EARLY CHILDHOOD CARIES

EARLY CHILDHOOD CARIES
KOMAL GHIYA

INDEX
• DEFINITION
• CLASSIFICATION
• CONSEQUENCES
• IDENTIFYING PATTERNS
• PREVALENCE STUDIES
• FACTORS
• AAPD POLICY
• RAPIDD SCALE

• PREVENTIVE TREATMENT
• REBALANCING THE ORAL CAVITY
• PREVENTING TRANSMISSION
• FLUORIDES
• ESTABLISHMENT OF DENTAL HOME
• ANTICIPATORY GUIDANCE
• FOOD DIARY
• DIETARY RECOMMENDATIONS

• CARIES RISK ASSESMENT AND MANAGEMENT
• ARRESTING CARIOUS LESION
• ITR
• STAINLESS STEEL CROWN
• CONCLUSION
• REFERENCES

DEFINITION
• DAVIES(1998):COMPLEX DISEASE INVOLVING MAXILLARY
PRIMARY INCISORS WITHIN A MONTH AFTER ERUPTION AND
SPREADING RAPIDLY TO OTHER PRIMARY TEETH
• ISMAIL(1998) EARLY CHILDHOOD CARIES IS OCCURRENCE OF
ANY SIGN OF DENTAL CARIES ON THE TOOTH SURFACE DURING
FIRST 3 YEARS OF LIFE

• AAPD 2004- “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 71 months of age or
younger”.

HISTORY
• BELTRAMI:REPORTED THIS PATTERN OF EARLY CARIES IN YOUNG CHILDREN IN THE 1930s:BLACK
TEETH OF THE VERY YOUNG
• 1962:ELIAS FASS:FIRST COMPREHENSIVE DESCRIPTION OF CARIES IN INFANTS,WHICH HE TERMED AS
NURSING BOTTLE MOUTH
• WINTER 1966:NURSING CARIES
• INFANT AND EARLY CHILDHOOD DENTAL DECAY:HOROWITZ 1998
• BABY BOTTLE DECAY:MIN KELLY 1987
• TOOTH CLEARING NEGLECT :MOSS 1996
• MATERNALLY DERIVED STREPTOCOCCUS MUTANS DISEASE
• 1994:CENTER FOR DISEASE CONTROL AND PREVENTION RECOMMENDED THE USE OF A TERM EARLY
CHILDHOOD CARIES
J BERG,R SLAYTON,EARLY CHILDHOOD ORAL HEALTH,2009

WAYNE H 1999
TYPE –I (MILD TO MODERATE ECC) :
 a carious lesion or two involving incisors or molars.
 The existence of isolated carious lesion(s) involving molars
and incisors
 Cause – a combination of cariogenic semi-solid or solid food
and lack of oral hygiene.
 The number of affected teeth usually increases as the
cariogenic challenge persists
J BERG,R SLAYTON,EARLY CHILDHOOD ORAL
HEALTH,2009

TYPE – II (MODERATE TO SEVERE ECC)
• Labio-lingual carious lesions affecting maxillary incisors, with or without molars
depending on the age of the child and stage of the disease and unaffected
mandibular incisors.
• Cause – inappropriate use of feeding bottle or at will breast feeding or a
combination of both, with or without poor oral hygiene.
• Poor oral hygiene most probably compounds the cariogenic challenge.
• This type of ECC could be found soon after the first teeth erupts. Unless
controlled it may proceed to become type III ECC.
HEALTH,2009

TYPE III : (SEVERE ECC)
• Carious lesions affecting almost all the teeth including the lower incisors.
• Cause : a combination of cariogenic food and poor oral hygiene.
• This condition is usually found between 3-5 years
• The condition is rampant and involves tooth surfaces which are usually
unaffected by caries.
HEALTH,2009

CHILDREN YOUNGER THAN 3 YEARS OF
AGE
ANY SIGN OF SMOOTH SURFACE CARIES
3-5 ONE OR MORE CAVITATED,MISSING(DUE
TO CARIES),OR FILLED SMOOTH SURFACE
IN PRIMARY MAXILLARY ANTERIOR TEETH
OR A DECAYED ,MISSING OR FILLED
SURFACES(DMFS) SCORE OF GREATER
THAN 4 (AGE 3 YEARS),GREATER THAN
5(AGE 4 YEARS) OR GREATER THAN 6(AGE
5 YEARS)
Pediatric dentistry- Infanct through adoloscence.
Casamassimo,Fields,Mctigue,Nowak.5th edition.
Elsevier.Mosby

VEERKAMP AND WEERHEIJM 1995
STAGE AGE FEATURES
INITIAL 10-18 MONTHS CERVICALLY AND OCCASIONALLY INTERPROXIMAL
AREAS OF CHALKY WHITE DEMINERALIZATION
NO PAIN
DAMAGED 16-24 MONTHS LESIONS IN THE MAXILLARY ANTERIOR TEETH ,MAY
SPREAD TO DENTIN AND SHOW YELLOWISH
DISCOLORATION
HYPERSENSISTIVITY ON HOT AND COLD FOOD
INTAKE
DEEP 20-36 MONTHS MOLARS ARE ALSO AFFECTED
FREQUENT COMPLAIN OF PAIN
PULPALLY INVOLVED MAXILLARY INCISORS
TRAUMATIC 30-48 MONTHS TEETH BECOME SO WEEKENED BY CARIES THAT
RELATIVELY SMALL FORCES CAN FRACTURE THEM
MOLARS ARE NOW ASSOCIATED WITH PULPAL
PROBLEM
MAXILLARY INCISORS BECOME NONVITAL
J BERG,R
SLAYTON,E
ARLY
CHILDHOO
D ORAL
HEALTH,2
009

CARIES ANALYSIS SYSTEM(DOUGLAS 1994)

IDENTIFYING PATTERN
CAVITATION ON THE OCCLUSAL SURFACE OF FIRST MOLARS
PITS AND FISSURES OF SECOND MOLARS WITH PROGRESSION TO CAVITATION
HEALTH,2009

FREQUENTLY OCCURS FOLLOWING THE ERUPTION OF PERMANENT
MOLARS AND SUBSEQUENT CLOSING OF SPACE BETWEEN PRIMARY
MOLARS
HEALTH,2009

