This document discusses the management of early childhood caries (ECC). It covers various preventive measures including community, professional, and home-based methods. Community measures involve educating parents, water fluoridation, and fluoride applications. Professional measures include early dental exams, diet counseling, prenatal counseling, and fluoride varnishes. Home care involves fluoride toothpaste use, oral hygiene techniques, and the role of non-dental professionals. Treatment options are also outlined, separating invasive methods like restorations from microinvasive approaches such as resin infiltration and sealants.

1. 1
MANAGEMENT OF EARLY
CHIILDHOOD CARIES
Dr. Parvathy Manu
Second Year MDS
Department of Pediatric and Preventive
dentistry

2. CONTENTS
2
 PREVENTION
 COMMUNITY BASED MEASURES
 PROFESSIONAL MEASURES
 HOME CARE METHODS
• TREATMENT MEASURES
 INVASIVE MEASURES
 MICRO INVASIVE MEASURES

3. 3

4. Preventive methods
of ECC
Community
Education
Community
fluoridation
Community and
personal development
Professional
Early detection
Diet counselling
Prenatal counselling
Regular Fluoride
application
Home care
Fluoride dentifrices
Oral hygiene
measures
Non dental
professionals
4

5. Goal should be to educate and increase the knowledge of
mother about ECC, to improve the dietary and nutritional
habits of infants and mothers
Reisine 1993 said that knowledge about ECC and its
prevention could be increased by educational programs for
low income mothers and found a positive change in their
attitude and knowledge about ECC compared with control
mothers
Reisine S and Douglas J: psychological and behaviour issues in early childhood
caries. Com. Dent. Oral epidemol. 1998;26: suppl.1 32-44
5

6. Parents/Caregivers education
6
 Educating parents regarding the causes and
prevention of ECC for their children is necessary
 Family‐centered and customized
recommendations have been shown to be more
successful in engaging parents to change specific
parenting practices than such generic
recommendations such as “brush your teeth
twice a day” and “don't eat candy”

7. 7
Message in educational programs
Target should be on mothers
Importance of Fluorides, supervised tooth brushing
with fluoridated tooth paste
Silver 1987 and Rossow 1990 said that mothers are the
primary promoters of oral hygiene practices and they
have a major influence on the dietary habits and food
choices of infants, toddlers and children
•Remind parents and care givers to clean their teeth with soft
brush or moist cloth as soon as it erupts
• Feeding practices and oral health education
Silver D H: A longitudinal study of infant feeding practices diet and caries related to social class in
children aged 3 and 8-10yrs. Br. Dent . Journal 1987 ;163: 296-300
Rossow I, intrafamilial influences on health behaviour: a study of interdental cleaning behaviour. J.
CLIN. Periodontology, 1992; 19: 774-778

8. MOTIVATIONAL INTERVIEWING
8
 One possible method to enhance health
behavioural change is motivational interviewing.
 This counselling technique relies on two‐way
communication, rapport and trust between the
clinician and the parent/caregiver.
 Following the interviewing, the parent/caregiver
may be asked to commit to self‐management
goals that will be discussed at the child's
subsequent appointment

9. WATER
FLUORIDATION
SALT
FLUORIDATION
MILK
FLUORIDATION
COMMUNITY
FLUORIDATION
9

10. COMMUNITY WATER
FLUORIDATION
10
 Community water fluoridation (CWF) is the
process of adjusting the amount of fluoride found
in water to achieve optimal prevention of dental
caries (Centers for Disease Control and
Prevention 2016).
 The fluoride concentration of water in CWF
programmes typically ranges from 0.5 to
1.1 mg/L.
 The recommended ratio of fluoride to water is 0.7
parts per million (ppm), which results from years
of scientific analysis of the amount of fluoride
people receive from all sources. This
recommendation replaces the previous
recommended range of 0.7 to 1.2 ppm issued in

11. COMMUNITY WATER FLUORIDATION
11
• It helps for children with low socio economic
status
• Only prevention that doesn't require dental
visit or parental motivation
• Strong evidence to support water fluoridation
in prevention of dental caries in primary
dentition

12. SALT FLUORIDATION
12
 Traditionally, the fluoridation of salt has been
considered as an effective method for reducing
caries, especially in areas where water fluoridation
cannot be implemented
 Salt fluoridation is suggested (Pollick 2013;
O’Mullane et al. 2016) when water fluoridation
cannot be implemented, but one concern is that
promotion of salt consumption for oral health
benefits would be contradictory to the desired
reduction of consumption of salt to decrease the risk
of hypertension, and the drawbacks related to
variation in ingestion resulted in difficulties in
maintaining an ideal concentration.

