PREVENTION OF EARLY CHILDHOOD CARIES

Prevention of early childhood caries1

For a healthy smile tomorrowPrevention of early childhood caries

Submitted by Indu.G Under the guidance of Dr Mehamood muthedath and Dr Aseela

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Index

IntroductionClassification of early dental cariesDifference between nursing bottle caries and rampant cariesInfant oral health careParent counselingFluoridesPit and fissure sealants school dental health programsMethods on horizonConclusionReference

3 INTRODUCTIONEarly childhood caries (ECC), also known as baby bottle caries, baby bottle tooth decay or bottle rot is a syndrome characterized by severe decay in the teeth of infants and young children ECC is a very common bacterial infectionIt is a public health problem with biological, social and behavioral determinants. Hence prevention is essential4Classification of early childhood caries55

NURSING BOTTLE CARIESAlso called nursing caries, baby bottle syndrome & bottle mouth syndromeThe disease presents clinically as a widespread carious destruction of the deciduous teeth, most commonly the four maxillary incisors, followed by the first molars & then cuspids if habit is prolongedCaries in mandibular teeth absentCaries process in affected teeth may be so severe that only tooth stumps remain6EtiologySeveral factors primarily related to improper feeding practices7RAMPANT CARIES A condition which is characterized by sudden, rapid & almost uncontrollable destruction of teeth; affecting surface of teeth that are carious freeProximal and cervical surface of teeth which are relatively caries free are also involvedA caries increment of 10 or more new caries lesions over a period of about a year is characteristic of rampant cariesMost often observed in the primary dentition & permanent dentition of teenagers8

EtiologyMultifactorial

9Based on severityType 1 ECC(Mild to moderate)Carious lesions involving the molars and incisorsSeen in 2 to 5 yearsCause is usually a combination of cariogenic semisolid or solid food & lack of oral hygiene

10Type 2 ECC(Moderate to severe)Labiolingual carious lesions affecting the maxillary incisors with or without molar cariesSeen soon after the first tooth eruptsUnaffected mandibular incisorsCause is usually inappropriate use of feeding bottle or at will breast feeding or a combination of both & poor oral hygiene11

11 Type 3 ECC(severe)Carious lesions involve almost all the teeth including mandibular incisorsUsually seen in 3 to 5 yearsCause is usually a combination of factors & a poor oral hygieneRampant in nature & involves immune tooth surfaces12

Difference between nursing caries & rampant cariesNursing cariesRampant cariesSpecific form of rampant cariesAcute, widespread caries with early pulpal involvement which are usually immune to decayAge of occurrenceSeen in infants & toddlersAffects primary dentitionSeen at all ages including adolescenceAffects primary & permanent dentitionCharacteristic featuresMandibular incisors are not involvedMandibular incisors are involvedEtiologySeveral factorsBottle feeding before sleepPacifiers dipped in honey or other sweetenersProlonged at will, breast feeding

Multifactorial factorsbottle factors before sleepFrequent snacks, excessive sticky refined carbohydrate intakeDecreased salivary flowGenetic background13Conti..Treatment Early stages- fluoride applications & educationDirected towards maintenance of teeth till transition occurs

With presence of multiple pulp exposures would generally require pulp therapyLong term treatment may be required when permanent dentition is involved

14Etiologic agents in ECCPathogenic microorganismPrinciple microorganism- streptococcus mutansTransmitted to infants mouth primarily through mother15SubstrateCarbohydrates are used utilized by microorganism to form dextrans whichAdhere organism to tooth surfaceCause organic acid to demineralise toothIn infants & toddlers the main source of fermentable carbohydrates are

16An integral component 17HostTeeth act as host to microorganismHypomineralisation or hypoplasia increases the susceptibility to cariesThin enamel in the primary teethDevelopmental grooves

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TimeImportant factor that determines caries activityMore the child sleeps with he bottle in the mouth, the higher risk of caries

1919Other predisposing factorsOver indulgence of parentsCrowded homesChild who has less sleepMalnutrition

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By definition, infant oral health care can be understood as the foundation on which a life time of preventive education and dental care can be built up in order to help acquire optimal oral health into child and adulthood21Infant oral health care

Goals of an infant oral health care programTo identify, intercept and modify the potentially harmful parenting practices that may adversely affect the infants oral healthParent education right from the prenatal period highlighting the importance of their role in prevention of dental disease for their childParent/caregiver orientation to perceive dental services as an integral part of infants overall health programPeriodic evaluation of the orofacial development and oral health by the clinician22

