Author |   Erin A. Kierce, RDH, MS, MPH

The Early Management of ECC

A twenty-month old girl, Alexandra, presents with her mother for her first dental visit. Alexandra’s medical history reveals a possible allergy to amoxicillin, but is negative for any other systemic conditions or complications, and she does not take any medications. Alexandra lives in a community with water fluoride levels of 0.2 ppm F. During the initial discussion with the dental hygienist, Alexandra’s mother states that Alexandra still gets fed a bottle of whole milk every night before bed and mostly drinks juice out of a sippy cup throughout the day. Her mother also states that Alexandra likes to snack multiple times during the day, asking for either crackers or yogurt.

Alexandra’s mother was referred by the family pediatrician who was concerned about a possible cavity on her front tooth, identified at her 18-month well-baby visit. Her mother states that her daughter’s pediatrician had first noticed something on her tooth at Alexandria’s twelve-month check-up, but was unable to find a dentist that accepted Medicaid.

Clinical Examination

  • 16 primary teeth are identified, with partially erupted mandibular right and left primary canines
  • All four primary second molars are unerupted
  •  Plaque biofilm accumulation is observed on the gingival margin of the primary molars and maxillary incisors
  • Marginal demineralization (white-spot lesions) identified on the maxillary right primary lateral and central incisors, and on the maxillary left primary central incisor
  • Cavitated lesion on maxillary left primary lateral incisor
  • No radiographs are indicated at this appointment due to patient’s age
Which of the following are high-risk clinical findings that increase Alexandra’s caries risk?
 
 

Explanation: High-risk clinical findings are the physical signs of either the presence of dental disease, (cavitated or non-cavitated carious lesions or restorations) or a past history of dental disease.  Dental plaque (biofilm) is considered a moderate risk factor because the quantity can be variable due to changes in oral hygiene efficacy. The practice of drinking sugar-sweetened juice on daily frequency is a behavioral risk factor, not a clinical indication of disease risk. The American Academy of Pediatric Dentistry (AAPD) guidelines for caries risk factors for children up to age 5 are:

AAPD Guideline for caries-risk assessment and management for infants, children and adolescents.  http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf. Accessed August 3, 2016.

According to research, which of Alexandra’s behavioral risk factors is the most significant for increasing her caries risk?
 
 

A child’s dietary practices become established by twelve months of age. Cariogenic feeding habits may significantly increase a child’s risk for developing early childhood caries (ECC). During Alexandra’s appointment, her mother revealed that Alexandra drinks juice out of a sippy cup, snacks on foods that contain free sugars frequently throughout the day, and still consumes a bottle of whole milk each night before bed. 

While frequent night-time bottle feeding with milk is associated with, but not consistently implicated in ECC development (milk sugar or lactose, is not readily metabolized by cariogenic bacteria), high frequency consumption of drinks and foods containing free sugars enables abundant acid production by cariogenic bacteria that are adherent to teeth.  This acid can demineralize tooth structure depending on the absolute pH decrease, as well as the length of time that the pH is below a ’critical pH‘ level of approximately 5.2 to 5.5.

Adequate anticipatory guidance and parental education relating to dietary counseling during preventive dental appointments is an essential component in oral disease prevention, especially among high-risk groups. Oral health providers must counsel parents and/or guardians on the increased risk of caries through the high frequency consumption of sugars by bottle feeding, sippy cup use, or between meal consumption of sugars.  Since juice drinks contain between 10-15% sugar, the American Academy of Pediatrics has recommended children one through six years of age consume no more than four to six ounces of juice per day, from a cup (i.e., not a bottle or sippy cup) and as part of a meal or snack.

American Academy of Pediatrics Committee on Nutrition. Policy statement: The use and misuse of fruit juices in pediatrics. Pediatrics 2001;107(5):1210-3. Reaffirmed October, 2006.

American Academy of Pediatric Dentistry. Guideline on perinatal and infant oral health care. Reference Manual 2016.

American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. http://www.aapd.org/media/Policies_Guidelines/P_ECCClassifications.pdf Accessed August 3, 2016.

