early childhood caries

1. PREVENTION AND MANAGEMENT OF
EARLY CHILDHOOD CARIES
Presented By:
Dr. Louis Solaman Simon
1st year PGT

2. CONTENTS
• ANTICIPATORY GUIDANCE
• PRENATAL COUNSELLING
• PERINATAL COUNSELLING
• INFANT ORAL HEALTH CARE
• DENTAL HOME
• CARIES-RISK ASSESSMENT
• FLUORIDE THERAPY
• EFFECT OF ANTIMICROBIALS ON ORAL MICROBIOTA AND ECC
• CLASSIFICATION OF ECC AND IT’S MANAGEMENT
• BARRIERS TO CHILDHOOD CARIES TREATMENT

3. Caries-risk Assessment
(AAPD 2014)
• Caries risk assessment is the determination of the likelihood of the incidence
of caries during a certain time period or the likelihood that there will be a
change in the size or activity of lesions already present.
• Risk assessment:
1. Fosters the treatment of the disease process instead of treating the outcome of
the disease.
2. Gives an understanding of the disease factors for a specific patient and aids in
individualizing preventive discussions.
3. Individualizes, selects, and determines frequency of preventive and restorative
treatment for a patient.
4. Anticipates caries progression or stabilization.

7. Oral Health Risk Assessment Tool
The American Academy of Pediatrics (AAP)

10. Fluoride Therapy
• Fluoride has several caries-protective mechanisms of action.
– inhibit the demineralization
– enhance the re-mineralization
– affects the metabolic activity of cariogenic bacteria
• Water fluoridation at the level of 0.7-1.2 mg fluoride ion/L (ppm F) but
the Department of Health and Human Services recently has proposed to
not have a fluoride range, but rather to limit the recommendation to the
lower limit of 0.7 ppm F.
• The rationale is to balance the benefits of preventing dental caries while
reducing the chance of fluorosis.

11. • Fluoride supplements also are effective in reducing prevalence of dental
caries and should be considered for children at high caries risk who drink
fluoride deficient (less than 0.6 ppm F) water.
The optimal F intake from both & dietary sources should be 0.05mg/kg/day

12. .
• Using no more than a smear or rice-size amount of fluoridated toothpaste
for children less than 3 years of age.
• Using no more than a pea-size amount of fluoridated toothpaste is
appropriate for children aged three to six
• To maximize the beneficial effect of fluoride in the toothpaste, teeth
should be brushed twice a day, and rinsing after brushing should be kept
to a minimum

13. • Professionally-applied topical fluoride treatments
• 5% sodium fluoride varnish (NaF V; 22,500 ppm F) and
• 1.23 percent acidulated phosphate fluoride (APF; 12,300 ppm F).
• used at least twice a year
• Children at increased caries risk should receive a professional fluoride
treatment at least every six months.
• Other topical fluoride products
– 0.2 percent sodium fluoride (NaF) mouthrinse (900 ppm F)
– brush-on gels/pastes (eg, 1.1 percent NaF; 5,000 ppm F)
• AAPD 2014

14. Effect of antimicrobials on oral
microbiota and ECC.
Chlorhexidine (CHX):
• Some reports show a significant reduction in mutans streptococci (MS) at
an early stage of the intervention; however, after three months, the
reduction was diminished.
• Results from the systematic reviews presented show insufficient evidence
to conclude that the daily use of CHX alone or in combination with
fluoride application for an extensive period reduces the levels of MS or
lactobacillus (LB) or incident caries in young children.
(PEDIATRIC DENTISTRY V 37 / NO 3 MAY / JUN 15)
Povidone-iodine (PVP-I) :
• PVP-I has been explored as a topical antimicrobial therapy in the
prevention of dental caries in clinical studies.

16. Effect of xylitol on oral microbiota
and ECC.
• A meta analysis by Li and Tannner (2015) demonstrated that xylitol-based
interventions have resulted in a significant reduction of MS colonization
and caries in young children.
• Additionally, xylitol interventions in mothers aimed at affecting MS levels
and caries in their offspring show a marginal caries-protective effect
compared with non-xylitol intervention.
PEDIATRIC DENTISTRY V 37 / NO 3 MAY / JUN 15

18. Effect of silver compounds on oral
microbiota and ECC.
• For centuries, silver has been known to exhibit antimicrobial effects due to its
properties as a heavy metal.
• Renewed interest in the therapeutic application of silver diamine fluoride, silver
fluoride, nano-silver fluoride, and silver nitrate to arrest and prevent dental caries.
• There are several reports of silver compounds used at very high concentrations (30
to 38 percent) to affect ECC progression, but published studies to date have a high
risk of bias.
• Evidence from high quality randomized clinical trials is necessary before the use of
silver compounds become a recommended management approach for ECC.
• PEDIATRIC DENTISTRY V 37 / NO 3 MAY / JUN 15

