Definition of ECC and sECCOther names previously usedEtiology of ECCClinical appearance of ECCEpidemiology of ECCComplications of ECCManagement of ECC

Outline

Definition according to AAPD: Presence of 1 or more

Decayed (cavitated or non-cavitated) Missing due to caries

Filled tooth surface In any primary tooth in a child of 71 months of

age or younger

SEVER early childhood caries

*Any sign of smooth surface caries in child younger than3 years of age

*From age of 3 through 5 the presence of decayed, missing and filled tooth surface in any primary teeth.

*DMF≥4 at age of 3

DMF≥5 at age of 4 DMF≥6 at age of 5

Previous names for ECC:-Nursing bottle syndrome- Nursing bottle mouth- Nursing mouth decay- Nursing caries- Bottle propping caries- Milk bottle syndrome- Baby bottle tooth decay (bbtd)- Baby bottle mouth

For many years , it has been recognized that after the eruption of 1st primary tooth begins, exclusively bottle feeding and/or prolonged bottle or breast feeding is associated with “nursing bottle caries” as sever form of caries.

However recognizing that this clinical presentation was not consistently associated with poor feeding practices and that caries was an infectious disease

∴AAPD adopted the new term Early Childhood Caries (ECC) (during the 1998 NIH sponsored ECC conference)to reflect better its multifactorial etiology

Etiology:

It is a multifactorial , complex disease resulting from imbalance of multiple risk factors and protective factors over time.

Cariogenic bacteria

Cariogenic diet

Saliva

Susceptible host

caries

Mutans streptococci especially streptococcus mutans and streptococcus sorbinus as they can colonize tooth surface and produce acids at a faster speed than capacity of neutralization of biofilm in an environment below critical enamel PH(≤5.5)

The severity of ECC is directly related to early establishment of MS in infants

Caries is a transmissable , infectious disease∴understanding acquisition of cariogenic

micro-organisms is necessary to improving preventive strategies

Vertical transmission Horizontal transmission

1-cariogenic micro-organisms:

From caregiver (mother) to the child The major reservoir from which children

acquire cariogenic bacteria is their mother saliva.

So ECC is also known as“maternally DerivedStreptococcusMutans disease(MDSMD)

Vertical transmission:

This also may occur by transmission of MS from members of family or group of daycare due to sharing of saliva contaminated objects

Horizontal transmission

Infants whose mothers have high level of MS(result of untreated caries)are at a higher risk of acquiring MS earlier than others.

The success of transmission and resultant colonization of maternal MS may be related to several factors

Magnitude of inoculum Frequency of small dose inoculum .

Minimum infective dose

Sucrose is most important type as it turns non cariogenic and anti-cariogenic food into cariogenic (caries producing)Experimentally human milk have been proven not

to be cariogenic because: ∮it doesn’t decrease PH of oral cavity

significantly in breastfed infants ∮it promotes enamel remineralization Single exposure isn’t the problem but frequent ,

prolonged contact of these substances is a major problem.

2-cariogenic diet

ECC is associated with inappropriate feeding pattern: child is put to sleep at afternoon nap times or at night with a nursing bottle holding milk or sugar containing beverages . child fall asleep (salivary flow decreased during sleep & clearance of liquid from oral cavity is slowed)

and the liquid become pooled around teeth which provide an excellent culture medium for acidogenic MS.

Also prolonged use of pacifierdipped in honey

There are some risk factors such as:o yet immature post-eruptive enamelo Presence of enamel defects (enamel

hypoplasia)o Morphology & genetic characters of teetho crowding

3-susceptable host (teeth)

It is the major defense system of host against caries through:

I. Flow of saliva (that remove food and bacteria).II. Buffering capacity (against acid produced)III. Mineral reservoir of calcium and phosphate

ions (for enamel remineralization).IV. Contain antibacterial substances. these factors decrease during sleeping thus

increasing tooth susceptibility to caries. Any disease affecting the flowabilty or

viscosity of saliva has an impact on incidence of caries

4- saliva

Typical and follow a definite pattern where there is early carious involvement of:

upper anterior teeth. upper and lower primary 1st molar. sometimes lower canine.(following

sequence of primary teeth eruption) Mandibular anterior teeth are un affected as

they are mostly protected by tongue and saliva from mandibular salivary gland

Clinical appearance of ECC

Early onset of caries attack ,or may appear years after stoppage of bottle/breast feeding.

May be more sever unilaterally depend on which side child sleeps.

It is a specific form of rampant decay of primary teeth.

ECC Rampant Caries

Type of rampant caries. Presence of one or more decayed, missed (due to caries) or filled in child ≤ 71 months.

Suddenly appearing wide spread affect immune surface of teeth resulting in early pulped involvement.

Definition

Nursing habits. Still not known Etiology

Affect children under 6 years.

Affect any age Onset

Can be unilateral Bilateral Distribution

Most affected maxillary anterior Lower anterior not effected.

All teeth affected Even immune areas-lower ant)

Teeth affected

Epidemiology of ECC

TINATOF,1997,confirmed that children with parents in lower income group had mean dmf 4 times those whose parents are in a higher income groups

Ismail ,2003 found that socioeconomic status can have an impact on environment, availability of food , access to proper health care and education of children and parents about oral health

RAMOS-GOMEZ ET AL 2OO2,found strong inverse relation between mother’s level of education and presence of ECC as subjects demonstrated prolonged feeding habits because their mothers indicated that they don’t know when weaning should occur.

