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A protocol for early childhood caries diagnosis and risk assessment

Article  in  Community Dentistry And Oral Epidemiology · July 2018

DOI: 10.1111/cdoe.12405

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Received: 10 December 2017 | Accepted: 19 June 2018

DOI: 10.1111/cdoe.12405

ORIGINAL ARTICLE

A protocol for early childhood caries diagnosis and risk

assessment

Robin Wendell Evans1 | Carlos Alberto Feldens2 | Prathip Phantunvanit3

1
Formerly, University of Sydney, Sydney,
NSW, Australia Abstract
2
Universidade Luterana do Brasil, Rio The global Early Childhood Caries (ECC) burden is of concern to the World Health
Grande do Sul, Brazil
Organisation (WHO), but the quantification of this burden and risk is unclear, partly
3
Thammasat University, Bangkok, Thailand
due to difficulties in accessing young children for population surveys and partly due
Correspondence to diagnostic criteria for ECC experience. The WHO criterion for caries diagnosis is
Robin Wendell Evans, Formerly, University
of Sydney, PO Box 52, Balmain, Sydney, the late stage event of dentine cavitation. Earlier stages of the caries lesion are clini-
NSW 2015, Australia. cally detectable and should be registered earlier in the life of children and arrested/
Email: wendell.evans@optusnet.com.au
remineralized before lesions progress to the cavitation stage. A protocol for ECC
diagnosis is proposed to guide those engaged in clinical dentistry in their characteri-
zation of the ECC lesion. As management of early lesions is a critical step to reduce
risk of their progression to later stage lesions, a practical method for assessing ECC
risk is proposed also. Risk assessment is very important because it determines (a)
urgency for interventions aimed to arrest lesion progression; (b) the frequency of
such interventions and (c) the need to enhance the primary prevention of ECC. The
guidelines are set out separately for ECC diagnosis for ongoing clinical care and for
epidemiologic purposes. Similarly, guidelines are set out for ECC risk assessment and
ongoing monitoring.

KEYWORDS
deciduous dentition, diagnosis, early childhood caries, epidemiology, risk assessment

1 | INTRODUCTION whose floor is in dentine – or its sequelae.5 A more informed

A Global Consultation on Early Childhood Caries (ECC) was held in
1
Thailand in 2016, in response to reports which had identified dental
caries in the deciduous dentition as the 10th most common disease
of the 291 health conditions assessed as well as a condition that sig-
nificantly affects quality of life of children and their families.2,3 ECC
experience 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 child aged 71 months or
younger.4
At the consultation, it was noted that the understanding of
ECC is hindered by a lack of epidemiologic data and by variation in
the diagnostic criteria used for ECC. The WHO standard for caries
diagnosis is highly conservative in that the condition is confirmed
following the detection of the late stage caries lesion – a cavity
understanding depends on age‐related detection of early stage
lesions. ECC lesions are highly prevalent in the first years of life,
and treatment measures are available to arrest lesion progression
and prevent dentine cavities.6,7 Thus, it is appropriate that deci-
sions on diagnosis are reached on the basis of early stage lesions,
so that they can be treated noninvasively and that the key risk fac-
tors which maintain the disease process can be controlled. More-
over, personalized care and public policies may benefit from ECC
risk assessment, which indicates the likelihood an individual will
develop new lesions in the near future. Risk assessment tools
should be used to assist clinicians when they consider ECC treat-
ment options and recall schedules.8 Additionally, they can be used
to identify common risk factors with other conditions, to inform
dental public health strategies and health education and to direct
the allocation of resources.9

