Periodontitis in children

Inflammation of the periodontal tissue in children is closely related to caries and the condition of the dental pulp. Inflamed periodontal ligaments, decaying enamel and pulp interfere not only with the normal formation and development of permanent teeth, but can cause more serious consequences. Of all dental problems, periodontitis in children accounts for almost a third - about 35%. The disease is much more difficult than in adults, since periodontal tissues in childhood are constantly being rebuilt and do not have a clear anatomical boundary, so inflammation, regardless of the cause and localization, affects literally all structural elements of the periodontium.

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Causes of periodontitis in children

According to statistics, about 35% of chronic forms of periodontitis develop as a result of incorrect or incomplete treatment of pulpitis, about 40% of all cases of periodontal disease are associated with undiagnosed and untreated caries, 30% - with trauma.

However, all these factors are, one way or another, connected with the anatomical and physiological specificity of the structure of periodontal tissues in children:

• Periodontal tissue in children is looser, its collagen fibers are very vulnerable and do not have the density characteristic of the periodontium of adults.
• All processes associated with blood circulation in the periodontium are much more active in children than in adults.
• In children, the periodontal gap is much larger than in adult patients.
• In childhood, the entire periodontal apparatus is unstable, which is due to the upcoming replacement of baby teeth with permanent ones (root resorption).

Thus, the periodontal ligament structure in a child is represented by a rather loose and unstable connective tissue, which sensitively and quickly reacts with inflammation to any pathogenic factor. Factors and causes of periodontitis in children can be as follows:

• Inflammation of infectious etiology as a complication of caries.
• Complication after pulpitis.
• Trauma – bruise, fall, blow.
• Medicinal iatrogenic factor – incorrect treatment of a baby tooth.
• Acute viral and infectious diseases of the body (hematogenous route of infection).

It should be noted that the most common cause of periodontal inflammation in childhood is tooth decay and its consequence – pulpitis. The second place in the list of causes is occupied by injuries that are typical for babies standing on their feet and learning to walk. As a rule, at the age of up to 2 years, children have damaged front teeth, which is caused by frequent falls forward. It is worth mentioning a rather rare cause – infection per continuitatem (lymph-hematogenous route), when tissues located in close proximity to the periodontium become inflamed.

The main causative agents of the inflammatory process are streptococci and staphylococci, they can combine with yeast-like microorganisms, fusobacteria, actinomycetes and act as a polyinfection. Most often, chronic granulating periodontitis is diagnosed in childhood, acute course in dental practice is rare, which is explained by the specific structure of bone tissue.

To summarize, the causes of periodontitis in children can be presented in the form of a list where the provoking factors are arranged according to the degree of prevalence (in descending order):

• An infection that spreads from a carious lesion, pulp.
• Trauma, including dislocation or root fracture.
• A powerful drug introduced into the canal during dental procedures to treat the pulp.
• Mechanical damage to the periodontium during dental treatment.
• Allergy to medicinal dental treatment.
• A viral or bacterial infection spread by hematogenous means – tonsillitis, flu.
• Mechanical factor associated with malocclusion and tooth overload.
• Infection that enters the periodontium from nearby inflamed tissues of the oral cavity (per continuitatem).

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Symptoms of periodontitis in children

Acute forms of periodontitis, which fortunately are quite rare, are expressed by obvious clinical symptoms:

• A sharp deterioration in the child's general health, lethargy.
• Loss of appetite, the inflammatory process is accompanied by severe pain in the entire periodontal tissue, any food intake, especially hot food, provokes pain.
• Poor sleep, periodontal pain torments the child at night, preventing him from falling asleep.
• The pain may be pulsating, which indicates the accumulation of purulent exudate and requires urgent dental care.
• In the acute form of periodontitis, the child clearly points to the diseased tooth.
• An increase in body temperature from subfebrile to high levels (38-39 degrees) is possible.

Acute inflammatory process in periodontium in children develops rapidly, exudative and serous stage lasts literally several hours, quickly transforming into purulent phase. Local inflammation also spreads aggressively through tissues and becomes diffuse.

