Prevention of
early childhood
caries
For a healthy smile tomorrow
1
Prevention of early childhood caries
Submitted by Indu.G
Under the guidance of
Dr Mehamood muthedath and Dr Aseela
2
Index
Introduction
Classification of early dental caries
Difference between nursing bottle caries and
rampant caries
 Infant oral health care
 Parent counseling
 Fluorides
 Pit and fissure sealants
 school dental health programs
 Methods on horizon
 Conclusion
 Reference



3
INTRODUCTION
Early 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 infection
 It is a public health problem with
biological, social and behavioral
determinants. Hence prevention is
essential

4
Classification of early childhood caries
5
NURSING BOTTLE CARIES
Also called nursing caries, baby bottle
syndrome & bottle mouth syndrome
 The 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 prolonged
 Caries in mandibular teeth absent
 Caries process in affected teeth may be so
severe that only tooth stumps remain

6
Etiology
 Several factors primarily related to
improper feeding practices

Bottle
feeding
before sleep
Pacifiers
dipped in
honey
Prolonged at
will, breast
feeding
7
RAMPANT CARIES
A condition which is characterized by sudden,
rapid & almost uncontrollable destruction of
teeth; affecting surface of teeth that are carious
free
 Proximal and cervical surface of teeth which are
relatively caries free are also involved
 A caries increment of 10 or more new caries lesions
over a period of about a year is characteristic of
rampant caries
 Most often observed in the primary dentition &
permanent dentition of teenagers

8
 Etiology
 Multifactorial
Feeding practices
Frequent snacks, excessive
sticky refined carbohydrate
intake
Decreased salivary flow
Genetic background
9
Based on severity
Type 1 ECC
(Mild to moderate)
Carious lesions involving the molars and
incisors
Seen in 2 to 5 years
Cause is usually a combination of
cariogenic semisolid or solid food & lack
of oral hygiene

10
Type 2 ECC
(Moderate to severe)

 Labiolingual
carious lesions affecting the
maxillary incisors with or without molar caries
 Seen soon after the first tooth erupts
Unaffected
mandibular incisors
 Cause
is usually inappropriate use of feeding
bottle or at will breast feeding or a combination
of both & poor oral hygiene
11
Type 3 ECC
(severe)
Carious lesions involve almost all the
teeth including mandibular incisors
 Usually seen in 3 to 5 years
 Cause is usually a combination of factors
& a poor oral hygiene
 Rampant in nature & involves immune
tooth surfaces

12
Difference between nursing caries & rampant
caries
Nursing caries
Rampant caries
Specific form of rampant
caries
Acute, widespread caries
with early pulpal
involvement which are
usually immune to decay
Age of occurrence
Seen in infants & toddlers
Affects primary dentition
Seen at all ages including
adolescence
Affects primary &
permanent dentition
Characteristic features
Mandibular incisors are
not involved
Mandibular incisors are
involved
Etiology
Several factors
•Bottle feeding before
sleep
•Pacifiers dipped in honey
or other sweeteners
•Prolonged at will, breast
feeding
Multifactorial factors
•bottle factors before
sleep
•Frequent snacks,
excessive sticky refined
carbohydrate intake
•Decreased salivary flow
•Genetic background
13
Conti…..
Treatment
• Early stages- fluoride
applications & education
•Directed towards
maintenance of teeth till
transition occurs
•With presence of
multiple pulp exposures
would generally require
pulp therapy
•Long term treatment
may be required when
permanent dentition is
involved
14
Etiologic agents in ECC
Pathogenic
microorganism
Principle microorganism- streptococcus mutans
 Transmitted to infants mouth primarily through
mother

Streptococcus
mutans
Actinomycetes
Treponema
denticola
Pervotelle
intermedia
15
Substrate
 Carbohydrates are used utilized by
microorganism to form dextrans which
a) Adhere organism to tooth surface
b) Cause organic acid to demineralise
tooth
 In infants & toddlers the main source of
fermentable carbohydrates are

16
An integral component
Bovine milk
and milk
formulas
Human milk
Pacifiers
dipped in
honey
Fruit juices &
other sweet
liquids
Sweet syrups
like vitamin
preparations
Chocolates
& other
sweet
17





Host
Teeth act as host to microorganism
Hypomineralisation or hypoplasia increases
the susceptibility to caries
Thin enamel in the primary teeth
Developmental grooves
18
 Time


Important factor that determines caries
activity
More the child sleeps with he bottle in
the mouth, the higher risk of caries
19

Other predisposing factors
Over indulgence of parents
 Crowded homes
 Child who has less sleep
 Malnutrition