PLAQUE ACCUMULATION AT THE GINGIVAL MARGIN
GINGIVAL MARGIN WHITE SPOT LESION/DECALCIFICATION
CAVITATION OF MAXILLARY INCISORS FOLLOWED BY MAXILLARY FIRST
MOLAR,MANDIBULAR FIRST MOLAR,MAXILLARY CANINESAND THEN
SECOND MOLARS
J BERG,R
SLAYTON,EAR
LY
CHILDHOOD
ORAL
HEALTH,2009

CONSEQUENCES OF ECC
• higher risk of new carious lesions in both the primary and
permanent dentitions (O’Sullivan DM 1996)
• hospitalizations and emergency room visits(Griffin SO 2000)
• high treatment costs(Ladrillo TE 2006)
• loss of school days(Edelstein BL 2015)
• diminished ability to learn(Blumenshine SL 2008)
• reduced oral health-related quality of life(Filstrup SL et al 2003)
AAPD REFERENCE MANUAL V 38 / NO 6 16 / 17

PREVALENCE STUDIES
P PRAKASH 2012(BANGLORE) 27.5%,
Sobha Kuriakose 2015(TRIVANDRUM) 54%
H. R. Priyadarshini 2011(BANGLORE) 37.3%
R Mahejabeen 2006(DHARWAD) 54.1%
DHAR V 2007(UDAIPUR) 46.75%
D AGGARWAL 2012(MYSORE) 56.6%
A STEPHEN 2015 (TAMILNADU SALEM) 16%

BREAST AND BOTTLE FEEDING
KOTLOW 1977 BREAST FEEDING AND ECC BEGINNING WITH CASE REPORT S IN
1977
ADA AND AAPD UNRESTRICTED AT WILL NOCTURNAL BREAST FEEDING AFTER
ERUPTION OF CHILD’S FIRST TOOTH SHOULD BE AVOIDED AS IT
PUTS CHILD TO RISK OF ECC
DYE et al 2004
LIDA 2007
KRAMER et al 2007
NO RELATIONSHIP BETWEEN BREAST ,BOTTLE FEEDING
JOEL BERG SOME CHILDREN NURSE IN SUCH A WAY THAT EITHER CORRELATE
WITH OR LEAD TO ECC

.
Brams M,1983, Wendt
LK,1996, Ismail 1999
NO ASSOCIATION BETWEEN
BREASTFEEDING AND ECC
Valaitis R 2000 (1) there is no strong and consistent
evidence between breastfeeding and
the development of ECC; (2) there is
no specific period for weaning, and
women should be encouraged to
continue breastfeeding for as long as
they wish; and (3) rigorous studies are
necessary before issuing any public
statements correlating breastfeeding
with the development of ECC.
T KATO 2015 found an association between breast
feeding for at least 6 or 7 months and
elevated risk of dental caries at age
30 months
Neves P.A.M 2016 Breastfeeding did not provoke a
decrease in biofilm Ph. Breastfeeding
may not contribute to ECC.

HUMAN MILK
• HUMAN BREAST MILK HAS A LOWER MINERAL CONTENT,HIGHER
CONCENTRATION OF LACTOSE(7% VS 3% )AND LESS PROTEIN (1.2 g
VS 3 gm per 100 ml) AS THAT OF BOVINE MILK
• THESE DIFFERENCES ARE INSIGNIFICANT IN TERMS OF CARIOGENICITY
(DRAKE 1976)
• BREASTFEEDING MORE THAN SEVEN TIMES DAILY AFTER 12 MONTHS
OF AGE IS ASSOCIATED WITH INCRAESED RISK OF CARIES (LIDA H
2007,MOHEBBI SZ 2008)
Mohebbi SZ, Virtanen JI, Vahid-Golpayegani M, Vehkalahti MM Community Dent Oral
Epidemiol 2008 Aug;36(4):363-9.Feeding habits as determinants of early childhood caries
in a population where prolonged breastfeeding is the norm.

• Frequent night time bottle feeding with milk and ad libitum
breast-feeding are associated with, but not consistently
implicated in, ECC.
• Night time bottle feeding with juice, repeated use of a sippy or
no-spill cup
• While ECC may not arise from breast milk alone, breast feeding
in combination with other carbohydrates has been found in
vitro to be highly cariogenic
Erickson PR, Mazhari E. Investigation of the role of human breast milk in caries
development. Pediatr Dent 1999;21(2):86-90.
Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood
caries. Comm Dent Oral Epidem 1998;26(suppl 1):32-44.

PACIFIER HABIT
Although the habit of dipping the
pacifier in sugar is associated with
early colonization by Streptococcus
mutans in predentate infants, a
systematic review did not find any
consistent correlation between the
use of pacifiers and the development
of ECC, regardless of the length of
use of pacifiers and of the
introduction of sweeteners or not.
Wan AKL,2001
Peressini S 2003
SWEETENED PACIFIERS IS AN
IMPORTANT FACTOR IN CAUSING S
ECC
C NOBILE 2014
ECC is more prevalent in children
accustomed sweetened pacifier
S GOPAL 2016
2.9% ECC sweetened pacifier Vozza I 2017

INFANT FORMULAS
Pamela R. Erickson 1998 INFANTS FORMULA REDUCE PLAQUE PH
AND CAUSE ECC
K HALLET 2006 Infant bottle-feeding habits (either
allowing a child to sip from a bottle
during the day or put to sleep at
night) cause ECC
Olatosi, O. O 2015 INFANT FORMULAS CAUSES 3.5 TIMES
MORE ECC THAN BOTTLE FEEDING
K HALLET,P ROURKE,PATTERN AND SEVERITY OF ECC,VOLUME 34, ISSUE ,FEBRUARY
2006 ,PAGES 25–35
Olatosi, O. O., et al. "The prevalence of early childhood caries and its associated risk
factors among preschool children referred to a tertiary care institution." Nigerian
journal of clinical practice 18.4 (2015): 493-501.