Kranz S, Smiciklas-Wright H, Francis LA. Diet quality, added sugar, and dietary fiber intake in American pre-schoolers. Pediatr Dent 2006;28(2)16 -71.

Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Commun Dent Oral Epidem 1998;26(suppl):32-44.

Tinanoff N, Kanellis MJ, Vargas CM. Current understanding of the epidemiology mechanism, and prevention of dental caries in preschool children. Pediatr Dent 2002;24(6):543-51.

Tinanoff N, Palmer C. Dietary determinants of dental caries in preschool children and dietary recommendations for preschool children. J Pub Health Dent 2000;60(3):197-206.

During subsequent oral health appointments, which components would help to manage Alexandra’s oral disease, and could be incorporated into the anticipatory guidance and preventive education program presented to Alexandra’s mother?
 
 

Since Alexandra has one diagnosed cavitated lesion and multiple early, white-spot lesions, she is at high-risk for further disease progression and development. Therefore, it is imperative that certain preventive measures, including patient-specific dietary counseling and oral hygiene instructions, with a reinforcement of using fluoridated toothpaste and receiving professionally-applied fluoride varnish, are integrated into all dental appointments. 

As discussed in Question 2, providers should reinforce limiting the frequency of sugar-containing beverages and snacks.  Caries risk assessment should be performed at each appointment to identify changes in risk and protective factors.    

Fluoride exposure through brushing twice daily with the appropriate amount of fluoridated toothpaste is perhaps the most important preventive procedure.  Professionally-applied topical fluoride treatments also are efficacious in reducing the prevalence of ECC. The recommended treatment for children at risk for ECC who are younger than six years is 5% sodium fluoride varnish (NaFV; 22,500 ppm F), two to four times per year. Topical treatment with 38% silver diamine fluoride (SDF) also is gaining popularity in arresting dental caries in young children. Because it darkly stains carious lesions and white spot lesions, providers should inform parents of this associated esthetic effect.

Fluoride Protocol for Preschool Children

American Academy of Pediatric Dentistry. Guideline on perinatal and infant oral health care. http://www.aapd.org/media/Policies_Guidelines/G_Perinatal and infant oral health care.pdf.  Accessed Sept 15, 2016.

American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf. Accessed August 3, 2016.

American Academy of Pediatric Dentistry. Guideline on fluoride therapy. http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf.  Accessed August 3, 2016.

Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep 2001;50(RR-14):1-42.  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm Accessed January 28, 2016.

Weyant RJ, Tracy SL, Anselmo T, Beltrán-Aguilar EJ, et al. Topical fluoride for caries prevention: Executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc 2013:144(11):1279-91.

What are some important components of an ideal preventive education dialogue for facilitating oral hygiene behavioral change?
 
 

The goal of oral health education and anticipatory guidance is to improve oral health behaviors and reduce disease development. Motivational interviewing techniques (MI) have been successful in promoting behavioral change relating to behaviors such as smoking, drug addiction, diabetes management, and oral health. MI is a patient-centered approach that increases awareness, establishes goals, and promotes the patient’s own decisions about behavior change. 

MI facilitates behavioral change by helping patients/parents examine their ambivalence about change, and facilitates the motivation and confidence to implement oral health recommendations. The collaborative style of MI supports the autonomy and self-efficacy of the patient and emphasizes that the decision to change belongs to the patient and/or parent. Open-ended questions, affirmations, reflective listening, and summarizing (OARS) distinguish the patient-centered approach.

Examples:

Open-ended questions:What is your understanding of how sugary drinks affect teeth?”

Affirmations: “It seems that you will be successful in brushing your child’s teeth two times every day.”

Reflections: “It seems you will find it hard to not give your child juice in the sippy cup at bedtime when he/she is crying for it.”

Summaries: “So, you are not sure exactly how much juice your child is drinking per day, but you’ve decided that only giving him/her juice with one meal will help to ensure he/she is getting only the recommended amount.”

