Doctor123.org

Gingivitis, Pediatric

Doctor123.org

Gingivitis, Pediatric

Basics

Description

Epidemiology

Gingivitis is a reversible dental plaque-induced inflammation of the gingival tissues. Symptoms may include bleeding, swelling, ulceration, and pain, although gingivitis is usually mild and asymptomatic.

Panoramic or individual tooth radiographic imaging is important to assess the bones for evidence of periodontal extension of the gingivitis in the more severe cases.

Mouth rinses for plaque inhibition can be used to augment daily oral care routine. The most commonly used rinses include 0.12% chlorhexidine and 0.075% or 0.1% cetylpyridinium chloride.

Only the most severe cases require gingivectomy.

Routine dental exam and cleaning should be performed every 6 months to monitor for signs of inflammation.

- American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for children. http://www.aapd.org/media/PoliciesGuidelines/GPeriodicity.pdf. Accessed February 14, 2015. - Bacci C, Sivolella S, Pellegrini J, et al. A rare case of scurvy in an otherwise healthy child: diagnosis through oral signs. Pediatr Dent. 2010;32(7):536-538. [View Abstract] - Califano JV, American Academy of Periodontology-Research, Science and Therapy Committee. Periodontal diseases of children and adolescents. J Periodontol. 2003;74(11):1696-1704. [View Abstract] - Kallio PJ. Health promotion and behavioral approaches in the prevention of periodontal disease in children and adolescents. Periodontology. 2001;26:135-145. [View Abstract] - Mankodi S, Bauroth K, Witt JJ, et al. A 6-month clinical trial to study the effects of a cetylpyridinium chloride mouth rinse on gingivitis and plaque. Am J Dent. 2005;18:9A-14A. [View Abstract]

  • Affects >90% of children between the ages of 4 and 13 years. Most of these children have low-grade gingivitis.
  • 13-40% of children aged 6-36 months have eruption gingivitis, which commonly resolves after teeth eruption.
  • The prevalence of gingivitis increases with age; by puberty, nearly 100% of all children are affected. This pubertal peak is likely due to hormonal influences and inconsistent dental hygiene.
  • After puberty, the prevalence remains relatively constant at 50% of all adults.

Risk Factors

  • Behavioral factors: smoking, stress, alcohol consumption
  • Medications: antiepileptic, cyclosporine, calcium channel blockers
  • Hormonal changes: puberty, pregnancy
  • Chronic illnesses: diabetes mellitus, chronic renal failure, histiocytosis X, scleroderma, secondary hyperparathyroidism
  • Immunologic deficiencies: HIV, Ch ©diak-Higashi, cyclic neutropenia
  • Neurologic problems: cerebral palsy, mental retardation, seizures, and other conditions where routine dental care is difficult
  • Miscellaneous: chronic mouth breathing, malnutrition, viral illnesses

General Prevention

  • Consistent daily oral hygiene described as the following by age:Infants: gum massage, washcloth to remove plaque; toothbrush using baby toothpaste (i.e., enzyme-based; no fluoride)Young children: assistance with brushing with a small amount of fluoridated toothpasteSchool-aged children: Supervise brushing and assist if necessary.Older children and adolescents: Brush teeth twice a day with fluoridated toothpaste in addition to daily flossing. Some dentists recommended flossing as early as age 4 years.Children with fixed orthodontics: Careful brushing and flossing is critical.
  • Fluoride: Supplements are appropriate if the water supply is not fluoridated. It is important to be careful to treat with the appropriate amount of fluoride in order to prevent fluorosis.
  • Sealants: Adherent plastic coating may be applied to the pits and fissures of the permanent teeth to provide a mechanical barrier.
  • The American Academy of Pediatrics (AAP) recommends that children at high risk for dental caries should establish routine dental care by their first birthday. Children should then continue routine dental checkups at a minimum of every 6 months.
  • Infants: gum massage, washcloth to remove plaque; toothbrush using baby toothpaste (i.e., enzyme-based; no fluoride)
  • Young children: assistance with brushing with a small amount of fluoridated toothpaste
  • School-aged children: Supervise brushing and assist if necessary.
  • Older children and adolescents: Brush teeth twice a day with fluoridated toothpaste in addition to daily flossing. Some dentists recommended flossing as early as age 4 years.
  • Children with fixed orthodontics: Careful brushing and flossing is critical.

Etiology

  • Poor dental hygiene
  • Bacterial plaque, calcified and noncalcified
  • Caries
  • Orthodontic appliances
  • Malocclusion
  • Crowded teeth
  • Mouth breathing
  • Erupting teeth margins
  • Poor nutritionVitamin deficiencies (e.g., vitamin C deficiency)Diet low in coarse detergent like foods (e.g., raw carrots, celery, apples)High prevalence of anaerobic microflora
  • InfectionsHerpes simplex virus (HSV) type ICandida albicansHIVBacterial pathogens
  • DrugsPhenytoinCyclosporineNifedipineOral contraceptive pills
  • Trauma
  • Vitamin deficiencies (e.g., vitamin C deficiency)
  • Diet low in coarse detergent like foods (e.g., raw carrots, celery, apples)
  • High prevalence of anaerobic microflora
  • Herpes simplex virus (HSV) type I
  • Candida albicans
  • HIV
  • Bacterial pathogens
  • Phenytoin
  • Cyclosporine
  • Nifedipine
  • Oral contraceptive pills

