BDS 7136: Gingival and Periodontal Problems in Children PDF

BDS 7136: Gingival and periodontal problems in children Aims: The aim of this lecture is to give an overview of the gingival and periodontal problems and discuss management options. Objectives: Subject Title Goes Here On completion of this lecture, the student should be able to: -Describe a class...

BDS 7136: Gingival and periodontal problems in children Aims: The aim of this lecture is to give an overview of the gingival and periodontal problems and discuss management options. Objectives: Subject Title Goes Here On completion of this lecture, the student should be able to: -Describe a classification of gingival and periodontal diseases in children -Describe appropriate screening for periodontal diseases in children -Understand the risk factors influencing management -Have an awareness of the systemic diseases that affect the periodontium Normal Healthy Gingiva In adults: •Pale pink •Firmly bounded to alveolar bone •Knife-edge gingival margins •Stippled In children: •More reddish •Flabbier •Rounded margins •Greater sulcular depth •Lack of stippling Anatomy of the periodontium in children • Marginal gingival tissues around the primary dentition are more highly vascular and contain fewer connective tissue fibers than tissues around the permanent teeth. • The epithelia are thinner with a lesser degree of keratinization, giving an appearance of increased redness that may be interpreted as mild inflammation. Anatomy of the periodontium in children • Cementum: Thinner & less dense. • Periodontal membrane : wider Less fibers /unit area Increased hydration, B.V, lymph vessels • Alveolar bone: Thinner lamina dura Flatter alveolar crest Fewer trabeculations & wider marrow spaces Decreased mineralization Greater blood & lymph supply Universal scaler • The localized hyperaemia that accompanies eruption of the primary dentition can lead to an appearance of swollen and rounded interproximal papillae and a depth of gingival sulcus exceeding 3mm. • During eruption the junctional epithelium migrates apically from the incisal or occlusal surface towards the cementoenamel junction (CEJ). • False pockets are common around erupting first permanent molars and incisors at 7 years of age, but significantly reduced and stability of the gingiva is achieved around 12 years of age and false pockets almost non-existent by age 16 years. False pockets are still problematic around second molars till up to 17 years of age. • Therefore, usually construction of fixed custom-made crown on permanent first molar is postponed till 16-18 years of age. Gingival and periodontal diseases in children • Periodontal diseases comprise a group of infections that affect the supporting structures of the teeth: marginal and attached gingiva, periodontal ligament, cementum, and alveolar bone. The new periodontal classification (Lecture BDS5045 New Classification of Periodontal Disease) I. Periodontal Health, Gingival Diseases and Conditions: 1. Periodontal health and gingival health 2. Gingivitis: Dental Biofilm-induced 3. Gingival disease: Non-Dental Biofilm-induced II. Periodontitis: 1. Necrotizing Periodontal Diseases 2. Periodontitis 3. Periodontitis as a Manifestation of Systemic Diseases The new periodontal classification III. Other Conditions Affecting the Periodontium 1. Systematic diseases or conditions affecting the periodontal supporting tissues 2. Periodontal abscess and Endodontic-periodontal lesions 3. Mucogingival deformities and conditions 4. Traumatic Occlusal forces 5. Tooth and prosthesis related factors Following are some of the gingival and periodontal conditions that can be seen in children: Eruption gingivitis: This is a type of localized inflammation at the site of an erupting tooth. Plaque accumulation around erupting tooth due to discomfort during brushing these friable areas, may contribute to gingivitis. Treatment: Complete dental care, improve oral hygiene. Pericoronitis: Acute inflammation of the gingiva surrounding an erupting tooth most often in: • Lower third molar. • Lower second primary molar • Lower first or second permanent molar. Treatment: • Gentle debridement • Saline mouth wash • Antibiotic in case of fever/lymphadenopathy • Surgical removal if persistent (Very rarely needed) Gingival problems associated with exfoliation of primary teeth Uneven resorption of the roots of primary teeth can cause increased tooth mobility, thus encouraging : food impaction, accumulation of deposits & mechanical irritation Treatment Improve the oral hygiene. Removal of the primary tooth only if necessary. Primary herpetic gingivostomatitis Acute infectious disease caused by Herpes Simplex virus Most frequently seen in children between 2 and 5 years of age, although older age groups can be affected, infection in the first 