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Literature Review:
Early Childhood Caries (ECC)

Paige Humphries
Community Dental Health DH 237
November 22nd, 2023
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Introduction to Early Childhood Caries

Early childhood caries (ECC) is a complex yet preventable condition, that is considered

to be one of the most common chronic childhood diseases. It is a global issue that impacts the

quality of life of many children and their families. ECC can be described as, “the presence of 1

or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth

surfaces in any primary tooth in a child 71 months of age or younger” (Definition of Early

Childhood Caries). ECC are a prevalent worldwide health problem that drives research in

attempts to understand why the disease is so prevalent, the risk factors associated with it, and

how to prevent it.

Prevalence of Early Childhood Caries

The prevalence of ECC is examined in many different studies, focusing on how common

the condition is and how to prevent it. A meta-analysis conducted by Head and Face Medicine

examined data and statistical research from many sources to conclude that the prevalence of

dental caries in primary teeth is high in children all around the world (Kazeminia et al., 2020).

This study pulled from 164 different peer-reviewed articles and had a range of data extending

from 1995 to 2019, encompassing research over 20 years. This meta-analysis examined the

prevalence of dental caries in primary teeth of children around the world. They evaluated a

sample size of 80,405 participants and the results showed that 46.2% of these children faced

ECC (Kazeminia et al., 2020). This statistical information emphasizes the prevalence of ECC

and shows the need for intervention.

A meta-analysis conducted by the International Journal of Paediatric Dentistry

examined cross-sectional studies using the World Health Authority (WHO) diagnostic criteria to

show the prevalence of ECC. The meta-analysis stated that “studies on the prevalence of early
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childhood caries that used the most common outcome measure for caries, the WHO criteria,

show a combined prevalence of 48%, with variations both between and within countries. There

were no significant changes observed in the reports for the period from 1990 to 2019” (Uribe et

al., 2021). This study compared to the study conducted by Head and Face Medicine shows

similar results in terms of the prevalence of ECC. Overall, these studies emphasize how

prevalent ECC are and represent it as an ongoing issue around the world.

Risk Factors and Causes of Early Childhood Caries

With ECC being so prevalent and affecting children all over the world, it is important to

understand the risk factors associated with the disease. Factors that increase a child’s risk for

ECC include “improper feeding practices, familial socioeconomic background, lack of parental

education, and lack of access to dental care” (Anil & Anand, 2017). Each of these factors can

make a child more susceptible to the demineralization process.

The article “Risk Predictors of Early Childhood Caries Increment- A Systematic Review

and Meta-Analysis” states that “pathological factors contribute to the probability of initiation and

progression of caries. Hyposalivation, frequent consumption of fermentable carbohydrates, and

presence of acidogenic bacteria may tip the caries balance to demineralization and caries

progression” (Lam et al., 2022). This meta-analysis analyzed research from cohort and case-

control studies with a duration of at least two years, and which had over 300 participants. They

examined 18 studies and included a sample size of 1,159,226 preschool-age children. The

analysis noted that “lower parental education attainment was found associated with ECC

increment, whereas immigration status, gender, and dental service utilization, were not

significant factors for ECC increment” (Lam et al., 2022). More research is continuing to
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surface about factors that increase children’s risk for ECC. Often the risk of ECC is related to

the oral health condition of the child’s caregiver/parent.

A meta-analysis conducted by the National Library of Medicine found that “the presence

of dentinal caries, high levels of MS, frequent consumption of sweetened foods, poor oral

hygiene, and the presence of visible plaque were the significant risk factors” (Kirthiga et al.,

2019). Each piece of literature reviewed shared similar and some of the same risk factors for

ECC. Understanding these risk factors can aid in the prevention of ECC.

Prevention and Treatment of Early Childhood Caries

The cause of ECC is multifactorial, yet understanding the common factors associated

with the disease can support different treatment modalities. With understanding that low

parental education and low socioeconomic status are associated with ECC, a plan can be

implemented to provide care and resources to those in need. The article “Risk Predictors of

Early Childhood Caries Increment- A Systematic Review and Meta-Analysis” examined the

causes of these ECC but also explained that “increased protective factors such as salivary flow,

antimicrobials, and fluoride can restore the balance towards remineralization and lead to caries

arrest” (Lam et al., 2022). These protective factors can be utilized as methods of primary

prevention or secondary prevention. Primary prevention involves absolute disease prevention,

whereas secondary prevention involves stopping the disease progression.

Fluoride is a method that is used to prevent demineralization (primary prevention), and it also

re-mineralizes the tooth structures when early demineralization is present (secondary

prevention). Therefore, fluoride can be effective in the prevention and treatment of ECC.

