P E R I O D O N TOP E G

L O R Y
I O D O N T O L O G Y

Periodontal Diseases in Children and

Adolescents: 2. Management
VALERIE CLEREHUGH AND ARADHNA TUGNAIT

carried out in practice;

Abstract: Many of the periodontal diseases affecting children and adolescents can be
patients with systemic medical
successfully managed in general dental practice. The decision to treat the young patient
in the practice setting or to refer to a periodontal specialist will depend on the complexity
conditions associated with
of treatment, patient factors and the expertise of the practitioner. Treatment should be periodontal destruction, such as
provided in three phases: the initial cause-related phase is aimed at controlling microbial poorly controlled Type 1 (insulin
plaque; the corrective phase is intended to restore function and aesthetics; supportive dependent) diabetes mellitus;
periodontal therapy is aimed at preventing recurrence and progression of periodontal
patients with genetic conditions
disease. Even in cases requiring specialist referral, the dental team in general practice predisposing them to periodontal
has a key role in the initial and supportive phases of therapy. destruction;

children or adolescents with drug-
Dent Update 2001; 28: 274-281
induced gingival overgrowth;
Clinical Relevance: Periodontal diseases in various forms can affect a sizeable
patients for whom periodontal
proportion of children and adolescents, therefore knowledge of the strategies for therapy brings other risks (e.g. risk
periodontal management and insight into when to treat the patient in practice or refer of bacterial endocarditis);
to a specialist are essential.
patients with local factors, such as
root morphology, that adversely
affect prognosis;

patients requiring periodontal

F ollowing the history, examination and

diagnosis of periodontal disease
(covered in the first article1), a treatment
patient will depend on the complexity
of the treatment, various patient factors
and the general dental practitioner’s
surgery;

patients requiring complex co-
ordinated medical or dental multi-
plan needs to be drawn up for the child or expertise (Figure 2). The British Society disciplinary treatment.
adolescent and a decision made about of Periodontology has recently
who will provide this treatment (Figure 1). formulated a referral policy which is Irrespective of who provides the
In many cases, it will be feasible for the dependent on periodontal screening treatment, it is usually undertaken in
patient to be managed in the practice having been undertaken using the three phases: initial periodontal
setting by the dental team, incorporating Basic Periodontal Examination (BPE).2 therapy, corrective therapy and
the skills of the practitioner, hygienist Although primarily targeted at adults, supportive therapy (previously called
and perhaps also an oral health educator. the following principles may be applied maintenance therapy) (Figure 1).
For some youngsters, however, it may be equally well to the younger age groups.
appropriate to refer for specialist advice Cases with a BPE score of 1–3 may
or treatment. generally be treated in practice. INITIAL CAUSE-RELATED
However, consideration should be THERAPY
given to referral of: The first phase of therapy is critical to
TREAT OR REFER? the successful outcome of treatment,
The decision to treat or refer a young
patients with any index teeth with a irrespective of the patient’s age and the
BPE score of 4 or * or any other specific diagnosis, because it is aimed
deep pockets in the mouth; at controlling the primary causative
Valerie Clerehugh, BDS, PhD, Senior Lecturer in
cases diagnosed as aggressive factor in periodontal diseases –
Restorative Dentistry, and AradhnaTugnait, BChD, periodontitis; microbial plaque. This stage of
MDentSci, FDS RCS (Edin.), Lecturer in

cases of incipient chronic periodontal therapy can generally be
Restorative Dentistry, Department of
Periodontology, Leeds Dental Institute, Leeds. periodontitis that has not provided by the general dental
responded to non-surgical therapy practitioner or hygienist in general

274 Dental Update – July/August 2001

 P E R I O D O N TO L O G Y

movement horizontally; III =

Note age, health and
 TAKE HISTORY
 Assess motivation
and compliance
movement of tooth both


modifying factors
horizontally and vertically);

furcation involvement of multi-
Do BPE screening;
take radiographs  EXAMINE CHILD rooted teeth (horizontal probe


if indicated penetration into furcation: F1 = up


to 3 mm; F2 = over 3 mm; F3 =
Assess complexity
DIAGNOSIS of case
through and through between two