American Academy of Pediatric Dentistry Guideline on behavior guidance for the pediatric patient.  http://www.aapd.org/media/policies_guidelines/g_behavguide.pdf. Accessed Aug. 3, 2016

Bray, KK. Using brief motivational interviewing to sustain tooth brushing behavior change. Special supplement to Access, 2010. https://www.adha.org/sites/default/files/7821_Tooth_Brushing.pdf. Accessed August 5, 2016

In addition to recommendations for brushing twice daily with fluoridated toothpaste and more frequent fluoride varnish applications for this high risk patient, what else should be considered as part of this child’s fluoride therapy?
 
 

Concentrated fluoride toothpaste (0.5% F) is generally not recommended for children under age 6 because young children are likely to swallow rather than spit out toothpaste, possibly adding to the risk of fluorosis to the premolars, canines, and incisors.  Over- the- counter fluoride mouth rinses also are not recommended because of their inconsistent efficacy in clinical trials and again young children would likely swallow rather than spit. 

However, dietary fluoride supplements should be considered for all children at high caries risk who do not receive fluoride by consuming optimally fluoridated water (< 0.6 ppm). For patients whose water supply comes from a well, clinicians must encourage parents/caregivers to have their water supply analyzed first in order to determine the well’s naturally occurring fluoride levels. Some well water may have naturally occurring fluoride and taking supplements in addition to consuming the well water can increase the risk of developing fluorosis. State and local public health departments can aid parents/caregivers in the analysis of their well water.

*Provided that the child is at high caries risk

American Academy of Pediatric Dentistry. Policy on Use of Fluoride. http://www.aapd.org/media/Policies_Guidelines/P_FluorideUse.pdf. Accessed Aug. 3, 2016. American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy. http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf. Accessed Aug. 3, 2016.

Tinanoff N.  Use of Fluorides, in Early Childhood Oral Health, eds, Berg J and Slayton RA, Wiley-Blackwell, pp. 104-119, 2015.

What is the recommended amount and frequency of fluoridated dentifrice for children under 6 years old?
 
 

The AAPD recommends that all children should use fluoridated toothpaste twice daily, regardless of caries risk. For children age 3 and younger, no more than a “smear or rice-sized” amount should be used. For children between 3 and 6 years of age, a “pea-size” amount is indicated. Using more than the recommended application sizes depicted below can increase a child’s chances of developing fluorosis.

Children age 3 or younger: No more than a “smear” or “rice-size” amount, 2 times/day;

Children 3-6 years of age: No more than a “pea-size” amount, 2 times/day

American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy. http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf. Accessed Aug. 3, 2016.

Based upon Alexandra’s clinical photograph, which tooth/teeth appear to be in need of restorative care?
 
 

There is no definitively correct answer.  The decision on how, and if, to proceed with restorative therapy is dependent upon multiple considerations, including the child’s future caries risk and the interest of the parent to comply with preventive recommendations (i.e., consistent recalls with topical fluoride applications, consistent brushing with fluoridated toothpaste, and improving dietary habits). These factors will impact the probability of whether some of these carious lesions may or may not arrest. In this case, Alexandra is high risk and her mother is engaged, which suggests the possibility of “chronic disease management” or “active surveillance” to treat the caries with non-surgical approaches.  Permanent restorations or interim therapeutic restorations of the cavitated lesion also can be considered.  Interim therapeutic restorations (ITR) will temporarily restore teeth until a time when conventional restoration is probable. The utilization of ITR with glass ionomer or resin-modified glass ionomer cement has good success when applied to single surface or small two surface lesions. Silver diamine fluoride has been shown to arrest caries and can also be used to temporarily or permanently treat carious lesions in primary teeth.

Chronic disease management centers upon preventive measures of engaged and motivated parents and provides the potential to postpone or avoid definitive restorative care. Chronic disease management involves the dental providers helping parents reduce caries risk factors and modify daily protective behaviors (oral hygiene practices, dietary habits, fluoride use).

Active surveillance is a non-surgical approach in which the oral health providers carefully monitor the progression of incipient lesions through more frequent visits, fluoride varnish applications, and active parental engagement. The continual assessment of caries-risk, the identification of risk factors, and patient-centered preventive education recommendations, are integral components of active surveillance.

