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BDS 7132: Early Childhood Caries, Nursing and Rampant Caries Aim: To describe the epidemiology and etiology of caries in children Objectives : Goes Here Subject Title • Describe the epidemiology of caries in children, including early childhood caries • Explain how bacteria, diet and susceptibilit...

BDS 7132: Early Childhood Caries, Nursing and Rampant Caries Aim: To describe the epidemiology and etiology of caries in children Objectives : Goes Here Subject Title • Describe the epidemiology of caries in children, including early childhood caries • Explain how bacteria, diet and susceptibility can cause caries • Evaluate different methods for diagnosing caries in children and apply them where appropriate • Explain the types and stages of ECC • Understand how to manage ECC What is Caries? A complex process of enamel demineralization and remineralization that occurs due the action of organic acids produced by micro-organisms within the dental plaque. Dental caries is a multifactorial disease, resulting from the interplay between environmental, behavioural and genetic factors. What is Caries? Almost all research on the process of dental caries supports the chemo-parasitic theory proposed by W.D. Miller in 1890. This is now more commonly known as the acidogenic theory of caries aetiology. Pathogenesis of Dental Caries: The main features of the caries process are as follows: 1. Fermentation of carbohydrate to organic acids by micro-organisms in plaque on Host the tooth surface. 2. Acid production, which lowers the pH at the enamel surface below the level (the critical pH 5.5) at which enamel will dissolve. MI Caries Time CHO Pathogenesis of Dental Caries: 3. When carbohydrate is no longer available to the plaque micro-organisms, the pH within plaque will rise because of the outward diffusion of acids and their metabolism and neutralization in plaque, so that remineralization of enamel can occur. 4. Dental caries progresses only when the balance Host between demineralization and remineralization favours the former. The realization that demineralization and remineralization are in equilibrium is key to understanding the dynamics of the carious lesion and its prevention. MI Caries Time CHO Epidemiology of Dental Caries: Dental caries is one of the most prevalent diseases, unfortunately it is the most common disease in the world. Its prevalence varies between countries, between regions within countries, between areas within regions, and between social and ethnic groups. Epidemiology of Dental Caries: • Since 1968 there have been surveys of adult and child dental health every 10 years in the UK. • Unfortunately well conducted national surveys in Egypt are not available Epidemiology of Dental Caries: • Caries prevalence and extent have fallen markedly since the late 1970s in developed countries whereas this was not the case in the underdeveloped countries. However, this decline may have ceased. • Dental caries is one of the most prevalent diseases in the preschool child population of Western countries. • By 3 years of age 12% of children in England already have dental decay. Epidemiology of Dental Caries: • While the state of the permanent dentition in children has improved dramatically in many countries, caries in primary teeth is still a considerable problem in preschool and school-aged children. • In industrialized countries, caries experience is highest in the more deprived groups of society and often in ethnic minority groups. Epidemiology of Dental Caries: • In developing countries, the reverse social trend is observed, with the well-off urban children having the most caries experience. • Most of these variations in children’s dental health can be explained in terms of the preventive role of fluoride and the cariesinducing role of sugary snacks. Rampant caries • Rampant caries has been defined by Massler as 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”. Cont. Rampant caries: • Rampant caries has been observed in both children and adults of all ages. • There is no evidence that the mechanism of the decay process is different in rampant caries. • The term rampant caries should be applied to a caries rate of 10 or more new lesions/year. Etiology of Rampant caries: • • • • Emotional disturbances Depressed emotions Dissatisfaction, fear Continuous general tension and anxiety All the previous factors lead to comfort eating, administration of medications that maybe associated with salivary deficiency- - impaired remineralization). Early Childhood Caries (ECC): • Terms such as ‘nursing bottle mouth’, ‘bottle mouth caries’, or ‘nursing caries’ are used to describe a particular pattern of dental caries in which the upper primary incisors and upper first primary molars are usually most severely affected. The lower first primary molars are also often carious, but the lower incisors are usually entirely caries free or only mildly affected. Early Childhood Caries (ECC): • Some children present with extensive caries that does not follow the ‘nursing caries’ pattern. Such children