Community Dent Oral Epidemiol. 2018;1–8. wileyonlinelibrary.com/journal/cdoe © 2018 John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
2 |
In response to the Global Consultation, the purpose of this paper
is to propose a protocol for ECC diagnosis that will differentiate
between early and later stage lesions for use in the clinical manage-
ment of ECC and in epidemiologic surveys. As preventive and treat-
ment schedules for ECC are dependent on the risk status of the
child, a practical method for ECC risk assessment is proposed also.
2 | ECC—THE DISEASE AND ITS
DIAGNOSIS
The disease of ECC is a process driven primarily by excessive expo-
sure to free sugars.10 Free sugars are fermented to acids by plaque
bacteria, but excessive exposure to them transforms the plaque bio-
film into a cariogenic vehicle.11 The resultant acid build‐up within
plaque shifts the natural demineralization‐remineralization balance at
the enamel‐biofilm interface so that demineralization outstrips rem-
ineralization.12 Intraorally, ECC pathogenesis is mediated by saliva
and fluoride exposure.1 Notably, socioeconomic status (SES) has a
critical influence on ECC occurrence and polarization.13 The greater
risk of ECC in children with lower SES may be related to more cario-
genic eating practices, worse oral hygiene, and to differences in con-
structs that represent the ability to perceive health problems as well
as the perceived benefits of taking action.14,15
It is important to note that caries lesions, by themselves, are not
the disease. Actually, they are the clinical manifestation of the dis-
ease process and indicate only that a child has experienced ECC.16
Similarly, the presence of restorations and signs of missing teeth
usually indicate previous ECC experience. Furthermore, the patho-
logic activity within plaque is not directly observable and, because
ECC lesions progress slowly, it is not always apparent on any day
whether or not the disease is active or in remission. A later observa-
tion of a lesion following an interval of several months is necessary
to confirm whether or not it has progressed and thus to determine
whether the disease (not the lesion) is active or in remission. It may
also be assumed that, if the causative factors continue to be con-
trolled satisfactorily, then the risk of future ECC episodes is negligi-
ble. On the other hand, if new lesions emerge and/or existing lesions
progress, it may be concluded that the causative factors have not
been controlled and that ECC is still active.
In general, a visual inspection of the dentition is a quick and easy
method to detect: (a) the presence or absence of caries lesions in
deciduous teeth; and (b) the size and extent of any lesions.17 It is
also claimed that lesion activity may be assessed via visual inspec-
tion, but the value of assessing them is unclear because the defini-
tions of “active” and “nonactive” lesions are, in fact, descriptions of
their morphology which indicate more and less enamel degradation,
respectively.18 The characteristics of lesions cannot be direct mea-
sures of lesion activity because, as already noted, the pathologic
activity occurs within the plaque biofilm.
The most important advance in caries diagnosis was the recent
development of the International Caries Detection and Assessment
System (ICDAS) which recognizes that lesions progress through
EVANS ET AL.
defined stages.8 For too long, a caries diagnosis was reached on evi-
dence of dentine cavities, while ignoring early signs. Dental caries is
a dynamic disease and it can go into remission; initial lesions may or
may not progress to the late stage of dentine cavitation.19
2.1 | Guidelines for the clinical care setting
The examination of the child has the objective of collecting data
to enable the diagnosis of diseases and conditions that affect chil-
dren, such as dental caries, traumatic dental injuries and malocclu-
sion in order to develop a programme of treatment and ongoing
monitoring.
The collection of medical/dental data and dental risk factors is
important for the individual diagnosis and for monitoring the pro-
gress of clinical situations and patient home care. The following per-
sonal particulars and history data should be recorded: (a) date of
examination, name of the child, sex, date of birth, age and ethnicity;
(b) SES data: parents’ level of education, occupation, family income
and location type (urban, rural); (c) medical history; (d) experience of
pain; (e) previous use of dental services, including previous treat-
ment; and (f) behaviours: (a) dietary practices: breastfeeding and bot-
tle feeding duration and exposure to free sugars; (b) fluoride
exposure; and (c) toothbrushing frequency.
In a clinical care setting, children may be examined in a dental
chair or while they are being held by a parent/carer. It is best if teeth
are cleaned and dried to allow for more accurate diagnosis of ECC
lesions.20 The examination of all tooth surfaces (mesial, distal, buccal,
lingual/palatal, occlusal/incisal) should be conducted in a systematic
manner in order that no surface is missed, regardless of the method
used.
The clinical examination for the detection and diagnosis of ECC
may be described as visual‐tactile using basic equipment including
the WHO CPI probe and mouth mirror or wooden spatula. Four
principles govern the use of the CPI probe: (a) it should be used only
to confirm a suspected lesion; (b) only light pressure should be
applied; (c) a decision on the status of a lesion should be reached
quickly without repeated probing; and (d) in cases of doubt, assign
the lower score.
2.1.1 | Clinical stages of the ECC lesion
Figure 1 shows the clinical stages of the ECC lesion. The first clinical
sign of a caries lesion appears as a smooth white spot or zone on
enamel; the Stage 1 lesion (defined as code ECC‐1). Stage 1 lesions
may progress to Stage 2 (defined as ECC‐2) where the surface of
the white zone is roughened due to enamel breakdown. With
ongoing enamel breakdown, the lesion reaches Stage 3 (defined as
ECC‐3) at which point a cavity involving dentine is visible. This ECC
classification was informed by ICDAS,8 but the more complex ICDAS
system of seven stages has been reduced to four (0, 1, 2, 3). In both
clinical and epidemiologic settings, a four‐stage ECC classification
renders diagnostic decision‐making more simple, quick and valid and,
importantly, indicates stage‐specific treatment options.
EVANS ET AL. | 3