SALIVA
•PROVIDES THE MAIN
HOST DEFENCE •ORGANIC COMPOUNDS WHICH
AGGLUTINATE ORAL BACTERIA
AND ENHANCE THEIIR REMOVAL
•THESE AGGUTININS INCLUDE
MUCINS,AGGLUTINATING
GLYCOPROTEINS,FIBRONECTIN,L
YSOZYME AND SECRETORY
IMMUNOGLOBULINS
CONTAINS SEVERAL
ANTIMICROBIAL PROTEINS
INCLUDING LACTOFERRIN
,LYSOZYME,AGGLUTININS
•ORAL CLEARANCE
,BUFFERING CAPACITY
ALL ARE RESPONSIBLE
Thick ropy saliva ,has
been found to be
associated with ECC
DENTISTRY FOR THE CHILD AND ADOLOSCENT.
MCDONALD, DEAN, AVERY. 10TH EDITION. ELSEVIER
.MOSBY

MUTANT STREPTOCOCCI
BERKOWITZ 2003,1996 MUTANS STREPTOCOCCI ,PLAQUE AND
CARIES ASSOCIATION
DOUGLASS 2008 INTERFERING WITH TRANSMISSION MAY
HOLD STRONG PROMISE TO REDUCE
DISEASE ONSET AND EXPERIENCE
Kohler 1988 Children who acquire mutans streptococci
by 2 years are at a higher risk to develop
caries by age of 4
Berkowitz 1981, berkowitz and jones
1985,caufield 1988
Transmission of bacteria from mother to
child being associated with increase risk
for caries

VIRULENCE OF MUTANT STREPTOCOCCI
SYNTHESIZE ALPHA 1,3
RICH WATER INSOLUBLE
GLUCANS FROM
SUCROSE(TANZER JM et al
1984)
ADHESION AND
COLONIZATION AND
ENHANCED RATES OF
SUGAR DIFFUSION AND
ACID PRODUCTION(HOUTE
J et al 1985)
INTERCELLULAR
POLYSACCHARIDE
SUPPORT CONTINUAL
ACID PRODUCTION
DURING PERIODS OF LOW
CONCENTRATION OF
EXOGENOUS SUBSTRATE
MAINTAINS ACTIVITY AND
FOSTERS TOOTH
DEMINERALIZATION
DURING PERIODS OF
SLEEP(SPATAFORA G et al
1995)
PRODUCES LARGE
AMOUNT OF LACTIC ACID
WHICH CAUSE
DEMINERALIZATION
PRODUCTION OF
DEXTRANASE ALLOWS
INVASION OF M
STREPTOCOCCI TO
REPLACE S
SANGUIS(TANZER JM 1989)
.MOSBY

TRANSMISSION OF MUTANTS
STREPTOCOCCI
• CORRELATION BETWEEN SALIVARY MUTANT STREPTOCOCCI COUNTS IN
MOTHERS AND THEIR CHILDREN HAVE BEEEN REPORTED
• MS MAYBE TRANSMITTED VERTICALLY FROM CAREGIVER TO CHILD
THROUGH SALIVARY CONTACT, AFFECTED BY THE FREQUENCY AND
AMOUNT OF EXPOSURE
• HORIZONTAL TRANSMISSION (EG, BETWEEN OTHER MEMBERS OF A FAMILY
OR CHILDREN IN DAYCARE) ALSO OCCURS
• SALIVARY CONCENTRATION OF 105 CFU /MM OF MATERNAL SALIVA WERE
ASSOCIATED WITH A 52 % INFECTION RATE IN THEIR CHILDREN ,COMPARED
TO ONLY 6% INFECTION RATE WHEN MATERNAL SALIVA CONCENTRATION
WAS 103 CFU OR BELOW(BERKOWITZ RJ et al 1981)
Berkowitz RJ. Mutans streptococci: Acquisition and
transmission. Pediatr Dent 2006;28(2):106-9.

DIET
MARRIRI 2003 IOWA:4-7 YEARS:SUGARED
BEVERAGES
SOHN et al 2006 HIGH CARBOHYDRATE SOFT DRINK
GROUP HAD HIGHER CARIES
DYE et al 2004 NOT EATING BREAKFAST ON A DAILY
BASIS AND NOT CONSUMING THE
RECOMMENDED 5 FRUIT AND
VEGETABLES DAILY
Tinanoff NT et al 2002 frequent in between meal
consumption of sugar-containing
snacks or drinks (eg, juice, formula,
soda) increase the risk of caries
Tinanoff NT, Kanellis MJ, Vargas CM. Current understanding of the epidemiology
mechanism, and prevention of dental caries in preschool children. Pediatr Dent
2002;24(6):543-51.

• Caries-conducive dietary practices appear to be established by
12 months of age and are maintained throughout early
childhood. Douglass JM 2009
• Frequent consumption of between-meal snacks and beverages
containing sugars increases the risk of caries due to prolonged
contact between sugars in the consumed food or liquid and
cariogenic bacteria on the susceptible teeth. Tinanoff NT 2000
Douglass AB, Douglass JM, Krol DM. Educating pediatricians and family
physicians in children’s oral health. Academic Pediatr 2009;9(6):452-6.
Tinanoff NT, Palmer C. Dietary determinants of dental caries in preschool
children and dietary recommendations for preschool children. J Pub Health Dent
2000;60(3): 197-206.

SUGARS
• THE MOST WIDELY USED SUGAR SUCROSE IS THE MOST
IMPORTANT IN DENTAL CARIES AS IT IS THE ONLY SUBSTRATE
USED FOR BACTERIAL GENERATION OF PLAQUE DEXTRANS
(NEWBRUN 1982)
• SUCROSE,GLUCOSE AND FRUCTOSE FOUND IN FRUIT JUICES
AND VIT C DRINKS ARE MORE ASSOCIATED WITH ECC
.MOSBY

FREQUENCY OF CONSUMPTION
INCREASES ACIDITY OF
PLAQUE AND ENHANCES
ESTABLISHMENT AND
DOMINANCE OF THE
ACIDURIC MUTANTS
STREPTOCOCCI
ENAMEL
DEMINERALIZATION
DECREASES AND
INADEQUATE
REMINERALIZATION
DEMINERALIZTION
BECOMES
PREDOMINANT
MECHANISM
.MOSBY

ORAL CLEARANCE OF CARBOHYDRATES
• HANAKI M et al (1993): CLEARANCE OF GLUCOSE IS SLOWEST
ON THE LABIAL SURFACE OF MANDIBULAR MOLARS AND
MAXILLARY INCISORS
• THIS SHOWS THE PATTERN OF ECC
.MOSBY

TOOTHBRUSHING
• ECC OCCURS ON SURFACES THAT CAN BE EASILY ACCESSIBLE BY
ROUTINE TOOTH BRUSHING ,ORAL HYGIENE LEVELS ARE
ASSOCIATED WITH ECC
• FREQUENCY OF BRUSHING,QUALITY OF PLAQUE REMOVAL ARE
ALSO ASSOCIATED WITH THE OCCURRENCE OF ECC

TOOTH MATURATION AND DEFECTS
• TOOTH IS MOST SUSCEPTIBLE TO CARIES IN THE PERIOD
IMMEDIATELY AFTER ERUPTION AND PRIOR TO MATURATION
• THIS IN MANY INFANTS A COMBINATION OF RECENTLY IMMATURE
ENAMEL IN AN ENVIORNMENT OF CARIOGENIC FLORA WITH
FREQUENT INGESTION OF FERMENTABLE CARBOHYDRATES WOULD
RENDER THE TOOTH PARTICULARLY SUSCEPTIBLE TO CARIES
• THE PRESENCE OF STRUCTURAL DEFECT OF ENAMEL MAY INCREASE
CARIES RISK
• ENAMEL DEFECTS ARE COMMON IN CHILDREN WITH LOW
BIRTHWEIGHT OR SYSTEMIC ILLNESS OR UNDERNUTRITION DURING
THE PERINATAL PERIOD
Seow WK. Biological mechanisms of early childhood caries. Community Dent Oral Epidemiol
1998;26(suppl): 8-27.