12 months of life is rare (circulating maternal antibodies are transferred from the mother) Transmission of the virus is by droplet infection and the incubation period is about a week. Raised temperature, headache, malaise, oral pain, dysphagia, drooling and cervical lymphadenopathy precede the onset of a severe oedematous marginal gingivitis. Primary herpetic gingivostomatitis (cont.) Characteristic fluid-filled vesicles appear on the gingiva and other areas, such as the tongue, lips, and buccal and palatal mucosa but usually not the tip of interdental papilla. The vesicles, which have a grey membranous covering, rupture spontaneously after a few hours to leave extremely painful yellowish ulcers with red inflamed margins. Primary herpetic gingivostomatitis (cont.) Management: Self-limiting (7-14 days) Bed rest and avoid sharing utensils and cups with other children to avoid infection. Soft diet is recommended and the child should be kept well hydrated. Symptomatic and palliative treatment, pyrexia is reduced using antipyretic. Secondary infection of ulcers may be prevented using chlorhexidine. In severe cases of herpes simplex, acyclovir can be prescribed. Recurrent Herpes Labialis After the primary infection, the herpes virus remains dormant in sensory nerve ganglia. Reactivation of the latent virus occurs in subjects with lowered immunity as emotional stress, lowered body resistance, common cold, etc. Recurrent disease presents as herpes labialis, the common ‘cold sore’ on the mucocutaneous border of the lips . Treatment: Applying antiviral as acyclovir cream (5% five times daily for about 5 days). To prevent auto-inoculation and herpetic whitlow (spread of the lesions onto hands and face) children should avoid touching the vesicles. RECURRENT APHTHOUS ULCER (CANKER SORE) • The recurrent aphthous ulcer (RAU)—also referred to as recurrent aphthous stomatitis (RAS) Painful ulceration on the unattached mucous membrane that occurs in school-aged children and adults. Lesions appear as round to oval whitish ulcer with crateriform base, raised reddened margins, and painful. RECURRENT APHTHOUS ULCER (cont.) • The cause of RAU is unknown. • Local and systemic conditions along with a genetic predisposition, as well as immunologic and infectious microbial factors, have been identified as potential causes. • Local factors as trauma. • Current treatment is focused on promoting ulcer healing, reducing pain, maintaining the patient’s nutritional intake and hydration, topical anti-inflammatory and analgesics. Acute Necrotizing ulcerative gingivostomatitis (ANUG)/ Vincent's disease Etiology : Borrelia vincenti and Bacillus fusiformis • Rapid destruction of the interdental papillae. • IDP punched out with an erythematous line below the necrosed tissue. • Pain and bleeding, a pseudo membrane, characteristic foul odor. • Excessive salivation • Lymphadenitis may occur in severe cases. • Systemic findings In severe cases, anorexia, general malaise & fever may be present. Acute Necrotizing ulcerative gingivostomatitis (cont.) Treatment a) Local therapy • Removal of local irritating factors. • Debridement of the necrotic portion of the tissues. • Swabbing with 3 % hydrogen peroxide and use at home as mouth rinse . b) Systemic Antibiotics Systemic antibiotics are recommended only when: • Massive necrosis has occurred • Systemic findings as fever or prominent regional lymphadenitis Example : Metronidazole and Penicillin c)Periodontal surgery : to correct gingival deformities Recurrence: The disease may recur. Acute Oral Moniliasis (Candidiasis or Thrush) Moniliasis is an infection by a yeast like fungus called Monilia albicans. • Sites: Oral cavity “ thrush” and the gastrointestinal tract, the respiratory tract, vagina, skin….. Acute Oral Moniliasis (cont.) The oral surfaces frequently involved include labial and buccal mucosa, tongue, hard and soft palate and oropharynx. Presents as white to whitish-yellow creamy confluent plaques resembling milk curds or cottage cheese. The superficial pseudo-membrane can be removed by wiping gently, leaving behind an underlying erythematous and occasionally bleeding surface. Acute Oral Moniliasis (cont.) Etiology • Monilia albicans is a common inhabitant of the oral cavity. When tissue resistance is lowered or equilibrium between oral microorganisms is altered ➔ multiply rapidly and cause a pathologic state, as prolonged broad spectrum antibiotic therapy, premature, debilitated or malnourished children, mothers with monilial vaginitis may transmit the infection to the newborn. Treatment: • Stop topical or systemic antibiotic • Antifungal as Mycostatin (Nystatin) Puberty Gingivitis Etiology: - Hormonal changes. -Subclinical nutritional deficiencies (faulty diet as quick meals) -Pubertal gingivitis is controversial as to whether it exists