Lupine Publishers | Sugar and Dental Caries: Guidelines for Sugar Consumption Suggested by the World Health Organization

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Dental caries is a dynamic multifactorial disease, determined by sugar consumption and mediated by biofilm formation and activity that results in an imbalance between the processes of demineralization and remineralization of enamel. Untreated dental caries is the most prevalent oral diseases in the world and its treatment is one of the most expensive treatment. For these reasons, caries prevention must be mainly related to the control of sugar intake. Since 2002, some publications of WHO recommend the consumption of free sugars should be below 10% of the daily energy consumption. In 2015, they published a new guide for adults and children, with a strong recommendation that the consumption of these sugars should be reduced in all life cycles. In 2019, WHO published the “WHO Implementation Manual: Ending childhood dental caries”, part of the “Oral Health Program, Prevention of Noncommunicable Diseases”. This review aims to discuss the current guideline recommended by the World Health Organization for the consumption of sugar as an improvement approach for the prevention of dental caries.

Abbreviations: WHO: World Health Organization; GRADE: Grading of Recommendations Assessment Development and Evaluation; ECC: Early Childhood Caries

Introduction

The Global Burden of Disease Study 2017 revealed that 3.5 billion people worldwide are affected by oral diseases. Untreated dental caries is the most prevalent non-communicable oral diseases [1]. Despite the advances in preventive actions, caries is still a prevalent disease, causing pain, anxiety, and limitations in daily activities. Indeed, caries development can directly affect the population’s quality of life. The treatment for caries is the 4th most expensive treatment among diseases [2]. Dental caries is a dynamic multifactorial disease, determined by sugar consumption and mediated by biofilm formation and activity that results in an imbalance between the processes of demineralization and remineralization of enamel. It is determined by biological, behavioral, psychosocial factors, and also the individual’s environment [3]. In 1989, for the first time, the World Health Organization (WHO) established dietary guidelines for controlling the consumption of free sugars. Afterward, several documents were produced, and, in 2015, after rigorous analysis of scientific articles, the “Guideline: Sugars Intake for Adults and Children” was published. This important guideline recommends the adequate consumption of free sugars to reduce the prevalence of non-communicable diseases in adults and children, focused on the prevention and control of obesity and dental caries [4]. This review aims to discuss the current guideline recommended by the World Health Organization for the consumption of sugar as an improvement approach for the prevention of dental caries.

Literature Review

Dental caries is considered a dynamic multifactorial disease and is currently considered a non-communicable disease and shares risk factors common to other non-communicable diseases associated with sugar consumption, such as cardiovascular disease, diabetes, and obesity [3]. For these reasons, caries prevention must be mainly related to the control of sugar intake. Sugars are classified into monosaccharides (glucose, galactose, and fructose) and disaccharides (sucrose, maltose, and lactose). Sugars located in the cellular structure of grains, fruits, and vegetables and those naturally present in milk and its derivatives are considered natural sugars. These sugars may not significantly contribute to the development of caries due to the amount of fiber and water [4]. It also possesses protective factors such as polyphenolic compounds and calcium. Hence, the impact of fruits, vegetables, and grains on the mechanical stimulation of salivary flow, would help to reduce the risk of caries related to its consumption [5]. Other sugars that are not considered to be natural are classified by the WHO as free sugars. All monosaccharides and disaccharides are added to food during preparation and can be processed or not. The sugars naturally present in honey, syrups and fruit juices are also classified as free sugars. Accordingly, the consumption of these foods should be controlled to prevent non-communicable diseases better [5].

Since 2002, some publications of WHO recommend the consumption of free sugars should be below 10% of the daily energy consumption [6]. In 2015, they published a new guide for adults and children, with a strong recommendation that the consumption of these sugars should be reduced in all life cycles. It was emphasized the need to control sugar consumption to below 10%, also providing an additional recommendation for a subsequent reduction to 5% [4]. Adults with a healthy body mass index could consume 50 grams of free sugars (about ten teaspoons of sugar), considering 10% of their daily energy consumption. These sugars are present in sweets, soft drinks, pasta, stuffed cookies, cakes, among others. The amount of free sugars in some foods is shown in Table 1. The recommendations of the WHO guidelines were related to the Grading of Recommendations Assessment Development and Evaluation (GRADE) process [7]. Therefore, the WHO guidelines were based on significant evidence according to the type of study, limitations, consistency, presence of bias, effect size, dose-response, and analysis of confounding variables. After considering these factors, the evidence could be classified as high, moderate, low, or very low.

Table 1: Determination of the amount of sugar per serving indicated in some foods consumed by children..

The analysis of cohort studies in children suggested a positive association between the number of free sugars ingested and dental caries. The evidence suggested that when the intake of these foods was higher than 10% of daily consumption, the experience with caries was also more significant. In addition, epidemiological studies demonstrated a low prevalence of caries in individuals with low consumption of sugar per year (less than 10 kg, approximately 5% of the total energy consumption). Overall, there is a doseresponse between the number of free sugars ingested and the prevalence of caries. The GRADE process classified these evidences as moderate significance [8]. Conceivably, the WHO produced recommendations for the consumption of sugar by adults and children [4]. The frequency of sugar ingestion and the amount of sugar consumption can be considered risk factors for tooth decay. Although few epidemiological assess this relationship, the WHO concluded that both variables are essential [4]. The WHO meeting Expert Consultation on Public Health Intervention against Early Childhood Caries (ECC) in Bangkok, Thailand, in 2016 discussed several strategies to prevent caries in the first years of life. The need to control sugar consumption has been reinforced so that it does not exceed 10% [3]. In 2019, WHO published the “WHO Implementation Manual: Ending childhood dental caries”, part of the “Oral Health Program, Prevention of Non-communicable Diseases” [9]. This manual discusses nutritional recommendations, encouraging exclusive breastfeeding until six months of age, and avoiding the consumption of free sugars in drinks and food in the first two years of life. The WHO also recommends that governments publish national guidelines on food and nutrition. Brazil developed food guides according to the cultures of the country and its populations.

