Periodontitis in children

Inflammation of periodontal tissue in children is closely related to caries and the state of the tooth pulp. Inflated toothed ligaments, destroying enamel and pulp prevent not only the normal formation and development of permanent teeth, but can cause more serious consequences. Among all dental problems, periodontitis in children is almost a third - about 35%. The disease is much more complicated than in adults, as periodontal tissues in childhood are constantly rebuilt and do not have a clear anatomical distinction, so inflammation regardless of the cause and localization affects literally all the structural elements of periodontal disease.

[1], [2], [3], [4]

Causes of periodontitis in children

According to statistics, about 35% of chronic forms of periodontitis develop due to improper 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, one way or another, are related to the anatomical and physiological characteristics of the structure of periodontal tissues in children: 

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

Thus, the periodontal ligamentous structure in a child is represented by a rather loose and unstable connective tissue that reacts quickly and sensitively to inflammation to any pathogenic factor. The 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, stroke.
• Medical iatrogenic factor - incorrect treatment of a milk tooth.
• Acute viral and infectious diseases of the body (hematogenous pathway of infection).

It should be noted that the most common cause of periodontal inflammation in childhood is tooth decay with caries and its consequence is pulpitis. The second place in the list of causes is occupied by traumas that are typical for toddlers who stand on their feet and are trained to walk. As a rule, at the age of up to 2 years, frontal teeth are damaged in children, which is caused by frequent falls forward. It is worth mentioning and a fairly rare reason - infection of the continuation (hemofohematogenous), when the tissues located in close proximity to the periodontium become inflamed.

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

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

• Infection that spreads from a caries focus, pulp.
• Trauma, including dislocation or fracture of the root.
• A strong drug injected into the canal during dental manipulations in the treatment of pulp.
• Mechanical damage to the periodontal during the treatment of the tooth.
• Allergy to medical dental treatment.
• Viral or bacterial infection spreading by the hematogenous pathway - tonsillitis, influenza.
• The mechanical factor associated with improper bite and overload of the tooth.
• Infection, entering the periodontium, from the nearest inflamed tissues of the oral cavity (per continuitatem).

[5]

Symptoms of periodontitis in children

The acute forms of periodontitis, which, fortunately, are rare, are expressed by obvious clinical symptoms: 

• Sharp deterioration in the general health of the child, lethargy.
• Loss of appetite, inflammatory process is accompanied by strong pains of all periodontal tissue, any food intake, especially hot food, provokes painful sensations.
• Bad sleep, periodontal pain torments the child and at night, preventing him from falling asleep.
• The pain can be pulsating, it indicates the accumulation of purulent exudate and requires urgent dental care.
• In acute periodontitis, the child clearly points to a sick tooth.
• It is possible to raise the body temperature from subfebrile to high levels (38-39 degrees).

The acute course of the inflammatory process in periodontitis in children develops rapidly, the exudative and serous stage lasts literally for several hours, rapidly transforming into a purulent phase. Local inflammation also aggressively spreads through the tissues and passes into a diffuse state.

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

Symptoms of chronic periodontitis, which develops in childhood, depend on the type of inflammation and its localization. The chronic inflammatory process is most often primary and occurs in shallow cavities afflicted with caries, the dental canal, as a rule, is closed. In 65% of children affects the granulating form of inflammation, which is characterized by the formation of abscesses or fistulas in the gum. In addition, such a 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 pain in the tooth when eating.
• Slight swelling of the gums in the area of the affected tooth.
• With a developing fistula, the mucous membrane may swell in the area of the lower jaw. The apparent fistula formed has a course, it is noticeable on the skin of the face or inside the mouth. There are so-called migratory granulomas, when the fistula closes and recurs in a new place.

Because the symptoms of the chronic process are nonspecific and not expressed, any anxious symptom and discomfort to which the child complains should be an occasion for a visit to a children's dentist. Only the doctor will be able to identify the disease and differentiate it from others, similar in symptomatology.

Acute periodontitis in children

Acute inflammatory process in periodontitis in children is very active and fast. Local inflammation rapidly develops into a purulent, diffuse, almost avoiding serous phase. Acute periodontitis in children is complicated by the cessation of the tooth growth zone, in fact, it ceases to grow. In addition, almost all structures of the periapical apparatus are involved in the process - the mucous membrane, periosteum, bone, lymph nodes, soft facial tissues.

