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Position Paper
Periodontal Diseases of Children and Adolescents*
This paper was prepared by the Research, Science and Therapy Committee of the American Academy ofPeriodontology and is intended for the information of the dental profession and the public. It represents a briefsummary of the current state of knowledge about periodontal diseases in children and adolescents. J Peri-odontol 2003;74:1696-1704.
Epidemiologic studies indicate that gingivitis of the microbiology of this disease has not been com- varying severity is nearly universal in children pletely characterized, increased subgingival levels of and adolescents.1-19 These studies also indicate Actinomyces sp., Capnocytophaga sp., Leptotrichia sp., that the prevalence of destructive forms of periodon- and Selenomonas sp. have been found in experimen- tal disease is lower in young individuals than in adults.
tal gingivitis in children when compared to gingivitis in Epidemiologic surveys in young individuals have been adults. These species may therefore be important in its performed in many parts of the world and among individuals with a widely varied background. For the Normal and abnormal fluctuation in hormone lev- most part, these surveys indicated that loss of peri- els, including changes in gonadotrophic hormone lev- odontal attachment and supporting bone is relatively els during the onset of puberty, can modify the uncommon in the young but that the incidence gingival inflammatory response to dental plaque.28,29 increases in adolescents aged 12 to 17 when com- Similarly, alterations in insulin levels in patients with pared to children aged 5 to 11.15-22 In general, in the diabetes can affect gingival health.28,29 In both situ- United States, epidemiologic studies indicate that the ations, there is an increased inflammatory response prevalence of severe attachment loss on multiple teeth to plaque.28,29 However, the gingival condition usually among children and young adults is approximately0.2% to 0.5%.23 Despite this low prevalence, children responds to thorough removal of bacterial deposits and adolescents should receive periodic periodontal evaluation as a component of routine dental visits.
On October 30-November 2, 1999, the American PERIODONTITIS
Academy of Periodontology assembled an International Aggressive Periodontitis, Chronic Periodontitis,
Workshop for a Classification of Periodontal Diseases and Periodontitis as a Manifestation of Systemic
and Conditions, which resulted in a new classification.24 Diseases
Periodontal diseases discussed here will reflect the new Children and adolescents can have any of the several classification system. Clinically distinct periodontal forms of periodontitis as described in the proceedings infections that can affect young individuals include: 1) of the 1999 International Workshop for a Classifica- dental plaque-induced gingival diseases; 2) chronic tion of Periodontal Diseases and Conditions (aggres- periodontitis; 3) aggressive periodontitis; 4) periodon- sive periodontitis, chronic periodontitis, and titis as a manifestation of systemic diseases; and 5) periodontitis as a manifestation of systemic diseases).
However, chronic periodontitis is more common inadults, while aggressive periodontitis may be more DENTAL PLAQUE-INDUCED GINGIVAL
DISEASES
The primary features of aggressive periodontitis Gingivitis Associated with Dental Plaque Only
include a history of rapid attachment and bone loss and Gingival Diseases Modified by Systemic
with familial aggregation. Secondary features include Factors Associated with the Endocrine System
phagocyte abnormalities and a hyperresponsive Gingivitis characterized by the presence of gingival macrophage phenotype.24 Aggressive periodontitis inflammation without detectable loss of bone or clini- can be localized or generalized. Localized aggressive cal attachment is common in children.1-19,25 Although periodontitis (LAgP) patients have interproximalattachment loss on at least two permanent first molars * This paper was developed under the direction of the Research, Science and incisors, with attachment loss on no more than and Therapy Committee and approved by the Board of Trustees of theAmerican Academy of Periodontology in August 2003.
