Ecc

EARLY CHILDHOOD CARIES
Dr Lilavanti Vaghela
MDS in Pediatric and preventive dentistry

Contents
• Introduction
• Various terminologies
• Definition
• Identifying patterns
• Biological mechanism of ECC
• Risk factors of ECC
• Consequences
• Prevalence studies
• AAPD policy

• Preventive treatment
• Rebalancing the oral cavity
• Preventing transmission
• Fluorides
• Establishment of dental home
• Anticipatory guidance
• Dietary recommendations
• Caries risk assesment and management
• Arresting carious lesion
• Conclusion
• References

Introduction
• Early childhood caries (ECC) is still one of the most prevalent diseases in children
worldwide.
• ECC does not only aﬀect children’s oral health, but also the general health of
children.
• With ECC not only oral pain , orthodontic problems, and enamel defects, but also
problems with eating and speaking can occur as well as an increased risk for
caries development in the permanent dentition.
EarlyChildhoodCaries:Epidemiology,Aetiology,andPrevention
International Journal of Dentistry Volume 2018, Article ID 1415873, 7 pages
https://doi.org/10.1155/2018/1415873

• Thus , ECC leads not only to temporary pain, but more importantly has major
eﬀects on the quality of life of the family/caregivers including ﬁnancial and health
implications.
EarlyChildhoodCaries:Epidemiology,Aetiology,andPrevention
International Journal of Dentistry Volume 2018, Article ID 1415873, 7 pages
https://doi.org/10.1155/2018/1415873

• 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.
J BERG,R SLAYTON,EARLY CHILDHOOD ORAL HEALTH,2009

• Beltrami 1930 recognized a typical pattern of early caries as
“les dents noire de tout-petit” - “black teeth of the very young”
• 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.

• 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.

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.

• According to Davies (1998)
Early childhood caries is a complex disease involving maxillary primary incisors
within a month after eruption and spread rapidly to involve other primary teeth
• According to Amid Ismail (1998)
ECC is defined as occurrence of any sign of dental caries on any tooth surface
during the first 3 years of life.

• In 1999, A workshop, convened by the national institute of dental and
craniofacial research,proposed that the term early childhood caries (ECC)
should be used to describe
“The presence of one 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.”

AAPD 2016
The disease of ECC Is the presence of one or more decayed (noncavitated or
cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary
tooth in a child under the age of six.

Severe-ECC
• In children younger than three years of age, any sign of smooth-surface caries is
indicative of severe early childhood caries (S-ECC ).
• From ages three to five, one or more cavitated, missing (due to caries), or filled
smooth surfaces in primary maxillary anterior teeth
Or a decayed, missing, or filled score of greater than or equal to 4 (age 3),
Greater than or equal to 5 (age 4),
Or greater than or equal to 6 (age 5) surfaces also constitutes S-ECC

TERMINOLOGIES
• Metarnally derived st. mutans disease
• 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 Dental Decay
• Severe Early Childhood Caries (S-ECC)

RAMPANT CARIES ECC
Acute, wide spread caries with early pulpal involvement
of teeth which are usually immune to dacay.
Specific form of rampant caries
Age – all Infants and toddlers
Dentition – both Primary
Characteristic feature
• Surfaces consider immune to dacay are involved, so
mandi incisors are affected
Mandi incisors are not involved
Multifactorial Several factors , primarily related to improper feeding
practices
T|t –Generally required pulp therapy if detected in early stages , can be managed by topical f-
application
• Directed toward maintenance of teeth till the
transion occurs
Prevention – Dental health education at a mass level
involving people at all ages
education of prospective and mothers is desired
specifically

Classification
Rule (1982):
Occlusal, posterior proximal, anterior proximal, Facial and lingual

WAYNE H 1999
Type –I (mild to moderate ECC) :
• Age 2 – 5 years
• 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

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.

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.

Veerkamp and weerheijm 1995
STAGE AGE FEATURES
Initial 10-18 months Cervically and occasionally interproximal areas of
chalky white demineralization
No pain
Damaged 18-24 months Lesions in the maxillary anterior teeth ,may spread
to dentin and show yellowish discoloration
Hypersensistivity on hot and cold food intake
Deep 24-36 months Molars are also affected
Frequent complain of pain
Pulpally involved maxillary incisors
Traumatic 36-48 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

Stage 1 : initial reversible stage
Stage 2 : damaged stage

Stage 3 Deep Lesion
Stage 4: Traumatic stage

Identifying patterns of ECC
• Two approaches to identifying caries patterns in young children
1. start with presumed pattern that are based on knowledge of caries etiology
and then fits the clinically observed distributions of cavities in to those
patterns. ( Johnsen et al, 1987)
Type of tooth surfaces
• Pit and fissure
• Hypoplasia
• Faciolingual
• Molar approximal
• Faciolingual + molar approximal

2. Presumes no patterns a priori but simply asks the computer to cluster cavity
occurrence into patterns based on how frequently lesions tend to occur
together.
• This computerized classification technique is called “Multi-dimensional scaling”

• This approach identified a similar set of patterns, which were more tooth-type
specific and were termed , ( psoter at al, 2003)

• This approach partially explained ECC variants as being influenced by the
sequence of primary tooth eruption and noted a specific progression by tooth
type and age .

