Contents

 Introduction
 Early Childhood Caries
o Definitions
o Classification
o Developmental Stages of ECC
o Etiology
o Clinical Feature
o Prevention
o Treatment
 Rampant Caries
o Definitions
o Etiology
o Clinical Feature
o Prevention
o Treatment
 Conclusion
 References
Introduction

Early childhood caries is a specific form of severe dental caries that affect's infants
and young children, most commonly seen in poor and minority population A baby
bottle, fitted with liquid containing sugar, is used as pacifier in aiding sleep, these
liquids pool around the maxillary incisors and can causes rapidly progressive, severe
destruction of tooth structures.

A very early sign of caries development is chalky white spots of lines In premature
stages Caries can be reversible and caries progression can be avoided with proper
care; Fluoride application and diet changes. Untreated caries may lead to early loss of
the primary dentition and affect's the growth and maturation of the secondary, adult
dentition.

Rampant caries name is given to multiple active carious lesion occurring in the same
patient. It is seen at all ages, including adolescence, affect's the primary and
permanent dentition. It occurs usually due to poor oral hygiene and taking frequent
cariogenic snacks sweet. It is acute, wide spread caries with early pulpal involvement
of teeth.

Dental caries is the most prevalent chronic disease affecting the human race. The
word 'CARIES' is drived from the Latin word meaning 'rot' or decay. The plaque is
the essential forerunner of caries and therefore the sites on the tooth surface which
encourage plaque retention and stagnation are particularly prone to progression of
lesions. Most commonly seen bacteria's associated with caries are streptococcus
mutan's, lactobacillus species, veillomella species and actinomyces species.
Early Childhood Caries

Early childhood caries, also known as baby bottle caries, baby bottle tooth decay and
bottle rot because it is common in young children: a baby bottle, filled with liquid
containing sugars, is used as pacifier in aiding sleep, these liquids pool around the
maxillary incisors and can cause rapidly progressive, severe destruction of tooth
structure.

Definition

AAP:- Early childhood caries are defined as the presence of one or more decayed,
missing or filled tooth surfaces in any primary tooth in child of 71 months of age or
younger.

According to Davies, 1998

Early childhood caries are defined as a complex disease involving maxillary primary
incisors within a month after eruption and spread rapidly to involve other primary
teeth.

According to Abid Ismail (1998)

Early childhood caries is defined as occurrence of any sign of dental caries on the
tooth surface during 1st 3 year of life.

Classification

Given by Wayne H

Type -I Early childhood caries (Mild to Moderate)

 Carious lesions involving the molars and incisors.

 Seen in 2 to 5 years of age.
 Cause is usually a combination of cariogenic semisolid or solid food and lack
of oral hygiene.
 Number of affected teeth usually increases as the cariogenic challenge persists.
Type-II Early childhood caries (Moderate to severe)

 Labio-lingual carious lesions affecting the maxillary incisors with or without

milar caries, depending on age.
 Seen soon after the first tooth erupts.
 Unaffected mandibular incisors.
 Causes are usually inappropriate use of seeding bottle, at-will breast seeding or
combination of both, poor oral hygiene.
 Unless controlled it may proceed to an advanced stage.

Type-III Early childhood (Severe)

 Carious lesions involve almost all the teeth, including mandibular incisors.
 Usually seen in 3 to 5 years of age.
 Cause is a combination of factor and a poor oral hygiene.
 Rampant in nature and involves immune tooth surfaces.

Age wise classification of severe Early childhood caries

Age in years dmfs

(Number of smooth surfaces involved)
3 4
4 5
5 6
Development Stages of Early childhood child

1. Stage 1 (Initial reversible stage)

Age – 10-18 months.

Features-

- cervically and occasionally interproximal areas of chalky with

demineralization.
- No pain

2. Stage II (Damaged carious state)

Age – 18-24 months

Features-

- Lesion in maxillary anterior teeth, may spread to dentin and show yellowish
brown discoloration.
- Pain on having cold food items.