Why infant oral health care?The following are few reasons why infant oral health care should be an integral component Infectious diseases of the oral cavityTraumatic injuriesHabits Child abuse and neglectCare of alternately abled childrenProblems of speech and language23

Infectious disease of the oral cavityTraumatic injuriesWith lack of motor coordination trauma to developing primary dentition may also occurHabitsSuch as thumb sucking usually have their inception at this age and may persist to cause several dental problemsChild abuse and neglect may also be detectedCare of the alternatively abled childrenCleft lip and palate cases and other such children requiring special attention, may do so right from birthProblems of speech and language would require special attention24

To all these problems, the traditional approach has been to treat the effect of the disease. By delineating an infant oral health care policy, one may not have to encounter the disease process or its effects.Thus Nowak(1997) has stated that the goal of the first oral supervision visit is to assess the risk of dental disease, initiate a preventive program, provide anticipatory guidance and decide on the periodicity of subsequent visits.25

How to proceed for infant oral health care?As evaluation of any case a proper history coupled with a vigilant assessment including what is normal & what is not at this age is necessaryHistoryExaminationRisk assessment based on dietary factors, amount of plaque present on teeth, feeding practices etc. This should be followed by customization of a preventive protocol rather than generalizationAny therapy, restorative procedures or prophylactic measures needed should be instituted

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Role of dentist The timing of first visitShould be within 6 monthsParents must be made aware about the:Signs of teethingAge of eruption

27AgeTeeth erupted6-10 monthsBottom front teeth, then top front or side bottom front teeth9-13 monthsTop front teeth13-19 monthsFirst molars then canines, then second molars2.5- 3 yearsAll teeth

Various traditional home remedies such as rubbing of honey should be discouragedFeeding practicesAdvantage of breast feeding over bottle feedingBottle feeding instructionsProvide more attention to the childRemove the bottle immediately after feedingEncourage your baby to stay upright position with a bottleIntroduce a cup to drink as soon as possibleUse a bottle with a nipple that has small holesSubstitute milk or non- sweetened juices with plain waterBottle feeding be allowed at intervalsIt should not be used as a pacifierGive water after feeding with the bottle & clean the mouth soon after feeding

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Use of pacifiersseveral disadvantages have been found with the use of pacifiersThose dipped in honey and sugar can cause increased cariesMalocclusionUnhygienic conditions leading to infections and GIT problems29

Oral hygiene practicesProper technique for positioning and tooth cleaning should be demonstratedGum pads

Teeth

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Role of pediatricians

Monitor the growth and development of the childForebearers in providing information to parentsFollowing topics needed to be discussed by a pediatricianTooth eruptionPreventive oral hygieneOrofacial developmentFluoridationDietWeaning foods free of, low in non-milk extrinsic sugars should be recommended to the mothersDepending on the amount of fluoride present in community water, and the requirements of the child, fluoride supplementation program can be institutedShould be aware of the dentist population in his vicinity for the purpose of referral31

Nurse, midwifes:- information about immunization, accident prevention & dental healthGynecologists or obstetrician:- can emphasize commencement of tooth brushing or cleaning with gauze on prenatal classesNeonatologist:- advising and counseling the parents regarding any congenital defect such as cleft lip, regarding dental and overall health aspect of the childImportance of breast feeding can be emphasized by these medical personnelMothers can be informed about the transmission of antibodies via breast milk & their effect on dental healthImportance of mothers own oral hygiene 32Role of other personnel

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Parent counseling

DefinitionParent counseling can be defined as educating parents regarding the childs oral health status, optimal health care and informing them about the prevention of potential dental disease33Purpose

Discussion of emotional problems of children, particularly in relation to dental treatmentTo offer the dentist an insight into parental influences which may produce unnecessary anxietiesKnowing about the behavioral management techniques used during dental treatment for childrenObtaining the cooperation of a child patient, establishing a good rapport with the child and also using effective techniques of behavior managementEducating the parents about various dental problems & diseases and their sequelae and how they can be prevented with accurate preventive measure if recognized earlier

34Education of parent in various aspects of dentistryPrenatal counselingParents should be educated regardingDental development of their childThe dental disease processAppropriate feeding practices emphasizing the hazards of improper bottle and breast feeding Oral hygiene measures appropriate for infants and toddlersImportance of primary teeth