• No single taxonomy has succeeded in capturing all young children’s clinical
presentations.
• However, distinguishing at least the following 3 overall patterns holds strong
utility for diagnosis and disease management:
1. Nursing habit associated pattern/maxillary anterior pattern/faciolingual
pattern/faciolingual molar apttern.
2. Molar occlusal/pit and fissure patterns and hypoplasia pattern
3. Molar proximal pattern

1. Nursing habit associated pattern ( Grindefjord et al, 1995)
• Earliest
• Most aggressive
• Most destructive
• Most consequential pattern

• Identified clinically first as soft glutinous plaque accumulation at the gingival
margin of maxi incisiors
• Then calcified bands underlying that plaque
• Soon there after facial and lingual cavitation of maxillary incisors

• The sequence of teeth affected by this subset of ECC typically follows the
sequence of primary tooth eruption with the exception of the relative immunity
of the mandibular incisors.
• The lower incisors are physically protected by lip and tongue and kept awash in
protective saliva from the sublingual and labial mucosal salivary glands.
• Thus, a common progression begins on the smooth surfaces of
• maxillary central incisors
• Maxi lateral incisors
• Maxi 1st primary molar
• Mandi 1st primary molar
• Maxi canines
• 2nd primary molars

2. Molar occlusal/ pit and fissure patterns and hypoplasia pattern
• Related to the irregularities in the surfaces of primary teeth
• Associated with/ without nursing habit pattern
• Frequently associated with cariogenic solid food which become mechanically
retained in these defects

• Hypoplastic enamel, commonly observed on the facial aspects of mandi primary
canines but also the 2nd primary molars.

3. Molar proximal pattern
• Classically associated with lack of interdental spacing
• Also occurs as smooth surface lesions in the presence of intermolar spacing when
the nursing habit associated pattern is extensive.

• The inter-molar space if present early in the primary dentition, typically close as
the 1st permanent molars move into place when children reach the end of the
early childhood period.
• So, children who erupt their 1st permanent molars prior to their 6th birthday are
more susceptible to this ECC pattern.

Caries analysis system (CAS)
• It is another approach to distinguish ECC pattern within the dentitions of
individual children.
• This system utilizes the traditional, circular tooth surface charting from and
differentiates each ECC subtype by using shading schemes for each pattern.
• parameters - Prevalence
Severity
Distribution
Douglass et al: Community Dent Oral Epidemiol 1994 22:94-9

Douglass et al: Community Dent Oral Epidemiol 1994 22:94-9

• An alternative clinical approach to assessing the occurrence , extend, and impact
of ECC could distribute tooth surface from each of the three patterns as concentric
rings.
• Maxillary anterior pattern – 1st ring
( which would be located at the center of the chart—typically happens first )
• occlusal pattern- 2nd ring
(cavitation may then sequentially “spread” outward through the dentition next to
the occlusal pattern)

• Molar proximal pattern- 3rd ring
• Such a chart could also indicate the next teeth that are most likely to be
affected if the underlying caries process is not arrested.

Factors affecting patterns of ECC
3 factors:
• the chronology of primary tooth eruption
• the duration of the deleterious habit
• the muscular pattern of infant sucking.
NURSING CARIES: Ripa: Pediatric Dentistry: December, 1988 ~ Volume 10, Number 4

The Chronology Of Primary Tooth Eruption
• The primary incisors erupt by 1 year, the canines and first molars before 2, and the
second primary molars by 2 years, 6 months ( lunt and law 1974).
• The maxillary incisors, which are among the first to erupt, will be the first to
experience the cariogenic challenge and will suffer the longest caries attack.

• If the habit continues, the other teeth will be subjected to the cariogenic
challenge in sequence with their eruption order.
• Conversely, if the habit is discontinued by 1 year, 6 months to 2 years, newly
erupted teeth, such as the canines and first molars, may be minimally affected,
and the unerupted second molars would not be affected at all.

The Duration Of The Deleterious Habit
• If the liquid is consumed frequently and for prolonged periods during the day or
night, the liquid will pool around the teeth (kroll and stone 1967; picton and
wiltshear 1970; dilley et al. 1980).
• If the liquid contains a fermentable carbohydrate it will be metabolized by oral
microorganisms into organic acids that demineralize the teeth.

The Muscular Pattern Of Infant Sucking
• During sucking, the natural or artificial nipple rests against the palate, while the
tongue is extended over the lower incisors.
• Liquid from the nursing bottle or a mother's breast will bathe all of the teeth except
the lower incisors which are physically protected by the tongue.

BIOLOGICAL MECHANISMS OF ECC
BIOLOGICAL MECHANISMS OF ECC Davies 1998

All carious lesions, including those associated with nursing caries, result
from the interaction among 4 variables:
(1) pathogenic microorganisms in the Mouth
(2) fermentable carbohydrates that the microorganisms metabolize to
organic acids
(3) tooth surfaces that are susceptible to acid dissolution
(4) time

DENTAL PLAQUE
• In absence of fermentable carohdrates
Organic acids like acetate, propionate
and butyrate are produced
▪ On presence of fermentable
carbohydrates
LACTATE is mainly produced, which
drops pH in plaque
▪ The presence of early plaque and its early accumulation have been related
to caries occurrence among children (Tinanoff et al 2002)
Berkowitz RJ. Mutans streptococci: Acquisition and transmission. Pediatr Dent 2006;28(2):106-9.

