EARLY CHILDHOOD CARIES

ECC, EARLY CHILDHOOD CARIES

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2. Early childhood caries Dr. Nabeela Basha Seminar – 14 2

3. Contents: Introduction Definition Classification Development stages of ECC Prevalence of ECC Etiological risk factors for development of ECC Management & Prevention of ECC Barriers in ECC Conclusion Previous year questions References 3

4. INTRODUCTION Caries in the early stages of life is an unsolved enigma for most of us around the world. Despite the fact that it is largely preventable, dental caries is the most common chronic disease of childhood. In 1862, an American physician, Abraham Jacobi, was the first to describe the clinical appearance of early childhood caries, which he observed in one of his own children. 4

5. Dr. Ellias Fass , 1962 – 1st published comprehensive description of caries in infants and termed as “ Nursing bottle caries”. In 1978, the American Academy of Pedodontics released “Nursing Bottle Caries”, a joint statement with the American Academy of Pediatrics, to address a severe form of caries associated with bottle usage. Initial policy recommendations were limited to feeding habits, concluding that nursing bottle caries could be avoided if bottle feedings were discontinued soon after the first birthday. 5

6. Over the next 2 decades, however, recognizing that this distinctive clinical presentation was not consistently associated with poor feeding practices and that caries was an infectious disease, AAPD adopted the term “early childhood caries” (ECC) to reflect better multifactorial etiology. In 1985 the term “baby bottle tooth decay" was proposed by Healthy Mothers-Healthy Babies Coalition as an alternative which would be more appropriate for patient acceptance and would focus attention on potential damage of using a nursing bottle. 6

7. IN 1994, CONFERENCE AT THE CENTRES FOR DISEASE CONTROL AND PREVENTION “EARLY CHILDHOOD CARIES” The link between bottle habits and caries was not absolute. The finding that sleeping with a bottle of milk or other sweetened beverages does not always cause caries. Surveys from China, Thailand and Tanzania where feeding with baby bottles is rare, show high caries rate in primary maxillary incisors, a pattern that is generally assumed to be due to bottle feeding practices. 7

8. Children who are 4-5 years old (bottle use discontinued) develop caries in the maxillary anterior teeth. Potential cariogenicity of the most common bottle contents - milk & milk formulas – remains unclear. 8

9. TERMINOLOGIES – Labial Caries (L.C.) Caries Of The Incisors Rampant Caries (R.C.) Infancy Caries Nursing Bottle Caries (N.B.C.) Nursing Caries (N.C.) Baby Bottle Tooth Decay (BBTD) Maxillary Anterior Caries (MAC) Early Childhood Caries (ECC) Early Childhood Dental Decay Severe Early Childhood Caries (S-ECC) 9

10. Rampant caries Acute, Widespread, Rapid All ages Primary + permanent dentition Mandibular incisors Etiology : Multifactorial Treatment : Pulp therapy Prevention : Dental health education Nursing caries Specific form of RC Age – infants, toddlers Primary dentition Max incisors - molars Bottle feeding, Pacifiers dipped in honey, At will breast feeding Topical Fluorides, Maintenance of teeth Dental health education 10

11. DEFINITIONS Davies (1998) : Complex disease involving maxillary primary incisors within a month after eruption and spreading rapidly to other primary teeth is called childhood caries. The American Academy of Pediatric Dentistry (2002) : ECC is 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 of age or younger. 11

12. In children younger than 3 years of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC). From ages 3 through 5, 1 or more cavitated , missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces constitutes S-ECC. 12

13. CLASSIFICATIONS Rule (1982): Occlusal, posterior proximal, anterior proximal, Facial and lingual Caries analysis system (Douglass et al 1994): Fissure pattern Maxillary anterior pattern Posterior proximal pattern Posterior bucco -lingual smooth pattern 13

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15. DEVELOPMENTAL STAGES OF ECC

16. PREVALENCE OF ECC Despite the decline in the prevalence of dental caries in children in western countries, caries in preschool children remains a major problem in both developed and developing countries. Congiu G (2014) et al suggest that in most developed countries the prevalence rate of ECC is between 1 and 12%. 16

17. In less developed countries and among the disadvantaged groups in the developed countries, the prevalence has been reported to be as high as 70%. ECC has been found to be more prevalent in low socioeconomic groups. The prevalence ranged from 11.4% in Sweden to 7–19.0% in Italy. A high prevalence of ECC has been reported in some Middle Eastern countries, such as Palestine (76%) and the United Arab Emirates (83%). 17

