Early Childhood Caries – An insight

Contents

IntroductionDefinitionEpidemiology and PrevalenceOther namesClassificationEtiology & Risk factorsClinical featuresPreventionConclusionReferences

Introduction

Definitions

• (DeGrauwe et al., 2004).A great variety of definition and diagnosis of ECC is used worldwide, and a clear classification is still to be developed.

• Abid Ismail (1998): ECC is defined as occurrence of any sign of dental caries on the tooth surface during first 3 years of life.

• (Carino et al., 2003).ECC has also been defined as the presence of any dmf teeth, regardless of being anterior or posterior.

Definitions Contd…

• Dury et al (1999): the presence of one or more decayed (non cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months age or younger.

Adopted by AAPD (2000)

Epidemology & Prevalence

• >40% of children get caries before joining KG. (pierce et al 2002)

• While collective oral health , the prevalence from 24% to 28% for 2-5 yr olds. (dye et al)

• England 6.8 – 12% and USA 11-53.1%

Epidemology & Prevalence

• For 8 – 48 mnths old in India – 44% (Joes & King 2003)

• Udupi – 19.44% & Davangere 19.2%

• Among Europe, Africa, Asia, Middle east, North America ……

Epidemology & Prevalence

• Filstrup SL, Briskie 2003

• In USA, ECC is single most common chronic childhood caries.– X 5 common than Asthma– X 7 common than Hay fever– X 14 common than Chronic Bronchitis

Other Names for ECC

• baby bottle tooth decay, • early childhood caries, • early childhood dental decay, • early childhood tooth decay, • comforter caries, • maxillary anterior caries• Tooth Clearing Neglect• MDSMD – Maternal Derived Streptococcus

Mutans Disease.

Classification

Type 1 : Mild to moderate

Type 2 : Moderate to severe

Type 3 : Severe

S - ECC

< 3 years Any sign of smooth surface caries

3 through 5 1 or more cavitated, missing or filled 1° max’ ant’

age 3 dmf ≥ 4

age 4 dmf ≥ 5

age 5 dmf ≥ 6

Etiology & Risk Factors

• 1 Factors

• 2 Factors

Keys Triad (1960)1

° fa

ctor

s

Newburn (1982)modified Keys Triad

1° f

acto

rs

Colonization starts after eruption or before eruption of 1st tooth?(Tanner 2002, Berkowitz 2006)

• Salivary flow rate• Salivary viscosity• Race and ethnicity • Socio economic status• Tooth brushing• Cognitive factors• Dental knowledge• Stress • Birth weight• Chronic illness • Host factors

– Anatomic characteristic of the tooth– Arch form– Presence of dental appliance and restoration– Composition

2 ° F

acto

rs

Risk Factors

The most important are probably– high-frequency intake of sugary snacks – Frequent intake of drinks– sweetened feeding bottles (night)

Prolonged contact of enamel with human milk

Remineralization Demineralization

•Noctunal Breast feeding•↓ nocturnal salivary flow

•↑ lactose in resting saliva•Prolonged contact than day time

• ↑ Demineralzation

Risk

Fac

tors

Nocturnal Breast Feeding

Breast Feeding for over 1year beyond tooth eruption may be associated with ECC (Valaitis et al 2000)

Breast Feeding and ECC

• Children of Low socio-economic status and of illiterate mothers have 32 times more risk than general population (drury et al 1999)

Risk

Fac

tors

Low socio-economic status

Disadvantaged Children

Maternal MS ↑ levels of maternal salivary MS,↑ the risk of infant being colonized.

Risk

Fac

tors

Enamel Hypoplasi

a

Low birthweight / systemic illness @ neonatal

period

Undernutrition / malnutrition

@ perinatal period

ECC

Perinatal Nutrion (Horowitz 1998)

Clinical Features

• Initial Lesion– Chalky white

As the lesion progressess…

• Pattern of involvement follows the sequence eruption of 1° teeth.

• Usually symmetric

• Mand’ incisors, 1° canines, 1° 2nd molars are least involved.

• If mand’ incisors were involved – indicative of Rampant caries or due to inappropriate use of pacifiers. (Ripa 1988, Tinanoff et al 1997)Se

quen

ce o

f inv

olve

men

t

Prevention

3 principal measures to prevent ECC:• 1) Community-based measures• 2) Professional measures and • 3) Home-care measures.