3. State III (Deep Lesion)

Age – 24-36 month

Features-

- Molar's are affected

- Frequent complaints of pain
- Pulpal involvement in maxillary incisors.

4. State IV (Traumatic stage)

Age – 36 to 48 months

Features-
 - Teeth become to weakened by caries that relatively small forces can
fracture them.
- Parents may report a history of trauma.
- Molar's are now associated with pulpal problem.
- Maxillary incisors become non-vital.

Etiology

 Bovine milk, milk formulas and human breast milk have are been implicated in
early childhood caries because of their lactose contents. Additional sweeteners
in the form of juices, honey dipped pacifier can also cause this type of caries.
 The basic mechanism of demineralization is the same and the caries tetralogy is
the key in the whole process of early childhood caries as all the four variable
pathogenic microorganisms, substances, host factor (tooth) and time are
essential in causing demineralization.

1. Pathogenic Microorganism

 Streptococcus mutans is the principle organism which colonizes the tooth after
patient erupts into the oral cavity.
 It is considered more virulent because of following reasons:-
o Mutans streptococci synthesize -1, 3 rich water in soluble glucans from
sucrose. In addition to the mediation of in eversible adhesion and
colonization of mutans streptococci to the tooth.
o Synthesize intracellular polysaccharides which support continual acid
production during periods of low concentration of exogenous substrates.
o Mutans streptococci produce large amount of acid particularly lactio
acid, which are potent in driving tooth demineralization.
o It has been suggested that the production of dextronase allows the
invasion a mutans streptococci to replace earlier colonizing, dextran
producing bacteria such as S. Sanguis.
  Initial attachment of the mutans streptococci is now throught to be independent
of sucrose and mediated by adhesion. On the bacterial surface interacting
directly with the salivary proteins in the presence of fermentable carbohydrates
especially sucrose, mutans streptococci irreversibly adhere to the pellicle
through the synthesis of glucans.
 It is transmitted to the infants mouth primarily through mother. It is seen that
a childs infection is nine times greater when maternal salivary count of S.
mutans is greater than 10,000 colony forming units per ml.

2. Substrate (Fermentable Carbohydrate)

 Sucrose, glucose and fructose found in fruit juices and vitamin-C drinks as well
as in solids are probably the main sugars associated with infant caries.
 Other sources of fermentable carbohydrates are bovine milk, human milk,
sugar solution, chocolates or other sweets.
 Sucrose, the most widely used sugar, is considered the most important in dental
caries, as patient is the only substrate used for bacterial generation of plaque
dextrans. This is essential for bacterial adherence and thus facilitates the
implantation of cariogenic bacteria in the oral cavity.
 Human milk is more cariogenic than bovin milk because of lower mineral
content, higher concertration of lactose and less protein.

3. Host

 Teeth acts as the host for the micro-organisms.

 An important area in the micro-organism currently not well emphasized, is the
area of tooth defects.
 Tooth is most susceptible to caries in the period immediately after eruption and
prior to final maturation. Thus, in many infants, a combination of recently
erupted immature enamel in an environment of cariogenic flora with frequent
ingestion of fermentable carbohydrates would render the tooth particularly
susceptible to caries.
  The presence of development grooves also may act as the plaque retentive
areas so increase the caries risk.

4. Time

Time is an important factor that determines caries activity. More the time child
sleeps the bottle in the mouth, the higher is the risk of caries. This is because the
salivary show and swallowing reflex decrease and increases the length of contact time
between plaque and substrates thus increasing the carcinogenicity of the substrate by
acid production.