often have multiple carious teeth and may be slightly older (3 or 4 years of age). This presentation is sometimes called ‘rampant caries’. There is no clear distinction between rampant caries and nursing caries, and the term ‘early childhood caries’ is all-encompassing term. Definition of Early Childhood Caries (ECC) • Early childhood caries (ECC) is a virulent form of dental decay that can destroy the primary dentition of toddlers and preschool children. • It is a specific pattern of rampant caries affecting primary teeth of infants during the first 3 years of life. Definition of Early Childhood Caries (ECC) • According to the American Academy of Paediatric Dentistry (AAPD) ECC is defined as the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of six. • Other names mentioned in the literature are; Baby-bottle caries, Nursing bottle syndrome, Baby-bottle tooth decay, Nursing caries and recently Early Childhood Caries as this term better reflects the complex etiologic factors of the disease. Etiology of Early Childhood Caries (ECC): • The same etiological factors as for dental caries: Aciduric Bacterial factor- substrate – hard tooth structure- sufficient time. Rapid demineralization and cavitation of tooth structure. • In many cases, ECC is related to the frequent consumption of a drink containing sugars from a bottle or ‘dinky’ type comforters. • Fruit-based drinks are most commonly associated with nursing caries. Even many of those claiming to have ‘low sugar’ or ‘no added sugar’ appear to be capable of causing caries. • prolonged on-demand breastfeeding. Most affected children sleep with their parents, suckle during the night, and are often still being breastfed at 2 years of age or older. Etiology of Early Childhood Caries (ECC): • Frequency of consumption is a key factor. • Affected children often have a history of taking a bottle to bed as a comforter or using a bottle as a constant comforter during the daytime. • Research has shown that children who tend to fall asleep with the bottle in their mouths are most likely to get ECC, and this is probably a reflection of the dramatic reduction in salivary flow that occurs as a child falls asleep. Etiology of Early Childhood Caries (ECC): • Studies indicated that other factors, such as linear enamel defects, malnutrition, and hypomaturation enamel defects, may play an important role in the etiology of this condition in some children. • It is important to appreciate that this does not imply that normal breastfeeding up to around 1 year of age is harmful for teeth, indeed it is to be positively encouraged, but that prolonging ondemand feeding beyond that age may carry a risk of causing dental caries. Etiology of Early Childhood Caries (ECC): • Some clinical studies have suggested that the night-time consumption of cows’ milk from a bottle beyond the normal weaning age might be associated with early childhood caries in some children. • Hence, leaving infants unattended suckling milk from a bottle once they have fallen asleep should be discouraged. Etiology and aggravating factors of (ECC): To sum it up: • Inappropriate nursing habits. • The regular use of a sweetened comforter and ‘grazing’ (snacking on food constantly). • Feeding close to or during bedtime • Breast-feeding prolonged beyond the normal age for weaning. • The regular use of syrups for therapeutic reasons during chronic or recurring illnesses. Mechanism of (ECC): • When the child falls asleep milk pools around the maxillary anterior teeth. • Long periods of exposure to cariogenic substrate. • The sparing of the lower incisors (remain sound) seen in nursing caries is thought to result from shielding of the lower incisors by the tongue during suckling, whilst at the same time these teeth are being bathed in saliva from the sublingual and submandibular ducts. The upper incisors, are the most affected on the other hand; are bathed in fluid from the bottle/feeder. Stages of Early Childhood Caries (ECC) Stages are arranged from the least to the most severe except for the arrested one as the caries activity stops at any stage. • • • • • Initial ( reversible)stage: Cervical chalky demineralization. Damaged (carious)stage: Marked discoloration due to dentin caries. Deep lesion stage: Pulp involvement. Traumatic stage: Fracture of the weakened maxillary incisors. Arrested caries: When the cause of caries is eliminated. Initial (Chalky white) Arrested (Brown to black appearance ) Traumatic (Tooth fracture) Damaged (Marked discolouration) Deep lesion (Pulpal problems ) Stages of Early Childhood Caries (ECC) Initial or reversible stages: • Cervically chalky white demineralization on the maxillary incisors • This stage is often missed. Pain and toothache does not occur in this stage. • This stage needs a remineralizing agent and feeding at well cessation to be reversed. Cont. Stages of Early Childhood Caries (ECC): Carious (Damaged) stage: • Caries extended into the dentine with marked discoloration. • Child starts complaining about toothache when cold food is ingested. • The upper first primary molars are affected as in the