ECC Code and Description Anterior teeth Posterior teeth

ECC-0 Sound
There is no existing restoration nor signs of the early stage
ECC lesion.

ECC-1 Smooth white spot lesion

Tooth surface has a smooth white spot or white zone lesion,
especially noticeable on buccal surfaces. Arrested white spot
lesions which have a translucent appearance should also be
registered as ECC-1.

ECC-2 Enamel breakdown*

Tooth surface has a white zone lesion showing signs of
enamel breakdown. This sign will be confirmed when the
WHO CPI probe discloses a roughened or broken enamel
surface. However, the base of the defect must be hard, and
therefore, within enamel to qualify for ECC-2. Lesions of this
type mostly occur on buccal and occlusal surfaces and
sometimes on lingual surfaces. Lesions on occlusal surfaces
may present as dentine shadows, with or without enamel
breakdown, and should be scored ECC-2.

ECC-3 Cavity into dentine

Tooth surface has a visible cavity extending into dentine. If
necessary, this sign will be confirmed when use of the WHO
CPI probe discloses a soft dentine base. Lesions of this type
may occur on any tooth surface and may occur alongside an
existing restoration, or separate from it.

Other categories of surface status

f - Filled and sound (includes crowns). A restoration is present and there are no signs of ECC lesions anywhere on this surface.

m - Missing. A tooth has been extracted due to ECC. This code should be used only if the child is at an age when normal exfoliation would
not be a sufficient explanation for absence.

u - Unerupted. A gap in the dentition of a toddler due to an unerupted deciduous tooth

x - Excluded (developmental defect, other opacity, etc)

* Note: Defective restoration margins should NOT be classified as ECC-2. In addition, possible carious enamel alongside
restorations should not be classified as ECC-2 because such lesions cannot be diagnosed with certainty.

FIGURE 1 Criteria for Early Childhood Caries lesion Classification and Other Clinical Findings
4 | EVANS ET AL.

