Periodontal disease in children

           Periodontal disease in children 

I- Introduction: 

   Long ignored, the child’s periodontium remains a structure that is still little known. However, the observation of pathological situations in children has led periodontologists to look for their possible origins in children.  

   A better understanding of the periodontium in children makes it possible to detect risk situations and prevent periodontal disorders in adults. 

II-Definition of childhood: in Latin “infantia” 

   It is the period of human life from birth to puberty. 

There are several periods in childhood, namely the newborn, the young child, the puberty phase and adolescence. And each period corresponds to a particular physiological oral-dental state. The same goes for the pathologies that can affect the child’s oral cavity. 

III- Anatomo-histological, physiological and ecological characteristics: 

   1- Anatomo-histological characteristics: 

1. The gingiva: the gingiva is often described as redder, due to the abundant capillary network and a thinner, more translucent epithelium and for some authors, less keratinized. The height of the attached gingiva is reduced with often frenulums which retract it, it increases with age. 

   The depth of the sulcus has a constant value of 1mm on average. 

2. The desmodont: it is wide especially at the level of the furcation, the desmodont communicates with the medullary spaces of the alveolar processes and with the pulpal connective tissues by the apical orifices and numerous pulpoperiodontal canals. 
3. Cementum: The cementum of temporary teeth is thin, it is generally acellular in the coronal part of the root and cellular in the apical region. 
4. Alveolar bone: it is covered with dense blood and lymphatic vascularization, it is less calcified. 

   The cortices are thin, especially in the anterior sector, the alveolar ridges can be convex or flat, especially if they are associated with diastemas.   

 2- Physiological characteristics: 

• The alveolar bone changes structure to create conditions for physiological adaptations. 
• The rich vascularization of the periodontium leads to a significant nutritional supply and significant defense potential. 

 3- Ecological characteristics of the oral environment: a- Saliva and gingival fluid: the same elements as in adults, an increased leukocyte density, an acidic pH which tends to become alkaline with age. 

  b- Microbial flora: at birth the oral cavity is sterile. After 6 to 10 hours there is a rapid increase in the number of detectable bacteria, the first ^organism detected is Streptococcus Salivarius which is found in 80% of one-day-old children. On the second day colibacilli appear, on the 5th ^day salivary streptococci, staphylococci dominate. 

   The eruption of teeth, through the physiological upheavals that it involves, most certainly contributes to changes in bacterial ecology as the child grows. 

IV- Physiological gingival transformation associated with dental eruption: 

1. Pre-eruptive swelling:  

   Before the crown appears in the oral cavity, the gingiva presents a firm swelling, which may be slightly paler and which follows the contour of the underlying crown. 

2. Formation of the gingival margin: 

   The marginal gingiva and sulcus develop as the tooth penetrates the oral mucosa. 

   During eruption the gingival margin is edematous, rounded and slightly redder. 

3. Normal prominence of the gingival margin: 

   During the mixed dentition, it is normal for the marginal gingiva around the permanent teeth to be quite prominent, particularly in the antero-upper region. 

 At this stage the gum is still attached to the crown and appears to be prominent. 

V- Gingivopathies in children: 

   Morphological characteristics of the gingiva in children can lead to an overestimation of the degree of inflammation. 

 1- Local gingivitis: a- Acute gingivitis:  

   → Acute herpetic gingivostomatitis: this is the most common condition during childhood, it is characterized by a diffuse erythematous gingival lesion, with the formation of ephemeral vesicles, giving way to small ulcers with red edges in the form of a halo, it is associated with vesicles, crusts on the lips and face, cervical adenopathy and fever. ● Treatment: it is purely symptomatic 

• Local analgesics (anesthetic ointment: viscous xylocaine) 
• Mouthwash (avoid hydrogen peroxide) 
• Antiviral ointment applied to the lips (acyclovir)  
• If there is extension to other organs, the patient must be referred to the specialist department. 

   → Thrush: this is an oral mycosis caused by candida Albicans, characterized by isolated or disseminated whitish lesions in all regions of the oral mucosa, they are strongly adherent but can sometimes be detached without hemorrhagic traces.  

• Treatment :
  • Fight against dry lips 
  • Combat salivary acidosis with alkaline mouthwashes (sodium borate, baking soda) 
  • Antifungal (Fungizone, Nystatin Pure Mouthwash) 

   → Ulcerative-necrotic gingivitis: this is a reversible ulcerative and necrotic disease affecting the gums, with a sudden onset, rare in children but very common in adolescents and young adults. 

