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Early childhood caries 

Early childhood caries is a severe rapidl developing form of tooth decay in infants and young children . It affects teeth that erupt first at about 6 months and are least protected by saliva . ( formerly called baby bottle tooth decay or nursing caries ) 

The American Dental Association recognizes that early childhood caries is a significant public health problem in selected populations and is also found throughout the general population. Link

Early Childhood Caries is defined as the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a preschool-age child between birth and 71 months of age. The term "Severe Early Childhood Caries" refers to "atypical" or "progressive" or "acute" or "rampant" patterns of dental caries.

Stages of early childhood caries 

  1. Normal 
  2. Very mild : clinical appearance show very mild demineralization usually at gingival crest and no cavitation 
  3. Mild : Clinical appearance shows demineralizaiton in gingival third of tooth and cavitation 
  4. Moderate : Clinical appearance shows frank cavitation on multiple tooth surface 
  5. Severe : Clinical appearance consists of wide spread destruction of tooth and partial to complete loss of clinical crown . 

Severe ECC leads to Extreme pain , spreading of infection difficulty in chewing , poor nutrition , below average weight , extensive and costly dental treatment . 

The patterns of ECC are usually specific destruction of teeth , most parents will notice either brown or black collars of the child maxillary incosors at around 2 years old . The newly exposed enamel surfaces undergo final stages of post-eruptive maturation and hardening when ions such as fluoride are incorporated . 


Role of Bacteria in ECC

Cariogenic bacteria (especially mutans streptococci) are transmitted soon after the first teeth erupt, decreasing the mother's mutans levels may decrease the child's risk of developing ECC. It is recommended that parents, including expectant parents, be encouraged to visit a dentist to ensure their own oral health and the baby's . As early as 1975 , S.Mutans are implicated as the principle bacterial component responsivle for dental caries in humans , MS are the principle bacteria isolated from children with ECC . The " window of infectivity " , which was brought forward by Page Caufield in the year 1993 , states that mosti nfants acquired S.mutans at a median age of 2 years old . ( 25% by 19 months and 75% by 31 months ) 

"window if infectivity " is used to describe the time period when children are at greatest risk for acquiring S.mutans . A second "window" is speculated to occur when 1st molars are erupting into the oral cavity . 

Intake of Sugary products 

It is indicated that frequent consumption of liquids containing fermentable carbohydrates (e.g., juice, milk, formula, soda) increases the risk of dental caries due to prolonged contact between sugars in the liquid and cariogenic bacteria on the teeth. The relationship of dietary sugars and caries has been investigated using total weight of sugar intake and frequency of sugar intake . Children who receive bottles containing sweetened milk or other sweet drinks have a higher prevalence of maxillary anterior caries than those whose bottle contain only water . Therefore it is advised to first educate the parents on this matter as most Malaysians neglect this important aspect of dental care for infants 

Other risk factors : 

- Low socio economic status 

- Low educational level 

- inadequate fluoride 

- poor oral hygiene . 


Prevention and Management of ECC 

Prevention of ECC can be subdivided into three categories : 

1) Community - Education and fluoridation --- The prevention of ECC should begin with the intervention in the prenatal and peri-natal period , mother needs to have a healthy mouth to prevent transmission of infection . 

2) Dentists - Early detection , diet counselling , fluoride chlx or sealents ( to control the transmission of cariogenic bacteria 

3) Home care - Diet habits : Avoid prolonged breast-feeding and bottle feeding especially during bed times and DO NOT fill the bottle with sugary products and also avoid sweetened pacifiers  , Fluoride dentrifices , fluoride supplements or [ oral hygience instructions : Start brushing when the baby's first tooth erupts into the mouth , clean with soft nylon brush and small pearl of toothpaste with fluoride , all should be done under adult supervision] 

Role of Fluoride : 

Children at risk for decay should receive fluoride 

0-6 years old : Fluoridated toothpaste ( 1000 ppm ) , F supplements ( 0.5mg / day ) , F varnish every 3 months 

more than 6 years old : F toothpaste ( 1000 + ppm ) , F supplements ( 1mg/day ) , Acidulated phosphate fluoride ( APF ) which can be found in gel form or solution form . applied twice . 

Management of ECC : treatment should be definitive yet specific for each individual patient , ART technique using GIC should both be used as prevetive and therapeutic measures . As an aggressive therapy , Stainless steel crowns can also be used . 

Various restorative strategies involves : Acid etch composite resin technique along with pediatric strip crowns . or GIC restorations . For posterior teeth , Composite resins can be used to restored the cavities or Stainless steel crowns . 

For extensive cavitations with pulpal involvements : pulpotomy / pulpectomy followed by permamnet restorations can be done . Last resort will be extractions followed by issuing of space maintainers or a partial denture for the child . 


Typical Visit by visit procedures for a child with ECC : 

  • Visit 1 : E and D , bite wing x-rays , diet sheet ,discuss Fluoride toothpaste with parents ,  plaque scores and oral hygiene instructions , Temporary restorations / restorations 
  • Visit 2 : Repeat Plaque score and OHI , collect diet sheet + diet counselling , apply duraphat ( colgate ) and GIC restorations 
  • Visit 3 : Diet counselling again with restorations or pulpotomy , fissure sealants 
  • Visit 4 : Duraphat again , and repeat plaque score to review any changes . 
  • Visit 5 : Review Diet and Fluoride therapy and give a review period of 4 months . 

Note : fluoride varnish may be effective in early white spot lesions , advantages are , they can be applied quickly so that the child dont have to feel uncomfortable , does not require special equipments or the need for prophylaxis before application , sents on contact with saliva and it can delay caries progression . (brands -- Duraphat , Duraflor , Fluor protector , Cavity shield ) 



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