SOCIOECNOMIC STATUS
ANSARI et al 2003 ETIOLOGICAL DETERMINANTS IN PATHOGENESIS OF AVARIETY
CONDITIONS INDEPENDENT OF THE BIOLOGICAL FACTOR
EDELSTEIN 2002 PRESCHOOLERS IN POVERTY ARE 2 TIMES MORE PRONE THAN
AFFLUENT COUNTERPARTS
PERES 2005 EARLY LIFE INFLUENCES OF SOCIAL CLASS ,FAMILY INCOME
AND PARENTAL EDUCATION
A SHAH
2015(KASHMIR)
Prevalence of ECC was 39.9%
A GADHIANE
2013(WARDHA)
33.48% children were having ECC

Infant through adoloscence.
Elsevier.Mosby

RACE AND ETHINICITY
• MILNES:
• INCREASED RISK THAT COULD BE ASSOCIATED WITH CULTURAL NORMS
INCLUDING CONCERN FOR ORAL HEALTH
• PRENATAL DIET THAT COULD CONTRIBUTE TO ENAMEL HYPOPLASIA
• CARE OF PRIMARY TEETH
• CHILD REARING PRACTICES
• ACCESS TO DENTAL AND MEDICAL CARE
• MINORITIES MAY EXPERIENCE SIGNIFICANT BARRIERS TO DENTAL
CARE,INCLUDING COST OF CARE AND AVAILABILTY OF ACCESSIBLE SERVICES
AAPD.INFANT ORAL HEALTH CARE.PEDIATR DENT,1994;16:29

IMMUNOLOGICAL FACTORS
• HOST IMMUNE MECHANISM INCLUDE SPECIFIC IMMUNE FACTORS
DERIVED FROM SALIVA SECRETORY IG A,sIgA),OR SERUM AND
GINGIVAL CREVICULAR FLUID(IMMUNOGLOBULIN G,IgG) AND NON
SPECIFIC ANTIMICROBIAL SYSTEMS DERIVED MAINLY FROM SALIVA
• SECRETORY IMMUNOGLOBULIN A MAY INHIBIT BACTERIAL
ADHERENCE OR AGGLUTINATION AS WELL AS NEUTRALIZATION OF
BACTERIAL ENZYMES
• BRANDTZAEG:1973:THE PROTECTIVE EFFECTS OF sIgA IN OTHER
MUCOSAL AREAS ARE WELL KNOWN,THERE IS LITTLE EVIDENCE THAT
NATURALLY OCCURING sIgA ANTIBODIES PROTECT AGAINST DENTAL
CARIES
.MOSBY

CYCLIC EFFECT OF ECC
• CHILDREN AFFLICTED REMAIN AT RISK THROUGHOUT
CHILDHOOD EVEN WHEN PREVENTIVE MEASURES ARE TAKEN
Pediatric dentistry- Infanct through adoloscence.
Casamassimo,Fields,Mctigue,Nowak.5th edition. Elsevier.Mosby

AAPDPOLICY ON EARLY CHILDHOOD CARIES
(ECC): UNIQUE CHALLENGES AND TREATMENT
OPTIONS 2016
• Beause restorative care to manage ECC often requires the use of sedation and
general anesthesia with its associated high costs and possible health risks, and
because there is high recurrence of lesions following the procedures, there now
is more emphasis on prevention and arrestment of the disease processes.
Approaches include methods that have been referred to as:
• 1. Chronic disease management, which includes parent engagement to facilitate
preventive measures, and temporary restorations to postpone advanced
restorative care
• 2. Active surveillance, which emphasizes careful monitoring of caries
progression and prevention programs in children with incipient lesions.
• 3. Interim therapeutic restorations (ITR) that temporarily restore teeth in young
children until a time when traditional cavity preparation and restoration is
possible.
REFERENCE MANUAL V 38 / NO 6 16 / 17

PREVENTION
COMMUNITY BASED STRATEGY:EDUCATING MOTHERS IN THE HOPE OF INFLUENCING
DIETARY HABITS AS WELL AS THOSE OF INFANTS
SECOND:PROVISION OF EXAMINATION AND PREVENTIVE CARE IN DENTAL CLINICS
THIRD:DEVELOPMENT OF APPROPRIATE DIETARY AND SELF CARE HABITS AT HOME

AAPD GUIDELINES
• Avoiding frequent consumption of liquids and/or solid foods containing sugar, in
particular:
• Sugar-sweetened beverages (e.g., juices, soft drinks, sports drinks, sweetened tea) in a
baby bottle or no-spill training cup.
• Ad libitum breast-feeding after the first primary tooth begins to erupt and other dietary
carbohydrates are introduced.
• Baby bottle use after 12-18 months.
• 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 under the age of three, a
smear or rice-sized amount of fluoridated toothpaste should be used. In children ages
three to six, a pea-sized amount of fluoridated toothpaste should be used.
Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive
Strategies, REFERENCE MANUAL V 38 / NO 6 16 / 17

• 3. Providing professionally-applied fluoride varnish treatments for
children at risk for ECC.
• 4. Establishing a dental home within six 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. Working with medical providers to ensure all infants and toddlers
have access to dental screenings, counseling, and preventive
procedures.
• 6. Educating legislators, policy makers, and third party payors
regarding the consequences of and preventive strategies for ECC.
Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive

