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Early childhood caries

Presented by: Deepak Thakur

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Early childhood caries

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Contents

• Definition• Terminologies• epidemiology• Classification• Developmental stages of ECC• Primary etiological risk factor• Secondary etiological risk factor• Prevention of ECC

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Definition

AAPD:The disease of early childhood caries is the presence of one or more decayed,missing,or filled tooth surfaces in any primary tooth in a child 71 months of age or younger.

In children younger than 3 years of age,any sign of smooth surfaces caries is indicative of severe early childhood caries.from ages 3 through 5 ,one or more cavitated,missing or filled smooth surfaces in primary maxillary anterior teeth or decayed,missing,or filled score of >4(age3),>5(age4),or >6(age 5) surfaces constitutes S-ECC.

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Terminologies for early childhood caries

• Nursing caries: Winter(1966)• Tooth clearing neglect: Moss(1996)• Infant and early childhood dental decay:

Horowitz(1998)• Early childhood caries: Davies(1998)• MDSMD: Maternally derived streptococcus

mutans disease.

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Epidemiology

• United states 24.7 percent • 58.6 percent of all 5 to 17 years old.Poor and minority children:70 percentIn philippines:ECC is at least 1 in 4(25%)of 5 to 6

years old.According to who: southeast asia,south

asia,eastern mediterranian region and developing countries,dental decay is important cause of disablity in 5 to 6 years old.

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classification

• Classification of ECC by wayneType 1 •Mild to moderate

•Existence of isolated carious lesion involving molars and incisors•Number of carious teeth increases as cariogenic challenge persists•Cause is usually a combination of cariogenic semisolid food and lack of oral hygiene.•Seen in 2-5 years old.

Type 2 Moderate to severeLabiolingual carious lesion affecting maxillary incisorsMandibular incisors are not affectedUse of feeding bottle or at will breastfeeding or a combination of both with or without poor oral hygieneSeen soon after eruption of teeth

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ClassificationType 3 Severe

Carious lesion affecting all the teeth including lower incisorsCause is cariogenic food and poor oral hygieneCondition is rampant

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Developmental stages

Stage Clinical features Age FeaturesI Initial reversible stage 10-18months Cervically and occasionally interproximal

areas of chalky white demineralization.No pain.

II Damaged carious stage 18-24months Lesion in maxillary anterior teeth,may spread to dentin and show yellowish brown discoloration.Pain on having cold food.

III Deep lesion 24-36months Depending on time of eruption,cariogenicity of sweetner and frequency of its use this stage can reach in 10-14months also.Molars are also affectedFrequent complaint of painPulpal involvement in maxillary incisors

IV Traumatic stage 36-48months Teeth becomes so weakenedReport of history of traumaMolars associated with pulpal problemsMaxillary incisors become non vital.

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Etiological factors

Primary• Pathogenic microorganism• Substrate(Fermentable carbohydrate)• Host• Time

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Pathogenic microorganism

• Streptococcus mutans• Transmitted to the infant’s mouth primarily

through mother.(vertical transmission)• Considered more virulent• It is seen that a child’s infection is nine times

greater when maternal salivary count is greater than 100,000 colony forming units per ml.

• It is more common in rapid and smooth surface caries and less common in pit and fissure caries.

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Substrate(Fermentable carbohydrate)

• Carbohydrates are utilized by microorganisms to form dextrans which

Adhere organisms to tooth surface Cause organic acid to demineralize the tooth.

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Host

• Teeth acts as a host for microorganisms.• Hypomineralized or hypoplasia of the teeth

increases the susceptibility of the child to caries.

• Thin enamel in the primary teeth is one of the reasons for early spread of lesions.

• Developmental grooves act as the plaque retentive areas.

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Time

• It is an important factor that determines caries activity.

• More the time child sleeps with bottle in the mouth,higher is the risk of caries.

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Secondary etiological factor

• Immunological factors• Tooth maturation and defects• Race and Ethnicity• Acid fruit drink• Socioeconomic status• Dental knowledge

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Immunological factors

• Host immune mechanisms include specific immune factors derived from saliva(sIgA) or serum and gingival crevicular fluid(IgG)

• IgA inhibit bacterial adherence or agglutination,as well as neutralization of bacterial enzymes.

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Tooth maturation and defects

• Tooth is most susceptible to caries in the period immediately after eruption and prior to final maturation.

• In addition, presence of developmental structural defects in enamel may increases the caries risk.

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Race and Ethnicity

• Children living in ethnic areas demonstrate an extremely high rate of Early Childhood Caries.

• Milnes noted that ECC is so pervasive among these children that parents consider it a normal childhood disease that affects all children.

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Acid fruit drink

• Acid in fruit juices and soft drinks may decrease the oral pH.

• This fall in pH enhances the fermentation of carbohydrates and thus cause more profound enamel demineralization..

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Socioeconomic status

• Individuals from lower socioeconomic status experience financial,social and material disadvantages that compromises their ability to care for themselves,obtain professional health care services,and live in a healthy environment,all of which lead to reduced resistance to oral and other disease.

