early childhood caries

I

Just

Can’t

Smile

Without

You….

Interhospital Case PresentationApril 2, 2014

PERPETUAL SUCCOUR HOSPITAL

DEPARTMENT OF PEDIATRICS

Ma. Claire R. Granada, M.D.

Pediatric Resident

Objectives

• To present cases of children with dental caries

• To review dental anatomy and development

• To discuss early childhood caries as to its definition, epidemiology, etiology, diagnosis, prevention and its update

• To emphasize the role of the Pediatrician in the prevention, early diagnosis and management of early childhood caries

Objective # 1

• To present cases of children with dental caries

CASE 1 CASE 2

PROFILE L.T. 13 y.o. male

Cebu City

dental abscess

Ht: 140cm wt: 34.6kg

BMI: 17.6 kg/m2

Z score: -2

M.M. 5 y.o. Female

Cebu City

PSH-OPD palpable purpura

+ abdominal pain

Ht: 117 cm wt: 24 kg

BMI: 17.5 kg/m2

Z score: 1

PRENATAL Unremarkable Unremarkbale

NATAL Delivered Full term via

NSD

Delivered Full term via NSD

POSTNATAL Breastfed until 1 month oldBottle fed until 5 years old(+) carious teeth started at 3 years old

Bottle fed up to presentDaytime 3 bottlesBedtime 5 bottles2 y.o. (+) dental trauma sec to fall4y.o. (+) carious teeth; (+) recurrent dental abscess over central incisors

HEREDOFAMILIAL DISEASE

None HypertensionDiabetes MellitusBronchial Asthma

MANIFESTATIONS 6 months PTA (+) recurrent

toothache tolerated

1 day PTA (+) toothache PS 7/10

(Right premolar)

Afternoon (+) toothache; (+)

fever; (+) swelling of Right

submandibular area

PE:

(+) swelling on right submandibular

area, (+) carious teeth at the right

and left premolar teeth, (+) abscess

on right premolar area

1 day PTC (+) palpable

purpura on both lower

extrimities

AM PTC (+) abdominal pain

PSH OPD:

(+) palpable purpura on lower

ext

(+) epigastric tenderness

(+) carious teeth on upper

incisors, 1st & 2nd molar

DIAGNOSTICS CBC

Hgb - 16.4 Hct - 50.2 Platelet – 244

WBC 10.27 (Neutro - 81, Lympho - 10,

Mono - 8, Eos – 1)

CBC & UA requested

CASE 1 CASE 2

MANAGEMENT Mefenamic acid 500mg/tab;

1 tab q6H PO

Co-amoxiclav 1 gram/ tab;

1 tab BID PO

Discharged on the 3rd hospital

day

Opted to visit her Pediatrician

Advised for dental evaluation

FINAL DIAGNOSIS Dental Abscess, Right

Submandibular area

T/C Henoch-schonlein Purpura

Early Childhood Caries

Case # 2

Objective # 2

•To review dental anatomy and development

Anatomy of the tooth

Teeth There are 4 kinds of teeth:

1. Incisors

2. Canines

3. Premolars

4. Molars

Anatomy of a Tooth

The tooth consists of a crown and a root.

The crown is visible above the gums.

The root is covered with cementum, which anchors it to the periodontal membrane.

Used with permission from Miller Medical Illustration & Design

•The enamel protects the dentin, a hard, thick substance containing thousands of tubules that surround the nerve.

•These tubules contain tiny projections of the nerve and are sensitive to exposure to air, acid, and touch.

•The pulp is the soft core of the tooth that contains blood vessels, connective tissue, and the nerve itself.

Dental Development

Normal Development • Oral structures begin to form during the third and fourth weeks of embryonic development.

• The teeth begin to develop around the sixthweek of fetal life

• Development continues throughout fetal life and beyond.

Tooth Eruption: Primary Teeth

Primary teeth begin to erupt around 6 months of age.

Eruption is completed by 24 to 36 months.