• Water Fluoridation• National educational programs• Community based oral health

education programs

Com

mun

ity b

ased

mea

sure

s

- Wider coverage of population- Lower cost- Reduce inequalities in

children’s oral health

• Parents education

• Diet counseling

• Topical fluoride if needed

• Application of fissure sealants

• Regular recalls

• Motivational Interviewing.

• Preventive dental programs for mothers

• Use of anti-bacterial agents

Prof

essi

onal

car

e

• Elimination of cariogenic food items from the diet

• Substitution with tooth friendly food

• Discouraging bottle feeding at night

• Falling asleep with pacifiers should be stopped

• Digital or baby tooth brushing as the teeth erupts

• Regular visit to dental clinic once in six months.

Hom

e ca

re

Dental Health Education – DHE (in general)

DHE by professionals + Regular home visit

Motivational Interviewing

Fluoride tooth paste

NaF tablets

Counselling + Fluoride varnish applications (twice/yr)

Fall-asleep-pacifier with 0.25mg NaF

CHX varnish

Topical application of 10% Povidone Iodine every 2 months

Probiotic (among 3-4yr old)

Maternal preventive dental health program

Maternal use of Xylitol Gum (compared with CHX & F varnish)

Com

pari

son

of P

reve

ntive

mea

sure

s

AAPD Policy statement – Prevention of ECC

1) Reducing the mother’s/primary caregiver’s/sibling(s) MS levels (ideally during the prenatal period) to decrease transmission of cariogenic bacteria.

2) Minimizing saliva-sharing activities (eg, sharing utensils) between an infant or toddler and his family/cohorts.

3) Implementing oral hygiene measures no later than the time of eruption of the first primary tooth.

• If an infant falls asleep while feeding, the teeth should be cleaned before placing the child in bed.

• Tooth brushing of all dentate children should be performed twice daily with a fluoridated toothpaste and a soft, age-appropriate sized toothbrush. Parents should use a ‘smear’ of toothpaste to brush the teeth of a child less than 2 years of age. For the 2-5 year old, parents should dispense a ‘pea-size’ amount of toothpaste and perform or assist with their child’s tooth brushing.

Comparison of a smear (left) with a pea-sized (right) amount of toothpaste.

AAPD Policy Statement Contd…

4) Establishing a dental home within 6 months of eruption of the first tooth and no later than 12 months of age to conduct a caries risk assessment and provide parental education including anticipatory guidance for prevention of oral diseases.

5) Avoiding caries-promoting feeding behaviors. In particular:• Infants should not be put to sleep with a bottle containing fermentable carbohydrates. • Ad libitum breast-feeding should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates are introduced. • Parents should be encouraged to have infants drink from a cup as they approach their first birthday. Infants should be weaned from the bottle at 12 to 14 months of age. •Repetitive consumption of any liquid containing fermentable carbohydrates from a bottle or no-spill training cup should be avoided. •Between-meal snacks and prolonged exposures to foods and juice or other beverages containing fermentable carbohydrates should be avoided.

Conclusion

References• Policy on Early Childhood Caries (ECC): Classifications,

Consequences, and Preventive Strategies (AAPD revised 2008)

• Guideline on Infant Oral Health Care (AAPD 2009)

• Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment Options (AAPD 2008)

• Topical antimicrobial therapy in the prevention of early childhood caries: a follow-up report (Lydia Lopez, DDS, MPH Robert Berkowitz, DDS Charles Spiekerman, PhD Phillip Weinstein, PhD)

• The High Incidence of Early Childhood Caries in Kindergarten-age Children (Jean-Marc Brodeur, DDS, MSc, PhD Chantal Galarneau, DMD, MSc, PhD) (JODQ 2006)

• Importance of Early Diagnosis of Early Childhood Caries (Souad Msefer, DCD, DSO, Cert. Pedo.) (JODQ 2006)

• Prevention of Early Childhood Caries (ECC) (Daniel Kandelman, DDS, Nabil Ouatik, DMD) (JODQ supplement -2006)

• Pit and Fissure Sealants: An Important Adjunct in the Control of Childhood Caries Charles Dixter, BSc, DDS, Cert. Pedo. Aaron Dudkiewicz, BSc, DDS, Cert. Pedo. Irwin Fried, DDS, MS, Cert. Pedo, FRCD(C)

• Textbook of Pediatric Dentistry: Nikhil Marwah