1. Epidemiology and Risk Factors for Early Childhood Caries

2. Module 2 Objectives:
Discuss the epidemiology of Early Childhood Caries (ECC)
Discuss the factors that place children at higher risk for developing ECC
Discuss clinical findings that are predictive of high ECC risk

3. How Do Cavities Develop?
Streptococcus mutans
Carbohydrates
Acid formation
Demineralization
Tooth destruction
Teeth
Sugar
Bacteria
Decay
In simple terms, cavities (aka: caries and tooth decay) can be defined as the disease which decays the teeth and is attributed to the bacteria in dental plaque that convert carbohydrates into acids (Burt, 2005).
Streptococcus mutans (SM) is the main microorganism involved in the initiation of the cavity process (Aaltonen & Tenovou, 1994; Berkowitz et al., 1984; Matee et al., 1992; Tinanoff, 1988).
Role of fermentable carbohydrates in the caries process:
Fermentation of carbohydrates by a cariogenic bacterium such as (SM) produces organic acids, which act on susceptible teeth.
These acids cause a drop in the pH, which may lead to demineralization of tooth enamel (Seow, 1998).
The source of carbohydrates in ECC is usually the sugars in the beverages and solid foods consumed by young children.
Sucrose is one of the most cariogenic foods; SM relies on this disaccharide for its intraoral colonization (Edwardssson & Krasse, 1967; Loesche, 1985; Ripa, 1988; Tinanoff, 1988).

4. How Do Cavities Develop?
Streptococcus mutans
Carbohydrates
Acid formation
Demineralization
Tooth destruction
Teeth
Sugar
Bacteria
Decay
Other common sugars of significance in ECC include the monosaccharides glucose and fructose. In vitro studies have suggested that these two monosaccharides are as cariogenic as sucrose in their abilities to cause a pH drop and to demineralize enamel (Koulourides, Bodden, & Keller, 1976; Seow, 1998).
Fermentable carbohydrates also include starches (e.g., long glucose chains). Because starch must be digested to simpler units prior to bacterial fermentation, the actual caries risk associated with raw or cooked food starches, such as potatoes, rice and bread, is minimal.
However, recent advances in starch processing have resulted in the introduction of hydrolyzed starch products (e.g., glucose syrups and maltodextrins) which, in turn, have been associated with increased caries risk.
Extensive food processing or preparation techniques can increase the likelihood of bacterial fermentation of food carbohydrates.
Processes that refine carbohydrate by removing protein, fat and fiber components (e.g., milling grain, juicing fruits); concentrate sugar (e.g., drying fruits, juicing fruits); or add sugar (e.g., baked starches with sugar, candies) result in foods that are more cariogenic than natural foods.
Minimally processed foods (e.g., whole fruits, fresh vegetables, pastas, bread) are considered safer than highly processed foods (e.g., soda-pop, chips, cookies, candies), (Moyniham, 1998; Al-Khatib, Duggal, & Toumba, 2001; Marshall, 2003).
Tooth enamel undergoes demineralization after exposure to acid produced by fermentation of carbohydrates.
It is likely that the process of demineralization and remineralization (through exposure to protective factors such as fluoride in toothpaste or fluoridated water) is dynamic throughout the day.
Depending on the length of time that tooth enamel is exposed to acid and the frequency of these exposures (frequency of exposure to simple sugars & subsequently acid), the net effect may be progressive demineralization.
Without protective enamel, the tooth is vulnerable to further destructive effects from the bacteria.