It should be noted that the symptoms of periodontitis in children may be hidden, unmanifested. According to statistics, acute apical periodontitis in teeth with incomplete root formation occurs in only 5-7% of cases, much more often the inflammation occurs in a chronic form.

Symptoms of chronic periodontitis developing in childhood depend on the type of inflammation and its localization. The chronic inflammatory process is most often primary and occurs in shallow cavities affected by caries, the dental canal is usually closed. In 65% of children, the granulating type of inflammation affects, which is characterized by the formation of abscesses or fistulas in the gum. In addition, this disease affects a large area of bone tissue, granulation formations often grow into the lumen of the root canal.

Signs of chronic periodontal inflammation in a child:

• Periodic complaints of toothache when eating.
• Slight swelling of the gums in the area of the affected tooth.
• When a fistula develops, a bulge of the mucous membrane in the lower jaw area is possible. An obvious formed fistula has a passage, it is noticeable on the skin of the face or inside the oral cavity. There are so-called migrating granulomas, when the fistula closes and recurs in a new place.

Since the symptoms of a chronic process are non-specific and not expressed, any alarming sign and discomfort that a child complains about should be a reason for a visit to a pediatric dentist. Only a doctor can determine the disease and differentiate it from others with similar symptoms.

Acute periodontitis in children

Acute inflammatory process in periodontium in children proceeds very actively and quickly. Local inflammation rapidly develops into purulent, diffuse, practically bypassing the serous phase. Acute periodontitis in children is complicated by the cessation of the tooth growth zone, in fact, it stops growing. In addition, almost all structures of the periapical apparatus are involved in the process - mucous membrane, periosteum, bone, lymph nodes, soft tissues of the face.

The main clinical sign of aggressive inflammation is severe pain, an immediate pain reaction to touching the affected tooth, to percussion. The pain symptom is constant and does not subside even at night. The gum is swollen, hyperemic, a unilateral enlargement of the lymph node in the region of the inflammatory process is possible. The accumulation of purulent exudate in the periodontium provokes pulsating pain, the child begins to have headaches, the body temperature rises, the general condition significantly worsens due to extensive intoxication. Weakened children, after an illness or during it, tolerate such inflammation especially hard.

The reasons for the development of acute periodontitis in children may be associated with a bruise, a fall, or incorrect pulpitis treatment. Fortunately, such conditions are rare in dental practice; much more often, inflammation is diagnosed as an exacerbation of chronic periodontitis as a result of a viral or infectious disease, or hypothermia. The clinical manifestations are identical to the symptoms of true acute inflammation; the process is more aggressive and more severe than a similar type of periodontitis in adults.

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Chronic periodontitis in children

Chronic periodontitis is the most common type of periodontal tissue inflammation in children. As a rule, it develops on its own, i.e. it is primary. Chronic periodontitis in children is provoked by weak irritants that act constantly. This can be a chronic form of pulpitis, bad habits (chewing pencils), malocclusion. The clinical picture with this course of inflammation is non-specific and does not manifest itself with noticeable symptoms. Moreover, chronic periodontitis can develop for years, and its treatment often begins in adulthood. Sluggish symptoms are explained by the loose structure of the child's periodontal tissues, through which the accumulated exudate finds an outlet, thus not accumulating.

Specific features of chronic periodontal inflammation in childhood:

• The inflammatory process occurs in a closed cavity of the tooth in a shallow carious lesion.
• Chronic periodontitis in childhood most often occurs in a granulating form with the growth of granulomas into the root canal, accompanied by the formation of fistulas in the gum tissue.
• Often, chronic inflammation is localized in the furcation zone of the tooth root (the place where the parts of the root diverge in a multi-rooted tooth).
• Chronic inflammation in the periodontium of an unformed root leads to the cessation of its growth, while the apical region becomes pathologically wide, and the walls become thinner.
• The inflammatory process often involves the follicles of the adjacent tooth.
• The granulating chronic process is quite often accompanied by the formation of fistulas and cysts.