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Nursing bottle caries Definition:condition attributable to frequent prolonged

contact with bottle containing sweet beverages or milk. Clinical features:• It affects primary teeth in following sequence:a.Maxillary central incisors:b.Maxillary lateral incisors:c.Maxillary first molars:d.Maxillary canine and second molars:e.Mandibular molars:• Mandibular anterior teeth are usually spared because:

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Progression of the lesion• Initially a demineralized dull,white area is seen along the gum line on the labial aspect of maxillary incisors,which is undetected by the parents.

These white lesions become cavities which involve the neck of the tooth in a ring like lesion.

Finally the whole crown of the incisors is destroyed leaving behind brown black root stumps

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Implications

• The child with nursing caries has an increased risk of developing caries even in the permanent dentition.

• The child with caries is also susceptible to other health hazards.

• The treatment may prove to be financial burden for some parents.

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Management

Aims• Management of existing emergency• Arrest and control of the carious process• Institution of preventive procedures• Restoration and rehabilitation

Factors affecting management:• Extent of the lesion• Age of the patient• Behavioral problems

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Treatment

1st visit:• All lesions should be excavated and restored.• Indirect pulp capping or pulp therapy procedures can be

evaluated by further investigation.• If abscess is present it can be treated through drainage.• X-rays are advised to assess the condition of the

succedaneous teeth.• Collection of saliva for determining the salivary flow and

viscosity.• Application of fluoride topically.

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Parent counseling

• Parents should be questioned about child’s feeding habits.

• Should be asked to try weaning the child from using the bottle as a pacifier while in bed.

• Should be instructed to clean the child’s teeth after every feed.

• Adviced to maintain a diet record for 1 week.

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2nd visit• Analysis of diet chart and explanation of the

disease process of the child’s teeth with a simple equation.

• Isolate sugar factors from the diet chart and control sugar exposure by intelligent use.

• Reassess the restoration and redo if needed.• Caries activity tests can be started and repeated at

monthly intervals to monitor success of treatment.

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3rd and subsequent visit:• Restoring all grossly decayed teeth• Endodontic treatment• In case of unrestorable teeth,extractions can

be done followed by space maintenance.• Crowns can be given for grossly decayed or

endodontically treated teeth.• Review and recall after every 3months.

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Prevention

• Early screening for signs of caries development, starting from the first year of life,could identify infants and toddlers showing the risk of developing early childhood caries.

• 3 general approach:Community basedProfessional basedHome based

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Rampant caries

• Massler(1945) defined rampant caries as suddenly appearing widespread ,rapidly spreading,burrowing type of caries,resulting in early involvement of pulp and affecting those teeth,which are usually regarded as immune to decay.

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Nursing vs Rampant caries

• 1.Nature• 2.Age• 3.Characteristic features• 4.Etiology• 5.Treatment• 6.Prevention

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Difference between nursing and rampant caries

type/nature Specific form of rampant caries acute generalized spread of caries & pulpal involvement in selected teeth of dentition.

Acute genaralized spread of caries and pulpal involvement in all teeth.

Age Infants and toddler At any age, both primary and permanent teeth are involved and no specific teeth in particular

etiology Feeding children with milk bottles while the child is lying down or sleeping breast feeding whenever the child asks & at will for prolonged duration of time.Use of pacifier which are coated with honey or any artificial sweeteners to stop baby from crying.it involves only feeding factor.

Frequent intake of sweet sugary & sticky food substitute throughout the day decreasesd water intake through the day & decreases salivary flow.Genetic predilection if seen in parents or family.it is combination of many factor.

Nursing bottle caries Rampant caries

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Continue…Nursing bottle caries Rampant caries

Characteristic features

Specific teeth are involved mandibular incisor are not affected at all(because of constant flow of saliva from submandibular gland & constant cleansing movement of tongue.

No specific teeth are involved.all teeth are equally involved .It can be seen at any age.

Treatment It depends on the stage & time of detection& intervention by parents & dentist .if diagnosed at an early stage fluoride application and parent education is needed.Pulpectomy , pulpotomy & space maintainer are decided based on signs/ symptoms until transition occurs.

It depends on the stage of intervention.Early intervention requires removal of caries and restoration/crowns depending on stage of tooth decay.In case of pulp involvement pulp therapy/root canal treatment is required.

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Age specific prevention of rampant caries

Dentition:0-5 years• Therapy :Toothpaste Fluoride tablets, if in area without water fluoridation Professional topical fluoride application every 6 months • Control: Oral hygiene instructions to parents Toothbrushing with parental supervision 6 month recall

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Age specific prevention

Dentiton 5-12 years• Advice: diet counseling with parents and patients• Therapy: toothpaste fluoride tablets up to 8 years if in area without water fluoridation. mouth rinse professional topical fluoride application every 6 months.

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Age specific prevention

• Control: oral hygiene instructions to patient toothbrushing without parental supervision. sealants 6 months recall permanent dentition: 12 years onwards• Advice: diet counseling with parents and

patients

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Age specific prevention

• Therapy: toothpaste mouth rinse professional topical fluoride application every 6 months• control: oral hygiene instructions to patient toothbrushing interdental cleaning with floss sealants

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References

• Sobha Tondon-Textbook of pedodontics 2nd edition.

• Nikhil Marwah-Textbook of Pediatric Dentistry 3rd edition.

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Thank you