Early childhood caries

ecc pediatric dentistry

1. Seminar on Early childhood caries Clincal features and Etiology Dr Milind rajan 1 st Mds cids

2. CONTENTS Introduction Definition of ECC (AAPD) Terminology Classification of ECC Clinical features Developmental stages of ECC Aetiology of ECC

3. INTRODUCTION It is considered as one of the most chronic disease that have an adverse effect on young childrens health & still considered as serious public health. ECC can develop immediately after eruption of primary max. incisors. Despite the fact that caries can be prevented in school aged children and youth, there are still a considerable no, of preschool children developing caries including advanced multiple carious lesion. 4 Agarwal V, Nagarajappa R, Keshavappa SB, Lingesha RT. Association of maternal risk factors with early childhood caries in schoolchildren of Moradabad, India. International journal of paediatric dentistry. 2011 Sep;21(5):382-8.

4. This may be result of limited IQ of parents and the failure of dental profession to provide timely and practical anticipatory guidance on caries prevention. It is commonly postulated that ECC is a preventable disease. 5 Twetman S, Dhar V. Evidence of effectiveness of current therapies to prevent and treat early childhood caries. Pediatric dentistry. 2015 May 15;37(3):246-53.

5. Early childhood caries (ECC) is one of the most severe and pandemic form of dental caries affecting almost all sections of the modern world with a global incidence ranging from 3% to 45 %. Biologically, ECC is an infectious process catalysed by the frequent and prolonged exposure of sugars, such as those present in milk, formula, and fruit juice, to the teeth’s surface with the S. mutans being the primary microbiological agent. The children with S-ECC have a higher susceptibility to dental caries in permanent dentition and are likely to be underweight with slower growth. Kumar D, Pandey RK, Agrawal D, Agrawal D. An estimation and evaluation of total antioxidant capacity of saliva in children with severe early childhood caries. International journal of paediatric dentistry. 2011 Nov;21(6):459-64.

6. History Caries in infants and young children have long been recognized as a clinical syndrome . Beltrami characterized this pattern of early caries in young children in the 1930s as les dents noire de tout- petits . In 1962, Dr Elias Fass published the first comprehensive description of caries in infants, which he termed as nursing bottle mouth. The first sentence of his paper begins “Nothing is so shocking to dentist as the examination of child patient suffering from rampant caries,” and this is particularly the thought we get on observing a child with nursing caries. 7

7. Since that first description in 1962 the term nursing bottle mouth has been succeeded by many names but only recently have the original concepts been rethought . In 1994 , conference at the CDC and prevention recommended the use of a less specific term such as early childhood caries (ECC) because it was the consensus of the attendees that the link between bottle habits and caries was not absolute. 8

8. Dental Caries DEFINITION ( SHAFER) Dental caries is an irreversible microbial disease of calcified tissues of the teeth, characterized by demineralization of inorganic portion and destruction of organic substance of tooth, which often leads to cavitation . 10

9. DEFINITION: DAVIES, 1988 A complex disease involving maxillary primary incisors within a month after eruption and spread rapidly to involve other primary teeth . 11

10. Abid Ismail (1998): Early childhood caries (ECC) is defined as occurrence of any sign of dental caries on the tooth surface during first 3 years of life . AAPD: “ the presence of 1 or more decayed ( noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of six”. 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, one 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 Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies. American Academy Of Pediatric Dentistry 2016;37(6):50-52

11. Terminologies used for dental caries in infants and preschoolers DC in infants and toddlers has a unique pattern. Different terms have been used to refer to the presence of dental caries in those <6 years of age. Many of the earlier terms used to describe this condition were related to etiology with the focus on inappropriate infant feeding practisces . Both nursing and bottle feeding . 14

12. Terms used for ECC Baby bottle - fed tooth decay, labial caries, comfortier caries, Maxillary anterior caries, R ampant caries, B aby bottle tooth decay, N ursing bottle caries, B aby bottle caries, sucking up caries B ottle mouth caries. 15

13. TERMINOLOGIES FOR ECC Nursing caries: Winter (1966) Tooth clearing neglect: Moss (1996) Infant and early childhood dental decay: Horowitz (1998) ECC: Davies (1998) MDSMD: Maternally derived Streptococcus mutans disease.