The main clinical sign of aggressive inflammation is severe pain, instantaneous painful reaction to touching the affected tooth, percussion. The pain symptom is permanent and does not subside even at night. The gums are edematous, hyperemic, possibly one-sided enlargement of the lymph node in the region of the inflammatory process. The accumulation of purulent exudate in periodontium provokes throbbing pain, the child begins to ache and the head, the body temperature rises, the general condition worsens due to extensive intoxication. Especially difficult to tolerate such inflammation weakened children, after the disease or during it.

The reasons for the development of acute periodontitis in children may be associated with a bruise, a fall, an incorrect treatment of pulpitis. Fortunately, such conditions in dental practice are rare, much more often inflammation is diagnosed as exacerbation of chronic periodontitis as a result of a viral, infectious disease, hypothermia. Clinical manifestations are identical to those of true acute inflammation, the process proceeds more aggressively, more heavily than a similar kind of periodontitis in adults.

[6], [7]

Chronic periodontitis in children

The chronic form of periodontitis is the most common type of inflammation of periodontal tissues in children. As a rule, it develops independently, that is, it is primary. Provoke chronic periodontitis in children, weak stimuli, acting constantly. This can be a chronic form of pulpitis, bad habits (pencil cracking), an incorrect bite. The clinical picture with this course of inflammation is non-specific and does not show significant symptoms. Moreover, chronic periodontitis can develop for years, and its treatment quite often begins already in adulthood. Sluggish symptomatology is due to the loose structure of the periodontal tissues of the child, through them accumulated exudate finds an outlet, thus not accumulating.

Specificity of the chronic form of periodontal inflammation in childhood: 

• Inflammatory process proceeds with the closed cavity of a tooth in a shallow caries focus.
• Chronic periodontitis in childhood often occurs in a granulating form with the germination of granulomas into the root canal, accompanied by the formation of fistulas in the tissues of the gum.
• Often, chronic inflammation is localized in the area of furcation of the root of the tooth (the place of divergence of parts of the root in the multi-rooted tooth).
• Chronic inflammation in the periodontitis of the unformed root leads to the cessation of its growth, while the apical region becomes pathologically wide, and the walls - thinner.
• In the inflammatory process, the follicles of the nearby tooth are often involved.
• The granulating chronic process is often accompanied by the formation of fistulas, cysts.

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

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

As a rule, children do not undergo probing, electrodiagnostics or thermal tests during diagnostic activities. These methods are painfully carried by children and are not informative, because the child is not able to describe in detail, objectively, his feelings when conducting such a diagnosis.

The method of treatment of chronic periodontitis in childhood is determined by the nature of the inflammation and its prevalence. If there is a possibility, the affected periodontium is treated conservatively, if the inflammation affects the root rudiment of a nearby permanent tooth, the milk tooth is removed from the inflammatory process, that is, the pathological process is stopped.

[8], [9], [10], [11]

Periodontitis of infant teeth in children

Often parents do not pay due attention to the diseases of infant teeth in children, hoping that the temporary teeth will eventually change permanently. And even the removal of the milk tooth is not a serious danger to the oral cavity of the child. This is a huge mistake, because according to statistics, 75-80% of temporary teeth are removed just due to inflammatory processes in the dental tissue - pulpitis or periodontitis.

Why is it important to keep your baby teeth?

First of all, it is necessary to understand that the physiologically normal age of the change of teeth is 6-7 years, the general process of forming permanent teeth is completed by 12-14 years, not earlier. If you do not take care of your baby's teeth, the digestive function is impaired, your immune defenses are reduced, and temporary teeth are responsible for preparing the gums for the eruption of denser permanent teeth. Thus, it would seem that a not very suitable milk tooth can play an important role in the overall development of the child, and therefore literally every tooth should be kept up to the period determined by nature.

The main causes of periodontitis of infant teeth in childhood are caries and the following pulpitis. Unfortunately, temporary teeth are more vulnerable and can not withstand such pathologies, this is due to the anatomical structure and structure of bone tissue. Tooth dentin is not sufficiently mineralized, the enamel is thinner than in permanent teeth, so any infection quickly infects the milk tooth, first forming a caries focus, and then penetrating into the pulp.

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

What is the danger of temporary periodontitis in your teeth?

