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
plan needs to be drawn up for the child or
adolescent and a decision made about
who will provide this treatment (Figure 1).
In many cases, it will be feasible for the
patient to be managed in the practice
setting by the dental team, incorporating
the skills of the practitioner, hygienist
and perhaps also an oral health educator.
For some youngsters, however, it may be
appropriate to refer for specialist advice
or treatment.
TREAT OR REFER?
The decision to treat or refer a young
Valerie Clerehugh, BDS, PhD, Senior Lecturer in
Restorative Dentistry, and AradhnaTugnait, BChD,
MDentSci, FDS RCS (Edin.), Lecturer in
Restorative Dentistry, Department of
Periodontology, Leeds Dental Institute, Leeds.
patient will depend on the complexity
of the treatment, various patient factors
and the general dental practitioner’s
expertise (Figure 2). The British Society
of Periodontology has recently
formulated a referral policy which is
dependent on periodontal screening
having been undertaken using the
Basic Periodontal Examination (BPE).2
Although primarily targeted at adults,
the following principles may be applied
equally well to the younger age groups.
Cases with a BPE score of 1–3 may
generally be treated in practice.
However, consideration should be
given to referral of:

patients with any index teeth with a
BPE score of 4 or * or any other
deep pockets in the mouth;

cases diagnosed as aggressive
periodontitis;

cases of incipient chronic
periodontitis that has not
responded to non-surgical therapy
surgery;

patients requiring complex co-
ordinated medical or dental multi-
disciplinary treatment.
Irrespective of who provides the
treatment, it is usually undertaken in
three phases: initial periodontal
therapy, corrective therapy and
supportive therapy (previously called
maintenance therapy) (Figure 1).
INITIAL CAUSE-RELATED
THERAPY
The first phase of therapy is critical to
the successful outcome of treatment,
irrespective of the patient’s age and the
specific diagnosis, because it is aimed
at controlling the primary causative
factor in periodontal diseases –
microbial plaque. This stage of
periodontal therapy can generally be
provided by the general dental
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
Figure 1. Key stages in periodontal management for the young patient.
practice unless there are medical
contraindications. The various steps
that constitute the initial phase of
therapy are depicted in Figure 3.
Baseline Measurements
At the beginning of treatment,
periodontal indices appropriate to the
BPE codes and diagnosis (Figure 4)
should be undertaken. These provide a
baseline against which change
(whether improvements or
deteriorations) can be measured and are
also used to motivate the patient.
Monitoring involves measuring the
periodontal condition using a chosen
index and remeasuring it after a defined
interval. All periodontal assessments
should be recorded in the patient’s
notes.
Where a BPE of 3, 4 or * is found
periodontal probe with millimetre
markings;

bleeding on probing from the base
of the pocket at the same six sites
per tooth – this indicates
inflammation at the base of the
pocket, and the percentage of sites
with bleeding on probing can be
calculated (in approximately 30% of
sites with bleeding on probing
attachment loss progresses 3);

mobility (I = up to 1 mm movement
horizontally; II = more than 1 mm
GDP
Knowledge
Experience
Expertise
measure of gingivitis, which
correlates with supragingival
plaque control; the presence or
absence of marginal gingival
bleeding elicited by gently running
a blunt periodontal probe around
the gingival margin can be
recorded, usually on four sites per
tooth (buccal, mesial, distal,
lingual) to give the percentage of
surfaces with gingival bleeding;

plaque can then be disclosed and
measured at the same sites;

a simple, effective motivational tool
is to give the child a score based
on the plaque-free surfaces or
marginal bleeding-free surfaces so
PATIENT
Age
Health COMPLEXITY
Modifying factors OF TREATMENT

local

systemic

  
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
Are adjunctive antibiotics indicated?
Arrange any further work to restore
function and aesthetics
Figure 3. The three stages of periodontal therapy for children and adolescents.
that, as they improve their tooth
cleaning, the score gets higher;

partial recording can be undertaken
if a very quick index is indicated
for a less co-operative child (e.g.
using only the six teeth designated
for the BPE).
Every encouragement should be
given to the child to improve his/her
score, and it helps to set realistic
targets. Giving the patient colourful
stickers as a reward (positive
reinforcement) can be very effective
(Figure 5).
Re-motivate/re-educate child and parent younger patients and are effective.5–7
Repeat plaque control instruction Because the interdental cleaning
Re-treat disease achieved by various electric
Monitor .................... further recall ....................
toothbrushes can be better than that
achieved with manual brushes, it is
worth considering recommending these
for the younger age groups.4,6
Reductions in price and targeting of
but the popular Bass technique can models specifically at children have
equally well be taught to the older age made many brands more affordable and
groups. Children and adolescents attractive. The use of a brush with a
appreciate a ‘tell–show–do’ rotary head movement has been shown
management approach, involving a to be more effective at plaque removal
simple explanation of the procedure to than one with a side-to-side motion.7
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
procedure. It may be useful to provide abrasive than manual brushes7 and can
AFTER BPE FOR
SCREENING
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