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 in 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.

Microbial Characteristics of ECC
• Bacteriologic studies have demonstrated that in children with ECC, streptococcus
mutans regularly exceeded 30% of the cultivable plaque flora. This dense level of
dental infection was associated with carious lesions, white spot lesions and sound
tooth surfaces near the lesions.
• Conversely, S. Mutans typically constitutes less than 0.1% of the plaque flora in
children with negligible to no caries activity.
• So ECC is an infectious disease and that S. MUTANS is the most likely infectious
agent

Early Acquisition of S. mutans:
• The mouth of a normal pre-dentate infant contains only mucosal
surfaces exposed to salivary fluid flow.
• S. Mutans could persist in such an environment by forming adherent
colonies on mucosal surfaces or by living free in the saliva and
duplicating at a rate exceeding the washout rate of salivary flow.

• Because the oral flora averages only 2 to 4 divisions per day and swallowing
occurs every few minutes, it is reasonable to assume that bacteria cannot
maintain themselves in saliva by proliferation, but instead must become
attached to an oral surface.
• S.Mutans has a feeble capacity to become attached to epithelial surfaces.
Therefore, it seemed unlikely that these organisms could colonize the mouth of
a normal infant before the eruption of teeth

• Karn T et al 1998 stated that MS prevalence in a population of 149 inner city
infants , Evidence of MS was seen as early as 10 months of age. For children 12
months old, 25% had detectable MS levels; in the 15-month-old age group,
60% were colonized.
• Earlier many clinical studies reported that S. Mutans could not be detected in
the mouths of normal predentate infants; instead, the organisms were found
only after the insertion of acrylic cleft palate obturators or eruption of primary
teeth.
• Accordingly, the concept that S. Mutans required a non-shedding oral surface
for persistent oral colonization became a basic tenet of oral microbial ecology

S. Mutans can colonize the mouths of predentate infants; the furrows of the
tongue appear to be an important ecological niche.
Tanner and others, using DNA probe technology, reported that S. Mutans was
present in 55% of plaque samples and 70% of tongue scraping samples of 57
children 6–18 months of age
Berkowitz et all :Mutans Streptococci: Acquisition and Transmission: Pediatric Dentistry – 28:2 2006

Early Acquisition of S. mutans and Dental Caries
• Early colonization by S. Mutans is a major risk factor for ECC as well as future dental caries.
• Gindefjord and others evaluated 786 children at 1 year of age for caries risk factors (s.
Mutans infection, exposure to fluoride, dietary habits, oral hygiene) and re-examined them
at 3.5 years of age for the presence of dental caries.
• The presence of s. Mutans at 1 year of age was the most effective predictor of caries at 3.5
years of age

Transmission of S. mutans:
• The major reservoir - mothers.
• S. mutans strains isolated from mothers and their babies exhibited
similar or identical bacteriocin profiles and identical plasmid or
chromosomal DNA patterns.
Caufield PW, Ratanpridakul K, et al. Plasmid-containing strains of Streptococcus mutans cluster within family and racial cohorts: Implication in natural transmission. Infect Immun
1988;56:3216-3220.

Berkowitz and others reported that the
• Frequency of infant infection was approximately 9 times greater when maternal
salivary levels of the organism exceeded 105 colony-forming units (cfu)/ml than
when maternal salivary reservoirs were less than or equal to 10 3 cfu/ml (58% vs.
6%).
• Suppression of maternal reservoirs of S. Mutans prevented or delayed infant
infection,
• Only 3 (11%) of 28 babies whose mothers underwent suppression of the s. Mutans
reservoir (by dental treatment and topical antimicrobial therapy) were infected by
23 months of age; in contrast, 17 (45%) of 38 babies in the control group (whose
mothers did not undergo S. Mutans suppression) were infected.

• More likely if mother has decay
• Passed from caregiver to child through
• food/drink and kissing
• utensils
• toothbrushes
• Blowing or pre-chewing food

HORIZONTAL TRANSMISSION
• Horizontal transmission is the transmission of microbes between members of a group
(eg, family members of a similar age or students in a classroom).
• More recent reports indicate that vertical transmission is not the only vector by which
ms are perpetuated in human populations.
• Horizontal transmission also occurs.

• Mattos-graner and others isolated S. Mutans from groups of nursery school
children (12–30months of age) and genotyped the isolates with primed
polymerase chain reaction and restriction fragment-length polymorphism
analysis.
• Many children had identical genotypes of S. Mutans , which indicated that
horizontal transmission may be another vector for acquisition of these
organisms.

• Van Loveren and others, using bacteriocin typing, demonstrated that when a child
acquires S. Mutans after the age of 5 years, there may be similarity in S. Mutans strains
in mother, father and child, which indicates that horizontal transmission can also occur
among family members

• Caufield and coworkers (1993)
found that initial acquisition of mutans streptococcus in 38 out of 46 children
occurred at a median age of 26 months, ranging from 19-31 months coinciding
with the emergence of primary molars
WINDOW OF INFECTIVITY IS Combination of
• Frequent and close maternal contacts.
• Cessation of lactation with its protective antibodies.
• An immature immune response.

