What needs to be considered in treating gingival diseases and conditions in systemically healthy children and adolescents

At the focused workshop, the term “periodontal disease” was deemed to include not only conditions limited to the gingival tissues but also those affecting the periodontal attachment apparatus. In its broadest sense, this includes conditions that were or were not induced by dental biofilm in both systemically healthy patients and in those with underlying systemic diseases or conditions that impacted upon the periodontium. It was recognized that the periodontal tissues of children—whether in the primary, mixed, or early permanent dentition—significantly differ anatomically from those of adults (Bimstein et al., 2001; Bimstein and Matsson, 1999).

Periodontal diseases in children and adolescents are common. However, the use of multiple measures to examine and record disease, together with the historical lack of consistency in case definitions, hinder the interpretation and comparison of prevalence and incidence estimates for periodontitis found in the literature. The workshop’s working group 2, chaired by Mariano Sanz and Phoebus Madianos, focused on gingivitis and gingival diseases, and the systematic review compiling the evidence was led by Georgios Tsilingaridis and Rodrigo López (Tsilingaridis et al., 2026).

Although dental-biofilm-induced gingivitis is the most common manifestation of gingival diseases in systemically healthy children and adolescents, gingival diseases may exhibit several distinctive features that differ from those observed in adults, and the presence of local and systemic determinants strongly influences these conditions.

Dental-plaque biofilm, which contains microorganisms that cause gingival inflammation, is the main local cause of inflammation in children and adolescents. This condition is frequently associated with inadequate oral-hygiene practices. In this population, the presence of local factors has been linked to increased plaque accumulation, which significantly contributes to gingivitis in children and adolescents. Among these local factors, plaque-retentive dental-plaque-biofilm factors include:

          (a)   orthodontic appliances
          (b)   open dental caries lesions
          (c)   overhanging restorations
          (d)   anatomical issues
                    (i)    crowded and misaligned teeth
                    (ii)   partially erupted teeth
                    (iii)  food impaction
                    (iv)  dental calculus.

Similarly, the presence of mouth breathing—which frequently occurs in children with allergies or adenoid hypertrophy—leads to the drying of the gingival tissues, reduced plaque removal by saliva, and heightened inflammation.

What is the prevalence?

Gingivitis induced by dental biofilm is common in children and adolescents, with its incidence increasing with age. In epidemiological studies, the prevalence data for gingivitis is challenging to interpret because of variations in studies from different countries. The overall estimate is about 50%, but published results are highly heterogeneous, and statistics derived from the community periodontal index (CPI) in two studies vary from 18% to 92%. (Tsilingaridis et al., 2026). 

Clinically, gingivitis is characterized by redness, swelling, and bleeding of the gums; it is generally painless and without loss of alveolar bone. Gingival inflammation is typically less frequent and less severe in younger children than in older ones, possibly because of the greater thickness and height of the gingival tissues. However, depending on the presence of specific local or systemic determinants, various gingival conditions have been identified, although their pathophysiology is similarly the consequence of the accumulation of dental plaque. For example, during the eruption of primary or permanent teeth, there is usually localized inflammation around erupting teeth. Similarly, hormonal changes, usually around puberty, influence the response to plaque exposure, leading to a higher prevalence and severity of gingivitis, typically presenting with significant enlargement of the interdental papillae.

Diagnosis is based on visual examination of gingival inflammation, including evaluation of changes in the colour, contour, consistency, and texture of the gingival margins and papillae; detection of bleeding on brushing; and periodontal probing. However, periodontal probing should not be used in children, because of the immaturity of their periodontal tissues, or in children with mixed dentition including erupting teeth. These methods need to be adapted to each child’s developmental stage and level of co-operation. Radiographic examinations should be undertaken only when diagnosing caries lesions or when there is a clear clinical indication. 

While the 2018 classification of periodontal diseases and conditions established a threshold of 10% bleeding on probing (BOP) sites for defining gingivitis in adults, there is a consensus that this threshold is not suitable for defining gingivitis in children and adolescents until there is a clear understanding of the prevalence and distribution of gingivitis in this population.

Systemic modifying factors often interact with local factors to enhance plaque accumulation and/or response to plaque accumulation. The most relevant factors in this population are the hormonal changes during puberty and being overweight or obese—both associated with increased low-grade inflammation—or an increased gingival response to plaque. Environmental factors—such as exposure to tobacco smoking or the intake of carbohydrate-rich diets—are less common in children, and the evidence is very scarce.