Diagnosis of chronic inflammation in the periodontium is difficult due to latent symptoms, so it always requires the use of a differential algorithm. The main method that confirms or excludes chronic periodontitis in children is X-ray. X-ray solves the following diagnostic problems:

• Evaluation of the condition of the tooth root – its formation, resorption, presence or absence of granuloma within the pulp.
• Assessment of the condition of the tooth socket – integrity, thickness, size of the periodontal gap.
• Determining the localization of the inflammatory process - at the apex or in the furcation zone of the root.
• Determination of root length, presence of a rudiment of a potential permanent tooth.

As a rule, probing, electrodiagnostics or thermal tests are not performed on children during diagnostic procedures. These methods are painful for children and are not informative, since the child is not able to describe in detail and objectively his feelings during such diagnostics.

The method of treating chronic periodontitis in childhood is determined by the nature of the inflammation and its prevalence. If possible, the affected periodontium is treated conservatively, but if the inflammation affects the root rudiment of a nearby permanent tooth, the affected baby tooth is removed, that is, the pathological process is stopped.

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Periodontitis of baby teeth in children

Often parents do not pay due attention to diseases of baby teeth in children, hoping that temporary teeth will sooner or later be replaced by permanent ones. And even the removal of a baby tooth does not pose a serious danger to the child's oral cavity. This is a huge misconception, because according to statistics, 75-80% of temporary teeth are removed precisely because of inflammatory processes in dental tissue - pulpitis or periodontitis.

Why is it important to keep baby teeth?

First of all, it is necessary to understand that the physiologically normal age for teeth to change is 6-7 years, the general process of formation of permanent teeth is completed by 12-14 years, not earlier. If baby teeth are not taken care of, the digestive function is disrupted, immune protection is reduced, in addition, temporary teeth are responsible for preparing the gums for the eruption of denser permanent teeth. Thus, it would seem that a baby tooth, which is not very necessary, can play an important role in the general process of a child's development, and therefore literally every tooth must be preserved until a certain period determined by nature itself.

The main causes of periodontitis of baby teeth in childhood are caries and subsequent pulpitis. Unfortunately, temporary teeth are more vulnerable and cannot withstand such pathologies, this is due to the anatomical structure and structure of bone tissue. Dentin is not sufficiently mineralized, the enamel is thinner than that of permanent teeth, so any infection quickly affects the baby tooth, first forming a carious lesion, and then penetrating into the pulp.

Most often, periodontitis of baby teeth in children has a granulating form, which is accompanied by the formation of abscesses or fistulas. The disease progresses sluggishly, in a chronic form, acute periodontitis of temporary teeth is diagnosed extremely rarely.

What is the danger of periodontitis of temporary teeth?

The influence of inflammation on the phase of tooth formation	Risk	Complications and consequences
The rudiment of a permanent tooth is formed	The inflammatory process in the periodontium slows down the growth of the rudiment	The root rudiment may die
Beginning of mineralization, formation of the dental follicle (dental sac)	The rudiment is preserved, but later the disturbed mineralization affects the condition of the permanent tooth.	Underdevelopment of the tooth crown, tooth hypoplasia, yellow tint of the tooth, possible enamel aplasia
Inflammation at the stage of formation of the crown of a permanent tooth	Death of the growth plate, destruction of the cortical plate	The tooth may not form or grow.
Inflammation at the stage of root formation of a permanent tooth	The bone septum is destroyed, and the permanent tooth may erupt prematurely, without being fully formed.	The root of the permanent tooth is shortened, which leads to tooth mobility. There is a risk of complete tooth dislocation

Treatment of periodontitis of baby teeth does not depend on the child's age, or the date of eruption of the permanent "substitute", but on the nature of the inflammatory process and the risk of complications. If it is possible to save the tooth, the pulp is vital, then conservative treatment is carried out; if the chronic process affects nearby tissues and the roots of the teeth, the affected baby tooth is removed.

Periodontitis of permanent teeth in children

Periodontitis of permanent teeth in children should be diagnosed using an algorithm similar to the diagnosis of periodontal inflammation in adult patients. However, there are also features associated with the phase of tooth root formation. The onset of inflammation could have occurred even during the period when the root has not yet completed its growth. This is often due to the death of the pulp, when the ability of the root to develop in length is completely associated with the degree of damage to the growth zone. Quite often in dental practice, there are situations when a child at the age of 14 has a permanent toothache, there are all the symptoms of chronic periodontitis, and the root continues to develop. Such phenomena complicate both the diagnostic process and the choice of treatment tactics for periodontal tissue. An X-ray may show a short root, which is shorter than the length of the already formed permanent tooth, its apex is pathologically expanded, the root walls are thin and converge in a cone in the apical zone, dentin is not developed. The socket is very often destroyed, the bone tissue is sparse, which indicates a chronic course of granulating periodontitis over a long time.

