Continuing Education Activity

The presence of dental caries in the primary dentition of young children is known as early childhood caries (ECC), which is defined as one or more decayed, missing (resulting from caries) or filled teeth in primary dentition in children of up to 71 months of age. The term early childhood caries include the sometimes called nursing caries and rampant caries. This activity reviews the cause, pathophysiology, and presentation of early childhood caries and highlights the role of the interprofessional team in its management.

Objectives:

• Identify the etiology of early childhood caries.
• Review the presentation of an infant with early childhood caries.
• Outline the treatment and management options available for early childhood caries.
• Explain the interprofessional team strategies for improving care coordination and communication regarding the management of patients with early childhood caries.

Introduction

The presence of dental caries in the primary dentition of young children is known as early childhood caries (ECC), [1][2] which is defined as one or more decayed, missing (resulting from caries) or filled teeth in primary dentition in children of up to 71 months of age.[3]

The term early childhood caries includes the sometimes called nursing caries and rampant caries. “Baby bottle syndrome,” “nursing caries,” or “bottle mouth caries” are names to describe a pattern of caries where the deciduous upper incisors and molars are more severely disrupted. A key feature of this type of caries is the sparing of the lower incisors, which can be completely healthy or mildly affected. The term rampant caries is usually given to extensive caries affecting children of three to four years of age that do not follow the nursing caries pattern.

Despite early childhood caries can be easily preventable, it is one of the most prevalent childhood diseases worldwide, mainly affecting socially disadvantaged populations.[4]

Etiology

All types of caries, including nursing caries, result from the interaction of cariogenic microbiota, fermentable carbohydrates, and susceptible teeth that interact during a prolonged period.[5]

Cariogenic Microorganisms

Streptococcus mutans and Streptococcus sobrinus are the main bacteria found in early childhood caries.[6][7] Lactobacilli also play a role in the progression of caries, but not in their initiation. The bacteria consume and metabolize carbohydrates like sucrose, fructose, glucose and produce lactic acid.[8][9] This acid lowers the intraoral pH and causes demineralization of tooth enamel. Prolonged demineralization eventually leads to corrosion of dentin and cavitation.[10]

Children that acquire Streptococcus mutans earlier in life, even before the first tooth's eruption, are at greater risk of developing caries. This period is called the window of infectivity. If preventive measures are put in place during this crucial period, the risk of developing caries is much lower because less pathogenic bacteria will colonize the oral niches.[11][12][13]

Direct Transmission of Infection

The vertical transmission of Streptococcus mutans from the mother to the child occurs through infected saliva and sharing food and utensils. Droplet infection through habits in the mother such as tobacco or betel-nut chewing can also spread the bacteria. 

Babies delivered by the cesarian section have a higher risk of developing caries than those born vaginally as the aseptic environs and atypical microbial environment increases the chances of opportunistic Streptococcus mutans colonization. Studies suggest that mothers are the primary source of Streptococcus mutans in their children. Therefore, the level of Streptococcus mutans in children correlates with those of their mothers.[11] Horizontal transmission of the cariogenic bacteria is also seen between siblings and caregivers.

Improper Dietary and Feeding Practices

A retrospective cohort study on early childhood caries and associated risk factors was performed among mothers with 25- to 30-month-old infants from a community where prolonged breastfeeding was common practice. The study concluded that children that consumed sugary food or rice that was pre-chewed by the mother and fell asleep with the breast nipple in the mouth were found to have ECC.[11] However, children who were breastfed beyond the age of twelve months without those habits did not have ECC.[14] Cariogenic habits and breastfeeding at night after the age of twelve months increase the risk of developing early childhood caries.[14] Other behavioral risk factors include bottle sipping during the day and putting the child to bed with a bottle of formula.[15]

Sugary Diets

Studies have found that early childhood caries are more frequent in children who consume juice between meals and sweetened solid food.[16] Salivary flow reduces while sleeping; therefore, combining low salivary flow and a child who falls asleep with a bottle filled with a sweet liquid significantly increases the risk of early childhood caries.[16]

Developmental Enamel Defects

Developmental enamel defects, such as enamel hypoplasia, have been recognized as a significant risk factor for developing ECC [16] - Streptococcus mutans rapidly colonize the rough defects of the enamel surface.