35Conti..Expected parents can also be told regarding the mothers health during pregnancy & the potential determinant effect that poor health and unhealthy habits may have on their childs development

36Prevention of dental disease from conception to 3 years of ageA large number of children experience a dental disease before 3 years of age.CausesSequelae to nursing cariesEating practices after weaning37ti37Content areasDentists actionOral developmentGum pads to completion of primary dentition

Establishment of occlusionDiscuss the patterns of eruptionDiscuss the myths about unhygienic practice practiced during teethingDiscuss oral stimulatorDiscuss the importance of primary teethDiscuss bruxism and its illsFluoridesImportance of systemic and topical fluoridesRecommendation against topical fluoride use till 3 years of ageAssess fluoride statusDiscuss fluoride supplements if neededProfessional application of fluoride begins at 3 years when swallowing can be controlled Oral hygienecare of gumpadsMouth cleaning techniques

Periodicity of dental visit

Clean gumpads with a soft clean cloth after each feedingInstruct about the use of a soft toothbrush and pea size toothpasteBrushing technique taught to the parentsEducate parents about the importance and need for periodic dental visits38Content areas Dentists actionHabits Non nutritive suckingPacifier useThumb suckingReview pacifier use and safety and hygiene issuesDiscuss ill effects of thumb sucking to the dentofacial structuresNutrition and dietBaby bottle tooth decay patternImportance of dietDiscuss proper feeding practices & the use of bottleRole of diet in growth & developmentDiscuss how frequent sugar intake results in initiation of cariesInjury and cariesOral trauma

Home child proofingImmediate referral into the dentist as an injury to the teeth of young child can have serious and long term consequenceUse of baby walker when infants begins to learnUse or car seat or the child should be in mothers lapChild should not be left alone for a long time

39Prevention of dental disease from 3 to 6 years of ageDietRole of frequency of intake & rate at which sugar is cleared from the oral cavity in initiation of cariesFood items can be recommendedOral hygiene 3-6 years require parental assistanceParents should be instructed to brush for the child at least once a day, and to clean between any teeth that are in contact with each other using dental flossAdditional brushings may be performed by the child unaidedFluoridesFluoride consumption should be investigatedUse of fluoride containing tooth paste(once daily)Professional application of fluoride

40Prevention of dental caries from 6 to 12 years of ageEruption of first permanent molarsSealantsDietChildren of this age have their own food choices & may purchase snacks. Parents are instructed to monitor dietary practicesFluoridesTopical fluoride applicationRegular use of toothpaste(twice daily fluoridated toothpaste)Oral hygienemonitoringHabits Education about any oral habit, if it is presentAlso educate parents about transitional changes in developing dentition and the importance of primary and permanent dentition41Prevention of dental diseases in adolescentsPrevention of dental caries and periodontal diseasesOral hygieneDietHigh caries rate-usually associated with poor oral hygiene habits &high frequency of sugar consumptionProgress of lesion-halted with diet control & topical fluoride therapyFluoridesSystemic fluorides no longer benefitTopical fluoridesUse of fluoride containing dentifrice-thrice dailyOrthodonticsMany patients undergo orthodontic therapy- high risk for gingivitis &the resultant gingival hyperplasia & for dental cariesTopical fluoride therapyA thorough removal of plaque from gingival areasSmokeless tobaccoEvidence of tobacco use- motivate the patient to discontinue the habitParents should be instructed/ counseled not to nag or punish- enrich the habit

42Preventing dental injuriesInjury of young child teeth can have serious and long term effects- discoloration, malformation or even loss of teeth emotional impactAvulsed tooth- keep under the tongue of child, milk or salineTrauma- immediately contact the dentistBest approach is to take active measures to prevent injuriesAthletic mouth protectors

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FluoridesFluoride delivery systemSystemic fluoridesSelf appliedDentifricesRinsesGelsTooth picksFlossChewing gums44Fluoridated saltFluoridated citrus fruitsFluoride in sugarFluoridated dietary supplementsFluoride dropsFluoride drops with vitaminsFluoride tablets/ lozengesFluoride tablets with vitaminRinseSolutions Water fluoridationSchool water fluoridationMilk fluoridationProfessionally applied Solutions Varnishes GelsTopical fluorides

Pit and fissure sealantsPits and fissure sealants are defined as whereby pits and fissures that occur principally on the occlusal surface of the molar and premolar teeth are occluded by application of fluid materials, which are then polymerized.Sealant materialsAlkyl cyanoacrylatesPolyurethanesBISGMAUV light activated resinsVisible light activated resinsChemical activated resinsGlass ionomer cements45

