Periodontal disease in children and adolescents ... - Wiley Online Library

Periodontology 2000, Vol. 67, 2015, 34–57 Printed in Singapore. All rights reserved

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PERIODONTOLOGY 2000

Periodontal disease in children and adolescents of Latin America € ING, ANDRES DUQUE, J A V I E R E. B O T E R O , C A S S I A N O K U C H E N B E C K E R R OS ADRIANA JARAMILLO & ADOLFO CONTRERAS

Periodontal diseases are a group of inflammatory pathologies that mainly include gingivitis and periodontitis. Gingivitis is a prevalent type of periodontal disease in subjects of all ages, including children and adolescents (2, 68, 71). Less prevalent periodontal diseases include aggressive periodontitis, acute necrotizing ulcerative gingivitis and diseases of herpesvirus and fungal origin (6). Gingivitis and periodontitis are considered to be a continuum of the same inflammatory process, although it is important to note that many gingivitis lesions do not progress to periodontitis (46, 89). Immediately after tooth eruption, bacterial biofilm begins to form at tooth surfaces exposed to the oral cavity and in intimate contact with the gingival margin. The severity of periodontal disease depends on the level of biofilm accumulation, the virulence of the biofilm bacteria and the humoral and cellular immune responses to the biofilm microbiome. Gingivitis in young individuals typically remains chronic for a prolonged period of time without causing any damage to the periodontal ligament or bone. However, an alteration of the balance between the biofilm and the host can give rise to loss of periodontal attachment. Chronic periodontitis and aggressive periodontitis start as gingivitis but it has been difficult to ascertain the biological processes involved in the progression to periodontitis (7). Microbial dysbiosis, overgrowth of pathogenic bacteria, herpesvirus reactivation, immune-system disruption and acquired and/or genetic susceptibility factors are probably involved in disease progression from gingivitis to periodontitis (23, 31, 70). Epidemiology assesses the prevalence of diseases and disease-associated factors in populations. Epidemiologic data allow the identification of highrisk populations and measures of potential value for preventing disease. The topic of epidemiology of peri-

34

odontal diseases in children and adolescents of Latin America, which is the focus of this review, is challenging as problems are encountered in terms of case definitions and the availability of adequate scientific reports. Epidemiological data are scarce for some parts of Latin America, especially with respect to nationwide representative studies (38). The present article addresses methodological issues pertaining to the definition of periodontal disease in children and adolescents, and then overviews the available epidemiological findings on periodontal diseases of young individuals in Latin America and potential risk factors associated with the diseases. Information was retrieved from country-wide studies and from studies of selective populations.

Search methods A systematic search was carried out using MEDLINE (PubMed), LILACS, BIREME and SciELO to obtain information on the periodontal condition of children and adolescents in Latin America. The following keywords in English, Spanish and Portuguese were used in the search: ‘prevalence’, ‘frequency’, ‘gingivitis’, ‘prepubertal periodontitis’, ‘juvenile periodontitis’, ‘aggressive periodontitis’, ‘marginal bone loss’, ‘periodontal disease’, ‘children’, ‘adolescents’ and ‘ulceronecrotizing gingivitis’. The previous terms used for the disease currently known as ‘aggressive periodontitis’ include ‘localized juvenile periodontitis’ (Fig. 1) and ‘generalized juvenile periodontitis’ (Figs 2 and 3), and these older diagnoses were also used in the search of the available literature. The World Health Organization (98) and the Panamerican Health Organization databases were also explored and a manual search of local journals was performed. In addition, the internet sites of the Ministry of Health from each country were searched for data on oral health issues.

Periodontal disease in Latin American children and adolescents A

C

B

D

E

G

F

H

Fig. 1. Radiographic aspect of a 19-year-old patient with localized aggressive periodontitis. Baseline radiographs of maxillary (A, C) and mandibular (E, G) molars show initial bone levels, and radiographs taken 1 year later demonstrate rapid bone-loss progression of the same maxillary (B, D) and mandibular (F, H) molars.

Literature reviews of periodontal disease in children and adolescents have previously been published in Periodontology 2000 (2, 43). Therefore, we decided to focus on information that was not included in earlier publications (i.e. mainly studies published in the past 10 years). The studies included were preferably of a size sufficient to provide a relatively precise account of periodontal disease distribution in the various countries of Latin America.

Methodological issues Demmer & Papapanou (33) have provided a detailed analysis of methodological issues in the study of

chronic and aggressive periodontitis. The present article highlights some of the important issues in periodontal epidemiology.