Virulence Of Streptococci Mutans
• The main virulence factors associated with cariogenicity include adhesion,
acidogenicity, and acid tolerance.
• Each of these properties works coordinately to alter dental plaque ecology.
• The ecological changes are characterized by increased proportions of S. mutans
and other species that are similarly acidogenic and aciduric.
VIRULENCE PROPERTIES OF STREPTOCOCCUS MUTANS
Jeffrey A. Banas Frontiers in Bioscience 9, 1267-1277, May 1, 2004

• Adhesion - sucrose independent adhesion
- sucrose dependent adhesion
Sucrose independent adhesion
• Sucrose-independent adhesion of S. mutans is thought to be most profoundly
influenced by antigen I/II, a 185kDa surface protein.
• Similar proteins are found on most oral streptococci and have been designated by
a variety of names including P1, SpaP, Sr, PAc, and antigen B.

Sucrose-Dependent Adhesion
• The action of glucosyltransferases (GTFs) in the synthesis of glucans is the major
mechanism behind sucrose-dependent adhesion.
• The GTFs possess a sucrase activity that results in the splitting of sucrose, the
only natural substrate for the GTFs, into glucose and fructose
• The glucose moiety is then added to a growing polymer of glucan.
• S. mutans possesses three GTFs encoded by gtfB, gtfC, and gtfD

Acidogenicity
• S. mutans contains a complete glycolytic pathway and can produce lactate,
formate, acetate, and ethanol as fermentation products.
• Fermentation products will depend on growth conditions with lactate being the
major product when glucose is abundant.
• The velocity with which S. mutans produces acid when tested at a pH in the range
from 7.0 to 5.0 exceeds that of other oral streptococci in most instances

• S. mutans leads to ecological changes in the plaque flora that includes an
elevation in the proportion of S. mutans and other acidogenic and acid-tolerant
species.
• cariogenic flora will reduce plaque pH to lower levels than will a healthy plaque
flora upon the ingestion of fermentable carbohydrate, and the recovery to a
neutral pH will be prolonged.
• Sustained plaque pH values below 5.4 favor the demineralization of enamel and
the development of dental caries.

Acid-tolerance
• Accompanying the acidogenicity of S. mutans is its aciduricity or acid-tolerance.
• S. mutans retains glycolytic capabilities even at pH levels that are growth
inhibitory (as low as pH 4.4)
• The acid tolerance of S. mutans is largely mediated by an F1F0-ATPase proton
pump but also involves adaptation with an accompanying change in gene and
protein expression.
• Together they constitute the acidtolerance response (ATR).

S.mutans produce large amounts of acid particularly lactic acid, which
are potent in tooth demineralization.
Aciduricity or acid tolerance of bacteria is extremely high, thus
allowing colonization and persistence under cariogenic conditions.
It has been suggested that production of dextranase allows the
invasion of mutans streptococci to replace earlier colonizing, dextran
producing bacteria such as s.mitis and s.sanguis.
SM produces – mutacins which inhibit growth of other
streptococci and gram positive organisms by stopping enzyme
functions & generation of ATP.

Lactobacilli
▪ Most acidouric and acidogenic
▪ Number directly co-relates with caries experience
▪ Brown (1985)bacteria are found in relatively high proportions in cavitated lesions –
role in progression, rather than in initiation of disease.
▪ Van houte et al In clinical studies of preschool children there is generally a low
frequency of isolation of lactobacillus form plaque

INFANT FEEDING PATTERNS
• Prolonged bottle feeding at bed time associated with ECC
• But other factors are also associated
• Bottle feeding beyond the 1 yr is a major caries risk factor.
• Children with caries eliminated bottle feeding 4 – 7 months later than caries free
children (marino rv et al 1989)
• Prolonged breast feeding also associated with the ECC

Difference between breast feeding and bottle feeding
Sucking on the Breast and on the Bottle Dr Peter P W Weiss ,july 2013
➢ Attachment
➢ Sucking pressure
➢ Muscular activity
➢ Volume of Feed Ingested
➢ Holes

Volume of Feed Ingested--. In bottle fed infants, there appears to be a linear
pattern of milk intake over the first 10 min of feeding, by which time 81% of the
feed has been consumed.
• This contrasts with a two-phase intake pattern in breast fed infants in whom a
total 84% of the feed was consumed either in the first 4 min or between 15 and
19 min after the start of the feed.
Sucking on the Breast and on the Bottle Dr Peter P W Weiss ,july 2013

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 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.

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
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
(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.

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

Saliva
• PROVIDES THE
MAIN HOST
DEFENCE
• Organic compounds which agglutinate
oral bacteria and enhance theiir
removal
• These aggutinins include
mucins,agglutinating
glycoproteins,fibronectin,lysozyme 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

The Stephan Curve describes the changes in plaque pH in response to
cariogenic activity.
An initial rapid drop in plaque pH is observed which is dependent on the
speed with which plaque microbes are able to metabolise sucrose,
producing acid as a by-product which lowers pH.
The lowest pH attained depends:
• on the types of microbials in the plaque
• the nature of the fermentable carbohydrate
• the rate of diffusion of substrates and metabolites in and out of the
plaque.
The Stephan Curve
Saliva –a review of its role in maintaining oral health and preventing dental disease.-micheal dodds,british dental journal