5. Sugar Consumption & Risk of ECC
Acids persist for minutes after eating
Frequency of sugar ingestion more important than quantity
Safe zone
Danger
zone pH
Bottle Breakfast Snack Sippy-cup Sippy-cup Lunch
This graph displays the pH of the surface of a child’s teeth over the course of a morning. Each time the child eats, takes a bottle or drinks from a sippy-cup filled with juice, acid is produced by bacterial metabolism of the carbohydrates.
The frequency of simple sugar intake is the main dietary variable in caries etiology, affecting both colonization with Streptococcus mutans and the development of caries itself.
After bacteria metabolize sugar into acid it takes minutes for the acid to be neutralized or washed away by saliva.
Therefore the more frequently that simple sugars are consumed the greater the potential period of demineralization.
The graph shows pictorially how easy it is for a young child to keep his teeth in the “danger zone” all day unless the intake of sugar containing drinks and foods is restricted.
Adapted from: A PRACTICAL APPROACH TO INFANT ORAL HEALTH : Developed by J. Douglass BDS, DDS, H. Silk MD, A. Douglass MD
Schools of Dental Medicine and Medicine University of Connecticut, In cooperation with Connecticut Department of Public Health; Funded by Connecticut Health Foundation, Children’s Fund of Connecticut
Time
J. Douglass BDS, DDS H. Silk MD A. Douglass MD

6. Risk Factors for Early Childhood Caries (ECC)

7. Bottle-feeding: Risk of ECC
Studies show low cariogenicity of bovine milk
Phosphoproteins in milk inhibit enamel dissolution
Cariogenicity increases when bovine milk serves as a vehicle for sugary substances
The cariogenicity of bovine milk is frequently questioned and it is still an area of doubt on the part of the public.
Bowen & Lawrence (2005): confirmed previous studies showing low cariogenicity of bovine milk.
Ripa (1980) has stated that even with high levels of lactose, breast milk and bovine milk also contain high concentrations of calcium and phosphorus that may contribute to the remineralization of enamel, as well as a number of proteins which could offer a protective organic layer on the enamel surface. For these reasons, milk could be considered minimally cariogenic in normal circumstances and may even demonstrate a cariostatic feature.
Seow (1998) has also reported that current literature suggests that milk is not cariogenic, and evidence further shows that milk is cariostatic. Even when combined with relatively high concentrations of sucrose, bovine milk may exert a somewhat protective effect, compared to sucrose alone. The addition of sucrose, however, does increase the cariogenicity of milk (Bowen, Pearson, VanWuyckhuyse, & Tabak, 1991; Bowen & Pearson, 1993; Bowen & Lawrence, 2005; Jenkins & Ferguson, 1966; Weiss & Bibby, 1966).
Cariogenicity increases when milk serves as a vehicle for more cariogenic substances, especially sugary products. Parents are known to mix milk with cariogenic substances, such as chocolate powder, honey, sugary liquid medications and other sugary products (Mohan et at, 1998).

8. Breastfeeding: Risk of ECC
Epidemiological studies of breastfeeding
& ECC are rare
Possibility that deleterious dietary practices other than breastfeeding cause ECC
Breast milk alone is not cariogenic
Breast milk becomes highly cariogenic in the presence of other sugars
Compared to bovine milk, human breast milk presents with lower mineral content, higher concentration of lactose, and less protein (Darke, 1976); however, these differences are probably insignificant regarding cariogenicity.
The literature available (case reports) suggesting an association between excessive breastfeeding and caries is not very convincing (Brams & Maloney, 1983; Gardner, Norwood & Eisenson, 1977; Kotlow, 1977).
Erickson et al. (2000) found that breast milk alone is not cariogenic but in the presence of other sugars, becomes highly cariogenic.
In addition, epidemiological studies are rare and the possibility of deleterious dietary practices other than breastfeeding cannot be ruled out as causes for ECC in the breastfed child. However, if a child has a suboptimal diet and is exposed to other conditions that increase caries risk, human milk can be much more cariogenic than bovine milk since it contains almost twice as much lactose as bovine milk (Erickson & Mazhari, 1999).

9. Risk Factor for ECC: Nocturnal Feeding
Nocturnal feeding plays a role in caries development
When practiced for prolonged periods of time
Related to reduction of salivary flow during sleep
Highest risk:
Nighttime sugary liquids and/or prolonged on-demand nighttime breastfeeding combined with poor oral hygiene
Nocturnal feeding is also described in the literature as playing a major role in caries development, due in part to a reduction of salivary flow during sleeping hours. This may be especially important when nocturnal feeding is practiced for prolonged periods of time.

