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The normal periodontium consists of gingiva, connective tissue, the periodontal ligament, cementum, and the surrounding alveolar bone. Clinicians commonly describe the healthy gingiva as being scalloped, firm, and knife-edged. The lack of bleeding on probing and the lack of exudates are also taken as clinical signs of health. In children, similar characteristics are observed and recorded (although there are more spaces between primary teeth resulting in a flatter, less scalloped appearance). Several different forms of gingival and periodontal disease in children and adolescents that can change the appearance (eg, erythema), contour (eg, swelling), size (eg, hyperplasia or overgrowth), and shape (eg, blunted papillae) of the gingiva range from reversible conditions such as inflammation of gingival tissues (ie, gingivitis) to those characterized by the destruction of the periodontal connective tissue attachment and alveolar bone (ie, periodontitis). If these conditions are left untreated, the deciduous or permanent dentitions may be jeopardized. Thus, fundamental principles concerning the etiology and the contributing factors of periodontal diseases need to be understood in order to identify and manage them as well to minimize or prevent complications.

According to the American Academy of Periodontology, periodontal disease in children and adolescents can be classified into 5 distinct periodontal disease categories:

  1. Dental plaque–induced gingival diseases

  2. Chronic periodontitis

  3. Aggressive periodontitis

  4. Periodontitis as a manifestation of systemic diseases

  5. Necrotizing periodontal diseases

In 2014, the American Academy of Periodontology proposed an update that focuses on guidelines for determining the severity of the disease, taking into consideration the following parameters: probing depth, bleeding on probing, radiographic bone loss, and clinical attachment loss. The 3 categories for the severity remained the same: slight (mild), moderate, and severe (advanced). Further guidelines were presented in order to differentiate between chronic and aggressive forms of periodontitis. Aggressive periodontitis is diagnosed when there is onset of clinical attachment and radiographic bone loss (detected on clinical and radiographic examination) before the age of 25. An updated comprehensive classification is planned for development by 2017 will include peri-implant diseases and risk assessment factors for periodontal diseases.


Gingivitis of varying severity is nearly universal in children and adolescents; however, the prevalence of destructive forms of periodontal disease is lower in children and adolescents than in adults. The prevalence rate of periodontitis in children ages 5 to 11 years is up to 9% and increases to up to 46% for those 12 to 15 years of age. Thus, children and adolescents should receive a periodic periodontal evaluation as a component of routine dental visits, because periodontitis is usually preceded by gingivitis.

Periodontitis is a multifactorial disease, and there are several local and systemic factors that are associated with it. Local contributing factors such as caries, inadequate restoration, and subgingival calculus may contribute to a bacterial accumulation resulting in a host-mediated inflammatory response (Fig. 372-1). Patients with an impaired host response ...

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