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

Review Article

Gingival and Periodontal Diseases in Children and Adolescents

1 2 3 4 5
Vivek Singh Chauhan , Rashmi Singh Chauhan , Nihal Devkar , Akshay Vibhute , Shobha More

Periodontal diseases are among the most frequent diseases affecting children and adolescents. These include gingivitis, 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

Key words: Periodontal disease, Children, Pedodontics,Aggressive periodontitis, Chronic gingivitis

Introduction hypophosphatasia, cyclic neutropenia, agranulocytosis,

Epidemiologic studies indicate that gingivitis of varying histiocytosis X, leukocyte adhesion deficiency, Papillon-
1-5 8
severity is nearly universal in children and adolescents. Lefèvre syndrome and leukemia. Although destructive
These studies also indicate that the prevalence of destructive forms of periodontal disease in infants are relatively
forms of periodontal disease is lower in young individuals uncommon, children and adolescents may manifest any form
than in adults. Gingivitis is defined as an inflammation of the of periodontitis. However, it has been shown that aggressive
gingiva. The gingiva is all soft tissue surrounding the tooth periodontitis may be more common in children and
coronal to the crest of alveolar bone and to a varying extent adolescents, while chronic periodontitis is more frequent in
lateral to the bone, extending to the mucogingival junction. adults.
On the other hand, the definition of periodontium includes
cementum, periodontal ligament, alveolar bone, and the Epidemiologic surveys indicate that loss of periodontal
gingiva; and periodontitis includes loss of attachment of attachment and supporting bone at one or more sites can be
periodontal tissues from the tooth and net loss of alveolar found in 1% to 9% of 5 to 11 year-olds and anywhere from 1%
bone height.
to 46% of 12 to 15 year-olds. The relatively wide variation
in these prevalence figures is probably due to differences in
The majority of periodontal diseases can be classified as the populations surveyed and the criteria and the methods
either gingivitis or periodontitis which occur as a result of the used for establishing the diagnosis of periodontitis.
presence of bacterial plaque or calculus on supra-gingival or
sub gingival tooth surfaces. It is generally accepted that Bimstein stressed the importance of prevention, early
periodontal diseases begin as gingivitis, which progresses, diagnosis and early treatment of periodontal diseases in
only in some individuals, to periodontitis.
7 children and adolescents because (1) the prevalence of and
severity of periodontal diseases are high; (2) incipient
The 1999 International Workshop for a Classification of periodontal diseases in children may develop into advanced
Periodontal Diseases and Conditions classified periodontal periodontal diseases in adults; (3) there is association
disease in children as follows: Dental plaque-induced between periodontal and systemic diseases; (4) patients,
gingival diseases; aggressive periodontitis (previously families, or populations at risk may be identified and included
known as 'prepubertal' or 'early onset periodontitis'); chronic in special prevention or treatment programs; and (5)
periodontitis; periodontitis as a manifestation of a systemic prevention and treatment of most periodontal diseases are
disease; and necrotizing periodontal diseases. Most of the relatively simple and very effective, providing lifetime
literature reports of severe periodontal destruction in children benefits.
are associated with systemic diseases such as
The aim of this paper is to review the most common
Lecturer, Dept. of Pedodontics, periodontal diseases affecting children: chronic gingivitis
Lecturer, 3Reader, 4Lecturer, 5Professor & HOD, and aggresive periodontitis. In addition, systemic diseases
* Dept. of Periodontology,
Sinhgad Dental College & Hospital, Pune - 411 041, India that affect the periodontium and necrotizing periodontal
e-mail: diseases found in young children will be discussed.