In 2002, the first version of the Food Guide was published and then revised in 2010 [10,11]. This publication demonstrated the 10 Steps to Healthy Eating. Later, a new edition was prepared in 2019 due to social changes and changes in eating in recent years [12]. This document also recommended food and nutrition education actions on an individual and collective level in the Unified Health System (SUS) and in other sectors. This is a guide for policies, programs and, actions that aim to support, protect, and promote the health and food and nutritional security of Brazilian children. In this updated version, “12 Steps for Healthy Eating” were suggested. In this regard, the impact of the steps to healthy eating was evaluated according to a randomized clinical trial. Individuals that followed the dietary guidelines proposed by the guide demonstrated a higher proportion of children breastfed exclusively until six months of age, and they experience fewer events of caries [13].

Conclusions

Dental caries is one of the most prevalent non-communicable disease in the world. Despite the use of fluoridated toothpaste, caries is a multifactorial disease, and all contributing factors must be known and controlled. Preventive measures, as dietary guidance, has been discussed over the years. The patient’s eating habits must be registered by the dentist to identify the frequency and amount of ingestion of free sugars. One way to conduct this interview is through the 24-hour Recall Diary, a method in which the patient informs everything that was ingested the previous day. The WHO recommendation for free sugars consumption (10% of the total daily intake) [4] is an alert for the worldwide population, since many processed or ultra-processed foods, can carry this amount of sugar in a single portion (Table 1). The WHO guidelines reinforce the need for this control to be carried out in all life cycles since caries is a cumulative disease [4]. In addition, these recommendations are useful in guiding public policies and in managing health promotion programs, such as restricting the amount of sugar for foods, emphasizing the warning of food composition in its labels, and encouraging the eating of healthy food. In this way, all efforts should be directed towards the prevention of caries once it is a prevalent disease-causing pain, discomfort, limitations, anxiety, in addition to impairing the child’s school development, social life, and, consequently, their quality of life.

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Lupine Publishers | Identification and Characterisation of Periodicum Pradatorius: An Emerging Pathogen of Physicus Novicius and Litterae Scientific

 Lupine Publishers | Journal of Pediatric Dentistry

Short Communication

“The way to reason with a predator is to make it aware that it can live in a cage, or it can die, but it can no longer prey upon us”. Litterae scientific has, over the last decade in particular, been the subject of escalating insult from a number of rogue elements; none more insidious than Periodicum pradatorius [1]. Coinciding with the growth of the internet [2], this opportunistic infectious agent gains access to its intermediary host (Physicus novicius) primarily via Email, though social media platforms have also been implicated [3]. Once established in the hosts’ inbox, the virus either remains dormant until activated by the unwitting host or neutralized by the hosts’ immune defenses (i.e. antispam software). Several subspecies of P Pradatorius exist, each exhibiting varying degrees of sophistication in terms of the infection process: ranging from the rather simplistic subspecies generalist (which lacks any discernible host specificity; including the target’s name, correct salutation or area of specialization), to the more targeted variant, P. pradatorius certis. While P. pradatorius generalist usually addresses the host in general terms, including “Dear Doctor”, “Dear Professor” or in some less evolved strains, “Respected Sir” (presumably suggesting a sex specific tropism), P. pradatorius certis, by contrast, exhibits some degree of specificity. Indeed, subspecies certis not only uses the host’s full name, but often refers to one of the host’s previous publications. The cited paper (usually the source of the P. novicius contact details used by the pathogen to initiate the infection in the first instance) often bares little or no relevance to the P. pradatorius subject matter. A typical line from a P. pradatorius letter of invitation will read “We have read with interest your work on Acne vulgaris and feel that it would make an excellent addition to our journal Life on Mars”. To illustrate the absurdity of such an association: our team’s Prof Throb, a noted expert in acne (particularly of the rhino variety), has never as much as set a foot on Mars!

Another characteristic of P. pradatorius is an innate sense of urgency in the nature of the initial contact; P. novicius is often informed that a single submission is needed to close a planned future issue, which is usually due for publication in as little as two weeks. This demand is usually followed by the reassurance that “if your research is not ready” … “review articles, case reports, short communications, perspectives, editorials, letters to the editor, etc.” are all welcome (in essence, anything will do!). Peer review is rarely mentioned (and, with such rapid turn-around times, is hardly likely). Furthermore, analogous to prion-like spread, P. pradatorius will endeavor to sequester P. novicius itself as part of the infectious process; forwarding the request to others, encouraging them to contribute their “important research”. Indeed, some strains of P. pradatorius go even further; inviting P Novicius onto the journal Editorial Board; thereby endeavouring to actively assimilate the host in true Borg-like fashion [4]. The overall effect of P. pradatorius infection of P. novicius varies from the relatively minor inconvenience of a cluttered inbox [5] to the much more serious reputational damage associated with publishing in a journal which lacks credibility, is not appropriately indexed and as such is unlikely to be extensively cited [6,7]. Indeed, the long-term effects are likely to, at best, retard and at worst completely prevent the normal evolution of P. novicius to Physicus statutum; the most evolved of the genus Physicus. Furthermore, and perhaps more detrimental in global terms is the combined effect on the primary host, L. scientific. If sufficient P. novicius numbers succumb to P. pradatorius, then the entire L. scientific complex will be compromised [8]; the key symptoms being a lack of public trust in the scientific process which ultimately risks the integrity of the Academy as a whole [9].
A separate, yet related, species within the genus Periodicum (P Colloquium), has also begun to emerge in recent years [10]. While this variant has only a minor impact on P. novicius (who have limited access to research budgets), it can exist in a symbiotic relationship with certain strains of P Statutum. In exchange for exorbitant registration fees, P Statutum can enjoy grant funded trips to exotic climes (no talk or poster presentation required!). In conclusion then, P. pradatorius, and related species, are on the rise and continue to pose a real and present threat to both P. novicius and L. scientific [11]. While vigilance is key in the battle against these insidious imposters [12], humor is also an important ally - Castigat ridendo mores!

Acknowledgements

The authors wish to thank Dr Croc for expert editorial assistance.

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Lupine Publishers | An Assessment of Emergency Care Following Tooth Avulsion Among A Selected Population of Nigerian School Children

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Aim: To assess the knowledge of school children on the first aid administered after traumatic tooth avulsion.

