Gingivitis and

Periodontal Disease
INTRODUCTION
The gingival tissues are normally light pink, depend on the
thickness of the tissue, and the degree of keratinization.
The gingival color of the young child may be more reddish
due to increased vascularity and thinner epithelium.
The surface of the gingiva of a child appears less stippled or
smoother than that of an adult.
In the healthy adult the marginal gingiva has a sharp,
knifelike edge. But during the period of tooth eruption in
the child, the gingivae are thicker and have rounded
margins due to the migration and cervical constriction of
the primary teeth.
Gingivitis
 is an inflammation involving only the gingival tissues
next to the tooth. Microscopically, it is characterized
by the presence of an inflammatory exudate and
edema.
 Marginal gingivitis is the most common form of
periodontal disease and starts in early childhood.
 SIMPLE GINGIVITIS

ERUPTION GINGIVITIS
 A temporary type of gingivitis is often observed in
young children when the primary teeth are erupting.
This gingivitis, often associated with difficult
eruption.
 The greatest increase in the incidence of gingivitis in
children during( 6- to 7-y)when the permanent teeth
begin to erupt. Bec. the gingival margin receives no
protection from the coronal contour of the tooth
during the early stage of active eruption, and the
continual impingement of food on the gingivae causes
the inflammatory process.
This inflammation is most commonly associated with
the eruption of the first and second permanent molars
TREATMENT:
=Mild eruption gingivitis requires no treatment other
than improved oral hygiene.
=Painful pericoronitis may be helped when the area is
irrigated with irregant.
=Pericoronitis accompanied by swelling and lymph
node involvement should be treated with antibiotic
therapy.
GINGIVITIS ASSOCIATED WITH POOR ORAL
HYGIENE
This gingivitis is quickly reversible and can be treated
with a good oral prophylactic treatment and
instruction in good tooth brushing and flossing
techniques.
 Gingivitis is generally less severe in children than in
adults with similar plaque levels.
Acute Gingival disease
 HERPES SIMPLEX VIRUS INFECTION
 Herpes virus causes one of the most widespread viral
infections. The primary infection usually occurs in a
child under 6 years of age who has had no contact with
the type 1 herpes simplex virus (HSV-1) and who has
no neutralizing antibodies.
 In some preschool children the primary infection may
be characterized by only one or two mild sores on the
oral mucous membranes, which may be of little
concern to the child or may go unnoticed by the
parents.
Ulcerated stage of primary herpes in a young adult. Notice the
circumscribed confluent areas of inflammation
Other children the primary infection may be manifested by
acute symptoms (acute herpetic gingivostomatitis). This
can occur in children with clean mouths and healthy oral
tissues.
 The symptoms develop suddenly and include, the fiery red
gingival tissues, malaise, irritability, headache, and pain
associated with the intake of food and liquids of acid
content. A characteristic oral finding is the presence of
yellow or white liquid filled vesicles.
 The ulcers may be observed on any area of the mucous
membrane, including, buccal mucosa, tongue, lips, hard
and soft palate, and the tonsillar areas.

 Treatment of acute herpetic gingivostomatitis in children,

which runs a course of 10 to 14 days, should include specific
antiviral medication(like zovirax) as well as provision for
the relief of the acute symptoms so that fluid and
nutritional intake can be maintained.
Primary herpetic infection involving the dorsal surface of the thumb of a 3-
year-old child. An acute primary infection was present in the mouth.
 The application of a mild topical anesthetic, such as
dyclonine hydrochloride (0.5%) (Dyclone) before
mealtime will temporarily relieve the pain
 Ingestion of a vitamin supplement. Because fruit juices
are usually irritating to the ulcerated area.
 Recurrent herpes labialis (RHL).
 The recurrence of the disease, related to:
 1-conditions of emotional stress
 2-lowered tissue resistance resulting from various types of
trauma.
 3-Excessive exposure to sunlight may be responsible for
the appearance of the recurrent herpetic lesions on the lip.

 Use of sunscreen can prevent sun-induced recurrences.

 Lesions on the lip may also appear after dental treatment.
 The most effective treatment for these recurrences is the
use of the specific systemic antiviral medication(Zovirax).
 recurrent aphthous stomatitis (RAS)
 is a painful ulceration on the unattached mucous
membrane that occurs in school-aged children and
adults.
 The peak age for RAU is between 10 and 19 years of
age.
 It has been reported to be the most common mucosal
disorder in people of all ages and races in the world.
 Current treatment is focused on
 promoting ulcer healing,
 reducing ulcer duration and patient pain,
 maintaining the patient's nutritional intake, and
 preventing or reducing the frequency of recurrence of the
disease.
ACUTE CANDIDIASIS (THRUSH)

