Perio in children and adolescents

• What are the figures for Grade C bone loss in children up to 18yrs old?

  • Grade C bone loss

  • >5% in up to 5 year old

  • >10% in up to 10 year old

  • >15% in up to 15 year old

  • >18% in up to 18 year old

  
• What are features of healthy periodontium in children/adolescents?

  In Children: Marginal gingival tissues more vascular

  • Less connective tissue fibres

  • Less keratinisation (tissue looks redder)

  • Gingival margin several mm coronal to cemento-enamel junction

  • Gingival sulcus 0.5-3mm on a fully erupted tooth (can be 6-7mmin an erupting permanent tooth)
• What is periodontal ligament space like in children?

  Wider

  
  

  Less Fibrous

  
  

  More vascular

  
• What is the alveolar bone like in children?

  • Larger marrow spaces

  
  

  • Fewer trabeculae

  
  

  • More vascularity(enhanced rate of progression of disease)

  
• How are periodontal treatment needs assessed in children?

  Warning signs in primary dentition in the under 7 year old

  
  

  • Unexplained premature exfoliation

  
  

  • Gross mobility of primary teeth not due for exfoliation

  
  

  • Red oedematous gingivae

  
  

  • Suppuration with no other dental cause

  
• Are false pockets common in children?

  • False pockets common around erupting incisors and first molars at 7 yrs(in the process of passive eruption/apical retreat of gingival margin)

  
  

  • Significantly reduced by 12 yrs

  
  

  • Non existent by 17 yrs

  
  

  • False pocketing may still be an issue around 2nd molars at 17 yrs
• What BPE is used with children?

  Use simplified BPE on Index Teeth

  UR6, UR1, UL6 LR6, LL1, LL6

  
• What BPE codes are used on children ages 7-11 years?

  Use BPE codes 0,1 and 2 on index teeth

  • 0 (no treatment required)

  • 1 (OHI and prophylaxis)recall 1 yr(or sooner if other dental needs)

  • 2 (OHI, Supra/sub gingival scaling/prophylaxis remove plaque retention factors)recall 6/12(or sooner if other dental needs)

  
• What BPE codes are used in children 12-17years old?


  Use all BPE codes on index teeth

  
  

  • 0 (no treatment required)

  
  

  • 1 (OHI and prophylaxis) recall 1 year (or sooner if other treatment needs)

  
  

  • 2 (OHI, Supra/sub gingival scaling/prophylaxis/remove plaque retention factors )recall 6/12 (or sooner if other treatment needs)

  
  

  • 3 (as for code 2 [account for false pocketing] + RSD) recall 3/12

  
  

  • 4,* (radiographs, full perio assessment- DPC)referral perio/paeds specialist

  
• Loss of periodontal attachment and supporting bone is....

  uncommon in children and adolescents

  
• Plaque induced gingival disease in children is more or less common than in adults?

  less common

  
• What are local contributing factors for plaque induced gingival disease?

  ▪ Partially erupted teeth

  
  

  ▪ Exfoliating deciduous teeth

  
  

  ▪ Calculus

  
  

  ▪ Crowding

  
  

  ▪ Mucosal factors (frenum/recession)

  
  

  ▪ Restorations

  
  

  ▪ Orthodontic appliances

  
  

  ▪ Mouth breathing and lack of lip sea
• What are systemic modifying factors in plaque induced gingival disease?

  Changes in Gonadotrophic Hormone (oestrogen and progesterone) levels

  ▪ Puberty

  ▪ Pregnancy

  ▪ Contraceptive pill
• How does diabetes affect plaque induced gingival disease?

  • Alteration in insulin levels in diabetes modifies gingival response to plaque

  
  

  • Hyperglycaemic state induces hyper-reactive over secretion of inflammatory mediators IL-1, IL-6, TNFα

  
  

  • Usually responds to removal of bacterial plaque

  
• How is plaque induced gingivitis managed in children?

  • Involve the carer - they purchase the oral hygiene aids and need to carry out(up to at least age 7)/supervise daily oral hygiene

  
  

  • Advise home disclosing• Ask the child to "colour in" a plaque chart

  
  

  • Involve the child in Plaque Score - set targets, older children will understand percentages

  
  

  • Regular appointments to maintain motivation• The dentition is constantly changing - modify the techniques accordingly

  
  

  • Assess maturity, manual dexterity and motivation before introducing interdental aids
• What is the treatment for plaque induced gingivitis?

  • Intensive OHI

  - Supra and subgingival plaque remova

  l- Interdental plaque removal (tailor to dexterity)

  • Floss loop

  • Flossettes

  
  

  • Supra and subgingival scaling (PMPR)

  
  

  • Follow-up tailored to OH standard

  
  

  • 3/12 review
• What are the primary host features of Periodontitis Grade C?

  Primary host features:

  
  

  • Onset tends to be circum-pubertal

  
  

  • Rapid attachment loss

  
  

  • Rapid bone loss

  
  

  • Familial aggregation (genetic)

  
  

  • Prevalence- African/Afro-American 2-5%- Hispanics/South Americans 0.5-1%- Asians 0.4-1%- Caucasians 0.1-0.2%

  
• Does systemic disease affect periodontits Grade C?

  Often systemic disease with generalised condition

  
  

  - Functional cell defects (neutrophils/monocytes)

  
  

  - Abnormal cell chemotaxis/Phagocytosis

  
  

  - Hyperresponsive macrophages (increased PGE2 and IL1b)

  
  

  - Recurrent otitis media

  
  

  - Upper respiratory tract infections

  
  

  - Cementopathia/

  hypophosphatasia

  
• Why is it important to check the lymph nodes?


  • Lymphatic system carries lymph which has removed inflammatory exudate and antigens from tissues to lymph nodes

  
  

  • Lymph nodes filter lymph fluid to remove pathogens

  
  

  • Antigens react with lymphocytes in lymph nodes to trigger adaptive immune response
• IS bone loss severe with Periodontitis Grade C?

  YES!!

  
• What is Periodontitis Grade C, Molar/Incisor pattern?


  • Interproximal attachment loss affecting incisors and 1stmolars (and up to 2 other teeth)

  
  

  • Minimal plaque and calculus

  
• When does molar/incisor pattern commence?


  • Commences around puberty

  
  

  • Usually minimal microbial deposits and gingiva appear healthy until probed

  
  

  • Strong antibody response to AggregatibacterActinomycetemcomitans (Aa)

  
  

  • JP2 clone of Aa (increased leucotoxin)

  
  

  • Neutrophil function abnormalities

  
  

  • Robust serum antibody response to infecting agents(thought to protect later erupting permanent teeth)
• What are features of Generalised Perio Grade C?

  • Can begin at any age and tends to affect under 30 years of age (may see in older ages when not picked up and treated)

  
  

  • Interproximal attachment loss affecting incisors 1st molars (and 3 or more other teeth)

  
• Features of generalised Perio Grade C?

  • May be marked inflammation

  
  

  • Pronounced episodic nature of attachment/bonedestruction

  
  

  • Presence of Aa and Porphyromonas Gingivalis (Pg)

  
  

  • Poor serum antibody response to infecting agents
• How is Perio Grade C treated?

  Evidence that scaling and RSD are ineffective in controlling Aa counts(Tissue Invasion)

  
  

  General principle is to prescribe antibiotics after RSD

  
  

  Flap surgery may be required later

  
  

  BSP suggest referral to a Specialist Periodontist