10. Risk Factors for ECC: Juice and Sugary Beverages
Ad lib consumption from bottle or sippy-cup throughout the day or from a bottle taken to bed:
Leads to frequent exposure of teeth to carbohydrate,
contributing to caries
Linked to malnutrition & short stature
Replaces more nutritious foods & blunts appetite
Fruit juices offer no nutritional benefits over whole fruit
Sugary beverages have no nutritional value
In older children: sugary beverages (especially soda) also contribute to the epidemic of obesity
The American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) recommendations state that juice should be offered to infants in a cup, not a bottle, and that infants not be put to bed with a bottle in their mouth. The practice of allowing children to carry a bottle, cup, or box of juice around throughout the day leads to excessive exposure of the teeth to carbohydrate, which promotes the development of dental caries (AAP Policy Statement, 2001).
Excessive consumption of sugary beverages has detrimental effects, such as malnutrition, short stature, diarrhea, abdominal distension, flatulence and dental caries. Sugary beverages include soda, sports drinks, juice mixtures and other flavored sweetened beverages.
AAP acknowledges that fruit juice offers no nutritional benefit for infants younger than 6 months and no nutritional benefits over whole fruit for infants older than 6 months and children (AAP Policy Statement, 2001).
In response to a resolution for the House of Delegates of the AAPD, it was reported that acids that are present in carbonated beverages may cause more erosion and have a more deleterious effect on enamel than the acids that are generated by oral flora after being exposed to sweetened drinks (American Dental Association Council on Access, Prevention and Interprofessional Relations and Council on Scientific Affairs to the House of Delegates, 2001).
In general, there is no good nutritional reason to introduce fruit juices to infants & toddlers. Increasingly, pediatricians are encouraging delayed introduction, strict limitation of amount and frequency of juice offerings or complete elimination of fruit juices, in favor of offering age appropriate fruits.

11. Risk Factors for ECC: Cariogenic (Sugary) Snacks
Daily frequent exposure to sugary foods is associated with increased ECC risk.
Sugary foods that are especially cariogenic:
Sticky foods that are retained in the mouth for prolonged periods of time & not easily washed out by saliva
Consumed as between meal snacks (>2X/day)
Some studies have also suggested that children with ECC present with a high frequency of sugar consumption (Marino, Bomze, Scholl, & Anhalt, 1989; Weinstein et al., 1992). The increased frequency of sucrose consumption increases the acidity of plaque, and enhances the establishment and dominance of the aciduric Streptococcus mutans (van, 1994).
When the total time that sugar remains in the mouth increases, the potential for enamel demineralization also increases, and saliva may not have enough time to promote remineralization. The net effect will be predominance of demineralization rather than a balance between demineralization and remineralization (Loesche, 1986).
Raisins, other dried fruits, sticky candies, fruit rollups, granola bars, donuts, sugared cereals (especially if offered dry as a continuous snack) are very cariogenic foods.

12. Risk Factors for ECC: Transmission of Streptococcus mutans (SM)
Early contamination with SM increases ECC risk
Mothers with high levels of SM tend to have:
High level of decay
Poor oral hygiene
Frequent sugar consumption/snacking
Children with high levels of SM
High dental caries rates within family members increases child’s risk
SM transmission occurs from one individual to another. In most cases this transmission occurs vertically, usually from mother to infant. The relationship between maternal salivary levels of SM and the risk of infant infection seems to be relatively strong (Berkowitz et al., 1980; Matee et al., 1992).
Mothers with high levels of SM tend to have children with high levels, while those with low levels tend to have children with low levels (Caufield, 1997; Köhler et al., 1984). The evidence for this concept comes from several clinical studies that demonstrate that SM strains isolated from mothers and their babies exhibit similar or identical bacteriocin profiles and identical plasmid or chromosomal DNA patterns (Caufield et al., 1988; Caufield et al., 1993; Emanuelsson et al., 1998; Li & Caufield, 1995).
The age at which SM is first acquired in children is thought to influence their susceptibility to caries. The earlier that colonization occurs, the higher the risk for future caries. Early establishment of SM not only affects caries prevalence but to a greater extent also the levels of caries experience, that is the number of new caries lesions during the study period (Alaluusua and Renkonen, 1983).