Influence of inflammation on the tooth formation phase	Risk	Complications and consequences
The rudiment of a permanent tooth is formed	Inflammatory process in periodontium slows the growth of the rudiment	The root of the root may die
The beginning of mineralization, the formation of the follicle of the tooth (dental sac)	The rudiment remains, but later the impaired mineralization affects the state of the permanent tooth	Underdevelopment of the tooth crown, hypoplasia of the tooth, yellow shade of the tooth, aplasia of the enamel is possible
Inflammation in the stage of the formation of the crown of a permanent tooth	Death of the growth zone, destruction of the cortical plate	The tooth may not form, grow
Inflammation in the stage of the formation of the root of the permanent tooth	The bone septum breaks down, a permanent tooth can erupt prematurely without being fully formed	The root of the permanent tooth is shortened, which leads to the mobility of the tooth. There is a risk of complete dislocation of the tooth

Treatment of periodontitis of infant teeth depends not on the age of the child, not on the date of eruption of the permanent "substitute", but on the nature of the inflammatory process and the risk of complications. If there is an opportunity to save the tooth, the pulp is vital, then conservative treatment is performed, if the chronic process affects nearby tissues and the roots of the teeth, the affected tooth is removed.

Periodontitis of permanent teeth in children

To diagnose the periodontitis of permanent teeth in children follows an algorithm similar to the diagnosis of periodontal inflammation in adult patients. However, there are also peculiarities associated with the phase of tooth root formation. The onset of inflammation could occur even at a time when the root has not finished its growth. This is often caused by the death of the pulp, when the ability of the root to develop in length is completely related to the degree of lesion of 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 tactics for treating periodontal tissue. The radiograph can show a short root that is smaller than the length of the already formed permanent tooth, its apex is pathologically expanded, the root walls are thin and converge with a cone in the apex zone, the dentin is not developed. The well is very often destroyed, bone tissue is rarefied, which indicates the chronic course of granulating periodontitis over time.

Symptoms of periodontitis of permanent teeth: 

1. Serous periodontitis in acute form is manifested by periodic aching pains, which are greatly enhanced by eating, percussion. The pain is clearly localized, the child accurately points to the affected tooth. The pain symptom can subside when the jaw is closed, but again recurs with mechanical or nutritional loads. Soft tissues are not swollen, not hyperemic, the tooth may lose stability, but no apparent mobility is noted. As a rule, the roentgenogram in the serous form of inflammation is not informative, more effective in the diagnostic sense of the survey, examination of the oral cavity, vertical percussion.
2. Serous form of periodontitis in children is quickly transformed into purulent. Purulent periodontitis is always characterized by a pronounced symptomatology: 
   • Pulsating intense pain.
   • The pain radiates along the trigeminal nerve.
   • The pain symptom is activated with food, mechanical stress.
   • Pain is enhanced by exposure to heat (hot food, drink).
   • Pain depends on the position of the body, is strengthened in a horizontal position (lying down).
   • The baby's mouth is half open, closing the jaw causes painful sensations.
   • The tooth becomes mobile, the gum is edematous.
   • There is a syndrome of the "grown tooth" when the child feels the tooth as foreign, too large.
   • Lymph nodes are enlarged.
   • The body temperature rises.
   • If the purulent exudate does not find an outlet, the person swells around the side of the inflammation (asymmetric edema).
3. Chronic periodontitis of permanent teeth occurs with lethargic symptoms, but more intensely than a similar form of inflammation in adult patients. This is due to the insufficient density of the periodontal ligament apparatus and the possibility of exudate outflow. The fibrotic form of inflammation, which ends with the replacement of the periodontal cleft with fibrous fibers, is least manifest. 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 cystogranul and requires surgical treatment.

Chronic inflammation of periodontitis in children more often than in adults, exacerbated and proceeds with clinical symptoms characteristic of acute forms of the inflammatory process.

Diagnosis of periodontitis in children

Diagnosing periodontitis in children is difficult, it is associated with the characteristics of morphological, anatomical character and the continuous process of forming dairy and permanent teeth. In addition, the difficulties in determining the shape and type of periodontal inflammation are explained by the limited possibilities of cooperation with a small patient. Children are not so afraid of the dentist, how many can not objectively evaluate their feelings, therefore, the evaluation of clinical manifestations of inflammation depends only on the knowledge and practical experience of the doctor.