Symptoms of periodontitis of permanent teeth:

1. Serous periodontitis in its acute form is manifested by periodic aching pains, which significantly increase during food intake and percussion. The pain is clearly localized, the child accurately points to the affected tooth. The pain symptom may subside when the jaw is closed, but relapses again under mechanical or food load. Soft tissues are not edematous, not hyperemic, the tooth may lose stability, but there is also no obvious mobility. As a rule, an X-ray is not informative in the serous form of inflammation, a survey, examination of the oral cavity, and vertical percussion are more effective in the diagnostic sense.
2. Serous periodontitis in children quickly transforms into purulent. Purulent periodontitis is always characterized by clearly expressed symptoms:
   • Throbbing intense pain.
   • The pain radiates along the trigeminal nerve.
   • The pain symptom is activated by food and mechanical stress.
   • The pain intensifies when exposed to heat (hot food, drinks).
   • The pain depends on the position of the body and intensifies in a horizontal position (lying down).
   • The child's mouth is half open, and closing the jaw causes pain.
   • The tooth becomes loose and the gums become swollen.
   • The “overgrown tooth” syndrome is observed when the child feels the tooth as foreign and excessively large.
   • The lymph nodes are enlarged.
   • The body temperature rises.
   • If the purulent exudate does not find an outlet, the face on the side of the inflammation swells (asymmetric edema).
3. Chronic periodontitis of permanent teeth occurs with sluggish symptoms, but is more intense than a similar form of inflammation in adult patients. This is explained by the insufficient density of the periodontal ligament apparatus and the possibility of exudate outflow. The fibrous form of inflammation is the least pronounced, ending with the replacement of the periodontal gap with fibrous fibers. The most common form of granulating periodontitis, when the granulation process intensively spreads in the tissues, destroying the periodontal gap and forming fistulas. Granulomatous inflammation in children is extremely rare, it is characterized by the formation of cystogranulomas and requires surgical treatment.

Chronic periodontal inflammation in children is more likely than in adults to worsen and occurs with clinical symptoms characteristic of acute forms of the inflammatory process.

Diagnosis of periodontitis in children

It can be difficult to diagnose periodontitis in children, due to the morphological and anatomical features and the continuous process of formation of milk and permanent teeth. In addition, the difficulties in determining the form and type of periodontal inflammation are explained by the limited opportunities for cooperation with a small patient. Children are not so much afraid of the dentist as they are unable to objectively assess their feelings, therefore, the assessment of clinical manifestations of inflammation depends only on the knowledge and practical experience of the doctor.

The main task facing the specialist is to differentiate periodontitis from carious inflammation and pulpitis. Differential diagnostics is confirmed by X-ray examinations, and the criteria that help to distinguish these diseases may be the following indicators:

Symptoms and signs	Caries	Pulpitis	Periodontitis
Dependence of pain symptom on thermal stimulus	The pain subsides with cold.	The pain is aggravated by hot food and drinks	Chronic periodontitis does not depend on thermal irritants; in the acute form, pain increases with heat.
Response to probing	The pain increases with probing, usually in the area of the carious cavity	Pain is felt in the pulp	As a rule, there is no pain. In acute forms of periodontitis, pain may be associated with the passage of granulation formations.
X-ray	Doesn't show changes in apex	Changes are possible in the furcation zone of a multi-rooted tooth, less often in the apex	Clearly defined changes in the apical zone of the root

The diagnosis of periodontitis in children should be as accurate as possible, since the choice of treatment tactics and an objective assessment of the advisability of preserving temporary teeth depend on it.

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Treatment of periodontitis in children

The general tasks that periodontitis treatment in children involves are no different from the treatment of periodontal diseases in adult patients. The only difference is taking into account the child's age and ensuring maximum anesthesia during treatment.

