Periodontal diseases in children

Periodontal diseases in children:

1. Introduction:

Long ignored, the periodontium of children 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.

2. Definition of childhood:

In Latin Infantia

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

3. Anatomical-histological, physiological and ecological characteristics:
4. Anatomical-histological characteristics:

• The gum: the gum 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 gum is reduced with often frenulums that retract it, it increases with age. The depth of the sulcus has a constant value of 1mm on average.
•  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 pulpo-periodontal canals.
• 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.
• Alveolar bone: it is covered by dense blood and lymphatic vascularization, it is less calcified. The cortices are thin, particularly in the anterior sectors, the alveolar crests 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:

• Saliva and gingival fluid : the same elements as in adults, an increased leukocyte density, an acidic pH which tends to become alkaline with age.
• 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.

4. Physiological gingival transformations associated with dental eruption:
5. 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 erupts into 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 especially in the anterior-upper region. 

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

5. Gingivopathies in children:

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

1. Local gingivitis:
2. 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: Xylocaine viscous

-Mouthwash (avoid hydrogen peroxide)

-Antiviral ointment applied to the lips (Aciclovir)

-If there is extension to other organs, the patient must be referred to the specialized service

→ 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, pure Nystatin mouthwash)

→ Ulcerative-necrotic gingivitis: this is a reversible ulcerative and necrotic disease affecting the gum, with a sudden onset, rare in children but very common in adolescents and young adults. It develops in 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 relaxation reaction results in cellular and fibrillar proliferation, clinically resulting in the appearance of tissue masses of variable shape and distribution.
• Hypertrophic gingivitis of mouth breathing: 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 reduction in its resistance. This phenomenon is undoubtedly linked to changes in osmotic pressures or in the permeability of cell membranes as a result of drying of the integuments.

• Hypertrophic gingivitis of adolescence 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 reduces spontaneously but it disappears only after the total removal of local irritants.
• Hereditary familial gingival hyperplasia (Elephantiasis gingivitis): this is a rare hyperplastic disease of unknown etiology, it is called idiopathic or “Elephantiasic” gingival hyperplasia
  • Clinically: hyperplasia covering the vestibular and lingual surfaces of the arches or a single arch, the hyperplastic tissue is pink, firm, elastic and does not tend to hemorrhage. The hypertrophy can 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 produced is not a function of the duration of treatment or the size of the doses prescribed.
  • Treatment: Gingivectomy

2. 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 due to 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 a desquamation of the gingival epithelium exposing a bleeding and painful surface at the slightest contact (a simple sudden contact with air can be painful). The subjects feel a burning sensation and hygiene measures are practically impossible. This form seems to be more of a particular sign of different diseases than a specific clinical entity.

2. Gingivitis related 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 rash appears. 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. A diffuse erythema of the oral mucosa with the formation of vesicles is also commonly observed during 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 fairy to malnutrition: 

• Gingivitis associated with vitamin C deficiency (scurvy): Vitamin C deficiency causes an increased tendency to gingival bleeding (bluish discoloration), degeneration of collagen fibers and edema of the connective tissue.
• 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 reviews:

Recession is the denudation of the root surface by the apical displacement of the gingival position, this means a migration of the functional epithelium a resorption of the alveolar bone and the periodontal ligament. Among the most frequent causes of recession we have:

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

7. Periodontal disease in children:
8. Prepubertal periodontitis:

– Appears during or immediately after the eruption of temporary teeth

– Child under 14 years old, both sexes affected equally.

– Little plaque and tartar, little susceptibility to tooth decay.

– A decrease in the chemotaxis of neutrophil polymorphonuclear cells.

– It could be of genetic origin.

– Gingival inflammation is severe with spontaneous gingival bleeding and proliferation of gingival tissues.

-Bone destruction is rapid, leading to the loss of temporary teeth.

– It has 2 distinct forms:

• Superficially located.
• Deep generalized.

– 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 deep periodontal involvement.

– 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 with 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 good apparent 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 having periodontal disease. In the majority of cases, parents know the general disease that their child suffers from. However, it may happen that the general symptoms are not obvious and the loss of attachment is the only sign of this disease. In these cases, the practitioner must collect all the medical information and perform the complementary tests in order to make a differential diagnosis.

-Hypophosphatasia:

-Lefèvre Butterfly Syndrome:

-Chediack Higashi syndrome:

-Familial neutropenia:

– Cyclic neutropenia:

– Down syndrome:

-Eosinophilic granuloma and related syndromes (histocytosis X)

-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 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 )

8. The psychological approach:

– Place 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 thereafter

– 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 through 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.

9. 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 mention:

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

The periodontal treatment plan in periodontology is the same as for adults, while emphasizing the psychological aspect in order to gain the patient’s trust throughout the process.

11. Conclusion :

In children, the evolution of periodontal disease is assessed differently than that observed in adults. Pre-pubertal children are less subject to exposure to periodontal disease than adolescents, as much as the latter is less exposed compared to adults, and this epidemiological observation finds its explanation in the specific physiological characteristics of young children and adolescents, particularly with regard to the physiology of the oral environment.

Periodontal diseases 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.