health programmes.22 WHO recommends the use of simplified

2.1.2 | ECC codes and descriptions
These guidelines do not follow the traditional practice in two impor-
tant respects. First, the criterion for a decayed tooth was previously
defined as a dentine cavity, yet a caries lesion may be present, diag-
nosable and reversible long before this stage, especially in child-
hood.21 Hence, this new guideline requires that decay is registered
according to lesion stage. Second, the status of each tooth was pre-
viously defined by a single code, whereas this guideline requires that
lesions on each tooth surface are diagnosed and their status
recorded separately, according to Figure 1. If a surface has more than
one lesion, that surface is coded according to the more severe
presentation.
2.1.3 | Recording of ECC status for clinical care
The status of each tooth surface is determined and charted on the
ECC chart (Figure 2). This information is used additionally to deter-
mine ECC risk status. By comparing the information in this chart
with that in future charts, it will be apparent whether new lesions
have appeared or whether existing lesions have progressed or
remained static (“arrested”). By this means, ECC status and risk are
monitored (see below).
2.2 | Guidelines for the epidemiologic survey setting
The examination of the child in the field setting has the objective of
collecting data to determine the occurrence of dental diseases and
conditions that affect children, later serving as a reference for plan-
ning health activities at the individual and collective level.
Similarly, as for the clinical care setting, the collection of medi-
cal/dental data and dental risk factors is important for the analyses
of diagnostic findings and for monitoring and evaluating oral
structured questionnaires for collecting data5 which corresponds
with those gathered in the clinical care setting, and in addition: (a)
identification number; (b) examiner; (c) area‐based deprivation
measures; and (d) family impact on oral health‐related quality of
life.
The human resources needed for the dental examination are a
calibrated examiner and a recording clerk. It is highly recommended
that calibration exercises are conducted prior to the survey to
enhance examiner reliability (also known as reproducibility). Agree-
ment between different examiners, when examining the same
patient, is referred to as interexaminer reliability, whereas the ability
by a single examiner to repeat the result on the same patient at dif-
ferent times is referred to as intra‐examiner reliability. For continu-
ous data (such as dmfs), the intraclass correlation coefficient may be
used to quantify the extent of reliability,23 whereas for categorical
variables, reliability is assessed through use of the kappa statistic.24
For the examination of preschool children, parents and caregivers
can stay together and can contribute to the protective stabilization
of children when necessary.
Instruments and supplies required for each examiner are as fol-
lows: mouth mirrors, WHO probe, rubber gloves, toothbrushes and
gauze. Containers for used instruments and for sterilizing instru-
ments are also required.
Positioning of children and examiner depends on the location
and the availability of furniture. The most favourable situation for
the quality and safety of the examination in preschool children is
with the child lying on a table, or in a parent's lap, and the examiner
seated behind the child's head.
The lighting can be artificial or natural, and should remain the
same for all examinations. Regardless of the source, the position of
furniture, the examiner and the child should maximize the use of
light.

ECC CHART - Ongoing Clinical Care

NAME ECC codes
0 Sound. No sign of ECC lesion
Date of birth (dd.mm.yy) 1 Smooth white spot lesion
2 Enamel breakdown
3 Dentine cavity (includes cavities
alongside restorations)
Other codes
f Filled and sound (includes crown)
m Missing due to caries
u Unerupted
X Excluded (eg developmental defect)

Date of examination 1
55 54 53 52 51 61 62 63 64 65

O M D B L O M D B L M D B L M D B L M D B L M D B L M D B L M D B L O M D B L O M D B L

85 84 83 82 81 71 72 73 74 75
Date of examination 2
55 54 53 52 51 61 62 63 64 65

