palate,
attached gingiva and oral mucosa.
• Manifestations include blister outside the lip so
disease commonly called recurrent herpes
labialis.
17
18. • Characteristic oral finding:
• Diffuse erythmatous involvement of gingiva.
• Initial stage in characterized by discrete
spherical gray vesicles.
• Lip- excoriation involving lip become
hemorrhagic
• Course is self limited to 7-10 days.
18
19. • Oral symptoms:
• Generalized soreness
• Ruptured vesicles – focal site of pain
• Infants show irritability and refusal to eat
• Pain upon swallowing
• Extra oral symptoms:
• Cervical lymphadenopathy
• Fever ( 101- 105℃)
• Generalized malaise, irritability
19
20. Treatment
• Symptomatic & supportive.
• Application of mild anesthetic such as dyclonine
hydrochloride(0.5%)
• Bed rest , soft diet are recommended during the
febrile stage & the child should be kept well
hydrated.
• Pyrexia - paracetamol suspension and secondary
infection of ulcers may be prevented using
chlorhexidine.
• In severe case, systemic acyclovir(200 mg daily for 5
days).
20
21. Recurrent aphthous ulcer
• Characterized by painful ulceration on the oral
mucosa
• Occurs between school age and adults
• Recurrent ulceration with painful discrete and
confluent lesions.
• Lesions are round to oval crateriform base,
raised and reddened margins.
21
22. • Etiology:
• Immunological abnormality: mucosal destruction
T-mediated immunological reaction.
• Microbial organism: ∝-hemolytic strept. And S.
sanguis.
• Systemic factors: like nutritional deficiency
22
23. • Clinical features:
• Occur between second and third decade of life.
• Buccal and labial mucosa tongue and gingiva are
commonly involved.
• Symptoms- lesions are typically very painful.
• Signs- begins as single or multiple superficial erosion
covered by grey membrane, surrounded by localized
area of erythema.
23
24. Treatment
• Symptomatic treatment
• Topical corticosteroid triamcinolone 3-4 times daily
by rinse and expectorate method.
• Nutritional diet.
• Maintenance of oral hygiene.
24
25. Acute necrotizing ulcerative
gingivitis
• Characterized by sloughing of gingival tissue
• Uncommon in children
• Predisposing factors:
• Local: poor oral hygiene, pre-existing gingivitis
and smoking
• Systemic: Emotional stress
• Nutritional deficiency –Vit B and C
25
26. • Clinical features
• Characteristic lesions are punched out, crater
like depression at the crest of interdental
papillae
• Surface of gingival craters is covered by
pseudomembranous slough.
• Linear erythma.
26
.
Atout RN, Todescan S. Managing patients with necrotizing ulcerative gingivitis. J Can Dent Assoc. 2013;79:d46.
27. • Extra oral and systemic symptoms:
• Local lymphadenopathy
• Elevation in temperature
• Increased pulse rate, leukocytosis, loss of
appetite, and general lassitude
• Systemic reactions are more severe in
children, insomnia, constipation, GIT
disorders, headache etc.
27
28. • Treatment:
• Perform debridement under local anesthesia.
• Remove pseudomembrane.
• Patient counselling should include specific oral
hygiene instructions, instruction on proper nutrition,
• For any signs of systemic involvement, the
recommended antibiotics are:
o Amoxicillin, 250 mg 3 x daily for 7 days and/or
o Metronidazole, 250 mg 3 x daily for 7 days
28
30. • Clinical features:
• Pearly white or bluish white plaque present on
oral mucosa which may extend to circumoral
tissues.
• Painless and noticed on careful evaluation. They
may be removed with little difficulty.
• Patient may complain of burning sensation.
30
31. • Treatment:
• Infants and very young children
• Nystatin 1ml (100,000U) dropped in to
mouth for local action four times a day.
• Clotrimazole suspension (10mg/ml) 1 to 2
ml applied over affected areas four times
daily
• Systemic fluconazole suspension
(10mg/ml) 6mg/kg body weight
31
33. Chronic inflammatory gingival
enlargement
• Long standing gingivitis in young patient
sometimes results in chronic inflammatory
gingival enlargement, which may be localized or
generalized.