13. Practices that Allow Transmission of Streptococcus mutans
Factors that increase the risk of transmission of bacteria to the child include:
frequent sugar exposure in infants
habits that permit saliva transfer from mother to infant
high maternal bacteria levels
poor maternal oral hygiene
low socioeconomic status
frequent maternal snacking.
Also it has been shown that the dietary preferences and oral hygiene habits of the mother are passed to the child at an early age. If the mother has a “sweet tooth” or snacks frequently, this is a concern as the children are likely to follow her example.

14. Risk Factor for ECC: Poor Oral Hygiene
Visible plaque correlated with high levels of Streptococcus mutans
Infants & Toddlers:
Visible plaque is an indication of poor & inconsistent daily oral hygiene
The level of Streptococcus mutans in dental plaque and saliva samples is high in children with Early Childhood Caries (up to 60% of total microorganisms), compared to only 1% in children who are caries-free (Matee et al., 1992; Ripa, 1988).
Dental plaque visible to the naked eye (observed without the use of a disclosing solution) is a straightforward indication of poor and inconsistent daily oral hygiene.

15. Risk Factor for ECC: Inadequate Fluoride
No regular use of fluoride toothpaste
Drinking non-fluoridated water
Two very important caries protective factors include:
1) exposure to fluoridated community water provided at home, school and/or work; and
2) use of fluoridated toothpaste on a daily basis (Featherstone, 2007).
When children are not exposed to fluoride in drinking water or in toothpaste, they miss a valuable, easy and cost-effective caries preventive measure.

16. Risk Factor for ECC: Children with Special Health Care Needs (CSHCN)
More caries (treated and untreated)
More missing teeth
Poor oral hygiene due to behavior problems
Higher prevalence of gingivitis and periodontal diseases
Inadequate dietary habits
REFERENCES:
Waldman HB, Perlman SP, Swerdloff M. Periodontics and Patients with Special Needs. Journal of Periodontology, 71(2): , 2000.
Weddell JA, Sanders BJ, Jones JE. Dental problems of children with disabilities. In McDonald RE, Avery DR. Dentistry for the Child and Adolescent (7th ed.). St. Louis, MO: Mosby, pp
Horwitz SM, Kerker BD, Owens PL, Zigler E. Dental health among individuals with mental retardation. In The Health Status and Needs of Individuals With Mental Retardation. New Haven, CT: Yale University School of Medicine, pp
Shenkin JD, Davis MJ, Corbin SB. The oral health of special needs children: Dentistry’s challenge to provide care. Journal of Dentistry for Children, 68(3): , 2001.

17. Risk Factor for ECC: Children with (CSHCN)
Enamel Hypoplasia
More difficulty obtaining dental care than any other population
Frequent exposure to sugary medications
Medication side effects
(xerostomia: salivary flow)
Compromised immune system
Enamel hypoplasia
Enamel Hypoplasia (EH) is a defect in tooth enamel.
There is less quantity of enamel than normal.
In some cases of EH, the quality of the enamel may also be affected.
EH enhances plaque deposition , increases bacteria colonization, may cause tooth sensitivity, and cause teeth to be more susceptible to caries.
Most children’s medication dispensed orally is mixed with a sugary syrup to enhance acceptance. Because many CSHCN take several medications daily, their teeth may be exposed frequently to sugary liquids.
Saliva has a natural role in washing away acids produced by oral bacteria. If the CSHCN takes a medication that diminishes the formation & flow of saliva, acids produced in the mouth will remain on the teeth longer.
Children with compromised immune systems are at increased risk for a number of infections, including oral infections and ECC.

