Dental caries:- “Dental caries is a microbial disease of the mineralized tissues of the teeth, characterized by the demineralization of the inorganic portion & destruction of the organic substances of the tooth.”• Nursing caries :- Nursing caries is a unique pattern of dental caries seen in very young children due to prolonged & improper feeding habits.
Synonyms Nursing bottle caries Baby bottle tooth decay Nursing bottle syndrome Milk bottle syndrome Early childhood caries New name is …… Maternally derived streptococcus mutans disease (MDSMD) It is seen in infants & toddlers It affects the primary dentition only.
Classification of early childhood caries Type I ECC ( Mild to moderate) Carious lesions involving the molars & incisors Seen in 2-to-5 year-old children Cause is usually a combination of cariogenic semisolid or solid food & lack of oral hygiene Number of affected teeth usually increases as the cariogenic challenger persists
Type II ECC (Moderate to severe) Labiolingual carious lesion affecting the maxillary incisors with or without molar caries, depending on age Seen soon after the first tooth erupts Mandibular incisors are unaffected Cause is usually inappropriate use of feeding bottle or at-will breast feeding or combination of both with poor oral hygiene Unless controlled, it may proceed to an advanced stage.
Type III ECC ( Severe) Carious lesions involve almost all the teeth, including mandibular incisors Usually seen at 3-to-5 years of age Cause is a combination of factors & poor oral hygiene Rampant in nature & involves immune tooth surfaces
Etiologic agents in nursing caries1.Food Products: Bovine milk Milk formulas Human breast milk Honey Fruit juices Sweetened beverages Pacifiers sweetened with jam & jelly Milk or water with added sugar
2.Pathogenic Microorganism “Streptococcus Mutans ” It is transmitted to the infants mouth primarily through mother It colonizes the teeth It produces large amount of acid It provides large amount of extracellular polysaccharides
3. Substrate “ Fermentable carbohydrate” Main sources are Bovine milk or milk formulas Human milk (breast feeding at will or on demand) Fruit juices & other sweet liquid Sweet syrups like vitamin preparations Pacifiers dipped in honey or sugar solution Chocolates or other sweets
4. Host Teeth act as hosts for microorganisms Hypo-mineralization or hypoplasia of teeth increases caries-susceptibility of the child Thin enamel in primary teeth is one of the reasons for early spread of lesions Developmental grooves also may act as plaque retentive areas
V. Time It is an important factor that determines caries activity More the time child sleeps with the bottle in the mouth the higher is the risk of caries. During sleep salivary flow is diminished & swallowing reflex is absent. Hence milk cannot be eliminated from the oral cavity & it pools around the tooth surfaces, providing more time for accumulation of carbohydrates in the mouth which are acted upon by microorganisms to produce acid, leading to caries.
Other etiologic risk factors : Feeding at night always poses a serious threat especially if the if the teeth are not cleaned after feeding. Feeding beyond the weaning age i.e. beyond 12 to 15 months Single parent households. Child neglect could also be one of the major reasons for nursing caries to occur as the parent is too busy. Camping with financial stress and responsibilities.
High socio-economic status.it has been seen that some mother avoid breast feeding.The children are left to the mercy of the domestic help who think it their duty to continuously force a bottle in to the child’s mouth. Low socio-economic status. Both the parents if working, leave the children to be looked after by the young siblings and the resultant neglect leads to tooth decay
Immuno compromised children, are at higher risk due to decreased salivary flow. A strong tempered child such as the only child or on over protected one world always demand and force the parents to give in to its wishes. Children who present sleep disorders are found to be affected by nursing caries. Low birth- weight infants (less than 2500 G.)
Despite, its cariogenic potential mother’s milk remains the ideal food for a child. It is sweeter as compared to bovine milk because of its higher lactose content. It is:- a) The perfect food at the perfect temperature b) It provides a natural transfer of immuno-globulins by way of colostrums c) The continuous sucking leads to development of orofacial structures d) A bond of love and affection is formed between the infant and the mother which provides the child with a much needed security and warmth It is important to realize and educate mothers about the importance of proper feeding habits.