13. MILK FLUORIDATION
13
 Milk fluoridation has been reported to be
successful in dental caries prevention, particularly
among children, and schemes have been
developed in countries around the globe based
on integration with school health and nutrition
programmes (Jürgensen and Petersen 2013).
 Fluoridated milk is only ingested by children on
school days and therefore not at weekends and
school holidays

14. RECOMMENDATION FOR MILK
AND SALT FLUORIDATION
14
 Fluoridated milk and fluoridated salt could be part
of community health programmes in target groups
with high caries prevalence and low compliance
for tooth brushing with fluoridated toothpaste in
areas without water fluoridation
Toumba KJ, Twetman S, Splieth C, Parnell C, Van Loveren C,
Lygidakis NΑ. Guidelines on the use of fluoride for caries
prevention in children: an updated EAPD policy document.
European Archives of Paediatric Dentistry. 2019 Dec
1;20(6):507-16.

15. PROFESSIONAL METHODS
15
1.Early dental examination
Early dental examination is very important to prevent
ECC
The first dental visit is recommended by 12 months of
age, or within 6 months of the first tooth coming in. The
first visit often lasts 30 to 45 minutes. Depending on
your child's age, the visit may include a full exam of the
teeth, jaws, bite, gums, and oral tissues to check growth
and development.
At or before the age of 1 year - white demineralization
area – indicates high caries cavity

16. 2. DIET COUNSELLING
16
Diet is a combination of breast milk and solid food
By 1 year child should be having 4 feed / day
By 2 year child self selects food and eating
habits are fixed and difficulty to change
AAP suggest that “ nocturnal breast feeding should be
avoided after the first primary teeth begins to erupt”
“ Breast feeding should be done for one year”
American academy of pediatrics. Breast feeding and the use of human milk.
Pediatrics.1997:1001:1035-1039

17. 17
 Children should be weaned from breast or bottle feeding by 12-
14 month of age
 Sippy cups with cariogenic substrate consumption should not be
recommended
 Diet counselling:
-Soft spell approach
-Should not take place near chair side
-Suitable alternatives should be provided
-Follow up and reinforcement in home care to control plaque is
important for
long term prevention

18. 3. PRE NATAL COUNSELLING
18
 Pregnancy is an ideal period to promote ECC
prevention given the profound influence of
maternal oral health and behaviors on children’s
oral health
 Studies have shown that maternal untreated
caries and greater level of salivary S.
mutans increase the risk of ECC in children.
 Children’s dietary and oral hygiene behaviors rely
on parents or caregivers’ oral health knowledge,
beliefs and behaviors [Finlayson et al]

19. 4.REGULAR FLUORIDE
APPLICATIONS
19
FLUORIDE GELS
FLUORIDE RINSE
FLUORIDE
VARNISHES

20. GELS
20
Fluoride gels: Fluoride deficient communities with
high risk for caries
Caution: Children who have not mastered
swallowing reflex

21. FLUORIDE RINSE
21
•Fluoride mouth rinses: children only above 6yrs or older, high risk
children with prosthetic appliances or with children with special health
care needs those with reduced salivary flow.
• 0.05% NaF for daily use or 0.2%NaF solution for weekly use. Swish
and expectorate regimen is effective
Toumba KJ, Twetman S, Splieth C, Parnell C, Van Loveren C, Lygidakis NΑ. Guidelines on the use of fluoride for caries prevention in
children: an updated EAPD policy document. European Archives of Paediatric Dentistry. 2019 Dec 1;20(6):507-16.