18. Risk Factor for ECC: Deleterious Habits During Pregnancy
Inadequate prenatal care
Drug abuse
Genitourinary or oral infections (periodontal disease)
Alcohol or tobacco use are associated with:
Premature and/or Low Birth Weight Baby
Enamel Hypoplasia
Prematurity is also associated with Enamel Hypoplasia
REFERENCES:
Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm birth. J Am Dent Assoc, 132(7), , 2001.
Offenbacher S, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996; 67:
Offenbacher S, Jared HL, O'Reilly PS, et al. Potential pathogenic mechanisms of periodontitis associated pregnancy complications . Ann Periodontol 1998;
Boggess KA, Maternal Oral Health in Pregnancy. Obstetrics & Gynecology 2008;111:

19. Risk Factor for ECC: Socioeconomic Status
Ethnic & Cultural factors
Children from families with:
Low-income
Low educational levels
Low dental health literacy
are more likely to have caries
Ethnic and cultural factors influence children’s feeding/dietary patterns, leading to a high ECC risk among immigrant & Native American populations, as well as minority groups.
There are profound disparities in Early Childhood Caries experiences such that children from minority & low-income families suffer a disproportionate share of the disease burden & generally have limited access to dental services. The prevalence of ECC among disadvantaged groups in the United States can be as high as 70% (Milnes, 1996; Weinstein, 1998).
Preschool children from low-income families are more likely to have caries (Vargas et al., 2000).
Studies of Head Start pre-school children have reported decay rates frequently exceeding 60 percent (Edelstein & Douglass, 1995), a rate much higher than in the general population.
Tinanoff reported that caries prevalence in Head Start children in a community in Connecticut was 34 percent higher than the prevalence among middle class children in the same community (Tinanoff, 1995).
Caries rates of 35 percent to 56 percent have been reported for children under the age of 3 years enrolled in Women, Infants, and Children (WIC) programs (Lee et al., 1994; O’Sullivan et al., 1994).
Higher caries rates are seen among children whose caregivers have lower levels of education; and the opposite effect is also observed (Tang et al, 1997).

20. What Clinical Findings Are Predictive of High Caries Risk?

21. Previous Caries Experience
One of best predictors of future caries (Reisine et. al, 1994)
For children under age 5, a history of decay should automatically classify a child as high risk
Not useful caries-risk predictor for infants and toddlers
(not enough time for ECC to
be expressed)
The presence of any restorations (as well as missing teeth due to caries) in children under 5 years of age is an indication that caries have occurred very early in the child’s life possibly due to early contamination by Streptococcus mutans, and/or poor dietary & oral hygiene habits. Most likely this child will continue to be at high risk for caries in the future.
While previous caries experience is the best predictor of future caries experience, many young children who are at high risk for dental caries may have no previous caries experience simply because the disease has not had time to express itself. This situation is especially true for children under the age of 3 years.

22. Visible Plaque
One of the best predictors of future caries risk in young children
Screening for visible plaque is relatively easy and inexpensive
Dental Plaque
Alaluusua & Malmivirta (1994) reported that visible plaque was the best predictor of future caries risk in 92 (19-month-old) children who were followed for 1-½ years. Ninety-one percent of these children were successfully classified as to caries risk exclusively based on the presence or absence of visible plaque.
Fraiz & Walter (2001) investigated the factors associated with the development of dental caries in preschool children receiving routine dental care & found presence of visible plaque on the maxillary incisors to be strongly associated with the presence of dental caries.
The presence of visible plaque was also found to be correlated with the presence of Streptococcus mutans (Law & Seow, 2006).
Screening for visible plaque is relatively easy, inexpensive and can be performed by primary care providers during an oral exam.

