Periodontal Diseases in Children and Adolescents

Periodontal Diseases in Children and Adolescents

Healthy gingivae in children are soft and slightly red as compared to those of adults since the blood vessels in connective tissues are relatively transparent due to the loose collagen
fibers under the thin keratinocyte layer.

Stipplings in the gingiva are initially found at the age of 2-3 years and these become
prominent at around 6-7 years old.

– The marginal gingiva appears to be round and thick, which is associated with the protruded morphology of the cervical areas in the primary teeth.

The average periodontal pocket depths are approximately 1 mm for all teeth, whereas those of the maxillary primary molar regions tend to be slight deeper.

When permanent teeth emerge in the oral cavity, the gingival sulcus becomes deeper and the marginal gingivae become extremely thin.

– The thickness of the marginal gingiva in children and adolescents increases to the same amount as adults by their late teens.

1. Definition, Classification, and Clinical Evaluations

– Table below lists the well-known classification of the periodontal diseases defined by the
American Academy of Periodontology in 1999, which was a revision of the previous
classification developed in 1989.

According to the 1989 classification, there were no descriptions of gingival diseases, whereas dental plaque-induced or non-induced gingival diseases are listed in the 1999 classification.

In addition, the term “Adult periodontitis ” was replaced with “Chronic periodontitis based on the epidemiological data and clinical experience, in which this form of periodontitis is also identified in adolescents.

Classification of periodontal diseases defined by the American Academy of Periodontology



I. Gingival diseases

A. Dental plaque-induced gingival diseases

B. Non-plaque-induced gingival diseases


V. Necrotizing Periodontal Diseases

A. Necrotizing ulcerative gingivitis (NUG)

B. Necrotizing ulcerative periodontitis (NUP)



II. Chronic Periodontitis

A. Localized

B. Generalized

VI. Abscess of the Periodontium

A. Gingival abscess

B. Periodontal abscess

C. Pericoronal abscess



III. Aggressive periodontitis

A. Localized

B. Generalized

VII. Periodontitis Associated With
Endodontic Lesions

A. Combined periodontic-endodontic lesions



IV. Periodontitis as a Manifestation of
Systemic Diseases

A. Associated with hematological disorders

B. Associated with genetic disorders

C. Not otherwise specified (NOS)


VIII. Developmental or Acquired Deformities and Conditions

A. Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis

B. Mucogingival deformities and conditions around teeth

C. Mucogingival deformities and conditions on edentulous ridges

D. Occlusal trauma



As for the periodontitis identified in young patients, the term “Early-onset periodontitiswas used in the 1989 classification, however, the term was changed to “Aggressive periodontitisin order to minimize potential problems with age-dependent features of classification.

– There was another category “Periodontitis associated with systemic disease” in the 1989
classification, which was changed to “Periodontitis as a manifestation of systemic diseases.

Despite this small change,this category wasbasically retained. In addition, replacement of “Necrotizing ulcerative periodontitis with “Necrotizing periodontal diseases and addition of the categories of “Periodontal abscess”, “Periodontic-endodontic lesionsand
Developmental or acquired deformities and conditions were implemented.

– These classifications will likely be reviewedin the future based on discussions of updated

Considering periodontal diseases in children, we classify the clinical conditions into gingivitis, chronic periodontitis, invasive periodontitis (localized or generalized), periodontitis
associated with systemic disease, and necrotizing periodontitis.

– In addition, it is clinically useful to designate prepubertal and juvenile periodontitis
corresponding to the primary and permanent dentitions, respectively.

In our daily practice, clinical evaluations are performed using the standard parameters of
periodontal diseases, ie.probing depth, bleeding on probing, pus discharge, tooth mobility, plaque index , and gingival index.

We generally measure periodontal pocket depths to the nearest millimeter at 6 points around the circumference of each tooth (mesio-, mid-, and disto-buccal; and disto-, mid-, and mesio-lingual) from the gingival margin to the deepest probing point, using
a round-ended probe tip 0.4 mm in diameter. Bleeding on probing is scored as follows;
(+) immediate bleeding on probing or (-) no bleeding.