5. Other factors

 Acid fruits drinks because they decrease the oral pH & enhances the
fermentation of carbohydrates.
 Over indulgence of parents.
 Crowded homes.
 Child who have less sleep.
 Malnutrition
 Recently, it has been seen that salivarly gland function is impaired by iron
deficiency and excess of lead exposure, which makes the oral environment
more caries susceptible because saliva provides the main host defense systems
against dental caries. Saliva has major roles in the clearance of foods and the
buffering of acid generated by dental plaque.
 Pacifiers dipped in sugar or honey can also lead to tooth decay since the sugar
or honey can provides food for the bacteria's acid attacks.
 Tooth decay can occur when the baby is pat to bed with a bottle or when a
bottle used as a pacifier for a fussy baby. The sugar liquid pool around the
teeth while the child sleeps. Bacteria in the mouth use these sugars as foods.
They then produce acids that attacks the teeth. Each time your child drinks
these liquids, acid attack for 20 minutes or longer. After multiple attacks, the
teeth can decay.
  Infants and toddlers who do not receive an adequate amount of fluoride may
also have an increased risk for tooth decay time fluoride combines with the
outer covering of the tooth and makes the tooth more resistant to the acid
attack.

Clinical Feature

The intraoral decay pattern of nursing caries is characteristic and pathognomonic of

the condition. It affects the primary teeth in the following sequence-

a) Maxillary central incisors:- Facial, lingual, mesial and distal surfaces.

b) Maxillary lateral incisors:- Facial, lingual, mesial and distal surfaces.

c) Maxillary first molars:- Facial, lingual and occusal, proximal surfaces.

d) Maxillary canine and second molars:- Facial, lingual, and proximal surfaces.

e) Mandibular molars: At later stages.

Mandibular anterior teeth are usually spared because of:-

a) Protection by tongue
b) Cleaning action of saliva due to presence of the orifice of the duct of the
sublingual glands very close to lower incisors.

Progression of the lesion

 Initially, a demineralized dull, white spot or area is seen along the gum line on
the labial surface of maxillary incisors, which is undetected by the parents.
 These white lesion become cavities which involve the neck of the tooth in a
ring like lesion.
 Lesion in maxillary anterior may spread to dentin and show yellowish brown
discoloration.
  Finally, the whole crown of the incisors is destroyed leaving behind brown-
black root stumps.
 This unique pattern and un equal severity of the lesions is due to three factor-
o Chronology of primary tooth eruption.
o Duration of deleterious habits of feeding.
o Muscular pattern of the infants sucking.

Prevention of Early Childhood Caries

 The main strategies for the prevention of early childhood caries should be to
create awareness and alert. Prospective parents and new parents about the
condition and its causes.
 Community based education, the goal of education is to increase the knowledge
of mothers or caregivers about early childhood caries and to improve the
dietary and nutritional habits of infants and mothers.
 Sealing of all caries free pits and fissures.
 Use of antimicrobial therapy topically. Such as 40% chlorhexidine varnish for
every 6 months.
 Lower the risk of the baby's infection with decay causing bacteria. This can be
done two ways by improving the oral health of the mother/caregiver which
reduces the number of bacteria in her mouth and by not sharing saliva with
baby through common use of feeding spoons or licking pacifiers.
 After each feeding, wipe the baby's gums with a clean, dump gauze pad or
wash cloth.
 Brush the child's teeth until he or she is at least six years old.
 Place only formula milk or breast milk in bottles. Avoid filling the bottle with
liquid's such as sugar water, juice or soft drinks.
 Infants should finish their bed time and naptime bottles before going to bed.
 Professional fluoride programs.
  Systemic fluoride, if there is sub-optimal fluoride concentration in drinking
water.