TREATMENT PLAN OPTIONS

roots);

suppuration;

recession of the gingival margin (in

 
millimetres) apical to the cemento-
enamel junction.
TREAT IN PRACTICE REFER
For BPE codes of 1 or 2 in a child
Initial periodontal therapy
Corrective therapy with gingivitis, only plaque and
Supportive therapy marginal gingival bleeding need to be


recorded:

RECALL
marginal gingival bleeding is a

at appropriate interval measure of gingivitis, which
Figure 1. Key stages in periodontal management for the young patient. correlates with supragingival
plaque control; the presence or
absence of marginal gingival
practice unless there are medical periodontal probe with millimetre bleeding elicited by gently running
contraindications. The various steps markings; a blunt periodontal probe around
that constitute the initial phase of
bleeding on probing from the base the gingival margin can be
therapy are depicted in Figure 3. of the pocket at the same six sites recorded, usually on four sites per
per tooth – this indicates tooth (buccal, mesial, distal,
inflammation at the base of the lingual) to give the percentage of
Baseline Measurements pocket, and the percentage of sites surfaces with gingival bleeding;
At the beginning of treatment, with bleeding on probing can be
plaque can then be disclosed and
periodontal indices appropriate to the calculated (in approximately 30% of measured at the same sites;
BPE codes and diagnosis (Figure 4) sites with bleeding on probing
a simple, effective motivational tool
should be undertaken. These provide a attachment loss progresses 3); is to give the child a score based
baseline against which change
mobility (I = up to 1 mm movement on the plaque-free surfaces or
(whether improvements or horizontally; II = more than 1 mm marginal bleeding-free surfaces so
deteriorations) can be measured and are
also used to motivate the patient.
Monitoring involves measuring the
periodontal condition using a chosen PATIENT
index and remeasuring it after a defined Age
GDP
interval. All periodontal assessments Knowledge Health COMPLEXITY
should be recorded in the patient’s Experience Modifying factors OF TREATMENT

local
notes. Expertise

systemic
Where a BPE of 3, 4 or * is found

  
during the initial BPE screening, the
following periodontal indices need to
be undertaken in the affected area:

probing depths/clinical attachment TREATMENT IN GENERAL

levels in millimetres, traditionally at DENTAL PRACTICE OR
six sites per tooth (mesiobuccal, REFERRAL TO SPECIALIST
PERIODONTIST
mid-buccal, distobuccal,
mesiopalatal, mid-palatal,
distopalatal) using a graduated Figure 2. Factors influencing the decision to treat in practice or refer.

Dental Update – July/August 2001 275

 P E R I O D O N TO L O G Y

eye-catching leaflets specifically

INITIAL THERAPY targeted at children and adolescents
Baseline measurements of periodontal status containing key messages to reinforce
Plaque-control instruction:

toothbrush/interdental cleaning advice
the main points (Figure 6).

advice on dentifrice, mouthrinse Periodontal lesions are predominantly
Smoking cessation counselling interdental and therefore interdental
Professional cleaning cleaning (under the contact point) is
Arrange extractions of teeth with hopeless prognosis important. Research findings support
Monitor response to initial therapy – repeat measurements
the recommendation that interdental

 Yes
Are probing depts > 4mm with bleeding on probing?
No
plaque removal every 12–48 hours is
sufficient.4 Use of interdental aids such
Is corrective therapy required? as floss should be reserved for the
  adolescent with sufficient manual
dexterity to cope and individual advice
CORRECTIVE THERAPY SUPPORTIVE THERAPY
Further non-surgical periodontal
needs to be given.4
Recall at interval appropriate to diagnosis
Electric toothbrushes are well liked by


therapy Monitor periodontal status

Periodontal surgery Re-motivate/re-educate child and parent younger patients and are effective.5–7
Are adjunctive antibiotics indicated? Repeat plaque control instruction Because the interdental cleaning
Arrange any further work to restore Re-treat disease achieved by various electric
function and aesthetics Monitor .................... further recall ....................
toothbrushes can be better than that
achieved with manual brushes, it is
Figure 3. The three stages of periodontal therapy for children and adolescents.
worth considering recommending these
for the younger age groups.4,6
Reductions in price and targeting of
that, as they improve their tooth but the popular Bass technique can models specifically at children have
cleaning, the score gets higher; equally well be taught to the older age made many brands more affordable and