– Tooth mobility is scored as follows; (2) moderate mobility (1~2 mm) in a bucco-lingual
direction, and (1) slight mobility (0.2~1 mm) in a bucco-lingual direction, or (0) physiological mobility within 0.2 mm.

Pus discharge is scored as follows; (+) spontaneous pus discharge, or (-) no pus discharge.

2. Gingivitis

Gingivitis is defined as localized inflammation of the marginal gingival without resorption of alveolar bone.

The affected gingiva shows swelling and redness as well as ready bleeding upon probing or brushing.

All of the cases are derived from poor oral hygiene.

The basic treatment is mechanical removal of the dental plaque or calculus in combination with professional tooth brushing instructions. Simple gingivitis is the term representing
gingivitis initiated by poor oral hygiene conditions.

The condition of the inflamed lesion is reversible in most of the cases in children, and removal of the dental plaque or calculus allows the lesions to return to the normal state.

When we encounter the cases of erupting tooth, it is difficult to maintain adequate hygiene conditions in these areas due to the difficulty of cleaning.

– “Erupting gingivitis” which represents gingivitis with poor hygiene of the erupting teeth, also belongs to this category.

The incidence of gingivitis in children increases as they grow and reaches its peak at the age of 10-12 years, which we specifically call “Pubertal gingivitis.

This gingivitis is often found in girls with gingival swelling and redness especially at the dental papilla.

– It is likely that hormonal changes are associated with this increased susceptibility to gingival inflammation.

Thorough oral hygiene interventions can readily reverse this condition.

On the other hand, acute necrotizing ulcerative gingivitis (ANUG) is a rare condition in Japan although the incidences in developing countries are reported to be high.

– The gingival tissues of dental papilla and the gingival margin were observed to be red with
ulcerative lesions with the morphology of a crater.

The ulcerative lesion is gray and covered with a pseudomembrane which is easily removed and even a slight stimulation is known to cause severe pain.

At the initial stage, systemic antibiotics rapidly reverses this condition.

– The lesion should also be differentiated from viral stomatitis. It should be noted that cases with herpetic gingivostomatitis are occasionally encountered in infants and children.

The severe inflammation, such as swelling, redness, erosion, is identified with specific foul breath odor.

At the initial stages, severe fever is observed, whereas it is generally cured within 2 weeks.

However, it takes more time to recover in cases with difficulties in ingesting food due to
severe pain in the oral cavity. Antibiotic administration and the adequate availability of
water as well as nutrients are very important for healing the lesions.severe gingivitis erupting gingivitis acute necrotizing ulcerative gingivitis acute herpetic gingivostomatitis.

3. Periodontitis

Periodontitis is defined as the disease leading to destructionof periodontal tissues, such as the periodontal ligament, cementum and alveolar bone.

Periodontitis in children is generally regarded as an extremely rare finding.

In generalized prepubertal periodontitis, the alveolar bone of all teeth are resorbed, with
severe redness and swelling due to the intensive inflammation.

Although the incidence is extremely low, early exfoliation of primary teeth is prominent.

Generalized prepubertal periodontitis is known to be an oral manifestation of leukocytes
adhesion deficiency.

Antibiotics therapy is carried out to stabilize the lesions in acute inflammation to prevent the lesions progressing gradually leading to the spontaneous exfoliation of the affected teeth.

On the other hand, localized pre pubertal periodontitis is initiated by sudden pain and
mobility of the several limited teeth.

The repeated acute attacks develop into progressive alveolar bone loss.

The inflammation can be observed only during the period of acute attack and no abnormal findings can be seen in periods without acute inflammation.

The incidence is considered to be higher than localized juvenile periodontitis.

It should be noted that this category does not include cases of hypo-phosphatasia associated with problems in the generation of periodontal ligaments.

Antibiotic treatment is carried out to stablize the lesion as with generalized prepubertal

– In order to preserve the affected teeth as long as possible, thorough oral hygiene instruction and local application of antibiotics are performed.

