Gingival and periodontal health in children: an overview

Question 1

Visual assessment of plaque 2013 (national statistics)

Answer 1

Visible plaque present in:

• 46% of 5 year olds
• 71% of 8 year olds
• 50% of 15 year olds

Question 2

Visual assessment of calculus 2013 (national statistics)

Answer 2

Calculus detected in

• 9% of 5 year olds
• 28% of 8 year olds
• 46% of 15 year olds

Question 3

Exceptions: children who would not have plaque or calculus

Answer 3

Children who are fed only by a gastrostomy tube (PEG)

Question 4

Gingival bleeding on probing (BPE for 6 teeth) amongst 15 year olds

Answer 4

Present in 40%

Question 5

Periodontal pocketing

Answer 5

Predominantly in mild category 3.5-5.5mm

Question 6

Gingivitis less prevalent where?

Answer 6

Left than right side of mouth

Question 7

Differences according to social class

Answer 7

No

Question 8

Differences between boys and girls

Answer 8

Generally no significant differences except plaque & calculus scores for 12 year olds

• 72% of boys and 56% of girls had visible plaque
• 46% of boys and 31% of girls had visible calculus

Question 9

Gingival disorders in children

Answer 9

1. Chronic gingivitis (plaque-induced)
2. Gingival hyperplasia
3. Traumatic lesions
4. Acute gingivitis (infective)

Question 10

Chronic Gingivitis

Answer 10

Common
Reversible with improved oral hygiene
Painless, red, swelling of gingiva, no loss of function
Cultivable flora similar to that in adults
-gram +ve rods and cocci
-gram -ve anaerobic rods and spirochaetes
May be exacerbated by exfoliating teeth, malocclusion or presence of orthodontic appliances

Question 11

Challenges to toothbrushing

Answer 11

Retroclined teeth in cleft lip and palate pxs
Abnormalities of tooth morphology
Orthodontic appliances
Sensitive teeth - amelogenesis imperfect
Physical disabilities e.g. Cerebral palsy, hemiplegia
Learning disabilities e.g. Down syndrome, autism

Question 12

Localised gingival recession

Answer 12

Stillman’s cleft
10% of children < 10 years of age
Usually labial to lower incisors
Associated with malaligned teeth, self-inflicted injury, toothbrushing habits
Need to educate and improve plaque control, orthodontic therapy

Question 13

Gingival hyperplasia: drug induced

Answer 13

Phenytoin (anti-epileptic)
Cyclosporin (immunosuppressant)
Nifedepine (calcium channel blocker)

Question 14

Cyclosporin

Answer 14

Selective immunosuppressant - inhibits T lymphocyte proliferation
Used mainly to prevent graft rejection
Gingival hyperplasia in around 30% of cases
Hyperplasia is exacerbated by poor OH
Effects fibroblasts promoting protein synthesis and collagen formation
Recurs after gingival surgery

Question 15

Gingival hyperplasia: systemic disease

Answer 15

Carcoid

Cyclic neutopenia

Question 16

Traumatic gingival injury: self-inflicted injury

Answer 16

Type A: injuries superimposed upon pre-existing source of irritation
Type B: injuries are secondary to another established habit
Type C: injuries are of complex aetiology and are a physical manifestation of an underlying emotional disturbance - resistant to conventional treatment

Question 17

Acute gingival conditions and infections

Answer 17

Acute herpetic gingivostomatitis
Necotising ulcerative gingivitis
Hand, foot and mouth
Herpengina

Question 18

Acute herpetic gingivostomatitis

Answer 18

Common in childhood
HSV type I infection
Can present as subclinical infection, febrile illness, encephalitis/ meningitis
5-7 day incubation period

Question 19

Signs/ symptoms of AHGS

Answer 19

Pyrexia, >39 degrees C
Lymphadenopathy
Malaise and irritability
Profuse salivation
Refusal to eat
Sore throat and mouth
Symptoms for 7-10 days

Question 20

Clinical features of AHGS

Answer 20

Multiple small irregular ulcers on gingiva, tongue and palate
Erythematous gingiva
Occasional extra-oral lesions
Salivation
Lymphadenopathy
Recurrence as herpes labialis in 30%

Question 21

Management of AHGS

Answer 21

Symptomatic and supportive

• fluids & soft diet
• analgesics & antipyrexics
• isolation of eating/ drinking utensils
• OHI - chlorhexidine and sponges, soft toothbrush
• rest
• reassurance and review
• not acyclovir (unless immunocompromised)

Question 22

Who does necrotising ulcerative gingivitis/ periodontitis affect?

Answer 22

Affects young adults and HIV+ in Western contries (0.7-7%)
-risk factors = smoking and stress
More commonly affects children in developing countries - with underlying malnutrition and infections (HIV) up to 20%

Question 23

Necrotising ulcerative gingivitis: symptoms, clinical and treatment

Answer 23

Characterised by necrosis and ulceration -usually interdental papillae, gingivae bleed profusely, distinctive halitosis
Broad anaerobic infection
Treatment with oral hygiene, hydrogen peroxide mouthwash, metronidazole 3-days
Can spread rapidly to facial tissues –> cancrum oris

Question 24

Systemic conditions that may present with gingival changes e.g. bleeding, ulceration

Answer 24

HIV
Chrons' disease
Leukaemia
Langerhans' cell histiocytosis
Scurvy

Question 25

Periodontal disease in children

Answer 25

Loss of tooth tissue attachment very uncommon in children

Question 26

Clinical features of aggressive periodontal disease in children

Answer 26

~0.1% of white Caucasians and 2.6% of black Africans may suffer from localised aggressive forms of periodontitis Onset ~ puberty May present with tooth mobility, drifting or periodontal abscess Rapid periodontal attachment loss, usually incisors and first permanent molars Often a positive family history Healthy apart from periodontitis Progression of attachment loss and bone loss may be self-arresting

Question 27

Clinical features of aggressive periodontal disease in children (Microbiology)

Answer 27

``` Amounts of microbial deposits inconsistent with severity of destruction Elevated proportions of A. actinomyecetemcomitans and in some populations, P.gingivalis Phagocyte abnormalities (host defence defects): hyper-responsive macrophage phenotype, including elevated levels of PGE2 and IL-1β ```

Question 28

Management of aggressive periodontal disease in children

Answer 28

Refer to specialist: early diagnosis and interventions critical for better outcome - standard mechanical periodontal therapy - systemic or local drug therapy (metronidazole AND amoxicillin tds 1 week) - maintenance therapy - periodontal surgery

Question 29

Systemic/ genetic conditions in which periodontal disease is exacerbated

Answer 29

``` Insulin-dependant diabetes Down syndrome Papillion-lefevre syndrome Enlers-Danlos syndrome Langerhans' cell histocytosis Neutropenias Hypophosphatasia ```

Question 30

Papillion-Lefevre syndrome

Answer 30

``` Itchy feet (hyperkeratosis of soles) Loose teeth (generalised gingival recession) Hyperkeratosis of palms of hands ```