two teeth other than first molars and incisors. Gener- alized aggressive periodontitis (GAgP) patients exhibit tibility of individuals to LAgP is unknown, but it is generalized interproximal attachment loss including possible that they play a role in the clinical course of at least three teeth that are not first molars and disease in some patients. Indeed, in some cases incisors. In young individuals, the onset of these dis- exhibiting phagocyte abnormalities, neutrophil defects eases is often circumpubertal. Some investigators may still be present after treatment.77 Molecular have found that the localized form appears to be self- markers of LAgP can include an abnormally low num- limiting,30 while others suggest that it is not.20 Some ber of chemoattractant receptors78-81 and an abnor- patients initially diagnosed as having LAgP were found mally low amount of another cell surface glycoprotein to have GAgP or to be periodontally healthy at a 6- designated GP-110.82,83 Adherence receptors on neu- trophils and monocytes, such as LFA-1 and Mac-1, LAgP occurs in children and adolescents without clinical evidence of systemic disease and is charac- GAgP, often considered to be a disease of adoles- terized by the severe loss of alveolar bone around cents and young adults, can begin at any age and permanent teeth.31 Frequently, the disease is local- often affects the entire dentition.84,85 Individuals with ized to the permanent first molars and incisors. How- GAgP exhibit marked periodontal inflammation and ever, some retrospective data obtained from LAgP have heavy accumulations of plaque and calculus.84 patients suggest that bone loss around the primary In the United States, the reported prevalence of GAgP teeth can be an early finding in the disease.33 Link- in adolescents (14 to 17 years of age) is 0.13%.23 age studies of the Brandywine population (a segre- Subgingival sites from affected teeth harbor high per- gated group of people in Maryland that represents a centages of non-motile, facultatively anaerobic, relatively closed gene pool) have found a gene con- Gram-negative rods including Porphyromonas gingi- ferring increased risk for LAgP on chromosome 4.34 valis.86,87 In one report, the levels of P. gingivalis and Subsequent linkage studies of African American and Treponema denticola were significantly higher in GAgP Caucasian families did not confirm linkage to this and LAgP patients compared to matched controls, locus, suggesting that there may be genetic and/or with GAgP patients having the highest levels.88 Neu- etiologic heterogeneity for aggressive periodontitis.35- trophils from patients with GAgP frequently exhibit 37 Reported estimates of the prevalence of LAgP in suppressed chemotaxis as observed in LAgP77,87 with geographically diverse adolescent populations range a concomitant reduction in GP-110. This suggests a from 0.1% to 15%.23,33-35,37-42 Most reports suggest relationship between the two variants of aggressive a low prevalence (0.2%), which is markedly greater in African American populations (2.5%).
Alterations in immunologic factors such as immuno- Many reports suggest that patients with LAgP gen- globulins are known to be present in aggressive peri- erally form very little supragingival dental plaque or odontitis. Immunoglobulins appear to be influenced calculus.31,43 In contrast, other investigators find plaque by both genetic and environmental factors and have and calculus at levels similar to other periodontal dis- important protective disease-limiting effects in aggres- eases.44,45 Bacteria of probable etiologic importance sive periodontitis patients.89-93 Human IgG antibody include highly virulent strains of Actinobacillus actino- molecules (immunoglobulin G) are categorized into mycetemcomitans in combination with Bacteroides- four subclasses designated as IgG1-4. Most of the anti- like species.46-49 In some populations, Eubacterium body reactive with A. actinomycetemcomitans is spe- sp. have been associated with the presence of cific for high molecular weight lipopolysaccharide and LAgP.50,51 To date, however, no single species is found is of the IgG2 subclass. This antibody response appears to be protective, as early-onset periodontitis patients A variety of functional defects have been reported having high concentrations of antibody reactive with in neutrophils from patients with LAgP.53-55 These A. actinomycetemcomitans lipopolysaccharide have include anomalies of chemotaxis,56-58 phagocyto- significantly less attachment loss (a measure of dis- sis,59,60 bactericidal activity,61 superoxide produc- ease severity) than patients who lack this antibody.89,90 tion,62-66 FcγRIIIB (CD16) expression,67 leukotriene Overall levels of IgG2 in serum are under genetic B4 generation,68,69 and Ca2+-channel and second control.91 These levels have also been shown to be messenger activation.70-75 The defect in chemotaxis affected by periodontal diagnosis (LAgP patients have is thought to be an intrinsic defect by some investi- very high levels), race (African Americans have higher gators56-58 and an induced defect by others.76 The levels than Caucasians), and smoking (smokers have influence of these functional defects on the suscep- lower levels of IgG2, with notable exceptions in some Position Paper