 Candida (Monilia) albicans is a common inhabitant of

the oral cavity but may multiply rapidly and cause a
pathogenic state when tissue resistance is lowered.
Young children sometimes develop thrush after local
antibiotic therapy, which allows the fungus to
proliferate. The lesions appear as raised, furry, white
patches, which can be removed easily to produce a
bleeding underlying surface.
 ACUTE BACTERIAL INFECTIONS
The diagnosis is difficult to make, without extensive
laboratory tests. Broad spectrum antibiotics are
recommended if the infection is believed to be
bacterial in origin.
 Improved oral hygiene is important in treating the
infection, chlorhexidine mouth rinse are also
appropriate.
CHRONIC NONSPECIFIC GINGIVITIS
 A type of gingivitis commonly seen during the
preteenage and teenage years. The chronic gingival
inflammation may be localized to the anterior
region, or it may be more generalized. Although the
condition is rarely painful, it may persist for long
periods without much improvement. The cause of
gingivitis is complex and is considered to be based on a
multitude of local and systemic factors.
 *Dietary inadequacies are often found in the preteenage
and teenage groups, Insufficient quantities of fruits and
vegetables in the diet, leading to a subclinical vitamin
deficiency, An improved dietary intake of vitamins and the
use of multiple-vitamin supplements will improve the
gingival condition in many children.
 *Malocclusion, which prevents adequate function, and
crowded teeth, are also important predisposing factors in
gingivitis.
 Carious lesions with irritating sharp margins, as well as faulty
restorations with overhanging margins (both of which cause
food accumulation), also favor the development of the
chronic type of gingivitis
The irritation to the gingival tissue produced by mouth
breathing is often responsible for the development of the
chronic hyperplastic form of gingivitis, particularly in the
maxillary arch.
 CHLORHEXIDINE AS A THERAPEUTIC PLAQUE
CONTROL AGENT
Chlorhexidine (CH) is a chlorophenyl biguanide with broad
antimicrobial activity.
It has been used commonly as an antiseptic skin and wound
cleanser for presurgical preparation of the patient and as a hand
wash and surgical scrub for health care personnel.

The mouth rinse contains 0.12% CH gluconate as the active

ingredient.
It had an excellent safety record.
Few adverse side effects have been reported with CH mouth
rinses,like
dryness and burning sensations in some persons.
Poorly defined desquamative lesions have been observed in
others after the mouth rinse was used.
 GINGIVAL DISEASES MODIFIED
BY SYSTEMIC FACTORS
 GINGIVAL DISEASES ASSOCIATED WITH THE
ENDOCRINE SYSTEM
 Puberty gingivitis is a distinctive type of gingivitis that
occasionally develops in children in the prepubertal and
pubertal period.
 The enlargement of the gingival tissues in puberty
gingivitis is confined to the anterior segment and may be
present in only one arch. The lingual gingival tissue
generally remains unaffected.
 Treatment of puberty gingivitis should be directed toward
improved oral hygiene, removal of all local irritants,
restoration of carious teeth, and dietary changes
necessary to ensure an adequate nutritional status.
 GINGIVAL LESIONS OF GENETIC ORIGIN
 Hereditary gingival fibromatosis (HGF) is characterized by a
slow, progressive, benign enlargement of the gingivae.
 The gingival tissues appear normal at birth but begin to
enlarge with the eruption of the primary teeth.
 Although mild cases are observed, the gingival tissues
usually continue to enlarge with eruption of the permanent
teeth until the tissues essentially cover the clinical crowns of
the teeth.
 The dense fibrous tissue often causes displacement of
the teeth and malocclusion. The condition is not
painful until the tissue enlarges to the extent that it
partially covers the occlusal surface of the molars and
becomes traumatized during mastication.
 Surgical removal of the hyperplastic tissue achieves a
more favorable oral and facial appearance. However,
hyperplasia can recur within a few months after the
surgical procedure.

 PHENYTOIN-INDUCED GINGIVAL OVERGROWTH
 Phenytoin (Dilantin), a major anticonvulsant agent used in
the treatment of epilepsy.
 Varying degrees of gingival hyperplasia are one of the most
common side effects of phenytoin therapy.
ASCORBIC ACID DEFICIENCY GINGIVITIS
 Scorbutic gingivitis is associated with vitamin C
deficiency and differs from the type of gingivitis
related to poor oral hygiene. The involvement is
usually limited to the marginal tissues and papillae.
The child with scorbutic gingivitis may complain of
severe pain, and spontaneous hemorrhage.
 the gingivitis will respond dramatically to the daily
administration of 250 to 500 mg of ascorbic acid.
Older children and adults may require 1 g of vitamin C
for 2 weeks to speed recovery.
 PERIODONTAL DISEASES IN CHILDREN

 Periodontitis, an inflammatory disease of the gingiva and deeper

tissues of the periodontium, is characterized by pocket formation and
destruction of the supporting alveolar bone.

