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A. DE GRAUWE, J.K.M. APS, L.C. MARTENS
ABSTRACT. Aim It is evident from the number of published scientific papers on Early Childhood Caries (ECC)
that interest in this problem has grown in recent years. Many authors have been trying to devise a clear
definition or classification for ECC. The aim of this review was to inventory the prevalence of ECC and to seek
a consensus regarding definition and diagnosis. Further attention was paid to the aetiological factors including
the role of microrganisms. Finally, education, parenting and treatment procedures were discussed. Methods
For this review, epidemiological studies on caries prevalence in children aged between 0 and 36 months were
compiled through a systematic approach using Medline. Review This clearly showed that ECC continues to be
a serious public health problem and that there is a great variety of definitions and diagnoses used worldwide,
reflected in the prevalence data. This review confirms the multicausal aetiology and the need for further
research. The authors strongly support the recommendations formulated at the workshop in Bethesda 1999, and
the policy statements by the AAPD. Conclusion More efforts should be made to reach the high risk groups
within populations, in order to reduce the prevalence of ECC and S-ECC (Severe Early Childhood Caries) and
consequently to ameliorate the quality of life of these children. Long-term intervention studies are required for
the evaluation of these efforts.
I. Rapid development. Progression from the enamel into the dentine occurs in 6 months or less.
II. Maxillary incisors are affected first. These teeth usually erupt around 8 months of age.
III. The next teeth to be affected are the primary maxillar and mandibular molars, which begin to erupt around 12 months of age.
IV. Finally, when the disease becomes very severe and remains untreated, the mandibular incisors are also affected.
[Johnston and Messer, 1994; Wyne, 1999]. combination of semi-solid or solid food and lack of
Furthermore there is a strong belief that oral hygiene. In Type II (moderate to severe) ECC
environmental factors such as social deprivation are was described as ‘labiolingual lesions’ affecting
most important [Ramos-Gomez et al., 2002; maxillary incisors, with or without molar caries,
Quinonez et al., 2001]. depending on the age of the child and stage of the
ECC is a form of early, moderate and late dental disease. Typically are the unaffected mandibular
decay that affects the primary teeth of infants and incisors. The cause is usually inappropriate use of a
toddlers. It develops in tooth surfaces that are usually feeding bottle or at-will breast-feeding or a
at low risk for caries, such as the labial surfaces of combination of both, with or without poor oral
maxillary incisors and lingual and buccal surfaces of hygiene. Finally, a Type III (severe) ECC was
maxillary and mandibular molars. ECC usually described as carious lesions affecting almost all teeth
begins with the maxillary primary incisors, initially including the mandibular incisors. A combination of
developing a dull white demineralized band, the so- cariogenic food substances and poor oral hygiene is
called ‘white spot’, along the gingival margin. As the the cause of this type of ECC.
condition progresses, caries develops and may evolve A system developed by Johnston and Messer
to a complete destruction of the crown, leading to [1994] classifies ECC into 3 main patterns:
root stumps. ECC always begins with an early stage; - lesions associated with developmental defects (pit
starting with white or brown spots, appearing at the and fissure defects and hypoplasia);
gum line. In the moderate stage, cavitation starts and - smooth surface lesions (labial-lingual lesions,
caries begins to spread to the maxillary molars. In the approximal molar lesions);
severe stage, the caries process destroys the maxillary - rampant caries.
teeth, and spreads to the mandibular molars. Finally, The latter was defined as having caries in 14 out of
in very severe cases the mandibular incisors are 20 primary teeth, including at least one mandibular
affected (Table 1). The pattern of caries development incisor.
is characteristic for the disease and is affected by the Another, but not specifically ECC, classification
sequence of eruption of the primary teeth, the system is the Caries Analysis System (CAS) of Ismail
duration of the causative behaviour and the patterns and Sohn [1999]. The CAS defines 4 patterns of
of tongue movement and oral muscular action caries in the primary teeth, according to the site of
[Horowitz, 1998]. occurrence. This classification system excludes the
buccal and lingual surfaces of the maxillary canines,
the buccal, lingual and mesial surfaces of the
Classification mandibular canines, and all tooth surfaces of the
During the last 20 years, different research groups mandibular incisors. The fissure pattern was 3 to 4
have attempted to develop classification systems for times more likely to develop caries compared with
ECC. In a first approach [Wyne, 1999], the disease-free children. Children with the maxillary
severeness of ECC can be defined in three types and anterior pattern had 2.4 times greater two-year
associated with different aetiology. In Type I (mild to increments of pit and fissure caries compared with
moderate) ECC was defined as the existence of caries-free children and they also had 8 times more
‘isolated carious lesion(s)’ involving incisors and/or caries increments in the buccal/lingual and proximal
molars. The most common causes are usually a areas than caries-free children.