patient groups).91,92,94,95 These factors also influence flora. In GAgP patients who have failed to respond to specific antibody responses to A. actinomycetem- standard periodontal therapy, laboratory tests of plaque comitans.91-93,95 Thus, the protective antibody response samples may identify periodontal pathogens that are afforded by IgG2, as well as the clinical manifestations resistant to antibiotics typically used to treat periodon- of aggressive periodontitis, is modified by patients’ titis.103 It has been suggested that follow-up tests genetic background as well as environmental factors after additional antibiotic or other therapy is provided such as smoking and bacterial infection.89,91-93,95,96 may be helpful in confirming elimination of targeted Successful treatment of aggressive periodontitis depends on early diagnosis, directing therapy against Chronic periodontitis is most prevalent in adults, the infecting microorganisms and providing an envi- but can occur in children and adolescents. It can be ronment for healing that is free of infection.97 While localized (less than 30% of the dentition affected) or there is some disagreement among individual studies generalized (greater than 30% of the dentition regarding treatment of LAgP, most authors recommend affected) and is characterized by a slow to moderate a combination of surgical or non-surgical root debride- rate of progression that may include periods of rapid ment in conjunction with antimicrobial (antibiotic) ther- destruction. Furthermore, the severity of disease can apy.47,98 These findings are supported by other work be mild (1 to 2 mm clinical attachment loss), mod- in which meticulous and repeated mechanical therapy erate (3 to 4 mm clinical attachment loss), or severe with antibiotics proved to be sufficient to arrest most (≥5 mm clinical attachment loss). Children and young cases of LAgP.99 However, surgical treatment may be adults with this form of disease were previously stud- effective in eliminating A. actinomycetemcomitans with- ied along with patients having LAgP and GAgP. There- out the use of antibiotics.100 In a study of 25 deep peri- fore, published data are lacking for this group.
odontal lesions (probing depths 5 to 11 mm) in young In patients with one of several systemic diseases that LAgP patients, scaling and root planing alone were predispose to highly destructive disease of the primary ineffective for the elimination of A. actinomycetem- teeth, the diagnosis is periodontitis as a manifestation comitans, while surgical therapy was effective.100 It is of systemic disease. As with adults, periodontitis asso- not known, however, if A. actinomycetemcomitans is ciated with systemic diseases occurs in children and the only organism involved in disease pathogenesis.
adolescents. Such diseases include Papillon-Lefèvre The majority of reports suggest that the use of syndrome,121-125 cyclic neutropenia,126-130 agranulo- antibiotics is usually beneficial in the treatment of cytosis,131,132 Down’s syndrome,133-135 hypophos- LAgP. Two reports described using antibiotics exclu- phatasia,136 and leukocyte adherence deficiency.137,138 sively.97,101 In both reports, LAgP patients attained It is probable that defects in neutrophil and immune significant clinical attachment gain when assessed cell function associated with these diseases play an after 12 months with tetracycline therapy alone. Most important role in increased susceptibility to periodon- reports in the past 10 years, however, have recom- titis and other infections. In Down’s syndrome, for exam- mended combination therapy using antibiotics and ple, the amount of periodontal destruction has been surgical or non-surgical root debridement as the opti- shown to be positively correlated with the severity of the mal treatment for LAgP.98,102-116 The most successful neutrophil chemotaxis defect.135 In some cases, specific antibiotics reported are the tetracyclines, sometimes genes have been associated with these diseases. Exam- prescribed