Periodontal diseases in children and adolescents: a clinician's perspective part 2

Periodontitis as a manifestation of systemic diseases

Periodontitis as a manifestation of systemic diseases is classified in Table 1.1

The ‘Not otherwise specified’ category includes diseases like osteoporosis and oestrogen deficiency, which have been shown to affect the periodontium, but data regarding their effect requires confirmation. It was emphasized in the consensus report that other systemic conditions may be added after the evidence is available.

Defects in neutrophil and immune cell function associated with these diseases may play an important role in increased susceptibility to periodontitis and other infections. Periodontitis as a manifestation of systemic disease in children is a rare disease that frequently begins between the times of eruption of the primary teeth up to the age of 5.2^,3 In the localized form, affected sites exhibit rapid bone loss and minimal gingival inflammation.2

Quantitative (agranulocytosis or neutropenia) or qualitative (chemotactic or phagocytic) leukocytic deficiencies show evidence of severe annihilation of the periodontal tissues. Quantitative deficiencies are generally accompanied by destruction of the periodontium of all teeth, whereas qualitative defects are often associated with localized destruction affecting only the periodontium of certain teeth.4

Neutropenia

Patients present with diverse periodontal manifestations. In the malignant form there is ulceration and necrosis of the marginal gingiva. Bleeding from gums is generally present and attached gingiva may become involved.5 In cyclic, chronic and familial benign neutropenia, the lesions show deep periodontal pockets and extensive, generalized bone loss involving the permanent dentition.6–8 Bone resorption may be seen in the deciduous dentition.9^,10

Leukaemia

Periodontal lesions have been frequently observed in patients with leukaemia, particularly those with an acute form. Generalized gingival enlargement was apparent in 36% of the individuals with acute, and in 10% of those with chronic, forms.11 Gingival swelling due to infiltration by leukaemic cells is a feature of acute monocytic leukaemia.12 Gingival bleeding is also a common sign of the disease in both acute and chronic leukaemia and may relate to the associated thrombocytopenia.13

Down's syndrome

Patients with Down's syndrome show a generalized early periodontitis, which commences in the deciduous dentition14^,15 and continues into the adult dentition. The prevalence and severity of periodontal disease in individuals with Down's syndrome is high in comparison to their siblings16 or other mentally disabled people.15 Several studies have reported increased prevalence and severity of periodontal disease in children of older age groups.14^,15 The periodontal destruction is most commonly seen around the incisor and molar teeth.14 The short roots of the mandibular incisors,17 and the bone loss in the mandibular anterior region, can lead to the premature loss of these teeth.15

Leukocyte adhesion deficiency syndrome

Defects in numbers of cell-cell adhesion receptors on the neutrophil surface may lead to increased inclination to periodontitis and other infectious diseases in conditions such as leukocyte adhesion deficiency syndrome.18 Young patients with leukocyte adhesion deficiency syndrome present with severe inflammatory periodontal disease.19–21 Leukocyte adhesion deficiency syndrome is a rare autosomal recessive disease. The disease is generally fatal and children with deficiencies in expression of the leukocyte function associated family of adhesions suffer from severe periodontal infections.18

Papillon-Lefèvre syndrome

The palmoplantar keratodermas are a heterogeneous group of more than 40 keratinization disorders characterized by erythema and hyperkeratosis of the palms and soles.22^,23 A prevalence of 1–4 cases per million people has been reported.24 Papillon-Lefèvre syndrome is an uncommon autosomal recessive type-IV palmoplantar ectodermal dysplasia.25

Papillon-Lefèvre syndrome is a rare genodermatosis inherited as an autosomal recessive trait, affecting children between the ages of 1–4 years.26^,27 Males and females are equally affected.23 The disorder is characterized by diffuse palmoplantar keratoderma and premature loss of both deciduous and permanent teeth. The palmoplantar keratoderma starts between the ages of 1 and 4 years.26 The sharply demarcated erythematous keratotic plaques involve the surface of the palms and soles, occasionally extending on to the dorsal surfaces of the hands and feet.24 Elbows and knees may also get involved.27 Often, there is associated hyperhidrosis of the palms and soles resulting in a foul-smelling odour.24

Another key feature of Papillon-Lefèvre syndrome is severe periodontitis, which starts at age 3 or 4 years.27 The development and eruption of the deciduous teeth proceed normally, but their eruption is accompanied by gingival inflammation and ensuing rapid destruction of the periodontium. The resulting periodontitis characteristically is unresponsive to conventional periodontal treatment and the primary dentition is usually exfoliated prematurely by the age of 4 years. After exfoliation, the inflammation subsides and the gingiva appears healthy. With the eruption of the permanent dentition, gingivitis and periodontitis initiates again and there is premature exfoliation of the permanent teeth.28^,29 Teeth are normally lost in the order of eruption.29 The degree of dermatologic involvement may not be related to the level of periodontal infection.30 A multidisciplinary approach is important for the care of patients with Papillon-Lefèvre syndrome. A dermatologist and oral medicine specialist, along with a periodontist, should be involved in treating such cases. Involvement of other specialists may be required and depends upon the systemic and dental conditions of the patient.