Sugar clock
• An important factor in the prevention of dental caries is limiting the number of
times in a day that sugar enters the mouth.
• This can simply illustrated by using the sugar clock
• Fuller ss at al , 1991 concluded that the sugar clock is an effective method of
teaching the importance of limiting frequency of sugar intake ( 9-11yr )
The use of the sugar clock in dental health education, Fuller SS, et al Br Dent J. 1991

www.dentalhealth.ie, demtal health foundation

• The concept of sugar clock must be stressed upon. This means we must explain
to the parents/caretaker, the importance of abstaining from frequent snaking
through the day.
• It helps to reduce the intermittent food intake.
• This will decrease the amount of time the pH of oral fluids remains below the
critical pH(5.2-5.5)and thus fewer , demineralization attacks on the tooth
surface.
Importance of diet counselling to prevent dental caries ,Das saumalyaat al,2018

Importance of diet counselling to prevent dental caries ,Das saumalyaat al,2018

DIET
• 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.

SOHN et al 2006 High carbohydrate soft drink group had higher caries
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.

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
DENTISTRY FOR THE CHILD AND ADOLOSCENT. MCDONALD, DEAN, AVERY. 10TH EDITION.
ELSEVIER .MOSBY

Frequency Of Consumption
Increases acidity of
plaque and enhances
establishment and
dominance of the
aciduric mutants
streptococci
Enamel
demineralization
increases and
inadequate
remineralization
Demineraliztion
becomes
predominant
mechanism
ELSEVIER .MOSBY

Oral clearance of carbohydrates
• The low salivary rate during sleep decreases oral clearance of the sugars and
increases the length of contact time between plaque and substrate.
• 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
DENTISTRY FOR THE CHILD AND ADOLOSCENT. MCDONALD, DEAN, AVERY. 10TH EDITION. ELSEVIER .MOSBY

Fluorides
• Low concentration of fluoride affects the demineralization process by:
• Decreasing the rate of subsurface dissolution
• Enhancing the deposition fluoridated apatite in the surface zone.
• Direct inhibitor of enzymes, affect the metabolism of the s. Mutans
ELSEVIER .MOSBY

Secondary Factors Associated With ECC

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
• 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.

Social determinants of ECC
• Successful prevention and management of ECC will require effective stratergies
that consider not only the biologic but also the underlying
social
sociopsychological
socioeconomical
socioenvironmental --- causes of illness known as
social determinants of health.

• SDH describe the conditions in which people live and work and may include a
range of non biological factors in the contexts of the child’s family, community and
society
• Disease risk and protective factors include inherent characteristics such as age,
gender, race and ethnicity.
• Acquired characteristics such as education, occupation, employment, income,
religion and housing
• Psychosocial risk factors consist of low self-esteem, low self efficacy, depression ,
anxiety, insecurity , stress, isolation etc.

Socioeconomic STATUS
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 among preschool children of low SES in district Srinagar was
39.9%
A GADHIANE
2013(aanganwadi, WARDHA)
33.48% children were having ECC

RACE AND ETHINICITY
• 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
AAPD.INFANT ORAL HEALTH CARE.PEDIATR DENT,1994;16:29

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

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) 16%
VASUDHA SODANI 2016(VADODRA) 59.8%
SHIKHA DOGRA 2018(HIMACHAL PRADESH) 55.38%

AAPD Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment
Options 2016
• The 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
REFERENCE MANUAL V 38 / NO 6 16 / 17

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.

AAPD GUIDELINES
1. 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.
• Desired breast-feeding after the first primary tooth begins to erupt and other
dietary carbohydrates are introduced.
• Baby bottle use after 12-18 months.
Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies, REFERENCE MANUAL V 38 / NO 6 16 / 17

2. 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.

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.

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
REFERENCE MANUAL V 38 / NO 6 16 / 17

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. Casamassimo,Fields,Mctigue,Nowak.5th edition. Elsevier.Mosby

• Eliminating saliva-sharing activities (eg, sharing utensils, orally cleansing a
pacifier) may help decrease an infant’s or toddler’s acquisition of cariogenic
microbes.

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 pertinent ,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:

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

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
2001;107(5):1210-3. Reaffirmed October, 2006.

• 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.
Policy on Dietary Recommendations for Infants, Children, and Adolescents REFERENCE MANUAL V 38
/ NO 6 16 / 17

• 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.

Fluoride dentifrice
• The use of ant cariogenic 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.

Pacifier and ECC
• A pacifier (dummy) sucking is one of the most common nonnutritive sucking
habits.
• It is a nursing object that has an imperforated nipple, such a device used by
many infants and children to provide a sense of comfort, security and pleasure
Pacifier Sucking Habit and its Relation to Dental Caries and Type of Feeding Habits among Group of Children (Comparative Study)
AseelHaidar Al-Assadi1, Zainab A.A. Al-Dahan2 International Journal of Science and Research (IJSR) · July 2017

• Prolonged pacifier sucking habit may produce deleterious effects ,especially if it
persists beyond 3 years of age , including interruption of breast-feeding, or even
its cessation , recurrent otitis media , candidal infection and thrush.
• In addition, it may act as a predisposing factor that may increase the chance of
developing dental caries.

