Title Page
Copyright Page
Foreword
Preface
Acknowledgements
Chapter 1 Periodontal Problems in the Young: Myth or Reality?
Aim
Outcome
Children, Adolescents and Young Adults
Key Features of the Periodontium in Health
Gingiva
Connective Tissue
Periodontal Ligament
Cementum
Alveolar Bone
Key Features of Gingivitis
Key Features of Periodontitis
Classification of Periodontal Diseases in Children, Teenagers and Young Adults
Classification of Gingivitis
Classification of Periodontitis
Chronic periodontitis
Aggressive periodontitis
Periodontitis as a manifestation of systemic diseases
Periodontitis associated with endodontic lesions
Necrotising periodontal diseases
Classification of abscesses
Epidemiology of Chronic Periodontitis and Aggressive Periodontitis
Incipient Chronic Periodontitis
Aggressive Periodontitis
Key Points
References
Further Reading
Chapter 2 Development of Periodontal Diseases in the Younger Population
Aim
Outcome
Balance: Microbial Challenge Versus Host Defence
The Nature of Plaque
Biofilm
Specific plaque hypothesis
Non-specific plaque hypothesis
Ecological plaque hypothesis
Host defence systems
Host Defence Defects in the Young Patient
Genetic disorders
Periodontal Disease Risk
Periodontal risk factors
Determining periodontal risk
Development of Periodontitis in the Younger Age Groups
Initial Inflammation
Established Gingivitis
Periodontitis
Key Points
References
Further Reading
Chapter 3 History and Systemic Risk Factors for Periodontal Diseases
Aims
Outcomes
Consent
Adults
Children
The History
Presenting Complaint and History of Complaint/Reason for Attendance
Family History of Periodontal Diseases
Medical History
Comments about medical history
Dental History
Social History
History as an Aid to Diagnosis
Key Points
References
Further Reading
Chapter 4 Clinical Examination and Local Risk Factors for Periodontal Diseases
Aims
Outcome
Examining Children, Adolescents and Young Adults
Local Risk Factors
Calculus
Restorations
Fraenal Attachment
Orthodontic Appliances
Malocclusion
Local Trauma
Mouth Breathing and Lack of Lip Seal
Xerostomia
Anatomical Features
Periodontal Screening
Using the BPE in Children, Adolescents and Young Adults
WHO 621 Probe
Sextants/Index Teeth
Recording BPE
Frequency of Recording BPE
Use of Radiographs
Justification
Optimisation
Radiographic Information
Radiographic Views
Radiographic Report
Guidelines
Key Points
References
Chapter 5 Periodontal Diagnosis in Young Patients
Aim
Outcomes
Principles of Periodontal Diagnosis
Gingival Diseases
Chronic Periodontitis
Incipient Chronic Periodontitis
Chronic Periodontitis
Smoking-related Chronic Periodontitis
Aggressive Periodontitis
Localised Aggressive Periodontitis
Generalised Aggressive Periodontitis
Poorly controlled diabetes
Necrotising Periodontal Diseases
Abscesses of the Periodontium
Gingival Abscess
Periodontal Abscess
Pericoronal Abscess
Periapical Abscess (not an abscess of the periodontium)
Periodontitis Associated With Endodontic Lesions
Developmental or Acquired Deformities and Conditions
Localised Gingival Recession
Occlusal Trauma
Key Points
References
Chapter 6 Non-plaque-induced Periodontal Diseases I: Gingival Lesions
Aim
Outcome
Introduction
Viral Infections
Herpangina
Hand, Foot and Mouth Disease
Herpes Simplex Virus I (HSV-I)
Primary Herpetic Gingivostomatitis
Secondary HSV-I Infection
Herpes labialis
Mucosal or oral herpes
Molluscum Contagiosum
Fungal Infections
Genetic Conditions
Hereditary Gingival Fibromatosis
Coeliac Disease
Delayed Gingival Retreat
Systemic Diseases With Gingival Manifestations
Haematological Conditions
Agranulocytosis
Cyclical neutropenia
Familial benign neutropenia
Myelodysplastic syndromes
Leukaemia
Granulomatous Inflammations
Wegener’s granulomatosis
Tuberculosis
Disseminated pyogenic granuloma
Immunological Conditions
Hypersensitivity reactions
Lichen planus
C1-esterase inhibitor deficiency/dysfunction
Traumatic Lesions
Drug-induced Lesions
Erythema Multiforme
Cytotoxic Drugs
Pigmenting Drugs
Anti-retroviral Drugs
Key Points
References
Further Reading
Chapter 7 Non-plaque-induced Periodontal Diseases II: Periodontal Lesions
Aim
Outcome
Introduction
Genetic Conditions with Periodontal Manifestations
Down Syndrome
Type 1 Diabetes
Papillon-Lefèvre Syndrome
Ehlers-Danlos Syndrome
Hypophosphatasia
Cohen Syndrome
Job Syndrome