22. Professionally applied fluoride varnish
22
1.DURAPHAT VARNISH
2. CLINPRO WHITE VARNISH
3.EMBRACE VARNISH
4. MI VARNISH

23. HOME CARE METHODS
23
•Fluoridated toothpaste
•Non dental professionals
•Oral hygiene

24. FLUORIDE TOOTHPASTE
24
 Fluoride dentifrice:Twice daily under
supervision
Children < 2yrs -
Smear
Children 2-6 yrs - pea-
size
Children > 6yrs -
regular

25. 25
 The widespread use of fluoride toothpastes has most
likely been one of the major reasons for the reduction of
dental caries recorded over the past 40 years. Tooth
brushing with fluoride toothpaste is close to an ideal
public health method being convenient, inexpensive,
culturally approved and widespread (Burt 2008)
POTENTIAL HARM
 One problem with young children’s use of toothpaste
is that they swallow some paste with a subsequent
risk of fluorosis (Wong et al. 2011). Fluoride
toothpaste may be responsible for up to 80% of the
“optimal” total daily intake of fluoride (Mejare 2018)
and the first 3 years of life seems most critical.
Therefore, parents must be strongly advised to apply
an age-related amount of toothpaste and
assist/supervise tooth brushing until at least 7 years
of age.

26. 26
 Tooth brushing should be conducted so each
tooth surface is reached and brushing should
exceed 1 min, also in preschool children.
 Children should avoid rinsing with a lot of water
afterwards.
 Children’s teeth should be brushed using either a
soft manual or power toothbrush.

27. ORAL HYGIENE
27
 Small head and soft round bristles with a smear layer of tooth
paste should be used
 Positions
Sitting on the floor
• Child on the floor with seated position and sit behind him
on chair. Lean child's head on your knee
• Uncooperative - gently place your legs on him to keep still
On a bed or sofa
• Place the child on bed or sofa with head on your lap.
support his head and shoulders with your arm
• Uncooperative – second person can gently old hand and
feet
On a bean bag chair
• Sitting on bean bag will relax the child without fear of falling

28. 28
Lying on the floor
• Place the child on the floor lying position with the head on
a pillow
• Kneel behind the child to brush
In a wheel chair
• Stand behind the wheel chair, use your arm to brace
the child’s head
• You can use pillow if necessary
Fluoride tooth brushing
recommendations
American academy of pediatrics. A pediatric guide to children’s oral health. Elk Grove

29. NON DENTAL
PROFESSIONALS
29
 Paediatricians, nurses, obstetricians, and family
physicians generally see the caregiver and their
child much earlier than oral healthcare
professionals.
 Engaging these professionals in collaborative
care with oral health professionals and delegating
areas of care pathways to the interprofessional
team can provide better outcomes for preventing
ECC

30. TREATMENT
MEASURES
INVASIVE
RESTORATIONS EXTRACTION PULP THERAPY
MICROINVASIVE
RESIN
INFILTRATION
PIT AND FISSURE
SEALANTS
30

31. INVASIVE
MEASURES
RESTORATIONS
ANTERIOR
POSTERIOR
PULP THERAPY
VITAL PULP
THERAPY
NON VITAL PULP
THERAPY
31

32. ANTERIOR RESTORATIONS
32
 According to How to Intervene in the Caries
Process in Children: A Joint ORCA and EFCD
Expert Delphi Consensus Statement-
 Composite strip crowns or other preformed
crowns should be preferred over direct fillings
(GIC, composite, and others) in anterior upper
primary teeth of children with severe ECC

33. Composite Strip Crowns
33
• These are composite filled
celluloid crowns forms.
• Lack of tooth structure, & the
presence of moisture or
hemorrhage contributes to
compromised retention.

