Early Childhood Caries

Mary Bove ND

Early Childhood Caries

• Defined as 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 preschool-age child between birth and 71 months of age.

http://www.ada.org

Severe Early Childhood Caries (S-ECC)

• Children younger than 3 years of age, any sign of smooth-surface caries is indicative of S-ECC

• Ages 3-5, one or more cavitated, missing (due to caries), or filled smooth sur-faces in primary maxillary anterior teeth or a decayed, missing, or filled score of greater than or equal to four (age 3), greater than or equal to five (age 4), or greater than or equal to six (age 5) surfaces also constitutes S-ECC

Early Childhood Caries

• The biology of ECC may be modified by several factors unique to young children, related to the implantation of cariogenic bacteria, immaturity of the host defense systems, as well as behavioral patterns associated with feeding and oral hygiene in early childhood

• A transmissible infectious disease and which is responsive to preventive strategies

Etiology of ECC • Dental caries is a common chronic infectious

transmisible disease resulting from tooth-adherent specific bacteria, primarily mutans streptococci (MS), that metabolize sugars to produce acid which, over time, demineralizes tooth structure.

Loesche WJ.,Microbiol Rev 1986;50(4):353-80

Etiology of ECC

• ECC is caused by mutans streptococci that

ferment dietary carbohydrates to produce acid attacks on susceptible teeth over a period of time

• Sugared beverages are readily metabolized by MS and lactobacilli into organic acids that can demineralize enamel and dentin

Early Childhood Caries

• Common causative agents are mutans streptococci (MS), including Streptococcus mutans, Streptococcus sobrinus, Streptococcus salivarius, Streptococcus mitis, Streptococcus sanguis

• Lactobacilli also participate in the development of caries playing an important role in lesion progression, but not its initiation

• Salivary gland hypofunction

Etiology of ECC • The major reservoir of MS is the mother, from

whom the child acquires it during a window period of around 2 years of age

• Mothers with dense salivary reservoirs of MS are at high risk of infecting their infants very early in life [Pediatric Dentistry, vol. 28, no. 2, pp. 106–109, 2006.]

• Poor maternal oral hygiene and higher daily frequencies of snacking and sugar exposure increase the likelihood of transmission of the infection from mother to child [Journal of Dental Research, vol. 82, no. 7, pp. 504–508, 2003.]

ECC

• The time span between MS colonization and caries lesion development is approximately 13–16 months

• Prenatal and perinatal malnutrition/under nutrition lead to hypoplasia.

• A consistent association has been reported between enamel hypoplasia and ECC

Cesarean Section vs Vaginal Birth

• Infants delivered by CS acquire S. mutans earlier than vaginally delivered infants

• Vaginal delivery may expose newborns to early protection against S. mutans colonization by exposure to numerous bacteria earlier and with great intensity, affecting the pattern of microbial acquisition

• CS infants have an atypical microbial environment that may increase susceptibility to subsequent early S. mutans colonization

Cows Milk vs Breast milk

• Cow milk is essentially noncariogenic because of its mineral content and low level of lactose

• Human milk promoted the development of smooth-surface caries and was significantly more cariogenic than cow milk*

• Breast feeding and its duration were independently associated with an increased risk for ECC*

*Canadian Journal of Public Health, vol. 91, no. 6, pp. 411–417, 2000.

Caries Process• The presence of a fermentable carbohydrate

(e.g., sucrose, glucose, fructose, cooked starch) and biofilms on the teeth

• Support the metabolism of acidogenic microorganisms, leading to acidic substances

• Hydrogen ions dissolve the carbonated hydroxyapatite crystal lattice of enamel, cementum, and dentin

• Continued demineralization results in cavitation of the tooth enamel surface

ECC and Other Health Issues

• Infants with ECC grow at a slower pace • Young children with ECC may be severely

underweight because of associated pain and their disinclination to eat

• ECC may also be associated with iron deficiency

http://dx.doi.org/10.1155/2011/725320

Standard Dental Treatments• Prevention (People remain susceptible to the

disease throughout their lives)• Fluoride (2x/d brushing fluoridated paste with

eruption of 1st tooth)• Topical Antimicrobial Therapy• Casein Phosphopeptide-Amorphous Calcium

Phosphate (CPP-ACP)• Dental Fluorosis• Restoration or the surgical removal (40%

reoccurrence in 1st year)

Topical Antimicrobial Therapy

• Povidone-iodine has suppressive effects on the oral colonization of MS and prevented dental caries

• Povidone-iodine has strong bactericidal/virucidal effects and demolishes normal flora in the pharynx and the oral cavity, which interfere with pathogenic viral invasion