   It develops through successive acute attacks and can develop into periodontitis. 

• Treatment: (see the course “prodontic emergencies”) 

   → Hypertrophic gingivitis: 

• Inflammatory hypertrophic gingivitis: this is a gingival growth of an inflammatory nature, the body’s defense reaction results in cellular and fibrillar proliferation, clinically resulting in the appearance of tissue masses of variable shape and distribution.  
• Hypertrophic gingivitis of oral respiration: it is characterized by an edematous and sometimes hypertrophic reaction mainly in the areas exposed to air. 

   It seems that superficial drying of the mucosa leads to a decrease in its resistance. 

   This phenomenon is probably linked to changes in osmotic pressures or in the permeability of cell membranes as a result of the drying out of the integuments.  

• Hypertrophic gingivitis in adolescents and hormonal changes: it occurs in both sexes, the volume of gingival hypertrophy is much greater than that described in association with local factors alone. 

   After puberty, the hypertrophy spontaneously reduces but only disappears after the complete removal of local irritants. 

• Hereditary familial gingival hyperplasia (Elephantiasis gingivitis): this is a rare hyperplastic disease of unknown etiology, it is called “idiopathic gingival hyperplasia or 

Elephantiasic » 

• Clinically: hyperplasia covering the vestibular and lingual surfaces of the arches or a single arch, the hyperplastic tissue is pink, firm, elastic and has no tendency to hemorrhage. 

Hypertrophy may cover the entire dental crown to the point of interfering with occlusion  

• Treatment: gingivectomy 

    ● Drug-induced hypertrophic gingivitis due to Dihydan: the drug stimulates fibroblastic activity and collagen synthesis, the hyperplasia caused is not a function of the duration of treatment or the size of the doses prescribed. ➢ Treatment: Gingivectomy. 

  b- Chronic gingivitis: 

   → Chronic marginal gingivitis: (erythematous)  

   This is the most common gingivitis in children, the gum takes on a red color, more or less dark, by vasodilation and vascular proliferation.  

   The free gingiva increases in volume, creating a false pocket, thus promoting the accumulation of PB (biofilm) which maintains gingival inflammation. 

   → Desquamative gingivitis: (erosive)  

   Relatively rare in children, it seems to affect female subjects more, most often in middle age, it is characterized by desquamation of the gingival epithelium exposing a bleeding and painful surface at the slightest contact. 

(just a sudden contact with air can be painful)  

   The subjects experience a burning sensation and hygiene measures are practically impossible. 

   This form seems to be more of a particular sign of different diseases than a clinical entity of its own.  

 2- Gingivitis linked to general diseases: 

1. Chickenpox: a succession of papular eruptions and vesicles appearing on the oral mucosa, face and the rest of the body. 

   The vesicles rupture and form ulcerated craters. 

2. Measles: a pathognomonic sign, KOPLIK’s spots appear 2 to 3 days before the appearance of the rash.  

   The spots appear on the inner side of the lip, they are bluish spots, the size of a pinhead surrounded by a bright red halo. In addition to the spots, we have erythema and edema at the gingival level. 

3. scarlet fever: diffuse redness of the oral mucosa with a raspberry-colored tongue. 
4. Diphtheria: It is characterized by the formation of a pseudomembrane in the oropharynx that resembles a curtain in the areas of the anterior pillars. 

   Diffuse erythema of the oral mucosa with vesicle formation is also commonly observed in this disease. 

5. Specific infectious disease: (tuberculosis and syphilis)  

• Primary infection: appearance of a chancre 
• Secondary stage: very extensive ulcerations at the gingival level. 

   → Oral manifestations of HIV infection: 

   Comparison of a population of children infected with human immunodeficiency virus and control children highlights more oral lesions, in particular candidiasis and rhomboid glossitis.  

6. Hematological diseases:  

   → Acute leukemia: it is generally accompanied by significant gingival hypertrophy with a tendency to spontaneous bleeding. 

   → Erythroblastic anemia:  

7. Gingivitis related to malnutrition:  

   → Gingivitis associated with vitamin C deficiency (scurvy): vitamin C deficiency causes an increased tendency to gingival hemorrhage (bluish discoloration), degeneration of collagen fibers and connective tissue edema. → Vitamin A deficiency: significant gingival hyperplasia. 

8. Gingival tumors: they are rare in children and most of them are inflammatory rather than neoplastic and among these tumors we can cite: epulis, fibroma, papilloma. 
9. Periodontal recessions: 

   Recession is the denudation of the root surface by apical displacement of the gingival position, this means migration of the junctional epithelium, resorption of the alveolar bone and the periodontal ligament. 