Fluoride can be obtained through fluoridated water (primarily a topical mechanism of action),

topical application, or fluoride supplements (prescription or OTC). Often in dental offices,

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topical fluoride varnish is used in higher concentrations to strengthen the dentition's resistance to

the carious lesion process. The Dental Research Journal conducted a systematic review

analyzing information from 17 articles and studies. This systemic review aimed to understand

the role of fluoride varnish in the prevention of ECC. It states that “the term “topical fluoride” is

used to describe those delivery systems which provide fluoride to exposed surfaces of the

dentition, at elevated concentrations, for a local protective effect” (Mishra et al., 2017). The

fluoride varnish commonly used in dental offices is 5% sodium fluoride. Varnishes are a good

prevention method for young children because they are tolerable, easy/quick to apply, and

remain on the teeth for an extended period.

Other perspectives on the prevention of ECC include education. A systematic review titled

“Interventions with Pregnant Women, New Mothers, and Other Primary Caregivers for

Preventing Early Childhood Caries” acquired information by studying and comparing 17

randomized control groups. This systematic review compared different interventions involving

ECC with pregnant women, mothers, or caregivers of infants in the 1st year of life. The article

stated that “moderate‐certainty evidence suggests that providing advice on diet and feeding to

pregnant women, mothers or other caregivers with children up to the age of one year probably

leads to a slightly reduced risk of early childhood caries (ECC)” (Riggs et al., 2019). Prevention

does not always involve the use of medicaments, and instruction/advice can play a big role in the

prevention of disease. Dental hygienists prevent and control dental disease through clinical

interventions and oral home care instruction. This educational component will aid in the

reduction of ECC because mothers/caregivers are often responsible for passing on the bacteria

responsible for causing dental caries to their children. When providing the mother with advice

on good eating and feeding habits for their children, a child will be at reduced risk for ECC.
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Educational information that may reduce the child’s risk of developing ECC includes only

putting water or plain milk into bottles, not feeding right before bedtime, and providing your

children with healthy food options. In addition to education on feeding and nutrition, educating

mothers about when their children should visit the dentist (by the age of 6 months) can reduce

the risk of ECC.

Overall, primary prevention methods and secondary prevention methods can be used to

manage ECC. Some of these methods are used to inhibit the disease process from occurring,

while others can be used to stop disease progression. Silver diamine fluoride is another

medicament that is used to prevent the progression of carious lesions and is effective with

children. When carious lesions extend beyond the stage in which they can be remineralized,

fillings or stainless-steel crowns may be required. We have the technology to reduce the risk of

dental caries, but when they occur, they can be restored to improve the quality of life and oral

health of children.

Conclusion

With ECC spanning globally, continued research and product development is essential to

reducing the prevalence. The research concludes similar findings in how prevalent ECC are,

which is nearly 50% of children. There are many risk factors such as poor oral hygiene, a diet

high in fermented carbohydrates, lack of fluoride, and the presence of acidogenic bacteria that

place children at a higher risk for the development of ECC. Regular dental visits, fluoride,

parental/ patient education, antimicrobials, and adequate salivary flow can all help reduce the

risk for ECC. Without treating and preventing dental disease, many children around the world

will face dental pain and infections that impact their quality of life and overall health.
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Citations
Anil, S., & Anand, P. S. (2017). Early Childhood Caries: Prevalence, Risk Factors, and
Prevention. Frontiers in Pediatrics, 5(157). https://doi.org/10.3389/fped.2017.00157

Definition of Early Childhood Caries (ECC) . American Academy of Pediatric Dentistry. (n.d.).
https://www.aapd.org/assets/1/7/d_ecc.pdf

Kirthiga, M., Murugan, M., Saikia, A., & Kirubakaran, R. (2019). Risk Factors for Early
Childhood Caries: A Systematic Review and Meta-Analysis of Case Control and Cohort
Studies. Pediatric dentistry, 41(2), 95–112.

Lam, P. P. Y., Chua, H., Ekambaram, M., Lo, E. C. M., & Yiu, C. K. Y. (2022). Risk Predictors
of Early Childhood Caries Increment-A Systematic Review and Meta-Analysis. The
Journal of Evidence-Based Dental Practice, 22(3), 101732. https://doi-
org.lanecc.idm.oclc.org/10.1016/j.jebdp.2022.101732

Mishra, P., Fareed, N., Battur, H., Khanagar, S., Bhat, M. A., & Palaniswamy, J. (2017). Role of
fluoride varnish in preventing early childhood caries: A systematic review. Dental
research journal, 14(3), 169–176. https://doi.org/10.4103/1735-3327.208766

Riggs E, Kilpatrick N, Slack‐Smith L, Chadwick B, Yelland J, Muthu MS, Gomersall JC;

(n.d.). Interventions with pregnant women, new mothers and other primary caregivers
for preventing early childhood caries. The Cochrane database of systematic reviews.
https://pubmed.ncbi.nlm.nih.gov/31745970/

Uribe, S., Innes, N., & Maldupa, I. (2021, March 18). The global prevalence of early childhood
caries: A systematic review with meta-analysis using the WHO diagnostic criteria.
International Journal of Paediatric Dentistry.
https://onlinelibrary.wiley.com/doi/10.1111/ipd.12783