Paediatric periodontology Flashcards
What are the aims of 2021 guidelines for Periodontal screening and management of under 18years of age?
- Outline method of screening under 18years for periodontal diseases during routine clinical dental examination in order to detect presence of gingivitis or periodontitis at earliest opportunity
- Provide guidance on periodontal management and when it is appropriate to treat in practice or refer to specialist services, thus optimizing periodontal outcomes for children and young adolescents
What is the Mnemonic to remember the 2017 World Workshop classification for periodontal disease?
Please Give Greg Nine Percy Pigs Straight Past Meal Time Tonight
What are the categories for 2017 World Workshop Classification of periodontal disease?
- Periodontal health (Intact or reduced periodontium)
- Gingivitis - dental biofilm induced (intact or reduced periodontium)
- Gingival diseases and conditions - non dental biofilm induced
- Necrotising periodontal diseases
- Periodontitis
- Periodontitis as a manifestation of systemic disease
- Systemic disease or conditions affecting periodontal supporting tissues
- Periodontal abscesses and endodontic-periodontal lesions
- Mucogingival deformities and conditions
- Traumatic occlusal forces
- Tooth and prosthesis related factors
What is periodontal health?
- A state free from inflammatory periodontal disease
- Allows an individual to function normally
- Avoids physical and mental consequences due to current or past disease
What are features of healthy periodontium in children?
- Gingival margin several mm coronal to cemento-enamel junction
- Gingival sulcus 0.5mm-3mm deep on fully erupted tooth
- In teenagers, alveolar crest situated between 0.4mm-1.9mm apical to CEJ
What can cause reduced periodontium in the 2017 classification?
In a non-periodontal patient
- Crown lengthening surgery
- Recession
In a periodontal patient
- Stable periodontitis
In regard to BPE what is the clinical presentation of periodontal health?
- <10% Bleeding on probing is clinical periodontal health in either intact or reduced periodontium
What are the two types of gingival conditions?
- Plaque biofilm-induced gingivitis with either intact or reduced periodontium
- Non plaque biofilm-induced gingivitis/ gingival lesion
What is plaque biofilm-induced gingivitis?
- Supragingival plaque accumulates on teeth
- Inflammatory cell infiltrate develops in gingival connective tissue
- Junctional epithelium becomes disrupted
- Allows apical migration of plaque and increase in gingival sulcus depth
- Gingival pocket/ false pocket/ pseudo pocket
- Most apical extension of junctional epithelium is still CEJ
- Process is reversible
- No periodontal attachment loss
What can gingival diseases non-dental biofilm induced be?
- Manifestations of systemic conditions
- Pathologic changed limited to gingival tissues
What are the sub-classifications of Gingival diseases: non-dental biofilm induced?
1) Genetic/Developmental disorders
2) Specific infections
3) Inflammatory and immune conditions and lesions
4) Reactive processes
5) Neoplasms
6) Endocrine
7) Nutritional and metabolic diseases
8) Traumatic lesions
9) Gingival pigmentation
What genetic factors can cause gingival diseases and conditions: non-dental biofilm induced?
- Phenotype
- Hereditary fibromatosis (characterised by benign, non-haemorrhage, fibrous gingival overgrowth showing clinically pink gingiva with marked stippling and can prevent eruption)
What Infective factors can cause gingival diseases and conditions: non-dental biofilm induced?
- Viral
- Fungal
- Bacterial
- Deep mycoses (disease caused by fungi)
What Trauma factors can cause gingival diseases and conditions: non-dental biofilm induced?
- Thermal/ chemical
- Physical
What Drug induced factors can cause gingival diseases and conditions: non-dental biofilm induced?
- Immune complex reactions
- Anti-retro-viral
- Immunosuppressants
- Ca+ channel blockers
- Anti- convulsant
- Cytotoxic
What Manifestation of systemic disease factors can cause gingival diseases and conditions: non-dental biofilm induced?
- Granulomatous inflammation
- Immunological conditions
What are features of Necrotising gingivitis?
- Pain
– Necrosis of interdental papillae -“punched out” appearance
– Ulceration
– Spontaneous bleeding
– Secondary foetor oris
– Pseudomembrane may be present
– +/- lymphadenopathy
– Fever
– May manifest in teenagers
– May progress to necrotising periodontitis (NP)
What are risk factors of Necrotising gingivitis?
- Smoking
- Immunosuppression
- Stress
- Malnourishment
- Poor diet
What is the aetiology of Necrotising gingivitis?
- Fusiformspirochaetal microbial aetiology
- Socioeconomic factors esp in developing countries
- Local factors inc root proximity and tooth malposition
- Systemic factors inc HIV positive status
- Underlying undiagnosed pathology in immunosuppressed host
What are the modifying (systemic risk factors) factors for the other conditions affecting the periodontium?
- Smoking tobacco
- Metabolic factors (hyperglycaemia/ Diabetes type 1)
- Pharmacological agents (cyclosporin)
- Nutritional factors (Vit C deficiency)
- Increase in sex steroids (puberty or pregnancy)
- Haematological conditions (Leukaemia)
What are the predisposing (local risk factors) for other conditions affecting periodontium?