36-47 1 or more dmfs surfaces 1 or more cavitated, filled, or missing (due to caries) smooth
surfaces in primary maxillary anterior teeth or dmfs score >4
48-59 1 or more dmfs surfaces 1 or more cavitated, filled, or missing (due to caries) smooth
surfaces in primary maxillary anterior teeth or dmfs score >5
60-71 1 or more dmfs surfaces 1 or more cavitated, filled, or missing (due to caries) smooth
surfaces in primary maxillary anterior teeth or dmfs score >6
TABLE 2 - Proposed case definitions of Early Childhood Caries (ECC) and Severe Early Childhood Caries (S-ECC) by the
participants at the workshop in Bethesda 1999 [Drury et al., 1999]
Puerto Rico Lopez del Valle et al., 1998 6-47 months 62.6%
Sao Paolo (Brazil) Santos and Soviero, 2002 0-36 months 41.6%
TABLE 3 - An overview of prevalence data on ECC reported in the literature since 1998.
Mutans streptococci Aluluusua et al., 1996 - fermentation of simple carbohydrates - associated with caries activity
S. mutans Marchant et al., 2001 - tolerance to low environmental pH levels in young children
S. sobrinus Tanzer et al., 2001 - vertically transmitted
- only within the presence of hard
oral tissues (teeth, prosthodontics)
Lactobacilli Marsh and Martin, 1999 - number in saliva reflects simple - dorsum of the tongue
L. fermentum Marchant et al., 2001 carbohydrate consumption by the host - usually cultured from carious dentine
L. casei Tanzer et al., 2001 - comprise less than 1% of the total
cultivable microflora
Enterococci Tanzer et al., 2001 - not frequently found in the human - immuno and medically compromisedt
oral cavity patients have been associated with
their presence in the oral cavity
Actinomyces Marchant et al., 2001 - carbohydrate users - isolated from both carious
A. naeslundii Tanzer et al., 2001 - not associated with initiation of ECC and sound surfaces
A. odontolyticus - more associated with health
A. israelii - the most predominant Actinomyces
species in plaque of ECC
individuals is A. israelii
established carious lesions. Table 4 summarizes all nursing formulas, sweetened milk, fruit juices,
microrganisms associated with the caries process. carbonated and non-carbonated soft drinks. The
frequency and the duration of the habit, along with
the ingestion of cariogenic solids (e.g. biscuits), are
Aetiology a very important aspect of this condition [Johnston
Dietary factors. Many studies suggest that children and Messer, 1994; Peressini, 2003]. Ad libitum
with ECC have a high frequency of sugar intake, not exposure to cariogenic substances during the night
only from fluids given in a nursing bottle, but also intensifies the risk of caries, as oral clearance and
from sweetened solid foods. This dietary salivary flow rate are decreased during sleep
characteristic is likely to be one of the most [Milnes, 1996; Berkowitz, 2003].
significant caries risk factors in ECC. Milk. Milk (human and bovine) and infant milk
Although improper nursing bottle-feeding habits formulas present a complex role in the aetiology of
are the most frequently cited causes of ECC, the ECC as they contain protective components against
disease may occur in children who are breastfed at caries such as calcium, phosphorous, casein and
will [Weerheijm et al., 1998], and beyond one year other proteins, which provide a protective organic
of age, and in those who are given sweetened coating on enamel. Bovine milk has a higher
pacifiers or frequent sugar-containing snacks concentration of calcium and phosphorous than
[Horowitz, 1998]. The cariogenic contents of the human milk, bound in organic and inorganic
nursing bottle include bovine and human milk, molecules and also in free ionic form. In vitro
studies reported enamel to be 20% less soluble in an factors, derived from saliva (serum immunoglobulin
acidic buffer if initially exposed to bovine milk. A, sIgA) or serum and gingival crevicular fluid
Infant milk formulas, bovine and human breast milk (immunoglobulin G, IgG) and non-specific
contain relatively high concentrations of lactose, antimicrobial systems derived mainly from saliva,
which is potentially cariogenic [Yiu and Wei, 1992]. and phagocytic cells which transudate through the
Under conditions conductive to ECC, human milk gingival crevice [Lehner et al., 1976; Twetman et al.,
can be more cariogenic than bovine milk due to its 1981; Tenovuo et al., 1987].