• Etiology:
• Prolonged exposure to plaque
• Factors that favour plaque accumulation and
retention.
• Chronically dried gingiva in mouth breathing
33
34. • Clinical features:
• Characterized by slight ballooning of interdental papilla
and marginal gingiva.
• In early stage , it produces a life preserver-shaped bulge
around the involved teeth.
• Treatment:
• Removal of local irritants
• Oral hygiene maintenance
34
35. Acute inflammatory enlargement
• Gingival abscess
• Is a localized, painful rapidly expanding lesion that is
usually of sudden onset
• Etiology:
• Irritation from foreign substance
• Tooth brush bristle
• Piece of apple core
• Lobster shell fragment –embedded in to gingiva
35
36. • Clinical feature:
• Localized, painful, rapidly expanding lesion
• Limited to the marginal gingiva or interdental
papillae
• Early stage: red swelling with smooth shiny
surface
• With in 24 hours to 48 hours- lesion will be
fluctuant.
• Management: Incision and drainage
36
37. Drug-induced gingival enlargement
• Drug-induced gingival enlargement:
• Anticonvulsant
• Immunosuppressant cyclosporine
• Calcium channel blocker
• Clinical and microscopic features of enlargement
caused by different drugs are similar.
37
38. • Clinical features:
• The growth starts as a painless, beadlike enlargement
of the interdental papilla and extends to the facial
and lingual margins.
• As the condiiton progress, marginal and papillary
enlargment units and may develop into a massive
tissue fold.
• May interfere with occlusion.
38
39. Treatment modalities
Mild – < 1/3
of clinical
crown
oral hygiene maintenance and frequent
dental care
Moderate-
1/3 to 2/3 of
clinical
crown
oral hygiene
Antiplaque mouthrinse
4 consecutive weekly office visits for
prophylaxis, 5th week- evaluate the gingiva
If no improvement – surgical correction
Severe –
> 2/3 of
clinical
crown
If does not respond above treatment.
Surgical correction is done -meticulous
oral hygiene is essential .
Surgical procedure:- gingivectomy, laser,
or electrosurgery.
39
40. Ascorbic Acid Deficiency Gingivitis
• Associated with vit C deficiency
• Involves marginal and papillary gingiva in the
absence of local predisposing factors
• Complains of severe pain and spontaneous
hemorrhage
• Treatment: Complete dental care, improved dental
hygiene, and supplementation with vit C – improves
gingival conditions
40
41. Eruption Gingivitis
• Gingivitis associated with tooth eruption.
• Tooth eruption usually does not cause gingivitis,
however inflammation associated with plaque
accumulation around erupting tooth.
• perhaps secondary to discomfort caused by brushing
these friable areas, may contribute to gingivitis.
• Treatment: Complete dental care, improve oral
hygiene.
41
43. • It is inflammatory disease of gingiva and deeper
tissues of periodontium.
• Characterized by pocket formation and destruction of
supporting alveolar bone.
• Periodontal probing for attachment loss and bitewing
radiograph are often used to clinically confirm the
diagnosis.
43
44. • According to Delaney, in preschool children with
periodontitis, recession, gingival erythema, and
oedema are not usually found unless the child is
neutropenic.
• Bimstein and Colleagues demonstrated abnormal
alveolar bone resorption in 7.6% of 4yr old children
and 5.9% of 5yr old children with high caries.
• In its classification of periodontitis, the American
Academy of Periodontology categorized the early-
onset form under Aggressive Periodontitis.
Delaney JE. Periodontal and soft tissue abnormalities. Dent Clin North Am. 1995;39:837-850
Bimstein E, et al. Radiographic assessment of alveolar bonein children and adolescents. Pediatr Dent.1988;10:199
American Academy of Periodontology. Parameter on aggressive periodontitis. J Periodontol. 2000;71(suppl):867.44
45. Aggressive periodontitis
• Albander and associates proposed the term early-onset
periodontitis.
• This term is replaced by aggressive periodontitis following
the classification given by American Academy of
Periodontology in 1999.