Delays of more than 12 months merit further dental evaluation.

http://www.aap.org/oralhealth/pact

Delayed Eruption

Delayed eruption of more than 12 months can be caused by:

• Endocrine disorders

• Genetic disorders

• Oral space issues

• Dense gingival tissue

• Dental infection

• Radiation therapy

It is reasonable to refer a child who has not erupted a tooth by 18 months of age

to a dentist if they are not seeing one already.

Tooth Eruption: Primary Teeth

Tooth Eruption: Permanent Teeth

Eruption for the permanent teeth is similar to that of the primary teeth.

Eruption of the permanent teeth begins between 5 and 7 years of age and usually finishes by 13 to 14 years.


Tooth Eruption: Permanent Teeth

•The typical pattern for the eruption of permanent teeth is:

Central incisors

Lateral incisors

First molars

Premolars

Canines

Second molars

Third molars (wisdom teeth)


Natal and Neonatal Teeth

• Extraction of these incisors may be

considered if they are mobile,

interfere with breastfeeding, or lead

to Riga-Fede ulceration.

Objective # 3

• To discuss early childhood caries as to its definition, epidemiology, etiology, diagnosis, prevention and its update


ECC is a transmissible infectious process that affects children younger than 5 years and results in tooth destruction.

ECC is a virulent form of caries that rapidly spreads within the mouth.

S-ECC (Severe Early Childhood Caries)

< 3 y.o. any sign of smooth caries

3 – 5 y.o. 1 or more cavitated, missing, or filled smooth surfaces in primary maxillary anterior teeth, or a decayed, missing or filled score of ≥ 4 (age 3), ≥ 5 (age 4), ≥ 6 (age 5) surfaces

PPS Policy Statements Series 2004 Vol2 No.2


United States 24.7%

58.6 % of all 5 to 17 years old

poor and minority children 70%

Philippines

ECC is at least 1 in 4 (25%) of 5 to 6 years old children

2nd in the whole Western Pacific Region


PHILIPPINE DENTAL ASSOCIATION

< 12 y.o = 78%< 6 y.o = 97%

Affected Teeth

•ECC tends to affect the upper (maxillary) incisors first

•The primary molars are affected next

because of their grooved surfaces.

•Food easily becomes lodged in the

molar’s pits and fissures, which are

difficult areas to clean with

a toothbrush.

• The canines tend to be spared

because they are smooth

teeth that erupt later.

• The lower teeth are better

protected by saliva and the tongue.


Diagnosis and Stages

1. Plaque

2. Incipient lesions or white spots

3. Enamel caries

4. Dentine caries

5. Pulpitis

Factors in Development of ECC

1. Microbial factors

2. Salivary factors

3. Dietary factors

AAP Textbook of Pediatric CareChapter 33: Prevention of Dental Caries



2. Salivary factors

3. Dietary factors• S. mutans (30%)

• S. sobrinus

• Actinomyces sp.

• Lactobacillus sp.AAP Textbook of Pediatric CareChapter 33: Prevention of Dental Caries


S Mutans

• S mutans is transmitted from the primary

caregiver to infant by saliva.

• Transmission rates increase when parents:

Share utensils or toothbrushes.

Taste food or drink before serving it.

“Clean” a dropped pacifier with saliva.

Allow a child to place fingers into

an adult's mouth.



2. Salivary factors

3. Dietary factors

saliva buffers acid

saliva is bacteriostatic

saliva aids in remineralizing the

teeth by supplying calcium,

phosphate, and fluoride to help

construct enamel.AAP Textbook of Pediatric CareChapter 33: Prevention of Dental Caries



2. Salivary factors

3. Dietary factors


Consequences of Untreated ECC

Hakan et al; J Nat Sci Biol Med. 2013 Jan-Jun; 4(1): 29–38.