Glycogen Storage Disease
Haematological Disorders
Disorders of the White Blood Cells
Infantile genetic agranulocytosis
Leukocyte adhesion deficiency
Lazy leucocyte syndrome
Chédiak-Higashi syndrome
Agamma/hypogammaglobulinaemia
Chronic granulomatous disease
Histiocytosis-X
Lymphocyte deficiencies – T-cell
Lymphocyte deficiencies – T- and B-cell
Disorders of the Red Blood Cells
Acatalasia
Aplastic anaemia
Disorders of the Connective Tissues
Progressive Systemic Sclerosis
Localised Scleroderma
General Management Issues Surrounding Non-plaque-induced Periodontal Conditions
Key Points
References
Further Reading
Chapter 8 Principles and Phases of Treatment
Aim
Outcome
Phases of Treatment
Initial Therapy
Baseline Measurements
Other Baseline Measurements
Plaque and marginal gingival bleeding
Patient Plaque Control
Parental assistance
Disclosing agents
Toothbrushes and brushing techniques
Interdental cleaning
Chemical antiplaque agents
Counselling on Smoking Cessation
Professional Cleaning
How much scaling can be done in an appointment?
Use of Local Analgesia
Instrumentation
Extractions
Response to Initial Therapy
Corrective Therapy
The Non-Responding Site, Tooth, Mouth and Patient
Non-surgical or Surgical Therapy?
Systemic Antimicrobial Therapy
Local Antimicrobial Therapy
Additional Treatments
Supportive Therapy and Recall
Compliance
Plaque Control
Smoking Cessation
Assessment of Treatment
Recall
Management of Acute Periodontal Conditions
Necrotising Ulcerative Gingivitis
Necrotising Ulcerative Periodontitis
Periodontal Abscess
Periodontitis Associated with Endodontic Lesions
Key Points
References
Further Reading
Chapter 9 Communication
Aims
Outcome
Introduction
Communication with the Young Patient
The Developing Child
Communicating with the Child Patient
Communicating with Adolescent Patients
Tell-Show-Do and Positive Reinforcement
Communication with Young Adult Patients
Communication with the Parent: The Parent’s Role
Communication and the Dental Team
Key Points
Further Reading
Chapter 10 Treat or Refer?
Aim
Outcome
Making the Decision to Treat or Refer
The Referral Process
The Referral Letter
The Specialist’s Reply
The Dental Team
Who’s on the Team?
Delivery of Care
Discharge Process from Specialist and Back to the Practitioner
Key Points
Reference
Further Reading
Quintessentials of Dental Practice – 17
Periodontology – 4
British Library Cataloguing in Publication Data
Clerehugh, Valerie
Periodontal management of children, adolescents and young adults. -
(Quintessentials of dental practice. Periodontology; 4)
1. Pediatric periodontics
I. Title II. Tugnait, Aradhna III. Chapple, Iain L. (Iain Leslie) IV. Wilson, Nairn H. F.
617.6′32′0083
ISBN 1850973105
Copyright © 2004 Quintessence Publishing Co. Ltd., London
Age icons and Fig 10-4 by Laura Andrew.
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.
ISBN 1-85097-310-5
This book is dedicated to Tony and Mary with my love.
Val Clerehugh
Many young people have periodontal problems which if overlooked or inappropriately managed may adversely influence the prognosis of the dentition. This latest addition to the Quintessentials of Dental Practice series provides a practical, well-illustrated guide to the aetiology, screening and diagnosis of periodontal diseases which may affect children, adolescents and young adults.
The values of teamwork, effective communication and knowing when to treat and when to refer to a specialist periodontist are rightfully stressed as important elements of the take-home message of this expertly crafted book. Owning and reading this Quintessentials book will be a pleasure, and then to go on to apply the enormous amount of evidence-based advice captured between the covers of this volume will, in all probability, transform the periodontal management of the children, adolescents and young adults you treat in your clinical practice.
As you would expect of a book in the Quintessentials of Dental Practice series, Periodontal Management of Children, Adolescents and Young Adults is an attractive publication written in a style aimed to appeal to busy practitioners and students. This book is an important volume in the series, and a valuable addition to dental literature in general. This is a book you will be very pleased to have read and to have available for ready reference.