Localized juvenile periodontitis (LJP) is widely known as the specific form of periodontitis identified in adolescents.

The detection frequency of LJP in Japanese adolescents is reported to be 0.06-0.2%.

The vertical alveolar bone resorption is found predominantly in the first permanent molars and central incisors and is identified in females more frequently than in males.

Early diagnosis and intervention are required since the speed of the resorption of alveolar bone is very fast.

Thorough mechanical teeth cleaning and local application of antibiotics enables control of disease development.localized prepubertal periodontitis localized juvenile periodontitis

4. Gingival Recession

Gingival recession is occasionally identified at the labial gingiva of mandibular incisor teeth, which is dislocated out of the dental arch due to space limitations.

– The labial alveolar bone of the teeth is thin due to mechanical forces, such as traumatic
occlusion and tooth brushing.

In order to solve this problem, the affected teeth should be moved within the dental arch for the former case and instruction for appropriate tooth brushing for the latter case.gingival recession

5. Gingival Overgrowth

Gingival fibromatosis is a rare overgrowth associated with increased levels of mature collagen and the enlarged gingival tissues are usually normal in color, firm in consistency, painless and occasionally nodular with little inflammation.

– Gingival fibromatosis causes esthetic and functional problems, such as malposition of teeth, prolonged retention of primary teeth and delayed eruption of permanent successors.

In addition, the hyperplastic region produces conditions favorable for accumulation of dental plaque causing secondary inflammatory changes although alveolar bone is not affected.

– Gingival fibromatosis is known to have hereditary predispositions in some patients.

On the other hand, cases without apparent genetic links are also present, in which specific

medication, such as phenytoin,commonly used as an antiepileptic, can lead to the onset and development of the lesion.

Furthermore, cyclosporine, an immunosuppressant drug, and nifedipine, a calcium channel blocker used as an antihypertensive agent, are also known to cause similar gingival overgrowth.

Phenytoin is known to stimulate responsive subpopulations of gingival fibroblasts to accumulate extracellular matrix components, resulting in gingival overgrowth, whereas several studies have found a relationship between the quantity of accumulated dental plaque and phenytoin-induced gingival overgrowth.

It was also recently indicated that dental plaque accumulation is the most important determinant of phenytoin-induced gingival overgrowth.

– Therefore, it is now believed that enhanced matrix synthesis by fibroblasts responsive to phenytoin can be triggered or enhanced by chronic inflammation due to dental plaque.

– In general, professional teeth cleaning and tooth brushing instruction are performed and gingivectomy is carried out for severe cases although recurrence of the lesion is often observed.

A 10-year-old girl was referred to our clinic for consultation due to the swollen gingiva in her incisor regions that caused esthetic problems.

– Intraoral examinations showed severe generalized gingival overgrowth involving both
maxillary and mandibular teeth, which covered almost half of the crown.

She had no medical disorders and none of the family members exhibited any gingival

Gingivectomy was carried out under local anesthesia, which solved her esthetic problems.

Histopathological analyses showed the typical appearance of gingival fibromatosis.

There were no recurrences of the lesion reported in this case.

However, it is possible to speculate that poor oral hygiene can lead to the recurrence of
overgrowth, which should be periodically monitored.Gingival fibromatosis Gingival fibromatosis gingival fibromatosis.

6. Acute Periodontitis

Acute periodontitis is not listed in the classification now used in the field of periodontology.

However, cases of rapid loss of gingival attachment and alveolar bone resorption
development in a couple of days are described in the oral pathology literature.

Appropriate interventions enable recovery to healthy periodontal conditions for several months.

The initiation of these conditions is considered to be the result of infection by pyogenic
bacteria at the sites of small injuries present in the gingival sulcus.

– Although rarely encountered, irrigation of the gingival pocket and systemic antibiotic therapy generally suppress acute inflammation within a week.

A 10-year-old Japanese girl came to our hospital with the chief complaint of severe tooth
mobility in her lower permanent incisors.