Prevention

1. FLUORIDE

• Water Fluoridation

• Fluoride Supplements

• Fluoride Dentifrice (Toothpaste)

• Fluoride Rinses

• Fluoride Varnish


1. FLUORIDE



• Fluoride Dentifrice

• Fluoride Rinses


Recommended level

0.7 to 1.2 ppm fluoride


MCWD

< 1ppm fluoride

Ocean water 1.2 ppm fluoride

Well water 0-7.22 ppm fluoride

1. FLUORIDE




• Fluoride Rinses




1. FLUORIDE




• Fluoride Rinses



AAPD Guideline on Fluoride Therapy; revised 2013

1. FLUORIDE




• Fluoride Rinses



1. FLUORIDE




• Fluoride Rinses



WHO recommends varnish

applications for all children

2 – 4 x a year


Fluoride Varnish

Application frequency for fluoride varnish

ranges from 2 to 6 times per year.

The use of fluoride varnish leads to a 33%

reduction in decayed, missing, and filled tooth surfaces in the primary

teeth and a 46% reduction in the permanent teeth.

Application of Fluoride Varnish

2. ORAL HYGIENE

daily brushing and flossing of teeth

Parents should verify that the child’s teeth are clean before bedtime

because the buffering capacity and antimicrobial action of saliva

decreases during sleep with diminished secretion of saliva.


3. SEALANTS

effective in preventing pit and fissures caries


Summary of evidence-based clinical recommendations regarding pit-and-fissure sealants.

JADA, Vol. 139 http://jada.ada.org March 2008

4. Diet

↓ frequency of cariogenic substrate ingestion

use of gum, candy, and soft drinks containing sugar substitutes

(mannitol, sorbitol, xylitol and aspartame)

infants should be weaned from the bottle by 1 year of age to

eliminate their risk for ECC

bedtime and naptime nursing bottles should contain only water


Jeff Burges et al., Diet and Oral Health; Medscape article, updated: May 4, 2012

Dietary Factors Causing Dental Caries


Food with Anticaries Activity

• green tea

• Apple

• Red grape seeds

• Red wine

• Nutmeg

• Ajowan craway

• Coffee

• barley coffee

• chicory

• mushroom

• cranberry

• Glycyrrhiza root

• ethanolic ectract of Myrtuscommunis

• garlic aqueous extract

• cocoa extracts

• propolis


Caries Prevention: Three Materials Found Equivalent

1. Silver diamine fluoride

2. Resin-modified glass ionomer

3. Resin-based sealant

Laird Harrison, Caries Prevention: Three Materials Found Equivalent; Medscape article, March 22, 2013

Risk assessment tools

aid in the identification of reliable predictors and allow

dental practitioners, physicians, and other nondental health

care providers to become more actively involved in in

identifying and referring high-risk children.

Clinical management protocols

• assist in clinical decision-making

• provide criteria regarding diagnosis and treatment

• recommended courses of action

Treatment

low risk may not need any restorative therapy

moderate risk may require restoration of progressing and cavitated lesions, while white spot and enamel proximal lesions should be treated by preventive techniques and monitored for progression

high risk require earlier restorative intervention of enamel proximal lesions, as well as intervention of progressing and cavitatedlesions


CPG;management of S-ECC;2nd ed,2012

CPG;management of S-ECC;2nd ed,2012

Treatment

Silver amalgam

Plastic composite

Stainless steel crowns

Pulpotomy

Pulpectomy

Tooth extraction

Penicillin

Clindamycin

Erythromycin

Ibuprofen

Nelson textbook of PEDIATRICS 19th ed; ch 304 p 1255

Objective # 4

•To emphasize the role of the Pediatrician in the prevention, early diagnosis and management of early childhood caries

Role of the Pediatrician

Pediatricians should routinely question parents about feeding behaviors

and make recommendations that promote dental health

Examination of the dentition should be performed on every child as a

part of a routine physical examination

Any child with evidence of cavitation, stained fissures, or areas of

enamel decalcification should be referred to a dentist immediately

Every child should be evaluated by a dentist by 12 months of age

AAPD Guideline on Fluoride Therapy; revised 2013


today I am wearing the smile that you left me with…

Interhospital Case PresentationApril 2, 2014

Discussant: Ma. Claire R. Granada, M.D.

Pediatric Resident





“I just Can’t smile without you…”

Interhospital Case Presentation

Ma. Claire R. Granada, M.D.

Pediatric Resident

Health & Medicine

early childhood caries