Early childhood caries (ECC) is a general term that describes rampant dental caries in infants and toddlers.1 Its clinical appearance is unique because the maxillary incisors demonstrate the greatest carious destruction, while mandibular incisors are not generally affected, reportedly due to the child’s tongue in the suckling position protecting these teeth from the cariogenic challenge (Figures 1 and 2).2 The condition, when associated with a bottle habit or with extensive on demand breastfeeding, has been termed nursing caries (NC). This article presents the etiology of ECC, the steps required prior to treatment, and the types of treatment that are commonly used to manage this condition.
Etiology and Prevalence
Molecular studies have shown that the oral cavity harbors a complex, microbial community consisting of over 400 different non-harmful/commensal microbial species together with a limited number of acid-producing, cariogenic bacteria (eg, Streptococcus mutans and Lactobacillus).3 Streptococcus mutan (SM) is the principal microorganism responsible for coronal caries in humans.4 These cariogenic bacteria ferment sugars and produce acids that lower the local pH; the bacteria themselves thrive under these acidic conditions.5 In addition, these bacteria use sucrose to synthesize extracellular polysaccharides called glucans, allowing them to adhere to the tooth’s surface and form a biofilm of dental plaque. Cariogenic bacteria are usually found in small quantities in healthy plaque; S. mutans, for example, makes up less than 1% of the mouth’s natural flora. With biological and environmental perturbations, however, the cariogenic bacteria may become dominant, resulting in large amounts of acid in the dental plaque. Acid production drives the dissolution of calcium and phosphate in the hydroxyapatite crystalline structure of the tooth.5 Initially, this dissolution may be reversed by remineralization from calcium and phosphate in saliva. However, if the acidic conditions persist, especially in conjunction with repeated consumption of sugars (eg, NC) or impaired salivary flow, the acid-induced dissolution overcomes the remineralization of the saliva. The tooth surface softens progressively until its constituent crystals are sufficiently weakened and cavitations are evident.
Nursing caries are generally prevalent when the primary teeth are susceptible to decay, and specific microflora or fermentable substrates are introduced over time. While infants generally acquire SM from their mothers,6 transmission may also occur from the primary caregiver if eating utensils are shared between child and caregiver.7,8 Reports also indicate that horizontal transmission of SM may occur between members of a group (eg, family members of a similar age or students in a classroom).9-12 The contents of the nursing bottle responsible for nursing caries can include milk sweetened with sugar, sugared water, fruit juices, carbonated or noncarbonated beverages, and bovine milk. Milk-based baby formula, because of its lactose content, and soy-based formula, which is lactose free but contains sucrose or other sugars, also are potential promoters of nursing caries. Young children who fall asleep with a bottle or nursing on the mother’s breast, who nurse frequently at night, or who nurse past the usual period of bottle weaning are at risk for developing NC.
It is estimated that NC occurs in approximately in 3% to 6% of children 4 years old or younger.13-15 In non-industrialized countries and disadvantaged populations, the prevalence rate is as high as 70%.16 This condition can severely affect a child’s appearance and compromise dental function (Figure 3). In addition, NC has a lasting impact on the dentition; children with NC have a much greater probability of subsequent dental caries, in both the primary and permanent dentition.17-21
The Breastfeeding Controversy
While breastfeeding is generally recommended to be continued for at least the first year of life and beyond, prolonged and unrestricted breastfeeding has been reported to be a potential risk factor for ECC.22-24 Epidemiologic evidence linking infant breastfeeding and its duration to ECC in children is, however, very limited and may present conflicting results.25,26 In any event, all nursing toddlers must have their teeth brushed with toothpaste and proper oral hygiene should be practiced even prior to the eruption of the first tooth. Proper dietary instructions should be provided at the first dental visit.
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As mentioned, treatment of NC begins with proper counseling. Changing the feeding practices and implementing tooth brushing with fluoridated toothpaste are the first steps in controlling the disease. Once accomplished, other treatment modalities can then be mandated.
Toddlers and even young school-age children are not sufficiently competent to brush their own teeth without parental assistance. Parents should be instructed to sit with the child standing between the parent’s legs and reclining his or her head backward onto the parent’s lap. The parent should embrace the child’s head in a stable position and with the other hand proceed to brush the child’s teeth using a soft toothbrush with double-rounded bristles. A tiny dab of fluoridated toothpaste should be used to gently clean both the gums and teeth. The hygienist should reassure the parent that with time the child will be receptive to this process. In addition, the parent should understand that he or she is also desensitizing the child’s oral cavity thus facilitating future dental surgery if needed.