Methods: A structured questionnaire was used to obtain information from children of six primary and six secondary schools in Port Harcourt, Nigeria. Information elicited included respondents’ socio-demographics, exposure to dental trauma and knowledge on emergency care for tooth avulsion. Data collected was analysed using SPSS Version 22 and level of significance was set at p <0.05.

Results:There were 411pupils; 194 males and 217 females with a mean age of 12.5 (±2.6) years. One hundred and eighty-three (44.5%) had previous dental injuries. Three hundred and twenty-three (78.6%) would seek treatment in dental clinic after tooth avulsion. Only 16 (3.9%) would replace the tooth in its socket, 160 (38.9%) would take it to the dental clinic and 192 (46.7%) will throw the tooth on a roof top. Only 164 (39.9%) would seek immediate treatment. Twenty-two (5.4%) will use milk as storage/ transport media. There were statistically significant differences between
a) The males and females in their time for seeking treatment (p=0.01).
b) The public and private school pupils on where to go for treatment (p=0.013) and transport media use (p=0.00).
c) The primary and secondary school pupils on replantation of avulsed tooth (p=0.03) and transport media use (p=0.00).

Discussion: Although majority knew who a dentist is, their knowledge of emergency care when avulsion occurs is low; they require oral health education to bridge the gap in their knowledge.

Keywords:Tooth avulsion; traumatic dental injuries; emergency care; Nigerian school children; tooth replantation; transport media

Introduction

The school is an educational institution for learning both within [1] and outside [2] the classrooms under the guidance of teachers [3]. However, recreation and sport activities [2-4] in schools when unsupervised may predispose school children to traumatic dental injuries (TDI). Such injuries occur more among males than females and more commonly in urban children than rural children [5-8]. Sixty percent of TDI have been reported to occur during sporting activities among school aged children [9,10]. Of these, tooth avulsion; the complete displacement of the tooth out of the alveolar socket, is the most severe type of TDI and it occurs in both the primary and permanent dentitions [11]. In the permanent dentition, it occurs commonly among children aged between 6-12 years, [5,8,11,12] during the period in the tooth eruption cycle when root formation is incomplete and the periodontal ligament surrounding erupting teeth are loosely structured and provide very minimal resistance to an extrusive force. Tooth avulsion has an incidence of between 0.5 to 16% [8-14] among children and an incidence of 20.8% was reported among Nigerian adolescents [15].
Tooth loss, as a result of trauma, in addition to being distressing has both functional and psychosocial consequences in the permanent dentition [9,11,16]. First aid carried out minimizes the negative emotional/social consequences and ensuing cost of treatment that may result from premature tooth loss. Timely intervention at the site of the accident and immediate presentation to a dental clinic for professional care would result in a favourable outcome [7,10,16]. Replantation is the treatment option for avulsed permanent teeth and the treatment outcome is dependent on prompt and appropriate intervention at the site of the accident [3,17]. Other factors include short extra oral time, suitable transport media, immaturity of the root apex and patients’ general health [16,18,19]. The first aid carried out at the time of injury includes replacing the tooth within the alveolar socket and immediate referral to the dental clinic [8,13] for replantation procedure. However, if the tooth cannot be replaced into its original position, a suitable storage and transport medium would help maintain the viability of the periodontal ligament cells while seeking prompt professional attention in the dental clinic. The transport and storage media include Hanks Balanced Salt Solution (HBSS), Eagle’s medium, Normal saline, Via span, propolis, milk and coconut water [13,18,19]. The most recommended medium based on maintenance of PDL cell viability, availability, low cost and long shelf life is milk as reported in the reviews by Adnan et al. [18] and Udoye et al. [19]. Parents, teachers and students, especially, are almost always present where these injuries occur and need to be knowledgeable on what to do immediately it occurs. The knowledge of parents, [17,20] school teachers [3,9,10,20-23] and students [24,25] has been assessed in several studies both within and outside Nigeria. Most of these showed a poor awareness and low knowledge of first aid measures following tooth avulsion. Though the knowledge of students has been conducted in a study in Nigeria, it was done over a decade ago in another geopolitical region [24]. The aim of this study was to assess the level of knowledge of first aid administered following tooth avulsion among school children in the South-South geopolitical region in Nigeria.

Materials and Methods

Ethical clearance was obtained from the Research and Ethics Committee of the University of Port Harcourt Teaching Hospital. Consent was sought and obtained from the State Universal Basic Education Board and the proprietors of the private schools. Consent and assent were sought from the head teachers and pupils after being assured of confidentiality, respectively. Children aged 8 to 15 years were selected from six (three public and three private) primary and six (three public and three private) secondary schools using a multistage sampling technique. A structured questionnaire [24] was used to obtain information from each of the children. The information elicited were the socio-demographics such as age as at the last birthday and sex, other information were experience of exposure to dental trauma, response to past traumatic injuries, knowledge of the emergency treatment with particular focus on tooth avulsion and knowledge on the process of replantation. The information collected was entered into data spreadsheet and analyzed using the IBM Statistical Package for Social Sciences (SPSS) software, Version 22.0 (SPSS Inc., Chicago, IL, USA). Descriptive summary statistics was obtained for demographic variables and knowledge of emergency care. Pearson’s chi square was used to assess the differences in knowledge between groups and statistical significance was set at p<0.05.

Results

Figure 1: The distribution of the school pupils according to the type of schools, level of education and gender.

Four hundred and eleven students comprising 194 males and 217 females with a mean age of 12.5 (+2.6) participated in this study. Two hundred and four (49.6%) primary and 207 (50.4%) secondary school pupils participated in the study; 270 (65.7%) attended public schools while 141 (34.3%) attended private schools. Details in Figure 1. One hundred and eighty-three (44.5%) had history of previous dental injuries. Their responses to the questions on their knowledge of avulsion revealed that 323 (78.6%) would go to a dentist if they had tooth avulsion, 76 (18.5%) would see a medical doctor and 4 (1%) would go to the school clinic. Only 16 (3.9%) would replace the tooth in its socket. Although 164 (39.9%) would seek immediate treatment, 160 (38.9%) would take the tooth to the dentist. Two hundred and five (49.9%) would use normal saline as transport medium and only 22 (5.4%) would use milk. When avulsion occurs, 192 (46.7%) would throw it on roof top, while 160 (38.9%) would take the tooth to the dental clinic. Details in Table 1.

