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CASE REPORT
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IntroductionEarly childhood caries is a relatively new term that
describes rampant dental caries in infants and toddlers.1 The Early
Child-hood Caries (ECC) is a severe form of caries, defined in 2004
by the American Academy of Pediatric Dentistry, which affects
children of 25 years of age and which is characterized by pre-cise
topographical and clinical parameters. The decay pattern of ECC is
characteristic and pathognomonic of the condition. The four
maxillary incisors are most often affected. The lower primary
incisors are intact and the primary cuspids can be oc-casionally
affected. In very severe cases the mandibular inci-sors are also
affected.1 The academy also specifies that, in chil-dren younger
than 3 years of age, any sign of smooth-surface caries is
indicative of early childhood caries.2
Johnston and Messer classify ECC into 3 patterns: a)
develop-mental defects; b) smooth surface lesions; c) rampant
caries. Verkamp and Weerheijm use 4 stages to classify the ECC:
ini-tial, damaged, deep and traumatic lesions.1 Wyne suggested the
following classification for ECC: Type 1 ECC -mild to moder-ate-
the existence of isolated carious lesion(s) involving molars and /
or incisors, Type 2 ECC-moderate to severe -labiolingual carious
lesions affecting maxillary incisors, with or without molar caries
depending on the age of the child and stage of the disease, and
unaffected mandiblular incisors, Type 3 ECC severe-carious lesion
affecting almost all the teeth including the lower incisor. The
condition is rampant and involves tooth surfaces which are usually
unaffected by caries.3
The type of treatment based for each patient with ECC depends on
patients and parents motivation towards dental treatment, the
extent of the decay and the age and cooperchild. This pa-
per reports the management of a three year old female child
patient with Type 2 ECC under conscious sedation.
Case ReportA three year old female child patient accompanied
with her parents were reported to the Department of Pedodontics and
Prevent with a chief complaint of decayed upper anteri-or teeth and
pain in the molar teeth. Patient had a history of improper oral
hygiene maintenance and frequent intake of sweets. On examination,
crowns of all maxillary anteriors re-vealed cavities girdling the
necks of teeth in brownish collar (Figure 1). The primary molars
also showed similar brownish discoloration. Extensive cavitations
with no pulpal involve-ment were observed. The case was diagnosed
as Type 2 ECC and a two stage treatment plan was formulated;
Initial preven-tive therapy with strategies forand final
therapeutic interven-tion. The success of multiple restorations may
be influenced by the childs level of cooperation during treatment.
So it was decided that conscious sedation may provide optimal
condi-tions to perform the restorative procedures as with a less
risk potential than general anesthesia.
In the initial treatment regimen and home care instructions
included oral hygiene measures and diet counseling to the parents.4
The parents were asked to keep a five-day food dairy, to follow-up
the diet counseling. Gross excavation of all le-sions as an initial
approach was done in the first sitting.5, 6 APF Topical solution of
1.23% Fluoride was applied and temporiza-tion was done. In the
second visit, the food dairy was checked and the patient was found
to be adhering to the counseled diet changes and the oral hygiene
measures were reinforced. Under conscious sedation using Nitrous
oxide and oxygen
AbstrAct
The American Academy of Pediatric Dentistry (AAPD) defines early
childhood caries (ECC) as the presence of one or more decayed
(noncavitated or cavitated lesions), missing (due to caries), or
filled tooth surfaces in any primary tooth in a child under the age
of six. Untreated, ECC can irreversibly destroy the dentition,
cause abscesses, and lead to serious ill-ness. This paper reports
the management of a Type2 ECC lesion in a three year old female
child under conscious sedation.
Key Words: Early Childhood Caries; Caries; Conscious
sedation
Nanjunda Swamy K.V., Sumanth M. Shetty
MAnAgeMent of eArly childhood cAries under conscious sedAtion A
cAse report
Figure 1. Intraoral photograph showing Early childhood caries,
Figure 2. Placement of Pedo-strip crowns, Figure 3. Post treat-ment
photograph.
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analgesia, the anterior lesions were restored by Strip-Crown
method.7 A strip crown was used and the crowns were recon-structed
using composite resin (Figure 2).