Diagnosis

History

  • Review the frequency of dental care visits and the home dental hygiene regimen.
  • Review significant medical history, asking about chronic illnesses, bleeding disorders, and immunodeficiency.
  • Review the diet of the child to assess for nutritional deficiencies.
  • Dental appliances worn by patient:Orthodontic equipment makes gingiva more difficult to clean, and reactive tissue growth is more common.
  • Regular medications taken by patient:Phenytoin may result in gingival hyperplasia, and chemotherapeutic agents, exogenous hormone therapy, and calcium channel blockers may result in gingivitis.
  • Signs and symptoms:Edema and erythema of the gingivaBleeding at gum linePain near the gingival margin
  • Orthodontic equipment makes gingiva more difficult to clean, and reactive tissue growth is more common.
  • Phenytoin may result in gingival hyperplasia, and chemotherapeutic agents, exogenous hormone therapy, and calcium channel blockers may result in gingivitis.
  • Edema and erythema of the gingiva
  • Bleeding at gum line
  • Pain near the gingival margin

Physical Exam

  • Evaluate the gingival tissue for erythema, swelling, ulceration, fluctuance, or drainage. Erythema and edema are the most common findings in gingivitis.
  • In severe cases, the gingival tissues may bleed spontaneously from ulcerations in the sulcus and there may be significant gingival hypertrophy.
  • In herpetic gingivostomatitis, there is often significant ulceration and swelling of the gingiva associated with systemic symptoms such as fever and malaise.
  • Evaluate the teeth for caries, fractures, looseness, malocclusion, pain, and plaque.
  • Examine the face and neck for signs of swelling, erythema, warmth, or enlarged maxillary lymph nodes which may be signs of more extensive bacterial infection.
  • Tanner staging: Normal pubertal changes seem to aggravate gingival inflammation, so paying special attention to the gingiva of patients entering puberty is important.
  • Assess the patient's oral hygiene technique in the office. This is the single largest contributor to gingivitis.

Diagnostic Tests & Interpretation

  • Most patients will not need laboratory evaluation.
  • If there is a concern for excessive bleeding, a CBC with differential, PT, and PTT may be helpful to rule out thrombocytopenia, pancytopenia, or a clotting disorder.
  • Blood culture: if there is concern for sepsis
  • Direct fluorescent antibody testing for HSV-1: If herpes is suspected (stomatitis is usually present), swab the base of a stoma/vesicle and smear on a slide. HSV culture is the gold standard.
  • Biopsy is rarely necessary.

Differential Diagnosis

  • InfectiousAbscessHerpetic gingivostomatitis-ulcerative lesions of the gingiva and mucous membranes of the mouth
  • TraumaticFood impactionOrthodontic appliancesSelf-inflicted minor injury
  • HematologicGingival bleeding due to hemophilia (factor VIII or IX deficiency)Thrombocytopenia
  • ImmunologicNeutrophil disordersLeukemiaHIVGraft-versus-host disease (infiltrative gingivitis)
  • MiscellaneousGingival hyperplasia due to medications (i.e., phenytoin and nifedipine)PeriodontitisAphthous stomatitisVitamin C deficiencyBeh §et diseaseAcute necrotizing ulcerative gingivitis (ANUG)-painful gingivitis associated with rapid onset and tissue ulceration and necrosisPeaks in adolescence and young adulthoodRelated to high oral concentrations of spirochetes and/or Prevotella intermedia
  • Abscess
  • Herpetic gingivostomatitis-ulcerative lesions of the gingiva and mucous membranes of the mouth
  • Food impaction
  • Orthodontic appliances
  • Self-inflicted minor injury
  • Gingival bleeding due to hemophilia (factor VIII or IX deficiency)
  • Thrombocytopenia
  • Neutrophil disorders
  • Leukemia
  • HIV
  • Graft-versus-host disease (infiltrative gingivitis)
  • Gingival hyperplasia due to medications (i.e., phenytoin and nifedipine)
  • Periodontitis
  • Aphthous stomatitis
  • Vitamin C deficiency
  • Beh §et disease
  • Acute necrotizing ulcerative gingivitis (ANUG)-painful gingivitis associated with rapid onset and tissue ulceration and necrosisPeaks in adolescence and young adulthoodRelated to high oral concentrations of spirochetes and/or Prevotella intermedia
  • Peaks in adolescence and young adulthood
  • Related to high oral concentrations of spirochetes and/or Prevotella intermedia