first stage of ECC. Cont. Stages of Early Childhood Caries (ECC) Deep Stage: • Complain of pain during tooth brushing or eating due to pulpal problems in the maxillary incisors can provoke spontaneous pain during night. • The upper first primary molars are in the second stage while lower first primary molars have initial lesion. Cont. Stages of Early Childhood Caries (ECC) Traumatic stage: • The maxillary incisors become so weak by caries that relatively small forces are sufficient to fracture them. • The first maxillary molars are in the 3rd stage. The first mandibular molars are in the second stage. Cont. Stages of Early Childhood Caries (ECC) Arrested caries stage: • In all the previous stages given above, arrested caries might occur, when the cause of dental caries is eliminated. • The lesion might get a typical dark brown to black appearance. Impact of Early Childhood Caries (ECC): • Early childhood caries greatly affects the child general health, speech and self-esteem of the child. • Oral health has a definite effect on the Quality of Life of children. The most affected parameters by ECC were consumption of food (difficulty in eating) and sleep,as well as time off school. • Progression of nursing caries may affect growth adversely. Impact of Early Childhood Caries (ECC): In terms of health, preschool children with severe early childhood caries weigh less and are smaller than their peers, and children with severe early childhood caries are six times more likely to have iron-deficiency anaemia than their peers (Sheiham 2006). Management of Early Childhood Caries (ECC) Objectives: A. Prevention of the carious process. B. Treatment by restoration and oral rehabilitation. A. Prevention of Early Childhood Caries (ECC) I. On the community level: • National education programs for the parents about development of ECC and its etiological risk factors. • Personal and community preventive programs. • Water fluoridation. Cont. Prevention of Early Childhood Caries (ECC) II. Development of appropriate dietary habits and self-care habits at home: • Use of plain water after every feeding. • Do not use the bottle as a pacifier and never dip a pacifier in any sweet liquid. • Wipe the gums with a clean gauze pad if tooth brushing is not possible. • Vertical transmission of micro-organisms occur from the mother to the child. Thus, parents must not use their children’s cups, spoons or other utilities. Cont. Management of Early Childhood Caries (ECC) Cont. Prevention of Early Childhood Caries (ECC) III. Professional examination and preventive care: Early dental examination (as recommended by AAPD). Parents should be encouraged to bring their children for a dental check-up as soon as the child has teeth (around 6 months of age). Sealing of all caries free deep pits and fissure by pits and fissure sealant. Dietary counseling (advising): • Infant held up-right while feeding. • The child who falls asleep while nursing should be burped • Early weaning at 12-15 months of age. • Avoid prolonged and frequent infant feeding habits. B. Restoration and oral rehabilitation: • • • • Cessation of habit. Dietary advice. (Dietary history is a must) Fluoride application. Gross excavation of carious lesions and their restoration • Build-up of restorable teeth after caries excavation or pulp therapy if the tooth’s pulp was involved, This may consist of glass ionomer restorations, composite resin-strip crowns and/or stainless steel crowns. • Extractions if required. Finally It is important to give appropriate advice to the family about early childhood caries. Blame should never be attributed; in many situations the condition has arisen out of ignorance, misinformation, or in frustration of coping with a sleepless infant. Diagnosis of caries: The identification of caries depends on a systematic examination of clean wet and dry teeth. A ball-ended or blunt probe can be used gently to confirm the presence of cavitation. • Visual–tactile examination: The basic equipment consists of adequate lighting, compressed air for drying, a dental mirror, and a blunt or ball ended probe. The emphasis is on a visual examination, rather than a visual–tactile examination. Diagnosis of caries: • Visual–tactile examination: The sharp probes which were traditionally used to aid diagnoses are contraindicated for a number of reasons: • The probe does not improve diagnosis • Probing a demineralized lesion will break the enamel matrix, making remineralization impossible and thus creating an iatrogenic cavity. • The probe may transfer cariogenic bacteria from one site to another. A systematic review* concluded that visual–tactile examination is a simple, cheap, and reliable method for diagnosing obvious lesions on all tooth surfaces not contacting neighboring tooth surfaces. *Caries Diagnosis, Risk Assessment and Non‐operative Treatment of Early Caries Lesions. The Swedish Council on Technology Assessment in Health Care. SBU report No. 188, 2007 (in Swedish). Diagnosis of caries: The first visible sign of caries is the white spot lesion, which at first can only be seen when the surface