• Therefore, povidone-iodine should not be routinely used

Pediatric Dentistry, vol. 24, no. 3, pp. 204–206, 2002

Topical Antimicrobial Therapy

• Topical 0.12% chlorhexidine gluconate could significantly reduce MS levels

• Chlorhexidine therapy was much less effective

at reducing the levels of lactobacilli in the human mouth

Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP)

• Shown to reduce demineralization and promote remineralization of carious lesions

• CPP-stabilized amorphous calcium fluoride phosphate had a greater remineralizing effect than fluoride or CPP-ACP individually

• CPP-ACP used as a self-applied topical coating, after the teeth have been brushed with a fluoridated toothpaste

Caries Research, vol. 38, no. 6, pp. 551–556, 2004

Fluoride supplements recommended for preventing caries

• Evidence of effectiveness of supplements in caries prevention in primary teeth is weak

• For permanent teeth daily use of supplements prevented dental caries

• Supplements during the first 6 years of life, and especially during the first 3 years, is associated with an increase in fluorosis

• Fluoride supplement should not be given to infants

http://dx.doi.org/10.1155/2011/725320

AAPD Preventive Measures

Decrease transmission of cariogenic bacteria• Reduce parent/sibling MS levels • Minimizing saliva-sharing activities (eg,

sharing utensils)• Implement oral hygiene measures no later

than the first primary tooth eruption• Brush BID (age-related dose of fluoride

toothpaste)

AAPD Preventive Measures

• Establishing a dental care within six months of eruption of the first tooth and no later than 12 months of age – conduct a caries risk assessment – provide parental education

AAPD Preventive Measures

• Avoiding high frequency consumption of liquids and/or solid foods containing sugar.– sugar-containing beverages (eg, juices, soft drinks,

sweetened tea, milk with sugar added) in a baby bottle or no-spill training cup

– infants should not be put to sleep with a bottle filled with milk or liquids containing sugars

AAPD Preventive Measures

• Avoid ad libitum breast-feeding after the first primary tooth begins to erupt and other dietary carbohydrates are introduced

• Encouraged infants to drink from a cup as they approach their first birthday

• Infants should be weaned from the bottle between 12 to 18 months of age.

Therapeutic Strategies for EEC

• Dysbiosis of the mouth– Oral hygiene– Shift oral microbiota

• Immune System– Oral mucosal tissue– Immature Systemic Host Defense

• Microbiome Challenge– Microbiota Environment of Body

Therapeutic Strategies for EEC

• Improve the intraoral environment• Reduce Mutan Strep species • Shift oral environment to reduce strep and

lactobacilli affects on demineralization• Increase helpful oral strains of microbes• Support immune regulation of oral

environment

Probiotic Streptococcus salivarius strain M18

• Produces bacteriocins targeting the cariogenic species Streptococcus mutans, as well as the enzymes dextranase and urease

• RDBPC study of 100 dental caries-active children for 3 months

• Plaque scores were significantly lower for children in the M18-treated group

• Concluded that S. salivarius M18 can provide oral health benefits when taken regularly

J Med Microbiol (2013 Jun) 62(Pt 6):875-84

Lactobacillus rhamnosus GG

• Has shown antagonism to many bacteria including mutans streptococci

• LGG was found to reduce the risk of caries • Milk containing the probiotic LGG bacteria

may have beneficial effects on children’s dental health and reducing the risk of caries

Caries Res 2001;35:412–420 (DOI: 10.1159/000047484)

Lactobacillus reuteri

• Evaluate the effect on the oral health of 9 year olds after:

• Daily oral supplementation with the probiotic Lactobacillus reuteri, strain ATCC 55730, to mothers during the last month of gestation and to children through the first year of life

• A single-blind, placebo-controlled, multicenter trial of 113 children: 60 in the probiotic and 53 in the placebo group

Caries Res 2014;48:111-117 (DOI: 10.1159/000354412)

Lactobacillus reuteri• Saliva and plaque similar in both groups for

mutans streptococci (MS) and lactobacilli (LB) in saliva and plaque as well as salivary secretory IgA (SIgA)

• Within the limitation of this study it seems that daily supplementation with L. reuteri from birth and during the first year of life is associated with reduced caries prevalence and gingivitis score in the primary dentition at 9 years of age.