Recommended for preventive maneuvers for Early Childhood Caries:-

Intervention Target
 Community and personal development  Community
 Chlorhexidine varnish  High ECC risk groups
 Dietary counseling  High ECC risk groups
 Early detection  All infants before the age of 1 year
 Education  All infants and toddlers
 Education  High risk communities
 Fluorides supplements  High ECC risk groups
 Fluorides dentifrices  All infants and toddlers
 Fluoride varnish  High ECC risk groups
 Sealants  High ECC risk groups
 Water fluoridation  Community
 Xylitol substitutes  High ECC risk groups
 Control of mother infant  High ECC risk groups
 Infection with cariogenic bacteria

Early Dental Examination (According to American Academy of Pediatric

Dentistry)

No signs of ECC or low ECC risk Signs of ECC or high ECC risk status
status
 Fluoridated dentifrices  Fluoride varnish sealants
 Review of dietary and oral hygiene  Chlorhexidine varnish xylitol
pacifiers fluoridated supplements
 and dentifrices
Dietary counseling

Recommended Fluoride Supplements Dosage Schedule (mg F/day)

Age Fluoride level in water

<0.3 0.3-0.7 >0.7
0-2 0.25 0.00 0.00
2-3 050 0.25 0.00
3-16 1.00 0.50 0.00

Treatment

AIMS

 Management of existing emergency.

 Arrest and control of the carious process.
 Institution of preventive procedures.
 Restoration and rehabilitation.

Factors Affecting Management

 Extent of the lesion

 Age of the patient
 Behavioral problems due to young age of the child.

Treatment proper

It can be divided into three visits.

First Visit
This phase of treatment constitutes treatment of the lesion, identification of the cause
for counseling of the parent:-

 All lesions should be excavated and restored.

 Indirect pulp capping or pulp therapy procedures can be eraluated by further
investigation.
 If the abscess is present it can be treated through drainage.
 X-rays are advised to assess the condition of the sucedaneous teeth.
 Collection of saliva for determining the salivary flow and viscosity.

Parent counseling

 The parent should be questioned about the childs feeding habits, specially
regarding the use of nocturnal bottles, demand for breast.
 The parents should be asked to by weaning the child from using the bottle as a
pacifier while in bed.
 In case of considerable emotional dependence on the bottle, suggest the use of
plain or fluoridated water.
 The parents should be instructed to clean the childs teeth after early food.
 Parents are advised to maintain a diet record of the child for week which
includes the time, amount of foods given, the type of food and the number of
sugar exposure.

Second Visit

It should be scheduled one week after the first visit.

 Analysis of diet chart and explanation of the disease process of the childs teeth
should be undertaken by a sample equation.
 Isolated the sugar factors from the diet chart and control sugar exposure by
intelligent use.
 Reassess the restoration and redo if needed.
 Caries activity tests can be started and repeated at monthly intervals to monitor
the success of treatment.
Third and subsequent visits

 Restoring all grossly decayed teeth.

 Endodontic treatment.
 In case of unrestorable teeth, extractions can be done followed by space
maintenance.
 Crown can be given for grossly decayed or endodontically treated teeth.
 Review and recall after every 3 months.
Rampant Caries

Rampant caries is a severe form of tooth decay that can effects milk teeth or
permanent teeth. It is characterized by its speed of onset and progression, by the
pattern of attack and its cause.

Definition

 Massler, 1945 defined rampant caries as suddenly appearing widespread,

rapidly spreading, burrowing type of caries, resulting in early involvement of
pulp and affecting those teeth, which are usually regarded as immune to decay.
 Winter et al (1966) defined rampant caries as caries of acute onset involving
many or all the teeth in areas that are usually not susceptible.

Etiology

The two major etiological factors in rampant caries are a specific micro-organism and
diet.

1. Micro-organisms

 Streptococcus mutans is an important pathogen in the development of caries.

 The cariogenicity of s mutans is probably related to its unique combination of
properties, which include:
o Colonization of the teeth
o Production of large amount of extracellular.
 Polysaccharide that enable voluminous plaque formation.
 Production of large amount of acids even at low pH.
 Break down of salivary glycoprotein, which might be of great importance for
the initial development of carious lesions.