Malocclusion
- Instanding or rotating tooth
- Traumatic occlusion: Low frenal attachments
Traumatic dental injury
- Damage to PDL i.e. luxation/ intrusion/ avulsion
Dental plaque-biofilm retentive factors
- Tooth anatomy e.g. talon cusp, cingulum, enamel pearl, enamel defects like pits or grooves
- Restoration margins/ overhangs/ cavities
- Ortho/Prosthodontic appliances
- Incompetent lip seal lead to oral dryness as decrease saliva flow and decrease saliva quality
What is gingival overgrowth related to?
- Systemic and metabolic diseases
- Genetic factors like hereditary gingival fibromatosis
- Local factors
- Side effects by some medications e.g. cyclosporin, phenytoin and calcium channel blockers
How is gingival overgrowth treated?
- Rigorous home care and OHI
- Frequent appointments for professional mechanical plaque removal PMPR
- surgery? esp with drug induced gingival overgrowth
When to consider for referral to physician for haematinic screening?
- In cases where extent of condition is inconsistent with level of oral hygiene observed
- With unexplained gingival enlargement/ inflammation/ bleeding/ tooth mobility
What is periodontitis?
- A chronic multifactorial inflammatory disease
- Associated with dysbiotic (microbial imbalance) plaque biofilms
- Characterised by progressive destruction of the tooth-supporting apparatus.
- Multifactoral disease influences:
– dysbiotic microbiome changes ARE more likely for some patients than for others
– May influence severity of disease
What are the 4 main features of Periodontitis?
- Apical migration of Junctional epithelium beyond CEJ
- Loss of attachment of periodontal tissues to cementum
- Transformation of junctional epithelium to pocket epithelium (often thin and ulcerated)
- Alveolar bone loss
What pathogens can be found in subgingival microflora of teenagers with periodontitis?
- Porphyromonas gingivalis
– Prevotella intermedia
– Aggregatibacter actinomycetemcomitans. (AA)
– Tannerella forsythia (associated with subsequent
clinical attachment loss in a 3- year longitudinal
study in adolescents
What is included in Diagnosis of Periodontitis?
- Staging
- IP bone loss at worst site of bone loss due to periodontitis
- Stage I/ Stage II/ Stage III/ Stage IV - Grading
- Rate of progression (diabetes glycaemic control vital for grading)
- %bone loss/age
- Grade A/ Grade B/ Grade C - Assess current periodontal status
- Currently stable/ in remission/ unstable - Risk assessment
- Smoking
- Poorly controlled diabetes
What are the features of Necrotising Periodontitis?
- Necrosis/ulceration of the interdental papilla,
- Bleeding of the gingival tissues
- Periodontal ligament loss and rapid bone loss
- Pseudomembrane formation
- Lymphadenopathy
- Fever
What is Necrotising stomatitis?
- Severe inflammatory condition
- Necrosis extends beyond gingiva to soft tissues, leading to bone denudation (erosion)
- Severely systemically compromised patients
What to keep in mind about periodontitis in children?
Primary dentition - some evidence that bone loss can occur around primary teeth in some children and its not perio
Mixed dentition - False pocketing can be present around erupting dentition
What are the features of Periodontitis Molar Incisor Pattern?
- Present in small proportion of adolescents (uncommon)
- Rapid attachment loss and bone destruction
– Patient is otherwise healthy
– Onset around puberty
– Family history
– 0.1% Caucasians and 2.6% African Ancestry
What is localised Molar incisor pattern periodontitis?
- Localised to incisors and first molars
What is generalised Molar incisor pattern periodontitis?
- > = 3 permanent teeth other than incisors and first molars
- Onset usually older but sometimes under 30
- Staging and grading essential for up-to-date diganosis
What systemic diseases can paediatric patients have giving them periodontitis as a manifestation of systemic disease?
– Papillon – Lefevre syndrome (PLS)
– Neutropenias
– Chediak-Higashi syndrome
– Leucocyte adhesion deficiency syndrome (LAD)
– Ehlers – Danlos sydndrome
– Langerhans’ cell histiocytosis (LCH)
– Hypophosphatasia
– Down syndrome
When looking at gingival condition during periodontal screening what should be recorded?
- Gingival colour
- Contour
- Swelling
- Recession
- Suppuration
- Inflammation (presence and location)
- Consider use of marginal bleeding free chart
What to record when assessing OH status during periodontal screening?
- Description of plaque status
- Describe surfaces covered by plaque
– Is plaque easily visible?
– Detectable only on probing?
– Use of plaque-free scores (%)- motivational aid to patient
Assess if any calculus present and chart location
What to record when assessing local risk factors during periodontal screening?
– Plaque retention factors.
– Low frenal attachments
– Malocclusion
Incompetent lip seal:
-Reduced upper lip coverage- labial and palatal gingivitis
- Increased lip separation
Mouth breathing:
- Palatal gingivitis
What is a simplified BPE?
- Screening tool to guide clinician to arrive at provisional diagnosis of periodontal health, gingivitis or periodontitis
- Used in all co-operative children aged 7-18 years old
- Uses only 6 teeth 16,11,26,36,31,46
- Designed to be quick, easy, well tolerated and avoid false pocketing
How to perform a simplified BPE?