20

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 adulthood
21
Goals of an infant oral health care
program
 To
identify, intercept and modify the potentially
harmful parenting practices that may adversely
affect the infant’s oral health
 Parent education right from the prenatal period
highlighting the importance of their role in
prevention of dental disease for their child
 Parent/caregiver orientation to perceive dental
services as an integral part of infant’s overall
health program
 Periodic evaluation of the orofacial development
and oral health by the clinician
22
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 cavity
 Traumatic injuries
 Habits
 Child abuse and neglect
 Care of alternately abled children
 Problems of speech and language
23
Infectious disease of the oral cavity
 Traumatic injuries
With lack of motor coordination trauma to
developing primary dentition may also occur
 Habits
Such as thumb sucking usually have their inception
at this age and may persist to cause several dental
problems
 Child abuse and neglect may also be detected
 Care of the alternatively abled children
Cleft lip and palate cases and other such children
requiring special attention, may do so right from
birth
 Problems of speech and language would
require special attention
24



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?

1.
2.
3.
4.
As evaluation of any case a proper history
coupled with a vigilant assessment including what
is normal & what is not at this age is necessary
History
Examination
Risk 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 generalization
Any therapy, restorative procedures or
prophylactic measures needed should be
instituted
26
Role of dentist
a)
The timing of first visit
◦ Should be within 6 months
◦ Parents must be made aware about the:
 Signs of teething
 Age of eruption
Age
Teeth erupted
6-10 months
Bottom front teeth, then top front
or side bottom front teeth
9-13 months
Top front teeth
13-19 months
First molars then canines, then
second molars
2.5- 3 years
All teeth
27
Various traditional home remedies such as rubbing of honey should be discouraged
•
b)
Feeding practices
•
•
Advantage of breast feeding over bottle feeding
Bottle feeding instructions
a)
b)
c)
d)
e)
f)
g)
h)
i)
Provide more attention to the child
Remove the bottle immediately after feeding
Encourage your baby to stay upright position with a bottle
Introduce a cup to drink as soon as possible
Use a bottle with a nipple that has small holes
Substitute milk or non- sweetened juices with plain water
Bottle feeding be allowed at intervals
It should not be used as a pacifier
Give water after feeding with the bottle & clean the mouth soon after
feeding
28

Use of pacifiers
several disadvantages have been found
with the use of pacifiers
◦ Those dipped in honey and sugar can cause
increased caries
◦ Malocclusion
◦ Unhygienic conditions leading to infections and
GIT problems
29

Oral hygiene practices
◦ Proper technique for positioning and tooth
cleaning should be demonstrated
1. Gum pads
1. Teeth
30
Role of pediatricians



Monitor the growth and development of the child
Forebearers in providing information to parents
Following topics needed to be discussed by a
pediatrician
◦
◦
◦
◦
◦
Tooth eruption
Preventive oral hygiene
Orofacial development
Fluoridation
Diet
Weaning foods free of, low in non-milk extrinsic
sugars should be recommended to the mothers
 Depending on the amount of fluoride present in
community water, and the requirements of the child,
fluoride supplementation program can be instituted
 Should be aware of the dentist population in his
vicinity for the purpose of referral

31
Role of other personnel






Nurse, midwifes:- information about
immunization, accident prevention & dental health
Gynecologists or obstetrician:- can emphasize
commencement of tooth brushing or cleaning
with gauze on prenatal classes
Neonatologist:- advising and counseling the
parents regarding any congenital defect such as
cleft lip, regarding dental and overall health aspect
of the child
Importance of breast feeding can be emphasized
by these medical personnel
Mothers can be informed about the transmission
of antibodies via breast milk & their effect on
dental health
Importance of mother’s own oral hygiene
32
Parent counseling
 Definition
Parent counseling can be defined as
educating parents regarding the child’s
oral health status, optimal health care and
informing them about the prevention of
potential dental disease
33
Purpose





Discussion of emotional problems of children,
particularly in relation to dental treatment
To offer the dentist an insight into parental
influences which may produce unnecessary
anxieties
Knowing about the behavioral management
techniques used during dental treatment for
children
Obtaining the cooperation of a child patient,
establishing a good rapport with the child and also
using effective techniques of behavior management
Educating the parents about various dental
problems & diseases and their sequelae and how
they can be prevented with accurate preventive
measure if recognized earlier
34
Education of parent in various aspects of
dentistry
 Prenatal counseling
 Pa re n t s





s h o u l d b e e d u c a t e d re g a rd i n g …
D e n t a l d eve l o p m e n t o f t h e i r c h i l d
T h e d e n t a l d i s e a s e p ro c e s s
A p p ro p r i a t e fe e d i n g p r a c t i c e s
e m p h a s i z i n g t h e h a z a rd s o f i m p ro p e r
b o t t l e a n d b re a s t fe e d i n g
O r a l hy g i e n e m e a s u re s ap p ro p r i a t e
fo r i n f a n t s a n d t o dd l e r s
Importance of primary teeth
35
Conti…..