14. Most of them indicate the cause of dental caries in young children is related to feeding practices. Hence the term nursing caries was used by some authors because it designates inappropriate bottle use and nusing practises as the casual factors. However, current terminolgy is is ECC is used to refer the presence of any dental caries in child under the age of 6 17

15. Terminologies Author and Year Definition Nursing caries Winter et al 1966 A unique pattern of dental decay in young children due to prolonged nursing habit Nursing bottle mouth Kroll et al 1967 A syndrome characterized by a severe caries pattern beginning with the maxillary anterior teeth in a healthy bottle –fed infant or toddler. Nursing bottle syndrome Bottle – propping caries Labial caries Comforter caries Shelton et al 1977 A devastating condition that may render young children dentally crippled. Night bottle syndrome Baby bottle caries Nursing mouth Dilley et al 1980 A unique pattern of dental caries in young children Baby bottle mouth Nursing mouth decay Croll , 1984 A very destructive carious process, which can affect infants and toddlers. Nursing bottle caries Tsamtsouris , 1986 Caries caused by a prolonged use of a bottle filled with any liquid other than water. 18

16. 19 Terminologies Author and Year Definition Baby bottle tooth decay Mim kelly et al 1987 A caries caused by bottle feeding only, not by breast feeding Nursing bottle mouth Kroll et al 1967 A syndrome characterized by a severe caries pattern beginning with the maxillary anterior teeth in a healthy bottle –fed infant or toddler. Milk bottle syndrome Infancy caries Soother caries Circular caries Ripa 1988 A specific form of rampant decay of the primary teeth of infants. Tooth cleaning neglect Moss, 1966 Baby bottle decay is renamed to shift the emphasis away from bottle to the need for cleaning RIECDD (Rampant infant and early childhood dental decay) Horowitz 1998 It does not define the age groupaffected by the disease and the usual rapidity of it development.

17. CLINICAL FEATURES ECC in infants and children often begins to affect teeth upon eruption and its clinical pattern can sometimes be rampant. The intial caries lesion appear as ‘white spots’ along the gum line on the labial surface of maxillary central and lateral incisors.( undected by parents and caregivers) spreading later to max. and mand . 1 st molars, max. and mand canines followed by max. and mand . 2 nd molars (the teeth are affected in the order they erup ), whereas the mand . Incisors (not affected). 20

18. The white lesions may become frank lesion or caries within 6-12 months, causing cavities discolured by yellow, brown or even black stains. Finally , the whole crown of incisors is destroyed leaving behind brown black root stumps. 21

19. This unique pattern and unequal severity of the lesions is due to three factors: Chronology of primary tooth eruption. Duration of deletrious habit of feeding Muscular pattern of infant sucking.

20. SEQUENCE OF TEETH INVOLVED DUE TO ECC The intraoral decay pattern of nursing caries is characteristic and pathognomic of the condition. It affects the teeth in following sequence:- Maxillary CI: Facial, lingual, mesial and distal. Maxillary LI: Facial, lingual, mesial and distal. Maxillary 1 st Molars: Facial, lingual, occlusal and proximal. Maxillary canines and second molars: Facial, lingual and proximal. Mandibular molars are usually spared. Later stage ant. teeth are usually spared because of protection by the tongue and cleansing action of saliva. Sublingual gland- duct orifice. 24

21. Classification of ECC

22. TYPES OF DENTAL CARIES IN YOUNG CHILDREN 26

23. Developmental stages of ecc

24. DEVELOPMENTAL STAGES OF EARLY CHILDHOOD CARIES 28

25. 29 Initial reversible stage Damaged carious stage Deep lesion Traumatic stage

26. AETIOLOGY OF ECC

27. Aetiology ECC is multifactorial and has been well establish. The basic mechanism of caries initiation is the same and the caries tetralogy is the key in whole process of ECC as all the 4 variables Pathogenic Microrganism Substrates Host Time. 31

28. Excessive bottle feeding with sugar-containing liquids breastfeeding on demand and night bottle-feeding N ursing beyond the recommended age for weaning genetic predisposition parental education Nutritional. E nvironmental, S ocio-economic Parental lifestyle factors Bhaskar das , murugan satta muthu & jamaluddin mohammed farzan . Comparison of the chemical composition of normal enamel from exfoliated primary teeth and teeth affected with early childhood caries: an in vitro study. International journal of paediatric dentistry 2016; 26: 20–25.

29. ECC- associated microbiome The wide diversity of bacteria in dental caries has been revealed using both culture and molecular microbial methods. Most of the species detected make up a core microbiome , whereas other species in the climax community may be associated with disease. It is likely that several species interact with each other to produce the acidic conditions that promote dental caries.

30. Cultured bacteria formed the basis of the ecological plaque hypothesis applied to dental caries and its modification. Under these models, the biofilm composition changes with the development of carious lesions. As lesions progress, the proportions of acid producing Streptococcus and Actinomyces species increase, followed by acid-tolerant bacteria such as S. mutans and Lactobacillus species.