• One of the microorganisms responsible for dental caries is lactobacilli which are
aciduricacidogenic bacteria that present in large number in the mouths of
pacifier sucking children.
• Salivary lactobacilli counts are useful in the prediction of future cariesactivity.
• The use of pacifier increase the occurrence of salivary lactobacilli and it could
therefore be a factor influencing caries susceptibility and activity in children
• In addition, pacifier use often associated with a negligent attitude toward the
child's tooth brushing.

Pacifier use and early childhood caries: an evidencebased study of the literature. J Can Dent Assoc
2003; 69:16–19

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 6 years is 5% sodium fluoride varnish (nafv; 22,500
ppm f)

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

Caries risk assessment
• AAPD recognizes that caries-risk assessment and management protocols can
assist clinicians with decisions regarding treatment based upon caries risk and
patient compliance and are essential elements of contemporary clinical care for
infants, children, and adolescents.
• This document was developed by the Council on Clinical Affairs and adopted in
2002.
• This document is an update of AAPD’s Policy on Use of a Caries-risk Assessment
Tool (CAT) for Infants, Children, and Adolescents, revised in 2006 that includes
the additional concepts of dental caries management protocols.

• Caries-risk assessment models currently involve a combination of factors
including diet, fluoride exposure, a susceptible host, and microflora that
interplay with a variety of social, cultural, and behavioral factors.

CARIES RISK ASSESSMENT AND MANAGEMENT
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

Caries Management Protocol for 3-5 Year Olds

❑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

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
ELSEVIER .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 6
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

CONCLUSION
• Thus ecc is a multifactorial disease whose prevention is of utmost importance
and treatment comprises of rapid and active management of lesions.

RAPIDD Assessment Scale
• The Readiness Assessment Of Parents Concerning Infant Dental Decay Scale.
• It 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.
The reliability and validity of the RAPIDD scale:readiness assessment of parents concerning infant
dental decay, Weinstein P at al,ASDC J Dent Child2001 march-april

• Parents in precontemplative stage show low openness and low health score,
whereas those in action stage show high scores.
• RAPIDD scale consist of 38 items with responses on 5 point scale ranging from
strongly agree to strongly disagree.
• The parent or primary caretaker was instructed to select a box under on of the
five categories after the interviewer read them the question in their native
language.
The reliability and validity of the RAPIDD scale:readiness assessment of parents concerning infant
dental decay, Weinstein P at al,ASDC J Dent Child2001 march-april

• Each of the 38 items was placed into one of four constructs:
1) Openness to health information
2) Valuing dental health
3) Convenience and change difficulty
4) Child permissiveness
The reliability and validity of the RAPIDD scale:readiness assessment of parents concerning
infant dental decay, Weinstein P at al,ASDC J Dent Child2001 march-april

• In order to categorize respondents as precontemplators, contemplators or
action individuals, the the responses to the questions within each construct
were summed, these slimmed values were ranked, and percentile were
calculated for each individual within each construct.
• It is a tool that is used to determine parent’s stage of change for their child’s oral
health.
• Once particular stage of change has been established the counselor then
determines the best approach to move into next stage.
The reliability and validity of the RAPIDD scale:readiness assessment of parents concerning
infant dental decay, Weinstein P at al,ASDC J Dent Child2001 march-april

Lift the lip concept
• an assessment tool for childhood dental decay
• “Lift the Lip” concept was developed to provide appropriate oral health
information to parents and child health professionals.
• The information encourages people to “Check your child’s teeth – lift the lip”,
looking for early signs of tooth decay once a month.
Lift the Lip: an assessment tool for childhood dental decay
Mary Wilson – 2017

Purpose
• To demonstrate how and encourage parents to regularly check their child’s teeth
for signs of tooth decay
• To individualise oral health advice
• To highlight individual risk of dental decay
• To demonstrate the importance of good oral health behaviours
• To generate appropriate referrals to dental services
• To demonstrate the individual’s need for attendance to those dental services

Process
• The assessment itself was developed as a non-invasive, straightforward
procedure, which could be carried out in any setting.
• It is not a full clinical examination or a diagnostic test, but health professionals are
trained to look at the teeth to identify early signs of, as well as more developed,
tooth decay.
• It is intended to take only a couple of minutes to complete.

• Lift the Lip is recommended during visits from the age of 6 months, as part of
the general health assessment.
• When children are already receiving specialist care for existing conditions such
as cleft lip and palate, it is not necessary to complete the assessment.
• Parents should still receive the health education component and resources.
• Lift the Lip should be one element of an overall assessment of the risk factors
for dental decay.

• One of the main aims of Lift the Lip is to encourage parents to regularly examine
their child's mouth using the same approach.
• There is no need for the parent to have advanced health knowledge.
• While the nurse is carrying out Lift the Lip, they should demonstrate to parents
how to ‘lift the lip’ regularly at home, at least once a month, and what they
should be looking for as early signs of decay.