sequentially with metronidazole.103,117,118 ples include the cathepsin C gene and Papillon-Lefèvre Metronidazole in combination with amoxicillin has syndrome139-141 and the tissue non-specific alkaline also been utilized, especially where tetracyline-resis- phosphatase gene and hypophosphatasia.136 tant A. actinomycetemcomitans are present.111 A sin- The consensus report of the 1999 Workshop specif- gle randomized control study in which oral penicillin ically excluded diabetes-associated periodontitis as a was used reported that therapy was successful with specific form of periodontitis associated with systemic disease. Participants concluded that diabetes is a sig- While the use of antibiotics in conjunction with sur- nificant modifier of all forms of periodontitis. In a sur- gical or non-surgical root debridement appears to be vey of 263 type 1 diabetics, 11 to 18 years of age, quite effective for the treatment of LAgP, GAgP does 10% were found to have overt periodontitis often not always respond well to conventional mechanical localized to first molars and incisors, although peri- therapy or to antibiotics commonly used to treat peri- odontitis was also found in a generalized pattern.142 odontitis.30,118,120 Alternative antibiotics may be Affected subgingival sites harbored A. actinomycetem- required, based upon the character of the pathogenic comitans and Capnocytophaga sp.143 Position Paper
Periodontitis as a manifestation of systemic disease decrease in symptoms.157 If the patient is febrile, antibi- in children is a rare disease that often begins between otics may be an important adjunct to therapy. Metro- the time of eruption of the primary teeth up to the age nidazole and penicillin have been suggested as drugs of 4 or 5.144,145 The disease occurs in localized and generalized forms. In the localized form, affected sitesexhibit rapid bone loss and minimal gingival inflam- mation.144 In the generalized form, there is rapid bone Children and adolescents are subject to several peri- loss around nearly all teeth and marked gingival inflam- odontal diseases. Although there is a much lower preva- mation. Neutrophils from some children with a clini- lence of destructive periodontal diseases in children cal diagnosis of periodontitis as a manifestation of than in adults, children can develop severe forms of systemic disease have abnormalities in a cell surface periodontitis.23 In some cases, this destructive disease glycoprotein (LFA-1, leukocyte functional antigen–1, is a manifestation of a known underlying systemic dis- also known as CD11, and Mac-1). The neutrophils in ease. In other young patients, the underlying cause for these patients having LAD (leukocyte adhesion defi- increased susceptibility and early onset of disease is ciency) are likely to have a decreased ability to move unknown. These diseases are often familial, suggesting from the circulation to sites of inflammation and infec- a genetic predisposition for aggressive disease. Current tion.137 Affected sites harbor elevated percentages of modalities for managing periodontal diseases of chil- putative periodontal pathogens such as A. actino- dren and adolescents may include antibiotic therapy in mycetemcomitans, Prevotella intermedia, Eikenella cor- combination with non-surgical and/or surgical therapy.
rodens, and Capnocytophaga sputigena.146,147 Since early diagnosis ensures the greatest chance for Treatment of periodontitis as a manifestation of sys- successful treatment,97 it is important that children temic disease in children is similar to the treatment of receive a periodontal examination as part of their rou- localized and generalized aggressive periodontitis in the permanent dentition and has been reported to includesurgical or non-surgical mechanical debridement and ACKNOWLEDGMENTS
antimicrobial therapy.124,127-130,132,134,142,144 Localized The primary author for this paper is Dr. Joseph V.
lesions have been treated successfully with this ap- Califano. Members of the 2002-2003 Research, Sci- proach,144,145 but the degree of predictable success in ence and Therapy Committee include: Drs. Terry D.
managing generalized periodontitis is low when sys- Rees, Chair; Christopher Cutler; Petros Damoulis; temic diseases are contributing factors.144,145 In many Joseph Fiorellini; William Giannobile; Henry Green- cases, the affected teeth had to be extracted.138,144,145 well; Angelo Mariotti; Steven Offenbacher; LeslieSalkin; Brian Nicoll, Board Liaison; Robert J. Genco, NECROTIZING PERIODONTAL DISEASES
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Position Paper

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