Chediak-Higashi syndrome

Chediak-Higashi syndrome is an autosomal recessive disease associated with severe periodontitis.31^,32 The people suffering from this disease are extremely susceptible to bacterial infections; neutrophil chemotaxis and bactericidal functions are abnormal in these patients. Generalized, severe gingivitis, extensive loss of alveolar bone and premature loss of teeth are features commonly seen.33

Histiocytosis syndromes

Histiocytosis is a general name for a group of syndromes that involve an abnormal increase in the number of immune cells called histocytes.34 This group of diseases may affect infants, children and adults.

There are three major classes of histiocytoses:34

Langerhans cell histiocytosis is of importance to dentists because oral soft tissue and bony lesions are common and may be an initial indication of disease.35 Symptoms can vary between children and adults, although there can be some overlap. Tumours in weight-bearing bones, such as the legs or spine, may cause the bones to fracture without apparent reason. Symptoms in children may include:

Children over 5 years old often have only bone involvement. Oral soft tissue invasion by Langerhans cells can present as gingival inflammation and ulceration. The periodontal lesions may clinically resemble necrotizing ulcerative periodontitis lesions. The lesions are punched-out necrotic ulcers with considerable granulation tissue, tissue necrosis and marked bone loss.36

Manifestations in the jaws are seen in 10–20% of all cases. Swelling, tenderness, pain and loosening of teeth are frequent symptoms. The primary teeth may be lost prematurely. The jaw lesions often appear as punched-out radiolucencies but ill-defined radiolucencies are also seen, sometimes mimicking periodontal disease.

Tests in children may also include:

Biopsy of the granulation tissue can also help in diagnosing the condition.36

Glycogen storage disease

This is an autosomal recessive condition associated with defective carbohydrate metabolism. Clinical features include reduced neutrophil numbers, impaired neutrophil function and periodontal disease.37^,38

Infantile genetic agranulocytosis

This disease presents with severe neutropenia and has been linked with periodontitis similar to the early-onset form. This is a rare autosomal recessive disorder.39^,40

Cohen's syndrome

This is also an autosomal recessive condition characterized by frequent and extensive alveolar bone loss.38 The patients also suffer from non-progressive mental and motor retardation, obesity and neutropenia.41

Ehlers-Danlos syndrome

Ehlers-Danlos syndrome is an autosomal dominant disorder, is classified into 10 types and is characterized by defective collagen synthesis. Symptoms of EDS include:

Types IV and VIII have an increased susceptibility to periodontitis.43 Type VIII is linked with fragile oral mucosa and blood vessels. It is also associated with severe generalized periodontitis with manifestation of generalized aggressive periodontitis,44 causing premature loss of permanent teeth.45

Tests performed to diagnose EDS include:

Hypophosphatasia

Hypophosphatasia is an inherited disorder characterized by defective bone and tooth mineralization. Hypophosphatasia is due to mutations in the liver/bone/kidney alkaline phosphatase gene encoding the tissue non-specific alkaline phosphatase.46^,47 Clinical manifestations are varied and range from isolated premature loss of primary teeth to stillbirth.47^,48

Six clinical forms of hypophosphatasia are known, depending upon the age of onset:

Necrotizing periodontal diseases

Necrotizing periodontal diseases are classified as:

The working definitions and clinical features proposed are as follows.

Examination of the patient

The patient's history, along with the examination, helps in diagnosis of the periodontal diseases. The examination should include the chief complaint, history of present complaint, past dental and medical history. The child or adolescent's guardian can facilitate in collecting the information. The treatment planning of the child with a compromised medical status may involve consultation with the child's paediatrician.

Periodontal screening

Examination of the periodontal tissues in the younger patient should be a routine part of the dental examination. Periodontal screening in children and adolescents provides a simple process of identifying periodontal problems. It gives the dental practitioner an indication of whether the child/adolescent requires treatment or further assessment.

