ECC, EARLY CHILDHOOD CARIES

1. 1

2. EARLY
CHILDHOOD
CARIES
Dr. Nabeela Basha
Seminar – 14
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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
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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.
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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.
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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.
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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.
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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.
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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)
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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
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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.
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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.
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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
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14. 14

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%.
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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%).
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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.
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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:
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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
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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
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
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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.
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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-
50th %, 7.1% weighed less than ideal weight
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40. Psychological problems:
• Decreased appetite and depression
• Poor behavior in school & self esteem
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41. PREVENTION OF ECC
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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.
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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.
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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.
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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 106
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.
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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.
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49. PROFESSIONALAND HOME-BASED
PREVENTIVE APPROACHES
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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.
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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).
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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.
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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.
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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.
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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.
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57. POLICY STATEMENT
◦ To decrease the risk of developing ECC, the AAPD
encourages professional and at-home preventive measures that
include:
1. Reducing the parent’s/sibling(s)’ MS levels to decrease
transmission of cariogenic bacteria.
2. 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.
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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.
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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]
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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.
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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.
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