Expected parents can also be told
regarding the mother’s health
during pregnancy & the potential
determinant effect that poor
health and unhealthy habits may
have on their child’s development
36

Prevention of dental disease from
conception to 3 years of age
A
large number of children experience a dental
disease before 3 years of age.

Causes
◦ Sequelae to nursing caries
◦ Eating practices after weaning
37
Content areas
Dentists action
Oral development
•Gum pads to completion of primary
dentition
•Discuss the patterns of eruption
•Discuss the myths about unhygienic
practice practiced during teething
•Discuss oral stimulator
•Discuss the importance of primary
teeth
•Discuss bruxism and its ills
•Establishment of occlusion
Fluorides
Importance of systemic and topical
fluorides
•Recommendation against topical
fluoride use till 3 years of age
•Assess fluoride status
•Discuss fluoride supplements if
needed
•Professional application of fluoride
begins at 3 years when swallowing can
be controlled
Oral hygiene
care of gumpads
Mouth cleaning techniques
•Clean gumpads with a soft clean cloth
after each feeding
•Instruct about the use of a soft toothbrush
and pea size toothpaste
•Brushing technique taught to the parents
•Educate parents about the importance and
need for periodic dental visits
Periodicity of dental visit
38
Content areas
Habits
Non nutritive sucking
Pacifier use
Thumb sucking
Dentists action
•Review pacifier use and safety and
hygiene issues
•Discuss ill effects of thumb sucking to
the dentofacial structures
Nutrition and diet
Baby bottle tooth decay pattern
Importance of diet
•Discuss proper feeding practices & the
use of bottle
•Role of diet in growth & development
•Discuss how frequent sugar intake
results in initiation of caries
Injury and caries
Oral trauma
•Immediate referral into the dentist as an
injury to the teeth of young child can
have serious and long term consequence
•Use of baby walker when infants begins
to learn
•Use or car seat or the child should be in
mothers lap
•Child should not be left alone for a long
time
Home child proofing
39
Prevention of dental disease from 3 to
6 years of age
Diet
1.
•
•
Role of frequency of intake & rate at which sugar is cleared
from the oral cavity in initiation of caries
Food items can be recommended
Oral hygiene
2.
• 3-6 years require parental assistance
• Parents 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 floss
• Additional brushings may be performed by the child unaided
Fluorides
3.
1.
2.
3.
Fluoride consumption should be investigated
Use of fluoride containing tooth paste(once daily)
Professional application of fluoride
40
Prevention of dental caries from 6 to
12 years of age
 Eruption of first permanent molars
Sealants
Diet
1.
2.
•
Children of this age have their own food choices & may purchase
snacks. Parents are instructed to monitor dietary practices
Fluorides
3.
•
•
Topical fluoride application
Regular use of toothpaste(twice daily fluoridated toothpaste)
Oral hygiene
4.
•
monitoring
Habits
5.
•
•
Education about any oral habit, if it is present
Also educate parents about transitional changes in developing
dentition and the importance of primary and permanent dentition
41
Prevention of dental diseases in adolescents
 Prevention of dental caries and periodontal diseases
Oral hygiene
Diet
1)
2)
•
•
High caries rate-usually associated with poor oral hygiene habits
&high frequency of sugar consumption
Progress of lesion-halted with diet control & topical fluoride therapy
Fluorides
3)
•
•
•
Systemic fluorides no longer benefit
Topical fluorides
Use of fluoride containing dentifrice-thrice daily
Orthodontics
4)
•
•
•
Many patients undergo orthodontic therapy- high risk for gingivitis
&the resultant gingival hyperplasia & for dental caries
Topical fluoride therapy
A thorough removal of plaque from gingival areas
Smokeless tobacco
5)
•
•
Evidence of tobacco use- motivate the patient to discontinue the
habit
Parents should be instructed/ counseled not to nag or punish- enrich
the habit
42

Preventing dental injuries
Injury of young child teeth can have serious and long
term effects- discoloration, malformation or even loss
of teeth emotional impact
• Avulsed tooth- keep under the tongue of child, milk
or saline
• Trauma- immediately contact the dentist
• Best approach is to take active measures to prevent
injuries
• Athletic mouth protectors
43
Fluorides
Fluoride delivery system

