PEDODONTICS

1. EARLY
CHILDHOOD
CARIES
(ECC)
-Dr.Neha Thilak
Senior Lecturer
Department of Pedodontics

2. CONTENTS
Definitions
Terminologies
Classification
Developmental Stages
Prevention
Management
Conclusion
References

4. DEFINITIONS
"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 71 months of age or younger”
AAPD Reference
Manual 2016
"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 six”
Bangkok Declaration Nov
2018

5. AAPD Reference Manual
2016
Any sign of smooth-surface caries in a
child younger than three years of
age,and from ages three through
five,one or more cavitated,missing(due
to caries),or filled smooth surfaces in
primary maxillary anterior teeth.
A decayed, missing or filled score of
greater than or equal to four (age 3),
greater than or equal to five (age 4), or
greater than or equal to six (age 5)
SEVERE
ECC

6. DIFFERENT TERMINOLOGIES
NURSING CARIES
BABY BOTTLE TOOTH DECAY
INFANT AND EARLY CHILDHOOD DENTAL DECAY
MATERNALLY DERIVED STREPTOCOCCUS MUTANS
DISEASE
MILK BOTTLE SYNDROME

7. CLASSIFICATION OF ECC BY WYNE

8. TYPE I (MILD TO
MODERATE) ECC
TYPE III
(SEVERE) ECC
TYPE II (MODERATE
TO SEVERE) ECC

12. ETIOLOGY OF DENTAL CARIES

13. ETIOLOGICAL RISK FACTORS
 DENTAL PLAQUE
 MUTANS STREPTOCOCCI
 INFANT FEEDING PATTERNS
 TOOTH BRUSHING
 SALIVARY FACTORS
 SUGARS
 ORAL CLEARANCE OF
CARBOHYDRATES
 BOVINE MILK
 HUMAN MILK
 FLUORIDES
 TOOTH MATURATION &
DEFECTS
 RACE AND ETHNICITY
 ACID FRUIT DRINK
 SOCIOECONOMIC STATUS
 DENTAL KNOWLEDGE
 STRESS
 OTHER FACTORS
PRIMARY RISK
FACTORS
SECONDARY RISK
FACTORS

14. DENTAL PLAQUE
•Besides modulation of the oral flora, the acquired pellicle has functions such as
lubrication, protection from acid attack, prevention of crystal growth on enamel surface
and a role in remineralization.
•In the absence of fermentable carbohydrates – organic acids like acetate, propionate &
butyrate are produced;
•In the presence of carbohydrates like lactate – pH drops in plaque

15. MUTANS STREPTOCOCCI
Streptococcus mutans (SM) and Streptococcus sobrinus are the most common
microorganisms associated with ECC.
Lactobacilli also participate in the development of caries lesions and play an
important role in lesion progression, but not its initiation.

16. WINDOW OF INFECTIVITY
S. mutans are spread from mothers to their infants
during a discrete window of infectivity. This period is
believed to be during the time that teeth are erupting,
from seven or eight months until 36 months, with the
median age being 36 months (Caufield 1993)
Second window of infectivity in permanent teeth :6-
12 years

17. INFANT FEEDING PATTERNS
Night time feeding practices / Sleep time feeding practices
Prolonged bottle feeding / “on demand” or “at will” breast feeding after first
primary tooth erupts or beyond the age of 12-18 months[Should be weaned from
bottle at 12-14 months]
Children who are exclusively breastfed also appear to be susceptible to caries.

18. TOOTH BRUSHING
As early childhood caries starts on surface that can be easily accessed by routine
tooth brushing, oral hygiene levels may be associated with caries risk.
Increased frequency and better oral hygiene levels are associated with low caries
levels in preschool children.

19. SALIVARY FACTORS
oSaliva provides the main host defense systems against dental caries.
oIt has major roles in the clearance of foods and the buffering of acid generated by
dental plaque.

20. SUGARS
Sucrose, glucose and fructose found in fruit juices and Vitamin C drinks as well as
in solids are the main sugars associated with infant caries.
Increased frequency and total time the sugar is in the mouth, increases the potential
for enamel demineralization and there is in inadequate time for remineralization by
saliva.

21. ORAL CLEARANCE OF CARBOHYDRATES
In infants with ECC, the sleep time consumption of sugars is another common
characteristic.
The low salivary flow during sleep decreases oral clearance of the sugars and
increases the length of contact time between the plaque and the substrate.

22. BOVINE MILK
Why milk may be less cariogenic than other sugar containing
liquids?
◦ Phosphoproteins inhibit enamel dissolution
◦ Antibacterial factors in milk interfere with oral microbial flora.
◦ Cariogenic bacteria may not be utilize lactose for energy source
as readily as sucrose.

23. HUMAN MILK
Compared to bovine milk, human breast milk has a lower mineral content, higher
concentration of lactose (7% vs 3%), and less protein (1.2 g vs 3.3 g per 100 ml), but
these differences are probably insignificant in terms of cariogenicity.
However, the relationship between breastfeeding and dental caries is likely to be
complex, and confounded by biological variables such as mutans streptococci
infection, intake of sugars, and social variables which may affect behavior related to
health.

24. FLUORIDES
◦ Although the benefits of water fluoridation and postnatal fluoride supplementation
in the primary dentition are well known, there is minimal information on the
cariostatic effects of topical fluoride in the early primary dentition, particularly in the
prevention of ECC.
◦ The topical effects of fluoride are complex, and include changes on the mineral
phases, as well as the modulation of metabolic effects on mutans streptococci and
other bacteria in dental plaque.

