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Faculty of MedicineThe University of PristinaKosovska Mitrovica SECOND YEAR DENTAL STUDENT Unit 17 : Early childhood caries Working week: 06-10.04.2020. Lecturer: Ivana Stojiljkovicyear dental student
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Early childhood caries
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Introduction Primary teeth are also known as milk or deciduous teeth. The 20 primary teeth start to appear in a baby’s mouth around the sixth month and they stay in the mouth until they are gradually replaced by the permanent teeth between the ages of six to twelve years. Primary teeth start to develop from the 6th to 7th week of fetal life from epithelial cells of the mouth that form the tooth buds. The cells of these initial tooth germs continue to differentiate during pregnancy, and, when the baby is born most teeth are already partially formed in the jaws. The primary teeth play an important role in giving facial fullness and aesthetically pleasant facial shapes. Absence of teeth, due to any reason, not only hampers the masticatory activity of the individual, but also affect the facial features to great extent, affecting the concerned person physiologically, emotionally and socially.
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Role/importance of the primary teeth The role of the primary teeth is just as important as the role of the permanent ones. Humans use teeth to tear, grind, and chew food in the first step of digestion. Teeth also play a role in human speech. Additionally, teeth also provide structural support to muscles in the face and form the human smile and other facial expressions. So, broadly the main functions of the teeth can be summarized as follows: role in mastication (helps eating), aids in articulation and speech, role in aesthetics (gives shape and beauty to the face). One of the main functions of teeth is the mastication of the food. The first step of digestion involves the mouth and teeth. Each type of tooth serves a different function in the chewing process. Depending on the shape, teeth enable cutting, grinding, chewing and preparing food for swallow and further digestion in the digestive tract. The Incisors cut foods when you bite into them. The sharper and longer canines tear food, while the wider molars grind the food.
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Dental caries — Definition, etiology and epidemiology Dental caries is one of the most prevalent diseases in children worldwide. The Center for Disease Control and Prevention reports that dental caries is perhaps the most prevalent infectious diseases in children. Dental caries is five times more common than asthma and seven times more common than hay fever in children. Dental caries is pathological destruction of tooth hard tissue with progressive effluence. Initially it appears in enamel, the dentin is involved after that, and later the pulp and the periodontium, with the possibility of complications that will affect the general health. The consequences of caries may be numerous, ranging from the morphological changes to functional ones, e.g. complete crown destruction (early childhood caries), chewing difficulties, speech impediments, digestive tract disorders, odentogenic focal points
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Etiology Dental caries is a disease that is not caused by one factor. If only one factor would cause this disease, its prevention would have been much easier and more controllable. Many studies like clinical studies, but mostly longitudinal epidemiological studies, show convincing evidence for a multi-factorial nature of this disease. Numerous factors affecting the appearance of caries act team-wise and not separately, make caries pathogenesis very complex but also hinder the possibility to undertake effective preventive measures. There are several important factors that make up the dental caries etiological circle. Host respectively tooth, dental plaque respectively bacteria, and substrate respectively saliva carbohydrates, all in co-operation with the time factor, are vicious chain of dental caries development.
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The hard tooth structure, the enamel, is the forefront part that undergoes the demineralization process, respectively caries. The development of caries in enamel surface as much as it is affected by the internal structure of the hard tissue build of the tooth, equally, perhaps even more it depends on the strength of external factors affect. Sometimes for various reasons: local, general or even hereditary, tooth structure can be so poorly mineralized, that it would need a very small amount of external factors to cause dental caries. There are some important factors that comprise the etiological circles of the dental caries: host or the tooth, dental or bacterial plaque, substrate – carbohydrates and saliva, and altogether co-react with the time factor. The hard dental structures, initially the enamel, undergo the demineralization process, respectively the caries.
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The caries development in the enamel surface is equally dependent from the inner hard dental structure and from the intensity of the extrinsic factors’ action. The newest concept in dentistry explains the cause of dental caries as a consequence of disruption of "Caries Balance". Dr. John Featherstone introduced the concept of the Caries Balance in 2002. The theory of “Caries Balance” defines dental caries as a disease of hard dental tissues, and the destruction of the enamel surface as a result of the disruption of the balance of demineralization and remineralization. This misbalance may be manifested in the beginning of demineralization or during the process of remineralization. The defect in the enamel surface is a result of the domination of the demineralization process and such process has progressive course directed towards pulpar space. Which process will dominate depends on the proportions of the factors that constitute “Caries Balance”, i.e. protective and pathological factors.