Treatment may include both conservative, physiotherapeutic and surgical methods, depending on the condition of the periapical system. In 95% of cases, children are treated in dispensary conditions, very rarely a child needs hospitalization, usually this happens with concomitant severe diseases.

The goals of therapy for the inflammatory process in the periodontium:

• Immediate pain relief.
• Relief of inflammation in the oral cavity.
• Stopping the destructive atrophic process in periodontal tissues.
• Restoration of periodontal function.
• Stimulation of periodontal tissue regeneration.
• Maximum preservation of teeth as a functional dynamic system.

Thus, the treatment of periodontitis in children is aimed not only at neutralizing pain and inflammation, but also at improving the general condition of the oral cavity.

Also, the dentist, choosing the treatment path, especially in case of disease of baby teeth, faces the question of the advisability of their preservation. If the tooth affected by infection loses stability, its root is destroyed, the period of its replacement with a permanent tooth is near, the baby tooth is subject to extraction. Also, a temporary tooth is extracted if its inflammation interferes with the formation and development of nearby teeth and there is a risk of spreading the infection throughout the oral cavity. If the root and pulp are intact and it is possible to save the temporary tooth, it is subjected to sanitation and filling. The specificity of pediatric dentistry lies in the choice of a special filling material, which must be biocompatible and not cause complications. In addition to standard dental procedures, the child is prescribed rinses with a hypertonic solution or special antiseptic agents.

The prognosis for treating periodontitis in children is usually favorable, if you contact your dentist in a timely manner. Of course, the child's parents should take care of this, as well as compliance with all medical recommendations during the course of therapy.

The general treatment plan, depending on the type of inflammation, may look like this:

Form of inflammation	Possible reason	Therapeutic measures
Acute periodontitis	Exacerbation of pulpitis, pulp necrosis, purulent lesion of pulp tissue	Opening of the tooth cavity. Removal of non-viable pulp, removal of purulent contents. Sanitation of the canal, the tooth remains open for the outflow of exudate. After complete discharge of pus, the tooth is filled
Chronic form of periodontitis	Caries, pulpitis	Symptomatic treatment, pathogenetic treatment. Elimination of provoking mechanical factors (correction of bite) Electrophoresis Rinsing the oral cavity
Acute traumatic periodontitis	Bruise, fall, blow	Assessment of the pulp and root condition. Anesthesia. Dynamic observation for 2 weeks. If the pulp dies, it is removed, the canal is sanitized and filled.

Treatment of periodontitis of baby teeth

Before deciding on the treatment tactics for periodontal inflammation of baby teeth, the dentist evaluates the degree of tissue damage, the advisability of preserving the affected tooth and the possible risks of its removal. If there is a threat to the child's general health, and this happens with an acute inflammatory process and severe intoxication, the tooth is definitely removed. Also, periodontitis treatment of baby teeth can be surgical if there is a threat of periostitis, extensive gum abscess, or the risk of infection spreading to nearby teeth or to the rudiments of the roots of permanent teeth.

In case of a purulent process, drainage is possible by cutting the gum, despite the seriousness of this definition, this method is easier for a child to tolerate than passing the canal with a drill. In addition, the secreted pus indicates the outflow of exudate and eliminates the need for another opening of the pulp cavity. The peculiarity of the treatment of chronic periodontitis of temporary teeth is that most often it is not possible to completely restore bone tissue even with complex measures for sanitation and filling of the canal. Therefore, after conservative treatment of the tooth, the child must be observed by a doctor first monthly, then quarterly to assess the stability of the rehabilitation process. If a recurrent inflammatory process is detected during observation, the tooth is subject to extraction.

In what cases are baby teeth not treated conservatively?

1. If there are less than one and a half years left until the tooth is replaced with a permanent one.
2. If the child has a history of allergies or chronic infectious pathologies, diseases of internal organs.
3. If there have already been several periods of exacerbation during conservative treatment of periodontitis.
4. With significant root resorption.
5. In case of perforation of the bottom of the tooth cavity.
6. When the bone tissue plate located around the follicle of a forming permanent tooth is destroyed.
7. If a baby tooth is affected by inflammation, it is defined as a source of sepsis.
8. If a child is weakened by an underlying chronic disease, his immune defenses are reduced.
9. In case of significant tooth mobility.