Table 1: The knowledge of the school pupils on traumatic dental emergencies (tooth avulsion).

Gender of the subjects

When the gender was considered equal proportion of males and females would seek treatment from a dental clinic (78%) and immediate treatment within 15 minutes (40%). Though 40% of males and females would seek treatment within 15 minutes of the injury, there were statistically significant differences between the males and females (p=0.01) in their timing for seeking treatment (Table 2).

Table 2: The relationship between the Gender and knowledge to the process of tooth replantation.

*p<0.05 is statistically significant

Private and public schools

Following avulsion, 4.8%public and 2.1%private school pupils would attempt replacing the tooth within the tooth socket at the site of injury. Three hundred and twenty-three (78.6%) would go to a dental clinic for treatment, however only 164 (39.9%) would seek dental treatment immediately after the injury. More (51.1%) public school pupils compared to 38%private pupils had cultural beliefs on throwing an avulsed tooth on roof tops (p=0.06). Twelve (4.4%) and 10 (7.1%) public and private school pupils, respectively would use milk as a transport medium while 63.8% private as against 42.6% public school pupils preferred normal saline as transport medium. There were statistically significant differences between the public and private school pupils on where to go for treatment (p=0.013) and transport media (p=0.00) following avulsion (Table 3).

Table 3: The relationship between the pupil’s school type and the knowledge of the process of tooth replantation.

*p<0.05 is statistically significant

Level of education

Table 4 shows that 52.9% of primary school pupils and 44.9% secondary school pupils preferred normal saline while 7.4% of primary school pupils preferred milk compared to 3.4% secondary school pupils. There were statistically significant differences between the primary and secondary school pupils on replacing the avulsed tooth back to the sockets (p=0.03), transport media (p=0.00).

Table 4: The association between the type of school, knowledge of emergency dental care and the level of education of the pupils.

*p<0.05 is statistically significant

Discussion

Tooth avulsion is known to commonly occur among children in the mixed dentition phase hence the sample for this study was taken from among the school children. Though school children have teachers in the school premises, sometimes other pupils are the ones present when tooth avulsion occurs. The prognosis of treated avulsed tooth is dependent on prompt treatment which relies greatly on what is done at the site of the accident. Appropriate transport and storage media within the recommended period of storage will help maintain viability of the periodontal ligament cells, thus a favourable treatment outcome [18,19]. In this study 44.5% of the children had experienced dental trauma compared to 6-12.8% reported prevalence of TDI among the school aged children [15]. A good proportion (78.6%) of the participants would choose to receive treatment in a dental clinic. This demonstrates good awareness of whom a dentist is and understanding of the role a dentist plays in the healthcare. Such knowledge may have been fostered by series of outreaches and awareness programmes previously done in most of the schools [22]. However, there was a statistically significant difference in the level of knowledge between the private and public schools (p=0.013), the private school participants seem to know better. This finding is contrary to that reported in South Western Nigeria where the children preferred going to see a medical doctor thereby showing less awareness of the dentists’ role [24].

It was observed that 53.3% would seek professional care within 30 minutes after tooth injury, 23% may not seek care based on their choice of seeking care at “anytime”. This is a concern for a condition that requires urgent care and an off shoot of poor awareness of the importance of prompt treatment following dental trauma. The first aid measures at the site of injury include replacing the tooth in its original position [3,13] or placing in a suitable transport medium [13,18,19]. Only 16 (3.9%) would replace the tooth in its original position in the socket and there was statistically significant difference between the primary and secondary school pupils (p=0.03). This value is less than the 17.8% reported in the south west Nigeria [24]. When the gender and type of schools were considered there were no statistically significant differences between the males and females (p=0.19) and schools (p=0.39). There must be an understanding of tooth anatomy and most importantly there should be a formal teaching on what to do when tooth avulsion takes place. Though the most suitable transport medium listed was milk, [18,19] a good majority preferred normal saline, probably because normal saline appears more medicinal than milk. In this study it was observed that (46.7%) school children had a strong cultural belief on what should be done to a tooth that has been avulsed. This was shown by their response that they will throw the avulsed tooth on roof tops. This belief was commoner among pupils in public schools. The finding buttresses what was reported in a similar study in another geographical location within Nigeria with a different culture [24]. This belief stems from the myth that when a lizard sees an exfoliated tooth, that the succedaneous tooth would not erupt, so to prevent this from happening, the exfoliated teeth were thrown on roof tops away from the lizards [25]. The practice of throwing on roof tops has also been observed in some Asian countries like India, China, Japan, Korea, and Vietnam, although for different reasons [26]. The implication of this, is that the avulsed permanent tooth that would have had a chance of survival from replantation procedure in the dental clinic were being thrown away.

Conclusion

Traumatic dental injuries though a common occurrence amongst these school children (44.5%), their knowledge on first aid measures administered when tooth avulsion occurs before professional intervention is low. Although the children were aware of whom to see when they have dental injuries, the children still hold on to cultural beliefs which could be detrimental to the maintenance of the integrity of the dental arch hence oral health. These gaps in knowledge on first aid following tooth avulsion should be addressed by improving oral health education on traumatic dental injuries with emphasis on emergency care of tooth avulsion in schools. The curriculum on health education in schools should include oral care during dental emergencies.

Conflict of Interest

None of the authors have any conflicts of interest that should be disclosed.

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Lupine Publishers | Periodontitis in the Developmental Age: Pathogenesis, Epidemiology, Differential Diagnosis and Treatment. A Narrative Review

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Objective: The purpose of this study is to deepen the description of aggressive periodontitis in developmental age patients going through pathogenesis, epidemiology, diagnosis, treatment and differential diagnosis.

Methods: The database searching was performed on PubMed and Scopus using the following keywords: “prepubertal periodontitis, aggressive periodontitis, periodontitis in children, periodontal disease in children and adolescents, early-onset periodontitis”. Both clinical, laboratorial and review studies were taken into consideration.

Results: Aggressive periodontitis affects a low percentage of children, and in those patients. Actinomycetemcomitans is the main bacterium identified in affected sites. Moreover, it has been found that Genetics plays a fundamental role in development and progression, which is important to distinguish the various oral manifestations excluding the possibility that they are a consequence of systemic pathologies. Although it mainly affects young patients, the treatment does not differ from that applied in adult subjects and it consists of a causal therapy, a mechanic and a pharmacological one, in particular the antibiotics associated with professional hygiene has shown very satisfactory results.