Systemic Diseases and Medications

Children with juvenile diabetes mellitus due to high blood sugars or children with special needs who may have to cope with reduced oral hygiene are more susceptible to caries. Cancer patients undergoing radiotherapy consume sugary lozenges to increase salivary flow, posing a greater risk for caries.

Socioeconomic and Ethnic Factors

Early childhood caries is most common in children from a low socioeconomic background: prenatal and perinatal malnutrition predisposes to enamel hypoplasia; [17][18][9][19][20] a lower level of education and literacy correlates with poor oral hygiene and sugary food consumption; lack of access to dental care; and lack of fluoride exposure. 

Leroy et al. showed a proportional correlation between children exposed to environmental tobacco smoke at home and early childhood caries, although probably linked to the socioeconomic background of their parents.[21] 

Epidemiology

Early childhood caries are mainly seen in low socioeconomic populations.[4] Therefore, it is more prevalent in less developed countries and among the socially disadvantaged groups in developed countries, where the prevalence is as high as 70%.[22] By contrast, the prevalence of ECC in developed countries ranges between 1 and 12%.[23] In the USA, it is estimated that between 3 and 6% of children have early childhood caries.[24]

The condition is more frequent in 3 to 4 years old and male gender.[25] Young maternal age at childbirth and ethnicity other than white are other social risk factors for developing ECC.[15]

Pathophysiology

The typical pattern of nursing caries is explained by the chronology of tooth eruption, the duration of the detrimental habit, and the protective action of the tongue while breast or bottle feeding.[5]

The upper incisors are among the first to erupt; therefore, they will be exposed to the cariogenic habit for longer.[5] The other teeth will experience a cariogenic attack as they erupt, but newly erupted teeth will remain unaffected if the practice is discontinued. During breast- or bottle-feeding, the infant places the natural or artificial nipple against the palate. The lower incisors remain sound because the tongue's position protects them from contact with maternal milk or formula, and saliva from the salivary glands washes them.[5]

Primary Dentition's Enamel

The enamel of primary teeth is less organized and significantly thinner than in the permanent dentition. Consequently, the enamel of deciduous teeth is demineralized more rapidly than their permanent counterpart.[26]

History and Physical

Nursing caries characteristically affect the four primary upper incisors, whereas lower incisors remain sound. The rest of the teeth may be involved but less severely. These children usually experience pain and eating difficulties.

At first, the maxillary incisors present a white demineralization band along the gingival margin, usually missed by parents. The demineralization bands gradually progress to cavities that encircle the teeth' necks in a brown-black collar. By contrast, the lower incisors are unaffected - either completely healthy or mildly carious. Severe cases may show the crowns of the upper incisors destroyed, leaving root stumps.

Evaluation

Children with ECC need to be examined in detail. Poor dental health often extends beyond the oral cavity. As caries can affect the child’s mastication and phonetics, the ability to eat, drink, speak, or gain acceptance of peer groups may impact their physical, mental, and psychosocial development.A thorough dental examination is carried out with intraoral periapical radiographs or a panoramic x-ray. Pulp status should also be established to develop an appropriate treatment plan. Clinicians may also require other investigations like a complete blood count (CBC).

Treatment / Management

The treatment of ECC is complex and is determined by many factors, including the age of the child, the extent of dental damage, and concomitant complications.

In mild cases of white spots and enamel proximal lesions, extensive restoration may not be needed. The clinician can prevent further decay and spread through parent education, dietary advice, and topical fluoride indication. 

Varnish topical fluoride with resin base is highly recommended.[27] Toothpaste, gels, rinses, and drops containing fluoride have a brief effect. By contrast, fluoride varnish hardens on the tooth enamel after application and remains intact for about a week - even longer on demineralized tooth surfaces than on healthy teeth, [28] offering excellent protection against demineralization.[29]

Chlorhexidine varnish can also be applied to protect the tooth surface. Likewise, bimonthly application of 10% povidone-iodine has been recommended by some authors for its antimicrobial effect against Streptococcus mutans.

Applying casein phosphopeptide (CPP) stabilizes the calcium and phosphate and preserves them in an amorphous or soluble form called amorphous calcium phosphate (ACP). In the presence of casein phosphopeptide, calcium and phosphate form highly insoluble complexes. These CPP-ACP complexes enhance fluoride action and improve the remineralization of enamel.

In moderately severe to advanced cases, pulp treatment, extensive restoration, and tooth extractions are required. In these cases, deep sedation or general anesthesia with its inherent complications is needed due to lack of compliance within the age group.