Anticipatory guidance in pediatric dentistry
• Definition –
Anticipatory Guidance is defined as proactive counselling of parents and
patients about developmental changes that will occur in the interval between health
supervision visits that includes information about daily caretaking specific to that
upcoming interval.
• Anticipatory guidance is the process of providing practical developmentally
appropriate information on children’s health to prepare parents for significant
physical, emotional and psychological milestones.
• It provides a framework for prevention that goes beyond caries to address all
aspects of children’s oral health.
Anticipatory Guidance in Pediatric Dentistry
Dr. S. Aruna Sharma1e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 12 Ver. VI (Dec. 2014), PP 13-17

• Individualised discussion and counselling are an integral part of each visit and
parents are generally counselled on topics such as
✓ oral hygiene maintenance and its importance
✓ dietary habits
✓ development of oral tissues
✓ fluoride needs
✓ non – nutritive habits
✓ use of antimicrobials and medications on oral health
✓ speech and language development
✓ injury prevention
✓ substance abuse
✓ intraoral and perioral piercing

Prenatal Counselling
• Maternal oral health and caries status adversely affects infant’s oral health as
vertical transmission of mutans streptococci has been well documented and the
condition so caused is also aptly named as “Maternally derived Streptococcus
Mutans disease.”
• Also studies have revealed a reduction in the caries activity in children whose
mothers used xylitol products as xylitol significantly reduces the levels of mutans
streptococci.
• Preterm infants and infants with very low birth weight experience a higher
incidence of enamel (tooth) defects and enamel hypoplasia.
• So expecting mothers should take the necessary professional advice to ensure
optimal oral health for the infant.

Development Of Oral Tissues
• The eruption sequence, the ages of eruption of the primary teeth (from about 6
months to 3years of age) and the associated conditions are to be explained.
• Hygiene practices such as brushing and flossing to be inculcated at the earliest
to facilitate the maintenance of oral health.
• Importance of balanced diet and restriction of intake of refined carbohydrates is
to be stressed upon to minimise colonisation by cariogenic flora.
Dr. S. Aruna Sharma1e-ISSN: 2279-0853, p-ISSN: 2279-
0861.Volume 13, Issue 12 Ver. VI (Dec. 2014), PP 13-17

Proper Positioning During Child Examination
• Knee –to – Knee positioning is recommended for children aged 6 months to 3
years and up to 5 years for children with special health care needs.
This Knee –to - knee position allows
i) the child to see the parent throughout the examination
ii) Reduces anxiety for the child
iii) Allows parents to directly observe the oral findings and to receive hygiene
instructions
iv) Helps in stabilising the child during examination
Dr. S. Aruna Sharma1e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 12 Ver. VI (Dec.
2014), PP 13-17

• The need for establishment of a dental home and regular dental visits for the
child should be stressed.
• Once the child is over 3years the importance of sealant placement on primary
teeth and later on permanent teeth should be informed to the parents

Peri Natal Oral Health & Oral Hygiene
• Parents should be instructed to start wiping the baby’s mouth with a soft cloth
or finger along the baby’s upper and lower gums twice a day and to brush with a
soft toothbrush and a smear of fluoridated toothpaste as soon as the first tooth
erupts into the oral cavity.
• Parents should also be advised against sharing of utensils and cups with their
babies to reduce the spread of bacteria.

Teething
• Eruption of primary teeth at about 6-9 months may go unnoticed or may be
stressful for the child causing irritation, restlessness, drooling of saliva, loss of
appetite.
• Discomfort may be reduced by
i) Chewing on a hard or frozen teething ring
ii) Applying pressure over the gums or rubbing them with clean fingers
iii) Temporarily numbing the gums by applying topical anaesthetics

Diet, Nutrition And Food Choices
• Caries conducive dietary practices appear to be established early by 12 months
of age.
• The Parents / caregivers should be intimated against putting baby to bed with a
bottle.
• Children should be encouraged to use the cup as early as possible (by 1 year of
age)
• Prolonged bottle feeding with sugar containing drinks and frequent between
meal consumption of sugar containing snacks or drinks (juice, formula, soda)
should be thoroughly discouraged.
2014), PP 13-17

• Dietary analysis is to be done at periodic intervals and the role of dietary choices
on oral health.
• Healthy alternatives are to be suggested for replacing the cariogenic foods.

Fluoride Needs
• Since fluoride contributes to the prevention, inhibition and reversal of caries,
the family’s source of drinking is to be assessed for the content of fluoride.
• Supplements of fluoride or topical fluoride applications may be advocated
depending upon the needs of the patient.
• Uses of non-fluoride preventive measures such as xylitol wipes, chlorhexidine
mouthwashes, CPPACP are to be considered to minimise the caries risk.

Motivational Interviewing
• It is a counselling technique that relies on two-way communication between the
clinician and the patient or parent.
• It is meant to establish a therapeutic alliance that is based on rapport and trust.
• questions to help parents and patients to identify existing problems, risk factors
that can contribute to the existing clinical condition, and is asked to commit to
two self-management goals or recommendations for ensuring good oral health
and general health for the child patient.