45
Page and colleagues believe that
there are four different forms of
periodontitis : prepubertal,
juvenile, rapidly progressing and
adult.
46. COMMON FEATURES OF LAP AND GAP
• Aggressive forms of periodontal disease have
been defined based on the following primary
features (Lang et al. 1999)
Non-contributory medical history
Rapid attachment loss and bone destruction
Familial aggregation of cases
46
48. • Prevelence is 1%
• It is linked to presence of Actinobacillus
actinomycetemcomitans and successful
treatment outcomes correlate well with
eradication of bacteria.
• Treatment : local measures in combination with
systemic antibiotic therapy.
48
49. Generalized aggressive
periodontitis (GAP):
• It sometimes occurs in adolescents and
teenagers.
• Characterized by generalized interproximal
attachment loss affecting at least three
permanent teeth other than incisor and first
molar.
49
51. 51
• A combined regimen of regular SRP with 2-week
course of systemic tetracycline therapy (250
mg, four times daily) .
• Aa is sensitive to tetracycline, which also has
the ability to be concentrated up to 10 times in
gingival crevicular fluid when compared with
serum.
Treatment:
52. 52
• A combination of metronidazole (250 mg) &
amoxicillin (amoxycillin) (375 mg), three
times a day for 8 days, in association with
subgingival scaling, has also been found to be
effective.
• A more radical approach is to undertake flap
surgery so that better access is achieved for
root cleaning, and the superficial, infected
connective tissues are excised.
• An antimicrobial regimen can also be
implemented in conjunction with a surgical
approach.
53. Systemic diseases and conditions
with associated periodontal
problems
• Diabetes
• Down syndrome
• Hypophosphatasia
• Neutropenia
• Leukemia
53
54. Conclusion
• The early detection and treatment of periodontal
problems in children and adoloscents are
important for
1. Incipient periodontal diseases in children may develop
into advanced periodontal diseases in children.
2. Severe periodontal destruction in children may be
related to underlying systemic pathology.
• Education and motivation of children regarding
proper maintainence of periodontal health is the
simplest and most effective way for prevention of
periodontal diseases in the adult life.
54
55. References:
• Dean, Mcdonald, Avery. Dentistry for the child and
aolescented , ed 9, India, Elsevier, 2012.
• Newman, Takei, Klokkevold, Carranza. Carranza’s clinical
periodontology, ed 11, India, Elsevier, 2012 .
• Pinkham, Casamassimo, Fields, Mctigue, Nowak. Pediatric
Dentistry, ed 4, India, Saunders, 2005.
• Delaney JE. Periodontal and soft tissue abnormalities. Dent
Clin North Am. 1995;39:837-850
• American Academy of Periodontology. Parameter on
aggressive periodontitis. J Periodontol.2000;71(suppl) :867.
• Bimstein E, et al. Radiographic assessment of alveolar bonein
children and adolescents. Pediatr Dent.1988;10:199
55
In additoin, gingival anatomic problems, such as lack of attached gingiva , can arise during development and may necessitate early management.
Contour –shape of teeth , their alignment in arch, location n size of area of proximal contact, facial & lingual gingival embrassure.
Consistency- gingiva is firm and resilient , wih exception of free marginal gingiva,tightly bound to the underlying bon.
collagenous nature of lamina propria and its contiguity with the mucoperiousteum of the alveolar bone determine the firmness of attached Stippling- Best view in dried gingiva, produced by rounded protubence n depressions in gingival surface. Papillary layer of connective tissue projects into elevation, and the elevated n depressed area are covered by strat. Squamous epi.
Younger children have less plaque, and gingiva appear to be less reactive to the same amount of plaque.
Uncommon in early primary dentition.
Orthodontic applainces r associated with incresed plaque retention and incresed bleeding on probing.
Gingivitis is quick reversible and can be treated with a good oral prophylactic treatment
Gingivitis is generally less severe in children than in adults with similar plaque levels.
When gingivitis is establilshed, initial acute response is accompnied by chronic inflammation with lymphocytic and plasma cell accumulaiton, capilary formation, and collagen destruction.
