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A variety of periodontal diseases can present in children and adolescents, some of which are rapidly destructive. After years of debate and lack of consensus, a new classification system was agreed at the 1999 International Workshop for a Classification of Periodontal Diseases and Conditions.1 This comprised eight separate categories, all of which are applicable to the younger age groups. An up-to-date classification of the periodontal diseases allows the clinician to consider the full range of periodontal disorders that can affect the patient and provides a basis for their diagnosis and subsequent management (Table 1).

Table 1 Periodontal classification
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Gingivitis

Gingivitis was added as a new category in 1999.1 Plaque-induced gingivitis is common in young as well as older age groups and modifying factors can be identified from the history and examination that can influence the natural course and management. It is reversible when the aetiological agent, the plaque biofilm, is removed, and while it is not associated with attachment loss or bone loss, it is worth bearing in mind that it can occur on a periodontium with reduced support in which the attachment loss and bone loss has previously occurred and is not progressing.

Plaque displays typical properties of biofilms and microbial communities and the plaque ecology is a critical determinant in disease development.2 Crucially, gingivitis may be more important than previously thought. From the Fifth European Workshop in Periodontology in 2005, it was considered that gingivitis and periodontitis are a continuum of the same inflammatory disease.3 However, there is a wide range in individual susceptibility and not all individuals with gingivitis will progress to destructive periodontitis.4

Less commonly, non-plaque-induced gingival lesions can present and the diagnosis and management of some of these is challenging and may require specialist referral.5

Chronic periodontitis

It is significant that the terminology has changed from 'adult periodontitis' to 'chronic periodontitis' as this marks the increased international awareness that periodontitis is not just confined to adults over the age of 35 years, but can begin in early teenage years and progress slowly throughout the teens.6,7 The destruction resulting from chronic periodontitis is consistent with the microbial aetiology of the disease in the presence of local risk factors (such as subgingival calculus or plaque-retentive restoration overhangs) and/or systemic risk factors (such as smoking or poorly controlled diabetes mellitus). A diverse microflora containing putative periodontal pathogens can be found in the subgingival plaque biofilm in teenagers.8,9 Indeed, Tannerella forsythensis has been strongly associated with loss of attachment and the conversion of periodontally healthy sites to diseased sites over a three year period in adolescents.10

Aggressive periodontitis

Replacement of the previous term 'early onset periodontitis' by 'aggressive periodontitis' helps to depict a rapidly destructive disease without undue emphasis on the age of presentation, albeit a disease that 'normally' but not exclusively affects those young adults under the age of 30 years. It is a distinct and separate entity from chronic periodontitis and must be managed accordingly. Common features of aggressive periodontitis are:

  • Patients clinically healthy (apart from the presence of periodontitis)

  • Rapid loss of attachment and bone destruction

  • Familial aggregation.

The localised form affects incisors and first molars and can present around puberty. Amounts of microbial deposits may be inconsistent with the severity of periodontal destruction and other secondary features may include increased proportions of Aggregatibacter (previously Actinobacillus) actinomycetemcomitans (and possibly Porphyromonas gingivalis), phagocyte abnormalities and a hyper-responsive macrophage phenotype. A robust serum antibody response to A. actinomycetemcomitans is characteristic and neutrophil defects may have a role in the aetiology. The disease has a multifactorial nature, including a genetic element. Usually less than 1% of the population is affected, but an increased prevalence occurs in African and black ethnic groups. Recently, the JP2 clone of A. actinomycetemcomitans has been shown to be an important aetiological agent in the initiation of aggressive periodontitis in an adolescent Moroccan population.11 Early detection and treatment improves prognosis.

Detection of periodontal diseases in younger age groups

The basic periodontal examination has been advocated to screen for periodontal diseases in adults12 but at present there are no universally agreed guidelines for periodontal screening of the younger age groups. However, a simplified screening system for the under-18s as described by Clerehugh and colleagues is quick and easy to use in practice.5,13 It involves assessing index teeth (UR6, UR1, UL6, LL6, LL1 and LR6) using a WHO 621 probe with a 0.5 mm ball end and black band at 3.5 to 5.5 mm using BPE codes 0-2 in 7- to 11-year-olds and the full range of codes 0, 1, 2, 3, 4 and * in 12- to 17-year-olds (Figs 1 and 2). Currently, the British Society of Periodontology and the British Society of Paediatric Dentistry are working on a joint initiative with the aim of formulating and disseminating periodontal guidelines in the younger age groups.

Figure 1
figure 1

Index teeth UR6, UR1, UL6, LL6, LL1, LR6 and grid for recording simplified BPE in the under-18s

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Figure 2
figure 2

WHO 621 probe being used to undertake simplified BPE on LL6 index tooth; BPE codes

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Management

Periodontal management follows the principles of initial (cause–related) therapy, corrective therapy (definitive treatment plan produced) and supportive (maintenance) therapy with appropriate recall based on the diagnosis. Effective control of the plaque biofilm and preventive measures are fundamental to success. Child-centred approaches to behavioural management should be implemented as necessary.14 Much of the treatment can be carried out in the dental practice setting, but the decision to treat or refer to a specialist (Table 2) includes consideration of:

  • General dental practitioner's expertise

  • Patient-centred factors

  • Complexity of case.

Table 2 Younger patients who may need referral to a specialist
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In conclusion, many different forms of periodontal disease, some very destructive, can manifest in younger age groups but early diagnosis and treatment improves prognosis. Work is ongoing to produce guidelines for periodontal screening and management of the under-18s.