34. Advantages Disadvantages
It provides superior aesthetics & the
cost of materials are reasonable
It is extremely technique sensitive.
The time for placement is
reasonable.
Simple to fit and trim.
Adequate moisture control might
be difficult on an uncooperative
patient.
Leaves smooth shiny surface. Not recommended on patients
with a bruxism habit or a deep
bite.
34

35. Stainless steel crowns with facing
35
• The advent of composite
bonding, allowed for a
composite facing to be placed
on the facial surface of the
tooth, thus improving
aesthetics.
• Open faced stainless steel
crowns
durability
combine
and
strength,
improved
aesthetics

36. Advantages Disadvantages
The aesthetics are fair. The time for placement is
long.
They are very durable, wear
well and retentive.
Placement of the composite
facing may be compromised
when gingival hemorrhage
or moisture is present or
when the patient exhibits
less than ideal cooperation.
The materials are fairly
inexpensive.
36

37. NEW MILLENIUM CROWNS
37
• This is similar in form to
the pedo jacket and strip
crown, except that it is
lab enhanced composite
resin material.
• Like others, this is also
filled with resin material
and bonded to the tooth

38. Advantages Disadvantages
Esthetics Very expensive
compared to strip
crown and pedo jacket
crown.
Can be trimmed and
reshaped with high
speed finishing bur
Brittle
Adequate moisture
control
38

39. Polycarbonate Crowns
39
• These are heat-molded acrylic
resin shells that are adapted to
teeth with self cured acrylic resin.
• They were popular in the 1970’s,
however, although they were more
aesthetic than stainless steel
crowns the polycarbonate material
was:
i. brittle and
ii. did not resist strong
forces, exhibiting
abrasive
frequent
fracture and dislodgement.

40. Advantages Disadvantages
They are very aesthetic/U62 shade.
Greater durability & strength.
They are not recommended in
patients that are heavy bruxers.
They are not as technique sensitive
as composite strip crowns.
Greater tooth reduction is required.
Same amount of time to place as
SSC
Contours and crimp similar to
metal crowns.
40

41. PEDO JACKET
41
ADVANTAGES: DISADVANTAGES:
Crown placement can be
done in one sitting
Only one size and one color
available
Crown will not split, not stain
or crack.
Cannot be trimmed or
reshaped with high speed
finishing bur as the material
melt to bur
Can be trimmed with
scissors.

42. Pre-veneered Stainless Steel Crowns
42
• They were introduced in the mid
1990’s.
• Aesthetic
•Placement & cementation are not
significantly affected by hemorrhage
and saliva and can be placed in a
single appointment.

43. Advantages Disadvantages
They are aesthetically pleasing. They are 3 times more expensive
than stainless steel, strip and
polycarbonate crowns
They have the durability of a
steel crown.
As crimping is limited to lingual
surfaces there is not close
adaptation of crown to tooth.
There are reports of the veneer
facing fracturing, however it can
be easily repaired using the open
faced stainless steel crown
technique.
43

44. ZIRCONIA PEDIATRIC
CROWNS
44
Ceramic/
Zirconia
crowns
ZIRKIZ crown EZ crown Kinder krown

45. EZ CROWN
45
 They are metal-free prefabricated crowns which
are made of zirconia.
 They have superior esthetics, strength, durability,
and are completely bioinert.
 It is also resistant to decay and plaque
accumulation.

46. KINDER KROWN
46
 Kinder Krowns were introduced in 1989 and are
known for offering the most natural shades and
contour for the patient.
 Kinder Krowns aims to provide the most natural,
lifelike, and anatomically correct crown as
possible.
 They have a highly characterized incisal edge,
scientifically developed shades, and finely
feathered margins.
 The finely feathered margins help create an
esthetic emergence profile.

47. Invasive Treatment Recommendation
47
 EXTRACTION-
Due to the high failure rate of restorations in the
upper anterior teeth of children with severe ECC
and the lacking function as space maintainer for
the permanent dentition, the extraction of upper
anteriors can be a justified therapy. A
replacement, especially if a removable space
maintainer is incorporated for missing primary
molars, can be considered, especially for the
development of proper orofacial function

48. POSTERIOR RESTORATIONS
48
 Occlusal cavitated lesions should be restored
with a filling, preferably defect-orientated
composite after carious tissue removal, possibly
followed by sealing the remaining fissures
according to the caries risk.
 The traditional preparation “with extension for
prevention” involving the whole fissure system is
not advised

49. POSTERIOR
RESTORATIONS
ATRAUMATIC
RESTORATIVE
TREATMENT
COMPOSITE
RESTORATION
GIOMERS
HALL
TECHNIQUE
49

50. ATRAUMATIC RESTORATIVE
TREATMENT
50
 Unable to cooperatewith traditional operative
dentistry, The ART approach involves the use of
hand instruments only to remove carious tooth
substance and then restoring the cavity and sealing
any adjacent enamel fissures with usually a
conventional glass polyalkenoate (ionomer)
restorative cement (GIC).