2. Diet
  The carbohydrate component of the diet is associated with the formation of
dental caries.
 The cariogenic potential is closely related to the texture of the carbohydrate and
the frequency of consumption of sticky sugars, rather than to the amount of
sugar eatern.
 The carbohydrate provided the plaque bacteria with the substrate for acid
production and for the synthesis.
 Sucrose, has been considered to be the most cariogenic sugar in the human diet,
because it is a small, uncharged molecules that easily diffuses into the dental
plaques; it is highly soluble and acts as a substrate tooth both for the production
of extracellular polysaccharides and for acid production.
 There is some controversy as to whether bovine and breast milk are cariogenic.
Bovine milk contain high concentration of calcium and phosphorus which
could contributes to the remineralization of enamel.
 Breast milk contains a higher consent of lactose than bovin milk and therefore
possesses a greater cariogenic potential.

Although the condition is most often associated with drinks from bottles, it is rare,
but possible to develop rampant caries from breast milk if feeding is carried out on
demand, nocturnally or for prolonged periods.

 Dental caries is a diet supported disease. Children who consumed sweets

frequently during the day developed aggressive dental caries patterns,
where as children who consumed the same amount of sweets but confined
them to the three meals did not develop rich decay.
 Sticky sweets like toffees and caramels, were more cariogenic than less
retentive form.

3. Oral Dryness

In adequate salivary slow promotes rampant caries because pt. leads to

diminished ability to buffer acids, reduce clearance of food, micro-organisms and
microbial by products, gross impairment of remineralization capabilities loss of
salivary based host defence mechanism and compensatory and deleterious alteration in
eating and drinking habit.

A specific form of rampant caries may occur in children and adolescents who
have a greatly reduce salivary slow as a result of radiotherapy for treatment of cancer
of the head and neck region, this is called radiation caries.

Clinical Feature

 The initial lesion usually appears on the labial surface of the maxillary incisors,
close to the gingival margins, as a whitish area of decalcification or pitting
enamel surface shortly after eruption.
 Whitish lesions soon become pigmented to a yellow brown and at the same
extend laterally to the approximal surface and downward to the incisal edge.
 Less commonly, the decalcification may present initially on the palatal surfaces
or even at the incisal edge.
 At a more advanced stage, the carious process will often extend around the
circumference of the tooth to pathologic fracture of the crown as minimal
trauma.
 Rampant caries involve other teeth, namely first primary molars, second
primary molars and eventually the canine.
 Rampant caries may also occur in the permanent dentition because of frequent
intake of cariogenic diet.
 Typical rampant caries in adolescents is characterized by buccal and lingual
caries of premolars and molars and proximal and labial caries in mandibular
incisors.

Prevention of Rampant Caries

According to age of child, different preventive measures one used.

Dentition : 0-5 years

Advise : Diet counseling with parents on good nursing techniques.

Therapy : Tooth paste

- Tablets if in area without water fluoridation.

- Professional topical fluoride application every 6 months.

Control : - Oral hygiene instructions to parents

- Tooth burshing with parental supervision list to dental office at

around 12 months of age to 6 months recall.

Dentition : 5-12 years

Advice : Diet counseling with parents and patient.

Therapy : Tooth paste

- Tablets upto 6 years if in area without water fluoridation.

- Mouth rinse

- Professional topical fluoride application every 6 months.

Control : Oral hygiene instructions to patient

- Tooth brushing without parental supervision

- Disclosing tablets

- PPT and fissure sealants

- Recall after every 3-4 weeks.

Permanent dentition 12 years on ward

Advice : Diet counseling with parents and patients
Therapy : Tooth paste
Mouth rinse
Professional topical fluoride application every 6 months
Control : Oral hygiene instructions to patient
 Tooth brushing
Disclosing tablets
Interdental cleaning with floss or tooth dicks

Treatment

AIMS

 Management of existing emergency.

 Arrest and control of the carious process.
 Institution of preventive procedures.
 Restoration and rehabilitation.

Factor Affecting Management

 Extent of the lesion.

 Age and cooperation of patient.
 Management of carious depends on the patient's and parents motivation
towards dental treatment.
 Behavioral problems due to young age of the child.