20. Casein Phosphopeptide-Amorphous
Calcium Phosphate (CPP-ACP).
• CPP-ACP has been shown to reduce demineralization and promote
remineralization of carious lesions both in vitro and in situ.
• CPP-ACP cream, which is effective in remineralizing early enamel lesions of
primary teeth, was a little more effective than 500 ppm NaF .
• Moreover, additive effects were obtained when CPP-ACP was used in
conjunction with fluoride, CPP-ACP is better used as a self-applied topical
coating after the teeth have been brushed with a fluoridated toothpaste
by children who have a high risk of dental caries
• International Journal of Dentistry Volume 2011, Article ID 725320

23. Proposed by Veerkamp and Weerheijm [1995]
• This classification system assumes that dental caries occurs in
successive stages starting late in the first year (10 months) and ending
in the fourth year of life (48 months).
• Initial reversible stage age 10-20 months
• Damaged carious stage age 16-24 months
• Stage of deep lesions age 20-36 months
• Traumatic stage age 30-48 months

24. The initial stage (stage I)
• It is characterized by the appearance of chalky, opaque
demineralization lesions on the smooth surfaces of the maxillary
primary incisors when the child is between the ages of 10 and 20
months, or sometimes even younger
• At this stage, the lesions are reversible
• Lesions can be diagnosed only after the affected teeth have been
thoroughly dried

25. The second stage/damaged (carious): 16-24 mo
• The dentin is exposed and appears soft and yellow. The maxillary primary
molars present initial lesions in the cervical, proximal and occlusal regions

26. Deep lesion/stage 3 : 20-36 mo
• Pulpal involvement in maxillary incisors
• Molars are also affected.
• Frequent complaint of pain.
• Depending on the time of eruption, the cariogenicity of the sweetened
comforter and frequency of its use, this stage can be reached in 10-14
months also.

27. Traumatic stage/4th stage : 30-48 mo
 Neglecting all the previous symptoms, the teeth (starting with maxillary
incisors) can become so weakened by caries that relatively small forces
suffice to fracture them.
 Parents may report a history of trauma.
 Molars are now associated with pulpal problems.
 Maxilary incisors become non vital

28. A. Treatment of Stage I & II. Early
Childhood Caries.
• Conservative Phase:
• In stage I ECC, the child may be symptomless and the carious is
reversible. In such cases, no curative treatment is required.
• However, routine preventive measures like
– Diet counseling
– topical fluoride application,
– professional application of fluoride varnishes
– sugar free chewing gum, and
– Oral health education are employed.
• The caries should be monitored to ascertain that it remains in the
non- progressive stage until exfoliation.

29. .
• Restorative Phase:
• In stage II ECC the principal role of restorative treatment is to eliminate
active caries lesions to inhibit caries extension.
• Restorative treatment should always be used in conjunction with
preventive therapy, based on the child’s risk factors and age.
• The choices of restorative materials depend on:
– Site and extent of caries
– Level of child’s cooperation
– Whether permanent or temporary restoration.
– type of anesthesia to be used

30. • Stabilization:
• Materials of Choice for restoration & stabilization:
– Zinc-oxide Eugenol cements as temporary filling.
– Glassionomer cement in ART procedure
• Final Treatment
– Restoration of teeth using Glass ionomer cement or composite resins
– Pulpal therapy if indicated
– Stainless steel crowns for extensively damaged teeth. In young
children with high risk of caries, stainless steel crowns have been
shown to function better than multi-surface intra-oral restorations.
– Routine preventive Strategy.
• Follow up: Every 6 months

31. B. Treatment of Stage III & IV. Severe ECC
• Immediate treatment
• Children with acute S-ECC in stage III & IV often present with pain,
discomfort and infection, and may require medication including use of
antibiotics and analgesics.
• Systemic infection resulting from a local focus of dental infection should
be treated with antibiotics.
• Very Severe cases may require hospitalization prior to definitive
treatment.

32. .
• Stabilization Phase
• Identification and extraction without delay of teeth that are not indicated
for restoration or pulpal therapy.
• Palliative treatment of teeth that are to be preserved by endodontic
therapy to avoid further progress of the carious process

33. .
• Treatment Phase:
• Extraction of primary teeth and/or complete/partial pulpectomy and
restoration with stainless-steel crown.
• Clinical procedures in case of non-cooperative or medically compromised
patients may require the use of general anesthetics.

34. .
• Follow–up
• Routine preventive strategy.
• children with obvious signs of active oral disease or its predisposing factors
should be reviewed at 4- monthly intervals until well controlled
• Medically Compromised and other high-risk children should be reviewed
depending on the severity of their medical condition and oral findings.
• Reinforcement of appropriate preventive strategies for remineralization and
arrest of carious lesions should be carried out
• review should be carried out by the same clinician, where possible.
• International Journal of Health Sciences & Research 158 Vol.1; Issue: 2; Jan. 2012

36. Barriers to childhood caries treatment
 Child
Not able to cope very well with dental treatment
 Parents
Parents cannot control frequency of between meal
sugary foods and drinks
 Dentist
General dentist requires further training in pediatric dentistry
 Health care systems
payment, insurance