Case definition Case definition is one of the most important issues in epidemiology, and periodontal disease epidemiology is no exception. The definition of gingivitis is relatively simple, but the term ‘aggressive periodontitis’ is surrounded by controversy. One challenging issue in the case definition of gingivitis (Fig. 4) is the weight that should be given to gingivitis of little or no clinical significance. If the presence of just one site with bleeding on probing in a dentition is the

35

Botero et al. A

B

C

D

Fig. 2. Clinical (A, B, C) and radiographic (D) appearance of generalized aggressive periodontitis in a 16-year-old woman.

cut-off point for the definition of gingivitis, the prevalence of gingivitis is practically 100% in all age groups, including children and adolescents. If assessing more clinically relevant gingivitis, the high prevalence figures for gingivitis decrease considerably. It is also a matter of debate whether untreated severe gingivitis is indeed a necessary prerequisite for chronic or aggressive periodontitis (previously known as juvenile periodontitis, prepubertal periodontitis and early-onset periodontitis). A recent review in Periodontology 2000 concludes that although unique clinical features may exist for some types of aggressive periodontitis, the clinical difference between aggressive periodontitis and chronic periodontitis is not always discernable (7). Also, the microbiology, the inflammatory response and the outcome of treatment may not differ significantly between patients with chronic periodontits and those with aggressive periodontitis (7, 8, 32, 35, 89). The diagnosis of ulcerative necrotizing periodontal diseases, on the other hand, can be reliably made based on distinct clinical signs. The thresholds of clinical parameters used to define the extent and severity of periodontal disease are also fraught with uncertainty. Probing depths, clinical attachment loss, radiographic bone level and even tooth loss have been used to define degrees of periodontal disease, but the use of any single clinical parameter is associated with low diagnostic sensitivity. A combination of parameters, such as probing

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depth and clinical attachment loss, increases the probability of obtaining an accurate measure of the periodontal disease status. However, a change in cut-off points and in the number of affected sites can result in a very different case definition and prevalence rate of periodontal disease (29, 53, 75). Case definition is an important topic in adult periodontitis, but is not commonly considered in adolescents (4) and is rarely considered in children. Another problem of studying periodontal disease in young subjects is the lack of periodontal clinical recordings from dental visits at an early age. Difficult child behavior in response to the inherent discomfort of a periodontal examination can complicate data collection. In addition, assessment of periodontal conditions in children can be difficult as a result of the ongoing maturation of the dento–epithelial junction, a high position of the gingival margin (which may interfere with identification of the cemento–enamel junction and its distance from the alveolar bone), altered passive tooth eruption, the presence of a mixed dentition and exfoliation of deciduous teeth.

Periodontal indices Periodontal indices have been developed to study the epidemiology of periodontal diseases (Table 1). However, these indices can differ significantly in their estimation of disease prevalence because of differences

Periodontal disease in Latin American children and adolescents A

B

A

B

Fig. 4. Mild gingivitis in a 6-year-old male patient (A) and in an 8-year-old female patient (B). Gingival inflammation and plaque accumulation are present in the mandibular anterior teeth.

Fig. 3. Clinical (A) and radiographic (B) aspects of a 30-year-old man with generalized aggressive periodontitis. The patient was otherwise healthy and presented with advanced periodontal attachment and bone loss. Microbial analysis revealed a subgingival microbiota composed of Porphyromonas gingivalis (2.2 3 105 colony-forming units/ml), Fusobacterium spp. (1.5 3 105 colony-forming units/ml), Prevotella intermedia (2.9 3 106 colony-forming units/ ml), Tannerella forsythia (9 3 104 colony-forming units/ml), Campylobacter spp. (1.6 3 105 colony-forming units/ml) and Eikenella corrodens (1.1 3 105 colony-forming units/ml).

in case definition and the method of measuring periodontal disease. The use of partial mouth indices can lead to overestimation or underestimation of disease prevalence. A recent study of adolescents in Brazil showed that partial-mouth examination protocols may underestimate periodontal disease and suggested that examination of at least two diagonal quadrants may be necessary to quantify periodontal disease in adolescents and young adults (77). The Papillary, Marginal, Attached Index was originally designed for the examination of children, and although this index includes a score of periodontal pockets, the severity and extent of more severe disease is not calculated, and the index is highly subjective. The Periodontal Disease Index was developed by Ramfjord (81) to measure periodontal disease, but this index can potentially over- or underestimate disease severity because only selected teeth are examined, and clinical attachment loss tends to be underestimated because of recordings that fall inside the set ranges of the index. Other periodontal indices and their diagnostic proficiencies are presented in Table 1. The most serious deficiency of periodontal indices is their focus on past periodontal destruction rather than on current or future disease activity. Even gingival bleeding on probing, which is a sign of more

37

Botero et al.

