What do clinicians need to know in treating periodontitis and periodontal conditions in systemically healthy children and adolescents?

Our working group addressed the epidemiological characteristics of periodontitis, as well as diagnostic, preventive, and therapeutic strategies for systemically healthy children and adolescents. Available evidence on other periodontal conditions­—including necrotizing periodontal diseases (NPDs), mucogingival conditions (particularly gingival recession), periodontal abscesses, and endodontic-periodontal lesions—was also reviewed.

A total of 5,389 publications were identified, of which 205 relevant articles were included in the final review. Most of the available evidence concerned periodontitis, while considerably fewer studies examined mucogingival conditions, NPDs, and periodontal abscesses. There was essentially no evidence addressing some of the other periodontal conditions originally included in the review question. Most of the included studies were considered to have a high risk of bias, and the overall certainty of the evidence was rated as very low. This was largely attributable to substantial differences in diagnostic definitions, study populations, and methodological approaches. These limitations may partly explain the considerable variation in the reported prevalence of periodontitis among young populations, which ranged from 0.1% to 30.6%. However, most studies reported prevalence rates below 2%.

The review highlighted that some forms of periodontitis in adolescents may exhibit surprisingly aggressive patterns of disease progression. Severe periodontal destruction can occur despite relatively limited amounts of clinically visible dental biofilm. This suggests that host susceptibility and microbial factors, rather than dental-biofilm accumulation alone, may play an important role in disease development and progression. Children and adolescents also exhibit more dynamic immune modulation, which may either enhance or protect against disease progression, depending on the underlying host and microbial factors. This represents an important difference from the adult population.

NPDs demonstrate highly variable prevalence and are strongly associated with socioeconomic, nutritional, and environmental factors. Two completely different entitles were considered: one, associated with mild/temporal compromise of the immune system, usually manifests as necrotizing gingivitis, with limited impact and progression; the other, associated with chronic and severe compromise of the immune system, in which progression from necrotizing gingivitis to necrotizing periodontitis and stomatitis—and even Noma—may occur. Noma is a severe and mutilating disease of unclear aetiopathogenesis, that frequently affects young children in developing countries.

Considerable variability was also observed in the reported prevalence of gingival recession. Prevalence estimates ranging from 1% to 74% demonstrate the substantial influence of age, dentition, tooth position, and diagnostic criteria on reported findings. Regular monitoring and effective oral hygiene, together with the control of potentially detrimental oral habits, are essential to maintaining periodontal stability. In selected cases, specific orthodontic tooth movements may help control the progression of gingival recession. In contrast, mucogingival surgery for recession coverage is generally not recommended in children because of the continuing development and maturation of the gingival tissues.

Diagnosis in children

A particularly important clinical consideration is that the diagnosis of periodontal diseases in children cannot simply replicate the diagnostic approach used in adults. Diagnosis is particularly challenging because tooth eruption and developmental changes in the dentition can mimic clinical features of periodontal disease. The consensus supports the use of periodontal probing from around six years of age, except when unusual clinical findings warrant earlier or more comprehensive assessment. These findings may include exceptional tooth mobility, profound plaque accumulation, or marked gingival inflammation. In cases of suspected localized periodontitis in children and adolescents, periapical radiographs are the radiographic examination of choice as a supplementary diagnostic tool.

The diagnostic assessment should also incorporate information obtained from the child’s medical and dental history, as well as relevant parental and family history. Important factors include systemic conditions, a family history of periodontitis, exposure to smoking, diabetes, orthodontic appliances, and structural developmental defects of the teeth.

Successful periodontal prevention and treatment depend not only on the clinical procedures performed but also on the child’s co-operation and adherence to treatment, as well as active parental involvement. In general, periodontal treatment follows established clinical guidelines (Herrera et al., 2022; Sanz et al., 2020), while also taking into consideration the patient's dental age, stage of dentition, behavioural characteristics, and ability to co-operate with treatment.

A four-component approach to therapy

Periodontal therapy in the young population can be broadly structured into four components: supragingival biofilm control, subgingival instrumentation, re-evaluation, and additional treatment and surgical considerations.