Discussion: Given the great variability of oral manifestation symptoms, there is no specific criterion for defining a high-risk group at prepubertal age, further research is needed to identify a robust set of genetic, microbiological and host factors markers that may facilitate the diagnosis of the disease.

Keywords: Aggressive periodontitis; periodontal disease; developmental age; differential diagnosis

Introduction

Periodontal disease is one of the most widespread diseases in the world and is, as a prevalence, immediately after diseases such as diabetes and hypertension [1]. Its clinical aspects have long been analyzed since it constitutes a worldwide problem. The pathology affects subjects of every race, sex and age and also some risk factors are needed in addition to the individual susceptibility for it to develop. Even today there are not enough scientific certainties to establish the behavior of periodontal disease in the age group that affects children and young adults. In any case, we proceeded through a search in the literature with the attempt to deepen its clinical aspects, etiology, diagnosis, predisposing factors and treatment. Periodontal diseases, despite being widespread especially in the adult population, are not so rare even among young people [2]. For example, gingivitis affects over 70% of children over the age of seven [3]. Bimstein in 1991 underlined the importance of prevention, early diagnosis and treatment of periodontal diseases in children and adolescents because they have a high severity and prevalence [4] and furthermore, the oral-dental incipient pathologies on small subjects can develop into periodontal diseases in adults. However, the degree of extension and destruction of periodontitis also responds to a personal predisposition to the disease. The severity index of periodontal disease can also be mediated by the presence of some systemic diseases such as hypophosphatasia or leukocyte deposition deficiency [5].

According to Lamster IB and Pagan M, the metabolic syndrome (MetS) that is a spectrum of conditions that include dysglycemia, visceral obesity, atherogenic dyslipidemia (high triglycerides and low levels of high-density lipoprotein) and hypertension are associated with periodontal disease. They believe that this relationship is the result of systemic oxidative stress and an exuberant inflammatory response. Evidence suggests that periodontal therapy may reduce serum levels of inflammatory mediators so periodontitis treatment could become part of the metabolic syndrome therapy [6]. Among the various types of periodontitis, one of the less studied ones is aggressive periodontitis. The manifestations of aggressive periodontitis in young people have many controversial sides and consequently, the present study proposes to look for some clarifications regarding the aspects of the pathology

Methods

For this narrative review, the database searching was performed on PubMed and Scopus using the following keywords: “prepubertal periodontitis, aggressive periodontitis, periodontitis in children, periodontal disease in children and adolescents, early-onset periodontitis”, the investigation then focused on evaluating the specific aspects of aggressive periodontitis in children, consequently the following words have been introduced: “epidemiology, classification, progression, treatment, diagnosis”. Clinical and laboratorial studies were taken into consideration as well as literature reviews. The last database search was performed in September 2019.

Discussion

Aggressive periodontitis

Aggressive periodontitis can occur in several forms that is linked to a few dental sites or in a generalized sense. The first form usually affects smaller subjects and is connected to lesions of the first molars or incisors or both in the presence of little plaque and tartar, and the second form concerns post-puberty subjects with more permanent teeth. Very often, if left untreated, the localized forms evolve into general forms with the risk of a total compromise of the dental apparatus. Sometimes the signs of inflammation are not so easily detectable, which is why a child or teenager on the first visit should always be subjected to a more in-depth analysis by using probes to detect probing depth and radiological investigations. There are some mechanisms that regulate evolution in the various age groups, and the different anatomies and physiologies can modify the development of periodontitis. In particular, there are many structural inequalities between adults and children. The gingiva in the young is more vascularized, has less connective tissue around the deciduous teeth, the epithelium is thinner and less keratinized, characteristics that can expose to less defense to attacks bacterial. It can be said that a child, due to its thinness of tissues, is more exposed to risk and moreover a greater vascularization allows an easier transit of inflammation mediators and bacteria [7]. The typical signs that indicate the presence of a problem and that should alarm the parents are bleeding gums during home hygiene practices, swelling, halitosis accompanied by any recessions. Evidence shows that periodontal disease may increase during adolescence due to lack of motivation to practice oral hygiene but also due to changes related to puberty. Hormones such as progesterone, estrogen and testosterone cause greater blood circulation, greater sensitivity and greater response to any irritation, the gengiva are often red and swollen. Hormones are molecules with specific regulatory abilities and have powerful effects on the main determinants of development and on the integrity of the skeletal cavity including periodontal tissues [8].

Epidemiology

A 1987 study by Sweeney [9] evaluated alveolar bone loss around primary teeth in a population of 2,264 children. Nineteen patients (0.84%) showed periodontal bone destruction around one or more primary teeth; in 2 of these patients, periodontal disease was previously identified during clinical examinations. The microbiological study also revealed a high prevalence of Actinobacillus actinomycetemcomitans and Capnocytophaga. Another study carried out by Bimstein [10] in 1994 verified the prevalence of alveolar bone loss in a group of 317 5-yearold New Zealand children. The results identified that there was a questionable bone compromise in 8.5% of the children and a defined bone loss of 2.1%. Darby et al in 2005 studied bone loss in 542 children aged between 5 and 12 years. Reading the patient’s radiographs, each interdental site was evaluated as: no bone loss and therefore distance from the amelite-cementitious junction to the alveolar ridge of less than 2 mm, questionable bone loss i.e. distance greater than 2 mm but less than 3 mm and bone loss defined or distance greater than or equal to 3 mm.
The results showed that 61 (13%) children presented sites with definite bone loss, 60 children had only a questionable bone loss, 50 children had only a defined bone loss and 21 children had both lesions. It was also found that children of Asian-Far Eastern origin had a higher percentage of sites with bone loss than children of Caucasian origin, 29.5% and 19.7%, respectively, but lower than that of children of Middle Eastern origin (35.2%). In conclusion, the present study showed that in the population studied, 26% had bone loss but 13% had more severe and defined lesions [11]. The studies described above thus show that the prevalence of periodontal disease and in particular bone loss varies from 0.84% to 13%, but in reality, the heterogeneity of such research and the lack of standardization makes it clear how the results are discordant and the prevalence remains mostly dubious.