Puberty Gingivitis (cont.) Clinical characteristics: - Gingival enlargement usually anterior. - IDP are bulbous & prominent. - G. margins are red & bleed on touch. -Tooth brushing usually avoided (excessive bleeding) Treatment: - Proper O.H. -Remove local irritating factors as plaque and calculus. - Adequate nutrition. - Usually regress after puberty. Drug induced gingival enlargement • Enlargement of the gingiva is a well-recognized unwanted effect of a number of drugs . The most frequently implicated are phenytoin, cyclosporin, and nifedipine. • Phenytoin is an anticonvulsant used in the management of epilepsy. • Cyclosporin is an immunosuppressant drug that is used widely in organ transplant patients to prevent graft rejection • Most calcium-channel blockers e.g. Nifedipine that is used in adults for the control of cardiovascular problems and used in treatment of hypertension. Clinical features of gingival enlargement • First signs appear: 3–4 months of drug administration. • IDP become nodular before enlarging more diffusely to encroach upon the labial tissues. • Anterior part of the mouth most severely involved • Excessive enlargement appearance compromised. Oral functions, eating and speaking, impaired. • Enlarged gingiva is pink, firm, and stippled in subjects with a good standard of oral hygiene. When there is a pre-existing gingivitis the enlarged tissues compromise an already poor standard of plaque control. The gingiva then exhibits the classical signs of gingivitis Management of gingival enlargement • A strict program of oral hygiene instructions, scaling, and polishing must be implemented. • Severe cases of gingival enlargement may need gingivectomy. • A follow-up program is essential to ensure a high standard of plaque control and to detect any recurrence of the enlargement. • As the causative drugs need to be taken on a long-term basis, recurrence is common. • In cases of long-term treatment, the patient’s physician may be requested to modify or change the drug. Hereditary gingival fibromatosis Etiology: A rare type of gingival enlargement referred to as elephantiasis gingivae. May be due to: a) Idiopathic (of unknown cause). b) May follow a familial pattern. Clinical characteristics: - Free and attached G. - Localized or generalized. - Painless, firm and dense (feels like bone). - Colour slightly paler than normal gingiva with coarse stippling. Hereditary gingival fibromatosis (cont.) -At birth………G. normal -Eruption of primary t….. enlargement begins -Eruption of permanent….enlargement continues until the enlarged tissues cover the clinical crowns of teeth. -Enlarged fibrous tissues may -delay the eruption of teeth or -cause displacement, malocclusion. -During mastication the enlarged tissues may become traumatized resulting in secondary inflammation. Treatment: -Gingivectomy in several stages. -It may be followed by recurrence. - Recurrence has not been reported following removal of teeth and construction of dentures. Traumatic gingivitis (gingivitis artefacta/factitious gingivitis) • Gingivitis artefacta has minor and major variants. • Results from rubbing or picking the gingiva using the fingernail, or perhaps from abrasive foods such as crisps, and the habit is usually provoked by a locus of irritation such as an area of persistent food impaction or an already inflamed papilla. • The lesions resolve when the habit is corrected and the source of irritation is removed. Other areas of the mouth such as the lips and tongue may be involved and extra-oral injuries may be found on the scalp, limbs, or face (factitious dermatitis). Periodontitis PERIODONTITIS AS A MANIFESTATION OF SYSTEMIC DISEASE Papillon LeFevre syndrome: (Hyperkeratosis palmoplantaris) A rare inherited disease (autosomal recessive) Papillon Lefevre reflects Cathepsin C deficiency Clinical characteristic: -Severe gingival inflammation with alveolar bone loss and exfoliation of both primary and permanent dentition. - Hyperkeratosis of palms of hands and soles of feet. Papillon LeFevre syndrome (cont.) -Alv. bone destruction starts between 2-3 years of age and progresses rapidly. -By 4-5 years of age all primary teeth are lost. The inflammation subsides after loss of teeth. -The same cycle accompanies permanent teeth. Radiographic examination reveals severe horizontal bone resorption. Treatment: -Prognosis is poor. -Complete dentures are inserted at an early age. Neutropenias • The neutropenias comprise a group of blood disorders characterized by a periodic or persistent reduction in the number of circulating polymorphonuclear neutrophils. • Neutropenias can be drug-induced or secondary to severe bacterial or viral infections or autoimmune diseases. • The chronic benign 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. Neutropenias (cont.) • Patients with neutropenias may