The main task that faces a specialist is to differentiate periodontitis from carious inflammation and pulpitis. Differential diagnosis is confirmed by X-ray examinations, and the following indicators can be used to distinguish these diseases:

Symptoms and signs	Caries	Pulpitis	Periodontitis
Dependence of the pain symptom on the thermal stimulus	The pain subsides from the cold	The pain is aggravated by hot food, drinking	Chronic periodontitis does not depend on thermal stimuli, in acute form the pain increases with heat
Reaction to sounding	Pain is enhanced by sounding, 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 can be associated with the passage of granulation formations
Radiograph	Does not show changes in apex	Variations are possible in the zone of furrowing of the multi-rooted tooth, less often in the apex	Clearly defined changes in the apex of the root

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

[12], [13], [14]

Treatment of periodontitis in children

General tasks that involve the treatment of periodontitis in children do not differ from the treatment of periodontal diseases in adult patients. The only feature is the age of the child and the provision of maximum anesthesia in the conduct of medical activities.

Treatment can include both conservative, physiotherapeutic, and surgical methods, depending on the condition of the periapical system. In 95% of cases, children are treated in the dispensary conditions, the crane rarely needs a hospitalization, usually with accompanying serious illnesses.

Objectives of therapy of the inflammatory process in periodontium: 

• Immediate anesthesia.
• Cupping the focus of inflammation in the mouth.
• Stop the destructive atrophic process in the periodontal tissues.
• Restoration of the periodontal function.
• Stimulation of periodontal tissue regeneration.
• Maximum preservation of teeth as a functional dynamic system.

Thus, the treatment of periodontitis in children is directed not only to neutralize pain and inflammation, but also to improve the general condition of the oral cavity.

Also, before the dentist choosing the path of treatment, especially with the disease of infant teeth, the question arises as to whether they should be preserved. If the infected tooth is losing stability, its root is destroyed, the period of its replacement is close to a permanent tooth, the milk tooth is to be removed. Also, the temporary tooth is removed if its inflammation interferes with the formation and development of nearby teeth and there is a threat of spreading the infection throughout the oral cavity. If the root and pulp are preserved and there is an opportunity to save the temporary tooth, it is subjected to sanation and sealed. The specificity of pediatric dentistry is to choose a special filling material that must have a biocompatibility and does not cause complications. In addition to standard dental procedures, a rinse with hypertonic solution or special antiseptic agents is prescribed to the child.

The prognosis of treatment of periodontitis in children is usually favorable, with the catch of timely treatment to the dentist. Of course, parents of the child should take care of this, as well as observing the fulfillment of all medical recommendations during the course of therapy.

The general scheme or plan of treatment depending on a kind of an inflammation can look or appear thus:

Form of inflammation	Possible reason	Therapeutic events
The acute form of periodontitis	Exacerbation of pulpitis, necrosis of pulp, purulent lesion of pulpal tissue	Opening of the cavity of the tooth. Removal of non-viable pulp, removal of purulent contents. Sanitation of the canal, the tooth remains open for outflow of exudate. After the complete expiration of pus, the tooth is sealed
Chronic form of periodontitis	Caries, pulpitis	Symptomatic treatment, pathogenetic treatment. Elimination of provoking mechanical factors (bite correction) Electrophoresis Mouth rinsing
Acute traumatic periodontitis	Bruise, fall, stroke	Assessment of the state of pulp, root. Anesthesia. Dynamic observation for 2 weeks With the dying of the pulp, it is removed, the channel is sanitized and sealed

Treatment of periodontitis of infant teeth

Before deciding on the tactics of treating inflammation of the periodontal milk teeth, the dentist assesses the degree of tissue damage, the appropriateness of keeping the affected tooth and the possible risks when it is removed. If there is a threat to the general health of the child, and so it happens in acute inflammatory process and severe intoxication, the tooth is uniquely removed. Also, the treatment of periodontitis of infant teeth can be surgical in case of periostitis, extensive gum abscess, at the risk of spreading infection to nearby teeth, on the root of the roots of permanent teeth.

With a purulent process, drainage is possible with the help of a gum incision, despite the seriousness of this definition, this method is more easily tolerated by the child than passing the canal with a drill. In addition, excreting pus speaks about the outflow of exudate and eliminates the need for another expansion of the pulpal 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 canal filling. Therefore, after the conservative treatment of the tooth, the child should be observed at the doctor first monthly, then quarterly to assess the stability of the rehabilitation process. If the observation reveals a recurrent inflammatory process, the tooth should be removed.

In what cases is the milk teeth not treated conservatively?