18. In a systematic review, Ismail and Sohn found that the prevalence varied from 2.1% in Sweden to 85.5% in rural Chinese children. The national prevalence of ECC in the USA can be estimated between 3 and 6%, which is consistent with the prevalence in other western countries. Ramos-Gomez FJ et al (2002), the highest prevalence of ECC was found in the 3- to 4-year-old age group and that boys were significantly more affected than girls, aged between 8 months and 7 years. 18

19. The national surveys from some countries, such as Greece (36%), Brazil (45.8%), India (51.9%), and Israel (64.7%), showed inconsistent prevalence of ECC. Prevalence of dental caries in Indian children below 5 years: 19 Year Place Prevalence 1987 Bangalore 66.3% 1992 West Bengal 25.5% 1996 Udupi 65.5% 1997 Chandigarh 19.4% 2003 Kerala 12%

20. ETIOLOGICAL RISK FACTORS 20 PRIMARY Dental plaque Mutans Streptococci Infant feeding patterns Tooth brushing Salivary factors Sugars Oral Clearance of carbohydrates Bovine milk Human milk Fluorides SECONDARY Tooth maturation and defects Race and ethnicity Acid fruit drink Socioeconomic status Dental knowledge Stress Other factors

21. Dental plaque: Besides modulation of the oral flora, the acquired pellicle has functions such as lubrication, protection from acid attack, prevention of crystal growth on enamel surface and a role in remineralization. In the absence of fermentable carbohydrates – organic acids like acetate, propionate & butyrate are produced; presence – lactate – pH drop in plaque 21

22. Mutans streptococci: Streptococcus mutans (SM) and Streptococcus sobrinus are the most common microorganisms associated with ECC. Lactobacilli also participate in the development of caries lesions and play an important role in lesion progression, but not its initiation. Milgrom et al (2000), found that children having a high SM levels were five times more prone to have dental caries. The major source of acquiring the SM is from the mother during first 12–24 months. 22

23. Window of Infectivity: S. mutans  are spread from mothers to their infants during a discrete window of infectivity. This period is believed to be during the time that teeth are erupting, from seven or eight months until 36 months, with the median age being 36 months (Caufield, Cutter, & Dasanayake , 1993; Li & Caulfield, 1995). Second window of infectivity in permanent teeth :6-12 years 23

24. Infant feeding patterns: Reports suggest that putting a child to bed with a baby bottle is a widespread behavior, seen in 18-85% parents. Although the use of bottle is predominant in children with ECC, it is still not the sole factor. Length of contact with the bottle at night time is also important. Greater length of bottle contact appears to be positively associated with caries. 24

25. Furthermore, children who are exclusively breastfed also appear to be susceptible to caries. This suggests that the role of bottle in caries development is not as clear as previously thought and further research is required. 25

26. Tooth brushing: As early childhood caries starts on surface that can be easily accessed by routine tooth brushing, oral hygiene levels may be associated with caries risk. Increased frequency and better oral hygiene levels are associated with low caries levels in preschool children. 26

27. A major problem confronting the investigation of the relationship between tooth brushing and ECC is the methodological issue of assessing the frequency of brushing, quality of plaque removal, and actual levels of oral hygiene. 27

28. Salivary factors: Saliva provides the main host defense systems against dental caries. It has major roles in the clearance of foods and the buffering of acid generated by dental plaque. 28

29. Sugars: Sucrose, glucose and fructose found in fruit juices and Vitamin C drinks as well as in solids are the main sugars associated with infant caries. Increased frequency and total time the sugar is in the mouth, increases the potential for enamel demineralization and there is in inadequate time for remineralization by saliva. 29

30. Oral Clearance of Carbohydrates: In infants with ECC, the sleep time consumption of sugars is another common characteristic. The low salivary flow during sleep decreases oral clearance of the sugars and increases the length of contact time between the plaque and the substrate. 30

31. Bovine milk: Why milk may be less cariogenic than other sugar containing liquids? Phosphoproteins inhibit enamel dissolution Antibacterial factors in milk interfere with oral microbial flora. Cariogenic bacteria may not be utilize lactose for energy source as readily as sucrose. 31

32. Human milk: Compared to bovine milk, human breast milk has a lower mineral content, higher concentration of lactose (7% vs 3%), and less protein (1.2 g vs 3.3 g per 100 ml), but these differences are probably insignificant in terms of cariogenicity . However, the relationship between breastfeeding and dental caries is likely to be complex, and confounded by biological variables such as mutans streptococci infection, intake of sugars, and social variables which may affect behavior related to health. 32