PREVENTION OF TRANSMISSION OF
BACTERIA
• A NON RANDOMIZED STUDY DIVIDED MOTHERS WHO HAD ATLEAST
106 MUTANTS STREPTOCOCCI PER MM OF SALIVA INTO TEST AND
CONTROL GROUPS
• TEST PROGRAMME INCLUDED PROVISION OF DENTAL
EDUCATION,ORAL HYGIENE INSTRUCTIONS,DENTAL
TREATMENT,TOOTH CLEANING,APPLICATION OF 2% SODIUM
FLUORIDE,FLUORIDE VARNISH
• THE CHILDREN WHOSE MOTHERS WERE IN EXPERIMENTAL GROUP
HAD A DMFT OF 5.2 WHICH WAS MUCH LOWER THAN CONTROL
WHICH WAS 8.6:WANS AND COLLEAGUES
Pediatric dentistry Infancy through adoloscence.
Elsevier.Mosby

PREVENTING TRANSMISSION
• Eliminating saliva-sharing activities (eg, sharing utensils, orally
cleansing a pacifier) may help decrease an infant’s or toddler’s
acquisition of cariogenic microbes.
Berkowitz RJ. Mutans streptococci: Acquisition and
transmission. Pediatr Dent 2006;28(2):106-9.

REBALANCING THE ORAL CAVITY
High risk patient :rinse 10 ml of 0.12%chlorhexidiene digluconate solution once per
day for 1 week every 6 months(feather stone 2006)
Since children less than 3 years old will not be pertitnent ,this would be more
appropriate for mothers with high caries risk
Chlorhexidiene gel:1% applied for 5 minute per day over a period of 2 weeks(zickert
1982)
IODINE: lopez et al 1999,2002:topical iodine agents can significantly suppress levels
of mutants streptococci
XYLITOL:

RAPIDD SCALE
• READINESS ASSESSMENT OFPARENTS CONCERNING INFANT DENTAL
DECAY(RAPIDD SCALE)
• TO ASSESS A PARENT’S STAGE OF CHANGE OF
PRECONTEMPLATIVE,CONTEMPLATIVE ,OR ACTION WITH REGARD TO
HIS/HER CHILD
• BASED ON THE WORK OF PROCHASKA AND DICLEMENTE MEASURES PRO
AND CON PARENTAL BELIEFS ABOUT CARING FOR THE CHILD’S TEETH
• READINESSS ASSESMENT OF PARENTS CONCERNING INFANTS DENTAL DECAY
CONSISTED OF 38 ITEMS ON A FIVE POINT SCALE RANGING FROM STRONGLY
AGREE TO STRONGLY DISAGREE
Weinstein P, Riedy CA.The reliability and validity of the RAPIDD scale: readiness
assessment of parents concerning infant dental decay. ASDC J Dent Child 2001 Mar-
Apr;68(2):129-35, 142.

• THE PATIENT OR PRIMAY 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 ONTO ONE OF FOUR:
• OPENNESS TO HEALTH INFORMATION
• VALUING DENTAL HEALTH
• CONVENIENCE AND CHANGE DIFFICULTY
• CHILD PERMISSIVENESS.
Weinstein P, Riedy CA.The reliability and validity of the RAPIDD scale: readiness
assessment of parents concerning infant dental decay. ASDC J Dent Child 2001 Mar-
Apr;68(2):129-35, 142.

• THE SCORES ARE CALCULATED ,VALUES ARE RANKED AND
PERCENTILE IS CALCULATED
• THEN DIVIDES INTO PRECONTEMPLATORS,CONTEMPLATORS
AND ACTION
• USAGE:
• USED TO DETERMINE PARENT’S STAGE OF CHANGE FOR THEIR
CHILD’S ORAL HEALTH
Weinstein P, Riedy CA.The reliability and validity of the RAPIDD scale: readiness assessment of
parents concerning infant dental decay. ASDC J Dent Child 2001 Mar-Apr;68(2):129-35, 142.

ESTABLISHMENT OF A DENTAL HOME
• Non-dental health care providers who identify ECC should either
provide therapy or refer the patient to a licensed dentist for
treatment and establishment of a dental home
• DENTAL HOME: The dental home is the ongoing relationship between
the dentist and the patient, inclusive of all aspects of oral health care
delivered in a comprehensive, continuously accessible, coordinated,
and family-centered way.(2015 AAPD)
• The dental home should be established no later than 12 months of
age and includes referral to dental specialists when appropriate.
American Academy of Pediatric Dentistry. Policy on a
dental home. Pediatr Dent 2011;33(special
issue):24-5

• PERFORM CARIES RISK ASSESSMENT
• DEVELOP A TAILORED PLAN TO ANTICIPATE,PREVENT,SUPPRESS
CARIES ACTIVITY
• GROUNDWORK FOR THE PRACTIONERS TO PREVENT ECC

ANTICIPATORY GUIDANCE
• Anticipatory guidance is the process of providing practical,
developmentally-appropriate information about children’s
health to prepare parents for the significant physical,
emotional, and psychological milestones
• Topics to be included are oral hygiene and dietary habits, injury
prevention, nonnutritive habits, substance abuse,
intraoral/perioral piercing, and speech/language development
Guideline on Periodicity of Examination, Preventive
Dental Services, Anticipatory Guidance/Counseling,
and Oral Treatment for Infants, Children, and
Adolescents,2016/17

VasudhaSodani 2011 the health professionals lack the adequate
knowledge regarding ECC in Vadodara city
VasudhaSodani,Sunanda Gsujan, Harsh G
Shah,Bhavna Dave,Anticipatory Guidance regarding
Early Childhood Caries (ECC) among Health
Professionals in Vadodara city, Gujarat Journal of
Advanced Oral Research, Vol 2; Issue 3: Oct - Dec
2011

Food Group Portion size
considered one
serving
1st day 2nd day 3rd day 4th day 5th day Average
MILK (milk &
cheese)
8 oz (1 cup)
milk
1½ c cottage
cheese
| || ||| | || 2
MEAT (meat,
fish, poultry,
nuts, dry
beans)
2-3 oz lean
cooked meat,
fish or poultry
|| | 0 || | 1+
FRUITS and
VEGETABLES
(including
citrus fruits,
dark green and
deep yellow
vegetables)
½ c cooked
1 medium raw
|| | ||| ||||| 0 2
BREAD and
CEREALS
(Enriched Or
Whole Grain)
1 slice bread
¾ c dry cereal
½ c cooked
cereal, rice,
noodles,
macaroni
||||| ||||||| |||| |||||| ||| 4
FOOD DIARY

