The Importance of Periodontal Screening in Paediatric Patients

Periodontitis is a disease of chronic inflammation, often associated with dysbiotic plaque biofilms contributing to the progressive destruction of the tooth-supporting apparatus.¹ The clinical presentation includes inflammation contributing to the loss of periodontal tissue support, presence of periodontal pocketing, and bleeding from the gingival tissues.¹

Although dental caries is known to be the most prevalent non-communicable disease internationally,² the condition of the gingival tissues is also an important oral health indicator in children.³ While it has been reported that very few children demonstrate loss of periodontal attachment,⁴ paediatric patients can be affected by a range of different periodontal conditions, including necrotizing periodontal diseases and those where systemic diseases influence the disease status.⁵

The aim of this article is to reinforce the importance of periodontal screening in paediatric patients and discuss when referral of periodontal presentations to secondary care is appropriate.

The importance of screening for periodontal diseases and conditions

In 2013, nearly half of 8 year olds in England, Wales and Northern Ireland displayed some form of gingival inflammation.³ Furthermore, very few children and adolescents under the age of 16 were reported to have periodontal pocketing of 5.5 mm or greater.³ Despite this, periodontal screening is necessary to promptly identify those patients who do present with periodontal abnormalities and those who are at risk of disease progression. Early diagnosis of periodontal conditions in the paediatric patient may not only lead to the most successful clinical treatment and outcomes,⁵ but also could prove important in contributing to the child's overall well-being and development.⁶

Classification

Following the acquisition of knowledge and development of the evidence base, a new classification framework for periodontal conditions was introduced in 2017, which led to changes in terminology.⁷ For example, ‘chronic periodontitis’ has been replaced with ‘periodontitis’. This new system does not formulate the diagnosis, as this will be developed from a combination of the classification (which provides historical evidence of attachment or bone loss) and current disease status of a patient, taking the individual risk factors into account.⁸ Although this system has been in use for several years, many dental practitioners may still refer to the 1999 periodontal disease classification in their daily use.⁹

Patient assessment

Analysis of the patient's medical, dental and social history, alongside assessment and screening for periodontal disease, forms an essential part of a thorough clinical examination in both adult and paediatric patients. Furthermore, a visual inspection of the condition of the gingival tissues needs to be made, alongside recording the oral hygiene status.⁵

Systemic risk factors

A range of systemic diseases and conditions may influence the course of periodontitis or adversely affect the periodontal attachment apparatus.¹⁰ Analysis of the patient's medical history will aid prompt identification of such systemic risk factors, which should then be detailed upon referral, if such a pathway is indicated for the patient.

It is important to be aware that varied systemic risk factors exist and to consider how they could impact an individual's periodontal health. Some of these risk factors are rare, while others are more prevalent. Hypophosphatasia and Papillon–Lefèvre syndrome are two examples of rare genetic disorders that can influence periodontal inflammation and are associated with severe, early-onset periodontitis.^10,11,12

In contrast, diabetes mellitus is a highly prevalent group of metabolic disorders, known to be an important disease modifier in the pathogenesis of periodontitis.^10,13 There are more than half a million children aged 14 and under living with type 1 diabetes globally.¹⁴ Defective insulin production and/or action results in high levels of blood glucose,¹³ which may adversely affect the progression of periodontal disease and the outcomes of periodontal treatment.¹⁵ Children and adolescents with diabetes may therefore experience an increased risk of periodontal destruction early in life.¹³ In addition, evidence suggests that individuals with periodontitis are at an increased risk of impaired glucose tolerance and/or impaired fasting glucose, as well as insulin resistance.¹⁴ The dental team play an important role in counselling patients and their parents on the implications of periodontal disease on glycaemic control.¹⁴ Ultimately, screening may enable early detection of periodontal disease, timely access to the most appropriate treatment necessary for stabilization and help to promote the general health of the patient.

Local risk factors

Local risk factors, which should be identified and recorded in children as well as adults, include acquired and anatomical abnormalities, ranging from overhanging restoration margins to malpositioned teeth.¹⁵

Behavioural risk factors

Identifying behavioural risk factors is important for a thorough assessment of the general and oral health of any patient, including those under the age of 16. Smoking is one behavioural risk factor that can increase the risk of periodontal disease and may impact negatively upon periodontal treatment outcomes.¹⁶ Approximately 10% of 15 year olds report being a current smoker, and it is therefore important to identify such risk factors prior to treatment, in order to appropriately inform the patient of the risks of the behaviour and the likely outcomes of the proposed intervention.¹⁶

Periodontal assessment in the primary dentition

It should be acknowledged that detection of periodontal abnormalities in the primary dentition can be challenging for the clinician,¹⁷ as there may be a lack of clinical signs and symptoms, coupled with compromised cooperation. Despite this, rapidly progressing forms of periodontal disease have been reported in a patient as young as 3 years of age, where no systemic conditions were identified.¹⁸

Clinicians should be highly suspicious of unexplained mobility or early exfoliation in the primary dentition,⁵ particularly where there is no history of trauma. Prompt referral and opinion should be sought from specialist care in these situations,⁵ as rapid disease progression may be occurring in the absence of visible inflammatory changes.

