Table of Contents

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

This book is dedicated to Tony and Mary with my love.
Val Clerehugh

Foreword

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

Preface

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.

Having Read This Book

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

Acknowledgements

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.

Chapter 1

Periodontal Problems in the Young: Myth or Reality?

Aim

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...

Outcome

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.

Children, Adolescents and Young Adults

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.

Key Features of the Periodontium in Health

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.

Gingiva

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).

Connective Tissue

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.

Periodontal Ligament

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

Cementum can be classified into two types according to the presence or absence of cells (Fig 1-9):

1. 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.

2. 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).

Alveolar Bone

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.

1. 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).

2. 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.

Key Features of Gingivitis

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).

Key Features of Periodontitis

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.