Sonia Hernández-Cordero et al
BMC Public Health2015:1031:7
DAY DIARY TO BE MORE CORRECT
REPRODUCTION OF DIET THAN 24
HR RECALL
Comparing a 7-day diary vs. 24 h-
recall

SUGAR CLOCK-JHONSON AND
BIRKHED:1991
Advanced Dental Nursing, Robert Ireland,2 ND EDITION

SUGAR CLOCK
Advanced Dental Nursing, Robert Ireland,2 ND EDITION

DIETARY RECOMMENDATIONS
• The American Academy of Pediatrics has recommended children one
through six years of age consume no more than four to six ounces of
fruit juice per day, from a cup (ie, not a bottle or covered cup) and as
part of a meal or snack.(2016/17)
• School health education programs and food services to promote
nutrition programs that provide well-balanced and nutrient-dense
foods of low caries-risk, in conjunction with encouraging increased
levels of physical activity
• Pediatric dentists and other health care providers who treat children
to provide dietary and nutrition counseling (commensurate with their
training and experience) in conjunction with other preventive services
for their patients
American Academy of Pediatrics Committee on Nutrition. Policy statement:
The use and misuse of fruit juices in pediatrics. Pediatrics

• Pediatric dentists and other health care providers to recommend or
prescribe sugar-free medications whenever possible. Educating parents of
the risks of overdose from excessive consumption of candy-like chewable
vitamin supplements
• Eating a variety of nutrient-dense foods and beverages.
• Balancing foods eaten with physical activity to maintain a healthy body
mass index.
• Maintaining a caloric intake adequate to support normal growth and
development and to reach or maintain a healthy weight.
• Choosing a diet with plenty of vegetables, fruits, and whole grains and low
in fat, saturated (especially transsaturated) fat, and cholesterol.
Policy on Dietary Recommendations for Infants, Children, and Adolescents

FLUORIDE
AGE <0.3 0.3-0.7 >0.7
0-2 0.25 0.00 0.00
2-3 0.50 0.25 0.00
3-16 1.00 0.50 0.25
G NIKIFORUK,UNDERSTANDING DENTAL
CARIES,PREVENTION BASIC AND CLINICAL
APPROACH,KARGER

FLUORIDE DENTRIFICE
• The use of anticariogenic agents, especially twice daily brushing with
fluoridated toothpaste and the frequent application of fluoride
varnish, may reduce the risk of development and progression of
caries.
• Using no more than a ‘smear’ or ‘rice-size’ (approximately 0.1 mg
fluoride amount of fluoridated toothpaste for children less than three
years of age may decrease risk of fluorosis.
• Using no more than a ‘pea-size’ (approximately 0.25 mg fluoride)
amount of fluoridated toothpaste is appropriate for children aged
three to six
American Dental Association Council on Scientific
Affairs. Fluoride toothpaste use for young children. J
Am Dent Assoc 2014;145(2):190-191.

• Parents should dispense the toothpaste onto a soft, age-
appropriate sized toothbrush and perform or assist with
toothbrushing of preschool-aged children.
• To maximize the beneficial effect of fluoride in the toothpaste,
rinsing after brushing should be kept to a minimum or
eliminated altogether.
ADA Council on Scientific Affairs. Fluoride
toothpaste use for young children. J Am Dent Assoc
2014;145(2):190-1.

PROFESSIONALLY APPLIED FLUORIDE
• Professionally-applied topical fluoride treatments also are
efficacious in reducing prevalence of ECC.
• The recommended professionally-applied fluoride treatments
for children at risk for ECC who are younger than six years is
five percent sodium fluoride varnish (NaFV; 22,500 ppm F)
Policy on Early Childhood Caries (ECC):
Classifications, Consequences, and Preventive

WATER FLUORIDATION
• Fluoridation of community drinking water is the precise
adjustment of the existing natural fluoride concentration in
drinking water to a safe level that is recommended for caries
prevention.
• The United States Public Health Service has established the
optimum concentration for fluoride in the water in the range of
0.7–1.2 mg/L
G NIKIFORUK,UNDERSTANDING DENTAL CARIES,PREVENTION BASIC AND CLINICAL
APPROACH,KARGER

SILVER DIAMINE FLUORIDE
• Silver diamine fluoride (SDF) is a colorless liquid
• pH 10
• 24.4% to 28.8% (weight/volume) silver and 5.0% to 5.9%
fluoride.
• 44,800 ppm F
J.C LLODRA 2005 SDF solution was found to be
effective for caries reduction in
primary teeth and first permanent
molars in schoolchildren
C.H.CHU 2002 Silver diamine fluoride was found
to be effective in arresting dentin
caries in primary anterior teeth in
pre-school children.

RECOMMENDATIONS FOR PREVENTIVE
MANEUVERS FOR ECC
INTERVENTIONS TARGET
CHLORHEXIDEINE VARNISH HIGH RISK ECC GROUP
DIETARY COUNSELLING HIGH RISK ECC GROUP
EARLY DETECTION ALL INFANTS BEFORE AGE OF 1
YEAR
EDUCATION ALL INFANTS AND TODDLERS
EDUCATION HIGH RISK COMMUNITIES
FLUORIDE SUPPLEMENTS HIGH RISK GROUPS
FLUORIDE DENTRIFICE ALL INFANTS AND TODDLERS
FLUORIDE VARNISH HIGH RISK ECC GROUP
PRENATAL FLUORIDE
SUPPLEMENTS
ALL INFANTS AND TODDLERS
SEALANTS HIGH RISK ECC GROUP
J BERG,R
SLAYTON,EAR
LY
CHILDHOOD
ORAL
HEALTH,2009
Pediatric
dentistry-

WATER FLUORIDATION COMMUNITY
XYLITOL SUBSTITUTES HIGH RISK ECC GROUP
CONTROL OF MOTHER-INFANT INFECTION
WITH CARIOGENIC BACTERIA
HIGH RISK ECC GROUP
HEALTH,2009Pediatric dentistry-

CARIES RISK ASSESSMENT AND MANAGEMENT
Guideline
on Caries-
risk
Assessme
nt and
Managem
ent for
Infants,
Children,
and
Adolescen
ts, 2014
REFERENC
E MANUAL
V 38 / NO
6 16 / 17

Guideline
on Caries-
risk
Assessme
nt and
Managem
ent for
Infants,
Children,
and
Adolescen
ts, 2014
REFERENC
E MANUAL
V 38 / NO
6 16 / 17

Guideline on
Caries-risk
Assessment
and
Management
for Infants,
Children,
and
Adolescents,
2014
REFERENCE
MANUAL V
38 / NO 6
16 / 17