Table 1. Indices used to measure periodontal disease in epidemiological studies Index Authors (year) (reference)

Description

Extension

Considerations

Papillary Marginal Attached Gingiva Index Schour & Massler (1950) (57)

P0: normal; no inflammation

Partial mouth

Extensive, only selected teeth are assessed Mainly visible examination

Schour & Massler (1947) (100)

P2: obvious increase in size of gingival papilla; bleeding on pressure

Full mouth

Composite index, which takes into consideration changes caused by gingivitis and periodontitis. The major disadvantage is that it does not consider the degree of periodontal destruction (clinical attachment loss)

P1: mild papillary engorgement; slight increase in size

P3: excessive increase in size of gingival papilla with spontaneous bleeding P4: necrotic papilla P5: atrophy and loss of papilla (through inflammation) M0: normal; no inflammation visible M1: engorgement; slight increase in size; no bleeding M2: obvious engorgement; bleeding on pressure M3: swollen collar; spontaneous bleeding; beginning of infiltration into attached gingiva M4: necrotic gingivitis M5: recession of the free marginal gingiva below the cemento–enamel junction as a result of inflammatory changes A0: normal, pale rose; stippled A1: slight engorgement with loss of stippling; change in color may or may not be present A2: obvious engorgement of attached gingiva with marked increase in redness; pocket formation present A3: advanced periodontitis; deep pockets evident Periodontal Index Russell (1956) (86)

0: negative. Neither overt inflammation nor loss of function caused by the destruction of supporting tissue is noted 1: mild gingivitis. Overt inflammation in the free gingiva is present but does not circumscribe the tooth 2: gingivitis. Inflammation surrounds the tooth, but there is no apparent break in the epithelial attachment. 4: used only when radiographs are available. Early bone loss is noticeable 6: gingivitis with pocket formation. The epithelial attachment of gingiva to tooth is broken. There is no interference with normal function. The tooth is not loose or drifting 8: advanced destruction with loss of function. The tooth may be loose or drifting. It may sound dull on percussion and may be depressible in the socket

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Periodontal disease in Latin American children and adolescents

Table 1. (Continued) Index Authors (year) (reference)

Description

Periodontal Disease Index 0: normal gingiva; absence of clinical inflammation Ramfjord (1959) (81) and bleeding

Extension

Considerations

Partial mouth

Although it measures clinical attachment loss, the values between the ranges are underestimated. When index teeth are severely affected this could lead to overestimation

1: slight to moderate gingivitis in some areas around the tooth 2: slight to moderate gingivitis around the tooth 3: intense gingivitis; ulceration; bleeding 4: clinical attachment loss 6 mm Gingival Index 0: normal gingiva; absence of clinical inflammation ̈ Loe & Silness (1963) (48) and bleeding 1: slight inflammation; absence of bleeding 2: moderate inflammation; swelling; redness; bleeding on probing 3: intense inflammation; swelling; morphologic changes; spontaneous bleeding

Partial mouth

It does not consider periodontal destruction. Underestimation and overestimation could occur. Not designed for children and young adults (6 mm

Six sites per tooth, excluding third molars Mean probing depth = sum of all measurements/ number of teeth 9 6

Mean clinical attachment loss

Six sites per tooth excluding third molars Mean clinical attachment loss = sum of all measurements/number of teeth 9 6

serious disease, has not always been included in periodontal indices. The best available periodontal indices employ full-mouth examination with recording of

probing depths, clinical attachment levels and bleeding-on-probing sites. Radiographic analysis would be helpful, but may be impractical, or even unethical, in

39

Botero et al.

large epidemiological studies. Contemporary studies only request a radiographic examination if indicated by the clinical information and therefore radiographic epidemiological data are scarce. The Community Periodontal Index of Treatment Needs and the later variant, named the Community Periodontal Index, are perhaps the periodontal indices most commonly utilized in epidemiological studies (1). These two indices were designed for population-based studies and are easy to use, but have several disadvantages. For instance, only six teeth are examined in children and youngsters under 20 years of age. This was proposed to avoid mislabeling a deep sulcus, resulting from an erupting tooth, as periodontal disease. Only gingival bleeding and calculus are recorded in young individuals, which may lead to underestimation of the destructive types of disease. This was illustrated in the study of Benigeri et al. (10), who found that a tooth with a pocket depth of ≥6 mm was detected in 8.5% of adults if only two sites were examined per tooth. However, the percentage of teeth with a pocket depth of ≥6 mm increased to 21.4% if probing was performed in all surfaces of every tooth. The partial recording system resulted in underestimation of the prevalence of subjects having at least one tooth with Community Periodontal Index of Treatment Needs periodontitis scores of 3 and 4. Despite the criticism of the Community Periodontal Index of Treatment Needs index, especially with

regard to treatment needs, the index has been used in numerous epidemiological studies. The World Health Organization no longer supports the treatment-need part of the index and now also measures attachment loss instead of periodontal pocket depth. The lack of uniformity between the two World Health Organization indices can complicate the process of data analysis.