The incisors were shown to have severe alveolar bone loss and periodontal pocket depths
exceeding 7 mm.

– Periodontal treatment consisting of mechanical debridement and antibiotic medication
resulted in a significant improvement of the clinical parameters.

Three months after the first examination, periapical radiographs showed refilling of the
alveolar bone in the affected tooth.

– It is of interest that microbiological examinations at the first visit did not identify any typical periodontitis-related pathogens, whereas several periodontitis-associated species were identified in the examinations held after the healing of the lesions.

Orthodontic bands could also be one of the possible initiators of acute periodontitis.

– An 11-year-old boy was referred to our clinic for treatment of gingival swelling and severe
occlusal pain around the mandibular left permanent molar.

– Intraoral examinations showed that gingival swelling with apparent redness around the
affected tooth.

The maximum periodontal pockets depth was 9 mm and the affected tooth showed severe mobility.

According to the orthodontist, the orthodontic band was removed just before visiting our clinic.

Periapical radiograph showed alveolar bone loss on the distal side.

Irrigation of the marginal gingiva with systemic antibiotics was performed.

– Twelve days later, inflammation of the affected gingiva had diminished and the maximum periodontal pocket was reduced to 6 mm.

Three months later, bleeding on probing had stopped and the maximum periodontal pocket was reduced to 3 mm. Interestingly, there was no typical periodontitis related species
identified at the first examination, whereas some of the species were detected after the
lesion recovered.

Transitional changes of the periodontal condition in acute periodontitis associated with
orthodontic band


Days after the first visit







Periodontal pocket depth (mm)







Bleeding on probing





Gingival index







Plaque index







Tooth mobility




Pus exudate

acute periodontitis acute periodontitis

7. Accidentally-Induced Periodontitis

Accidentally-induced periodontitis is unique for infants and younger children in which the
materials fitted to the teeth, such as small plastic tubes, are accidentally inserted into the tooth crown and cause attachment loss.

In our clinic, only 4 cases have been encountered over a period of approximately 40 years, all of which were accidentally induced by the insertion of plastic tubes into the lower primary central incisor region.

– In 3 of those, a single plastic tube had been inserted into the left lower primary central incisor area, whereas 2 tubes were found simultaneously in the dental cervix of the lower primary central incisors.

A 4-year-old boy was referred with the chief complaint of swelling around his lower primary incisors.

Clinical examinations revealed inflamed gingival tissue around the lower primary central
incisors and severe mobility of these teeth. Small transparent plastic tubes were found in the dental cervix of the lower primary central incisors, which were likely accidentally
inserted during play.

A periapical radiograph revealed diffuse alveolar bone loss between the lower primary central incisors.

Irrigation of the affected teeth was performed.

Table 3 summarizes the transitional changes in his periodontal health.

– Three months after the first visit, an examination revealed recovery of gingival attachment, and a periapical radiograph showed that the alveolar bone defects between the lower
central incisors were being repaired.

However, the periodontal condition of the affected teeth could not be restored to their
original status.

It was concluded that the type of periodontitis caused by such an incident is not progressive, unlike other periodontal diseases such as prepubertal and juvenile periodontitis.

Transitional changes of the periodontal condition in acute periodontitis associated with plastic tubes insertion


Months after the first visit







Periodontal pocket depth (mm)







Bleeding on probing


Gingival index







Plaque index







Tooth mobility



Pus exudate

 accidentally-induced periodontitis accidentally-induced periodontitis

8) Periodontitis Associated with Systemic Diseases

In spite of the extremely low frequency of periodontitis in systemically healthy children,
periodontitis in children is identified in certain types of systemic diseases mainly due to the impairment of the host immune response.

It is well known that patients with neutropenia, Chédiak-Higashi syndrome, Papillon-Lefèvre syndrome, Down‘s syndrome, diabetes mellitus, hypophosphatasia, Histiocytosis syndrome, Ehlers-Danlos syndrome, and acquired immunodeficiency syndrome, are prone to develop periodontitis.