Stainless steel preformed crowns were used successfully to
restore the primary firsocclusion was checked and after the removal
of, resto interferences. Final finishing and polish-ing of the
restoration was performed using soflex tips and a post-operative
photograph was taken (Figure 3). Immediate recall check up was
scheduled after one week followed by the second recall check up
after three months. Third month recall showed no new lesions and
the restorations were well main-tained. Another round of Topical
Fluoride therapy was given. Recall check up after every six months
was scheduled to track the maintenance status of oral hygiene and
diet.
DiscussionDiscusitThe premature loss or unsightly appearance of
grossly decayed primary anterior teeth (nursing bottle caries,
Early childhood caries) may physically handicap, embarrass and
psychologically traumatize a young child.8, 9 The untreat-ed
decayed teeth may cause pain and infection which results the damage
to the developing permanent tooth4 and feelings of personal
inadequacy.9 Treatment of these badly decayed teeth will prevent
pain and infection and assist the child to a better social and
emotional adjustment.10, 11 To perform treat-ment effectively and
efficiently while instilling a positive den-tal attitude, the
practitioner caring for a child with ECC often must employ advanced
behavior guidance technique. These may include protective
stabilization and/or sedation or gen-eral anesthesia. The success
of restorations may be influenced by the childs level of
cooperation during treatment. NO/O2 analgesia was the preferred
mode of sedation in this patient as it is effective, safe and easy
to administer.12
Nitrous oxide is effective to perform short and relatively
pain-less procedures, with few, light and transitory side
effects.12 Restorative treatment modalities for early childhood
caries are directly related to stage of advancement of lesions.
Type 1 lesions suffice with glass ionomer or composite restorations
while Comprehensive treatment strategies for Type 2 ECC also
include Pedo strip crowns, or acrylic and/or stainless steel
crowns. Type 3 lesions require either
pulpotomy/pulpectomy/extraction followed by crowns / space
maintainers / partial or complete dentures as indicated. The
placement of crowns provides a satisfactory means of restoring
anterior teeth.7, 8, 12 Acrylic jacket crowns offer excellent
aesthetics, are insoluble in oral fluids and resist surface
staining.13 However, the mate-rial wears away rapidly, is expensive
and the process requires long dental appointments.7
Composite resin (tooth colored filling material) can be
success-fully used for full coronal coverage to crown severely
damaged primary teeth.7, 14 These composite resin crowns [Pedo
strip crowns] look just like normal teeth wear well, prevent the
de-velopment of a tongue thrust and bad speech habits, prevent the
formation of fibrotic tissue with delayed permanent tooth eruption,
prevent loss of space and the child cannot loose or
fail to wear the crown.8 Composite resin can be polished to a
smooth luster thereby decreasing plaque accumulation. This cost
effective treatment option does not require long dental
appointments and lasts the life of the primary tooth and is thus
the treatment of choice when restoring decayed primary anterior
teeth.8 Ripa has reviewed that, restorative dentistry is expensive
and by itself is not a complete cure for ECC. When children with
maxillary anterior caries were compared with .increased risk of
caries in other primary teeth by, OSullivan,16 it was found that
these children are three times at greater risk of developing molar
caries than children without anterior car-ies. The initial
preventive therapy measures will help deter-mine the ultimate
success or failure of the case by correlating with the re-emergence
of decay if any.
ConclusionIn conclusion,the treatment of such extensive lesions
under conscious sedation offers a risk-free complete oral
rehabilita-tion in a short span of time, allowing immediate relief
of pain with only little / no cooperation from the child. However,
more importantly oral health, diet and acceptance of routine dental
care should be maintained and monitored to ensure complete success
of the treatment.
Authors Affiliations1. Nanjunda Swamy K.V. MDS, Professor and
Head, 2. Sumanth M. Shetty MDS, Associate Professor, Department of
Pedodon-tics, Sri Aurobindo Dental College, Indore, Madhyapradesh,
India.
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Address For correspondence
Dr. Nanjunda Swamy K.V. MDS,Professor and Head,
Department of Pedodontics,Sri Aurobindo Dental College,
Indore, Madhyapradesh, India.Email: [email protected]
Source of Support: NilConflict of Interest: None Declared