partial recording can be undertaken groups. Children and adolescents attractive. The use of a brush with a
if a very quick index is indicated appreciate a ‘tell–show–do’ rotary head movement has been shown
for a less co-operative child (e.g. management approach, involving a to be more effective at plaque removal
using only the six teeth designated simple explanation of the procedure to than one with a side-to-side motion.7
for the BPE). be undertaken, a demonstration of what Furthermore, there is some evidence
is involved on a model, followed by the that electric brushes may be less
Every encouragement should be procedure. It may be useful to provide abrasive than manual brushes7 and can
given to the child to improve his/her
score, and it helps to set realistic
targets. Giving the patient colourful
AFTER BPE FOR
stickers as a reward (positive SCREENING
reinforcement) can be very effective
(Figure 5). Consider


If BPE 1 or 2 If BPE 3, 4 or * radiographs

  
Instruction in Plaque Control
RECORD INDICES RECORD INDICES Check bone
A parent or guardian of a patient under level
the age of 7 years should brush the
child’s teeth, as the child does not have
  
Plaque index Plaque index Probing depths
enough manual dexterity to brush
effectively. Older children can brush
their own teeth, under supervision if
  
Marginal gingival Marginal gingival Bleeding on probing
necessary. Disclosing plaque and bleeding index bleeding index
showing this to the patient/parent
when recording the plaque-free score

Check for:
can be useful as an educational and
Suppuration
motivational tool and home use of
Mobility
disclosing tablets can be recommended.
Furcation

Recession
The scrub toothbrushing technique is
effective in children and adolescents Figure 4. Periodontal indices following screening in young patients.

276 Dental Update – July/August 2001

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diplomatically. Brief counselling (less outcome to therapy are compliance with

than 3 minutes) delivered by a health personal and professional plaque
professional may influence up to 2% of control measures and meticulous root
patients to stop smoking;9 this debridement.
represents seven patients per general
practice (i.e. 63 000 quitters) per year.
These quit rates improve with more Restorations, Endodontics,
intensive advice. Extractions, Dentures,
Elimination of Local Factors
Any carious lesions, poorly contoured
Professional Cleaning restorations and pulpally involved
Scaling and prophylaxis is required to teeth requiring endodontics need to be
remove supragingival stain, treated. Preventive advice for
supragingival plaque and calculus and uncontrolled caries would include
subgingival deposits. For BPE codes 3, appropriate dietary advice to reduce
Figure 5. Colourful stickers can be used 4 and *, periodontal pocket charting the frequency and amount of intake of
to encourage and reward the child. will have located the site and depth of refined carbohydrates and sugars;
pockets. Root planing should be fluoride supplements may also be
undertaken in deep pockets, the goal considered. Extraction of teeth with a
being to create a smooth root surface hopeless prognosis should be arranged
be useful for children wearing fixed free from subgingival plaque, calculus and an immediate partial denture made
orthodontic appliances.5 and necrotic cementum. The distinction where aesthetics or function are
Mouthwashes are not indicated in between subgingival scaling and root affected. Any other modifiable local
very young children owing to their planing is one of degree, since it is not factors should be eliminated.
inability to spit out and there is little possible clinically to determine whether
justification in the current literature for or not necrotic cementum is being
their use in adolescents. Recent data removed. In essence, root planing is a Response to Initial Therapy
from a 3-year randomized controlled more intensive therapeutic effort to The response to the initial cause-
clinical trial of 641 adolescents debride root surfaces thoroughly in related periodontal therapy is crucial in
demonstrated that a dentifrice deep pockets of 6 mm or more (as in deciding the next phase of treatment,
containing 0.3% triclosan with 2.0% BPE code 4) exhibiting bleeding on and is determined by repeating the
copolymer and 0.243% sodium fluoride probing, using hoes and curettes to baseline periodontal indices 8–12
had a clinically small but statistically leave a smooth, clean root surface. The weeks after completion of the initial
significant effect in reducing the transition between performing therapy. Probing should be avoided in
development of attachment loss in the subgingival scaling and root planing is the 6–8 weeks following root planing to
subset of adolescents aged 11–13 years really rather seamless in clinical avoid disruption of the developing long
with the highest mean periodontal practice. Critical factors for successful junctional epithelium and measurement
pockets. 8