 EARLY-ONSET PERIODONTITIS
 This term used to describe a heterogeneous group of periodontal
disease occurring in young individuals who are healthy.
 EOP can be viewed as these categories:
 a localized form (localized aggressive periodontitis)
 a generalized form (generalized aggressive periodontitis)
 Localized Aggressive periodontitis is localized attachment loss and
alveolar bone loss only in the primary dentition in an healthy child.
 The exact time of onset is unknown, but it appears to arise around or before 4
years of age, the bone loss is usually seen on radiographs around the primary
molars and/or incisors. Abnormal probing depths with minor gingival
inflammation, rapid bone loss, and minimal to varying amounts of plaque have
been demonstrated at the affected sites of the child's dentition.

 CAUSES INCLUDS:
 Abnormalities in host defenses .
 extensive proximal caries facilitating plaque retention and bone loss.
 family history of periodontitis have been associated with L AP in children.
 Generalized Aggressive
periodontitis
 Occur during or soon after the eruption of the primary teeth.
 It results in severe gingival inflammation and generalized attachment loss,
tooth mobility, and rapid alveolar bone loss with premature exfoliation of the
teeth. Alveolar bone destruction proceeds rapidly, and the primary teeth may be
lost by 3 years of age. pediatrician is needed to rule out systemic diseases.

 Treatment of Aggressive depends on early diagnosis, dental curettage, root

planing, prophylaxis, oral hygiene instruction, restoration of decayed teeth,
removal of the primary teeth that have lost bony support, and more frequent
recalls. Use of antimicrobial rinses (chlorhexidine) and therapy with broad-
spectrum antibiotics are effective in eliminating the periodontal Pathogens
 Treatment of GAP is less successful overall and sometimes requires extraction
of all primary teeth.

LOCALIZED EARLY-ONSET PERIODONTITIS
(LOCALIZED JUVENILE PERIODONTITIS)
Occurs in healthy children and adolescents without
clinical evidence of systemic disease.
It is characterized by the rapid and severe loss of alveolar
bone around more than one permanent tooth, usually
the first molars and incisors.
It appears self limiting .Clinically, patients have
little or no tissue inflammation
very little supragingival dental plaque or calculus.
Progression of bone loss is three to four times faster
than in adult periodontitis.

 GENERALIZED EARLY-ONSET PERIODONTITIS
 (GENERALIZED JUVENILE PERIODONTITIS)
 The generalized form occurs at or around puberty in
older juveniles and young adults. It often affects the
entire periodontium of the dentition. Because of its
wide distribution and rapid rate of alveolar bone
destruction.
 TREATMENT OF EARLY-ONSET PERIODONTITIS
 Successful treatment of EOP depends on early
diagnosis, use of antibiotics against the infecting
microorganisms, and provision of an infection-free
environment for healing.
 Treatment of both the localized and generalized types,
includes surgery, and the use of tetracyclines
(sometimes in combination with metronidazole).

 GINGIVAL RECESSION

Several factors predispose patients to gingival recession. These factors

include
presence of a narrow band of attached or keratinized gingiva,
alveolar bony dehiscence, tooth brush trauma
tooth prominence, impinging frenum attachment
soft tissue impingement by opposing,occlusion
orthodontic tooth movement, use of impression techniques
including subgingival tissue retraction, oral habits
periodontitis, and pseudorecession (extrusion of teeth).