Example of “Active Surveillance”.

Radiographs 15 months apart showing that the dentist’s and parent’s active surveillance program eliminated the caries progression on proximal surfaces, especially noted on the maxillary second primary molar and first permanent molar.

15 months later

Caries Management Protocol for 1-2 Year-Olds

ECC: early childhood caries; DM: disease management; ITR: interim therapeutic restoration; SDF: silver diamine fluoride

∗Examples of disease indicators include demineralization, cavitated lesions, existing restorations, enamel defects, deep pits, and fissures.

*Only for children living in a non-fluoridated area and at high risk for dental caries

∗∗Examples of risk factors include patient/maternal/family history of decay, plaque biofilm on teeth, and frequent snacks of sugars/cooked starch/sugared beverages.

∗∗∗Examples of protective factors include fluoride exposure (topical and/or systemic).

†Brush with a smear of 1000ppm F toothpaste.

Active surveillance: Careful monitoring of caries progression and prevention program.

American Academy of Pediatric Dentistry. Guidelines on caries-risk assessment and management for infants, children, and adolescents.  http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf. Accessed Aug. 3, 2016.

American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Unique challenges and management options. http://www.aapd.org/media/Policies_Guidelines/P_ECCUniqueChallenges.pdf. Accessed Aug. 3, 2016.

American Academy of Pediatric Dentistry. Policy on interim therapeutic restorations (ITR). http://www.aapd.org/media/policies_guidelines/p_itr.pdf. Accessed, Aug. 3, 2016.

Arrow P, Klobas E. Minimum intervention dentistry approach to managing early childhood caries: a randomized control trial. Community Dent Oral Epidemiol, 2015;43:511-520.

Edelstein BL, Ng MW. Chronic disease management strategies of early childhood caries: Support from the medical and dental literature. Pediatric Dent 2015;37:281-287.

Frencken JE, Leal SC, Navarro MF. Twenty-five-year atraumatic restorative treatment (ART) approach: a comprehensive overview. Clinical Oral Investigations, 2012;16(5), 1337–1346.

Ng MW, Ramos-Gomez F, Lieberman M, et al. Disease Management of Early Childhood Caries: ECC Collaborative Project. International Journal of Dentistry. 2014;2014:327801. doi:10.1155/2014/327801.

What are the benefits to using silver diamine fluoride as an approach to managing dental disease?
 
 

Silver diamine fluoride (SDF) was recently cleared by the Food and Drug Administration for reducing tooth sensitivity. However clinical trials have also indicated that it has the ability to arrest and prevent dental caries. This off-label use of SDF is now permissible under U.S. law. Silver diamine fluoride (38% w/v Ag(NH3)2F, 30% w/w) is a topical agent comprised of 24.4-28.8% (w/v) silver and 5.0-5.9% fluoride. The indications for use of SDF are for caries arrest and treatment of dentin hypersensitivity.

Once SDF is applied to a carious tooth surface, a surface layer forms, increasing resistance to acid dissolution. Further, the treated lesion will experience an increase in mineral density and hardness while the depth of the original lesion decreases. SDF, like other heavy metals, is bactericidal, and since it remains in infected dentin, its effects are long-lasting. Studies have found that caries arrestment increased after re-application.

Chu CH, Lo ECM, Lin HC. Effectiveness of silver diamine fluoride and sodium fluoride varnish in arresting dentin caries in Chinese pre-school children. Journal of Dental Research. 2002;81(11):767–770.

Horst JA, Ellenikiotis H, UCSF Silver Caries Arrest Committee, Milgrom PM. UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications, and Consent. Journal of the California Dental Association. 2016;44(1):16-28.

Santos Dos VE, de Vasconcelos FMN, Ribeiro AG, Rosenblatt A. Paradigm shift in the effective treatment of caries in schoolchildren at risk. International Dental Journal. 2012;62(1):47–51.

Shah S, Bhaskar V, Venkataraghavan K, Choudhary P, Ganesh M, Trivedi K. Efficacy of silver diamine fluoride as an antibacterial as well as antiplaque agent compared to fluoride varnish and acidulated phosphate fluoride gel: an in vivo study. Indian J Dent Res. 2013;24(5):575–581.