Age ranges of sealant application3-4 years of age: primary molar6-7 years of age: first permanent molars11-13 years of age: second permanent molars and premolarsApproach that considers only selected patients: SimonsonGroup 1: caries free patients judged at no risk of decayGroup 2: patients judged at moderate risk of decayGroup 3: patients with rampant caries at a high risk to decayRealistic approachClinical judgment based onAge Oral hygieneFamilial and individual history of dental cariesFluoride environment & historyDietary habitsTooth type and morphology46

School dental health programDefinitionSchool health services are defined as procedures established To appraise the health status of pupils & school personnel'sTo counsel pupils, parents & other concerned appraisal findingsTo encourage the correction of remedial defects To assist in identification & education of handicapped childrenTo prevent & control diseases &To provide emergency services for injury or sudden sickness(by The Committee of Terminology of American Association for Health, Physical Education and Recreation 1951)47

Aspects of school health services48

ObjectivesTo help every school child to appreciate the importance of a healthy mouthTo help every school appreciate the relationship of dental health to general health & appearanceTo encourage the aid of all groups or agencies interested in promotion of school health To enlist the aid of all groups & agencies interested in promotion of school health To correlate dental health activities with the whole school health programsTo stimulate the development of resources to make dental care available to all childrenTo stimulate dentists to perform adequate health services for children 49

Elements of dental health programConducting dental inspectionConducting dental health educationPerforming specific programsReferral of dental careFollow up50

Methods on the horizonAntiplaque agentsRole of Plaque in caries is well documentedThus anti bacterial & anti adherence agents are being tested as plaque building blockers Some plant products such as mango leaf, neam leaf and tea extracts are found to be effective in reducing plaque formation as well as the S. mutans countProphy paste with ACP(Amorphous Calcium Phosphate)Lyre-Jet Instant Intraoral Camera with Plaque Detector

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Benign micro organism / replacement therapy

The lactic acid produced by S. mutans is controlled by a gene which can be mutatedGenetic engineering provides a better alternative producing inactivated forms & then cloning itFor eg.; a new approach is used to transfer genes from bacteria that naturally produces enzyme such as mutanase which degrades the extra-cellular sticky polymers involved in plaque adhesion & build up, into bacteria such as S. gordoni

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Altering surface modalities/ increasing tooth resistance

A so called surface active polymeric agent for surface adhesive binding comprising applications at two stages for increasing tooth resistance to dental decayMonomer which would have a chemical bond followed by a polymeric top coat which would enhance durability and estheticsTooth resistance is improved using two step procedure by enhancing the fluoride uptake in enamel. Initial application of acidified calcium phosphate followed by suitable fluoride system.5% NaF varnish is a new productToothpaste containing polyfluorite system(a combination of stabilized stannous fluoride0.054% and sodium hexametaphosphate) new generation ADA accepted tooth paste54

Co2 lasers

Used to alter the tooth surface of enamel & make it less prone to caries

Pits & fissures and root surfaces may be the areas targeted by lasers 55SAP( Self Assembling Polypeptides)Chewing gumsA novel technique the use of chewing gums after meals in order to counter the pH drop that occurs with the intake of sugarsVarious sugar free gums have been tried out, with additions such as xylitol, lactilol, and urea

Tooth friendly sweetsThey contain sweeteners that are not fermented by the microflora of the dental plaqueMicro dentistryHere treatment begins before conditions ariseEnables the use of microscope to detect conditions invisible to naked eyeCan be used as an educational or motivational tool

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Tele dentistryProvision of dental care where the patient and provider are not physically on the same locationCan also used as an adjuvant in providing preventive home care advicesIndigenous productsRecently a lot of emphasis has been placed on the utilization of rich natural sources such as neam, mangoleaf & teaCaries vaccineThe basis of vaccine is that it keeps patient in a state of readiness such that in case of infection does occur,the immune response which is more rapid and effective can be mounted

57Conclusion Prevention of dental caries is essential for maintaining a healthy dental state. For developing countries like as India, where dental health facility is not available to all the sections of the society, prevention of early childhood caries is a better option.58ReferenceTextbook of pedodontics- Shobha tandon 2nd editionEssentials of preventive and community dentistry- Soben peterShefers textbook of oral pathology- 6th editionInternet encyclopedia Dental caries prevention- M. Ganesh

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Thank you

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