Treatment by elimination of the stimulus if possible, while excellent oral

hygiene is maintained in the affected areas.
 SELF-MUTILATION
 occasionally children purposely traumatize their oral structures.
 Self-mutilation probably occurs more frequently than is realized because
relatively few children will admit to the act unless they are observed practicing
it.
 Therefore the self-inflicted lesions may be incorrectly diagnosed.
 Dentists should be aware of the possibility of this condition and should
approach the problem in the same manner as they do thumb sucking.
 An attempt should be made to determine the cause.
 If it is found to be the result of local dental factors, it can be corrected.
 the majority of children an emotional problem is involved
 and the family must be directed to competent counseling services.
 Tension and conflicts in the home can cause selfmutilation in
young patients
 Traumatic gingival recession in infants resulting from a
dummy (pacifier) sucking habit has been observed when the
unconventional sucking habit a segment of the plastic shield
is embraced by the infant's lower lip so that the inner surface
of the shield bears against the labial aspect of the incisors
and the gingival tissues.
 EXTRINSIC STAINS AND DEPOSITS ON TEETH
 Staining is generally believed to be caused by extrinsic agents,
which can be readily removed from the surface of the teeth with
an abrasive material. The agents that are responsible for staining
are deposited in enamel defects or become attached to the enamel
without bringing about a change in its surface.
 Pigmentation, in contrast to extrinsic staining, is associated with
an active chemical change in the tooth structure, and the resultant
pigment cannot be removed without alteration of the tooth
structure.
 GREEN STAIN
 The cause of green stain,is unknown, although it is believed to be
the result of the action of chromogenic bacteria on the enamel
cuticle.
 The color of the stain varies from dark green to light yellowish
green. The deposit is seen most often in the gingival third of the
labial surface of the maxillary anterior teeth. It tends to recur even
after careful and complete removal. The enamel beneath the stain
may be roughened or may have undergone initial
demineralization.
 It may affect boys more than girls
 Specially in mouth breather children
 ORANGE STAIN
 The cause of orange stain is unknown.
 Orange stain occurs less frequently and is more easily
removed than green stain. The stain is most often seen
in the gingival third of the tooth and is associated with
poor oral hygiene.
 BLACK STAIN
 A black stain occasionally develops on the primary or permanent
teeth of children, but it is much less common than the orange or
green type.
 The stain may be seen as a line following the gingival contour or it
may be apparent in a more generalized pattern on the clinical
crown, particularly if there are roughened or pitted areas.
 The black type of stain is difficult to remove, especially if it
collects in pitted areas. Many children who have black stain are
relatively free from dental caries.
 REMOVAL OF EXTRINSIC STAINS
 Extrinsic stains can be removed by polishing with a
rubber cup and flour pumice. If the stain is resistant
and difficult to remove, the excess water should be
blotted from the pumice and the teeth should be dried
before the polishing procedure is performed. Because
stains are most often seen in a mouth in which there is
poor oral hygiene, improving the oral hygiene will
minimize the recurrence of the stain.
 CALCULUS
 Calculus is not often seen in preschool children, and
even in children of grade school age it occurs with
much lower frequency than in adult patients. A low
caries incidence is related to high calculus incidence.
 Children with mental retardation often have
accumulations of calculus on their teeth. This
accumulation may be related to abnormal muscular
function, a soft diet, poor oral hygiene, and stagnation
of saliva.
ABNORMAL FRENUM ATTACHMENT
 Frenum is a mucous membrane fold containing
epithelium and connective tissue fibers but no muscle.
A normal frenum attaches apically to the free gingival
margin so as not to exert a pull on the zone of the
attached gingiva, usually terminating at the
mucogingival junction.
 Indications for treating a high frenum include the
following:
 1.a high frenum attachment associated with an area of
persistent gingival inflammation that has not
responded to root planning and good oral hygiene.
 2.a frenum associated with an area of recession that is
progressive
 3.a high maxillary frenum and an associated mid –line
diastema that persists after complete eruption of the
permanent canines.
 4.a mandibular lingual frenum that inhibits the tongue
from touching the maxillary central incisors. That
would interfere with the child’s ability to make /t/, /d/,
and /I/ sounds. As long as the child has enough range
of motion to raise the tongue to the roof of the mouth,
no surgery would be indicated.
 Most children cannot normally make these sounds
until after 6 or 7 years of age.
 Speech therapy may be indicated
 A frenectomy involves complete excision of the frenum
and its periosteal attachment.
 A frenotomy involves incision of the periosteal fiber
attachment and possibly suturing of the frenum to the
periosteum at the base of the vestibule.
PREMATURE BONE LOSS IN THE PRIMARY DENTITION

 Advanced alveolar bone loss associated with systemic

disease occurs in children and adolescents as well as
adults
 In the primary dentition, this is rare.
 Although most premature tooth loss from non
systemic disease results from:
 trauma or caries
 Bony destruction in the primary dentition in the
absence of local factors is highly suggestive of systemic
disease.
 Many possibilities exist; some of them are
 hypophosphatasia, Papillon-Lefevre syndrome,
histiocytosis X, agranulocytosis, neutropenias,
leukemias, diabetes mellitus, fibrous dysplasia,
 Down syndrome,
PAPILLON-LEFEVRE SYNDROME (precocious periodontosis )
 The syndrome is rare and the cause unknown
 the disorder is noted, an autosomal recessive mode of
inheritance has been identified. There is no racial or
gender predominance.
 The primary teeth erupted at the normal time.
 But, as early as 2 years of age, the child rubbed the
gingival tissues and acted as if they were painful.
 There was a tendency toward gingival bleeding when
the teeth were brushed.
 Hyperkeratosis of the palms and soles was present
 At 21⁄2 years of age, all the primary teeth showed
looseness, and full-mouth radiographs revealed severe
horizontal bone resorption.
 Because of gingival inflammation, patient discomfort,
and the presence of infected periodontal pockets
 all the primary teeth were removed by 3 years of age.
 complete denture were constructed 3 months after the
removal of the primary teeth
 the child tolerated the denture well, both functionally
and psychologically