Yee R, Holmgren C, Mulder J, Lama D, Walker D, van Palenstein Helderman W. Efficacy of silver diamine fluoride for arresting caries treatment. Journal of Dental Research. 2009;88(7):644–647.

Zhi QH, Lo ECM, Lin HC. Randomized clinical trial on effectiveness of silver diamine fluoride and glass ionomer in arresting dentine caries in preschool children. Journal of Dentistry. 2012;40(11):962–967.

Alexandra’s mother brought her daughter to the dentist after a recommendation made by the family pediatrician. What strategies would not occur in the medical setting during a well-baby visit?
 
 

Pediatricians and nurses have much more frequent access to new mothers and infants than dentists. According to the Medical Expenditure Survey, 89% of children under age one, had routine physician visits annually, while only 1.5% of these children had a dental visit.  Another study indicated that 99% of Medicaid-enrolled children had well-baby visits before age one, compared to only 2% who had a dental visit.  Therefore, it is important for medical professionals to be able to recognize and identify oral disease as well as incorporate oral health assessments into part of the medical preventive appointment. The understanding of dental disease and the associated risk factors will allow medical providers to reinforce health-promoting behaviors, apply fluoride varnish, and when necessary facilitate the establishment of the dental home.  However, performing actual procedures on teeth generally are best performed by the dental team of the established dental home.

American Academy of Pediatric Dentistry. Guideline on perinatal and infant oral health care. http://www.aapd.org/media/Policies_Guidelines/G_Perinataluqaveeuddbxzsaawfawrvyda and infant oral health care.pdf.  Accessed Sept 15, 2016.

American Academy of Pediatric Dentistry. Policy on the dental home. http://www.aapd.org/media/Policies_Guidelines/P_DentalHome.pdf. Accessed Aug. 5, 2016.

Chi DL, Momany ET, Jones MP, Kuthy RA, Askelson NM, Wehby GL, Damiano PC. Relationship between medical well baby visits and first dental examinations for young children in Medicaid. Am J Public Health. 2013 Feb;103(2):347-54.

Hale KJ, American Academy of Pediatrics Section on Pediatric Dentistry (2009). Oral health risk assessment timing and establishment of the dental home. Pediatrics, 111, 1113–1116.

Jackson EB. Outcomes of a Quality Improvement Project Examining Early Childhood Caries and Improving Identification of At Risk Patients in a Pediatric Medical Home Setting. J Ped Nursing, 2015;30: 543-549.

MEPS, Agency for Healthcare Research and Quality. Table 2.2. Percent of Children Age 2-17 with a Dental Visit in the Past Year: United States, 2010, Medical Expenditure Panel Survey of Household Component Data.

According to the American Academy of Pediatrics (AAP), at what age should medical providers first commence risk assessment for oral disease?
 
 

Due to the aggressive nature of ECC, the AAP recommends that the first oral health risk assessment performed by a medical professional should be at 6 months of age and continue at 9 months, 18 months, 24 months, 30 months, 3 years, and 6 years. The objective of caries risk assessment is to prevent the development of disease by identifying and decreasing contributory factors, such as cariogenic dietary habits, inadequate oral hygiene practices, and a lack of topical or systemic fluoride; as well as optimizing protective factors, specifically fluoride exposures, proper oral hygiene, and sealants.  Risk assessment also will allow medical providers to identify and refer children at caries risk to dental providers for timely care.

Oral Health Risk Assessment for Non-Dental Healthcare Providers**

**American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatr Dent 2015;37 (special issue):123-131.

American Academy of Pediatrics, Section on Pediatric Dentistry and Oral Health. A policy statement: Preventive intervention for pediatricians. Pediatrics 2008;122 (6):1387-94.

American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf. Accessed Aug 5, 2016.

Hale KJ, American Academy of Pediatrics Section on Pediatric Dentistry (2009). Oral health risk assessment timing and establishment of the dental home. Pediatrics, 111, 1113–1116.