O M D B L O M D B L M D B L M D B L M D B L M D B L M D B L M D B L O M D B L O M D B L

85 84 83 82 81 71 72 73 74 75

FIGURE 2 The Early Childhood Caries Chart for use During Ongoing Clinical Care
EVANS ET AL.
2.2.1 | ECC codes and descriptions for the
epidemiologic survey
The criteria for ECC and ECC codes used in the epidemiologic sur-
vey setting are the same as those used for children examined in a
clinical care setting (see above). As for the clinical care setting, it is
best if teeth are cleaned and dried before they are examined, but in
field conditions, it may not be possible to dry teeth.
2.2.2 | Recording of ECC status for the
epidemiologic survey
In an epidemiologic survey, the record of the clinical examination for
ECC should be entered on a chart formatted similarly to that of Fig-
ure 2 for future electronic analysis.
2.2.3 | Report of ECC experience
Age‐specific frequencies and distributions of lesion stages enable
valuable insights regarding onset and severity of ECC. Population
measures of ECC may be reported quantitatively, as the mean
dmfs (ECC) and mean dmft (ECC) indices, or as presence or
absence of ECC experience (Table S1). Other relevant statistics,
such as index median, standard deviation, range (minimum, maxi-
mum) and percentiles, may be calculated. Also reported should be
(a) ECC prevalence (proportion with dmfs (ECC) ≥ 1); (b) incidence
(the appearance of new ECC lesions [ECC‐1 or greater] during a
defined interval) on one or more tooth surfaces; (c) increment (the
sum of new lesions appearing during a defined interval); and (d)
the spread of existing lesions to other tooth surfaces during a
defined interval.
3 | ECC RISK ASSESSMENT
The schedule for ECC treatment should be risk‐specific and so it is
important to conduct ECC risk assessment at the time of ECC diag-
nosis.8 Additionally, ECC risk assessments can be used for the alloca-
tion of resources, design of dental public health programmes and the
identification of common risk factors with other conditions.9
The risk of any disease, including ECC, is dependent on expo-
sures to critical factors, both causative and protective. For dental
caries and ECC, the causative factors are exposures to free sugars
and build‐up of plaque biofilm (which separates vulnerable tooth sur-
faces from saliva), whereas protective factors are access to saliva
and fluoride exposure. In addition, the balance among these expo-
sures is profoundly affected by the determinants of health, also
known as risk indicators—social environment and lifestyle, physical
environment, genetic inheritance and the healthcare system.25
Essentially, exposures to the causative and protective factors—
free sugars, plaque, saliva and fluoride—are governed by the risk indi-
cators. As such, some quantification of these must be done during
medical and dental history taking and clinical decision‐making.26
| 5
The Plaque Index (Silness & Loe, 1964)
0 – No visible plaque
1 – Plaque not visible but can be detected by
wiping surface with a periodontal probe
or the ball-ended WHO probe.
2 – Visible plaque
3 – Thick plaque – has been present for days
or weeks.
FIGURE 3 The Plaque Index Criteria
T A B L E 1 Early Childhood Caries (ECC) risk categories based on
plaque level, ECC experience and exposure to free sugars
High risk A child under 6 y of age presenting with:
• Plaque Index score of 3
• or Dentine cavities (ECC-3)
• or Enamel breakdown (ECC-4)
• or Missing teeth due to caries
A child aged 2 years or younger presenting with:
• White spot lesions (ECC-1)
A child under 12 mo exposed to free sugars.
A child bottle feeding with sugary drinks.
A child under 6 y of age exposed to high‐frequency intake
of free sugars.
Medium A child aged 3 y or older presenting with:
risk • White spot lesions (ECC-1)
A high-risk child who, during a period of 2 y, has zero new
lesion incidence or no progression of existing lesions is
reclassified as medium risk.
Low risk A child under 6 y of age presenting with:
• Zero ECC experience
• Plaque Index score of less than 3
• Not exposed to high-frequency intake of free sugars
A medium risk child who, during a period of 2 y has zero
new lesion incidence or no progression of existing lesions
is reclassified as low risk.
The assessment of caries risk in a population, based on infor-
mation taken from questionnaires, gives rise to a population esti-
mate. Such as estimate relates to the average individual, but not
specifically to a patient of interest. Most risk assessment tools, cur-
rently available, which are designed to determine actual risk of indi-
vidual patients also involve the completion and analysis of
questionnaires which cover a range of caries risk factors and indi-
cators. The outcome is a score of some sort which is then con-
verted to a risk category. Unfortunately, these individual‐specific
determinations have not proved to be valid.27 A more sensitive
6 | EVANS ET AL.

approach to ECC risk is needed when dealing with individual

patients. The best guide to future caries risk is previous caries
experience, but, for children under the age of 3 years, exposure to
37
dietary free sugars is a critical ECC risk factor. Hence, the follow-
ing guidelines on ECC risk focus mainly on free sugar exposure,
plaque level, and ECC experience.
3.1.1 | ECC risk determination
Early Childhood Caries risk is determined on the basis of caries
experience and visible plaque level, according to the Caries
Management System,31 and, in addition, to free sugars exposure
(Table 1).