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The balance disorder will be manifested with early demineralization process or eventually with remineralization process. This concept is that dental caries can be viewed as a balance of healthy or protective factors (factor of remineralization), and disease or pathogenic factors (factor of demineralization). Cavities are caused by an imbalance between risk factors for the disease and protective factors. Pathological factors (risk factors) are: acid-producing bacteria, frequent eating/drinking of fermentable carbohydrates, sub-normal saliva flow and "function". Protective factors are: saliva flow and its components; fluoride, calcium, phosphate remineralization; antibacterials (chlorhexidine, xylitol), etc.
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Early childhood caries (ECC), formerly known as baby bottle tooth decay, is a disease that affects teeth in children aged between birth and 5years. ECC affects infants and preschool children worldwide. Even though it is largely a preventable condition, ECC remains one of the most common childhood diseases. The major contributing factors for the for the high prevalence of ECC are improper feeding practices, familial socioeconomic background, lack of parental education, and lack of access to dental care.
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Early childhood caries (ECC) has been on the increase in many countries and has become a significant health problem especially in socially disadvantaged populations. ECC is defined as the presence of one or more decayed, missing, or filled tooth surfaces in any primary tooth in a child at 71 months of age or younger. It has several unique characteristics in clinical appearance such as rapid development of caries, which affects a number of teeth soon after they emerge in oral cavity. These lesions involve tooth surfaces that are less prone to caries development. Several terminologies were used to describe the condition such as, nursing bottle caries, nursing caries, rampant caries, baby bottle caries, baby bottle tooth decay, milk bottle syndrome, and prolonged nursing habit caries.
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ECC is associated with other health problems, ranging from local pain, infections, abscesses, leading to difficulty in chewing, malnutrition, gastrointestinal disorders, and difficulty in sleeping. The etiology of ECC is multifactorial and is mainly attributed to a time-specific interaction of microorganisms with sugars on a tooth surface. Diet and feeding practices also play an important role in acquisition of the infection and development of caries. Factors such as high sugar intake, lack of oral hygiene, lack of fluoride exposure, and enamel defects are some of the major factors responsible for the development of ECC . Dietary practices also play a significant role in the development of ECC especially if it contains high levels of fermentable carbohydrates; the child is at higher risk for dental caries
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Environmental Factors Lack of good oral hygiene practices promotes the development of ECC. Children should begin receiving oral hygiene care upon the eruption of the first primary tooth. Children from low socioeconomic status are two times more likely to have dental caries than from higher income strata. Caregivers’ social status, poverty, ethnicity, deprivation, number of years of education, and dental insurance coverage are other factors which influence the oral hygiene habits of children and the severity of ECC.
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Early childhood caries has been shown to be a very common, bacterial infection. It happens when liquids and foods that contain sugar, like milk and juice, are left in your child’s mouth for many hours. Bacteria love sugar and use it to make acids that, overtime, destroy your child’s teeth. Remember, baby teeth are very important for speaking and chewing. If early childhood caries causes your child to lose teeth too early, your child’s permanent teeth may come in crooked or crowded. By following these suggestions today, you can help your child start a lifetime of good dental habits.
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The main bacteria responsible for dental caries are Streptococcus mutans and Lactobacillus.
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There is also evidence that supports those who are in lower socioeconomic populations are at greater risk of developing Early childhood caries. CLINICAL PRESENTATION ECC is a form of early, moderate and late dental decay that affects the primary teeth of infants and toddlers. It develops on tooth surfaces that are usually at low risk for caries, such as the labial surfaces of maxillary incisors and lingual and buccal surfaces of maxillary and mandibular molars. ECC initially presents as dull white or brown spots on maxillary incisors along the gingival margin, which progresses to a complete destruction of the crown, leading to root stumps. In moderate stage, the caries begins to spread to the maxillary molars. In the severe stage, the caries process destroys the maxillary teeth and spreads to the mandibular molars. Based on the clinical appearance, attempts were made to classify the ECC
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Severe early childhood caries (S-ECC) refers to children with ‘atypical,’ ‘progressive,’ ‘acute,’ or ‘rampant’ pattern of dental caries. A child with ECC may suffer from considerable pain, which may lead to difficulty in eating and talking. If the extent of the damage results in extraction of the anterior teeth by age 2 or 3 years, the child may suffer further developmental delays involving speech articulation and patterns. The consequences are delay in physical development due to poor nutrition and the pain and discomfort may compromise their desire to eat. The pain and suffering associated with the caries affect the child’s oral health quality of life.