Nairn Wilson
Editor-in-Chief
This is the fourth of five books in a series designed to provide the general dental practitioner with a contemporary, practical, illustrated guide for the management of patients with gingival and periodontal diseases. Our aim is to make the reader aware of the many and varied periodontal problems that can affect the young patient from childhood through to young adulthood and to provide a simple step-by-step approach to periodontal diagnosis and management in this group of patients. The need to look actively, and routinely, for periodontal disorders in these patients underpins our philosophy for their overall periodontal care. The role of the general dental practitioner in reaching an accurate diagnosis based on current disease classifications, in particular, is crucial to arranging appropriate treatment. Furthermore, the value of teamwork and good communication cannot be overemphasised, including an awareness of when to treat or when to refer to a specialist periodontist. The take-home message is that many young people really do have periodontal problems that can be easily missed unless appropriate screening is routinely undertaken to detect them and that the general dental practitioner has an important role in their management.
It is hoped that having read this book the reader will:
Appreciate that a variety of periodontal problems can affect children, adolescents and young adults.
Understand the key features of the periodontium in health and disease in the younger patient.
Become familiar with the current classification of the periodontal diseases and be aware of how common or uncommon the various periodontal problems are in the younger patient.
Appreciate that chronic periodontal destruction can begin in adolescence and that severe, aggressive forms of periodontal disease can affect children, adolescents and young adults.
Understand the aetiology of the periodontal diseases and the interplay between the host defence systems and microbial plaque.
Be aware of the nature of the local and systemic risk factors for periodontal diseases in the younger age groups.
Be aware of the concept of periodontal risk at four levels: the patient, the mouth, the tooth and the specific site.
Be knowledgeable about the rationale and methods of screening young patients quickly and simply for periodontal problems.
Know how to reach a periodontal diagnosis in the younger age groups.
Understand the principles of treatment planning and the three key stages of periodontal care.
Appreciate the role of the dental team and the value of effective communication in periodontal patient management of children, adolescents and young adults.
Appreciate the key stages in making a decision on whether to treat or refer a young patient for specialist periodontal care.
Valerie Clerehugh
Aradhna Tugnait
Iain LC Chapple
This book was written with the help and support of a number of people to whom we extend our grateful thanks: the Photography Department at Leeds Dental Institute for their photographic expertise; Multimedia Services at Birmingham’s Dental School; Dr Simon Wood and colleagues in Oral Biology for kind permission to use Fig 2-3, and the Journal of Dental Research for permission to reprint it.
We would like to thank Stephen Fayle for Fig 5-5; Jack Toumba for Fig 10-5; Lesley Bensley for Fig 8-6; and Mike, Katy and Chloe Ehrlich for Fig 8-5; George Warman Publications (UK) Ltd for kindly granting us permission to reprint Figs 1-15, 5-5, 5-10 – 5-12, 6-10, 6-29, 7-7, 7-8, 9-1 – 9-3; Don Glenwright for Figs 6-1, 6-2, 6-4, 6-7, 6-25, 6-26; and Mosby Year Book for Figs 6-7, 6-11 and 6-13. We would also like to thank Maggie Jackson who devised the interdental brushes and kindly supplied Fig 8-9 and Professor Andy Blinkhorn for the oral health promotion leaflets that he so graciously provided for Chapter 9.
Dr Val Clerehugh wishes to say a huge thank you to her husband Tony and daughter Mary for their love, support and forbearance during the preparation of this book, and always. She also wishes to thank her mum, dad and her family for their unconditional support and guidance.
Dr Aradhna Tugnait wishes to thank her husband Keith for his loving support and his encouragement in the writing of this text and Mum, Anuja and Carl for always being there.
Professor Iain Chapple wishes to thank his wife Liz for her patience and unconditional support and little Jessica for giving up her valuable play time during the preparation of this fourth book.
This chapter aims to dispel the myth that periodontal diseases are only of concern for adults in their thirties and older (Box 1-1). It provides an overview of the features of the different periodontal problems that can affect children, adolescents and young adults.
Box 1-1
Myth or Reality?
Q. Is it myth or reality that periodontitis only affects adults after 30 years of age?
A. Myth!
Q. Is it myth or reality that periodontitis affects some children?
A. Reality!
Q. Is it myth or reality that periodontitis affects many teenagers?
A. Reality!
Q. Is it myth or reality that periodontitis affects young adults under 30 years of age?
A. Reality!
Q. Is it myth or reality that the current classification of periodontitis (International Workshop 1999) recognises a variety of periodontal problems that can affect young people under 30 years of age?