Microbiology

There are some bacteria that mainly cause periodontal disease, and these can be transmitted within the family where the contact between subjects is very close; through the mother’s saliva, for example, children may be exposed to risk. Much attention has been paid to Actinomycetemcomitans as a species implicated in the etiology of aggressive periodontitis. Its main virulence factor is a leukotoxin capable of eliminating important cells of the immune system. Genetic analyses have identified a population structure of the clonal-type bacterium with evolutionary families corresponding to serotypes. A particular highly leukototoxic clone (JP2) of serotype b was discovered. Its characteristics are unique in fact that its increased leukototoxic activity is given by a deletion of 530 bases in the operon. The geographical mapping of the JP2 clone has revealed that its colonization mainly concerns individuals of African origin [12]. A study conducted by Burgess et al. in 2017 showed the prevalence of the highly leukotoxic JP2 sequence compared to the non-JP2 sequence of Aggregatibacter actinomycetemcomitans within a group of 180 young African Americans aged between 5 and 25 years with and without localized aggressive periodontitis (LAP).
Subgingival plaque was collected from diseased sites, i.e. from areas with probing depth greater than or equal to 5 mm that presented bleeding and from healthy sites, i.e. from areas with probing depth less than or equal to 3 mm that did not present bleeding. Overall, 90 subjects (50%) tested positive for the JP2 sequence, 50 subjects (83.33%) with aggressive periodontitis presented the sequence detected in 45 (75%) sick sites and 34 (56.67%) healthy sites [13]. Actinomycetemcomitans in general is considered an opportunistic pathogen of the oral microbiome, in fact many clonal types of the bacterium different from JP2 can be isolated from healthy subjects, however, patients who present the JP2 strain always show periodontal disease, so an etiological agent is important for aggressive periodontitis in children, adolescents and adults. In conclusion, there is a high risk for the development of the disease in individuals colonized by the JP2 clone, furthermore its transmission, as for other clonal types, occurs vertically by close contact between people, indicating that subjects of the same family may experience extrinsic routes of the subpopulation of the bacterium [12].

Genetics

Genetics plays an important role in the appearance and severity of the disease, so if a person is diagnosed with aggressive periodontitis, it is also good to investigate the other members of the family in order to cure or prevent their appearance. A 1994 study by Mary L Marazita studied evidence of autosomal dominant inheritance and specific heterogeneity in aggressive periodontitis. Analyses were conducted on 100 families, and 104 subjects were diagnosed with aggressive periodontitis. Heterogeneity tests were used to compare the parameter estimates and the conclusions obtained in the black and non-black families. The results of the segregation analysis have verified that an autosomal dominant locus is sufficient to explain the patterns of disease transmission to the whole family. In conclusion, in the present study, we saw how the disease has a chance of appearing in the same branch of descent at 70% [13]. Family aggregation of aggressive periodontitis is not an unusual discovery. The conditions of development of this pathology can be more complex than simple Mendelian syndromes. Genetic studies indicate that there are several genetic variants expressing different forms of aggressive periodontitis, but currently it is not clear how many genes may be involved in these non-syndromic forms of disease [14]. It is important to remember that family models can also indicate exposure to common environmental factors within the same family. Therefore, the behavioral components shared by the same parental group must also be considered: education, socioeconomic status, oral hygiene, possible transmission of bacteria, diseases such as diabetes and environmental characteristics such as even passive smoking influence the susceptibility of the subject as risk factors. Another decisive reason for determining whether individuals develop periodontitis appears to be regulated by the way they respond to their microflora. Genetic factors also in this case modulate the way in which individuals interact with many environmental agents, including biofilm. The mutual influence of genetic and environmental factors, and not only of genes, determines the result, lifestyle factors open the way to the development of aggressive disease [15].

Treatment

When a child is diagnosed with aggressive periodontitis, prompt action must be taken to achieve maximum reduction of periodontal microorganisms with the aim of blocking the development of a more severe clinical picture. The treatment of aggressive disease in children and adolescents does not differ from the techniques applied to adults, in fact the etiology is always known to be bacterial regardless of age group. The treatment therefore should be based on the elimination of pathogens by professional hygiene, but, in reality, in these forms of periodontal disease given the high toxicity of the microorganisms, a systemic therapy with antibiotics must be associated to resolve the picture. The goal is to create a clinical condition that favors the maintenance of the greatest number of teeth for as long as possible. The initial phase of active treatment consists of mechanical cleaning, performed with or without the use of antimicrobial drugs.