present with periodontitis. • The gingiva are inflamed and oedematous, gingival recession, ulceration, and desquamation can also occur. • The treatment of a neutropenic-induced periodontitis involves local removal of plaque and calculus. Strict plaque control measures are difficult to achieve in younger children, so use of an antibacterial mouth rinse may prove useful. Chediak–Higashi syndrome • Rare and very often fatal disease inherited as an autosomal recessive trait. • Neutrophils show defects in migration, chemotaxis and phagocytosis resulting in reduced bactericidal capacity • Clinical features include partial albinism, photophobia, and nystagmus. The patients suffer from recurrent pyogenic infections and malignant lymphoma, which is accompanied by neutropenia, anaemia, and a thrombocytopenia. Chediak–Higashi syndrome (cont.) • Periodontal features: include severe gingival inflammation and rapid and extensive alveolar bone resorption that can lead to premature exfoliation. The nature of the changes has not been fully established, but they may be plaque induced, secondary to infection, or related to the underlying defect in neutrophil function. Down syndrome (Trisomy 21) Usually show signs of periodontal disease. Local and general risk factors exist as a result of the syndrome. ❑Local factors that may increase dental plaque retention are: Class III malocclusion Anterior open bite Mouth breathing and xerostomia ❑General risk factors for periodontal disease are mainly centred on leucocyte defects. Hypophosphatasia • Hypophophatasia also called X-linked hypophosphatemic rickets. • Hypophosphatasia is a rare error of metabolism characterized by defective bone mineralization, deficiency of alkaline phosphatase (ALP) activity. • ALP plays a major part in the mineralization of hard tissues, and so the absence of the enzyme predisposes to a range of bone and cartilage defects. • The lesions of juvenile or childhood hypophosphatasia become apparent before 2 years of age. Bone defects are usually quite mild, with bowing of the legs, proptosis, and wide-open fontanelles being prominent signs. Hypophosphatasia (cont.) Dental features : • Resorption of alveolar bone • The absence of marked gingivitis • Premature exfoliation of anterior primary teeth • Non-vital non-carious teeth • Hypoplasia or complete absence of cementum, and the presence of ‘small teeth’ that have enlarged pulp chambers as a consequence of defective mineralization. • The aplastic or hypoplastic cementum and a weakened periodontal attachment is thought to render the patients susceptible to infection with periodontopathogens. Screening for periodontal diseases Screening for periodontal diseases • BSP (British Society of Periodontology) and BSPD (British Society of Paediatric Dentistry) recommend that periodontal screening becomes a routine part of the dental clinical examination in all co-operative children and adolescents, in the same way that extra-oral and intra-oral soft tissue examination should always accompany charting of the dentition. • The system of periodontal screening recommended by the BSP in General Dental Practice for adults is the Basic Periodontal Examination (BPE) which was based on the Community Periodontal Index of Treatment Needs (CPITN). Screening for periodontal diseases (cont.) • The BPE provides a quick and simple method of screening patients for periodontal problems, giving the practitioner an indication of the need for periodontal treatment and the level of further periodontal examination required for different disease levels. • Certain considerations need to be taken into account in adapting the use in children and adolescents: it needs to be quick, easy, well tolerated, and avoiding false pockets. BPE- Basic periodontal examination: Scoring codes 0: No pockets >3.5 mm, no calculus/overhangs, no bleeding after probing (black band completely visible) 1: No pockets >3.5 mm, no calculus/overhangs, but bleeding after probing (black band completely visible) 2: No pockets >3.5 mm, but supra- or subgingival calculus/overhangs (black band completely visible) 3: Probing depth 3.5-5.5 mm (black band partially visible, indicating pocket of 4-5 mm) 4: Probing depth >5.5 mm (black band entirely within the pocket, indicating pocket of 6 mm or more) *: Furcation involvement (Lecture BDS5045 New Classification of Periodontal Disease) Screening for periodontal diseases (cont.) 1. A simplified Basic Periodontal Examination should be carried out on the following six index teeth: UR6, UR1, UL6, LL6, LL1 and LR6. 