Earlychildhoodcaries:etiology, clinicalconsiderations ...

1 Intr oductionDental cari esaffectshumans ofallagesthroughouttheworld andremai nsth e maj ordent isa disease th atcanneverbeer adicatedbecauseofth e complexin teractionofcultural,social , behavio ral, nutriti onal, andbi ological ri skfa ctorsthatareassociatedwithitsinitiation andprogressio rly chi ldh ood ca ri es: eti olo gy,cl in ical consi der atio ns, co nseq uen cesand manageme ntSobiaZafar1, SorayaYasinHarnekar2, AllauddinSiddiqi3Ab str actEarlychildhoodcaries(ECC)isa diet-induceddiseasecharacterizedbyearly onsetandrapidprogression. Itresultsinfunctional, esthetic andpsychologicaldisturbancesofthe child, consequencesmay continuelongafteritsinitialtreatmentasma lnutriti on,lowselfesteem,decayandmalocclusioninp ermanentdenti venti ve measures cannot,andwill not,workunlesspare nts andcaregiversfollowandadheretotheprevent ivemethods beingpr esc ri ts , otherhealthprofessionals,andthepubliccom munity must also recognizethatECCisnotsi mply anindivi dual pr oblem.

2 Rather,it takesa collaborativeef forttomakethenecessary improvementsfortheseyoungchildrento beableto receiv e ywo rds:Early chi ldhoodcari es; etiology ;riskfactors; cl ini calconsiderations;consequences; , NO. 4 Clinical1 SobiaZafar,BDS,MSc Dent(PediatricDentistry)ConsultantPaedia tricDentistry,MultanMedical& DentalCollegeMultan,Pakistan2 SorayaYasinHarnekar,BChD,MSc DentHeadDepartmentof PaediatricDentistry,Universityof the WesternCape,CapeTown,SouthAfrica3 AllauddinSiddiqi,BDS,PDD,MSc (Maxillofacial& Oral Surgery),PhD (student)Oral ImplantologyResearchGroup,Sir JohnWalshResearchInstitute,Schoolof Dentistry,Universityof Otago,Dunedin,New ZealandCorrespondingAuthorAllauddinSiddi qiOralImplantologyResearchGroup,Sir JohnWalshResearchInstitute,Schoolof Dentistry,Universityof sisplaque-inducedaci ddemineralizationofenamel ,theinteractionofcariogenicmicroorganism sandfermentablecarbohydrates arecrucia l periodsinthedevelo pment ofhealthydentit lychildhoodcarie s (ECC)

3 Isa majorpublic heal thpr oblem,beingthemost commonchr onic in fectiouschild hooddis eas e,whichis di fficult life-threatening,itsimpactonindiv idual s andcommuni tiesis considerable,resultinginpain,impair mentof function,deleteriousinfluenceonthechild s growthrate,bodyweight,andabili tytothrive, furt her toothdest ructionandencouragebet terovera llhealth,treatmentshouldbeinstit utedimmedia tel yandspecif ic al iv eapproachincludesatraumatic restorativetr eatment(ART),fluorideapplicatio ns,oral hygieneinstructi on,dietary counseling,andrestora tive eve these inter ventions,advancedbehavioralmanagementisa nimportantpartofthetr eatment pl an,asevenwith theseproactiv e measur es,childrenwithECCarelikely ure 1: In itia l stag es of ECC - the les ion can be ar res ted by theappl ica ti on of fluor ide and impr ov ed OH ha , NO.

4 425 ClinicalDe fi ni tionECCinpre-schoolchildrenhasbeendiscus sedextensivelyinthescientificliteratureo verth e past50 fantsandyoungchildrenhaslong beenrecognizedasaclinicalsyndrome,descri bedby Belteramiin1930sas Lesdentsnoiredetout-petits whichmeans blackteethofthe veryyoung. 5 Fassisperhaps themost preeminent inthis per specti vefordefiningtheterm Nursingbottlemouth. 6 Subsequently, othertermssuchas babybottletoot h decay , nursingbottlesyndrome , bottlemouthcaries , nursingcaries , rampantcaries , nursingbot tl e mouth , milkbott lesyndro me , breastmilkto othdecay and facio-lingualpatt er n ofdecay ,8 Anenormous di versity ofdefin it ionanddiagnosisofECCisusedworld ,thereiscurrentlynouniversallyacceptedde finitionfo r th e , 10 SomeresearchersdefinedECCasthecarieson primarymaxillaryin cisors(thenumberofmaxillaryincisorsrange sfrom1 to4te ethaccor din gtothisdefinition).

5 7,1 0,11 Carinoetal .,12def inedECCasthepresenceof any decayed, missing,andfilled(dmf)teeth,regardlessof beinganterior ,convenedbytheNational In st itute s ofHealth(NIH) pr oposedthatthetermEarlyChildhood Caries(ECC)shouldbeusedtodescribeth e presenceofone ormoredecayed(noncavitated or cavitatedlesio ns),missing(d ue to caries),orfilledtoothsurfacesonanyprimar y toothinchildrenupto71monthsof , 14 Thisdefinition wasadopte d bytheAAPD15and, subsequently, byse ,17,18 Further more,theexpressionsevereECC(S-ECC) wasadoptedinlie uoframpant caries,inthepresenceofatleastone ofthefollowingcriteria: Anysignof carie sonasmoothsurfaceinchildrenyoungerthanth reeyears.