The downsizing and smoothing of the roots have proved effective in improving the clinical indices, but they do not always guarantee long-term stability, which is why systemic antibiotics as adjuvants for radicular treatment are to be administered during therapy, and they are more effective than root resizing alone with the additional application of local or antiseptic antibiotics [16].
A 2005 study by Guerrero et al. evaluated the systemic administration of amoxicillin and metronidazole in non-surgical therapy for the treatment of generalized aggressive periodontitis. Forty-one systemically healthy subjects in whom the disease was diagnosed were selected. Patients received non-surgical treatment over a 24-hour period and one half received a course of systemic antibiotic consisting of 500 mg of amoxicillin and 500 mg of metronidazole three times a day for 7 days while the other group of subjects received placebo. After two and six months, they were re-evaluated and the results were as follows: in patients on antibiotic therapy in the 7 mm pockets there was a gain of 1.4 mm and a recovery of bone equal to 1 mm in addition to the areas with depths greater than or equal to 5 mm had a probing less than or equal to 4 mm. Twenty five percent of sites in test patients had a successful improvement in clinical attack, whereas for patients treated only with placebo, the percentage of improved sites was 16% [17]. Another study by Kaner shows how the subgingival application of chlorhexidine via a controlled release device (CHX chip) does not improve the clinical outcome in generalized aggressive periodontitis. The purpose of that study is to compare whether the additional positioning of the CHX chip is as effective as the use of systemic antibiotics. A total of 36 patients were diagnosed with aggressive periodontitis, one half was treated only with slow-release chlorhexidine and the other half treated with systemic antibiotic therapy. The subjects were re-evaluated 3 and 6 months after therapy, and it was shown that the level of clinical attack, bleeding and probing depth had a significant improvement in patients receiving amoxicillin and metronidaziol compared to patients treated with the local application of antiseptics [18]. An alternative method for the decontamination of periodontal sites has been studied: photodynamic therapy. To reduce the excessive use of antibiotics, new disinfection strategies have been sought. Photodynamic therapy (PDT) or light-activated disinfection (LAD) was first tested by Oscar Raab in the early 1900s.
For years it was abandoned due to the use of antibiotics, but it has found a new application in the last decades both in the medical field and in the dental field. The photodynamic reaction takes advantage of the use of a photosensitizer (PS) and a light source calibrated to specific wavelengths in the presence of oxygen. It acts specifically against both Gram + and Gram- microorganisms without causing any damage to the host cells. The toluidine blue is very effective active against many bacteria including those involved in periodontal disease. One example is Arweiler’s [19] research in which the use of antibacterial photodynamic therapy (aPDT) was studied in addition to mechanical scaling and root planning therapy. The aim of that study was to evaluate the results following non-surgical periodontal therapy and additional use of aPDT or amoxicillin and metronidazole (AB) in patients with aggressive periodontitis. Out of 36 patients treated with antibiotic therapy or with two episodes of post-treatment photodynamic therapy, the results after six months were the following: the probing depth was found to be significantly reduced in both groups.
Despite this, the administration of amoxicillin and metronidazole produced higher improvements than the existence of photodynamic therapy, the number of pockets ≥7 mm was reduced from 141 to 3 after AB and from 137 to 45 after aPDT. Although both treatments led to statistically significant clinical improvements, AB showed a reduction in probing depth and a lower number of pockets ≥7 mm compared to aPDT. In conclusion, photodynamic therapy associated with the non-surgical periodontal therapy, despite giving favorable results, cannot be considered a definitive alternative to the systemic use of amoxicillin and metronidazole [20]. However, antibiotics must be administered during or after mechanical therapy since micro-organisms are particularly protected by biofilm in the subgingival plaque. With regard to surgical treatment in patients with aggressive periodontitis, it has been shown that it gives results comparable to non-surgical treatment provided that correct oral hygiene is maintained, that a rigorous maintenance program is followed and that risk factors are kept under editable control [18].

Differential diagnosis

Figure 1:

Periodontal disease is characterized by the imbalance between pathogens and host defenses leading to an inflammatory reaction around dental tissues. To diagnose aggressive periodontitis, it is necessary to investigate the health status of the subject and exclude the coexistence of systemic diseases. Some disorders can cause oral lesions clinically similar to those of aggressive periodontitis, but it is of fundamental importance to distinguish the various manifestations to make a correct diagnosis and intervene with the most appropriate treatment. Examples of significant conditions are AIDS, leukemia, diabetes or rare genetic disorders such as histiocytosis X and Papillon-Lefevre syndrome. The latter is a rare autosomal recessive disorder caused by mutations in the gene that codes for cathepsin C (dipeptidyl-peptidase I inhibitor). The syndrome is characterized by hyperkeratosis, destructive periodontitis that occurs from childhood, recurrent piogenic and systemic skin infections, susceptibility to bacterial infections and intra-cranial calcifications [21] (Figures 1&2). The prevalence is estimated to be between 1 / 250,000 and 1 / 1,000,000 subjects and is manifested in all ethnic groups. These dermatological features appear between the first year of life and 4 years and are accompanied by intraoral lesions that include gingival inflammation, mobility of the dental elements, even spontaneous bleeding and destruction of the periodontium. Patients with this syndrome show serious signs in the oral cavity until complete loss of deciduous bone, generating the normal appearance of the gum. However, with the eruption of permanent teeth, the form of aggressive periodontitis reappears. Any non-surgical but also surgical treatment is vain and almost always leads to partial or complete edentulism in the patient. The treatment is based on the intake of oral retinoids, which attenuate the palmoplantar keratoderma and slow down the lysis of the alveolar bone, and the skin lesions can also be treated with emollients in order to hydrate the affected area. Furthermore, good oral hygiene control, the use of mouthwashes and even antibiotics are recommended to slow the progression of periodontitis. Deciduous teeth or elements with excessive mobility must be extracted and eventually replaced by implants when the subject has completed growth.

Figure 2:

The identification of the syndrome at an early age is something multidisciplinary that can improve the patients’ prognosis [22]. Leukemia is a malignant neoplastic disease of white blood cells and very often strikes in the pediatric age giving oral manifestations prior to systemic onset [23]. Acute lymphoblastic leukemia (ALL or ALL), specifically, develops when a cell destined to give rise to cells of the immune system turns into a tumor and starts to multiply in an uncontrolled way. Many studies show that acute lymphoblastic leukemia is the most frequent tumor in children, representing 75% of all newly diagnosed leukemias and 25% of all childhood malignancies [23]. The typical symptoms that characterize lymphoblastic leukemia are fatigue, dyspnea, fever, pallor and weight loss. Patients with this form of leukemia in the oral cavity have pale mucous membranes and an important gingival bleeding accompanied by lymphadenopathy in the head and neck region. It has been shown that sometimes the initial sign of the disease may correspond to a pericoronitis associated with a prolonged contraction of the masticatory muscles. Numerous studies have also reported a greater incidence of abnormalities in the oral cavity such as the presence of large, irregularly shaped ulcers, halitosis and a loose mucosa [24].
Acute myeloid leukemia (AML) is a disease that originates from the bone marrow. The disease is more common in adults over 60 years and infrequent before the age of 45. Patients with AML have symptoms related to complications related to anemia, neutropenia and thrombocytopenia, including weakness and easy fatigue, infections of varying severity, gingival bleeding, ecchymosis, epistaxis [25]. The oral examination can show pallor of the mucosa (Figure 3), ulcerations (Figure 4), spontaneous bleeding and bleeding (Figure 5) petechiae on gums, palate (Figure 6), tongue or lips, gingival hyperplasia (Figure 7) caused from leukemic infiltration. Usually the lesions of the oral cavity are the first manifestations of the disease, in particular, gingival swelling represents 5% of the early complications [26]. In leukemic patients, regardless of the form of the disease, oral manifestations occur as initial evidence or of its recurrence. Symptoms mainly include gum enlargement and bleeding, oral ulceration, petechiae, mucosal pallor and oral infections. These lesions may be the result of direct infiltration of leukemic cells or altered granulocyte function [26]. With regard to oral hygiene, patients must undergo periodic checkups and deplaquing or scaling sessions to reduce the level of inflammation of the mucous membranes, local antiseptics or antibiotics can be combined with active infections. Chemotherapy, often used in the treatment of leukemia, also has consequences on the subject that also affect the oral cavity. Often patients in therapy are predisposed to the appearance of ulcers, lesions, infections and are prone to have a partial xerostomia favoring plaque buildup.