Counselling on Smoking a b
Cessation
Based on 1996 data, one in three 15-
year-old girls smoke, and on average
11% of boys and 15% of girls aged 11–
15 years smoke.9 Given the alarmingly
high proportion of teenage children
who smoke tobacco, smoking cessation
counselling should be provided, with
clear factual information of the risks
associated with continuing the habit.9
Admission of smoking, evidence of Figure 6. Information leaflets: (a) targeted at
nicotine staining or the characteristic children; (b) targeted towards adolescents.
odour from a recent cigarette should
prompt the dental professional to
approach the problem sensitively and

278 Dental Update – July/August 2001

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compromises function (eating,

a b chewing) and aesthetics, it may be
necessary to liaise with the medical
consultant about the possibility of
adjusting or changing the drug
regimen, as alteration of the drug
regimen can profoundly influence the
severity of gingival enlargement
(Figure 8). In any event, the advice of
Figure 7. (a) Lingual surfaces of lower anterior teeth in a 10-year-old Indo-Pakistani girl before the consultant should be sought before
initial therapy: plaque, supragingival calculus and severe hyperplastic gingival inflammation are surgery is considered. Adjunctive use
visible. (b) The appearance 3 months after initial therapy, showing reduction in plaque, calculus of 0.2% chlorhexidine mouthrinse to
and inflammation. However, resolution of inflammation is incomplete, some calculus has control plaque and reduce inflammation
reformed and plaque is visible. Corrective therapy is required for this patient.
can be useful before surgery and
during the healing postoperative phase.

errors related to soft-tissue changes gingivitis is the same as for chronic

during healing. gingivitis, although on occasion Linear Gingival Erythema in
Specific questions to be posed specialist referral for removal of HIV-positive Individuals
include: pregnancy epulis is needed if the lesion Fungal involvement is thought to be a
persists post-partum. causative factor in this condition. It is
1. Are the oral hygiene and gingival characteristically refractory to the
health satisfactory? Has the child mechanical therapy and plaque-control
achieved his or her maximum Gingival Overgrowth measures inherent in the initial phase of
potential for plaque-free and Phenytoin and cyclosporin, which may treatment of plaque-induced gingivitis
marginal bleeding-free surfaces? be used in conjunction with the and is best managed in association with
2. Are probing depths below 3 mm calcium-channel blocker nifedipine, a specialist.
and free from bleeding on probing pose a significant risk for gingival
from the base of the pocket? overgrowth in the young age groups
and generally specialist management is Necrotizing Periodontal
If the answers are yes, supportive indicated.10 Risk factors for the Diseases
therapy is required. If no, corrective expression of enlarged gingiva include Necrotizing ulcerative gingivitis
therapy is required. the presence of plaque and gingival responds to traditional initial therapy
inflammation; therefore the initial phase involving mechanical debridement by
of periodontal therapy is critical to ultrasonic scaler, instruction on oral
CORRECTIVE THERAPY managing this problem. In some cases, hygiene, the use of an oxidizing
The corrective phase is intended to gingivectomy may be indicated to mouthrinse (3% hydrogen peroxide and
restore function and aesthetics. improve the appearance and facilitate equal volume warm water) and
plaque control. In the most severe corrective antibiotic therapy.
cases of drug-induced overgrowth, Metronidazole (200 mg or 250 mg three
Gingivitis where the gingival overgrowth times daily) may be required until the
If gingivitis persists following initial
therapy, advice about plaque control
should be repeated and reinforced, and
every effort made to improve the a b
motivation of the patient and parent.
The presence of calculus deposits,
supragingivally and particularly
subgingivally, should be checked for
and further scaling or debridement
undertaken if necessary (Figure 7).
Other local plaque-retention factors
should be dealt with appropriately. This
treatment can be effectively carried out Figure 8. (a) Drug-induced gingival enlargement in an adolescent boy due to treatment with
cyclosporin and nifedipine following a heart transplant. (b) Reduction in gingival enlargement was
in general dental practice.
achieved by changing the drug to Tacrolimus.
Management of hormone-related