S. Karger AG, Basel; Caries Res 2014;48:111-117 (DOI: 10.1159/000354412)

Dietary Phenols

Support the microbiotaInhibit non-beneficial bacteria while having little

effect on beneficial bacteriaAntioxidant activityTannins flavonoids, bioflavonoids, polyphenols,

phenolic acidsFruits, berries, vegetable, herb, spices, cocoa,

red wine, dark chocolateHuffnagle, G,. The Probiotic Revolution, Bantum Books, 2007 pg 274-277

Calcium and ProbioticsAids probiotic bacteria to adhere to the intestinal wallDiscourages harmful bacteria from adhering to the intestinal wallAvoid calcium carbonate Food forms preferred

Huffnagle, G,. The Probiotic Revolution, Bantum Books, 2007 pg 257

Neem tree /Azadirachta indica

• Leaves Bark, and Seed oil• Anti-microbial for many bacteria, virus,

fungus, parasitic organisms, antimalarial• Immunomodulatory, antioxidant • Anti-inflammatory, antiulcer• Traditionally used in the treatment of

inflammation, infections, fever, skin diseases and dental disorders

Neem• Efficacious against caries-inducing

microorganisms • Streptococcus mutans• Streptococcus salivarius• Streptococcus mitis • Streptococcus sanguis

• Neem extract at maximum concentrations showed the maximum zone of inhibition

• Chewing neem sticks can be beneficial in preventing caries

J Contemp Dent Pract (2012 Nov-Dec) 13(6):769-72

Cranberry  Vaccinium macrocarpon

Several compounds isolated from cranberry juice inhibit the attachment of many oral bacteria to the surface of the tooth thus decreasing tooth decay

Cranberry eaten regularly

promotes both gastrointestinal and oral health. 

Oral health benefits of Cranberry• Polyphenols have very promising properties

with respect to cariogenic bacteria• Host inflammatory response • Enzymes that degrade the extracellular matrix • Inhibit acid production, adhesion, and biofilm

formation by Streptococcus mutans. • Glucan-binding proteins, extracellular

enzymes, carbohydrate production, and bacterial hydrophobicity

Crit Rev Food Sci Nutr (2008 Aug) 48(7):672-80, J Can Dent Assoc (2010) 76:a130

Deglycyrrhizinated Licorice Root Extracts (DG-LRE)

• Demonstrates antimicrobial activity against Streptococcus mutans.

• Significantly inhibited biofilm formation by

Streptococcus mutans UA159

Anaerobe (2012 Dec) 18(6):590-6

Licorice Root /Glycyrrhiza glabra

• Glycyrrhizol A has strong antimicrobial activity against cariogenic bacteria

• Two pilot human studies indicate that a brief application of licorice lollipops (twice a day for ten days) led to a marked reduction of cariogenic bacteria in oral cavity among most human subjects tested

Int J Oral Sci (2011 Jan) 3(1):13-20

Licorice Root /Glycyrrhiza glabra

• Licoricidin and licorisoflavan A shown to inhibit oral pathogens– Streptococcus mutans – Streptococcus sobrinus

• Periodontopathogenic species– Porphyromonas gingivalis – Prevotella intermedia

Anti-Cariogenic Essential Oils

• Achillea ligustica-linalool, viridiflorol, beta-pinene, 1,8-cineole and terpinen-4-ol

• Significant adhesion-inhibiting activity against P. gingivalis and S. mutans.– Manuka oil – Tea Tree oil– Eucalyptus oil– Lavandula oil– Romarinus oil

(Fitoterapia (2009 Sep) 80(6):313-9)

Anti-Cariogenic Essential Oils

• Macelignan isolated from Myristica fragrans (nutmeg)- S. mutans, S. sobrinus, S. salivarius, S. sanguis

• Lippia sidoides- thymol (56.7%) and carvacrol (16.7%) – 37 children ages 6-12, – one application of .6-1% solution of EO – significant MS reduction

Phytomedicine (2006 Mar) 13(4):261-6

Phytomedicine (2011 May 15) 18(7):551-6

Anti-Cariogenic Essential Oils

• Cinnamon oil was found to be more effective than clove oil exhibiting broad spectrum of antibacterial activity inhibiting all the ten test bacterial species involved in dental caries.

• Inhibition zone of diameter of 24.0 mm against Streptococcus mutans compared to the clove oil zone of 13.0mm

Acta Biomed (2011 Dec) 82(3):197-9

Anti-Cariogenic Essential Oils

• Other Aromatic Plants which contain thymol and carvacrol include:– Thymus vulgaris– Salvia officinalis– Rosmarinus officinalis– Zingiber officinale – Origanum vulgare

Botanicals impacting SIgA

• Echinacea species• Andrographis paniculata• Astragalus membranaceus• Ulmus fulva• Althaea officinalis• Medicinal Mushroom Species

Nutrients for Intraoral Health

• Folic Acid• Co Q10• Vitamin D • Vitamin C• Vitamin B 2• Vitamin B3 • Vitamin B12• Beta carotene

• Calcium• Phosphorus• Magnesium• Zinc• Iron• Potassium

Xylitol

• A sugar alcohol which has the ability to reduce S. mutans in the mouth– Chewing gum– Mints– Powder– Toothpaste

Early Childhood Caries

• Prevention– Mother– Child

• Diet• Oral Hygiene• Improving the oral microbiome