Oral Health ECC Tutorial

Introduction

Cavities in young children are known as Early Childhood Caries (ECC). ECC is now an epidemic. It can cause children great pain, loss of vigor, poor appetite or other significant problems. It is preventable. If ECC develops, it is better to treat at early stages rather than to wait so that permanent teeth are not damaged. Some definitions and terms often used when discussing ECC

Early Childhood Caries (ECC): Dental decay in the primary teeth in children under age 3 years
Rampant caries: ECC with > 1 cavity on the teeth in the upper (maxillary) and lower (mandibular) teeth
Baby bottle mouth caries (Nursing Caries): A form of ECC affecting upper front (anterior) teeth and molars without affecting lower front (anterior) teeth

Dental caries affects different parts of the teeth, (enamel, dentin, or cementum) in the crown or the root of the tooth. Nearly all cases contain bacteria such as Streptococcus mutans and Lactobacillus, which produce lactic acid as the products responsible for the caries.

Its prevalence is epidemic; in the US its rate is highest in minority and rural populations, at times infecting over 70% of the children.

Children and adults with disabilities are at risk for many dental problems. In these tutorials will highlight the oral health needs of this population, ways to identify ECC and means to prevent it.

TOGETHER WE CAN MAKE A DIFFERENCE! Not only can greater collaboration among health professionals result in better work environments, but by synergistically integrating the active involvement of those in your care with the expertise of educators and clinicians alike, the delivery of improved health care to patients and their families can be achieved.

Risk Factors for Early Childhood Caries

High exposure to sugar (sucrose)
Night time bottles with milk, juice, or soda
Frequent use of sippy cups with sweet drinks
Early oral exposure to common mouth germs (Mutans streptococci) from a caregiver with poor oral health who accidentally spreads germs to the child
Abnormal tooth development from genetics or malnutrition
Previous caries in the child or family
Low socio-economic status
Poor access to dental care
Poor oral health habits (such as lack of regular tooth brushing)
Developmental and behavioral problems or disorders in the child

Caries risk is even higher for children with special needs due to the following reasons:

Diet
- Usually harder to maintain a proper diet in those individual
Xerostomia
- Dry mouth due to medications
Difficulties performing oral hygiene
Gastroesophageal Reflux Disease and vomiting
Gingival hyperplasia and crowding of the teeth
Malocclusion and Crowded Teeth
Dental Anomalies
Trauma
Problems With Oral Care

How does ECC affect those children?

Serious dental and socio-behavioral problem
It is an infection disease
- It may become septic
Early Childhood caries may cause
- Pain
- Crooked permanent teeth
- Ear and speech problems
- Possible emotional problems
Estimated cost of treating ECC
- $1,000-2,000 per child
- Additional $6,000 if general anesthesia required

Impact of oral disease on quality of life

Oral Disease can cause

Pain
Speech delays
Poor nutritional status
Altered sleep habits
Poor self esteem
Recreational activities
Increase absences from school

Children with special health care needs (CSHCN) have more dental needs!

Lewis, Charlotte W. "Dental Care and Children with Special Health Care Needs: A Population-Based Perspective." Academic Pediatrics 9 (2009): 420-6

Barriers to Treatments of ECC/Access to care is Limited

High cost of care and lack of dental insurance
Difficulties finding dental care (in part because of limited availability of dentists)
Difficulties arranging for transportation to dentists
Lost income during time of dental visits
Poor education about the importance of dental care
Low priority of dental care for personal, community, or cultural reasons
Transportation or physical access to the building
Children with special health care needs may require sedation
Financial strain, especially with multiple visits or restorative work
If a child has numerous medical concerns, families may consider oral health a low priority.

Since access to care for those children may be limited, you are the front line!

Oral health training must be provided to all health care partners, including physicians, nurses, and health educators, and early interventionists (CDC)
Primary care providers should assess and manage oral health of children at high risk for ECC (Surgeon General)
Non-dental workforce can overcome many barriers to achieving goals of Healthy People 2010
Social workers can link health and oral health services

Prevention of Early Childhood Caries

Reduce frequent or prolonged exposure to sugar
- Discontinue the bottle at 15 to 18 months of age
- Do not allow the child to use Sippy cups for long periods
- Use water instead of milk, juice, or soda if child must have prolonged usage of bottle or Sippy cup
Reduce child's exposure to oral germs (Mutans streptococci)
- Encourage caregivers to maintain good oral health
- Recommend that caregivers receive appropriate dental care
Use appropriate amount of fluoride
- Use fluoridated toothpastes
- Evaluate with a dentist the amount of fluoride in water and foods - Supplement fluoride if necessary
- Consider having health professionals apply fluoride to teeth
Improve the child's oral hygiene habits (such as increasing caregiver involvement in tooth brushing)
Conduct early screenings and refer as necessary to dentists

Academy of Pediatrics – Children with neurodevelopmental disorders have higher risk of caries than other populations.
Children with cerebral palsy have higher rates of caries.
The rate of caries, periodontal disease and malocclusion in disabled children exceeds that of children without disabilities.