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ulcers begin to heal, which may be forms of periodontitis. They should be Other Genetic and Systemic
within 3 days. Review should be monitored a little earlier, 6–8 weeks after Conditions Associated with
undertaken every 2–3 days until initial therapy. Non-responding sites Periodontitis
symptoms subside. Adjunctive 0.2% should be re-root planed and For some genetic or systemic
chlorhexidine mouthwash aids oral adjunctive systemic antimicrobials conditions with periodontal
hygiene. Recurrence may be a feature considered at this stage, when the manifestations little has been published
of this condition unless the risk factors cause-related therapy will have non- on specific therapeutic measures.
are eliminated, or may indicate an specifically reduced the mass of Therefore residual periodontal
underlying systemic condition. microbial plaque. Systemic problems after initial therapy should be
Therefore, plaque control advice and antimicrobial therapy should not be identified and managed according to
smoking cessation counselling are administered without prior mechanical the therapeutic principles described in
important aspects of periodontal care therapy to disrupt the subgingival previous sections.
but consideration should also be given biofilm, because the structure of the Papillon–Lefèvre syndrome has
to appropriate direction for stress undisturbed biofilm prevents the proved refractory to treatment, and
management in affected teenagers. antibiotic from reaching the target tooth loss has been an inevitable
Necrotizing ulcerative periodontitis organisms. consequence of failure to respond to
is unlikely to occur in young There is no consensus regarding the therapy. However, successful regimes
individuals in the UK and developed use of antibiotics. Three options that have involved extraction of the affected
countries except in HIV-positive have been investigated and shown deciduous teeth to eradicate the
individuals or people with AIDS, for clinical benefit in the management of suspected putative periodontal
whom specialist management is the localized form are:11 pathogens with use of systemic
indicated. antimicrobial therapy during eruption

tetracycline (250 mg) four times per of the permanent dentition to eliminate
day for 14 days; the alternative use any re-emergence of putative
Incipient Chronic of doxycycline (200 mg loading periodontal pathogens, especially A.
Periodontitis dose then 100 mg daily for 13 days) actinomycetemcomitans. Referral for
Residual pockets that bleed on gives a more convenient regimen, specialist care is advisable for these
probing should be re-root planed, but there is less consistent types of cases.
usually non-surgically. Around 30% of evidence of efficacy;
sites that bleed on probing have been
metronidazole (200 mg) three times
shown to lose further attachment, per day for 10 days; SUPPORTIVE
whereas absence of bleeding on
metronidazole (250 mg) and PERIODONTAL THERAPY
probing is a good predictor of amoxycillin (375 mg) three times per AND RECALL
periodontal stability.3 Since it is day for 7 days. This is a most The aims of supportive therapy,
impossible to predict which bleeding effective regimen due to the formerly called maintenance therapy,
sites will progress, the rationale is to synergistic effect of the two are:14
re-treat all the affected sites. antibiotics and their
This form of periodontitis is hydroxymetabolites.12 1. To prevent recurrence and
characteristically slowly progressing, progression of disease in patients
although it may be episodic with acute These principles are equally who have previously been treated
exacerbations and quiescent periods. applicable to the generalized form of for periodontal disease.
It should normally be amenable to aggressive periodontitis but the 2. To prevent or reduce the incidence
management by the hygienist or microflora may be more diverse than the of tooth loss.
dentist in practice with the goal to localized form. Surgery can be 3. To increase the probability of
achieve healing by a long junctional successful in reducing Actinobacillus locating and treating other
epithelium and halt disease actinomycetemcomitans. diseases found within the oral
progression. However, if the disease Most cases of aggressive cavity.
progresses in spite of treatment, periodontitis occurring before puberty
referral to a specialist should be are associated with systemic (see Figure 3). Evaluation of plaque
considered. conditions.13 Management depends on control is needed together with
whether or not a systemic factor has monitoring of the periodontal status.
been identified, and whether the The decision to re-treat is based on
Early-onset Periodontitis periodontitis is generalized or localized. these clinical findings. The dental team
(‘Aggressive’ Periodontitis) Management should follow the in general practice has an important role
Specialist management is generally therapeutic principles already in providing supportive periodontal
indicated for patients with aggressive described. therapy.