Language, availability and local relevance of scientific papers Language, availability and local relevance of scientific papers are issues in Latin America, where a large proportion of articles are written in Spanish or Portuguese and are published in local journals or websites (i.e. that of the Ministry of Health). Articles not written in English may provide important information but are not readily accessible to researchers outside the region and hence are not frequently cited. Local studies may also show methodological deficiencies, which must be considered when interpreting the published results.

Periodontal disease in Brazil Brazil is the largest country (8,514,877 km2) in Latin America, with a population of more than 190 million and with almost 240,000 dentists (Fig. 5). Brazil is also

Fig. 5. Map showing demographic information and number of dentists in Latin American Countries. Disparity in the number of dentists available for the population is evident among the countries (99).

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the Latin American country with the greatest number of studies of periodontal disease occurrence (Table 2). However, large heterogeneity in periodontal case definition and great disparity among populations from various regions of the country make it virtually impossible to merge data from different studies. The 2004 nationwide representative survey of 15to 19-year-old individuals found, using Community Periodontal Index estimates, that 46.2% exhibited gingival health, 18.8% exhibited gingival bleeding and 33.4% exhibited supragingival calculus; regardless, periodontal pockets of ≥4 mm were present in fewer than 2% of the study individuals (59). Nicolau et al. (66), Antunes et al. (5), Biazevic et al. (11) and Freire et al. (36) found gingival bleeding and dental calculus in approximately 20% of children and adolescents, but virtually no pockets of ≥4 mm. However, Maltz & Barbachan e Silva (54), Maltz et al. (55), Feldens et al. (34) and Rebelo et al. (82), who also used the Community Periodontal Index estimates, demonstrated gingivitis in more than 90% of Brazilian children and adolescents, and 15–35% exhibited bleeding gingiva. Nogueira dos Santos et al. (67) found calculus in approximately 50% of young subjects. A higher prevalence of periodontal breakdown has been reported in large studies with full-mouth periodontal examination. Cortelli et al. (26), demonstrated, in the south-east region of Brazil, a prevalence of 3.7% for generalized aggressive periodontitis and a prevalence of 1.7% for localized aggressive periodontitis. Susin & Albandar (92) found a prevalence of 2.1% for aggressive periodontitis and a prevalence of 18% for chronic periodontitis in 14- to 19-year-old subjects. Susin et al. (91) demonstrated gingival recession in almost 30% of 14- to 19-year-old subjects. A radiographic-based study, performed by Guimaraes et al. (41) in 2- to 11-year-old children, found definite bone loss in fewer than 1% and questionable bone loss in approximately 10% of subjects. A retrospective longitudinal study based on bitewing radiograph examination of 3- to 10-year-old subjects with no obvious signs of periodontitis initially found that periodontal bone loss increased with age, and the presence of tooth surfaces with either caries or restorations increased the probability of bone loss (97). Two smaller studies of riverside isolated communities found clinical attachment loss of ≥3 mm in 100% of the individuals (24) and aggressive periodontitis in approximately 10% (25). One, 52-month longitudinal study of untreated children and adolescents

observed an increasing number of periodontal sites of ≥4 mm and a 34% increase in alveolar bone loss (28). Some peculiarities have been published on periodontal diseases in children and adolescents from Brazil. A nationwide epidemiological study of 16,126 adolescents, 15–19 years of age, found that 35.6% had experienced dental and gingival pain in the past 6 months (14). Significant associations were observed between dental and gingival pain and female gender, low income, nonstudents and students enrolled in public schools with grades that were low for the age group (14). Also, a higher prevalence of oral pain was associated with higher prevalences of dental caries and calculus (14). A study of HIV-infected children, 0–14 years of age, revealed that only 12.5% of subjects were plaque-free and that 58.9% showed gingivitis, with an average of 4.4 bleeding sites (84). A study in southern Brazil found a high level of gingivitis in children with cerebral palsy, which was probably related to poor oralhygiene habits (40). A microbiological study of aggressive and chronic periodontitis found that the occurrence of periodontopathic bacteria was similar to that reported in other countries (27). Interestingly, the level of periodontitis in adolescents was positively related to the presence of leukotoxic Aggregatibacter actinomycetemcomitans strains (27). A genetic study identified a positive association between aggressive periodontitis and two markers – rs1935881 and rs1342913 – in the FAM5C gene (19). In sum, the studies from Brazil point to increasingly severe periodontal disease in subjects with heavy accumulations of plaque and calculus and of low socio-economic status.

