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Table 1. Classification of periodontal diseases defined by the American Academy of
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| Table 1. 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 II. Chronic Periodontitis A. Localized B. Generalized III. Aggressive periodontitis A. Localized B. Generalized IV Periodontitis as a Manifestation of Systemic Diseases A. Associated with hematological disorders B. Associated with genetic disorders C. Not otherwise specified (NOS) V. Necrotizing Periodontal Diseases A. Necrotizing ulcerative gingivitis (NUG) B. Necrotizing ulcerative periodontitis (NUP) VI. Abscess of the Periodontium A. Gingival abscess B. Periodontal abscess C. Pericoronal abscess VII. Periodontitis Associated With Endodontic Lesions A. Combined periodontic-endodontic lesions 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 Periodontal Diseases in Children and Adolescents … 35 As for the periodontitis identified in young patients, the term ―Early-onset periodontitis‖ was used in the 1989 classification, however, the term was changed to ―Aggressive periodontitis‖ in order to minimize potential problems with age-dependent features of classification. There was another category ―Periodontitis associated with systemic diseases‖ 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 lesions‖ and ―Developmental or acquired deformities and conditions‖ were implemented. These classifications will likely be reviewedin the future based on discussions of updated concepts. 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 [3], and gingival index [4]. 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 (Figure 2). 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 lesionsto return to the normal state. When we encounter the cases of erupting tooth, it is difficult to maintain adequatehygiene 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 (Figure 3). 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 changesare associated with thisincreased susceptibility to gingival inflammation. Thorough oral hygiene interventions can readilyreverse this condition. On the Kazuhiko Nakano, Atsuo Amano and Takashi Ooshima 36 other hand, acute necrotizing ulcerative gingivitis (ANUG) is a rare condition in Japan although the incidences in developing countries are reported to be high (Figure 4). The gingival tissues of dental papilla and the gingival margin wereobserved 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 (Figure 5). 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. Figure 2. Two cases of severe gingivitis with a large amount of dental plaque accumulation. Figure 3. A case of erupting gingivitis at the mandibular left canine (arrow). Periodontal Diseases in Children and Adolescents … 37 Figure 4. A case diagnosed as acute necrotizing ulcerative gingivitis at first visit (A) and after antibiotic treatment (B).Arrows indicate the affected lesion. Figure 5. A case diagnosed as 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 preventthe lesions progressing gradually leading to the spontaneous exfoliation of the affected teeth. On the other hand, localized prepubertal periodontitis is initiated by sudden pain and mobility of the several limited teeth (Figure 6). 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 hypophosphatasia associated with problems in the generation of periodontal ligaments. Antibiotic treatment is Kazuhiko Nakano, Atsuo Amano and Takashi Ooshima 38 carried out to stablize the lesion as with generalized prepubertal periodontitits. 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 (Figure 7) 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. Figure 6. A case diagnosed as localized prepubertal periodontitis. Arrows indicate the vertical resorption of alveolar bone of the affected teeth. Figure 7. Radiographic features of localized juvenile periodontitis. White and black arrows indicate the resorption of the supportive bone in mandibular first molar and incisors, respectively. Periodontal Diseases in Children and Adolescents … 39 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 (Figure 8). 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. Figure 8. Two cases of gingival recession due to traumatic occlusion (A) and tooth brushing with excessive power (B). Arrows indicate the affected teeth. 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 [5]. 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. Figure 9 shows a case involving 11-year- old twin brothers, both of which showed typical features of gingival fibromatosis [6]. On the other hand, cases without apparent genetic links are also present, in which specific medication, Figure 9. Gingival fibromatosis identified in twin brothers. Intraoral photographs of the older (A) and the younger (B) brothers. Kazuhiko Nakano, Atsuo Amano and Takashi Ooshima 40 such as phenytoin,commonly used as an antiepileptic, can lead to the onset and development of the lesion (Figure 10). Furthermore, cyclosporine, an immunosuppressant drug, and nifedipine, a calcium channel blocker used as an antihypertensive agent, are also known to cause similar gingival overgrowth [7]. Phenytoin is known to stimulate responsive subpopulations of gingival fibroblasts to accumulate extracellular matrix components, resulting in gingival overgrowth [8], whereas several studies have found a relationship between the quantity of accumulated dental plaque and phenytoin-induced gingival overgrowth [9-11]. It was also recently indicated that dental plaque accumulation is the most important determinant of phenytoin-induced gingival overgrowth [12]. 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 [13]. 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 (Figure 11) [14]. 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 membersexhibited any gingival problems. 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. Figure 10. Gingival fibromatosis identified in subject with specific treatment with the antiepileptic phenytoin. Figure 11. Preoperative (A) and postoperative (B) photographs in a case of gingival fibromatosis. Periodontal Diseases in Children and Adolescents … 41 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 bypyogenic bacteria at the sites of small injuries present in the gingival sulcus. Although rarely encountered, irrigation of the gingival pocket and systemic antibiotictherapy generally suppress acute inflammation within a week. Figure 12. A case of ―acute periodontitis.‖ Intraoral photographs taken at first examination (A) and at the time when the lesion became stabilized (B). Periapical radiographs taken at the first examination (C), 2 weeks (D) as well as 4 months (E) after the first examination. Arrows indicate the affected tooth. A 10-year-old Japanese girl came to our hospital with the chief complaint of severe tooth mobility in her lower permanent incisors (Figure 12) [15]. 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 (Figure 13, Table 2) [16]. Intraoral examinations showed that gingival swelling with apparent redness around the affected tooth. Kazuhiko Nakano, Atsuo Amano and Takashi Ooshima 42 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 andthe 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. Figure 13. A case of ―acute periodontitis‖ caused by orthodontic band. Intraoral photograph of the affected tooth taken at 1st visit (A) and 5th visit (98 days after first visit) (B). Yüklə 14,48 Mb. Dostları ilə paylaş:
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