A. Reality!
READ ON...
After reading this chapter, the practitioner should be able to describe the features of periodontal health and diseases affecting the young patient during childhood, adolescence and young adulthood and be able to classify the different types of periodontal disease affecting this group of patients. They should also be aware of the epidemiology of key periodontal conditions affecting young patients.
As depicted in Fig 1-1, for the purposes of this text:
Children are: 0 – 12 years of age.
Adolescents are: 13 – 19 years of age.
Young adults are: 20 – 29 years of age.
Appreciation of the key clinical and histopathological features of the periodontium in health is fundamental to the subsequent understanding of the disease process (Figs 1-2 and 1-3). For a more detailed account, the reader should refer to the first book in this series Understanding Periodontal Diseases: Assessment and Diagnostic Procedures in Practice (Chapple and Gilbert 2002).
The principal components of the periodontium are:
gingiva (including epithelium and connective tissues)
periodontal ligament
cementum
alveolar bone.
The healthy gingiva has a firm, pink, scalloped, knife-edged appearance, although pigmentation is a normal characteristic of certain ethnic groups. In the healthy state in children and teenagers, the gingival margin is several millimetres coronal to the cemento-enamel junction (CEJ). The gingival sulcus is essentially a shallow groove, 0.5–3mm deep on a fully erupted tooth, which surrounds the tooth. It is lined by sulcular epithelium (SE) and junctional epithelium (JE), with the gingival margin forming its most coronal boundary (see Fig 1-3).
The gingiva attaches to the enamel via a weak junctional epithelial attachment, comprising the hemidesmosomes within the JE cells and a basal lamina that is produced by the epithelial cells. The hemidesmosomes attach the JE cells to the basal lamina, which in turn attaches to the tooth enamel. The cells of the JE attach to each other via desmosomes and gap junctions (Fig 1-4). JE is permeable with wide intercellular spaces, making it a leaky tissue through which various cells and substances transmigrate; for example, bacterial toxins may pass into the periodontal tissues and polymorphonuclear leucocytes (PMNLs) readily migrate from the tissues into the gingival sulcus as part of the first line of the periodontal host defence system (see Chapter 2). The JE is also weak and is readily disrupted by periodontal probing or flossing which can cause it to split. The split occurs within the JE, rather than between the JE and enamel; fortunately, this is soon repaired (two to six days) due to the rapid turnover of epithelial cells. The most coronal surface of the JE forms the base of the gingival sulcus, where it is approximately 0.15mm wide and comprises 20 – 30 cell layers. The most apical extent of normal, healthy JE is usually at the CEJ and is only a single cell layer wide (see Figs 1-3 and 1-4).
The presence of a plaque-free zone (PFZ) corresponding to the JE was first reported to be present on extracted teeth in the 1940s. Subsequent studies demonstrated that three zones can be identified within this PFZ: a narrow, permeable coronal zone with few JE cell remnants, a middle adhesive zone where many JE cell remnants are visible and an apical zone in which the JE cells have germinative characteristics. The studies showed that the width of the JE is variable, and that it is widest around the molars and narrowest around incisors. The JE generally decreases as the loss of attachment (LOA) and pocket depth increase. The base of the JE is confluent with the most coronal extent of the periodontal connective tissue attachment level, an important landmark (Fig 1-3).
In children free from periodontal disease, it would be expected that the periodontal connective tissue attachment level would be at the CEJ on the fully erupted tooth and that the epithelial attachment would be located on enamel. The molar tooth in Fig 1-5, extracted due to caries in a teenager, has been stained with Gomori’s stain for one minute. Two grooves can be seen that mark the gingival margin mid-buccally and mesiobuccally prior to extraction. Supragingival plaque is evident on the crown of the tooth that has a wide PFZ corresponding to the previous location of the JE. A band of adhesive JE cell remnants in the middle of the PFZ is visible. After extraction, some of the periodontal fibres remain in the tooth socket while the rest adhere to the tooth root. It can be seen that the periodontal fibres are attached right up to the CEJ, showing that there has been no LOA. This healthy status can be maintained through the teenage years to adulthood (see Fig 1-3).