Because it is not advisable to treat children less than two years of age using conscious sedation in a private dental setting, treatment will often be postponed until the child is older. During this period, in addition to proper counseling, a chemical approach may be employed to delay or prevent the progression of carious lesions. Topical fluoride varnishes contain a high concentration of fluoride in a resin or synthetic base that is applied to the tooth surface in order to retard, arrest, and reverse the process of cavity formation.27 The use of a fluoride varnish minimizes the risk of inadvertent fluoride consumption and can be easily used on young patients.
Although the primary side effect associated with the use of fluoride varnishes has been the temporary yellow-brown tooth discoloration apparent while the varnish adheres, this effect has been eliminated in newly marketed tooth-colored varnishes. Results of clinical trials indicate that fluoride varnish provides caries incidence reductions of 18% to 70%.28 A recent position paper of all fluoride vehicles concluded that until further evidence suggests otherwise, frequent periodic applications of fluoride varnish to open caries lesions in very young children should continue to be utilized as a means of controlling ECC.29 Varnish application should be repeated at three-month intervals for high-risk children and at six-month intervals for children who are not at high risk (Figure 4).29
Alternative Restorative Treatment
Another non-surgical approach to the initial restoration of NC is Alternative Restorative Treatment (ART), formerly known as atraumatic restorative treatment. This caries treatment modality involves the removal of soft, demineralized tissue using hand instrumentation, followed by restoration of the tooth with an adhesive restorative material.30 Glass-ionomer cement is often the material of choice for ART because of its bonding to enamel and dentin, fluoride release, and ease of use.31 Results may not be aesthetically pleasing using this approach, and parents should view the procedure as an interim option prior to definitive restoration (Figure 5).
Composite Resin Restorative Treatment
Composite resin strip crowns have been utilized for over two decades to restore carious primary teeth.32,33 The strip crown is the most aesthetic option available for the treatment of decayed primary incisors and parent satisfaction is high. Strip crowns are, however, also the most technique sensitive modality, and may be difficult to place. The gingival tissue of ECC patients tends to be inflamed, leading to hemorrhage and compromising aesthetic restoration. It is advantageous to obtain ideal oral hygiene prior to treatment (Figures 6-7-8). Parents should be instructed and convinced that they bear partial responsibility for success of treatment by preparing their child’s gingiva for the procedure. Obtaining good results is dependent on healthy, pink, non-bleeding gingiva (Figures 9-10-11-12). Three weeks preoperatively, the parents should be given an extra ultra soft toothbrush to cleanse the gingiva and be reassured that brushing causes no pain. It goes without mention that the baby bottle containing any liquid other than water should also be stopped preoperatively.
Pre-veneered Anterior Stainless Steel Crowns (PVC)
In extreme cases, (eg, severely inflamed gingival tissue, advanced coronal decay, poor parental compliance) hemorrhage and compromise of the composite aesthetic restoration may be a concern. In these cases, restoration of anterior teeth can be accomplished with pre-veneered anterior stainless-steel crowns (PVC). These restorations can be placed in a single, relatively short appointment, and their aesthetics are not affected by saliva or hemorrhage (Figures 13-14-15).34 There are disadvantages, however, that parents should be aware of, including breakage risk of the veneer under heavy force,35 significant removal of tooth structure, expense, limited shade choice, and placement difficulty in crowded spaces.
The treatment of NC begins with the initiation of proper parental counseling and patient preparation, and the dental hygienist plays a key role in this process. With proper consultation and treatment, ECC may be arrested by initiating proper feeding habits, simple home-based dental hygiene, and professional treatment via fluoride varnishes or other restorative measures. The success of future dental rehabilitation and teeth restoration may, thus, be enhanced when proper instruction is provided, and a regular routine is established to halt the progress of dental decay.
*Clinical instructor, Department of Pediatric Dentistry, Hebrew University – Hadassah Faculty of Dental Medicine, Jerusalem, Israel; Visiting Professor, Department of Pediatric Dentistry, UMDNJ-New Jersey Dental School, Newark, NJ; Private practice, Jerusalem, Israel.
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- Tsang P, Qi F, Shi W. Medical approach to dental caries: Fight the disease, not the lesion. Pediatr Dent 2006;28(2):188-191.
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- van Loveren C, Buijs JF, ten Cate JM. Similarity of bacteriocin activity profiles of mutans streptococci within the family when the children acquire strains after the age of 5. Caries Res 2000;34:481-485.
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