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

I) Chronic Gingivitis Generalized aggressive periodontitis (GAgP) patients exhibit

Chronic gingivitis is the most common periodontal infection generalized interproximal attachment loss including at least
among children, and adolescents. These may include plaque- three teeth that are not first molars and incisors. LAgP
induced chronic gingivitis (the most prevalent form), steroid occurs in children and adolescents without clinical evidence
hormone related gingivitis, drug-influenced gingival of systemic disease and is characterized by the severe loss of
overgrowth, and others. The initial clinical findings in alveolar bone around permanent teeth. Reported estimates of
gingivitis include redness and swelling of marginal gingiva, the prevalence of LAgP in geographically diverse adolescent
and bleeding upon probing. As the condition persists, tissues populations range from 0.1% to 15%.
that were initially edematous may become more fibrotic.
Probing depths may increase if significant hypertrophy or Bacteria of probable etiologic importance include highly
hyperplasia of the gingiva occurs.Although the microbiology virulent strains of Actinobacillus actinomycetemcomitans in
of this disease has not been completely characterized, combination with Bacteroides like species. A variety of
increased subgingival levels of Actinomyces sp., functional defects have been reported in neutrophils from
Capnocytophaga sp., Leptotrichia sp., and Selenomonas sp. patients with LAgP. These include anomalies of chemotaxis,
have been found in experimental gingivitis in children when phagocytosis, bactericidal activity, superoxide production,
compared to gingivitis in adults. These species may therefore FcγRIIIB (CD16) expression, leukotriene B4 generation and
17,18 22
be important in its etiology and pathogenesis. Ca2+-channel and second messenger activation.

Matsson performed a 21-day experimental gingivitis study GAgP, often considered to be a disease of adolescents and
comparing 6 children, aged 4 to 5 years, with 6 dental young adults, can begin at any age and often affects the entire
students, aged 23 to 29 years. They found that the children dentition. Individuals with GAgP exhibit marked periodontal
developed gingivitis less readily than the adults. After 21 inflammation and have heavy accumulations of plaque and
days without plaque removal, the children had less gingival calculus. Subgingival sites from affected teeth harbor high
exudate and a lower percentage of bleeding sites than the percentages of non-motile, facultatively anaerobic, Gram-
adults. Also, the children had a smaller increase in gingival negative rods including Porphyromonas gingivalis .
crevicular leukocytes than the adults in response to plaque Neutrophils from patients with GAgP frequently exhibit
accumulation. The study hypothesized that children may suppressed chemotaxis as observed in LAgP with a
have a different vascular response than adults. concomitant reduction in GP-110. This suggests a
relationship between the two variants of aggressive
Steroid hormone-related gingivitis is associated with periodontitis. Alterations in immunologic factors such as
elevated sex hormone levels. Increased levels of estrogen and immunoglobulins are known to be present in aggressive
progesterone during pregnancy, during puberty, or in patients periodontitis.
medicated with oral contraceptives have been reported to
result in increased gingival vascularity and inflammation. Successful treatment of aggressive periodontitis depends on
Removal of local factors is the key to the management of early diagnosis, directing therapy against the infecting
steroid hormone-related gingivitis; however, it is often microorganisms and providing an environment for healing
necessary to surgically excise unresolved gingival that is free of infection. The majority of reports suggest that
overgrowth. Drug-influenced gingival enlargement has been the use of antibiotics is usually beneficial in the treatment of
observed in patients taking cyclosporin, phenytoin and LAgP. Metronidazole in combination with amoxicillin has
calcium channel blockers, with higher prevalence in also been utilized, especially where tetracyline-resistant A.
children. actinomycetemcomitans are present. In GAgP patients who
have failed to respond to standard periodontal therapy,
II)Aggressive Periodontitis laboratory tests of plaque samples may identify periodontal
The primary features of aggressive periodontitis include a pathogens that are resistant to antibiotics typically used to
history of rapid attachment and bone loss with familial treat periodontitis. It has been suggested that follow-up
aggregation. Secondary features include phagocyte tests after additional antibiotic or other therapy is provided
abnormalities and a hyperresponsive macrophage may be helpful in confirming elimination of targeted
phenotype. Aggressive periodontitis can be localized or pathogenic organisms.
generalized. Localized aggressive periodontitis (LAgP)
patients have interproximal attachment loss on at least two III) Chronic Periodontitis
permanent first molars and incisors, with attachment loss on Chronic periodontitis is most prevalent in adults, but can
no more than two teeth other than first molars and incisors. occur in children and adolescents. It can be localized (less