- Use WHO 621 probe
- 20-25g force application same as adults
- Inserted parallel to root surface and walked around gingival margin
- Coronal to CEJ
- 16,11,26,36,31,46
What do the simplified BPE codes mean?
0 - Healthy
1 - Bleeding after gentle probing with black band fully visible
2 - Calculus or plaque retention factor with black band fully visible
3 - Pocketing 4mm-5mm with black band partly visible
4 - Pocketing >= 6mm with black band disappears
* - Furcation involvement
What BPE codes can only be used between 7 and 11years old?
0, 1 and 2 used for 7-11years
1-4 used for 12-17years
Why are plaque and bleeding scores useful?
- Can be motivational for child so higher score reflects improvement
What to do if BPE scores is code 3 or 4 for 12-17year old?
- 6 Point pocket chart (localised to 3 BPE or full if 4)
- Check alveolar bone level with bitewings for posterior and periapical for anteriors and OPG esp if part of orthodontic treatment
Should BPE be carried out before or after orthodontic treatment?
- Before
What preventative oral health messages should you be delivering?
- Plaque induced gingivitis / progression of early
periodontal disease in children and adolescents can be prevented by affective toothbrushing (careful and
regular removal of dental plaque biofilm)
– systematically clean all surfaces
– Hands on demonstration – supervised toothbrushing
– Modified bass technique
– Consider disclosing tablets
Standardised prevention with fluoride advice
Smoking cessation
– paramount importance in teenage years
– 11% of 15-year-olds reported being a current smoker and 29% reported having ever smoked cigarettes
Oral health measures
What to do if BPE code 0?
- No periodontal treatment
- Screen at routine recall or within 1 year (whichever is sooner)
What to do if BPE 1?
- OHI
- Screen at routine recall or within 1 year (whichever sooner)
What to do if BPE 2?
- OHI
- Supragingival / subgingival professional mechanical plaque removal (PMPR)
- Remove / manage plaque retention factors
- Screen at routine recall or within 6months (which ever sooner)
What to do if BPE 3?
- OHI as for codes 1 and 2
- Supragingival / subgingival PMPR in shallow 4 – 5mm pockets.
- Remove / manage plaque retention factors
- 3 months full periodontal assessment inc 6Point pocket probing depth (PPD) chart in affected sextants
What to do if BPE 4 or *?
- Unusual in young patients
- Full periodontal assessment, including 6-point
PPD chart, throughout entire dentition - Consider referral to a Specialist, while doing
initial therapy (as per code 3)
What is Step 1 Building Foundations for Optimal Treatment Outcomes in S3 Treatment Guidelines?
- Focus on behaviour change/motivation to successfully control plaque biofilm (OHI)
- Possible adjunctive therapies for gingival inflammation;
- Supragingival Professional Mechanical Plaque Removal (PMPR) to remove supragingival plaque/calculus
- Risk factor control.
What is Step 2 Cause-related Therapy in S3 Treatment Guidelines?
- Aims to control (reduce/eliminate) the subgingival plaque biofilm and calculus by subgingival instrumentation (subgingival PMPR).
- May also involve use of: adjunctive physical or chemical agents; adjunctive local or systemic host modulating agents; adjunctive subgingival locally delivered antimicrobials; adjunctive systemic antimicrobials.
What is Step 3 Management of Non-responding Sites (> 4mm with BOP or > 6 mm) in S3 Treatment Guidelines?
- Aims to gain access to further subgingival instrumentation or to achieve regeneration or resection in lesions (infrabony or furcation)
that increase complexity in managing periodontitis.
What is Step 4 Supportive Periodontal Care (Maintenance) in S3 Treatment Guidelines?
- Aims to maintain periodontal stability in all treated periodontitis patients.
- Combines preventive/therapeutic interventions from Steps 1 and 2.
- Regular recall intervals are needed, tailored to patient’s individual needs.
- Recurrent disease to be managed with updated
diagnosis and treatment plan. - Compliance with OHI/ healthy lifestyle are integral.
If patient given diagnosis of generalised periodontitis, stage III, grade C , currently unstable no risk factor - what are following steps?
- Systematic periodontal treatment needed initiated.
- Outcome of treatment will not result in a change of the initial disease classification.
-This patient will always be a periodontitis
patient, with evidence of high disease susceptibility (as indicated by grade C), requiring careful and intensive periodontal maintenance, risk factor control and monitoring.
When should a GDP consider referral to specialist service?
- Stage II, III periodontitis not responding to treatment
- Grade c or stage IV periodontitis
- MH that sig affects periodontal treatment or requiring multi-disciplinary care
- Periodontitis as direct manifestation of systemic disease
- Systemic/genetic disease that can affect periodontal supporting tissues
- Root morphology/furcation defects adversely affecting prognosis on key teeth
- Non-plaque induced conditions requiring complex or specialist care
- Cases requiring diagnosis/management of rare/complex clinical pathology
- Drug induced gingival overgrowth needing surgery
- Cases requiring evaluation for periodontal surgery