1. If the replacement tooth for a permanent tooth is less than a year and a half.
2. If a child has a history of allergies or chronic infectious diseases, internal diseases.
3. If conservative treatment of periodontitis already had several periods of exacerbation.
4. With a considerable resorption of the root.
5. When perforating the bottom of the tooth cavity.
6. When the plate of bone tissue is destroyed, located around the follicle of the forming permanent tooth.
7. If affected inflammation, the milk tooth is defined as the focus of sepsis.
8. If a child is weakened by a major chronic disease, his immune defense is reduced.
9. With considerable mobility of the tooth.

Treatment of periodontitis of temporary teeth

Chronic periodontitis of temporary teeth is treated in much the same way as a similar type of inflammation in adults. The only difference is that in children, due to age features, it is possible to replace a remote milk tooth with a permanent one, which is deprived of older people. The treatment of periodontitis of temporary teeth depends on how far the process has gone and how it affects the nearby forming teeth.

If the inflammation has spread to the bud of the developing permanent tooth, the damaged milk is removed. Also, removal is inevitable in case of root resorption by more than 2/3. There is one more reason why a temporary tooth can be extracted. This is due to the fact that children are very difficult to tolerate dental procedures and sometimes simply can not withstand a long course of therapy. In such cases, having weighed all the risks and pluses, the doctor often makes a decision to stop painful conservative therapy and removes the "culprit" of all ills.

With chronic periodontal inflammation in multi-rooted milk teeth, the main therapeutic task is to maximize the elimination of decomposition products, putrefaction from canals, their sanitation and further sealing. The prognosis of treatment for small foci of inflammation, preservation of the viability of the pulp, stability of the tooth is favorable. However, full recovery requires complex treatment and prevention of caries, which in most cases is the main cause of inflammation of periodontal tissue.

Prevention of periodontitis in children

Measures to prevent dental diseases in children should be undertaken long before the birth of the child, of course, ideally. In the antenatal period, when the future mother probably does not think about what kind of teeth the baby will have, the formation of the baby teeth as a whole takes place. This process is influenced by many factors - both the condition of the pregnant woman, and her nutrition, because it provides the mineralization of the crowns of the dentition in the baby. After birth, when the child begins to appear the first teeth, their health also depends on the care of their parents. Especially in the period when the baby is already taking "adult" food. Prevention of periodontitis in children - is the implementation of fairly simple procedures, and to introduce the baby to them should be a mom or dad.

The rules are simple - brush your teeth at least twice a day, older children need to use both dental threads (flosses), eat less sweets and monitor the oral cavity with regular visits to the dentist. The rules for oral care, which must be observed not only for children but also for adults:

• Dental plaque, which is an excellent medium for the development of caries, then pulpitis and, as a result, possible periodontitis, is removed by brushing teeth. Twice a day the teeth need to be cleaned with a toothbrush, the effect of cleaning will fix mouth rinsing with special solutions or simply purified water. Dentists say that rinsing the teeth within 2-3 minutes destroys up to 30% of bacteria in the mouth.
• The child should learn how to clean teeth properly - keep the toothbrush at the right angle (45 degrees), clean not only the outer side of the teeth, but also the inside.
• A child needs a special toothbrush, the degree of rigidity will help determine the children's dentist. Children's brush should be changed quarterly, as well as the toothbrush of an adult. Brush after cleaning should be thoroughly washed with running water.
• For children, the choice of toothpaste is very important, it is desirable that it contains fluoride, which significantly reduces the development of caries, and consequently, periodontitis. It is not recommended to purchase abrasive or whitening pastes for children, they can damage the fragile enamel of children's teeth.
• Baby food in principle is a very important factor affecting the development of the body, including nutrition depends largely on the condition of the teeth. Limiting sugar in the menu helps reduce the risk of caries, pulpitis and periodontitis.

Periodontitis in children in the list of all dental diseases takes more than half of the list. Unfortunately, as a complication of caries and pulpitis, it continues to affect both babies and adults. A consistently high incidence of the periodontal apparatus indicates a need for a more serious attitude towards preventive measures. In addition to prevention, which consists in observing the basic rules of oral hygiene, regular periodontal examinations in dental offices can prevent periodontal inflammation. Modern dentistry is equipped with perfect equipment, doctors own the latest methodological developments, materials and anesthetic preparations are presented in an extremely wide range, therefore, today any civilized person is simply stupid to hold on to outdated fears, especially because parents should show their children an example of taking care of their own health . Healthy teeth in a child - this is not a doctor's task, but an understanding of the importance of prevention by adults.