Treatment

Medication

Additional Therapies

  • Mild gingivitisCareful daily dental hygiene, including meticulous brushing and flossingMechanical plaque and calculus removal by scaling or root planing. This is then followed by frequent dental cleanings every 3-6 months to prevent recurrence.
  • Moderate to severe gingivitisCare as outlined for mild gingivitisShould be evaluated by a pedodontist in addition to a general dentistMouth rinses for plaque inhibition using either 0.12% chlorhexidine or 0.075% or 0.1% cetylpyridinium chlorideIrrigation devicesSonic toothbrushesGingivectomies in cases of overgrowth to permit better cleaningAntibiotics to cover mouth flora in more severe cases when bacterial superinfection is suspected
  • Careful daily dental hygiene, including meticulous brushing and flossing
  • Mechanical plaque and calculus removal by scaling or root planing. This is then followed by frequent dental cleanings every 3-6 months to prevent recurrence.
  • Care as outlined for mild gingivitis
  • Should be evaluated by a pedodontist in addition to a general dentist
  • Mouth rinses for plaque inhibition using either 0.12% chlorhexidine or 0.075% or 0.1% cetylpyridinium chloride
  • Irrigation devices
  • Sonic toothbrushes
  • Gingivectomies in cases of overgrowth to permit better cleaning
  • Antibiotics to cover mouth flora in more severe cases when bacterial superinfection is suspected

Issues for Referral

  • It is important for providers to evaluate the oral health of all children. When gingival inflammation is noted, the patient should be referred to a dentist.
  • Routine dental care with professional cleaning and plaque removal is recommended for all children and adults.
  • If the extent of involvement is great or the underlying disease of the patient requires more aggressive care, a periodontist should be consulted.
  • The inability to resolve gingivitis by oral hygiene measures necessitates the consideration of other causes such as leukemia, vitamin C deficiency, or other chronic disease.

Surgery/Other Procedures

Ongoing Care

Follow-up Recommendations

  • Routine dental care with professional cleaning and plaque removal is recommended for all children and adults.
  • Children with gingivitis should have frequent dental visits; most dentists recommend every 3 months.

Diet

  • Avoid high sugar content food and beverages.
  • Xylitol-containing chewing gum can improve oral hygiene by reducing plaque adherence to the gum line.

Patient Education

  • Establish a daily mouth care routine.
  • Brushing and flossing each morning and at bedtime will reduce plaque formation.
  • Mouth rinses, if recommended by your dentist, can also reduce plaque formation.
  • See the dental health professional every 6 months beginning at your child's first birthday for examination and cleaning.

Prognosis

  • Good oral hygiene may reverse mild to moderate gingivitis within several months.
  • Periodontal disease is not reversible; therefore, prevention is essential.

Complications

  • Periodontal disease
  • Osteomyelitis
  • Tooth decay

Additional Reading

  • American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for children. http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf. Accessed February 14, 2015.
  • Bacci C, Sivolella S, Pellegrini J, et al. A rare case of scurvy in an otherwise healthy child: diagnosis through oral signs. Pediatr Dent. 2010;32(7):536-538. [View Abstract]
  • Califano JV, American Academy of Periodontology-Research, Science and Therapy Committee. Periodontal diseases of children and adolescents. J Periodontol. 2003;74(11):1696-1704. [View Abstract]
  • Kallio PJ. Health promotion and behavioral approaches in the prevention of periodontal disease in children and adolescents. Periodontology. 2001;26:135-145. [View Abstract]
  • Mankodi S, Bauroth K, Witt JJ, et al. A 6-month clinical trial to study the effects of a cetylpyridinium chloride mouth rinse on gingivitis and plaque. Am J Dent. 2005;18:9A-14A. [View Abstract]

Codes

ICD09

  • 523.10 Chronic gingivitis, plaque induced
  • 523.00 Acute gingivitis, plaque induced
  • 101.0000 Vincent's angina

ICD10

  • K05.10 Chronic gingivitis, plaque induced
  • K05.00 Acute gingivitis, plaque induced
  • A69.1 Other Vincent's infections

SNOMED

  • 66383009 Gingivitis (disorder)
  • 31642005 Acute gingivitis (disorder)
  • 399050001 Acute necrotizing ulcerative gingivitis (disorder)

FAQ

  • Q: Are there differences among toothpastes and prevention of gingivitis?
  • A: Yes. A study demonstrated that stabilized stannous fluoride toothpaste is effective in preventing gingivitis. When essential oil mouthwashes (e.g., Listerine) are added, there is additional reduction in the amount of gingivitis noted.
  • Q: What dietary changes may improve gingival health?
  • A: Avoiding frequent carbohydrate intake may reduce gingivitis. Carbonated beverages, sugared chewing gum, and candy often adhere to teeth. When daily dental care is inconsistent, plaque formation is increased and gingivitis is much more likely.
  • Q: Why do children generally not have the significant periodontal disease that adults get?
  • A: No one knows for sure; however, it is known that the gingiva of the primary dentition is rounder and thicker and contains more blood vessels and less connective tissue than the gingival seen later in life. Whether these differences mask disease or are helpful is unclear.
  • Q: How do intraoral piercings impact gum health?
  • A: In addition to fractured teeth, gingival recession and gingivitis are complications of the trauma inflicted by a foreign body in the oral cavity.
  • Q: Why is smoking associated with gingival disease?
  • A: Nicotine inhibits phagocyte and neutrophil function, reduces bone mineralization, impairs vascularization, and reduces antibody production. Smokers do not respond as well as nonsmokers to surgical and nonsurgical treatments.