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Classification based on the stage of development of the dentition and severity of dental caries (initial and cavitated) was proposed by Veerkamp and Weerheijm. This system assumes that dental caries occurs in successive stages starting late in the first year (10 months) and ending in the fourth year of life (48 months). The four stages were referred to as: initial, damaged, deep lesions, and traumatic. During each stage, a different group of teeth are involved, and dental caries can range from enamel demineralization (opaque white demineralization) to cavitation involving enamel and dentine. Author Wynne 1999, classifies early childhood caries into three types: Type I (moderately easy) - usually involves two upper central incisors. Type II (moderate, severe) - includes incisors, first molar, canine, and does not include the lower incisors. Type III (widespread, severe) - including the mandibular incisors.
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Preventive measures: Early childhood caries preventive strategies should begin with prenatal education of expectant parent(s), progress through the prenatal period, and continue with the mother and infant. Adequate dental treatment and oral hygiene measures during pregnancy can reduce or delay ECC in infants. Parents also should be advised to maintain optimal dental health during pre- and postnatal periods . Measures should be taken in educating parent/caregiver about the etiology and prevention of ECC. Nurses are also in a position to carry out prevention efforts for infants, toddlers, and their families and can provide counseling and support for children who suffer from ECC.
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A recently published multilevel conceptual model, incorporating influences of ECC exerted at the individual, family, and community level suggests that both social and behavioral change is important in the prevention of this oral disease. Use of probiotics chewable tables or supplements also showed some evidence in controlling the caries in children. However, its effectiveness to prevent ECC is still under investigation. Many parents do not realize that nutritious food and drinks such as milk, formula, breast milk, and fruit juice have naturally occurring sugars that contribute to the decay process. When children go tobed with a bottle containing milk for example, liquid sits in the child’s mouth for an extended period creating a perfect environment for bacteria. You can’t stop feeding your child nutritious food, but you can regulate when and how often your child is exposed to “sugar hits.” Limit between meal snacking and if a bottle is needed, use only water at nap/bed time.
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Clinical diagnostic criteria of Early Childhood Caries (ECC) Due to the early appearance, typical localization, rapid destruction of the hard tissue of tooth, early childhood caries is a specific form of primary tooth decay. Childhood caries appears in caries resistant regions, such as: labial surfaces of the upper incisors, in the upper and lower molars, more rarely in the upper canine, and even less or not at all in the lower canine and incisors. In addition, during bottle-feeding with sugar-containing drinks, the upper incisors bathe in these sugar-containing drinks but the saliva from minor salivary glands in the area of these teeth has only limited remineralising properties, whereas the lower incisors remain largely protected by the tongue during bottle-feeding.
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Below are some criteria’s for defining early childhood caries : involvement of one or more maxillary incisors, without the involvement of mandibular incisors; a white or black spot in the labial surface of the maxillary frontal teeth; one or more carious lesions in maxillary incisors, along gingival margin; carious lesions in labial-buccal surfaces at one or more maxillar incisors; two or more maxillar incisors.
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Clinical course of ECC In order to explain the clinical course of ECC, we propose the following stages in the occurrence and progression of carious lesions in ECC: ECCi (initial stage), ECCc (circular stage), ECCd (destructive stage) and ECCr (radix relicta stage). ECCi (initial stage)—white spot lesion or initial defect in enamel of cervix. ECCc (circular stage)—lesion in the dentin and circular distribution of this lesion proximally. ECCd (destructive stage)—destruction of more than half the crown without affecting the incisal edge ECCr (radix relicta stage)—total destruction of the crown.
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Conclusion ECC is a chronic, infectious disease affecting young children, and constitutes a serious public health problem. It is one of the most common preventable diseases and is on the rise worldwide. ECC is a multifactorial disease consequent to the interaction of cariogenic microorganisms, exposure to carbohydrates, inappropriate feeding practices, and a range of social variables. It can affect a child’s well-being, learning ability, and quality of life. This virulent form of dental caries begins soon after dental eruption mainly on the smooth surfaces of the teeth, which progress at a rapid state. It has a lasting detrimental impact on the dentition. The associated pain from dental caries has a negative impact on children’s emotional status, sleep patterns, and ability to learn or perform their usual activities.
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A wide range of risk factors are associated with ECC in children from underprivileged and low socioeconomic status. Oral health has been recognized as an essential component of general health and quality of life. Hence both oral disease prevention and oral health promotion should be included as an integral part of chronic disease prevention and general health promotion programs. The literature contains a variety of other terms used to describe early childhood caries and its diagnostic criteria. Most of them relate to the use of a feeding bottle or prolonged breastfeeding (feeding bottle tooth decay, feeding bottle syndrome, nursing caries, nursing bottle mouth, and so on). The authors wish to highlight the danger of excessive drinking from a baby bottle, if it contains sweetened liquids, or prolonged on-demand breastfeeding (Schroth et al. 2007).
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Stay safe and sound! Lecturer : Ivana Stojiljkovic (ivana.mitov@gmail.com)