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Gingival & periodontal diseases - Vivek Singh Chauhan et al

than 30% of the dentition affected) or generalized (greater likely to have a decreased ability to move from the circulation
than 30% of the dentition affected) and is characterized by a to sites of inflammation and infection. Affected sites harbor
slow to moderate rate of progression that may include periods elevated percentages of putative periodontal pathogens such
of rapid destruction. Furthermore, the severity of disease can as A. actinomycetemcomitans, Prevotella intermedia,
be mild (1 to 2 mm clinical attachment loss), moderate (3 to 4 Eikenella corrodens, and Capnocytophaga sputigena.
mm clinical attachment loss), or severe (≥ 5 mm clinical Treatment of periodontitis as a manifestation of systemic
attachment loss). Children and young adults with this form of disease in children is similar to the treatment of localized and
disease were previously studied along with patients having generalized aggressive periodontitis in the permanent
localized aggressive periodontitis and generalized aggressive dentition and has been reported to include surgical or non-
periodontitis. Therefore, published data are lacking for this surgical mechanical debridement and antimicrobial therapy.
V) Necrotizing periodontal diseases
IV) Periodontitis as manifestation of systemic diseases The two most significant findings used in the diagnosis of
These may include insulin dependent diabetes mellitus necrotizing periodontal diseases (NPD) are the presence of
(IDDM), Papillon-Lefe`vre syndrome, hypophosphatasia, interproximal necrosis and ulceration and the rapid onset of
neutropenia, Chediak-Higashi syndrome, leukemias, gingival pain. Patients with NPD can often be febrile.
histiocytosis X, acrodynia, acquired immunodeficiency Necrotizing ulcerative periodontitis sites harbor high levels
syndrome (AIDS), Down syndrome, and leukocyte adhesion of spirochetes and P. intermedia, and invasion of the tissues
deficiency. Cianciola et al. studied the association between by spirochetes has been shown to occur.
juvenile diabetes and periodontal diseases in young
children. Children were found to have overt periodontitis Factors that predispose children to NPD include viral
often localized to first molars and incisors, although infections (including HIV), malnutrition, emotional stress,
periodontitis was also found in a generalized pattern. lack of sleep, and a variety of systemic diseases. Treatment
Affected subgingival sites harbored involves mechanical debridement, oral hygiene instruction,
A. actinomycetemcomitans and Capnocytophaga sp. Oral and careful follow-up. Debridement with ultrasonics has
manifestations of leukemias in children are gingival been shown to be particularly effective and results in a rapid
hemorrhage, petechiae, lymphadenopathy, gingival decrease in symptoms. If the patient is febrile, antibiotics may
hyperplasia or hypertrophy, and gingival pallor. be an important adjunct to therapy. Metronidazole and
penicillin have been suggested as drugs of choice.
Children with AIDS may develop an atypical form of acute
necrotizing ulcerative gingivitis (ANUG) however, no Conclusion
reports of prepubertal pediatric AIDS patients presenting Periodontal diseases are among the most frequent diseases
with alveolar bone loss exist. Due to a defective immune affecting children and adolescents. Dental clinicians must be
system, rampant and precocious periodontal disease is aware of the prevalence, diagnostic characteristics,
prevalent among children with down syndrome. In Down's microbiology, host-related factors, and therapeutic
syndrome, the amount of periodontal destruction has been management of each of these disease entities. It is well known
shown to be positively correlated with the severity of the that the primary etiology of periodontal diseases is bacterial
neutrophil chemotaxis defect. plaque. However, patients affected by early onset
periodontitis (or aggressive periodontitis) often present with
Periodontitis as a manifestation of systemic disease in impaired immune function, mainly neutrophil dysfunction.
children is a rare disease that often begins between the time of Therefore, it is important when managing periodontal
eruption of the primary teeth up to the age of 4 or 5. The diseases in young individuals, the dentist should rule out
disease occurs in localized and generalized forms. In the systemic diseases that can affect host defense mechanisms. It
localized form, affected sites exhibit rapid bone loss and is believed that the best approach to manage periodontal
minimal gingival inflammation. In the generalized form, diseases is prevention, followed by early detection and
there is rapid bone loss around nearly all teeth and marked treatment. To achieve this, profound knowledge about
gingival inflammation. Neutrophils from some children with periodontics and pedodontics as well as intimate periodontal-
a clinical diagnosis of periodontitis as a manifestation of pedodontics interactions are essential.
systemic disease have abnormalities in a cell surface
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