Periodontal disease in Argentina Argentina is the second-largest country in South America and has a population of over 40 million (Fig. 5). An epidemiological study of 2,279 children, 7–8 and 12–13 years of age, was carried out in eight different regions of Argentina (30) (Table 3). In the 7– 8 years’ age group, the prevalence of marked gingivitis was 2.7%, compared with the 12–13 years’ age group, in which the prevalence was 27.2%. The author also compared the prevalence of gingivitis between two populations of different ethnic origins and found that native Americans were more affected compared with Caucasians (24.7% versus 15.4%, respectively) (30).

41

Botero et al.

Table 2. Studies of periodontal disease in children and adolescents in Brazil Male/Female Age ratio (years)

Clinical findings

Maltz & 1,000 students Barbachan e from public Silva (2001) and private (54) schools

447/553

Representative sample. Full-mouth Gingival Bleeding Gingival Bleeding Index Index. Prevalence of gingival was higher in students bleeding in public and private from public schools schools: 98.1% and 95.7%, respectively. Extension of Gingival Bleeding Index (mean Gingival Bleeding Index) in public and private schools: 21.7% and 14.7%, respectively

Maltz et al. (2001) (55)

Not available 8–10

Full-mouth Gingival Bleeding Index. Mean Gingival Bleeding Index in 1975: 24.5%. Mean Gingival Bleeding Index in 1996: 35.5%

244/356

The presence of Full-mouth periodontal periodontal destruction examination and radiographic was higher in female examination. Prevalence of localized aggressive periodontitis: students than in male students (P < 0.05) 1.66%. Prevalence of generalized aggressive periodontitis: 3.66%. Prevalence of incipient periodontitis: 14.3%

Authors (year) (reference)

Number of subjects

233 students examined in 1975 and 185 students examined in 1996

Cortelli et al. 600 individuals (2002) (26) from the region of Vale do Paraıba

12

15–25

Nicolau et al. 652 adolescents Not available 13 (2003) (66)

Susin et al. (2004) (91)

42

266 individuals 133/130 from a representative sample of the metropolitan area of Porto Alegre

14–19

Remarks

Two school-based cross-sectional surveys performed in the same school, with different children, in 1975 and 1996. A significant increase (P = 0.001) was observed in average Gingival Bleeding Index

311 families were Full-mouth gingival bleeding interviewed and early (Community Periodontal Index life-course experiences score 1). Worst score in each (such as being born in tooth considered. Prevalence of a family with a low gingival bleeding: 99%. Severity of gingival bleeding – individuals socio-economic status, presently living in an with 2 mm was 3.0% and in no subjects did measurements exceed 3 mm

After studying dentistry for 2 years the prevalence of gingivitis was similar but the severity was lower. Periodontal condition was not substantially modified

Moreno & Esper (2003) (63)

394

227/167

14–18

Clinical attachment loss of 1 mm= 38.9% and of 2 mm=7.4%

Minimal clinical attachment loss was observed and in no case exceeded 2 mm

Barletta et al. (2006) (9)

149

57.6%/42.4%

14–15

67.7% with Gingival Index score = 1 13.4% with Gingival Index score = 2

Gingival Index was used. No signs of periodontitis were observed. None of the subjects presented a Gingival Index score of 3. However, 32.8% of subjects had gingival bleeding

group was almost free of gingival inflammation (Community Periodontal Index score 0 = 91.7%); the 10- to 14-year’ age group still presented high figures of health (Community Periodontal Index score 0 = 83.3%), despite the fact that 10.3% presented with gingivitis and 6.4% with calculus; and the 15- to 19-year’ age group revealed periodontal health in only half of the subjects, with 18.7% presenting with gingivitis, 15.9% with calculus, and, although 1.2% had pockets of 4–5 mm, only 0.2% showed pockets of >6 mm (88). Two studies assessed gingival inflammation in a sample of 6 mm was very low 15–19 Community Periodontal Index score 0 = 64.1%

25,764

7.8% presented marginal bone loss

Remarks

Bitewing radiographs were used to assess marginal bone loss. Incipient marginal bone loss was observed at an early age

No periodontal probe was used; a visual examination was performed. The prevalence of gingivitis increased with age

6–9

Community Periodontal Index score 1 = 18.7% Community Periodontal Index score 2 = 15.9% Community Periodontal Index score 3 = 1.1% Community Periodontal Index score 4 = 0.2%

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Botero et al.

Table 4. (Continued) Authors (year) (reference)

Number Male/Female Age Clinical findings of (% or (years) subjects number)

Remarks

Taboada & Talavera (2011) (94)

77

Papillary Marginal Attached Gingival Index was used. Gingivitis starts at an early age and was associated with poor plaque control. O’Leary plaque index was 75.4%

51.9%/ 48.1%

4–5

Gingival inflammation 39%

PDI, periodontal disease index.