Restoration is preferably done with prefabricated stainless steel crowns for primary or permanent teeth with caries.[30][31]

Newer Treatment Approach

The traditional restorative and surgical way of managing early childhood caries requires general anesthesia with its attendant health risks and is expensive and does not prevent further caries but only treats the result of the disease. Therefore, up to 79% of patients treated with conventional therapy relapse.[32] This is why the new management of ECC focuses on preventive measures, including parental involvement, preventive programs with active monitoring of the condition, temporary restorations, and postpones advanced restorations.

Differential Diagnosis

Early childhood caries possesses a clear clinical picture; however, it could be mistaken with developmental defects including dental fluorosis, amelogenesis imperfecta, and dentinogenesis imperfecta. The patient's medical, demographic and dietary history would aid in ruling out these conditions. It is worth noting that early childhood caries could coexist with developmental defects, which favors ECC development.

Prognosis

The prognosis of ECC depends on the stage at which it is found, the involvement of the parents, and the capacity to maintain appropriate hygiene and dietary habits in the long term. If the disease is diagnosed in the early stages, the caries process can be stopped in time through preventive measures and education, reversing the carious lesions, and protecting the unaffected teeth. By contrast, severe cases of ECC that remain untreated have a poor prognosis: impaired nutrition, chronic anemia, and growth retardation, affecting the child's quality of life and general health.

Complications

Children with ECC may experience significant pain, which makes eating and sometimes talking difficult, and a physical developmental delay will be seen due to poor nutrition. A study showed that children with early childhood caries were significantly shorter and lighter than controls without caries.[33]

Because of the altered appearance of their teeth, children with ECC can become socially and psychologically affected, leading to decreased school performance.[34][35][36][37]

Often, these children come from low-income families who lack access to healthcare, and the condition worsens. With time caries can progress to pulpitis and severe dental abscesses impairing erythropoiesis by affecting inflammation-induced metabolic pathways, causing chronic anemia and growth retardation.[33][38][39]

ECC poses further health issues in children with special needs. In severe cases, it serves as a potential nidus of streptococcal infection, which can cause potentially lethal endocarditis if it spreads to a defective heart valve. It could also spread to other organs causing fever, pneumonia, and urinary tract infection.

Deterrence and Patient Education

Early childhood caries is the most common chronic, infectious childhood disease worldwide and a health matter of most serious concern. Healthcare professionals should adopt the following measures in the systematic prevention of ECC:

Preventing Vertical and Horizontal Transmission of Streptococcus Mutans

Since mothers are the primary source of Streptococcus mutans to their infants, screening pregnant women for dental caries and improving their oral health reduces the transmission of bacteria.[16] Expecting mothers must receive antenatal oral health advice to reduce the risk of early childhood caries in their children. Sharing utensils, toothbrushes, and food, and licking pacifiers are discouraged.

Children's Oral Hygiene

Healthcare providers should educate parents and caregivers about children's oral hygiene. Fewer Streptococcus mutans have been found in children who toothbrush with fluoridated toothpaste.[40] Therefore, parents should be advised to start toothbrushing their children's teeth with a soft brush and fluoridated toothpaste when the first tooth erupts.[16]

Dietary Sugars

Fruit juice should be avoided in children younger than 12 months of age, limiting it to 120 ml up to 3 years of age and 120 to 180 ml in 4- to 6-year-olds.[41] Appropriate breast- and bottle-feeding practices must be emphasized: avoiding regular sipping of sweet drinks, putting the child to sleep with a bottle of formula, or falling asleep with the breast nipple in their mouth at night.

In children with chronic medical conditions, the prescribing clinician should consider the risk of early childhood caries when indicating sugar-containing oral medicines. Parents should be advised to brush the infant's teeth immediately after taking such medications.[42]

Enhancing Healthcare Team Outcomes

Despite being easily preventable, early childhood caries continue to be a public health issue affecting young children mostly of low socioeconomic backgrounds. The multifactorial etiology of the condition exhibits nutritional, socioeconomic, cultural, and educational foundations. The consequences for the children include loss of tooth structure, pain, and eating difficulty and go beyond the oral cavity affecting nutrition, growth, phonetics, and quality of life. The responsibility of providing preventive advice to expecting parents is in dental professionals, pediatricians, newborn and pediatric nurses to efficiently combat the high prevalence of early childhood caries seen worldwide. [Level 3]