3.1 | Guidelines for the clinical care setting
During medical/dental history taking, exposure to critical ECC risk
factors should be determined. Specifically, information should be
sought on: (a) early introduction of free sugars, especially in the first
year of life;28 (b) high‐frequency intake of free sugars;12 (c) bottle
feeding with sugary drinks;14 (d) breastfeeding beyond 12 months,
especially if frequent and/or nocturnal;29 (e) fluoridated toothpaste
use and if home water is fluoridated; and (f) plaque level.
Note that plaque level should be determined using the Plaque
Index (Figure 3) prior to cleaning teeth in preparation for the ECC
clinical examination.30 The entire surfaces of all visible teeth should
be assessed and the index score to be recorded should correspond
with the surface that has the highest index score.
3.1.2 | Record of ECC risk assessment
Information on free sugars exposure, Plaque Index score and sum-
mary data taken from the ECC chart (Figure 2) is recorded on the
ECC risk assessment form (Figure 4). This form serves as a focus for
one‐on‐one health education/promotion of parents/carers by den-
tists/dental therapists/hygienists to empower them to manage ECC
risk.
3.1.3 | Monitoring ECC risk
On first contact with a child at any age, a caries preventive pro-
gramme should commence. As ECC control is synonymous with the
control of sugar, plaque, and fluoride exposures, these are the

Name: Date: Date:

ECC Risk - FIRST assessment ECC Risk - SUBSEQUENT assessment

ECC Risk is to be assessed at diagnosis and then at recall appointments. Note that
some factors are age-specific - if not applicable at date of assessment, select No.

Risk factors (explanatory variables) Risk factors (explanatory variables)

Plaque control Plaque Index
Sugar exposure Free sugar exposure under 12 mo
Bottle feeding with sugary drinks in child under 3 y
Breast feeding beyond 12 mo
High frequency intake of free sugars in child under 6 y
Fluoride exposure Fluoridated toothpaste use
Home water is fluoridated
No
Clinical indicators
Number of cavitated lesions ─ ECC-3
Number of Stage 2 lesions ─ ECC-2
Number of white spot lesions ≥ 2 mm ─ ECC-1
Plaque control Plaque Index
Sugar exposure Free sugar exposure under 12 mo
Bottle feeding with sugary drinks in child under 3 y
Breast feeding beyond 12 mo
High frequency intake of free sugars in child under 6 y
Fluoride exposure Fluoridated toothpaste use
Home water is fluoridated
Yes No Yes
Clinical indicators - Do not include numbers of arrested lesions.
Number of cavitated lesions ─ ECC-3
Number of Stage 2 lesions ─ ECC-2
Number of white spot lesions ≥ 2 mm ─ ECC-1

ECC Risk Status (circle) ECC Risk Status (circle)

Exposure to free sugars in child under 12 mo High Exposure to free sugars in child under 12 mo High
Bottle feeding with sugary drinks in child under 3 y High Bottle feeding with sugary drinks in child under 3 y High
High frequency intake of free sugars in child under 6 y High High frequency intake of free sugars in child under 6 y High
Existence of ECC-3 or ECC-2 lesions High Existence of ECC-3 or ECC-2 lesions High
Existence of ECC-1 lesions in child aged 2 y or less High Existence of ECC-1 lesions in child aged 2 y or less High
Existence of ECC-1 lesions in a child aged 3 or more y Medium* Existence of ECC-1 lesions in a child aged 3 or more y Medium*
Othewise, risk is Low* Othewise, risk is Low*

If, after a period of 2 y, new lesion incidence = zero and

ECC-1 or 2 lesions do not progress, ECC risk is Low*
*But if Plaque Index = 3, ECC risk is high. *But if Plaque Index = 3, ECC risk is high.