33. Fluorides: Although the benefits of water fluoridation and postnatal fluoride supplementation in the primary dentition are well-known, there is minimal information on the cariostatic effects of topical fluoride in the early primary dentition, particularly in the prevention of ECC. The topical effects of fluoride are complex, and include changes on the mineral phases, as well as the modulation of metabolic effects on mutans streptococci and other bacteria in dental plaque. 33

34. Tooth maturation and defects: Tooth is most susceptible to caries in the period immediately after eruption and prior to maturation. Thus, in many infants, a combination of recently erupted immature enamel in an environment of cariogenic flora with frequent ingestion of fermentable carbohydrates would render the tooth particularly susceptible to caries. 34

35. Race, Ethnicity and Socioeconomic status: Children living in ethnic areas demonstrate an extremely high rate of ECC, ranging from 70-80%, despite efforts to educate parents to reduce baby bottle use. ECC is so pervasive among these children that parents consider it a normal childhood disease that affects all children. Social class may influence caries risk in several ways. 35

36. Dental Knowledge: Important variable in the etiology of ECC because understanding the relationship between the microbiology of caries, the role of cariogenic foods, and use of baby bottle is necessary for prevention of ECC. Stress: One of the underlying mechanisms that could account for the effects of social class on oral health status is the increased stress experienced by families with financial and social instability related to lower SES. 36

37. Consequences of ECC Higher risk of new carious lesion in both primary and permanent dentition Hospitalization and emergency room visits Increased treatment cost and time Insufficient physical development (especially in height and weight) Lack of adequate nutrition due to early loss of teeth 37

38. Loss of school days and restricted activity Diminished ability to learn Diminished health related quality of life In older children with rampant caries, low self esteem. 38

39. COMPLICATIONS OF ECC Effect on nutrition & weight: ECC inhibit adequate nutrition – affecting growth of the body, specifically weight. Acs (1992) – effect of nursing caries on body weight 8.7% - children with nursing caries weighed less than 80% of ideal weight. Ayhan (1996) – effect of height & body weight 126 children, aged 3-5 years, mean height fell between 25- 50 th %, 7.1% weighed less than ideal weight 39

40. Psychological problems: Decreased appetite and depression Poor behavior in school & self esteem 40

41. PREVENTION OF ECC 41

42. RAPIDD SCALE: The Readiness Assessment of Parents concerning Infant Dental Decay (RAPIDD) Scale was developed to assess a parent’s stage of change precontemplative , contemplative, or action with regard to his/her child’s dental health. This instrument based on the work by Prochaska and DiClemente , measures pro and con parental beliefs about caring for their child’s teeth. Parents in precontemplative stage show low openness and low health score compared to those in action stage. 42

43. It consists of 38-items with responses on five-point scale ranging from strongly agree to strongly disagree. The patient or primary caretaker was instructed to select a box under one of the five categories after the interviewer read them the question in their native language. Each of the 38-items were placed into one of the four contructs : 1. Openness to health information 2. Valuing dental health 43

44. 3. Convenience and change difficulty 4. Child permissiveness Once a particular stage of change has been established, the counselor then determines the best approach to move into next stage. 44

45. COMMUNITY BASED EDUCATION The goal of education is to increase knowledge of mothers about ECC, and to improve the dietary and nutritional habits of infants and mothers. The expectant mother should be monitored for dental problems during pregnancy and given the appropriate prevention recommendations before the birth of her baby. 45

46. PREVENTION OF TRANSMISSION OF CARIOGENIC BACTERIA: There is evidence that cariogenic bacteria are transmitted from mothers to their infants. Genotypes of mutans streptococci in infants appeared identical to those of the mothers in 71% of mother-infant pairs. 46

47. A nonrandomized study divided mothers who had atleast 10 6 mutans streptococci per mm of saliva into test and control groups. The test program included provision of dental education, oral hygiene instructions, dental treatment, tooth cleaning, application of 2% NaF , Fluoride varnish. This program was started when the child was 3 to 8 months of age and continued until they reached the age of 3 years. 47

48. On re-examination, it was found that children whose mothers were in the experimental group had a DMFT of 5.2, which was much lower as compared to the DMFT of control group, which was 8.6. 48

49. PROFESSIONAL AND HOME-BASED PREVENTIVE APPROACHES 49

50. Professional treatment for ECC ranges from Diet counseling to the prosthodontic rehabilitation of patient. The application of casein phosphor peptide (CPP) could stabilize the calcium and phosphate thereby preserving them in an amorphous or soluble form known as amorphous calcium phosphate (ACP). Calcium and phosphate are essential components of enamel and dentine and form highly insoluble complexes in the presence of CPP. 50

51. 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 ( Hedayati-Hajikand et al 2015; Jorgensen MR et al 2016). 51