51. • Tooth preparation is done
• Bevelling of cavosurface margins
• Enamel is etched with diluted phosphoric acid for
60 sec
• Look for frosty appearance
• Bonding agent is applied and cured
• Resin is inserted immediately and celluloid strip is
used to closely contour
COMPOSITE RESTORATION:
51

52. GIOMERS
52
Have characteristics similar to GIC but with
clinically demonstrated esthetics & durability
Composition – milled salinized glass
ionomer fillers, which has undergone
reaction b/w flouroaluminosilicate and
polyalkenoic acid before milling
Restoration of class 2 cavities have clinically
proven to have more longevity

53. HALL TECHNIQUE
53
 The Hall Technique without carious tissue
removal or selective caries excavation and
restoration seems advantageous in comparison
to complete nonselective carious tissue removal
in primary teeth without irreversible pulpal
involvement
 In proximal surfaces of primary molars without
irreversible pulpal inflammation, the HT is
significantly more successful than caries removal
and fillings

54. 54
MICRO-
INVASIVE
TREATMENT
RESIN
INFILTRATE
PIT AND
FISSURE
SEALANTS

55. RESIN INFILTRATE
55
Proximal
lesions

56. Etch with 15% HCl
Dry with Ethanol
Apply Infiltrant
56

57. Resin Infiltration in Primary Teeth
57
 The management of non-cavitated caries lesions
using the resin infiltration technique in primary teeth
differs from that in permanent teeth.
 Firstly, primary enamel is less mineralized, more
porous and aprismatic when compared to permanent
enamel. As a result, the diffusion coefficient seems to
be greater in primary enamel.
 In an in vitro study by Paris S et al., primary teeth
exhibited better infiltrant penetration than permanent
teeth, after 1 minute application of resin.
 On the other hand, 3–5 minutes are required to
almost completely infiltrate a natural lesion in
permanent teeth

58. PIT AND FISSURE SEALANTS
58
 Preventive sealants should be placed with low
viscosity resin composites. For teeth during
eruption and for problems with moisture control,
GIC can be used

59. SILVER DIAMINE FLUORIDE
59
 Dentine lesions in ECC without pulpal
involvement can be treated successfully with
silver diamine fluoride
 DISADVANTAGE- blackish discoloration

60. 60

61. 61

62. 62

63. CONCLUSION
63
 ECC is a significant public health problem, the
manifestations of which are symptomatic of
important underlying maternal and pediatric
problems.
 It has a debilitating effect on the development,
speech, general health and self-esteem of
infants.
 Traditionally the infant oral health care has been
neglected, which has lead to increased caries
incidence. Hence we being pediatric dentist
should look for early intervention of Early child
caries

64. REFERENCES
64
 Splieth CH, Banerjee A, Bottenberg P, Breschi L, Campus
G, Ekstrand KR, Giacaman RA, Haak R, Hannig M, Hickel
R, Juric H. How to intervene in the caries process in
children: a joint ORCA and EFCD expert delphi consensus
statement. Caries Research. 2020 Jul 1:1-9.
 Gordon Nikiforuk , Understanding dental caries, prevention
and management
 Toumba KJ, Twetman S, Splieth C, Parnell C, Van Loveren
C, Lygidakis NΑ. Guidelines on the use of fluoride for
caries prevention in children: an updated EAPD policy
document. European Archives of Paediatric Dentistry. 2019
Dec 1;20(6):507-16.
 Philip N. State of the art enamel remineralization systems:
the next frontier in caries management. Caries research.
2019;53(3):284-95.

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