FIGURE 4 Early Childhood Caries risk Assessment Form

EVANS ET AL.
factors which must be controlled through education of parents/car-
ers and by community health promotion. Successful ECC manage-
ment strategies should reduce ECC risk and, therefore, such risk
reduction should be measurable. At monitoring appointments, the
focus is directed at: (a) free sugars exposure—has this been reduced
—yes or no? (b) plaque level—has this been reduced—yes or no? (c)
incidence of new ECC lesions—yes or no? and (d) lesion behaviour—
did existing lesions progress, remain static, regress—yes or no? Out-
comes are entered on the risk assessment form at monitoring
appointments for comparisons with earlier findings. At the same
time, ongoing noninvasive treatment of early lesions and collabora-
tive modification of risk factors is required.
Monitoring frequency is risk specific: 3 monthly, 6 monthly and
yearly, respectively, for high‐, medium‐, and low‐risk children.31
Improved plaque control, lesion arrest rates and a reduction in new
lesion incidence provide objective measures of ECC risk reduction.
If, after 2 years, lesions have not progressed, they are presumed to
have arrested, and, if no new lesions have appeared, the ECC risk
status of such children should now be reclassified as defined in
Figure 4.
3.2 | Guidelines for the epidemiologic survey
setting
3.2.1 | Population measures of ECC risk
Age‐specific ECC risk may be determined according to the criteria
set out in Figure 4 from clinical data recorded in a format similar to
Figure 2, together with data on plaque level, and from questionnaire
data on free sugars exposure. Population measures of ECC risk may
be expressed as the proportions of children rated as high, medium
and low risk.
3.2.2 | Monitoring ECC risk in a population
Periodic surveys of ECC in child populations should be conducted to
determine the burden of ECC and whether ECC risk is decreasing or
otherwise.
4 | TEST OF PROTOCOL
The WHO Expert Consultation on Public Health Intervention against
ECC noted that the first clinical signs of ECC usually appear in the
first 2 years of life and recommended that children aged 3 years
should be included in future national surveys of ECC.32 The utility of
this protocol for assessing both ECC experience and risk may be
tested in those surveys. In addition, the value of this protocol for
monitoring ECC risk and the clinical progression/arrestment of ECC
lesions may be assessed in longitudinal studies of ECC preventive/
treatment interventions in child cohorts recruited at birth or during
their first 2 years of life.
| 7
5 | CONCLUDING STATEMENT
Use of this protocol will enable the collection of information that is
essential for the early diagnosis of ECC in both the clinical care and
epidemiologic settings. Earlier stages of the caries lesion are clinically
detectible and should be registered early in the life of children and
arrested. Consequently, this will advance ECC management because,
previously, ECC diagnosis was reached when the disease was well
advanced and too late for effective preventive measures to be
implemented.
Risk assessment and management of early lesions are critical
steps to reduce risk of their progression to later stage lesions, and
thus, use of the practical method for assessing and determining ECC
risk will further advance ECC management because it governs (a)
urgency for interventions aimed to arrest lesion progression; (b) the
frequency of such interventions and, most importantly; (c) the need
to enhance the primary prevention of ECC.
ORCID
Robin Wendell Evans https://orcid.org/0000-0002-2271-7155
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SUPPORTING INFORMATION
Additional supporting information may be found online in the
Supporting Information section at the end of the article.
How to cite this article: Evans RW, Feldens CA,
Phantunvanit P. A protocol for early childhood caries
diagnosis and risk assessment. Community Dent Oral
Epidemiol. 2018;00:1–8. https://doi.org/10.1111/cdoe.12405