What is Early Childhood Caries?
In 1978, the American Academy of Pediatric Dentistry (AAPD) described the term “Nursing Bottle Caries” and explained that this decay is related to bottle use. Following this, studies conducted over a period of 20 years have suggested that long-term intake of breast milk may also be the cause of tooth decay and that there is an infectious disease with a multifactorial etiology behind this decay picture, which is called early childhood caries ”(ECC). The use of the definition of childhood caries (ECC) has been recommended.
AAPD defined the presence of caries (cavities / cavities) on one or more deciduous teeth, the presence of a filled tooth surface due to tooth decay, or the loss of the tooth due to tooth decay. Severe ECC (s-ECC) is defined as the presence of more than 4 caries at the age of 3, more than 5 caries at the age of 4, or more than 6 caries, incomplete or filled tooth surface at the age of 5.
In the case of ECC and s-ECC, areas affected by caries are usually seen in the upper anterior teeth. However, caries can also be seen in the lower and upper first molars. Canine teeth are usually less likely to be affected by caries, as they are driven later. It is also typically described that lower incisors benefit more from the cleansing effect of the tongue and often remain unaffected because the salivary glands are at the opening site. The upper milk anterior incisors are first-lasting teeth. Therefore, they primarily experience acid attacks and therefore accumulate plaque. The buccal and occlusal surfaces of the molars and the vestibule surface of the milk canine teeth are affected.
Depending on the localization of the microbial dental plaque, white, yellow, brown or black discolorations and caries cavities can be seen in many parts of the teeth from gingival edges to buccal, palatinal and incisal edges. While early white demineralized bands can be seen on the laughing line in early periods, molar teeth are also affected due to the rapid progression of early childhood caries and initial caries are rapidly turning into cavitation. In the late stages, caries can be seen in the lower anterior milk incisors in an area which is not expected to occur.
Etiology of Early Childhood Caries
ECC is a very serious public health problem that is very effective on preschool children. In a study conducted in the United States, ECC has been reported to be a chronic disease that is effective in 28% of children aged 2-5 years and is very common in childhood, but is an even greater problem, especially for younger children. There are many etiologic factors that cause ECC. Carbohydrate-rich diet, susceptible host, microbial dental plaque, carcinogenic microorganisms and time factor are among the main factors that cause caries development.
Apart from these, mothers ‘educational level, parents’ attitude, oral hygiene habits of the child and the family, especially the mother, socio-demographic characteristics, socio-economic status, nutritional habits of children, use of baby bottles or pacifier use with honey or jam, the child’s breathing status It has been reported that children may have chronic diseases and special care needs, psychosocial factors, some drugs used in children and their ethnic origins may be related to ECC.
Important risk factors for ECC; that the enamel layer is not ripe during the new period of the teeth, that the teeth and the surrounding tissues are not taken care of, the development of enamel defects in milk teeth (hypoplasia on the enamel or hypomineralization on the enamel) and plaque accumulation in the posterior teeth is suitable for plaque accumulation. If there is an initial caries in the teeth in the presence of hypoplasia, rapid cavitation can be observed.
Consumption of sugar-rich nutrients, low socio-economic income, high levels of carcinogenic bacteria such as S. mutans in cases of enamel hypoplasia estimated to be caused by perinatal stress, and / or early childhood caries associated with s HAS-ECC is defined and classified as a sub-variant of s-ECC.
Caufield et al. reported that preterm children also carry a risk for HAS-ECC development. In addition, preterm birth and low birth weight are considered as one of the factors associated with ECC due to its association with high S. mutans colonization and also reported as one of the factors associated with enamel hypoplasia and / or hypomineralization. For the purpose, it is reported that the use of a bottle containing carbohydrates and vitamin C, milk or fruit / s / juices, which can usually be fermented at night time, increases the risk for ECC formation.
When the parent gives the child food and / or milk in a bottle before sleep, these nutrients accumulate around the teeth. At the same time, as the saliva flow decreases during sleep, the nutrients cannot be washed away from the oral cavity and the environment may become conducive to the proliferation of acid-producing microorganisms. For the same reason, there is little or no time for acid buffering and remineralization.