The intra-oral decay pattern of nursing caries affects the primary teeth in the following sequence: Primary maxillary incisors are first to get affected.a) Maxillary central incisors: facial, lingual, mesial & distal surfacesb) Maxillary lateral incisors: facial, lingual, mesial & distal surfacesn Maxillary first molars: facial, lingual and occlusal, prominent surfaces.
d) Maxillary canine and second molars facial, lingual and proximal surfaces.e) Mandibular molars: At later stage.The Mandibular incisors are usuallybecause of spared: They are protected by the mechanical cleansing action of the tongue Cleansing action of saliva due to presence of the orifice of the duct of the sublingual glands very close to lower incisors
Developmental process: 4 Stages:- Stage I : Initial (reversible) Stage Stage II: Damaged ( Carious) Stage Stage III: Stage of deep lesions Stage IV: Traumatic stage
Stage I : Initial (reversible) Stage: Cervical and interproximal opaque white chalky demineralization seen on maxillary anterior teeth Pain or toothache does not occur The dentist is the only one who can make the diagnosis, by using the air syringe and thus drying the teeth properly
Stage II: Damaged ( carious) Stage: Caries extends in to dentin and marked discolorations are seen Discontinuity of enamel surface is seen penetration of carious lesions occurs. Parents can now spot the decay Children start complaining of toothache on ingestion of extremely cold food for e.g.. Ice- creams.
Stage III: Deep Lesions: This stage is reached in 10-14 months. Complaints of pain during tooth brushing or eating especially while biting are frequent. Complaints of pain during intake of hot or cold drinks. Diagnosis is facilitated if patient complaints of pain during eating, brushing or if the child uses his canines to incise food.
Stage IV: Traumatic Stage: Fracture of one or more carious teeth, cerivcally are a frequent occurrence. A toddler learns to walk when his protective reflexes have not developed fully, the child falls on its face and sometimes the incisors fracture, as they are already weakened the parents do not notice the fracture at times.
Fracture of primaryteeth are rare because they arefrequently displaced or intruded Hencewhen weakened by nursing caries,thetooth will tend to fracture in theweakest spot cervically.At times, onlyroot stumps remain in the oral cavity.
Management Aims: Management of existing emergency Arrest and control of the carious process Institution of preventive procedure Restoration and Rehabilitation
Factors affecting management:- Extent of the lesion Age of the patient Behavioral problems of the child due to young age of the child.
Treatment :- Divided in to three visits:- First Visit:- This phase of treatment constitutes treatment of the lesion identification of the cause for counseling of the parent All lesions should be excavated and restored. Indirect pulp capping or pulp therapy procedures can be evaluated by further investigation.
It the abscess is present it can be treated through drainage. X-rays are advised to assess the condition of the succedaneous teeth. Collection of saliva for determining the salivary flow and viscosity. Also, the application of fluoride topically.
Parent Counseling The Parent should be questioned about the child’s feeding habits, specially regarding the use of nocturnal bottles, demand the breast feeding, pacifiers dipped in sweetening agents The parents should be asked to try weaning the child from using the bottle as a pacifier while in bed In case of considerable emotional dependence on the bottle suggest the use of plain or fluoridated water
The parents are should be instructed to clean the child’s teeth after every advised to maintain a direct record of the child’s teeth after every feed Parents are advised to maintain a diet record of the child for one week which include the time, amount of food given to the child, the type of food and the number of sugar exposure
SECOND VISIT It Should be scheduled one week after the first visit. Analysis of diet chart and explanation of the disease process of the child’s teeth should be undertaken by a simple question. Isolate the sugar factors from the diet chart and control sugar exposure by intelligent use. Caries activity tests can be started and repeated at monthly intervals to monitor the success of treatment.
Third and subsequent visits:- Restoring all grossly decayed teeth. Endodontic treatment In case of unrestorable teeth extractions can be done followed by space maintenance Crowns can be given for grossly decayed or endodontically treated teeth. Review and recall after every 3 months.
Complications:- Nursing caries is a severely disabling condition. It can result in a severely painful, unaesthetic appearance. Due to loss of tooth structure, the child may not be able to chew food properly and subsequent malnutrition may ensue Hence these children may show retarded growth as compared to normal children Prolonged bottle feeding often displaces other components of staple diet hence this can result in nutritional deficiencies for e.g. anemia, etc. The child who has nursing caries has an increased risk of developing caries in the permanent dentition
Rapid destruction of teeth may affect a child psychologically when he compares himself to other children Early extraction of maxillary incisors can create speech problems Loss of primary teeth can cause space problems, which may result in malocclusion
PREVENTION The main strategies for the prevention of nursing caries should be to create awareness and alert prospective parents and new parents about the condition and its causes Information on nursing caries can be distributed to new parents through obstetricians or gynecologist, pediatricians, paramedical staff, health workers and maternal and child health care centers Sealing of all caries free pits and fissures Professional fluoride programs
Use of antimicrobial therapy topicallySupervised home care should be taughtSystemic fluoride program if there is sub optimal fluoride concentration in drinking waterParents should be educated: • How and when to feed the child during the earliest stages of the child • When and how to introduce solid foods
• Breast feeding should be encouraged as human breast milk is highly adapted to the human infant and is almost a complete source of all required nutrients Broadly based committees at government level to address the tissue of caries and the risk factors in young children and how to recognize early signs of the condition and promote early intervention.