 P E R I O D O N TO L O G Y
Figure 5. Colourful stickers can be used
to encourage and reward the child.
be useful for children wearing fixed
orthodontic appliances.5
Mouthwashes are not indicated in
very young children owing to their
inability to spit out and there is little
justification in the current literature for
their use in adolescents. Recent data
from a 3-year randomized controlled
clinical trial of 641 adolescents
demonstrated that a dentifrice
containing 0.3% triclosan with 2.0%
copolymer and 0.243% sodium fluoride
had a clinically small but statistically
significant effect in reducing the
development of attachment loss in the
subset of adolescents aged 11–13 years
with the highest mean periodontal
pockets. 8
Counselling on Smoking
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
nicotine staining or the characteristic
odour from a recent cigarette should
prompt the dental professional to
approach the problem sensitively and
278
diplomatically. Brief counselling (less
than 3 minutes) delivered by a health
professional may influence up to 2% of
patients to stop smoking;9 this
represents seven patients per general
practice (i.e. 63 000 quitters) per year.
These quit rates improve with more
intensive advice.
Professional Cleaning
Scaling and prophylaxis is required to
remove supragingival stain,
supragingival plaque and calculus and
subgingival deposits. For BPE codes 3,
4 and *, periodontal pocket charting
will have located the site and depth of
pockets. Root planing should be
undertaken in deep pockets, the goal
being to create a smooth root surface
free from subgingival plaque, calculus
and necrotic cementum. The distinction
between subgingival scaling and root
planing is one of degree, since it is not
possible clinically to determine whether
or not necrotic cementum is being
removed. In essence, root planing is a
more intensive therapeutic effort to
debride root surfaces thoroughly in
deep pockets of 6 mm or more (as in
BPE code 4) exhibiting bleeding on
probing, using hoes and curettes to
leave a smooth, clean root surface. The
transition between performing
subgingival scaling and root planing is
really rather seamless in clinical
practice. Critical factors for successful
a b
Figure 6. Information leaflets: (a) targeted at
children; (b) targeted towards adolescents.
outcome to therapy are compliance with
personal and professional plaque
control measures and meticulous root
debridement.
Restorations, Endodontics,
Extractions, Dentures,
Elimination of Local Factors
Any carious lesions, poorly contoured
restorations and pulpally involved
teeth requiring endodontics need to be
treated. Preventive advice for
uncontrolled caries would include
appropriate dietary advice to reduce
the frequency and amount of intake of
refined carbohydrates and sugars;
fluoride supplements may also be
considered. Extraction of teeth with a
hopeless prognosis should be arranged
and an immediate partial denture made
where aesthetics or function are
affected. Any other modifiable local
factors should be eliminated.
Response to Initial Therapy
The response to the initial cause-
related periodontal therapy is crucial in
deciding the next phase of treatment,
and is determined by repeating the
baseline periodontal indices 8–12
weeks after completion of the initial
therapy. Probing should be avoided in
the 6–8 weeks following root planing to
avoid disruption of the developing long
junctional epithelium and measurement
Dental Update – July/August 2001