2. Assessment of periodontal treatment needs should be started at 7 years of age as it is rare to experience problems below this age and the index teeth are often still unerupted. Identification of periodontal disease in the primary dentition is unusual and young children with unexplained premature exfoliation or gross mobility of primary teeth or red, oedematous gingiva and/or suppuration for which no other dental cause can be seen should be referred for specialist advice. Screening for periodontal diseases (cont.) 3. At 7-11 years of age, in the mixed dentition phase, the index teeth should only be examined for bleeding of the gingiva, calculus and/or overhangs of fillings i.e. BPE codes 1 and 2 only, to avoid the problem of false pockets. In this age group both the erupting first permanent molar and later, the exfoliating second primary molar could give the appearance of periodontal pocketing. 4. At 12-17 years of age, the full range of BPE codes can be used on the six index teeth. (It would be uncommon to find periodontal breakdown at other teeth without the index teeth being affected. Whenever periodontal pockets are recorded i.e. BPE code 3 or 4, the alveolar bone level should be checked). • 5. A simplified BPE should be undertaken prior to commencing orthodontic treatment in the under 18s. Screening for periodontal diseases (cont.) • Although a brief periodontal examination similar to the BPE has been reported to be acceptable for children as young as 3 years of age , it would not normally need to be undertaken in the primary dentition. • Screening using the simplified BPE can be used in the assessment of the periodontal condition of most children and its use is to be encouraged. It may not be appropriate for use in children with extreme dental anxiety or diminished understanding. Risk factors for periodontal conditions and diseases • Risk factors for periodontal disease can be classified as local or general. • Local factors, for example a malposed lateral incisor, may serve to compromise local plaque control by hindering effective cleaning, resulting in dental plaque accumulation. On the other hand, general risk factors, such as an inherited disorder, may predispose an individual to periodontal disease despite a good level of plaque control. Risk factors for periodontal conditions and diseases (cont.) • It is important to understand that if a child possesses a risk factor for periodontal disease, it does not necessarily follow that he/she will develop the condition. • Conversely, a patient may appear to have no risk factors, but the disease may develop subsequently. Bearing this in mind, risk factors (both local and general) should be considered when assessing, diagnosing, treating, and maintaining children patients with periodontal disease. Local risk factors These can be grouped simply into four areas. There may be overlap between these areas: • Malocclusions • Traumatic dental injury • Plaque retentive factors : naturally occuring (malposed tooth) or iatrogenic (orthodontic appliances, ledges and overhangs on poorly fitting restorations). • Ectopic eruption. General risk factors • Genetic conditions • Metabolic conditions as diabetes • Haematological conditions • Environmental risk factors • Tobacco smoking Gingival and periodontal diseases Normal healthy gingiva in children Gingival diseases Related to childhood Infections Eruption Viral (HSV) Periodontal diseases assoc. with systemic conditions Enlargements Drug-induced Papillion le Fevre Neutropenia Periodontal screening Risk factors ˂ 7 years (Index teeth not erupted) 7-11 years (Index teeth BPE codes 1 and 2) Pericoronitis Shedding Aphthous ulcer Traumatic gingivitis Bacterial (ANUG) Fungal (Candida) Hereditary ginigival fibromatosis Chediak Higashi 12-17 years (Index teeth Down’s syndrome Hypophosphatasia Full range of BPE codes) Aims: The aim of this lecture is togive an overview of the gingival and periodontal problems and discuss management options. Objectives: Subject Title Goes Here On completion of this lecture, the student should be able to: -Describe a classification of gingival and periodontal diseases in children -Describe appropriate screening for periodontal diseases in children -Understand the risk factors influencing management -Have an awareness of the systemic diseases that affect the periodontium References: • Dean, J.A., Avery, D.R. and McDonald, R.E., 2010. McDonald and Avery Dentistry for the Child and Adolescent 10th edition, 2010. Elsevier Health Sciences. • Welbury R et al; Paediatric Dentistry; 5th Edition, Oxford Press. • Reading material: • Students are advised to review any relevant teaching provided in the first year. In addition they are advised to read relevant sections of the following texts: • Koch G et al; Pediatric Dentistry - a Clinical Approach; 3rd Edition, Wiley Blackwell • Welbury R et al; Paediatric Dentistry; 5th Edition, Oxford Press • BSP & BSPD guidelines for periodontal screening and management in children, https://www.bspd.co.uk/Portals/0/Public/Files/Guidelines/bspd-perio-guidelines-for-the-under-18s-2012.pdf