Needs (83). Deep periodontal pockets, as defined by the Community Periodontal Index of Treatment Needs, were observed in 1% of the 7- to 12-year-old individuals (83). Of the 15- to 19-year-old subjects, 31.4% exhibited localized attachment loss and 1.4% generalized attachment loss (83). Clinical attachment loss in 15- to 19-year-old subjects was slight (1– 2.9 mm) in 31%, moderate (3–4 mm) in 1.7% and severe (>5 mm) in 0.1%, according to the Extent and Severity Index (76). No attachment loss was seen in 67.3% of the study subjects. mez-Restrepo et al. (39), in a large random samGo ple of 14- to 17-year-old individuals, found clinical attachment loss of ≥1 mm in 40.6% of subjects, of ≥2 mm in 29.9% and of ≥3 mm in 16.0%, and attachment loss was greater in male subjects than in female subjects (P < 0.05). Interproximal attachment loss of ≥1 mm, ≥2 mm and ≥3 mm was, respectively, 34.2%, 21.4% and 11.7% (39). Orozco et al. (72) found that in 7- to 14-year-old subjects from a native island community, 45.4% had a Community Periodontal Index of Treatment Needs score of 1, 40.9% had a score of 2 and 13.7% had a score of 3. In the 15- to 19-year old subjects, a Community Periodontal Index of Treatment Needs score of ≥2 was observed in 77.8% of subjects and a Community Periodontal Index of Treatment Needs score of 4 was found in 11.1% (72). These results point to increased severity of periodontal disease in communities with low access to professional dental care. However, in another native community from the southeast of Colombia, Triana et al. (95) found a lower need for treatment (Community Periodontal Index of Treatment Needs score 0 = 59.7%, score 1 = 30.5% and score 2 = 9.7%) in children 7–12 years of age. nez et al. (44) Between 1965 and 2000, Jime described children and adolescents with acute necrotizing ulcerative gingivitis (n = 29), necrotizing ulcerative periodontitis (n = 7) and noma/cancrum oris (n = 9). The individuals were not infected with HIV, but virtually all presented with predisposing condi-

48

tions such as acute herpetic gingivostomatitis, measles and leukemia. Low socio-economic status, malnutrition and poor oral hygiene habits were identified as contributory factors. Microbiological examination of noma lesions identified gram-negative bacteria, Neisseria species, fusiform bacilli, Leptotrichia buccalis and fungi. Periodontal data from Venezuela are scarce. Navaz et al. (65) found a prevalence of gingivitis of 40–60% in children 6–9 years of age, and this high prevalence was associated with unfavorable attitudes and low educational level of the parents. Another study (12) found that necrotizing ulcerative gingivitis was more prevalent (32,44%) in the 15–20 age group than adults and it was associated with previous history of gingivitis and poor oral hygiene.

Periodontal disease in Chile Large population studies have been conducted in pez et al. (50) reported a Chile (Table 6). In 1991, Lo prevalence of aggressive periodontitis of 0.32% in 2500 adolescents, 15–19 years of age. Another large study of 9,163 individuals, of 12–21 years of age, found that clinical attachment loss of ≥1 mm occurred in 69.2% of the study subjects, of ≥2 mm in 16.0% and of ≥3 mm occurred in 4.5% (51). Interproximal clinical attachment loss of ≥1 mm was observed in 56.4% of the study subjects, of ≥2 mm in 13.1% and of ≥3 mm in 3.7% (51). The mean number of periodontal sites with clinical attachment loss of ≥1 mm ranged from 4.3 to 6.6, with clinical attachment loss of ≥2 mm in 2.6–4.3 sites and of ≥3 mm in 1.5–4.0 sites (51). Clinical attachment loss was positively associated with infrequent tooth brushing, dental visits 5 mm in 15- to 19-year-old subjects: 1%

Large-scale oral health survey. Gingivitis was highly prevalent. Community Periodontal Index of Treatment Needs and Extent and Severity Index. Periodontal pockets were only observed with increasing age

Colombia

Orozco et al. (2004) (72)

40

Not available

7–19

65% of subjects with Community Periodontal Index of Treatment Needs score of > 1, and complex periodontal treatment needs in 11.1% of those subjects

More than half of the sample required some type of periodontal treatment

Colombia

Triana et al. (2005) (95)

82

Not available

7–12

30.5% with Community Periodontal Index of Treatment Needs score of 1 and 9.7% with Community Periodontal Index of Treatment Needs score of 2