CARIES MANAGEMENT PROTOCOL FOR
1-2 YEAR OLDS
Guideline on
Caries-risk
Assessment and
Management for
Infants, Children,
and Adolescents,
2014 REFERENCE
MANUAL V 38 /
NO 6 16 / 17

CARIES MANAGEMENT PROTOCOL FOR
3-5 YEAR OLDS
Guideline on
Caries-risk
Assessment and
Management for
Infants, Children,
and Adolescents,
2014 REFERENCE
MANUAL V 38 /
NO 6 16 / 17

CARIES MANAGEMENT PROTOCOL >=6
Guideline on
Caries-risk
Assessment
and
Management
for Infants,
Children, and
Adolescents,
2014
REFERENCE
MANUAL V 38
/ NO 6 16 / 17

• Legends for Tables 4-6
• a Salivary mutans streptococci bacterial levels.
• THETA Interim therapeutic restoration.
• χ Periodic monitoring for signs of caries progression.
• γ Parental supervision of a “pea sized” amount of toothpaste.
• X Parental supervision of a “smear” amount of toothpaste.
• λ Indicated for teeth with deep fissure anatomy or developmental d Need to consider fluoride levels in
drinking water. defects.
• e Careful monitoring of caries progression and prevention program.
• μ Less concern about the quantity of toothpaste

ITR
• Interim therapeutic restorations (ITR), using materials such as glass
ionomers that release fluoride, are efficacious in both preventive
and therapeutic approaches
• Definitive restorative treatment in young children, in many cases,
can be postponed by use of ITR or silver diamine fluoride
treatments. 2016:AAPD
• The ITR procedure involves removal of caries using hand or rotary
instruments with caution not to expose the pulp. Leakage of the
restoration can be minimized with maximum caries removal from
the periphery of the lesion.
• Following preparation, the tooth is restored with an adhesive
restorative material such as glass ionomer or resin-modified glass
ionomer cement
Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment
Options 2016,2014
Yip HK, Smales RJ, Ngo HC, Tay FR, Chu F. Selection of restorative materials
for the atraumatic restorative treatment (ART) approach: A review. Spec Care
Dent 2001; 21(6):216-221

ARRESTING ACTIVE LESIONS
• ALL RESTORATIONS AND TREATMENT DONE UNDER GA OR
CONCIOUS SEDATION
• IF NOT THEN EXCAVATE GROSS CARIOUS LESION
• INTERIM THERAPEUTIC RESTORATION
• GIVES TIME FOR DESIGNING TREATMENT PLAN
• STOPS THE PROGRESSION OF CARIES
• DECREASES THE BACTERIAL COUNT
.MOSBY

• The use of ITR has been shown to reduce the levels of
cariogenic oral bacteria (e.g., Mutans Streptococci, lactobacilli)
in the oral cavity immediately following its placement.
• However, this level may return to pretreatment counts over a
period of six months after ITR placement if no other treatment
is provided
Policy on Interim Therapeutic Restorations (ITR), 2013, REFERENCE MANUAL V 38 / NO 6 16 / 17

STAINLESS STEEL CROWN
• Stainless steel crowns often are indicated to restore teeth with
large carious lesions and extensive white spot lesions and, at
early age, are less likely than other restorations to require
retreatment:2014
• large carious lesions, interproximal lesions, and extensive
white spot lesions since stainless steel crowns are less likely
than other restorations to require retreatment:2016
Policy on Early Childhood Caries (ECC): Unique
Challenges and Treatment Options,2014,AAPD

CONCLUSION
• THUS ECC IS A MULTIFACTORIAL DISEASE WHOSE PREVENTION
IS OF UTMOST IMPORTANCE AND TREATMENT COMPRISES OF
RAPID AND ACTIVE MANAGEMENT OF LESIONS

REFERENCES
• Prakash P, Subramaniam P, Durgesh BH, Konde S. Prevalence of early
childhood caries and associated risk factors in preschool children of urban
Bangalore, India: A cross-sectional study. European Journal of Dentistry.
2012;6(2):141-152.
• Kuriakose S, Prasannan M, Remya KC, Kurian J, Sreejith KR. Prevalence of
early childhood caries among preschool children in Trivandrum and its
association with various risk factors. Contemporary Clinical Dentistry.
2015;6(1):69-73.
• Priyadarshini HR, Hiremath SS, Puranik M, Rudresh SM, Nagaratnamma T.
Prevalence of early childhood caries among preschool children of low
socioeconomic status in Bangalore city, India. Journal of International Society
of Preventive & Community Dentistry. 2011;1(1):27-30. doi:10.4103/2231-
0762.86384.

• J BERG,R SLAYTON,EARLY CHILDHOOD ORAL HEALTH,2009Pediatric dentistry-
• Infant through adoloscence. Casamassimo,Fields,Mctigue,Nowak.5th edition. Elsevier.Mosby
• DENTISTRY FOR THE CHILD AND ADOLOSCENT. MCDONALD, DEAN, AVERY. 10TH EDITION. ELSEVIER
.MOSBY
• AAPD REFERENCE MANUAL V 38 / NO 6 16 / 17
• Mohebbi SZ, Virtanen JI, Vahid-Golpayegani M, Vehkalahti MM Community Dent Oral Epidemiol 2008
Aug;36(4):363-9.Feeding habits as determinants of early childhood caries in a population where
prolonged breastfeeding is the norm.
• Erickson PR, Mazhari E. Investigation of the role of human breast milk in caries development. Pediatr
Dent 1999;21(2):86-90.
• Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Comm Dent Oral
Epidem 1998;26(suppl 1):32-44.

• Berkowitz RJ. Mutans streptococci: Acquisition and transmission. Pediatr Dent
2006;28(2):106-9
• Tinanoff NT, Kanellis MJ, Vargas CM. Current understanding of the epidemiology
mechanism, and prevention of dental caries in preschool children. Pediatr Dent
2002;24(6):543-51.
• Douglass AB, Douglass JM, Krol DM. Educating pediatricians and family
physicians in children’s oral health. Academic Pediatr 2009;9(6):452-6.
• Tinanoff NT, Palmer C. Dietary determinants of dental caries in preschool
children and dietary recommendations for preschool children. J Pub Health Dent
2000;60(3): 197-206.
• Seow WK. Biological mechanisms of early childhood caries. Community Dent Oral
Epidemiol 1998;26(suppl): 8-27.