a b
Figure 7. (a) Lingual surfaces of lower anterior teeth in a 10-year-old Indo-Pakistani girl before
initial therapy: plaque, supragingival calculus and severe hyperplastic gingival inflammation are
visible. (b) The appearance 3 months after initial therapy, showing reduction in plaque, calculus
and inflammation. However, resolution of inflammation is incomplete, some calculus has
reformed and plaque is visible. Corrective therapy is required for this patient.
errors related to soft-tissue changes
during healing.
Specific questions to be posed
include:
1. Are the oral hygiene and gingival
health satisfactory? Has the child
achieved his or her maximum
potential for plaque-free and
marginal bleeding-free surfaces?
2. Are probing depths below 3 mm
and free from bleeding on probing
from the base of the pocket?
If the answers are yes, supportive
therapy is required. If no, corrective
therapy is required.
CORRECTIVE THERAPY
The corrective phase is intended to
restore function and aesthetics.
Gingivitis
If gingivitis persists following initial
therapy, advice about plaque control
should be repeated and reinforced, and
every effort made to improve the
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
in general dental practice.
Management of hormone-related
Dental Update – July/August 2001
P E R I O D O N TO L O G Y
gingivitis is the same as for chronic
gingivitis, although on occasion
specialist referral for removal of
pregnancy epulis is needed if the lesion
persists post-partum.
Gingival Overgrowth
Phenytoin and cyclosporin, which may
be used in conjunction with the
calcium-channel blocker nifedipine,
pose a significant risk for gingival
overgrowth in the young age groups
and generally specialist management is
indicated.10 Risk factors for the
expression of enlarged gingiva include
the presence of plaque and gingival
inflammation; therefore the initial phase
of periodontal therapy is critical to
managing this problem. In some cases,
gingivectomy may be indicated to
improve the appearance and facilitate
plaque control. In the most severe
cases of drug-induced overgrowth,
where the gingival overgrowth
a b
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
achieved by changing the drug to Tacrolimus.
compromises function (eating,
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
the consultant should be sought before
surgery is considered. Adjunctive use
of 0.2% chlorhexidine mouthrinse to
control plaque and reduce inflammation
can be useful before surgery and
during the healing postoperative phase.
Linear Gingival Erythema in
HIV-positive Individuals
Fungal involvement is thought to be a
causative factor in this condition. It is
characteristically refractory to the
mechanical therapy and plaque-control
measures inherent in the initial phase of
treatment of plaque-induced gingivitis
and is best managed in association with
a specialist.
Necrotizing Periodontal
Diseases
Necrotizing ulcerative gingivitis
responds to traditional initial therapy
involving mechanical debridement by
ultrasonic scaler, instruction on oral
hygiene, the use of an oxidizing
mouthrinse (3% hydrogen peroxide and
equal volume warm water) and
corrective antibiotic therapy.
Metronidazole (200 mg or 250 mg three
times daily) may be required until the
279
 P E R I O D O N TO L O G Y
ulcers begin to heal, which may be
within 3 days. Review should be
undertaken every 2–3 days until
symptoms subside. Adjunctive 0.2%
chlorhexidine mouthwash aids oral
hygiene. Recurrence may be a feature
of this condition unless the risk factors
are eliminated, or may indicate an
underlying systemic condition.
Therefore, plaque control advice and
smoking cessation counselling are
important aspects of periodontal care
but consideration should also be given
to appropriate direction for stress
management in affected teenagers.
Necrotizing ulcerative periodontitis
is unlikely to occur in young
individuals in the UK and developed
countries except in HIV-positive
individuals or people with AIDS, for
whom specialist management is
indicated.
Incipient Chronic
Periodontitis
Residual pockets that bleed on
probing should be re-root planed,
usually non-surgically. Around 30% of
sites that bleed on probing have been
shown to lose further attachment,
whereas absence of bleeding on
probing is a good predictor of
periodontal stability.3 Since it is
impossible to predict which bleeding
sites will progress, the rationale is to
re-treat all the affected sites.
This form of periodontitis is
characteristically slowly progressing,
although it may be episodic with acute
exacerbations and quiescent periods.
It should normally be amenable to
management by the hygienist or
dentist in practice with the goal to
achieve healing by a long junctional
epithelium and halt disease
progression. However, if the disease
progresses in spite of treatment,
referral to a specialist should be
considered.
Early-onset Periodontitis
(‘Aggressive’ Periodontitis)
Specialist management is generally
indicated for patients with aggressive
280
forms of periodontitis. They should be
monitored a little earlier, 6–8 weeks after
initial therapy. Non-responding sites
should be re-root planed and
adjunctive systemic antimicrobials
considered at this stage, when the
cause-related therapy will have non-
specifically reduced the mass of
microbial plaque. Systemic
antimicrobial therapy should not be
administered without prior mechanical
therapy to disrupt the subgingival
biofilm, because the structure of the
undisturbed biofilm prevents the
antibiotic from reaching the target
organisms.
There is no consensus regarding the
use of antibiotics. Three options that
have been investigated and shown
clinical benefit in the management of
the localized form are:11

tetracycline (250 mg) four times per
day for 14 days; the alternative use
of doxycycline (200 mg loading
dose then 100 mg daily for 13 days)
gives a more convenient regimen,
but there is less consistent
evidence of efficacy;

metronidazole (200 mg) three times
per day for 10 days;