   Among the most common causes of recession we have: 

• Dental malpositions, especially vestibuloversion of a tooth or vestibular projection of the root of a rotating tooth 
• Abnormal insertion of the brake 

7. Periodontal disease in children: 

   1- Prepubertal periodontitis: 

• Appears during or immediately after eruption of temporary teeth – Child under 14 years of age, equally affected in both sexes. 
• Little plaque and tartar, little susceptibility to tooth decay. 
• A decrease in neutrophil chemotaxis. 
• It could be of genetic origin. 
• Gingival inflammation is severe with spontaneous gingival bleeding and proliferation of gingival tissues. 
• Bone destruction is rapid, resulting in the loss of temporary teeth.  
• It can be divided into two forms:  

➢ Localized superficial. ➢ Generalized deep. 

• It is accompanied by damage to the general condition or certain diseases of the respiratory tract. 

 2- Juvenile periodontitis:  

• It appears around puberty (12 years) and affects the permanent teeth. – There is a disproportion between the relatively normal appearance of the gum and the severity of the damage to the deep periodontium. 
• In its localized form, only the first ^molars and/or incisors are affected, creating a mirror-symmetrical attack of an angular nature. 
• In its generalized form, all teeth are affected, although there is a greater degree of osteolysis in the molars and incisors. 
• There is little plaque and tartar. 
• Reduction of PNN chemotaxis. 
• Bone destruction is rapid with apparent good general condition. 

 3- Rapidly progressive periodontitis: 

• It can start from puberty but sometimes later. 
• Gingival inflammation is severe. 
• Generalized bone lysis. 
• Significant accumulation of tartar and susceptibility to caries. 

 4- Periodontal disease symptom of a syndrome:  

   Some systemic diseases predispose to periodontal disease. In most cases, parents are aware of the general disease their child is suffering from. However, it may happen that the general symptoms are not obvious and that the loss of attachment is the only sign of this disease. 

   In these cases, the practitioner must collect all medical information and perform additional tests in order to make a differential diagnosis. a- Hypophosphatasia: b- Papillon Lefèvre syndrome: c- Chediack-Higashi syndrome: d- Familial neutropenia: e- Cyclic neutropenia: f- Down syndrome: g- Eosinophilic granuloma and related syndromes (histocytosis X) h- Childhood diabetes (IDD): periodontitis in diabetics does not differ from that of healthy children, it appears late, its progression is very rapid and results in spontaneous tooth loss. 

• Diabetes does not trigger periodontal disease, but it precipitates it. 
• Several factors contribute to the weakening of local defenses (diabetic microangiopathies, alteration of PNN chemotaxis and collagen metabolism by activation of gingival collagenase)  

VIII- the psychological approach: 

• Reposition the child in his family environment and distinguish his relationships with his parents. – In the first ^session the presence of one or both parents is essential, it becomes less necessary later on. 
• Assess the child’s degree of physiological development, also assess by exchanging a few words with him, his degree of mental and intellectual development, especially during treatment, situate him in his academic and extracurricular knowledge by a banal conversation, without doctoral air to put him at ease. 
• Involve the child in the action by giving him a mirror in which he can follow the steps of the treatment. This captures his attention, diverting him as much as possible from the feeling of anxiety, while remaining in the therapy itself. This method is valid up to 10 years. 
• Beyond this age, explain simply and quickly what you are proposing to do, in care “with their agreement”. 
• For very young children, always match the first ^contact with the execution of a benign act, without pain. This is a preparation of the psychological ground, never deceive the vigilance and confidence of the child. 

IX- Preventive periodontics: 

   Since periodontal diseases and dental caries are of microbial etiology, preventive therapy consists of preventing the installation or formation of PB. It is necessary to strengthen dental structures and eliminate factors that promote PB and among the means of control we will cite: 

1. Administration of fluoride in case of deficiency: 
2. Balanced diet:  
3. strengthen motivation for oral hygiene (plaque revealer) and learning simple methods  

– Conclusion :  

The management of periodontal diseases in pedodontics requires a good knowledge of the anatomical and pathophysiological conditions specific to children and adolescents while taking into consideration the psychological aspect which characterizes each age group separately. 

The role of the dentist is essential not only in the curative aspect of periodontal therapy but it is also and above all preventive in aim not only for the appearance and the evolution of periodontal disease but even for a good growth in the child. 

Periodontal disease in children

Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.
 

Periodontal disease in children