Treatment of periodontitis of temporary teeth

Chronic periodontitis of temporary teeth is treated in almost the same way as a similar type of inflammation in adults. The only difference is that children, due to age-related characteristics, have the opportunity to replace a removed baby tooth with a permanent one, which older people do not have. Treatment of periodontitis of temporary teeth depends on how far the process has gone and how it affects nearby developing teeth.

If the inflammation has spread to the rudiment of a developing permanent tooth, the damaged baby tooth is removed. Also, removal is inevitable in the case of root resorption of more than 2/3. There is another reason why a temporary tooth may be subject to extraction. This is due to the fact that children have a very hard time with dental procedures and are sometimes simply unable to withstand a long course of therapy. In such cases, having weighed all the risks and advantages, the doctor often decides to stop painful conservative therapy and removes the "culprit" of all troubles.

In chronic periodontal inflammation in multi-rooted primary teeth, the main therapeutic task is to eliminate as much as possible the products of decay, putrefaction from the canals, their sanitation and subsequent sealing with fillings. The prognosis for treatment with small foci of inflammation, maintaining the viability of the pulp, and tooth stability is favorable. However, for complete recovery, complex treatment and prevention of caries is required, which in most cases is the main cause of periodontal tissue inflammation.

Prevention of periodontitis in children

Preventive measures against dental diseases in children should be taken long before the baby is born, ideally, of course. In the antenatal period, when the expectant mother most likely does not think about what kind of teeth the baby will have, the formation of baby teeth in general occurs. This process is influenced by many factors - both the condition of the pregnant woman and her diet, because it ensures the mineralization of the crowns of the baby's teeth. After birth, when the baby's first teeth begin to appear, their health also depends on the care of the parents. Especially during the period when the baby is already taking "adult" food. Prevention of periodontitis in children is the implementation of fairly simple procedures, and the baby should be introduced to them by mom or dad.

The rules are simple - brush your teeth at least twice a day, older children should also use dental floss, eat fewer sweets and take care of your oral cavity by visiting your dentist regularly. Oral care rules that should be followed not only by children but also by adults:

• Dental plaque, which is an excellent environment for the development of caries, then pulpitis and, as a consequence, possible periodontitis, is removed by brushing your teeth. Twice a day, teeth should be brushed with a toothbrush, the effect of brushing will be reinforced by rinsing the mouth with special solutions or simply purified water. Dentists claim that rinsing teeth for 2-3 minutes destroys up to 30% of bacteria in the oral cavity.
• The child must learn to brush his teeth correctly - hold the toothbrush at the right angle (45 degrees), clean not only the outside of the teeth, but also the inside.
• A child needs a special toothbrush, the degree of hardness can be determined by a pediatric dentist. A child's toothbrush should be changed quarterly, just like an adult's toothbrush. The brush should be thoroughly rinsed with running water each time after cleaning.
• For children, the choice of toothpaste is very important, it is desirable that it contains fluoride, which significantly reduces the development of caries, and therefore periodontitis. It is not recommended to buy abrasive or whitening pastes for children, they can damage the fragile enamel of children's teeth.
• Baby food is, in principle, a very important factor influencing the development of the body, including the condition of the teeth. Limiting sugar in the menu helps reduce the risk of caries, pulpitis and periodontitis.

Periodontitis in children takes up more than half of all dental diseases. Unfortunately, as a complication of caries and pulpitis, it continues to affect both children and adults. The constantly high percentage of periodontal diseases indicates the need for a more serious attitude to preventive measures. In addition to prevention, which consists of observing basic oral hygiene rules, regular check-ups in dental offices can prevent periodontal inflammation. Modern dentistry is equipped with advanced equipment, doctors have the latest methodological developments, materials and anesthetic drugs are presented in an extremely wide range, therefore, today it is simply stupid for any civilized person to hold on to outdated fears, especially since it is parents who should show children an example of caring for their own health. Healthy teeth in a child is not so much a doctor's task as an understanding of the importance of prevention on the part of adults.