is dried. This is because when demineralized enamel becomes porous, the pores contain water; if dried, the water in the pores is replaced by air and the lesion becomes more obvious. Diagnosis of caries: As the caries progresses the lesion will become obvious even when wet. Because even the most thorough visual clinical examination will detect only some of the enamel and dentine carious lesions present, the clinician needs to be helped by diagnostic aids. The most commonly used are radiographs. Diagnosis of caries: • Radiographic examination: Bitewings (the first-choice view for caries diagnosis) and periapicals. Bitewings provide information on both occlusal dentine caries and approximal enamel and dentine caries. This is the most commonly used method for detecting and assessing caries lesions on approximal surfaces with adjacent contacting surfaces. However, The early, noncavitated lesion on these surfaces, may not be detected in the radiographic image and usually not from direct visual–tactile examination. Diagnosis of caries: There are a variety of alternative/supplementary caries‐diagnostic tools available to the pediatric dentist: • Fiber optic transillumination (FOTI) • Digital fiber optic transillumination (DiFOTI) • Laser fluorescence (DIAGNOdent) • Near‐infrared (NIR) transillumination technique (DIAGNOcam) • Quantitative light‐induced fluorescence (QLF) • Electronic caries measurement (ECM). The first five are optical methods and the last one is based on electrical impedance. Diagnosis of caries: • Fiberoptic Transillumination (FOTI): FOTI consists of the placement of a 0.5mm light source in the embrasure. If a carious lesion is present, it will show as a dark shadow. Some studies have suggested that FOTI is as accurate as radiographs, while others question its benefit. Certainly, if it is used, FOTI provides the clinician with more information on which to base a decision. Diagnosis of caries: • Digital Imaging Fiberoptic Transillumination (DIFOTI): This device creates high resolution digital images of occlusal, interproximal and smooth surfaces. It enables dentists to discover or confirm the presence of decay that can not be seen radiographically, visually or through an explorer. FOTI (DiFOTI) is used as an alternative to bitewing radiography. Holt and Azevedo* compared the diagnostic gain from FOTI and radiography and concluded that the use of FOTI offered no advantage over radiography. BUT, in situations when radiography cannot be used, for example children not accepting having radiographs taken, FOTI can serve as an alternative. * Holt RD, Azevedo MR. Fiber optic transillumination and radiographs in diagnosis of approximal caries in primary teeth. Community Dent Health 1989;6:239–47. Advanced Caries detection tools The fluorescence of sound and carious tooth structure differs, and therefore this property is being utilized to assist with caries diagnosis. Laser fluorescence devices measure the fluorescence of the tooth and, of particular importance, the fluorescence of bacterial by-products in the carious lesion. This provides a digital reading indicating the status of the surface. When used appropriately these devices provide a standardized reproducible measure which helps with the diagnostic decision, allows the possibility of monitoring lesions over time. Infrared Laser Fluorescence (DIAGNOdent): Detection and quantification of dental caries of occlusal and smooth surfaces. Advanced Caries detection tools • Quantitative Light Fluorescence (QLF): The use of a laser light of selected wavelength enhanced the visibility of early noncavitated lesions. markedly In conclusion, each of these alternatives and supplementary diagnostic tools has shown advantages and drawbacks. A systematic review concluded that there is not sufficient evidence to decide on the accuracy of these diagnostic tools**. **Twetman S, Axelsson S, Dahlén G, Espelid I, Mejàre I, Norlund A, Tranæus S. Adjunct methods for caries detection: a systematic review of literature. Acta Odontol Scand. 2013;71:388–97. List of Readings and References Students are advised to read relevant sections of the following texts: 1. Early childhood caries, AAPD http://www.aapd.org/media/Policies_Guidelines/P_ECCClassifications.pdf 2. Welbury R et al; Paediatric Dentistry; 5th Edition, Oxford Press 3. Koch G et al; Pediatric Dentistry - a Clinical Approach; 3rd Edition, Wiley Blackwell 4. Massler JN. Teen-age caries, J Dent Child 12:57-64, 1945. 5. Acharya, S., & Tandon, S. (2011). The effect of early childhood caries on the quality of life of children and their parents. Contemporary Clinical Dentistry, 2(2), 98–101. http://doi.org/10.4103/0976-237X.83069 Aim: To describe the epidemiology and etiology of caries in children Objectives : Goes Here Subject Title • Describe the epidemiology of caries in children, including early childhood caries • Explain how bacteria, diet and susceptibility can cause caries • Evaluate different methods for diagnosing caries in children and apply them where appropriate • Explain the types and stages of ECC • Explain how to manage ECC