Periodontal screening and recording introduced by the American Dental Association60 has been found to be a sensitive, easy, quick method of screening patients for periodontal diseases that summarizes essential information.61 Periodontal screening and recording, when compared to full-mouth probing with a graduated periodontal probe in children and adolescents, was found to be better accepted, faster, and no differences were found in diagnosis and clinical management.62

After the eruption of the incisors and first permanent molars in children, the basic periodontal examination can be used for screening the index teeth UR6, UR1, UL6, LL6, LL1 and LR6 (International Dental Federation notation). The WHO 621 (Figure 1) probe with the 0.5 mm spherical ball on the tip and shaded band at 3.5–5.5 mm is used to detect normal sulcus and periodontal pockets.63 Usage of codes up to 2 is recommended until the age of 11 years because of the probability of pseudopockets associated with newly erupting teeth.64 Presence of a deep pocket in which the 3.5–5.5 mm black band disappears would necessitate further periodontal investigation.

The 0.5 mm ball end on this probe can be used to detect subgingival calculus. In 12–19 year-olds, the full range of scores can be used on the index teeth so that periodontal pockets can be detected as early as possible.64 It is crucial to assess the base of the pocket. In true pocket, the base of the pocket is apical to the cemento-enamel junction. If pockets are detected, then full-mouth monitoring should be undertaken. Screening of six index teeth is swift, easy and acceptable to young patients. Periodontal screening of new patients and 4- or 6-monthly recalls in children and adolescents is recommended so that periodontal problems can be detected early and treated properly.65 This basic periodontal examination screening system typically takes less than 1 or 2 minutes in children and adolescents.65

Basic Periodontal Examination (BPE) scoring criteria (Table 2)

Index Teeth used: UR6, UR1, UL6, LL6, LL1 and LR6. In children, the WHO probe is walked around the index teeth, covering six sites per tooth, whereas in young adults all the teeth in each sextant are probed.

In the age group of 7–11 years, codes 0–2 are used and the worst finding is recorded on each index tooth or in each sextant.

Frequency of recording BPE66

BPE is recorded for all new patients and patients requiring advanced restorative or orthodontic treatment. Score 0: Screen again within one year. Score 1 or 2: Treat and screen within one year.

Score 3: If score 3 is recorded in one or more sextants, treat and review. If still code 3, record full periodontal indices in affected sextants.

Score 4 or *: Record full periodontal indices and consider referral.

A detailed periodontal examination should include indices to record:

Radiographs can also be considered if BPE score is 3, 4 or * to assess bone levels. The diagnosis of periodontal problems is reached after deliberation of the findings of the history and examination.

Periodontal treatment assessment

The British Society of Periodontology recommends following complexity codes in its document on ‘Referral Policy and Parameters of Care’ on its official website.67

Based on the Basic Periodontal Examination Code:

Complexity 1: BPE Score 1–3.

Complexity 2: BPE Score of 4 in any sextant.

Surgery involving the periodontal tissues.

Complexity 3: Surgical procedures associated with osseo-integrated implants.

Surgical procedures involving periodontal tissue augmentation and/or bone removal.

BPE score of 4 in any sextant and including one or more of the following factors:

Periodontal treatment assessment sets complexity codes in a simplistic manner with the addition of a list of modifying factors that are relevant to periodontal treatment and an outline of medical history that significantly affects clinical management. It is strictly a complexity assessment and does not address either the motivational aspects of treatment or a prioritization of treatment.

Modifying factors that are relevant to periodontal treatment67

A modifying factor can only increase complexity by one increment. Multiple factors are not cumulative:

Medical history that significantly affects clinical management67

Referral policy of British Society of Periodontology67

Referral of patients with periodontal problems, to either specialist practitioners or hospital consultants, depends on several factors:

According to the British Society of Periodontology, it is difficult to be absolute in determining referral policy guidelines. The interpretations of Basic Periodontal Examination and the level of complexity help in deciding the referral guidelines.67

Complexity 1: cases may be treated in general practice.

Complexity 2: cases either referred or treated by the GDP.

Complexity 3: cases mostly referred. Although, depending on the treatment requirements, simple periodontal treatment may have to be delivered by specialists as part of a more complex integrated treatment strategy in order to maintain the integrity of the restored dentition. Also, Complexity 3 category may not necessarily require care from a specialist.

Periodontal treatment in children and adolescents

The periodontal therapy aims to preserve the natural dentition and periodontium and to improve comfort, aesthetics and function. The clinical signs of a healthy periodontium comprise the absence of redness, swelling, suppuration and bleeding on probing; maintenance of a functional periodontal attachment level; minimal or no recession in the absence of inter-proximal bone loss.68

Periodontal treatment may be undertaken in three phases:

Summary

Periodontal screening should be an integral part of the dental examination of children and adolescents. Most of the periodontal diseases respond well to appropriate periodontal therapy. Early diagnosis ensures the greatest likelihood for successful treatment. Periodontal management should follow the vital principles of initial cause-related, corrective and supportive therapy. Age, co-operation and motivation of the child or adolescent must be taken into consideration in periodontal treatment. A personalized periodontal maintenance schedule should be suggested to the patient for long-term control of the disease.