• Aasim Farooq Shah, Manu Batra, Vikram Aggarwal, Subha Soumya Dany,
Prashant Rajput, Tushika Bansal low socioeconomic status in district Srinagar,
Jammu and Kashmir,IAIM 2015;2(3):8-13
• Prevalence and determinant of early childhood caries among the children
attending the Anganwadis of Wardha district, India
Gaidhane Abhay M, Patil Manoj, Khatib Nazli, Zodpey Sanjay, Zahiruddin Quazi
Syed Year : 2013 | Volume: 24 | Issue Number: 2 | Page: 199-205
•
Dental caries prevalence among preschool children of Hubli: Dharwad city
Mahejabeen R, Sudha P, Kulkarni S S, Anegundi R Year : 2006 | Volume: 24 |
Issue Number: 1 | Page: 19-22

• Dhar V, Jain A, Van Dyke T E, Kohli A. Prevalence of dental caries and
treatment needs in the school-going children of rural areas in
Udaipur district. J Indian Soc Pedod Prev Dent 2007;25:119-21
• Nilza M. E. Ribeiro; Manoel A. S. Ribeiro, J. Pediatr. (Rio
J.) vol.80 no.5 suppl. Porto Alegre Nov. 2004,Breastfeeding and early
childhood caries: a critical review
• Mohebbi SZ, Virtanen JI, Vahid-Golpayegani M, Vehkalahti MM
Community Dent Oral Epidemiol 2008 Aug;36(4):363-9.Feeding
habits as determinants of early childhood caries in a population
where prolonged breastfeeding is the norm.

• Iida H, Auinger P, Billings RJ, Weitzman M Association between infant
breastfeeding and early childhood caries in the United States
Pediatrics. 2007 Oct;120(4):e944-52.
• Weinstein P, Riedy CA.The reliability and validity of the RAPIDD scale:
readiness assessment of parents concerning infant dental decay.
ASDC J Dent Child 2001 Mar-Apr;68(2):129-35, 142.
• Pamela R. Erickson, Kelly L. McClintock, Nicole Green, S Jamilla
LaFleu,Estimation ofthe caries-related risk associated with infant
formulas, Pediatric Dentistry -20.’Z 1998

• Norman Tinanoff, DDS, MS David M. O’Sullivan, BS Early childhood caries: overview and
recent findings, Pediatric Dentistry - 19:1, 1997
• K HALLET,P ROURKE,PATTERN AND SEVERITY OF ECC,VOLUME 34, ISSUE ,FEBRUARY
2006 ,PAGES 25–35
• Çolak H, Dülgergil ÇT, Dalli M, Hamidi MM. Early childhood caries update: A review of
causes, diagnoses, and treatments. Journal of Natural Science, Biology, and Medicine.
2013;4(1):29-38.
• G NIKIFORUK,UNDERSTANDING DENTAL CARIES,PREVENTION BASIC AND CLINICAL
APPROACH,KARGER
• Prevalence and Predictors of Early Childhood Caries in 3- to 6-year-old South Indian
Children – A Crosssectional Descriptive Study Satya Gopala /Vinay Chandrappab /Uloopi
Kadidalc /Chandrasekhar Rayalad / Madhuri Vegesna, Oral Health & Preventive
Dentistry,2014

• Vozza I, Capasso F, Marrese E, Polimeni A, Ottolenghi L. Infant and Child
Oral Health Risk Status Correlated to Behavioral Habits of Parents or
Caregivers: A Survey in Central Italy. Journal of International Society of
Preventive & Community Dentistry. 2017;7(2):95-99.
• Sonia Hernández-Cordero et al BMC Public Health201515:1031:7 DAY
DIARY TO BE MORE CORRECT REPRODUCTION OF DIET THAN 24 HR RECALL
• Guideline on Periodicity of Examination, Preventive Dental Services,
Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children,
and Adolescents,2016/17
• VasudhaSodani,Sunanda Gsujan, Harsh G Shah,Bhavna Dave,Anticipatory
Guidance regarding Early Childhood Caries (ECC) among Health
Professionals in Vadodara city, Gujarat Journal of Advanced Oral Research,
Vol 2; Issue 3: Oct - Dec 2011

• AAPD.INFANT ORAL HEALTH CARE.PEDIATR DENT,1994;16:29
• Policy on Early Childhood Caries (ECC): Classifications, Consequences, and
Preventive Strategies, REFERENCE MANUAL V 38 / NO 6 16 / 17
• Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment
Options 2016,2014
• Yip HK, Smales RJ, Ngo HC, Tay FR, Chu F. Selection of restorative materials for
the atraumatic restorative treatment (ART) approach: A review. Spec Care Dent
2001; 21(6):216-221
• Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment
Options,2014,AAPD

• Guideline on Caries-risk Assessment and Management for Infants, Children, and
Adolescents, 2014 REFERENCE MANUAL V 38 / NO 6 16 / 17
• G NIKIFORUK,UNDERSTANDING DENTAL CARIES,PREVENTION BASIC AND
CLINICAL APPROACH,KARGER
• Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory
Guidance/Counseling, and Oral Treatment for Infants, Children, and
Adolescents,2016/17
• Policy on Early Childhood Caries (ECC): Classifications, Consequences, and
Preventive Strategies, REFERENCE MANUAL V 38 / NO 6 16 / 17
• ADA Council on Scientific Affairs. Fluoride toothpaste use for young children. J
Am Dent Assoc 2014;145(2):190-1

• American Dental Association Council on Scientific Affairs. Fluoride
toothpaste use for young children. J Am Dent Assoc
2014;145(2):190-191
• American Academy of Pediatrics Committee on Nutrition. Policy
statement: The use and misuse of fruit juices in pediatrics. Pediatrics
2001;107(5):1210-3. Reaffirmed October, 2006.
• Advanced Dental Nursing, Robert Ireland,2 ND EDITION
• Weinstein P, Riedy CA.The reliability and validity of the RAPIDD scale:
readiness assessment of parents concerning infant dental decay.
ASDC J Dent Child 2001 Mar-Apr;68(2):129-35, 142.

• Llodra, J. C., et al. "Efficacy of silver diamine fluoride for caries
reduction in primary teeth and first permanent molars of
schoolchildren: 36-month clinical trial." Journal of dental
research 84.8 (2005): 721-724.
• Rosenblatt, A., T. C. M. Stamford, and R. Niederman. "Silver
diamine fluoride: a caries “silver-fluoride bullet”." Journal of
dental research 88.2 (2009): 116-125.

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