52. Restorative Strategies for ECC: Once ECC is under control, comprehensive restorative treatment can be carried out. Restorative strategies are as follows: Extensive cavitation with no pulpal involvement : Anterior teeth Acid etched composite resin restoration. Pedo strip crowns. Glass ionomer cement restoration. 52

53. Posterior teeth: Posterior composite resin restoration. Glass ionomer cement restoration. Stainless steel crowns. Extensive cavitation with pulpal involvement : Pulpotomy or pulpectomy. Extraction. Space maintainers. 53

54. Fluorides are very effective in preventing dental caries, including fluoride toothpaste, water fluoridation, fluoride mouth rinse, and professional topical fluoride application, primarily by inhibiting mineral loss from the tooth. The use of fluoride is done according to the level of fluoride in the water. 54

55. BARRIERS IN EARLY CHILDHOOD CARIES Any proposal to improve social, mental and physical health of children cannot be successful without adequate funding, political leadership and support. Some of the potential barriers in providing optimum care for children are: Lack of involvement and commitment from dental and other health organizations. 55

56. The dental community lacks a shared vision of the definition of the problem, how to prevent it and who is responsible for planning and implementation. There is no integrated plan to fight the social, economic and nutritional issues faced by people in low SES group. Dental health is not a priority of most programs and insurance packages. 56

57. POLICY STATEMENT To decrease the risk of developing ECC, the AAPD encourages professional and at-home preventive measures that include: Reducing the parent’s/sibling(s)’ MS levels to decrease transmission of cariogenic bacteria. Minimizing saliva-sharing activities ( eg , sharing utensils) to decrease the transmission of cariogenic bacteria. 57

58. 3. Implementing oral hygiene measures no later than the time of eruption of the first primary tooth. Toothbrushing should be performed for children by a parent twice daily, using a soft toothbrush of age-appropriate size. In children considered at moderate or high caries risk under the age of 2, a ‘smear’ of fluoridated toothpaste should be used. In all children ages 2 to 5, a ‘pea-size’ amount should be used. 58

59. 4. Avoiding high frequency consumption of liquids and/or solid foods containing sugar. In particular: • Sugar-containing beverages ( eg , juices, soft drinks, sweetened tea, milk with sugar added) in a baby bottle. Infants should not be put to sleep with a bottle filled with milk or liquids containing sugars. • Ad libitum breast-feeding should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates are introduced. 59

60. Parents should be encouraged to have infants drink from a cup as they approach their first birthday. Infants should be weaned from the bottle between 12 to 18 months of age. 5. Working with medical providers to ensure all infants and toddlers have access to dental screenings, counseling, and preventive procedures. 60

61. CONCLUSION ECC is a chronic, infectious disease affecting young children, and constitutes a serious public health problem. It has a debilitating effect on the development, speech, general health and self-esteem of infants. 61

62. Dental problems in early childhood have been shown to be predictive of not only future dental problems but also on growth and cognitive development. The critical change needed to accomplish in the prevention of ECC is to expand our network to include other health professionals, community leaders, national organizations serving children. 62

63. PREVIOUS YEAR QUESTIONS Baby bottle tooth decay. [R.G.U.H.S M.D.S. Degree Examination – April/May 2007 – 10marks] Early Childhood Caries and its management. [R.G.U.H.S M.D.S. Degree Examination – May 2009 – 10marks] Describe the Epidemiology of Early Childhood Caries. [R.G.U.H.S M.D.S. Degree Examination – May 2011 – 20marks] 63

64. REFERENCES Nikhil Marwah . Textbook of Pediatric Dentistry. Third Edition. Jaypee Brothers Medical Publishers (P) Ltd., 2014. Shobha Tandon. Textbook of Pedodontics . Paras Medical Publisher, 2009. Arathi Rao. Principles and Practice of Pedodontics . Rao Publisher, Motilal (UK) Books of India, 2006. Damle , S. G. Textbook of Pediatric Dentistry. New Delhi: Arya (MEDI) Publishing House, 2002. 64

65. Anil S and Anand PS (2017) Early Childhood Caries: Prevalence, Risk Factors, and Prevention. Front Pediatr . 5:157. Drury TF, Horowitz AM, Ismail AI, et al. Diagnosing and reporting early childhood caries for research purposes. J Public Health Dent 1999;59(3):192-7. Wyne A. Prevalence and risk factors of nursing caries in Adelaide, South Australia. Pediatr Dent (1999) 9:31–6. Tinanoff N.: Critique of evolving methods for caries risk assessment. J. Dent. Education. 1995; 59(10): 980-985. 65