Understanding Dental Caries in Children

Dental Caries

• It is the most common chronic childhood disease
• It is 5x more prevalent than asthma
• It is 7x more prevalent than hay fever
• It is the most prevalent unmet health need
• 51 million school hours are lost to it per year

Dental Caries Prevalence in Primary Teeth

• High socioeconomic status correlates to an 18% caries rate
• Low socioeconomic status correlates to a 42% caries rate
• Hispanic and African American children aged 2-8 have twice the untreated caries

Early Childhood Caries (ECC)

• ECC affects children under 6 years old
• Diagnosis requires at least one decayed, missing (due to caries), or filled tooth surface

Severe Early Childhood Caries (S-ECC)

• S-ECC includes any smooth-surface caries in children under 3
• For ages 3-5, diagnosed with one or more smooth surface lesions in primary maxillary anterior teeth
• Children 3 years of age with 4 or more decayed, missing, or filled surfaces are diagnosed as having S-ECC
• Children 4 years of age with 5 or more decayed, missing, or filled surfaces are diagnosed as having S-ECC
• Children 5 years of age with 6 or more decayed, missing, or filled surfaces are diagnosed as having S-ECC

Etiology of Dental Caries

• Demineralization occurs at a pH of 5.5 or lower, while neutral pH and above allow remineralization
• Caries occurs when microflora/host (teeth) and substrate (diet) overlap

Fermentable Carbohydrates

• Children breastfed for over 12 months have an increased caries risk
• Children breastfed nocturnally or frequently have an increased caries risk.
• The American Academy of Pediatrics (AAP) advises against introducing juice to infants before age 1
• Adolescents with low-educated parents consume more sugar-sweetened beverages (SSBs)
• They have a higher energy intake

Beverage Recommendations

• Healthy beverage patterns should be established in the first 5 years of life
• For 0-6 months, supplemental water and pasteurized milk and 100% juice is not recommended
• For 6-12 months, provide approximately 0.5-1 cup of drinking water (4-8oz) each day in a cup
• Introduce water during meals once solid foods are introduced
• Pasteurized milk and 100% juice are not recommended
• For 12-24 months, offer 1-4 cups of water (8-32oz) daily and 2-3 cups (16-24oz) of whole milk
• Whole fruit is preferred, limit 100% juice to no more than 0.5 cup (4oz) daily
• For 2-3 year olds, serve 1-4 cups of water (8-32oz) daily, and up to 2 cups (16oz) of skim (fat-free) or low-fat (1%) milk
• Whole fruit is preferred and reduce juice intake to less than 0.5 cup (4oz) of 100% juice daily
• For 4-5 year olds, provide 1.5-5 cups of water (12-40oz) daily, and up to 2.5 cups (16oz) of skim (fat-free) or low-fat (1%) milk
• Whole fruit is preferred, limit 100% juice intake to less than 0.5 cup (4oz) daily
• To minimize caries risk, avoid providing sugar-sweetened beverages in sippy cups
• Stop bottle use by age 1, avoid putting children to bed with anything other than water in a bottle
• Children from birth to five years old should not consume sugar-sweetened beverages

Cariogenic Microorganisms

• Mutans Streptococci (MS) are the primary microorganisms implicated in acid production
• Lactobacilli are important in dental caries
• The window of infectivity for MS is between 19-33 months
• MS can transmit from caregiver to child vertically, or horizontally

Socioeconomic Status

• 1 in 4 American children live in poverty
• Children from immigrant backgrounds have 3x higher caries rate than non-immigrants
• Children in poverty experience twice the tooth decay with less treatment
• Parental history of cavities predicts early childhood decay
• Chronic stress could relate to dental caries

Anatomic Characteristics of Teeth

• Enamel calcification is incomplete when teeth erupt
• Calcification requires an additional 2 years after eruption
• Teeth are especially susceptible to decay during the first 2 years after eruption due to incomplete calcification
• Permanent molars often have incompletely fused pits and fissures

Malocclusion/Crowding

• Crowded, irregular teeth are not easily cleaned by the natural chewing process
• It is challenging to properly clean the mouth with crowded, overlapping teeth
• The combination of reduced self-cleaning and difficulty brushing increases caries risk

Dental Appliances and Restorations

• Space maintainers and orthodontic appliances can increase food and plaque retention
• Tooth structure at the restorative material interface is susceptible to recurrent decay

CAMBRA (Caries Management by Risk Assessment)

• Caries Management by Risk Assessment entails several key steps
• Assess each child and their caregivers' caries risk
• Tailor a specific therapeutic management plan or “care plan”
• Create a restorative plan along with preventive care
• Establish a timely schedule

Caries Risk Assessment

• It fosters treating the etiology rather than the disease's results
• Provides comprehensive insights into individual disease factors, guiding personalized prevention strategies
• Helps tailoring preventative and restorative treatment frequencies
• Helps predict caries progression