This too can be reversed by initial therepy but will require a longer period for gingival tissue to heal and restore lost collagen fibers.
In some patients gingivitis proceeds to periodontitis , which is more difficult to treat. Therefore clinician must be vgilant to detect the early stage of gingivitis and carry out effective measures to prevent the progression of disease.
moniliasis
Remain letent untill reactivated, HSV-1 in trigeminal ganglion, HSV-2 in lumbosacral
With varying degree of edema and gingival bleeding
So that parting of lip during speech n swallowing become extreemly painful and difficult.
Diagnosis:Rise in serum antibodies HSV-1,in cytologic study ballooning degenrtion of cells, multinucleated gaint cells, hisotpahtological finding- lipschutxz bodies. Lesion culture
neutropenia of childhood is diagnosed between 6 and 24 months of age and is characterized by frequent and multiple pyogenic infections of the skin and mucous membranes.
IgG IgM bind to the mucosal surface of pts suffering from
Sussequently extending to the marginal gingiva anf rarely to attached gingiva and oral mucosa.
Overgrowth of yeast on oral mucose leads to desquamation of epithilial cells and accumulation of bacteria, necrotic tissue.
These debris combine to form pseudomb. Which adhere closely to mucosa.
Characterstically – interdental papillae & marginal gingiva become enlarged , tissue is usually erythmatous , bleeds easily.
t/t- it slowly resolves when adequat eplaque control is instituted, so gingivectomy is rarely required.
Prolonged exposure to dental plaque and factors favour the accumulation and retention of it
Exudative and prliferative features, deep red or bluish lesions are soft, friable with a smooth shiny surface, bleeds easily.
Vascular engorgemnt, new capillary formation and associated degenrative changes.
Firm , resilient, and pink- greater fibrotic components with an abundance of fibroblan and collagen.
Localized painful rapidly expanding lesion tht has a sudden onset
Limitied to marginal or interdental papilla
Appers as red swelling with smooth shiny surface.
Etiology; bacteria carried deep into the tissue when a forgein substance is forcefully embded into gingiva.
Infiltraiton of PMN , purulent focus in conn. Tissue, edematous tissue and vascular enlargment.
It is well-known consequence of administration of
Covering to considerable amount of crown portion.
h/f- hyperplasia of conn. Tissue and epi. Acanthosis of epi and elongated rete pages exiend deep into conn. Tissue, abundance of collagen bundles and fibroblant and formation of new BV.
Conditions can becomeextreemsymptoms covering the crowns of teeth and interfering with the eruption or occlusion.
scorbic acid is needed for accelerating hydroxylation and amidation reactions. In the synthesis of collagen, ascorbic acid is required as a cofactor for prolyl hydroxylase and lysyl hydroxylase. These two enzymes are responsible for the hydroxylation of the proline and lysine amino acids in collagen. Hydroxyproline and hydroxylysine are important for stabilizing collagen by cross-linking the propeptides in collagen. Defective collagen fibrillogenesis impairs wound healing. Collagen is an important part of bone, so bone formation is affected. Defective connective tissue leads to fragile capillaries, resulting in abnormal bleeding.
AP is used as a generic term to describe a heterogenous grp of periodontal disease occuring in younger individual who are otherwise healthy.
AP can be viewed as 2 categories of periodontits that may have overlapping etiologies and clinical presentations.
It is also called localized juvenile periodontitis, is
characterizd by the loss of attachment and bone around the permanent incisors and first permanent molars
Attachment loss is rapid, 3 times the rate of chronic disease.
15- yr old black female pt who had atwin wid similar disease
Metronidazole alone/ in combination with amoxicillin
Some reattachment and resolutoin of periodontal defects can occur after antibiotic therapy, but localized surgical intervention is often necessary to manage the residual defects.
It affect entire dentition and is not self-limiting.
Not associated with high level of AAC tht occur in LAP but istead has a microbial profile closer to that of chronic disease.
Clinical view showing minimal plaque and inflammation. A provisional wire and resin splint had been placed to stabilize the tooth.
22 Yr old black male patient with family history of early tooth loss