25. TOOTH MATURATION & DEFECTS
◦ Tooth is most susceptible to caries in the period
immediately after eruption and prior to maturation.
◦ Thus, in many infants, a combination of recently erupted
immature enamel in an environment of cariogenic flora with
frequent ingestion of fermentable carbohydrates would
render the tooth particularly susceptible to caries.

26. RACE,ETHNICITY & SOCIOECONOMIC
STATUS
Children living in ethnic areas demonstrate an extremely high rate of ECC, ranging
from 70-80%, despite efforts to educate parents to reduce baby bottle use.
ECC is so pervasive among these children that parents consider it a normal
childhood disease that affects all children.
Social class may influence caries risk in several ways.

27. DENTAL KNOWLEDGE
Important variable in the etiology of ECC
because understanding the relationship between
the microbiology of caries, the role of cariogenic
foods, and use of baby bottle is necessary for
prevention of ECC.

28. STRESS
One of the underlying mechanisms that could account for the effects of social class
on oral health status is the increased stress experienced by families with financial
and social instability related to lower SES.

29. CONSEQUENCES OF ECC
Higher risk of new carious lesion in both primary and permanent dentition
Hospitalization and emergency room visits
Increased treatment cost and time
Insufficient physical development (especially in height and weight)
Lack of adequate nutrition due to early loss of teeth

30. Loss of school days and restricted activity
Diminished ability to learn
Diminished health related quality of life
In older children with rampant caries, low self esteem.

31. PREVENTION OF ECC

32. PERI-NATAL CARE
• Initiation of caries preventive activities should be from the time of conception, whenever mother or child is
being examined- as teeth formation begins in utero
– Personnel Involved:
• Pediatricians, gynecologists
• Anganwadi workers, ASHA workers
• Skilled workforce- DISHAs (Dental Integrated Social Health Activist) to be created
– Expectant mothers to be educated on:
• Balanced diet during pregnancy
• Maternal free sugar intake – to be less than 10% of the total energy
• Effective maternal plaque control methods like brushing with fluoridated toothpastes

33. PREVENTION IN EARLY CHILDHOOD
(0-3 YEARS)
– Recommendations on maternal nutritional counseling
• 0-6 months exclusive breast feeding
• Less than 10% energy from free sugar
– Recommendations on maternal socio-behavioral counseling
• Cleaning of oral cavity with a soft, clean, boiled cotton or muslin cloth or disposable wipes
after every feed, from birth
• Supervised brushing twice a day with fluoridated toothpaste (1000- 15000 ppm) after 1st
tooth erupts
• Fluoride recommendations: 0-2 years – a smear, > 2 years - a pea-sized amount

34. – Other recommendations
• Yearly dental check-up on every birthday
• Educating pediatricians on emphasizing drinking water after consumption of
sugary syrups
• Pictorial warning on syrup bottles indicating caries risk and the need to drink water
or brushing after syrup consumption

35. PREVENTION IN EARLY CHILDHOOD
(4-14 YEARS)
A) Educate child on cariogenic impact of foods
• Involve teachers, employ dental educators
B) Supervised tooth brushing
• Fluoride toothpaste use (1000-1500 ppm), pea size
C) Sensitize pediatrician for better oral health care and dental referral
• Yearly dental check-up on every birthday
D) Collaborate with existing government school programs like midday meals
(hand washing followed by tooth brushing with fluoridated toothpaste
post meal)

36. E) Professionally applied fluoride varnishes by:
• Trained professionals
• Trained para-medics
F) School fluoride mouth rinse program
G) Dental clinic in schools
• Specific curriculum to be designed to train a school dental nurse
• Conducting 1 compulsory dental camp each year in every school with the report to
be sent to the concerned authorities

37. SECONDARY & TERTIARY
PREVENTION
Secondary prevention cannot be implemented alone but should be used in addition to
primary prevention
• Training of personnel for early detection - Involving interns, developing
new skilled workers- DISHA and training of ASHA skilled force
• Periodic oral health check ups, every 6 months or at every vaccination visit
in 1st year

40. MANAGEMENT
Once ECC is under control, comprehensive restorative treatment can be carried out.
Restorative strategies are as follows:
A) EXTENSIVE CAVITATION WITH NO PULPAL INVOLVEMENT:
Anterior teeth
• Acid etched composite resin restoration.
• Pedo strip crowns.
• Glass ionomer cement restoration.

41. Posterior teeth:
• Posterior composite resin restoration.
• Glass ionomer cement restoration
• Stainless steel crowns.

42. B) EXTENSIVE CAVITATION WITH
PULPAL INVOLVEMENT:
◦ Pulpotomy or pulpectomy.
◦ Extraction.
◦ Space maintainers.

43. ◦ Fluorides are very effective in preventing dental caries, including fluoride
toothpaste, water fluoridation, fluoride mouth rinse, and professional topical fluoride
application, primarily by inhibiting mineral loss from the tooth.
◦ The use of fluoride is done according to the level of fluoride in the water.

44. CONCLUSION
ECC is a chronic, infectious disease affecting young children and constitutes a
serious public health problem. It has a debilitating effect on the development,
speech, general health and self-esteem of infants.

45. REFERENCES
1) Shobha Tandon’s textbook of Pediatric Dentistry
2) Nikhil Marwah’s textbook of Pediatric Dentistry
3) DCI Workshop on Childhood Dental Caries