Figure 3

Figure 4:

Figure 5:

Figure 6:

Figure 7:

Scurvy is another disease that manifests itself with abundant gingival bleeding and which can be confused with aggressive periodontitis. The primary cause of scurvy is the insufficient intake of vitamin C mainly due to dietary imbalances. Childhood scurvy generally appears between the sixth and twelfth year of life. The child is easily irritated without appetite and fatigued. Sufferers of this disease develop anemia, weakness, fatigue, edema in some parts of the body, muscle pain in the lower limbs and ulceration of the gums (Figure 8) [27]. It occurs later as follicular hyperkeratosis and haemorrhage of the lower limbs, as well as bleeding in other areas such as the gingiva and joints [28]. If the disease is not treated it is potentially lethal due to important bleeding that can occur in the intracranial area or, due to the poor ability of the subject to heal due to open wound infections. At the oral level, the disease manifests itself in widespread hypertrophic areas of the violet-colored mucosa, a tendency for bleeding and the formation of hematomas. In small subjects, the symptoms that appear first are the pain and swelling of the joints accompanied by gingival hypertrophy [29].

Figure 8:

Patients suffering from this pathology are administered quantities of vitamin C orally or through injections and, in a short time , all symptoms disappear [28] (Figure 9). Diabetes mellitus is a disease that can present in the oral cavity as aggressive periodontitis and be confused with this. It includes a group of chronic metabolic disorders that turn out to be an altered glucose tolerance or an altered metabolism of lipids and carbohydrates [30]. It has been shown by numerous researches that in diabetic children with poor metabolic control, there is a greater tendency for gingivitis [30]. In fact, the high levels of glucose in the blood cause changes in microcirculation, promote bacterial proliferation and interact with the response of the host. Hyperglycemia caused by diabetes mellitus alters the immune system and the increased availability of glucose in the oral cavity environment increases the proliferation of periodontopathic bacteria and causes marked oral inflammation (Figure 10). In patients with diabetes, a microangiopathy occurs and this change in the periodontium reduces the functions of the polymorphonuclear cells, the chemotaxis, the adherence, the phagocytosis, the use of oxygen and the elimination of antigens, thus favoring the progression of periodontal disease. Hyperglycemia also reduces the solubility of collagen, reduces the production of fibroblasts and causes an increase in the levels of pro-inflammatory mediators responsible for the destruction of connective tissues. Changes to collagen metabolism result in accelerated degradation of both non-mineralized connective tissue and mineralized bone.

Figure 9:

Figure 10:

Even the saliva undergoes both qualitative and quantitative changes. Often in subjects with diabetes, the salivary flow is reduced leading to a further development of the bacterial species [31]. In diabetic patients, periodontal disease develops at a younger age than the healthy population and periodontal impairment usually occurs in adolescence but sometimes earlier in children with diabetes [32]. In the oral cavity, there is therefore an edematous and very inflamed gingiva, bleeding when the probe passes and bone resorption can occur especially in cases of poor metabolic control (Figure 11) [33], but in patients with a good diet with good glycemic supervision and good oral hygiene, do not show evident alteration in the mucosa (Figures 12&13). There is then a relationship between higher levels of plaque and a higher incidence of gingivitis in children with diabetes, moreover, the differences in oral microflora and the impact of metabolic control of diabetes on periodontal health have indicated a higher risk of periodontitis in children with type 1 diabetes [34]. In conclusion, when you are confronted with a child who has an oral situation of persistent inflammation, you need to perform more specific tests to understand if it is periodontitis as a manifestation of systemic pathology or aggressive periodontitis itself. The dentist or hygienist is usually the first to diagnose some diseases due to the involvement of the periodontium, and it is important to have multidisciplinary management to try to minimize the physical, psychological and social effects of the patient at an early age.

Figure 11:

Figure 12:

Figure 13:

Conclusion

In conclusion, the review of the literature shows that periodontal disease does not only affect adults but, even if less frequently, it also involves children and adolescents. The forms of aggressive disease show a family aggregation, cause an important and rapid destruction even in the absence of local irritative factors and occur in systemically healthy subjects. It has been seen that particularly virulent bacteria trigger the process of bone destruction in the disease, the main micro-organism involved is Actinomycetemcomitans, which produces powerful leucotoxins that can also severely damage the subject’s immune system cells. Some clonal types of the bacterium are very pathogenic, and JP2 is always isolated from subjects suffering from aggressive periodontitis indicating that it is an important etiological agent. Regarding the epidemiological aspects, the statistics show very variable data also depending on the country, and so far the prevalence of aggressive periodontitis is not known exactly but it can be said that it occurs mainly in subjects of African descent and in individuals who are predisposed from the genetic point of view.

To date there is no specific criterion for defining a high-risk group for prepubertal pathology, and further research is needed to identify a robust set of genetic, microbiological risk markers and host factors that favor a diagnosis of the disease in association with young people and adolescents. The identification of aggressive periodontitis can be implemented through periodontal screening associated with radiographs, and the routine use of BPE can be helpful for early diagnosis. The treatment consists of the same methods applied also to adult patients, that is to say a causal therapy, a mechanic and a pharmacological one, in particular the studies have shown that antibiotics associated with professional hygiene in patients with aggressive periodontitis give very satisfactory results. If, despite careful treatment and hygiene, a child continues to have periodontal problems, it is necessary to investigate the general health with more specific examinations. A form of periodontal injury in a young person can also be a symptom of systemic diseases that are extraneous to the parent’s awareness and early diagnosis can become vitally important. Aggressive periodontitis, although infrequent, is not to be underestimated and it is important to take children to regular checkups and scaling sessions. Preventing and diagnosing problems early is the key to success.

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