31. The major bacterial genera detected in ECC include Streptococcus, Lactobacillus , Actinomyces , Bifidobacterium , Propionibacterium , and Scardovia , all of which are Gram-positive bacteria . Many species of Gram-negative bacteria have also been detected, including Campylobacter , Haemophilus , Aggregatibacter , Fusobacterium , Prevotella , Porphyromonas , Capnocytophaga , and Treponema (Spirochetes ) species.

32. However, based on molecular methods, the traditional S. mutans , Lactobacillus Actinomyces , and Bifidobacterium species” appeared to be less important or missing, which suggests that additional species other than S. mutans and Lactobacillus may also be responsible for ECC. In fact, some of these discrepancies resulted from technical differences between methods, resulting in Actinomyces , Bifidobacterium , and Scardovia species being underestimated in molecular studies. Hence, understanding the microbial diversity of ECC requires information from both culture-based and molecular studies

33. Cariogenic pathogens in the bacterial microbiome . Several approaches have been used to isolate potential caries pathogens from the microbial complex. Culture studies for ECC have used acidic (low-pH) isolation media to select aciduric bacteria. Acidic agar (pH of five to 5.2) suppressed 90% of the microbiota but enhanced the growth of MS, Bifidobacterium and Lactobacillus species, suggesting the successful enrichment of putative caries pathogens.

34. S. mutans p rinciple micro-organisms, which colonize the tooth after it erupts into the oral cavity. Main cariogenic micro-organisms. This acid producing pathogen inhabiting the mouth cause damage by dissolving tooth structures in the presence of fermentable carbohydrates such as sucrose, fructose and glucose. It is considered more virulent (colonize on the teeth, produces large amount of acid and extracellular polysaccharide favors plaque formation. More common in rapid and smooth surface caries and less common in pit and fissure caries. 38

35. ECC-associated, acid-tolerant , and acidogenic bacteria cultured from a low-pH broth included S. mutans , Actinomyces israelii , and Lactobacillus species. The non-MS S. oralis and S. intermedius were acid tolerant but associated with caries-free children rather than ECC children, indicating that acid-tolerance per se is not sufficient to describe a caries pathogen. Using acid agar with anaerobic incubation, the major ECC-associated species were found to be S. mutans , S. sobrinus , Parascardovia denticolens , and the new species Scardovia wiggsiae .

36. S . wiggsiae was associated with ECC in S. mutans -negative samples, suggesting that this new species may be important in ECC that is not associated with MS. S . wiggsiae and P. denticolens belong to the family/ phylum Bifidobacteriaceae that includes Bifidobacterium species . The latter were cultured from occlusal lesions of children at similar proportions to those of S. mutans . Based on selective isolation, the dominant species in childhood caries were Bifidobacterium dentium and P. denticolens .

37. CONCLUSION ECC is a transmissible infectious disease, but these hazardous effects can be prevented by early effective interventions . Progression of ECC can lead to pain and reduced ability to chew and eat, which may also lead to malnutrition and reduction of quality of life of children. The focus on the prevention and management of ECC has been on modifying the dental, infectious, and behavioural determinants of the disease.

38. The management of ECC often requires education of both the parents and the child to improve their dental awareness and attitude toward dental health. Managing caries has shifted from surgical or restorative caries treatment to preventive early intervention to arrest and even reversal of initial non- cavitated caries lesions.

39. REFRENCES Tandon S. Paediatric Dentistry. 3 rd Edition Hyderabad Paras Medical Publisher; 2018 . Marwah N. Textbook of Pediatric Dentistry. New Delhi Jaypee Brothers Medical Publishers Pvt. Ltd. 4 th edition; 2018 Oct 31 . Mohanraj M, Prabhu VR, Senthil R. Diagnostic methods for early detection of dental caries-A review. International Journal of Pedodontic Rehabilitation. 2016 Jan 1;1(1):29. 43

40. Mital P, Mehta N, Saini A, Raisingani D, Sharma M. Recent advances in detection and diagnosis of dental caries. Journal of Evolution of Medical and Dental Sciences. 2014 Jan 6;3(1):177-92 . Yılmaz H, Keleş S. Recent methods for diagnosis of dental caries in dentistry. Meandros Med Dent J. 2018 Apr 1;19:1-8 . Zandoná AF, Zero DT. Diagnostic tools for early caries detection. The Journal of the American Dental Association. 2006 Dec 1;137(12):1675-84. 44

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