280 Dental Update – July/August 2001

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Communication intervals should not normally exceed 3 5. Clerehugh V, Williams P, Shaw WC, Worthington
Good communication between the HV, Warren P. A practice-based randomised
months until there is evidence of
controlled trial of the efficacy of an electric and
young patient, his or her parent/ periodontal stability.16 It may be very a manual toothbrush on gingival health in
guardian and the dental team is critical appropriate for supportive therapy to patients with fixed orthodontic appliances. J
to successful periodontal management be provided within general dental Dent 1998; 26: 633–639.
6. Van der Weijden GA, Timmerman MF, Danser
and maintenance.15 Palmer and Floyd15 practice once the corrective phase of
MM, van der Velden U. The role of electric
have suggested that the communication treatment has been completed by the toothbrushes: Advantages and limitations. In:
process starts with the provision of specialist; good dialogue and Lang NP, Attstrom R, Loe H, eds. Proceedings of
information, frequent summaries, communication between the the European Workshop on Mechanical Plaque
Control. Chicago: Quintessence, 1998; pp.138–
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understanding. Re-motivation of home facilitate the smooth delivery of 7. Walmsley AD. The electric toothbrush: a review.
plaque control is a key aspect of this appropriate ongoing care for the Br Dent J 1997; 182: 209–218.
phase of treatment. Verbal young patient. 8. Ellwood R, Worthington HV, Blinkhorn ASB,
Volpe AR, Davies RM. Effect of a triclosan/
communication can be reinforced with copolymer dentifrice on the incidence of
written messages in the form of periodontal attachment loss in adolescents. J
leaflets, diagrams or personal CONCLUSIONS Clin Periodontol 1998; 25: 363–367.
instructional notes to the patient (as Many children and adolescents with 9. Watt R, Robinson M. Helping Smokers to Stop. A
Guide for the Dental Team. London: Health
mentioned earlier for the initial phase periodontal problems can be Education Authority,1999.
of treatment). The young patient successfully managed in general 10. Seymour RA, Ellis JS, Thomason JM. Risk
should be reminded of his or her role dental practice. The decision to treat factors for drug-induced gingival overgrowth. J
in achieving good plaque control at Clin Periodontol 2000; 27: 217–223.
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11. Mombelli AW, van Winkelhoff AJ. The systemic
home and the reason for its advice or treatment depends on the use of antibiotics in periodontal therapy. In:
importance. The general dental complexity of the treatment required, Lange NP, Karring T, Lindhe J, eds. Proceedings of
practitioner can co-ordinate various various patient factors and the general the 2nd European Workshop on Periodontology.
Berlin: Quintessence, 1997; pp.38–77.
members of the dental team to educate, dental practitioner’s knowledge,
12. Pavicic MJAMP, van Winkelhoff AJ, de Graaf J.
encourage and motivate the patient: experience and expertise. Treatment Synergistic effects between amoxycillin,
the hygienist, oral health educator, should be planned in three phases: metronidazole, and the hydroxymetabolite of
dental nurse and reception staff. initial cause-related therapy; metronidazole against Actinobacillus
actinomycetemcomitans. Antimicrob Agents
Praise or simple rewards such as corrective therapy and supportive Chemother 1991; 35: 961–966.
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practice team can have a valuable role Ann Periodontol 1999; 4: 1–6.
14. American Academy of Periodontology. Position
in the initial and supportive stages of paper of the American Academy of
Recall treatment. Periodontology. Supportive periodontal therapy.
Recall visits every 4–6 months may be J Periodontol 1998; 69: 502–506.
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who have been successfully treated RM, Floyd PD, eds. A Clinical Guide to
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