Early childhood caries is a specific term used to describe a unique pattern of dental decay in infants and toddlers, and preschool children. Early childhood caries is a particularly virulent form of dental caries that is characterized by an overwhelming infectious challenge and is associated with unusual dietary practices. It initially presents with smooth- surface carious lesions affecting the primary maxillary incisors. As the disease progresses, decay appears on the occlusal surfaces of the primary maxillary first molars, with subsequent spread to other primary teeth, resulting in the eventual destruction of the primary dentition.
Definition
Early childhood caries(ECC):
It is defined as the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child of 71 months of age or younger.
Severe early childhood caries (SECC):
In children younger than 3 years of age, any sign of smooth surface caries is indicative of severe early childhood caries (SECC) and from ages 3 through 5, one or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth.
Rampant caries:
According to Massler, “Rampant caries is a suddenly appearing, widespread, rapidly burrowing type of caries resulting in early involvement of the pulp and affecting those teeth usually regarded as immune to ordinary decay”.
Early childhood caries is also a form of rampant caries. The distinguishing characteristic of rampant caries is the involvement of proximal surfaces of lower anterior teeth which are usually spared in early childhood caries.
Early childhood caries is one of the frequently encountered problem in children, affecting 3 to 45% of the pre school population worldwide.
Early childhood caries is also known as:
1. Nursing bottle caries
2. Baby bottle tooth decay
3. Nursing bottle syndrome
4. Milk bottle syndrome
Some of these descriptions may be misleading as regarding the specific etiology of the condition. For example breast milk may be as likely to supply the carbohydrate required for acidogenic bacteria, as the bottle formula does. So the bottle itself is probably not to be blamed.
Today, the new name for early childhood caries is
Maternally Derived Streptococcus Mutans Disease (MDSMDJ’
Pediatric dentists recognise that infants who use a nursing bottle containing milk or juice as a pacifier or those who are breast fed on demand specially at times other than normal feedings and throughout the evening often develop early multiple carious lesions.
During sleep, salivary flow is diminished. Moreover, the swallowing reflex is absent. Hence, milk cannot be eliminated from the oral cavity and it pools around the tooth surfaces. Opportunistic cariogenic microorganisms exploit this conducive environment and this result in tooth decay.
This process sometimes occurs so fast that the parents often complain that the child had decayed teeth at the time of eruption itself.
The biology of early childhood caries may be modified by following factors unique to young children:
1. Implantation of cariogenic bacteria .
2. Immaturity of the host defense systems.
3. Behavioral patterns associated with feeding and oral hygiene in early childhood.
ECC is characterized microbiologically by dense oral populations of mutans streptococci (MS). Scientific evidence strongly suggests that the development of ECC occurs in three steps.
1. The first step is characterized by the primary infection of the oral cavity with MS.
2. The second step is the accumulation of these organisms to pathogenic levels as a consequence of frequent and prolonged exposure to cariogenic substrates.
3. In the third step a rapid demineralization and cavitation of enamel occurs.
Etiological Factors :
1. Feeding beyond the weaning age i.e. beyond 12 to 15 months.
2. Feeding at night always poses a serious threat especially if the teeth are not cleaned after feeding.
3. Single parent households. Child neglect could also be one of the major reasons for nursing caries to occur, as the parents are too busy coping with financial stress and responsibilities.
4. High socio-economic status. It has been seen that some mothers avoid breast feeding. The children are left at the mercy of the domestic help who think it is their duty to continuously force a bottle into the child’s mouth.
5. Low socio-economic status. If both the parents are working, they leave the children to be cared by the young siblings and the resultant neglect leads to tooth decay. 6. Immunocompromised children are at higher risk due to decreased salivary flow.
7. A strong tempered child such as an only child or an overprotected one would always demand and force the parents to fulfill his demands.
8. Children who present sleep disorders are found to be affected by nursing caries.
It is not necessary that milk alone causes nursing caries. Other food products, which are equally responsible, are:
1. Honey
2. Fruit juices
3. Sweetened beverages
4. Pacifiers sweetened with jam and jelly
5. Infant milk formulae
6. Milk or water with added sugar.
7. Syrupy medications
Recent researches have suggested that the etiology of the condition is complex An important part of the etiology is the age at which children become infected with S.mutans, which is difficult to establish.
The second most important factor is the inappropriate use of night time or day time bottle or breast feeding as a pacifier. Early childhood caries is generally related to the problem of inappropriate bottle-feeding and also the cariogenecity of the most frequently consumed formula milk or breast milk.
Despite its cariogenic potential, mother’s milk remains the ideal food for a child. It is sweeter as compared to bovine mik because of its higher lactose content. It is:
(a) The perfect food at the perfect temperature.
