Perio disease in children and adolescents

• Healthy periodontium in kids and teens?

  • marginal gingival tissues more vascular
  • Less CT fibres
  • Less keratinisation = looks redder
  • GM several mm due to coronal to CEJ
  • Gingival sulcus 0.5-3mm on a fully erupted tooth (6-7 on adult)
• PDL ligament space in kids ?

  • wider
  • Less fibrous
  • More vascular
• Alveolar bone in kids ?

  • larger marrow space
  • Fewer trabeculae
  • More vascular
• the qualities of alveolar bone in kids makes

  disease progress faster
• Warning signs in under 7s?

  • premature exfoliation (unexplained)
  • Gross mobility of teeth not due to exfoliate
  • Red oedematous gingivae
  • suppuration with no othen dental cause
• False pocketing in kids?

  • common around erupting incisors and first molars due to passive eruption and apical retreat of GM
  • significantly reduces at 12
  • non existent at 17
  • may still be an issue around 7s at 17
• Simplified BPE index

  UR6, UR1, UL6, LR6, LL1, LL6
• 7-11 bpe 


  0, 1 , 2 used

  0 = no Tx

  1 = OHI + prophylaxis (RECALL 1/12)

  2 = OHI, sub and supra scaling, removal of PRF + prohylaxis ( RECALL 6/12)
• 12-17 BPE 


  all BPE codes

  0 = no Tx

  1 = OHI and prophy (RECALL 1/12)

  2 = OHI, sub/supra scale, prophy, remove PRF (RECALL 6/12)

  3 = code 2 and account false pockets, RSD (RECALL 3/12)

  4 = rads, full perio assess, DPC refers to paeds or perio specialist
• Loss of perio attachment and supporting bone is

  uncommon in kids and teens
• Incidence

  risk of developing periodontal attachment and bone loss within a specified period of time increases aged 12-17 compared to 5-11
• Prevalence

  evere attachment loss on multiple teeth = 0.2-0.5%
• Gingivitis

  • develop lesions less readily than adults
  • smaller inc in GC leucocytes w plaque accum.
  • inc subging levels of Actinomyces, Capnocytophaga,Leptotrichia, Selenomonas species associated with gingivitis resistance found in experimental gingivitis in children
  • dominated by lymphocytes and fe plasma cells, more T cells compared to b cells
• Local contributing factors ?

  • PE teeth
  • Exfoliating teeth
  • calculus
  • crowding
  • mucosal factors like frenum and recession
  • restorations
  • Ortho appliances
  • Mouth breathing
  • Lack of lip seal
• Systemic modifying factors ?

  • changes in gonadotriphic hormones
  • Diabetes
• Management of plaque induced gingivitis in children ?

  • involve carer
  • home disclosing
  • ask child to colour in plaque charty
  • involve child in plaque score by setting targets
  • Reg appts to maintain motivation
  • Dentition constantly changing = mod techs appropriately
  • Assess maturity and manual dexterity
• Tx

  intensive OHI - floss loops or flossettes

  PMPR

  follow up tailored to OH

  3/12
• Periodontitis Grade C in children primary host features

  • Onset tends to be circum-pubertal
  • Rapid attachment loss
  • Rapid bone loss
  • Familial aggregation (genetic)
• Prevalence of periodontitis grade C in kids

  – African/Afro-American 2-5%– Hispanics/South Americans 0.5-1%– Asians 0.4-1%– Caucasians 0.1-0.2%
• Perio is often A systematic disease with generalised condition EG?

  
  

  • Abnormal cell chemotaxis/Phagocytosis
  • Hyperresponsive macrophages (increased PGE2 and IL1b)
  • Recurrent otitis media
  • Upper respiratory tract infections
  • Cementopathia/hypophosphatasia
  • Functional cell defects (neutrophils/monocytes)
• Perio Grade C EO?

  • bilateral submandibular lymphadenopathy
  • Sometimes submental and often denotes lower anterior involvement
• Lymph does what?

  1. remove inflammatory exudate and antigens from tissue to lymph nodes
  2. Lymph nodes filter lymph to remove pathogens
  3. Antigens react w lymphocytes in lymph to trigger adaptive immune response
• in perio grade C bone loss is

  severe and inconsistent with local RF
• what is Perio Grade C with molar incisor pattern ?

  • IP attachment loss affecting incisors and 1st molars AS WELL AS up to 2 other teeth
  • Minimal plaque and calc
• Perio grade C molar incisor pattern qualities?

  • commences at puberty
  • minimal deposits and gingival look healthy until probed
  • Strong Ig response to Aa
  • JP2 clone of Aa
  • Neutrophil function abnormalities
  • Robust serum Ig response to infecting agents (to protect later erupting permanent teeth)
• 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)
  • Marked inflamm
  • Episodic nature of attachment/bone destruction
  • Aa and Pg
  • Poor serum Ig response to infecting agents
• Tx of perio grade C ?

  1. scaling and RSD infecting in control of Aa due to tissue invasion
  2. ABx after RSD
  3. Flap surgery may be required later
  4. BSP suggest periodontal specilialist
• Tx sequence when Tx perio grace C

  1: intensive OHI

  2: PMPR and RSD more than 4 mm all undertaken in 2 week for total mouth disinfection

  3: Last visit prescribe adjunctive systemic antimicrobials
• Dosages for ABx

  • Amoxicillin 500mg TDS + metronidazole 400mg TDS for 7 days

  or

  • Doxicycline 200 mg loading dose then 100 MG OD for 21 days

  or

  • Azithromycin 500 mg OD for 3 days