Generally, positive effects of breast milk are mentioned and breastfeeding is recommended until the age of two. In particular, long-term intake of breast milk was also associated with early childhood caries. Yonezu et al. found that infants receiving breast milk for 18 months and more had a 3-fold higher probability of having an early childhood caries when they reached the age of two compared to infants receiving less; Li et al. reported that those who received breast milk for nine months and more were 5 times more likely to have a early childhood caries at age 3 than those who received less.
It has been stated that night feeding is highly risky in terms of early childhood caries and frequent breast feeding or frequent breastfeeding may be a condition associated with early childhood caries. Having breastmilk intake more than 2 times at night and breastfeeding the child for more than fifteen minutes at night are among the factors associated with early childhood caries.
AAPD; recommends that breastfeeding and breastfeeding should be done frequently for the psychological and physical development of the baby. However, it is also recommended that the child falling asleep in the breast be separated from the breast by his mother and that the teeth should be brushed after the teeth come out. In an in-vitro study, it was reported that only breastmilk did not lower plaque pH, so it was not risky for IE, but tooth decay developed when breastmilk was consumed together with other carbohydrates.
Other risky behaviors associated with early childhood caries; It is reported that behaviors such as having the mother clean the pacifier by taking it in her own mouth or giving the pacifier to the child’s mouth by being chewed in the mother’s mouth before the pacifier is given to the child’s mouth, and using common spoons or forks are directly related to the passage of microorganisms to children. In addition, active or untreated caries lesions of the mothers and the kissing of the children’s lips were also associated with the presence of early childhood caries. It is recommended to prevent activities by reducing saliva sharing with mothers or first carers in order to prevent carcinogenic bacterial transmission.
The relationship between low socioeconomic level of family and caries prevalence has been reported in many studies. In addition, the low level of education of the mother and / or father leads to an increase in the prevalence of dental caries. In addition, Alaki et al. reported that children receiving antibiotics frequently during the first year of life are at risk for the development of early childhood caries because of the incomplete crown formation of the primary teeth and their root development.
In addition, it was determined that exposure of children to environmental cigarette due to smoking of the parents, ie passive smoking, is associated with the development of caries. Moreover, it has been reported that the prevalence of early childhood caries is higher when there is a cumulative effect. Hanioka et al. stated that there was a relationship between the presence of early childhood caries in children and the smoking of the mother and father, and the effect of the mother’s smoking on the development of caries was higher in children compared to the father.
Milsom et al. reported that children with caries lesions have a 5-6-fold higher chance of developing new caries lesions than children without caries.
Epidemiology of Early Childhood Caries
ECC is still one of the most common childhood diseases in the world. The results of the studies conducted in our country show similarities with the data of developing countries in terms of the prevalence of ECC. The incidence of IE in developed countries varies between 1 and 12%, while in developing countries it is seen that this value increases to 70%.
5-year-olds at 69.8% of caries prevalence in deciduous teeth, the average dft (decay per person, withdrawn and fill number of teeth made) value was reported to be 3.7. Namal et al. found the prevalence of dental caries to be 74% in children aged 3-6 years.
For example, data from Australia have reported that caries prevalence in primary teeth of 6-year-old children is more than 50% . According to data from different regions of the world, the proportion of children with ECC reaches 89.2% in Qatar and 36% in Greece. In the USA, the same prevalence (40%) has been reported in children aged 2-11 years. In a recent study from Germany, it was reported that the rate of 10% in children aged 3 years (up to 26% of initial lesions) increased by 50% in children aged 6-7.
Diagnosis of Early Childhood Caries
ECC is defined as lığı the presence of one or more cavities with or without cavities, tooth decay or filled tooth surface observed in primary teeth less than 71 months (before 6 years of age). In addition, if the dmft score is ≥4 at age 3, ≥5 at age 4, ≥6 at age 5, it is accepted as s-ECC in children aged 3-5 years.