Better oral health conditions in this population compared with Oral Health National Survey data

Colombia

nez et al. Jime (2005) (44)

45

Not available

2–26

Necrotizing ulcerative gingivitis: 29 subjects (64.4%). Necrotizing ulcerative periodontitis: 7 (15.6%). Noma: 9 (20%)

Not a population-based study. Reflects socioeconomic and hygiene conditions associated with necrotizing periodontal diseases such as necrotizing ulcerative gingivitis and necrotizing ulcerative periodontitis. Patients with no HIV infection, in contrast with other reports

Colombia

mezGo Restrepo et al. (2008) (39)

629

49.8%/ 50.2%

14–17

The prevalence of clinical attachment loss ≥1 mm was 40.6%; of ≥2 mm was 29.9%; and of ≥3 mm was 16%

Students randomly selected from public schools of low and medium socio-economic levels. Male gender was associated with a higher probability of having clinical attachment loss, using a logistic regression model

Venezuela

Navaz et al. (2002) (65)

132

Not available

6–9

40–60% presented with a gingival index of 1

Gingivitis was frequently associated with the unfavorable attitudes and low educational level of the parents

49

Botero et al.

Table 6. Studies of periodontal disease in children and adolescents in Chile Authors (year) (reference)

Number of subjects

Male/Female (% or number)

Age (years)

Clinical findings

Remarks

pez (1991) (50) Lo

2,500

52.7%/47.3%

15–19

Aggressive periodontitis 0.32%

After initial screening, 27 subjects were suspected as having aggressive periodontitis. Only in eight was this confirmed by clinical and radiographic examinations

pez et al. Lo (2001) (51)

9,163

4,652/4,510

12–21

Overall clinical attachment loss of ≥1 mm was observed in 69.2% of the students, clinical attachment loss of ≥2 mm was observed in 16% and clinical attachment loss of ≥3 mm was observed in 4.5%. Interproximal clinical attachment loss of ≥1 mm was observed in 56.4% of the students, interproximal clinical attachment loss of ≥2 mm was observed in 13.1% and interproximal clinical attachment loss of ≥3 mm was observed in 3.7%. Mean number of sites with clinical attachment loss of ≥1 mm = 4.3–6.6; with clinical attachment loss of ≥2 mm = 2.6–4.3; and with clinical attachment loss of ≥3 mm = 1.5–4.0

Overall, clinical attachment loss was highly frequent in adolescents. Nonetheless, more extensive clinical attachment loss of ≥4 mm was less frequent ( 90% in same age groups) in the rural population (58). Periodontal pockets of >5 mm were not found in children, but were a common finding in adults over 30 years of age. The national study of oral health in Panama (37) ̈ included 3,763 children of 6–19 years of age. The Loe and Silness Gingival Index revealed that slight gingival inflammation (Gingival Index = 0.63–0.73) was present in 55.0% of the young population. Three studies from Cuba (78–80), of 2- to 12-year-old children, found a prevalence of gingivitis of 20–52% and a relationship between gingivitis and poor nutritional condition. In the Dominican Republic, Collins et al. (22) examined the periodontal status of 12- to 21-year-old subjects. Gingivitis was detected in 39% of the subjects (22). Clinical attachment loss of ≥1 mm was present in 49.5%, of ≥2 mm in 15.0% and of ≥3 mm in

4.0% of the subjects (22). Interproximal attachment loss of ≥1 mm occurred in 33.6%, of ≥2 mm in 10.9% and of ≥3 mm in 3.5% of the subjects (22).

Periodontal disease in Bolivia, Ecuador, Paraguay and Uruguay In 1995, The Panamerican Health Organization and the World Health Organization examined the oral health situation in Bolivia (69). In children 6–15 years of age, 39% revealed slight gingival inflammation and 34% moderate gingival inflammation. Only 27% were essentially free of gingival inflammation (69) (Table 8). The National Study in Oral Health in Ecuador (60) reported a prevalence range of 30–44% for gingivitis in children 6–12 years of age. Gingivitis was more prevalent (44%) in the 10–11 years’ age group and lower in the 12 years’ age group (30%), which may indicate a tendency for reduced periodontal disease with increasing age in early puberty (60) (Table 8). The National Survey of Oral Health in Paraguay found that 54.5% of 12- to 15-year-old subjects were periodontally healthy, 38.8% showed slight gingivitis and 6.7% revealed both gingivitis and calculus (61) (Table 8). A study from Uruguay (15) found one patient (1%) with localized aggressive periodontitis in a small sample of 11- to 18-year-old subjects. Another study (3) in Uruguay in 76 HIV infected children found a prevalence of 75% for gingivitis and 0.7% for necrotizing ulcerative gingivitis.