lactose content, 7 versus 4.8% respectively, while Oral clearance. In children with ECC, the sleep-
the concentrations in infant formulas vary time consumption of sugar is a common
considerably characteristic. The cariogenicity of the substrate
Soya-based formulas could be considered as a increases significantly, as the length of contact time
good substitute for natural milks, but the added between the plaque and substrate increases. The
carbohydrates used in these formulas are mostly clearance of glucose is the slowest on the labial
sucrose derivates [Horowitz, 1998]. Under normal surfaces of the maxillary incisors and the buccal
dietary conditions, milk is minimally cariogenic and surfaces of the mandibular molars. These site
may even be cariostatic [Ripa, 1988]. However, it is differences in oral clearance may explain in part the
important to emphasize that adding sucrose to milk distribution of the carious lesions in ECC which are
renders milk cariogenic. This does not contradict the characteristically localized to the maxillary primary
clinical evidence attributing ECC to milk, as affected incisors and first molars [Ripa, 1988; Milnes, 1996].
children may have aberrant, rather than normal Oral hygiene. Primary infection with streptococcus
dietary habits, in association with inadequate oral mutans by vertical transmission is unavoidable, but
hygiene and a minimal fluoride exposure. measures should be taken to reduce the bacterial
Fruit juices and soft drinks. These contain a lot of numbers that are transferred, for example by
sucrose and have a low pH (pH 3-4), which presents avoiding transfer by sharing spoons or cleaning a
a potentially erosive and cariogenic effect. Loss of pacifier in the mothers mouth. Tooth brushing with
enamel from excessive consumption of fruit drinks in fluoridated toothpaste by the parents or caretakers
children has been documented in several studies. The should start as soon as the first primary teeth erupt
abusive use of fruit juices and soft drinks in and this at least two times a day. This
combination with inappropriate remineralization recommendation however is not appropriate for
activity by saliva eventually result in a predominant areas where adequate fluoridation is present (e.g.
enamel demineralization process [Seow, 1998] and Ireland), which implies that the use of fluoridated
are a common finding in ECC, since they are usually toothpastes in children could be prohibited. The use
given at will to the child and preferentially in a bottle. of a pea size of paste, however, can probably avoid
Syrup additives (e.g. vitamin preparations). These any risk. A gentle sideways scrub using a multi-
may be added by parents to the nursing fluid. Sucrose tufted toothbrush and an adapted toothpaste, low in
sweetened medication, such as paediatric antibiotic fluoride concentration (≤500 ppm), are
preparations have also been implicated in the recommended by the European Academy of
development of ECC [Horowitz, 1998]. Paediatric Dentistry [Oulis et al., 2000].
Salivary factors. It is known that the salivary flow Furthermore, brushing more than once a day and
rate is at the lowest during the night, due to the having less than two in-between meals a day is
circadian rhythm. With regard to ECC, the continuous strongly recommended [Martens et al., 2004b].
feeding of sugar-containing substances at night time, Environmental and living condition factors. ECC
when the flow rate is the lowest, increases the caries is one of the most prevalent diseases of infants and
risk of the child significantly. If cariogenic liquids are toddlers from families with a low income and from
consumed frequently, teeth may be exposed to families with an immigrant and ethnic minority
cariogenic conditions for lengthy periods with only background [Hallett, 2000]. Currently, although
short intervals allowing salivary remineralization of ECC is recognized as an infectious disease, its
demineralized enamel [Ripa, 1988]. extent and severity vary with cultural, genetic and
As the hard dental tissues are immunologically socioeconomic influences. Significant negative
inactive, specific salivary (host) defense mechanisms correlations have been shown between the
against bacterial colonization and pathogenic activity socioeconomic level of a family and the prevalence
of cariogenic organisms are essential. These host of ECC in that same family, and between poor oral
immune mechanisms include specific immune hygiene and the prevalence of ECC [Santos and
1. Infants should not be put to sleep with a bottle. Ad libitum nocturnal breast-feeding should be avoided after the first primary tooth
begins to erupt.
2. Parents should be encouraged to have infants drink from a cup as they approach their first birthday. Infants should be weaned from the
bottle at 12 to 14 months of age.
3. Repetitive consumption of any liquid containing fermentable carbohydrates from a bottle or no-spill training cup should be avoided.
4. Oral hygiene measures should be implemented by the time of eruption of the first primary tooth.
5. An oral health consultation visit within 6 months from eruption of the first tooth and no later than 12 months of age is recommended
to educate parents and provide anticipating guidance for prevention of dental disease.
6. An attempt should be made to assess and decrease the mother’s/primary caregiver’s mutans streptococci levels to decrease the
transmisson of cariogenic bacteria and lessen the infant’s or child’s risk of developing ECC.
TABLE 5 - Summary of policy statement of the American Academy of Pediatric Dentistry concerning early childhood caries
[revised 2003].
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