• The list of management goals include:
i) Regular dental visits for the child
ii) Dental treatment for the family
iii) Weaning off bottle especially during sleep
iv) Brushing with Fluoridated toothpaste twice a day
v) Water or milk in a Sippy cup
vi) No juice or no added sugar in juice
vii) Healthy Snacks
viii) No Soda
ix) Chew Xylitol gum
x) Drinking tap water
xi) Avoiding junk food and candies

Non-Nutritive Habits
• Non – Nutritive oral habits and pacifier habits may apply forces to teeth and dento
alveolar structures.
• Although the use of pacifiers and digit sucking are considered normal, habits of
sufficient intensity, duration and frequency can contribute to deleterious changes
in occlusion and facial development.
• So it becomes important to discuss the need to wean from the habits as early as
possible (by 3years of age)

Sucking Habits
• Sucking is a natural reflex which is present inutero and is generally given up by 4
– 5 years of age
Pacifier sucking is to be discouraged. If in the early ages child uses a pacifier then
certain precautions are to be taken such as
i) Never add or dip the pacifier into the flavouring agent
ii) Never allow children to share a pacifier
iii) Never leave an infant unattended with the pacifier in the mouth
iv) Do not allow an infant to sleep with the pacifier
v) Pacifiers are to be kept clean

vi) Replace the pacifier regularly to avoid using one that is torn or ripped
vii) Never force a pacifier into child’s mouth and never pull out one forcibly from
the child’s mouth
viii) Never attach a pacifier to the child’s body or crib with a string, ribbon or cord
ix) Pacifier is to be wider than child’s mouth. Use of the pacifier is to be
discouraged if the entire pacifier fits into child’s mouth
x) Never Substitute a bottle nipple for a pacifier
xi) Discourage the habit as early as possible

Speech And Language Development
• Speech and language are integral components of child’s early development.
• Deficiencies and abnormal delays in speech and language production should be
recognised early and appropriate referral made to address these concerns.
• Communication and Co-ordination of appliance therapy with a speech and
language professional can assist in timely treatment of speech disorders
Dr. S. Aruna Sharma1e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 12 Ver. VI (Dec. 2014), PP
13-17

Injury Prevention
• Practitioner needs to provide age appropriate injury prevention counselling for
orofacial trauma.
• Initially discussions should include advice regarding playing objects, pacifiers, car
seats and electric cords.
• As motor co-ordination develops parents and the patients should be counselled
on additional safety and preventive measures.
2014), PP 13-17

Antimicrobials, Medications And Oral Health
• Presence of sucrose and/or other fermentable carbohydrates in the formulation
of Pediatric medicines and the low pH values contribute to the cariogenic
potential of these drugs.
• One of the most common practices observed was the tendency to add sugar to
the medicine to make the taste more acceptable thus contributing to the
cariogenic potential of the drug.
Dr. S. Aruna Sharma1e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 12 Ver. VI (Dec. 2014),
PP 13-17

• The use of sugar products and those medications which can reduce the salivary
flow ,antiparkinsonian drugs, muscle relaxants, hypotensive drugs and diuretics
make the child more susceptible to dental caries .
• as they need to be administered for potentially longer duration of time period
and at night especially when the salivary flow is less and reduced reflexes of
swallowing and muscle movement thus ensuring the retention of carbohydrate
intraorally for a greater duration.
2014), PP 13-17

• Parents and caregivers should be informed that medicines containing
sweeteners can cause tooth decay and that the baby’s mouth is to be wiped
with a soft damp washcloth or should brush the child’s teeth after administering
medicines.
• Applying Anticipatory Guidance to dental preventive education is an organised
way for all dental practitioners to enjoy the attention of parents and be more
successful in preventive dentistry.
• Early dental intervention using Anticipatory Guidance may be the next frontier
in dental caries reduction.
Dr. S. Aruna Sharma1e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 12 Ver. VI
(Dec. 2014), PP 13-17

Oral hygiene measures
INFANTS (0 TO 1 YEAR OLD)
• It is important that a few basic home oral hygiene procedures for the child begin
during the first year of life.
• There is general agreement that plaque removal activities should begin on
eruption of the first primary teeth.
• Some practitioners recommend cleaning and massaging of the gums before this
to help in establishing a healthy oral flora and to aid in teething.
Mcdonald and avery’s dentistry for the child and adolescent

• It can be accomplished by wrapping a moistened gauze square or washcloth
around the finger and gently massaging the teeth and gingival tissues.
• This procedure should be performed once daily.
• Generally, other plaque removal techniques are not necessary.

• The introduction of a moistened, soft-bristled, child- or infant-sized toothbrush
during this age is advisable only if the parent feels comfortable using the brush.
• The use of a dentifrice is neither necessary nor advised as the foaming action of
the paste tends to be objectionable to the infant.
• The child's first visit to the dentist should take place during this period.
• In addition, an infant dental examination and fluoride status review should be
accomplished, and dietary issues related to nursing and bottle caries as well as
other health concerns are addressed.

TODDLERS (1 TO 3 YEARS OLD)
• During toddlerhood, the toothbrush should be introduced into the plaque
removal procedure if this was not accomplished previously.
• Because of the inability of children in this age group to expectorate and the
potential for fluoride ingestion, only a nonfluoridated dentifrice should be used.
• The use of additional instruments for plaque control is generally unnecessary;
however, flossing may be needed if any interproximal contacts are closed.

• Positioning of the child and parent is again important.

PRESCHOOLERS (3 TO 6 YEARS OLD)
• A fluoride dentifrice can be introduced at 3 years of age.
• In addition, it is during this age that flossing is most likely to begin.
• if the interproximal contacts are closed, the parent must begin flossing
procedures.

• It is also during this stage that fluoride gels and rinses for home use may be
introduced.
• Because of the risk of ingestion, however, these agents should be employed in
small quantities and their use should be limited to those patients demonstrating
a moderate to high risk of caries.

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.

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