23. White Spot Lesions Initial stage (precursor) of the caries process
Equivalent to caries for infants and toddlers
Often observed at the gum line and accompanied by plaque and bleeding gums
White spot lesions are the immediate precursors to cavitated lesions and generally appear on the smooth surfaces of teeth, close to the gum line, where plaque tends to accumulate.
White spot lesions should be considered equivalent to caries when determining caries risk in young children (Kanellis, 2000).
Chalky, white spots on primary teeth are demineralized areas and are considered early decay

24. From White Spots to Frank Caries
ECC has a rampant characteristic & may progress very rapidly, destroying all teeth present in the child’s mouth. For this reason, it is crucial to diagnose early signs of caries, such as white spots lesions, to promptly implement preventive measures (i.e., fluoride varnish application); arrest the disease process & avoid the rapid caries progression pictured in this slide.

25. Enamel Defects & Stained Pits and Fissures
Enamel hypoplasia
Stained pit and fissure surfaces of primary teeth
Consider both indicative of increased caries risk
Lack of enamel maturation or the presence of developmental structural defects in enamel (i.e., enamel hypoplasia) may increase the caries risk in young children. Enamel Hypoplasia enhances plaque deposition , increases bacteria colonization, may cause tooth sensitivity and may result in increased susceptibility to caries.
Strong correlation found between presence of enamel hypoplasia and high levels of Streptococcus mutans.
Enamel defects in baby teeth are most frequently associated with prenatal, perinatal or postnatal conditions. For the child, low birth weight & systemic illnesses many result in enamel defects. For the pregnant mother, malnutrition in the last (3rd) trimester may result in enamel hypoplasia.
While precavity lesions on smooth surfaces generally appear as white spots, precavity lesions in pits and fissures generally appear as brown or black staining that cannot be removed with a toothbrush. The ability of discolored pits and fissures to predict future caries in permanent molars has been documented in the literature.
Pit and fissure surfaces of primary teeth do not ordinarily appear stained; thus, the appearance of stained pit and fissure surfaces in primary molars should be viewed as indicative of increased caries risk, although this clinical characteristic has not been well documented in the literature (Steiner et al., 1993; Kanellis, 2000).
Stained Pits
and Fissures
Enamel Hypoplasia

26. Perceived Risk by Health Care Professional
Experienced practitioners are reasonably able to predict caries risk with high levels of accuracy
With experience:
By conducting an oral exam & assessing the child’s dietary & oral hygiene habits, as well as the child’s medical condition, family background, & socio-economic factors among others
Most practitioners (dentists, hygienists and other health professionals) are reasonably able to predict caries-risk status with high levels of accuracy.

27. Presence of Braces and Oral Appliances
Oral appliances worn by patients become plaque traps & can greatly increase the risk of white spot lesions & decay.
In a study conducted by Ogaard et al. (1988), it was found that visible white spot lesions can develop around fixed bonded orthodontic appliances within 4 weeks of the fitting.
It is very important for patients who wear oral appliances to follow a diet low in cariogenic foods & to maintain good oral hygiene.

28. Caries Risk Assessment and Management
Any observable decay or demineralization (white spots):
- Refer for dental care as soon as possible
Any factors on the oral screen or parent interview that increase the child’s risk for caries:
- Refer for dental care
Uncertain caries risk:
Refer to I-Smile Coordinator for care coordination & to ensure that dental care is established
Re-assess to ensure the child has been evaluated by a dentist & has established regular dental care & a dental home

29. I-Smile Coordinators
I-Smile coordinators are dental hygienists who serve as prevention experts and liaisons between families, health care professionals, and dental offices to ensure completion of dental care. Coordinators are located in regional public health agencies and provide local community support throughout Iowa. A coordinator can:
Assist with dental referrals for young children.
Provide Medicaid dental billing information.
Offer education for healthcare professionals regarding children’s oral health, including screening and fluoride varnish training.
I-Smile Coordinator contact information can be found at: or
I-Smile hotline

30. Summary: Oral Health Module 2
Dental caries develop in the presence of teeth, bacteria & sugars
Human & bovine milk have low cariogenicity
Ad lib use of a sippy cup or bottle filled with juice or sugary beverages is a significant risk factor
Previous caries & visible plaque are the best predictors of future caries for young children
Enamel defects & stained pits or fissures increase risk of caries 30