Concluding remarks and future perspectives This review shows that inflammatory periodontal diseases are prevalent in children and adolescents in Latin America. Gingivitis affects 34.7% of young Latin American individuals (Fig. 6), with the highest prevalences found in Colombia (77%) and Bolivia (73%) and the lowest prevalence in Mexico (23%). The prevalence of gingivitis ranged from 31 to 56% in the

51

Botero et al.

Table 7. Studies of periodontal disease in children and adolescents in Nicaragua, Panama, Cuba and the Dominican Republic Country


Number of subjects

Nicaragua

Medina et al. 1,080 (2007) (58)

Male/Female Age (% or number (years)

Clinical findings

Remarks

50%/50%

Urban

The Community Periodontal Index of Treatment Needs index was used. Rural areas presented more periodontal disease and were associated with household income. The presence of gingivitis and depth of periodontal pockets increased with age

5–15

12 years of age: 77% gingivitis 15 years of age: 68.5% gingivitis >5 mm pockets 0% Rural 12 years of age: 96.5% gingivitis 15 years of age: 97.5% gingivitis >5 mm pockets 0%

Panama

lvez et al. Total number of Ga Not available (2008) (37) subjects = 10,063: pez et al. 3,763 were children Lo (2010) (49) and adolescents

6–11 12 13–18 19

Gingivitis 55.9%. Gingival Index: 0.66 in 6- to 11-year-old subjects; 0.72 in 12-year-old subjects; 0.71 in 13- to 18-yearold subjects; and 0.73 in 19-year-old subjects

National oral health survey with a representative sample. Gingival Index was used. Slight gingival inflammation was prevalent and increased with age

Cuba

~ onez Quin 230 et al. (2004) (78)

Not available

2–5

Gingivitis 20%

Gingivitis was associated with poor nutritional condition

Cuba

~ onez Quin 52 et al. (2006) (79)

Not available

5–12

Gingivitis 52%


Cuba

~ onez Quin 400 et al. (2008) (80)

Not available

2–5

Gingivitis 52%


952/1,021

12–21

Oral health survey. Overall, 49.5% of the students examined had Logistic regression model revealed that at least one site with clinical attachment loss only age significantly increased the of ≥1 mm; clinical probability of having attachment loss was clinical attachment ≥2 mm in 15% and loss ≥3 mm in 4.0% of the students. 33.6% of students had interproximal clinical attachment loss of ≥1 mm; 10.9% had interproximal clinical attachment loss of ≥2 mm and 3.5% had interproximal clinical attachment loss of ≥3 mm

Dominican Collins et al. 1,963 Republic (2005) (22)

52


Table 8. Studies of periodontal disease in children and adolescents in Bolivia, Ecuador, Paraguay and Uruguay Country


Number of subjects

Male/Female (% or number)

Age (years)

Bolivia

Ocampo & Baez (1997) (69)

2,410

Not available

6–15

Clinical findings

Remarks

Community Periodontal Index score 0 = 27%

Representative sample. The Community Periodontal Index was used and increased with age in all locations. Gingivitis and, in general, poor oral health was associated with lack of preventive programs

Community Periodontal Index score 1 = 39% Community Periodontal Index score 2 = 34% Ecuador

Paraguay

Ministerio de Salud Publica (1988) (60)

Ministerio de Salud (2008) (61)

2,757

1,442

Not available

Not available

6–7

Gingivitis 39%

8–9

Gingivitis 42%

10–11

Gingivitis 44%

12

Gingivitis 30%

Information regarding pockets was not considered because the periodontal examination process was not explained in the article

Community Periodontal Index score 0 = 54.5%

National Oral health survey. Gingivitis was highly prevalent

12–15

Community Periodontal Index score 1 = 38.8% Community Periodontal Index score 2 = 6.7 Uruguay

Campi et al. (1996) (15)

100

Not available

Fig. 6. Adjusted prevalence estimate of gingivitis in Latin America. The adjusted prevalence was calculated by including the total number of subjects and the number of subjects with gingivitis from at least one representative study in each country. The dotted vertical line indicates the adjusted prevalence of gingivitis in Latin American countries (34.7%; 95% CI, 34.4–35.1). The box given for each country represents the mean prevalence and is relative in size according to the number of subjects included. Horizontal bars and ticks represent the minimum and maximum prevalence reported in the studies included. Boxes without horizontal bars are the results from only one national health study from a specific country.

11–18

Aggressive periodontitis 1%

After initial screening, just one case was compatible with the characteristics of juvenile periodontitis

remaining countries. Gingivitis needs to be identified and treated in young individuals as it poses a risk for development of periodontitis when such individuals become adults (47, 87). The average rate of periodontitis in the young population in Latin America was