The early childhood caries begins as a white decalcification band along the gingival line or in accordance with plaque distribution on occlusal surfaces. During the course of demineralization, enamel surfaces are deteriorated and the cavity formed becomes yellow, brown or black. If the lesion progresses further, it spreads around the tooth and becomes black ring with wide loss of hard tissue. As a result, it causes the tooth to become more sensitive to crown fracture.
The upper four incisors are the most affected, while the four lower incisors generally remain intact. It is known that milk teeth other than these may be involved in the decay process, but the caries lesions that occur in these teeth are not as common and severe as in the upper incisors.
Treatment of Early Childhood Caries
Treatment in children with early childhood caries is related to the extent of lesions, age, behavioral capacity of the child and the degree of cooperation of their parents. If these factors are not taken into consideration, the chances of success of treatment are low. The first stage of treatment is to detect and stop the harmful habits of children. Besides the extent of the disease process, the child’s comprehension ability and development level also affect the treatment approach to be applied by the physician. The compassionate attitude of the physician to the patient has priority over efficient and effective treatment.
During the treatment of general anesthesia, more radical methods should be chosen. This is because it is necessary to keep the procedure time as short as possible in order to minimize the possible risks of general anesthesia. In addition, procedures that are not proven to have good prognosis and which may not have a good prognosis after treatment should be avoided. Some of the treatment techniques that can be applied during general anesthesia are; tooth extraction process, glass ionomer, compomer and composite restoration, vital pulpotomy, strip crowns and stainless steel crowns.
In addition to these treatment options, various post treatments are tested especially after endodontic treatment of severely damaged anterior primary teeth. In addition to chemical and mechanical bonding properties, glass fiber glass posts were used in these teeth because of their good aesthetic results. The posts should be placed on the cervical 1/3 portion of the tooth to eliminate problems that may arise during root resorption of the primary tooth. In the study of Bayrak et al. in their research, they have strengthened the extremely damaged upper anterior milk teeth with polyethylene fiber, using the composite resin in the form of short post restoration have achieved quite successful results.
Grewal and Seth in their study, pulled for any reason, milk cutters with excessive loss of material in the anterior milk teeth canal cavity and have been restored. After the endodontic treatment, the teeth were placed in the canal cavity and the teeth were restored. Both studies were compared with each other and after one year observation period, biological restoration could be preferred as an alternative method.
However, children who have undergone early childhood caries have high risk of developing new lesions in milk and continuous dentition despite all these restorative treatments. Almeida et al. reported that in most of the children with early childhood caries treated under general anesthesia, restorative approaches such as placement of stainless steel crowns (SSC) were preferred. early childhood caries reduces the possibility of new or second caries on the surface of the teeth. However, successfully applied restorative treatments do not change the level of S. mutans and additional effective treatment methods are needed in order to reduce carcinogenic bacteria.
The infectious nature of early childhood caries should be accepted and antibiotics should be used in the treatment of this disease in order to improve its clinical outcomes. Iodine has been known for many years as one of the potential antibacterials during anti-caries treatments. According to preliminary studies in this field, the regional use of iodine against the S. mutans population has been found to have prolonged suppressive effects in the mouth.
Lopez et al. showed that inhibition of white opaque lesions was achieved in infants at high risk for early childhood caries with the application of 10% povidone iodine solution every two months. This showed that the administration of povidone iodine every 2 months or once a month could provide the desired control in the re-emergence of carcinogenic bacteria. Such exciting results show that more work is needed.
Zhan et al. stated that as a result of their studies using povidone iodine in patients under general anesthesia, fluoride gel application was insufficient to complete the surgical steps for prophylaxis and new lesions occurred in more than 60% of high-risk children. they have. Although povidone iodine has been administered once, S. mutans and Lactobacilli levels up to 3 months and new caries formation was observed to last for a year.
The traditional treatment of dental caries is to remove only the diseased tissues and to make restorations. In fact, the interventions are not intended to eradicate the causes of these diseases. Therefore, the presence of pathological factors in the oral environment cannot be prevented and new caries or secondary caries may occur. Not only the symptoms of the disease, but also the treatment itself. It is also important to control the effects of preventive and therapeutic measures in the long term.