The predominant tissues of the gingiva and periodontal ligament are the connective tissues that principally comprise collagen fibres (60%), with fibroblasts (5%), blood and lymph vessels, nerves and extracellular matrix forming the rest. The gingival collagen fibres are organised into bundles, which are named according to their course and insertion (Figs 1-6 and 1-7):
dentogingival fibres
alveologingival (alveolar crest) fibres
circular fibres
transseptal fibres.
The periodontal ligament (PDL) has several functions, the most important being to provide attachment between the root cementum and alveolar bone. It resists the forces applied to the tooth and thus protects the nerves and blood vessels at the root apex from damage during function. The PDL is responsible for the mechanisms by which the tooth attains and maintains its functional position after eruption, including the phenomenon of tooth drifting that may occur as a consequence of periodontal destruction. Cells from the PDL have a role in the formation, maintenance and remodelling of alveolar bone and cementum. Mechanoreceptors in the PDL provide sensory input for reflex jaw activities.
The periodontal ligament fibres (Fig 1-8) are grouped into:
alveolar crest fibres
horizontal fibres
oblique fibres
apical fibres.
The portions of the principal periodontal ligament fibres that are embedded in the cementum and alveolar bone are called Sharpey’s fibres.
Cementum can be classified into two types according to the presence or absence of cells (Fig 1-9):
Acellular (primary) cementum forms on the root dentine during root formation and tooth eruption. Mineralised Sharpey’s fibres form a large proportion of acellular cementum.
Cellular (secondary) cementum contains cementocytes in lacunae and canaliculi and forms after tooth eruption in response to function. It usually overlies the acellular cementum in the apical area of the root where the cementum layer is generally thicker (0.2–1.0mm) than in the coronal part of the root (0.05–0.10mm).
The alveolar bone is that part of the maxilla or mandible that supports and protects the teeth. There are two types of bone: compact (cortical) bone is dense and solid; spongy (cancellous) bone contains a lattice of bony trabeculae. The external and internal alveolar plates on both the buccal and the lingual surfaces are formed of compact bone, while in between is a variable amount of spongy bone. Posteriorly, the external alveolar plate is 1.5–3.0mm thick but is thinner and more variable around the anterior teeth. The thickest cortical bone is on the buccal aspect of the mandibular molars, whereas the thinnest is on the mandibular incisors. This anatomical variation accounts for two clinical phenomena.
It influences the ability of local anaesthetic solution to permeate the alveolus to reach the nerves supplying the anterior and posterior teeth in the mandible and maxilla. It is also one of the factors that influences the choice of local anaesthetic technique for periodontal therapy (see Chapter 8 and also Meechan 2002).
The thinness of bone in the lower incisor region predisposes to the development of bony fenestrations (windows in the bone), and dehiscences (gaps in the bone) which, in turn, may be associated with recession of the overlying gingiva (Fig 1-10).
The tooth sockets are lined by a thin layer of compact bone that provides attachment to some of the principal periodontal ligament fibres. Radiographically, this bone appears as a dense white line that is called “lamina dura”. Studies carried out by Clerehugh’s group (in conjunction with Hausmann’s team in Buffalo, USA) have shown that in healthy teenage subjects with no clinical loss of attachment, the alveolar crest is situated between 0.4mm and 1.9mm apical to the CEJ.
Plaque-induced gingivitis is characterised by micro-ulceration of the JE, inflammatory cell infiltration of the connective tissue, lateral proliferation of the JE and formation of rete ridges. It can occur at any age from childhood, through teenage years and young adulthood, to beyond (Fig 1-11). As the supragingival plaque accumulates, so the inflammatory infiltrate increases and attachment between the enamel and the JE weakens. This allows migration of the plaque in an apical direction with deepening of the gingival sulcus and extension of the plaque subgingivally. In this way a gingival pocket forms. The most apical extent of the JE is still, however, at the CEJ, no LOA has occurred and the alveolar bone is still intact. This process is entirely reversible provided the aetiological agent, plaque, is removed.
A severe inflammatory process may be accompanied by swelling of the gingival margin, thereby creating a false gingival pocket over 3mm deep, i.e. the base of the pocket is still at the CEJ (Fig 1-12), and there has been no LOA or bone loss. Although gingivitis may remain stable for weeks, months, years or may never progress, some patients or sites may be at risk of progression to irreversible periodontitis for a variety of reasons (see Chapter 2).
There are three key features of periodontitis, irrespective of the type:
Loss of attachment of the periodontal connective tissues to the cementum.
Apical migration of the JE beyond the CEJ (clinical attachment level now apical to CEJ) and transformation of the JE to pocket epithelium which is often thin and ulcerated.
Alveolar bone loss.