Richard H. Nagelberg, DDS
The causality between periodontal disease and periodontal pathogens is not only well established, it is factual. Similarly, the interconnections between the mouth and the body are also well established, including the periodontal disease and periodontal pathogen mechanisms. Studies are underway to determine if the presence of periodontal pathogens can be utilized in the future as a predictor of periodontal disease development. So when does the accumulation of periodontal pathogens begin? Are they common in the mouths of children, or confined to adolescents and adults?
Research indicates that the composition of the microflora changes as a child matures. Research also indicates that the bacteria in the mother's mouth can be passed on to the developing child prior to delivery, especially in mothers with periodontal disease during the pregnancy. Many of the periodontal pathogens are transmittable, so anyone who kisses the child can potentially unknowingly pass on bacteria as well.
The most common periodontal condition in children is chronic marginal gingivitis; however, research also indicates that the majority of children have periodontal pathogens, including highly pathogenic species in their mouths. With the exception of localized aggressive periodontitis, children rarely develop periodontitis.
Gingivitis in children differs from adult forms from an immunological standpoint. Childhood gingivitis triggers a different white blood cell response than that which occurs in adult forms of the disease, which may explain why it rarely progresses to periodontitis. Also, the junctional epithelium of primary teeth is thicker than the permanent dentition, which may reduce the penetration of bacteria and their endotoxins into the gingival structures.
Many studies have demonstrated the presence of periodontal pathogens in children. A 2014 study (Nadkarni et al. Clin Oral Investig. August 2014) concluded that early colonization of children by P. gingivalis and P. intermedia, among others, provides indication of risk for subsequent development of periodontal disease. Previous studies (Yang et al.) analyzed the microbiota of children between the ages of 18 and 48 months and found that 71% of the subjects were infected with one or more periodontal pathogens. Sixty-eight percent were infected with P. gingivalis and 20% had Tannerella forsythia, both of which are high-risk pathogens. Other studies had similar results, including the strong association between the presence of P. gingivalis and the onset of periodontitis in healthy children.
Is it appropriate to provide salivary testing for children to determine the presence of periodontal pathogens? That is up to each clinician to decide; however, when one or both parents have periodontal disease or when there is a strong family history of periodontitis, it is something to think about. This may also be the case when there is a strong family history of cardiovascular disease, given the independent association between certain perio pathogens and the development of atherosclerotic plaques. The development of atherosclerotic plaques starts in childhood. The first signs of atherosclerosis are fatty streaks, which are visible without magnification. A fatty streak consists of lipid-containing foam cells in the arterial wall just beneath the endothelium. It appears as a yellow discoloration in the artery's inner surface and occurs in the aorta and coronary arteries of most people by age 20 (Boston University School of Public Health, 2014).
The manner in which we communicate with parents as we recommend salivary diagnostic testing of their children is critically important, most notably to avoid causing unnecessary alarm. We must remember it is unethical to indicate that controlling the population of periodontal pathogens will reduce the risk of atherosclerotic plaque development.
If salivary testing confirms the presence of periodontal pathogens in a child, what should be done about it, especially if the gingiva is healthy? Providing periodontal treatment is not appropriate in these cases. Home-care recommendations should include the use of a child or adult power toothbrush, depending on the age and size of the individual, with follow-up bacterial testing after the implementation of power brush usage.
We naturally tend to focus on adults when we consider periodontal diseases, periodontal pathogens, and salivary diagnostic testing. Perhaps we should widen our scope to at least consider the possibility of salivary testing, power toothbrush recommendations, and the introduction of interdental biofilm control devices for our young patients.
Richard H. Nagelberg, DDS, has practiced general dentistry in suburban Philadelphia for more than 30 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact Dr. Nagelberg at firstname.lastname@example.org.