6 Anysmoothsurface ofanantero-poste riordeci duoustooththat isdecayed,miss ing(duetocaries) orfi lled,inchild renbetweenthreeandfiveyearsold. Decayed, missing,andfi lledteethindex(dmft)equaltoorgreaterthan 4 attheage of3, 5 attheage of4 and 6 attheageof5 iol ogyDenta l carie s isamultifa ctoria l diseasethat st art s wit hmicrobio logical shi ft s wit hinthecomplex biofilmandisaf fe cte dby sali vary flowandcomposit ion,exposuretofl uoride,consumptionofdietarysugars, and bypreventivebehavio seaseisinitia ll y reversibleandcanbehalt edat any sta ge,evenwhensome cavi ta tionoccurs,providedenoughbi anaggre ssive formof dentalcaries thatbeginsonto othsurfaceswhichareusuallynotaffectedbyd ecay,suchaslabialsurfacesof maxillaryincisors.

7 Incontrasttodenta l carie swhic husuallyinvolvesplaquere tentiv it is th ought th atth eremaybedi stinctiveri skfactorsinvolvedin theprogressio n his toric all yatt ributedtoinappropriat eandprolo ,especiallyatbedtime,isbelievedtobeassoc iatedwith incre ased ris k forcar ies , butthismight notbeth e onlyfactor incaries devel opment inearl y childhood. Cariouslesio ns areproducedfr omtheinteract ionofcari ogenicmicroorganisms,fe rmentablecar bohydrates,andsusc eptib letoothsurface. Giv entheproper time, thesefactorsin ducein cipientcarious associatedri skfactorshaveal so beenfo , NO. 4 ZafaretalPri maryrisk factorsSu bstrateTher e issuff icientevidencethatsugars(s uchassucrose,fr uct ose and glucose)and otherfermentablecarbohydratesplaya vitalroleinthein itiationand progressionofdentalcar , 25 Sucroseisthemost significant cariogenicfoodasitconver tsnon-cariogenic/a nticar iogenicfoodstocario creaseintheproportionsofmu tans streptococciandlac toba cilliand,simultaneouslydecr easesthelevelsofS.

8 Sangu ini earanceof carbohydratesislo west duringsleep,whensal ivar y flo wdecreasesandthecontactbetweenpl aqueand substr at esin creases,favoringthegrowthofcariogenicspe cie s. Ahealthybiofilmistherebyconvert edintoadiseasedone,consequentlyenhancing sceptibletoot h/hostSeveralfactorscanpredisposea r thedevelopmentofcariesarereducedsaliva, immunolo gicalfactors,presenceofenameldefect s, charact erizedmainl ybyhypopl asia , immatureenamel,toothmorphologyandgenetic chara ct er istics ofthetooth(s ize,surface,depthof fossaeandfi ssures)andcr , 27 Saliva is themajor defense sy stemof thehost againstcarie s. It re movesfoodsandbacteria, andprovidesabuffe rin ofunctionsasa mineralreservoir forcalciumand phosphatenecessaryfor enamelremineralizatio ep,thedecrease in sal ivaryflowrate reducesitsbuffering capacity,consequentlymakingto ,27 Because enamelisimmunologicallyinacti ve,themainimmunedef enceagainstS mutansis providedlargelybysal ivary secretoryimmunoglobulinA(IgA)

9 Roorganisms,theydevelo psal iv ar yIgAantib odi ,thenewlyexposedenamelsurfacesundergothe fi nalstagesofpost-er uptiv ematurati onandhardeni ngbyincor poratingor allyavailableio ns, in cl udingflu toothismost suscepti bl e tocarie s in theperi odimmediately after er oorganis msEvidencesuggeststhatth e firststepintheprogressionofECCinchildren isthroughtheacquisitio eptococci,(mutans st reptococci (M S), sobr inus)andla cto bac ill us. Thesepathogenscancol oniz ethetoothsurface. Whencombinedwithproductsthatcontainfe rmentablecarbohydrate s,theprocessofmetabolismisin it ia tedby the bact eri a, producingaci dicendproductsthatultimatelyle adtothedemineralizationoftoothenamel, thus ,2 9 The primarycaregiveroftheinfant,usually themother,hasbeenshowntoharbour thereservoirof e vehi cle by whichthetra exactmeth odoftransmissionisunknown,but it issuspectedtobe dueto thecl ose contactofmotherandchildand thesharing offoodandeatin.

10 30 TheAAPD reportedthatinf antsand to ddler s whosemoth ershavehig h le velsofMSar e atel evate d ri skfor acquir in g theorg anismthan childrenwhose nt al Pl aqu eThepresenceof visible plaque and itsearly accumulationhavebeen re la ted to caries ,33 Alaluusua and Malmivirta34fo und th at 91%ofthechildre nst udie dwerecorrectlycl assi fie dintocaries riskgroups,basedsolely on th e presenceorabsenceofvisiblepl iainthebiofilmarealways metabolicallyacti ve,causin gfluctuationsinthe sal carbohydra tesbycari ogenicpl aquebact eriaproduceorganicacids, whi chacton a suscepti bl e to d risk fact orsBo ttl e feed ingBot tle -feeding, especial lynocturnalfeedingor, particularly,whenchildr enareal lowedtosl eepwitha bott le intheirmouth, hasbeenconsid ,3 5, 36 Duand co-workers37foundthat chi ldrenwhohadbeenbottl e-fedhada five times greaterri sk of havingECCcomparedtochi ld re nwhowerebreast -fe -basedformulasforin fantfe edi ng,eventhosewit houtsucroseintheirformula tion,als oprovedcar iogeni cinsomest , prolongedmilk bottlefeeding atnight is notthesolecause baby bottl esdurin gthe nig htis associatedwithth e reduction in sal ivaryfl ow.