(b) It provides a natural transfer of immunoglobulins by way of colostrum.
(c) Suckling leads to development of orofacial structures.
(d)A bond of love and affection is formed between the infant and the mother which provides the child with much needed security and warmth
It is important for dentists to realize and educate mothers about the importance of proper feeding habits.However, the risk of devastating nursing dental decay exists for the breast fed child, as it does for the bottle fed child. It is related to repetitive feeding times with prolonged exposure of erupted teeth to fermentable carbohydrates without appropriate oral hygiene measures.
The crux lies with the feeding habit and not the milk.
Mother’s milk is a boon not a bane .
Arrested caries :
If during the process, the cause gets eliminated, the arrest of caries occurs. Full or partial remineralization results in a dark brown to black appearance.
Complications
*Nursing caries is a severely disabling condition. It can result in a severely painful unesthetic appearance . Due to loss of tooth structure, the child may not be able to chew food properly and subsequent malnutrition may ensue, hence these children may show retarded growth as compared to normal children.
*Prolonged bottle feeding often displaces other components of staple diet hence this can result in nutritional deficiencies, for e.g. anaemia, etc.
*Rapid destruction of teeth may affect a child psychologically when he compares himself to other children.
* Early extraction of maxillary incisors can create speech problems.
*Loss of primary teeth can cause space problems, which may result in malocclusion.
Prevention :
Care before a child’s teeth erupt:
1. Primary teeth start forming at 3 months after conception. at birth all crowns of primary teeth are partially or fully formed and mineralization of the first permanent molar also starts at the same time.
2. It is important that the mother gets the proper nutrition, stays in good health and avoids medications which are either harmful to her or to the baby’s teeth. The mother’s health during pregnancy is important. Imbalances in the mother’s calcium and phosphorus levels due to fever or infection during pregnancy can also lead to disruptions in the baby’s tooth structure. Highly significant effects on infant caries status have also been related to the pregnancy complications such as instrument delivery or caesarean section and the youth of the mother.
3.Precautions taken to prevent the childhood diseases until the age of 3-4 years is also advantageous, because the same calcium and phosphorus imbalances caused by fever or illness that affect prenatal tooth development, affect the mineralization of primary and permanent teeth that mineralize post natally.
Management :
This can be divided into:
1. Counselling regarding discontinuation of the habit
2. Dietary modifications
3. Restorative procedures
4. Education.
1. Discontinuation of the habit:
The first step is to identify the cause. Abrupt cessation of the habit is not advised; rather a gradual withdrawal must be done. The habit must be reduced to 70% at the end of the first week, 50% by the end of the second week, 20% at the end of the third week and so on. Feeding with the cup or spoon should be encouraged. Serial dilution of the contents of the bottle with water has been recommended over a period of 1-2 weeks so that eventually the child drinks only plain water. Feeding at night is to be strictly avoided. Clearance of the milk can be aided by intake of water after the feed.
Infants must be weaned at 12-14 months of age. On demand nocturnal breastfeeding must be denied. Consumption of juices from a bottle should be avoided and when juices are offered, they should be given in a cup.
2. Dietary modifications:
The mother in particular must know the deleterious effects of sugar. Elimination or at least gradual reduction of additional sugar must be done. Depending on the child’s age and chewing capacity, natural food like fruits should be given to the child. Oral hygiene measures must be implemented by the time the first tooth has erupted.
3. Restorative procedures :
These can be done under local or general anesthesia if necessary and it involves a thorough excavation of the decay followed by placement of sedative dressings. The patient is then given the necessary instructions regarding oral hygiene and diet. On subsequent recall visits, only if it is confirmed that the patient is complying, further treatment is carried out.
Small cavitations are restored with composite resins, amalgam or glass ionomer restorations as indicated. Pulpal treatment such as indirect pulp capping, direct pulp capping, pulpotomy and pulpectomy may be performed. Stainless steel crowns and polycarbonate or celluloid crown forms for anterior teeth are also other treatment alternatives Extraction of teeth is never to be encouraged. However, if the teeth are beyond repair extraction followed by placement of a suitable space maintainer is advocated. Fluoride supplements can be given depending on the age and need of the child.
4. Dental health education :
It plays a very important role in both the treatment and prevention of nursing caries. Expectant women and mothers should be taught how to take care of their baby’s teeth.
Regular teeth cleaning twice a day after feeding will have significant impact on child’s susceptibility to the development of early childhood caries. Cleaning teeth with clean cloth held between the fingers .Use of small amount of fluoridated dentifrice, will reduce the colonies of microorganisms and make fluoride available to the child’s teeth to facilitate remineralization of any early carious lesions.