Caries management and prevention

Feeding
- Unrestricted, at-will consumption of liquids, beverages and foods containing fermentable carbohydrates (e.g. juice drinks, soft drinks, milk, and starches) can contribute to decay after eruption of the first tooth.
- Infants should finish their bedtime and naptime bottle before going to bed.
- Children should be encouraged to drink from a cup by their first birthday.
Brushing
- Wipe their gums and teeth with a soft cloth after feeding and before bed and nap time.
- As soon as the first tooth appears, brush your child's teeth daily with a child size toothbrush
Using fluoride toothpaste
- Make sure the child receives fluoride. Fluoride toothpaste, fluoride water and fluoride treatments or drops are excellent sources.

Progression of ECC

The following slides show the progression of Early Childhood Caries.

Healthy Teeth - Major Findings

Figure one: Child aged 16 month
- Corners and edges slightly rounded and intact
- Coloration varies from mix of white to pale yellow hue
- Smooth intact surface, glossy coating
- Note: "Lifting the lip" technique
  - Must see where caries starts at border of teeth and gums
  - Inspection of the back surfaces of the teeth advised

Figure Two: Child aged 4 years
- Healthy dentition - similar to above information
Figure Three: Child aged 4 years
- Corners and edges rounded and intact
Figure four: Cartoon photo of both arches

Early Caries - Major Findings

Figure five: Child aged 3 to 5 years
- Discoloration of enamel near gums
- Darker stained areas combined with rough chalkiness on tooth surface

Figure six: Child aged 2 to 4 years
- Discoloration of enamel near gum line
- Areas of rough chalkiness

Figure seven: Cartoon photo of both arches
- This stage, called the “White Spots” stage, can be reversed.

Early Caries - Counseling for ECC

Health professionals should discuss with caregivers:

Referral to a dentist while treatment can be simple, such as fluoride varnish
Reduce sugar content and carbonated drinks in the diet
Discontinue bottles and/or sippy cups
Regular tooth brushing with fluoridated toothpaste twice daily

Advanced Caries - Major Findings

Figure eight: Child aged 2 to 4 years
- Large pits
- Destruction of the enamel of the tooth
- Note, also, signs of early caries, including chalky white discoloration of enamel near gum line

Figure nine: Child aged 3 to 6 years
- Surface not continuous and intact at corner and edge (arrow A)
- Obvious "hole" between the teeth
- Small stained pit with white chalky surrounding (arrow B) is early caries
Figure ten: Child aged 3 to 6 years
- Surface discontinuous not intact at corner and edge (arrow A)
- Large discoloration on chewing surface (arrow B)
- Early signs of discoloration of chewing surface (small dark pit arrow C)
- Upper and lower teeth with multiple caries indicate rampant caries
Figure eleven: Child aged 3 years
- This child will have to undergo major rehabilitation
  - Teeth have decayed to gums
  - Dental roots are still present
  - Arrow shows an abscess formed by infection of the remaining root
  - This tooth must be pulled (extracted) to avoid severe and infections
- Probably baby bottle caries because the lower teeth are not decayed

Advanced Caries - Counseling about ECC

Health professionals should recommend:

Visit dentist for fillings (restorations)
Discontinue the bottle and reduce use of sippy cup
Eliminate sweetened foods and carbonated drinks
Eliminate foods with high sucrose and acidic content
Brush teeth regularly with fluoridated toothpaste

Major Signs of Caries Include:

Chalky, white, rough lesions at the gum line
Presence of stains with other signs of caries
Decay of the enamel, looking like pits
Surfaces and edges not smooth and intact
Stains on the inner surface of front teeth
Stains surrounded by a ring of white
Obvious holes between teeth

Fluorosis of Permanent Teeth

Fluorosis occurs when fluoride incorporated into the enamel of teeth during tooth development
- Fluorosis rarely present in baby teeth
- Discoloration is spread throughout entire surface, not limited to the gum line
- Slight horizontal lines accompany this pattern
- Teeth are otherwise

Stephen Barrett, M.D. and Robert S. Baratz,, M.D., D.D.S., Ph.D.

Differentiating Fluorosis and Caries

White lesions in baby teeth are almost always caries
Caries forms at the border of tooth and gum
Fluorosis appears in permanent teeth
If caries is mistaken for fluorosis it leads to improper treatments
- Inappropriately limiting fluoride use
- Giving inaccurate guidance regarding water and tooth paste

SUMMARY

Oral Health in Primary Care

Oral health screening recommended at age 1 year
Children typically begin to see dentist at age 3 to 6 years
Pediatric clinicians can provide initial screening and care for oral health at health maintenance visits (6 in year 1, 3 in year 2)
Counseling about prevention
Analysis of children's risk factors for ECC
Possible interventions, such as applying fluoride varnish
Clinicians should recommend dentist and help reduce barriers to care for children at high risk of ECC

Items to Remember

Genetic malformations of enamel are extremely rare
Prenatal exposure to medications are not a major cause of early caries
Fluorosis rarely occurs in baby teeth
Cavities are most likely due to diet and feeding, not tooth brushing technique

All health professionals have a shared responsibility to recognize and discuss oral disease with patients and their families/caregivers. The knowledge and skills of non-dental health professionals can help patients and caregivers improve oral health. They can assist with home care and accessing dental treatment.

Role of health professionals

Enabling families to provide better oral hygiene and nutrition for their child.

Educating families about oral health needs.

Establishing good preventive habits.

Identifying the skills, procedures, and therapies in each profession which can be used to improve oral health.

Appreciate your responsibility for your patients overall health.

Refer and Coordinate with the patient’s dentist.