Hypophosphatasia is generally known as one of the systemic diseases associated with
periodontitis. It is an inheritable disorder characterized by hypomineralization of bone
associated with the impaired activity of tissue-nonspecific alkaline phosphatase, and the disease is highly variable in clinical expression, ranging from an almost total lack of skeletal formation to the premature loss of the permanent anterior teeth.

– There are 5 subtypes based on the age of onset and clinical features; perinatal, infantile, childhood and adult types, and odonto hypophosphatasia, in which only the teeth are

– The common clinical signs are premature exfoliation of primary teeth, which is thought to be caused by a defect in cementum formation although some reports have noted that
accumulation of bacteria accelerates the exfoliation.

Thus, initiation of periodontitis in patients with hypophosphatasia involves periodontal pocket formation without a clear inflammatory process and is caused by cementum
impairment due to a low alkaline phosphatase concentration.

It is difficult to prevent the early exfoliation of the primary incisors although only a limited number of teeth, mainly mandibular anterior teeth, are affected.

– In addition, it is extremely rare to observe cases with early exfoliation of the permanent teeth.

– Local antibiotic irrigation and professional tooth brushing instruction may lead to modulation of the exfoliation period.

– At 3Y4M, an intraoral examination of the elder brother showed that the mandibular left
primary lateral incisor was missing and exposure of the root of the mandibular right primary canine was prominent.

In contrast, there were no specific problems in the younger brother although one tooth was missing due to a previous traumatic injury.

– The elder brother was diagnosed with periodontitis and professional tooth cleaning was
performed, while brushing instructions were given to the patient and his parents to prevent progression to tooth exfoliation.

Periodical examinations were carried out and 2 additional teeth were found exfoliated in the elder brother.

At 5Y3M, there were 15 teeth identified in the elder brother, while 19 teeth were identified in the younger brother.

Although cases with twin brothers are considered to result from genetic influences, their teeth phenotypes were totally distinct.hypophosphatasia

9. Peridontitis Associated with Anatomical Anomalies

A tooth with a radicular gingival groove is considered to be susceptible to periodontitis due to the weak binding of periodontal ligaments to the root surface.

– Although it is not common that anatomical problems have effects on the development of
periodontitis, the radicular-gingival groove is an anatomical anomaly of the teeth with
a reported prevalence of 2-4%, with the maxillary lateral incisors regarded as the area with the most frequent occurrence.

Such a groove is sometimes found as a radiolucent line in radiographic examinations and its main feature has been described as a “parapulpal line, which is similar to the line
produced by a vertical tooth fracture.

The chief complaint regarding the lesion caused by the groove is gingival swelling and pain, and root canal treatment or a flap operation is typically selected as general treatment
modalities for severe cases.

– Nevertheless, the prognosis for the lesions is considered to be poor.

An 11Y5M female came to our clinic with a chief complaint of severe gingival inflammation in the mandibular left lateral incisor.

The periapical radiograph showed a para pulpal line and the lesion was estimated to be
derived from the radicular gingival groove.

A gingivectomy was carried out, followed by local irrigation and thorough instructions
regarding tooth brushing.

After a long interval between examinations, she returned to our clinic at the age of 18Y4M and reported repeated slight swelling that had occurred for several years, although without severe signs or symptoms.

– We rationalized that the lesion is susceptible to inflammation due to her anatomical anomaly, however, careful oral hygiene possibly stabilized the lesion.

According to previous reports regarding cases with radicular-gingival grooves, the subject ages range from 12 to 45 years old and the maximum periodontal pocket depths were
between 6 and 9 mm, which are regarded as severe conditions.

Prognoses are considered to be poor and extraction of the affected teeth was reported in most of the cases in a range of 6 months to 3 years, while no significant recurrent signs or symptoms were observed for 1.5 to 3 years in several of the cases.

– Thus, periodical observation is important once we identify teeth with radicular-gingival grooves in order to intervene in the onset and development of periodontitis.periodontitis associated with radicular-gingival groove


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