metronidazole (250 mg) and
amoxycillin (375 mg) three times per
day for 7 days. This is a most
effective regimen due to the
synergistic effect of the two
antibiotics and their
hydroxymetabolites.12
These principles are equally
applicable to the generalized form of
aggressive periodontitis but the
microflora may be more diverse than the
localized form. Surgery can be
successful in reducing Actinobacillus
actinomycetemcomitans.
Most cases of aggressive
periodontitis occurring before puberty
are associated with systemic
conditions.13 Management depends on
whether or not a systemic factor has
been identified, and whether the
periodontitis is generalized or localized.
Management should follow the
therapeutic principles already
described.
Other Genetic and Systemic
Conditions Associated with
Periodontitis
For some genetic or systemic
conditions with periodontal
manifestations little has been published
on specific therapeutic measures.
Therefore residual periodontal
problems after initial therapy should be
identified and managed according to
the therapeutic principles described in
previous sections.
Papillon–Lefèvre syndrome has
proved refractory to treatment, and
tooth loss has been an inevitable
consequence of failure to respond to
therapy. However, successful regimes
have involved extraction of the affected
deciduous teeth to eradicate the
suspected putative periodontal
pathogens with use of systemic
antimicrobial therapy during eruption
of the permanent dentition to eliminate
any re-emergence of putative
periodontal pathogens, especially A.
actinomycetemcomitans. Referral for
specialist care is advisable for these
types of cases.
SUPPORTIVE
PERIODONTAL THERAPY
AND RECALL
The aims of supportive therapy,
formerly called maintenance therapy,
are:14
1. To prevent recurrence and
progression of disease in patients
who have previously been treated
for periodontal disease.
2. To prevent or reduce the incidence
of tooth loss.
3. To increase the probability of
locating and treating other
diseases found within the oral
cavity.
(see Figure 3). Evaluation of plaque
control is needed together with
monitoring of the periodontal status.
The decision to re-treat is based on
these clinical findings. The dental team
in general practice has an important role
in providing supportive periodontal
therapy.
Dental Update – July/August 2001

Communication
Good communication between the
young patient, his or her parent/
guardian and the dental team is critical
to successful periodontal management
and maintenance.15 Palmer and Floyd15
have suggested that the communication
process starts with the provision of
information, frequent summaries,
clarification of messages, and ensuring
understanding. Re-motivation of home
plaque control is a key aspect of this
phase of treatment. Verbal
communication can be reinforced with
written messages in the form of
leaflets, diagrams or personal
instructional notes to the patient (as
mentioned earlier for the initial phase
of treatment). The young patient
should be reminded of his or her role
in achieving good plaque control at
home and the reason for its
importance. The general dental
practitioner can co-ordinate various
members of the dental team to educate,
encourage and motivate the patient:
the hygienist, oral health educator,
dental nurse and reception staff.
Praise or simple rewards such as
stickers can be effective motivational
tools (Figures 5 and 6).
Recall
Recall visits every 4–6 months may be
appropriate for most young patients
who have been successfully treated
for gingivitis or incipient chronic
periodontitis but this should be
determined on an individual basis,
taking into account the diagnosis, risk
factors, patient motivation and
compliance. Many studies have
reported the efficacy of supportive
therapy in reducing the progression of
gingivitis to periodontitis, and
reducing attachment loss and tooth
loss. 14
Patients with a history of
progressing periodontal disease or
systemic risk factors may need to be
recalled more frequently. The
aggressive forms of periodontitis need
particular vigilance and, since the
return to pretreatment pathogen levels
may take only 9–11 weeks, recall
Dental Update – July/August 2001
P E R I O D O N TO L O G Y
intervals should not normally exceed 3
months until there is evidence of
periodontal stability.16 It may be very
appropriate for supportive therapy to
be provided within general dental
practice once the corrective phase of
treatment has been completed by the
specialist; good dialogue and
communication between the
practitioner and specialist should
facilitate the smooth delivery of
appropriate ongoing care for the
young patient.
CONCLUSIONS
Many children and adolescents with
periodontal problems can be
successfully managed in general
dental practice. The decision to treat
or refer the patient for specialist
advice or treatment depends on the
complexity of the treatment required,
various patient factors and the general
dental practitioner’s knowledge,
experience and expertise. Treatment
should be planned in three phases:
initial cause-related therapy;
corrective therapy and supportive
periodontal therapy. Even in those
cases requiring referral, the dental
practice team can have a valuable role
in the initial and supportive stages of
treatment.
A CKNOWLEDGEMENTS
The authors are grateful to Stephen Fayle for
Figures 8a and 8b.
R EFERENCES
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Self-Assessment
Answers
1. A, C, D 6. B
2. A, B, C 7. A
3. A, B, D 8. C, D
4. B 9. B, D
5. A, B, C, D 10. A, C, D
281