Dental Disease: Early Childhood Caries Unit II: Oral Health University of Ottawa Faculty of Medicine Dr. B. Carol Janik Chief, Division of Dentistry Children’s Hospital of Eastern Ontario Dr. Stephanie Lauziere Staff Paediatric Dentist Children’s Hospital of Eastern Ontario

Objectives Explain the dental caries process and recognize the causes of dental decay Explain the significance of the multifactorial and transmissible nature of dental caries Demonstrate infant oral assessment and explain the rationale for early assessment and what is meant by anticipatory guidance Define Early Childhood Caries (ECC) and discuss the potential consequences and impact on paediatric health Identify ECC risk factors, recognize early clinical signs of decay through infant oral examination and recognize the need for early intervention

Most Common Forms of Dental Disease Dental decay Caries, loss of tooth structure Gingivitis Inflamed gums Periodontal disease Loss of tooth supporting bone

Bacteria Dental Plaque Oral Disease Process Dental Caries (cavities) Periodontal Disease

Dental Decay (caries)

Dental Caries is Multifactorial Susceptible tooth surface poor oral hygiene Specific microorganisms S. mutans bacteria Fermentable carbohydrates cariogenic diet, sweetened beverages Time frequent/prolonged exposure For caries to develop four interacting factors must be present:

3 variables in tooth decay teeth and host bacteriaFood

teeth and host Low socioeconomic groups AND General population Low birthweight Systemic illness –neonatal period Malnutrition/undernutrition – perinatal period

teeth and host SALIVA : the BLOODSTREAM of the teeth TEETH are NOT STATIC Saliva is saturated in CALCIUM, PHOSPHATE Topical or dietary FLUORIDE Oral clearance Buffering activity Remineralization

3 variables in tooth decay teeth and host bacteriaFood

Bacteria STREPTOCOCCI Streptococcus mutans Acidogenic Aciduric Oral flora is site-specific

Bacteria Transmission Window of infectivity ( months of age) High levels of s. mutans (>30%) VERTICAL Family member- especially mother HORIZONTAL Other children

3 variables in tooth decay teeth and host bacteriaFood

Substrate Cariogenicity of sugars Sucrose – glucose – fructose Sucrose = dextrans = microbial adherence Lactose = dissacharide Low potential

Substrate Child on medication Long term Hospital Oral hygiene Pediatric med Sucrose content (%w/v) Amoxil 125mg/5mL33% Ceclor 125mg/5mL60% Keflex 125mg/5mL60% EES 200mg/5mL32% J Camm -Handout

Dental caries process: formation of protein coating (pellicle) on tooth enamel bacteria adhere, forming a sticky mass fermentation of dietary carbohydrate lowers pH plaque prevents buffering actions of saliva demineralization of enamel exposes dentine to acid dentine erodes and caries reaches the pulp nerve endings respond to stimuli, signaling pain

Early Childhood Caries (ECC) Infectious Streptococcus mutans Transmissible vertical transmission Preventable proper oral hygiene proper dietary habits

ECC is a virulent form of tooth decay ECC has detrimental effects on paediatric health Children may first present for dental care with Severe ECC

Early Childhood Caries (ECC) Defined “ the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger ” American Academy of Pediatric Dentistry formerly known as “ nursing caries”,” baby bottle tooth decay”, “bottle-mouth”, “bottle-rot” …

Determinants of ECC Oral hygiene status Prolonged exposure to sweetened beverages, particularly night-feeding Bacterial infection, high counts of S. Mutans Enamel defects, hypoplasia

Clinical Presentation: early lesions begins soon after dental eruption typically develops on smooth surfaces appear as chalky white decalcification

Lesions can appear on the lingual surface on otherwise healthy appearing incisors

Clinical Presentation: advancing virulent caries with rapid progression enamel chips away as lesions advance

Clinical Presentation: rampant progressively involves molar and cuspid teeth maxillary and mandibular lesions present

Clinical Presentation: severe pulpal involvement abscess, fistula at risk for cellulitis

Extensively decayed teeth with dental abscess, can progress to facial cellulitis

Facial Cellulitis Infection spreading into surrounding tissues

Extensively decayed primary molar with pulpal infection spreading to the developing permanent tooth which can suffer developmental disturbance

ECC and Paediatric Health ECC progresses rapidly with related health risks pain, infection, loss of function affects learning, communication, nutrition, sleep lower body weight chronic inflammation psychological impact lasting detrimental impact on the dentition

The reality : too many cases of ECC go undiagnosed until comprehensive or emergency treatment is required AAPD/CAPD, CDA, AAP recommend: FIRST VISIT BY FIRST BIRTHDAY for infant oral assessment Infant Oral Assessment is advocated : to prevent ECC: to educate parents: to provide anticipatory guidance The challenge : to get healthcare professionals to accept the year 1 dental visit

Infant Oral Assessment the challenge: first visit by first birthday

Infant Oral Assessment Medical and dental history record prenatal, perinatal and postnatal periods Examination recommended in a knee-to-knee position Provide caries risk assessment and appropriate caries prevention plan behaviour modification tooth protection Provide anticipatory guidance regarding dental development oral habits injury prevention

Knee-to-knee examination Allows for child to be held by the parent and view parent face-to- face Allows the examiner to have control Enables parent and practitioner to view simultaneously Use mouth-prop or toothbrush as required

Caries risk assessment The following factors should be considered: Clinical evidence of current or previous disease Dietary habits, especially frequency of sugary food and drink consumption Social history, socioeconomic status Use of anticariogenic agent, fluoride Plaque control, oral hygiene Salivary composition and flow Medical history, status

Anticipatory guidance In addition to caries prevention, early assessment provides an opportunity for evaluation and guidance regarding: dental development oral habits injury prevention

Dental neglect … … caries detection and prevention is an essential component in the overall care and protection of children

Managing ECC Infant oral assessment is essential ECC is the most common chronic infective disease among children ECC is a significant public health problem ECC is preventable; rampant caries is difficult and costly to treat ECC may constitute dental neglect if left untreated Treatment is always indicated to avoid undesirable outcomes

Treatment of ECC ECC involves unique treatment challenges: young age of patient volume of treatment ECC requires advanced behaviour management techniques: general anaesthesia sedation ECC involves substantial treatment costs

ECC is Preventable early dental assessment proper oral hygiene proper dietary habits regular dental care

for further information: Dr. B. Carol Janik Dr. Stephanie Lauziere Questions ?