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6 Periodontal Diseases

Gingivitis

Definition

• Gingivitis is an inflammatory disease of the marginal gingiva, either localized or generalized.

Etiology

• It is primarily caused by bacterial plaque accumulation due to inadequate oral hygiene.

• Calculus, mechanical irritation, and irregularities in the position of the teeth may be contributory factors.

Occurrence in children

• Common.

Localization

• Free and interdental gingiva. Mainly observed during the mixed dentition, and more rarely in the primary dentition.

• Sometimes in areas of tooth eruption (eruption gingivitis).

Clinical features

• Redness and edema, usually without pain (Fig. 6.1).

• Gingival hyperplasia may sometimes be observed (Fig. 6.2).

• Bleeding may occur spontaneously, or after light probing.

• There is often halitosis.

• The diagnosis is made clinically.

Differential diagnosis

• Desquamative gingivitis

• Drug-induced gingival hyperplasia

• Gingivitis due to mouth breathing

• Acute leukemia

Treatment

• Plaque control and good oral hygiene.

• Gingivectomy, in cases of severe gingival hyperplasia.

Periodontitis

Definition

• Periodontitis is the result of progression of the inflammatory process from the gingiva to the deeper periodontal structures.

Etiology

• Bacterial plaque is important for the initiation of the disease.

• The same factors as in chronic gingivitis, which usually evolve into periodontitis.

• Systemic predisposing factors include: diabetes mellitus, human immunodeficiency virus (HIV) infection, immune diseases, metabolic diseases, etc.

• Host factors are also important, and appear to be influenced by genetic and environmental factors such as smoking.

Occurrence in children

• Rare, mainly in adolescents.

Localization

• Localized or generalized.

Clinical features

• The consequences of periodontitis are alveolar bone resorption and loss of attachment, followed by periodontal pocket formation.

• Inflammation and edema of the gingiva, pockets deeper than 3 mm (Fig. 6.3).

• Bleeding and malodorous breath, teeth migration, tooth movement.

• The diagnosis is usually made clinically.

Radiographic features

• Alveolar bone resorption.

Differential diagnosis

• Papillon–Lefèvre syndrome

• Langerhans’ cell histiocytosis

• Acatalasia

• Hypophosphatasia

• Leukemia

• Glycogen storage disease Type Ib

• Scurvy

Treatment

• Plaque control and good oral hygiene.

• Scaling and root planing and/or surgery.

• Maintenance therapy is very important.

Fig. 6.1 Chronic gingivitis

Fig. 6.2 Chronic hyperplastic gingivitis

Fig. 6.3 Periodontitis

Juvenile Periodontitis

Definition

• Juvenile periodontitis is a specific type of early-onset periodontitis, which usually affects adolescents, and is characterized by severe alveolar bone loss.

Etiology

• Actinobacillus actinomycetemcomitans and probably other pathogens may be involved.

• Reduced immune response to endotoxins of bacterial plaque or genetic immune insufficiency have been proposed.

Occurrence in children

• Only in adolescents.

• Familial occurrence.

Localization

• Affects only permanent teeth.

• Localized or generalized.

• Selectively affects incisors and first molars.

Clinical features

• Mild gingival inflammation (Fig. 6.4).

• Rapid and severe destruction of alveolar bone.

• Deep periodontal pockets, bleeding, malodorous breath.

• Absence of local factors (bacterial plaque, calculus).

• Tooth mobility and migration (Fig. 6.5).

Radiographic features

• Severe and rapid bone loss (Fig. 6.6).

Differential diagnosis

• Prepubertal periodontitis

• Adult periodontitis

• Papillon–Lefèvre syndrome

• Ehlers–Danlos syndrome, type VIII

• Crohn’s disease

• Chediak–Higashi syndrome

• Ulcerative necrotizing periodontitis in HIV infection

• Langerhans’ cells histiocytosis

• Glycogen storage disease Type Ib

• Cyclic neutropenia and agranulocytosis

• Juvenile diabetes mellitus (type I)

• Down’s syndrome

Treatment

• Conservative mechanical treatment or surgery.

• Systemic antibiotics, local antiseptics.

Desquamative Gingivitis

Definition

• Desquamative gingivitis is a relatively common clinical manifestation of various mucocutaneous diseases on the gingiva (a non-specific disease entity), with a well-defined clinical pattern.

Etiology

• The most common disorders that cause desquamative gingivitis are cicatricial pemphigoid, lichen planus, bullous pemphigoid, pemphigus, linear IgA disease and, rarely, other mucocutaneous diseases.

Occurrence in children

• Very rare.

Localization

• Buccal anterior gingiva of the maxilla and mandible.

• Usually localized and rarely generalized.

Clinical features

• Red gingiva, edematous with erosions (Figs. 6.7, 6.8).

• Characteristic desquamation of the epithelium or bleeding bullous formation after rubbing with the spatula.

• Painful gingiva during mastication and brushing.

• Rarely, bleeding. The disease has periods of remission and exacerbation.

• Searching for other signs and symptoms of the underlying disease is important for the diagnosis.

Laboratory examinations

• Histopathological examination.

• Direct immunofluorescence.

• Indirect immunofluorescence.

Differential diagnosis