1.
2.
3.
4.
Systemic fluorides
Fluoridated salt
Fluoridated citrus fruits
Fluoride in sugar
Fluoridated dietary
supplements
Fluoride drops
Fluoride drops with
vitamins
Fluoride tablets/ lozenges
Fluoride tablets with
vitamin
Rinse
Solutions
1. Water fluoridation
2. School water
fluoridation
3. Milk fluoridation
Topical fluorides
Professionally
applied
 Solutions
 Varnishes
 Gels

Self applied

Dentifrices

Rinses

Gels

Tooth picks

Floss

Chewing
gums
44
Pit and fissure sealants
Pits 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 materials








Alkyl cyanoacrylates
Polyurethanes
BISGMA
UV light activated resins
Visible light activated resins
Chemical activated resins
Glass ionomer cements
45

Age ranges of sealant application
 3-4 years of age: primary molar
 6-7 years of age: first permanent molars
 11-13 years of age: second permanent molars and
premolars

Approach that considers only selected patients:
Simonson
 Group 1: caries free patients judged at no risk of decay
 Group 2: patients judged at moderate risk of decay
 Group 3: patients with rampant caries at a high risk to
decay

Realistic approach







Clinical judgment based on
Age
Oral hygiene
Familial and individual history of dental caries
Fluoride environment & history
Dietary habits
Tooth type and morphology
46
School dental health program









Definition
School health services are defined as “procedures established
To appraise the health status of pupils & school personnel's
To counsel pupils, parents & other concerned appraisal
findings
To encourage the correction of remedial defects
To assist in identification & education of handicapped
children
To 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 services
Health
appraisal
Curative
services
Health
counseling
Maintenance of
school health
records
Emergency &
first aid
School health
education
48
Objectives







To help every school child to appreciate the importance
of a healthy mouth
To help every school appreciate the relationship of
dental health to general health & appearance
To 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 programs
To stimulate the development of resources to make
dental care available to all children
To stimulate dentists to perform adequate health
services for children
49

Elements of dental health program
Conducting dental inspection
Conducting dental health education
Performing specific programs
Referral of dental care
Follow up
50
Methods on the horizon

Antiplaque agents
 R o l e o f P l a q u e i n c a r i e s i s we l l d o c u m e n t e d
 T h u s a n t i b a c t e r i a l & a n t i a d h e re n c e a g e n t s
a re b e i n g t e s t e d a s p l a q u e b u i l d i n g b l o c ke r s
S o m e p l a n t p ro d u c t s s u c h a s m a n g o l e a f , n e a m l e a f
and tea extracts are found to be effective in
reducing plaque formation as well as the S.
mutans count
P ro p hy p a s t e w i t h AC P ( A m o r p h o u s C a l c i u m
Phosphate)
Ly r e - J e t
I n s t a n t I n t r a o r a l C a m e r a w i t h P l a q u e D e t e c t o r
51
52

Benign micro organism / replacement
therapy
The lactic acid produced by S. mutans is controlled
by a gene which can be mutated
 Genetic engineering provides a better alternative
producing inactivated forms & then cloning it

For 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
53
•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 decay
 Monomer which would have a chemical bond followed by a
polymeric top coat which would enhance durability and esthetics
• Tooth 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 product
• Toothpaste containing polyfluorite system(a combination of stabilized
stannous fluoride0.054% and sodium hexametaphosphate) – new
generation ADA accepted tooth paste
54
•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
•SAP( Self Assembling Polypeptides)
•Chewing gums
A novel technique the use of chewing gums after
meals in order to counter the pH drop that occurs with
the intake of sugars
Various sugar free gums have been tried out, with
additions such as xylitol, lactilol, and urea
55

Tooth friendly sweets
 They contain sweeteners that are not fermented by
the microflora of the dental plaque

Micro dentistry
 Here treatment begins before conditions arise
 Enables the use of microscope to detect conditions
invisible to naked eye
 Can be used as an educational or motivational tool
56

Tele dentistry

Provision of dental care where the patient and provider
are not physically on the same location
Can also used as an adjuvant in providing preventive
home care advices


Indigenous products

Recently a lot of emphasis has been placed on the
utilization of rich natural sources such as neam, mangoleaf
& tea

Caries vaccine

The 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
57
Conclusion

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.
58
Reference
Textbook of pedodontics- Shobha tandon
2nd edition
 Essentials of preventive and community
dentistry- Soben peter
 Shefer’s textbook of oral pathology- 6th
edition
 Internet –

◦ encyclopedia
◦ Dental caries prevention- M. Ganesh
59
Thank you
60