Anticariogenics

• Fluoride
• Xylitol
• Chlorhexidine
• Remineralizing agents
• Sealants
• Resin Infiltration
• Silver Diamine Fluoride

Fluoride- Mechanisms of Action

• Systemic Effect
  • Improves enamel crystallinity
  • Decreases acid solubility
  • Improves tooth morphology
  • Increases salivary concentration
  • Community water fluoridation
• Topical Effect
  • Inhibits demineralization
  • Promotes remineralization
  • Disrupts enzyme system of bacteria
  • Alters plaque accumulation

Fluoride Supplements

• Use is intended to provide daily fluoride, similar to optimally fluoridated areas at 0.7 ppm
• This effect is mainly topical, post-eruption, and post-natal
• They are indicated for high caries risk patients
• 35-65% caries reduction in primary teeth with 1ppm F

Fluoride Supplements- Prescriptions

• Select the dose based on age and water fluoride status
• Select supplement type
• Write the prescription Educate parents and patient
• Safety precaution: Prescribe no more than 120 mg F ion

Fluoride Dentifrices

• Best topical for compliance with twice daily brushing being more affective
• Recommendations:
  • Use a smear or rice grain sized volume (0.1mg F) for children under 3 years
• Use small, “pea-sized” amount (0.25mg F) of F dentifrice (parental brushing/ supervision) ages 3-6 Use a soft, appropriately sized toothbrush Ensure minimum rinsing post-brushing

Fluoride acute Toxicity

• Symptoms of lethal overdose include GI, central nervous system and death in 4 hours
• The probably toxic dose: 5-8 mg F/kg
• The certainly lethal dose: 16-32 mg F/kg (Hodge and Smith) or 15 mg F/kg (Whitford)
• Prescriptions should be for no more than 120mg F ion to reduce toxic effect

Xylitol

• It is naturally occurring 5 carbon sugar alcohol
• Looks, tastes like, and has the same amount of sweetness as sucrose, it is only 40% less calories
• It is derived from birch trees, and grasses and found in fruit in small amounts
• Reduces acid production of plaque
• Reduces plaque adherence
• It does not cause decay
• It reduces numbers of MS
• Some GI symptoms are associated with high consumption
• MS cannot metabolize this sugar as it accumulates intracellularly inhibiting growth
• Long term effect on MS: makes it less adherent to tooth surface
• Has best effect at 6.88 g/day

Chlorhexidine

• It is in the bisbiguanide family
• Bactericidal, it disrupts bacterial membranes and enzyme systems against gram +ve and -ve bacteria
• Does not offer superior caries prevention than multiple fluoride therapies
• Disadvantages include staining of the teeth and taste

Remineralizing Agents

• They include MI Paste and MI Paste Plus, and CPP-ACP
• They stabilize ions and fluoride on the tooth surface
• Applied by prophy cup, tray, or finger
• Costly

Sealants

• Types: Self cure and light cure, filled and unfilled, fluoride-releasing, radiopaque, clear/opaque, and glass ionomer
• Resin-based sealants are the first choice
• GIC sealants may be used when moisture control is an issue but show low strength
• Primary teeth: when tooth and/or patient is at risk
• Permanent teeth/ Adolescents: when tooth and/or patient is at risk
• After 4.5 years the sealed permanent molar teeth of children (5-10y) had caries reductions in over 50% of occlusal surfaces compared to non-sealed teeth
• Caries reductions ranged from 86% at 12 months to 57% at 48-54 months

Resin Infiltration

• Resin Infiltration represents an innovative way to arrest non-cavitated interproximal caries or white spot lesions
• Involves penetration of a low viscosity resin into porous lesion bodies of the enamel caries
• Procedure steps:
  1. Cleaning- Surface treated with Hydrochloric acid

2. Drying- Surface desiccated with air and ethanol
3. Material application- Capillary action to infiltrate an unfilled fluid resin up to the DEJ or slightly beyond
4. Light cure to complete material set up

Silver Diamine Fluoride (SDF)

• Approved by the FDA in Aug 2014 and has been used in Japan for over 40 years
• Consists of 24-28% silver, 5-6% fluoride at pH 10 in a solution that contains ammonia
• Specifically:
  • Silver acts as antimicrobial agent
  • Fluoride used as remineralization agent
  • Ammonia included stablize high concentrations
• SDF is more effective for arresting caries than fluoride varnish, but has NOT been proven effective in reducing restorative material bonding
• Squamous layer on exposed dentin partially plugs dentinal tubules
• It turns exposed dentin to silver
• Is a "Zombie effect”, it causes dead bacteria kills living bacteria
• One drop (25 uL) is ample material to treat five teeth and contains 9.5 mg SDF
• Limit to one drop/10 per kg of patient weight
• Contraindications include:
  • Silver allergy
  • Dark staining but will lessen
  • Show reference pics
• Includes with an metallic/bitter taste and possible with Temporary staining to skin resolving in 2-14 days or Mucosal irritation/lesions which will resolve within 48 hours