Treatment proper

1. Consultation
2. Control measures
3. Restorative measures
4. Preventive measures
5. Dental checkup and recall

1. Consultation

 Treatment is undertaken only after obtaining full cooperation of parents and

patient.
 Impress upon both parents and patient that their role in management of rampant
caries is equally as that of dentist.
  Patient and parents must follow up the instructions.

2. Control measures

 Control measures includes : excavation of all carious lesion, diet assessment,

and oral hygiene instructions.
 Caries stabilization and provisional restoration should be placed in symptom
free teeth with established dentinal caries to minimize the risk of pulpal
exposure in the suture and to improve function.
 Parents should be educated to reduce the frequency of sucrose consumption by
their child, especially between meals. Maintain balanced diet with milk, wheat
vegetables and fruits.
 Successful management of rampant caries necessitates severe dietary
modification. If bottle seeding is still being practiced, particularly at night. It
should be stopped by gradually diluting the bottle contents with water as well
as decreasing the amount of added sugar over a 2 to 3 weeks period and finally
substituting the bottle with a feeding up.
 Kohler et al have shown that the reduction of high salivary count of S mutans
through dietary counseling, professional tooth cleaning, oral hygiene
instruction, fluoride treatment and excavation of large cavities in mother's.

3. Restorative Measures

1. Early caries with minimal loss of enamel

Weekly professionally applied topical fluoride therapy.

2. Extensive cavitations with no pulpal involvement

(i) Anterior teeth

- Acid-etched composite resin restoration

 - Pedo-strip crowns

- Glass-ionomer cement restoration

(ii) Posterior teeth

- Posterior composite cement restorations

- Glass ionomer cement restorations

- Stainless steel crowns.

3. Extensive cavitations with pulpal involvement

- Pulpotomy or pulpectomy, where appropriate followed by

permanent restoration.

- Extraction followed by spare maintainer or partial or complete

denture.

4. Preventive measure

- Includes fluoride application

- 8% stannous fluoride is more effective than 2% sodium fluoride.

- Instead of stannous fluoride, APF can also be used as gel or sol.

- In deep pit and fissure sealants are used to prevent deciduous and
permanent teeth.

- Application of fluoride or pit and fissure sealants does not mean

that complete prevention will occur, dietary maintenance and oral
hygiene maintenance are equally required.

- Topical fluoride products such as fluoride gels, foams, or

varnishes, mouth rises. One much more effective at preventing
dental morbidity in caries active individuals than one low-
intensity products.
5. Dental checkup and recall

- Recall visit started after preventive and restorative measure are

completed.

- Recall visit scheduled at 2 to 3 months interval.

- At this stage, the patient should be checked clinically for carious.

Bitching radiography are taken to diagnose proximal caries.

- During recall visits check the oral hygiene and again and again
anaesthetize on maintenance of oral hygiene and dietary control.

- Topical application of stannous fluoride done every 6 months.

- If caries activity slows than increase the duration of recall to 6

months interval
 Summary

Bovine milk, milk formulas and human breast milk have all been implicated in early
childhood caries because of their lactose contents. Streptococcus mutans is the
principle organism which colonizes the tooth after it erupts into the oral cavity. Thin
enamel in the primary teeth is one of the reasons for early spread of lesions.
Prevention of early childhood caries begins with intervention in the prenatal and
perinatal periods. Hypoplasia is common in children with low birth weight or hygiene
illness in the no natal period. Early childhood caries term that better reflects the multi
factorial etiological process. Rampant caries name is given to multiple active carious
lesion, affects the primary and permanent dentition.

Untreated caries may lead to early loss of the primary dentition and affects the growth
and maturation of secondary, adult dentition. Thus prevention and early treatment is
necessary to controls the progression of caries.
 References

 Text book of Pediatric Dentistry

o Nikhil Marwah
 Pediatric Dentistry Infancy through Adolescence
o Pinkham
 Text Book of Pedodontics
o Shobha Tandon
 www.google.com