In developing countries , ECC is a critical problem due to increase of other factors as:

-low economic -mal nutrition -decreased level of educationWhich lead to increased prevalence to reach

as high as 70%

Untreated caries may lead to - pain - loss of school days and increased days with

restricted activities. -dental infection may lead to life threatening

facial spaces which result in medical emergencies requiring hospitalization and antibiotics.

- early loss of primary dentition. - affect speech articulation -malnutrition and GIT disorders - decreased self esteem (weintraub,1998)

Complications of ECC

1. Alter feeding and eating habits2. Delay colonization of teeth3. Ensure adequate fluoride4. Establish dental care5. Application of dental sealant6. Follow up 7. Behavioral and educational programs8. Use of xylatol

Management of ECC

A- practice:Investigators recommend that from birth the

infant should be held while feeding( the child who fall asleep should be burped & then placed to bed .

AAPD discourage breast/bottle feeding after 1 year of age.

1-alter feeding & eating habits

If the nursing habit is discontinued at 1.5-2 years of age,

newly erupted canines and 1st primary molars → Minimally or not

affected erupted 2nd molar → not effected.

B-frequency of feeding:AAPD states that frequent feeding at night and frequent use of spill proof drinking cups

is associated with ECC ∴AAPD recommend that : - infants should not be put to bed with baby bottle -ad libitum breast feeding at night should be avoided after eruption of first tooth.

Parents can’t stop feeding their children nutritious food but they can regulate when & how often they are exposed to “sugar hits”

C-choosing healthy food:-AAPD endores policy of AAP on breast feeding

and use of human milk as breast feeding ensures

*best possible health *best development and psychological outcome for infants

-AAPD no longer include breast feeding among cariogenic factors

- Use only water in the bottle during nap or bed time

- Diet counseling help parents change their children diatry behaviors to favor low or non-cariogenic snacks & limit sweet food to meal times . such recommendations must be realistic and based on family diatry behaviors*

-suppressing maternal reservoir of MS via dental rehabilitation and anti microbial treatment can prevent or delay infant inoculation . ideally those intervention would be initiated in prenatal period.

Also mothers should be instructed to avoid sharing spoon with child and use water to clean a pacifier instead of cleaning it in her mouth

2-delay colonization of teeth

Systemic fluoridation:Community water fluoridation is the most important type as it is effective,can reach people of different socioeconomic status, safe and of low cost.Topical fluoridation:-home applied as using fluoridated tooth paste and mouth rinses*-professionally applied as fluoride varnish*( ADA recommendations of twice a year for moderate caries risk children and 4 times a year for high risk ones

3- ensure adequate fluoride

A- anticipatory guidance:ECC can be prevented by parent’s early

counseling i.e. children should receive their 1st dental examination between 6 & 12 months when sECC is not likely to have developed so that parents should be educated to practice good oral hygiene measures for their children and avoid inappropriate feeding habits also this help identify infants who

are most at risk of ECC and apply early preventive intervention

4-establish dental care

B- improve oral hygiene:Fluoridated tooth paste :*-MARINHO ET AL.2003 stated that it is the

most cost-effective way in the prevention.-used twice daily, with amounts appropriate to

the age, specially before bed so that a high concentration of fluoride in saliva is maintained for longer period.

Flossing should be started as soon as contact between teeth is achieved

C-definitive treatment of existing disease:Depending on progression of caries , there are

various disease states of which each require appropriate treatment

1-very early sign of beginning of teeth demineralization: typically visualized as chalky white spots or lines

Reversible , caries progression can be avoided with proper care(fluoride application and diet changes)

2- once the teeth become cavitated restoration or fillings are required*

3-significant more seriousDecay treatment as SSC or veneers

4-pulp involvement

Pulp therapy or extraction+ space maintance

To perform treatment safely , effectively and efficiently , the practioner caring for child with ECC often employ advanced behavior guidance techniques . these may include protective stabilization and/or sedation or general anesthesia.

Occlusal pits and fissures sealant professionally applied to act as a physical barrier between tooth surface and food debris and bacteria

It is applied on newly erupted molars of older children ( at age of 6)

∴Sealants don’t protect against ECC which occur from birth to 71 months it only protect against future caries in the permanent dention

5- dental sealants

AAPD recommend dental check up at least twice a year for most children and more frequent visits for other children as needed.This will help to: -evaluate effectiveness of control program-asses oral hygiene -asses improvement of dietary habits-detect and restore carious lesions.- Topical application of fluoride

6- follow up

7-behavioral and education programs

WEINSTEIN,1998,stated that providing parents with information ,especially about benefits of changing parental practices will help some of them to be open to possibility of changing

Also educating parents “self-examination techniques on children will help to determine decay in children teeth which is important secondary prevention.

Programs should focus on educating adults because young children are dependent on adults (parent or caregiver) for their daily needs ∴behaviors to prevent ECC truly rest on the responsibility of adults and how much they are willing to make changes

In a comprehensive report prepared for oral health sub committee of healthy mothers-healthy babies coalition , Ripa states :Priority needs to be given to a major national educational program directed toward educating the public about ECCThe educational program must involve direct

contact with pregnant women , parents and caregivers in population subgroups with high ECC prevalence

a study by THORILD ET AL, 2006, found that:The transmission of MS from highly colonized

mothers to their off springs could be delayed or stopped by maternal use of xylitol containing chewing gum during period of eruption of primary teeth.

8-xylitol use

THANK YOU

McDonald and Avery’s dentistry (ninth edition)

WWW.ADA.ORG www.aapd.org www.cda.org Journal of young investigators Principles of pediatric dentistry Wikipedia , the free encyclopedia

References