Periodontal assessment in the mixed and permanent dentitions

The simplified Basic Periodontal Examination (BPE) is a screening tool developed to aid clinicians in their assessment of the periodontium in children and adolescents.⁵ Beginning at 7 years of age, when the patient enters the mixed dentition, a BPE code ranging from 0 to 2 should be assigned using a WHO 621 probe.⁵ This should be continued until the patient is 11 years of age.^5,15 The code range is restricted to 0–2, rather than the full range of scores (0–4) because identifying a true periodontal pocket is unlikely in this age group.⁵ If a true periodontal pocket is identified, the patient should be referred to a specialist centre for assessment.⁵ A diagram for BPE screening dependent upon patient age can be found in Figure 1.

For children over 12 years of age, screening should be conducted using the full coding range (0, 1, 2, 3, 4 and *) on the index teeth (UR6, UR1, UL6, LL6, LL1 and LR6),⁵ as highlighted in Table 1. It should be noted that the BPE does not record attachment loss or radiographic bone loss.⁸ Therefore, in patients who present with a history or previous diagnosis of periodontal disease or evidence of periodontal disease, a full periodontal assessment is required.⁸ A full periodontal assessment may include recording of baseline indices (plaque and bleeding scores), probing pocket depths (PPD), with the delivery of personalized oral hygiene instruction (OHI), including a detailed demonstration on the use of interdental brushes. This will depend on the severity and location of disease, as well as the cooperation of the child.

Recording of PPD and bleeding on probing (BOP) can be used to identify patients at risk of disease progression, and ultimately tooth loss, especially if periodontal pocketing remains at 6 mm or greater and BOP is evident.^19,20

Frequency of screening for periodontal disease

It is recommended that screening for periodontal disease forms part of each routine clinical examination in children and adolescents.⁵ Guidelines also highlight the importance of screening for periodontal disease in children and adolescents during all new patient examinations and in those patients planned for orthodontic treatment.⁵

Routine periodontal screening, as per recommended guidelines, may enable early detection of the disease process and timely access to appropriate care in affected patients. The benefits of periodontal screening are exemplified by the case seen clinically in Figure 2. This 14-year-old female patient presented with no oral health-related concerns and a lack of clinical gingival inflammation. Vigilance from the patient's general dental practitioner through routine periodontal screening led to the detection of BPE codes of 3 in multiple sextants. The patient was appropriately referred to a specialist paediatric department, where history revealed a potential genetic risk. The patient had a twin who presented with similar findings. Assessment of risk factors identified that their maternal grandfather was Black Caribbean, an ethnicity recognized to have a higher incidence of periodontitis in children.²¹ The patient underwent periodontal assessment and radiographic examination, which led to the diagnosis of localized periodontitis stage III, grade C, currently unstable, risk(s): genetics. Screening for periodontal disease in this patient enabled timely detection of periodontal disease and access to the appropriate care, which resulted in disease stabilization.

Radiographic assessment

Radiographic assessment may supplement clinical examination in children and adolescents, particularly when a BPE code of 3, 4 or * is detected.^5,22 Radiographs may also enable monitoring of long-term treatment outcomes and help to determine the rate of disease progression.²⁰

When performing a radiographic assessment in children and adolescents, it should be noted that the normal healthy bony crest lies 0.4–1.9 mm from the cemento-enamel junction in permanent teeth, but may be greater in primary teeth.⁵

In paediatric patients, posterior horizontal bitewing radiographs may be indicated for the assessment of dental caries, dependent on the level of patient cooperation, clinical findings and a personalized caries risk assessment.²² If indicated for the assessment of caries, clinicians should also use these radiographs to assess and record bone levels.⁵ Selected peri-apical radiographs may be indicated to supplement the clinical examination in certain cases, if there is generalized periodontal pocketing of 4–5 mm, a BPE of code 3 and above, or if the findings of the radiograph are likely to change the clinical management of that patient.^5,22

Figure 3 shows the level of detail that can be yielded from one peri-apical film. Radiographic evidence of one localized, moderate vertical defect, within the middle third of UR1 (distal surface) can be seen, as well as mild (10%) horizontal bone loss on the UR1 (mesial surface) and UL1 (mesial surface).

Referral and preventing deterioration

Specialist referral is recommended to be indicated for a range of periodontal conditions in patients under the age of 18, including drug-influenced gingival enlargement and non-dental biofilm-induced conditions.¹⁵ Failing to detect disease early and refer appropriately could lead to deterioration of the patient's oral health. Local guidelines should be consulted to ensure high-quality referral of appropriate patients into secondary care, where required. When referring patients, details of the patient's risk factors, clinical examination findings, and any relevant radiographs are important for appropriate triaging purposes.

The need for continued care and monitoring of patients with unstable periodontal disease is of great importance because the risk of further disease progression and tooth loss is high, especially if not carefully managed, and active periodontal pockets (greater than or equal to 6 mm in depth with BOP) remain.²⁰

Conclusion

Clinicians need to exert a high level of awareness of the presentations of periodontal disease in paediatric patients across the primary, mixed and permanent dentitions, and consider appropriate referral if there is uncertainty regarding a patient's diagnosis. Referral onwards to specialist management in secondary care is advised for a range of periodontal presentations in paediatric patients, to assist with the coordination of a multidisciplinary approach with a periodontal specialist, if necessary. As periodontitis can only be controlled and not cured, failing to screen and detect disease early could lead to dire consequences long-term in this cohort of patients.