DESCRIPTION

Dental caries is the process of tooth structure demineralization, ultimately leading to cavitation (cavities). Over time, bacterial metabolism of carbohydrates produces acid, leading to tooth demineralization. The presence of one or more decayed, missing, or filled primary tooth surfaces in children <6 years old constitutes “early childhood caries” (ECC).

EPIDEMIOLOGY

• Dental caries is one of the most common chronic diseases of childhood.
• About 1 in 4 preschool children have experienced caries in their primary teeth, and at least 1 in 6 children aged 6 to 11 years have experienced dental caries in their permanent teeth.
• 1 in 10 preschool children and 1 in 5 children aged 6 to 11 years have some form of tooth decay that requires treatment. Globally, 9% of children have untreated dental caries in their primary teeth. This represents the 10th most prevalent health-related condition worldwide.
• Children living in higher income households have seen significant decreases in caries experience, whereas those living in poverty have not (22–13% vs. 28–24%).
• Among preschool-age children, the prevalence of dental caries increased from about 24% to 28% between 1988−1994 and 1999−2004 but returned to 24% in 2011−2014.
• ECC may lead to increased emergency room visits and admissions, higher treatment costs, loss of school days, delayed growth and development, and diminished ability to learn.

RISK FACTORS

• Dental caries is multifactorial.
  • Factors increasing duration of sugar on teeth: frequent consumption of sugars (including prolonged bottlefeeding), sugary beverages, sticky sugars, medications sweetened with sucrose, inconsistent brushing/flossing after meals, pouching of food, tightly spaced teeth that are difficult to clean
  • Factors leading to dry mouth (less saliva, less acid buffering): mouth breathing, albuterol inhalers, psychiatric medications
  • Factors leading to weaker tooth enamel: lack of systemic fluoride (community water fluoridation) or topical fluoride, developmental enamel defects
  • Epidemiologic factors: low socioeconomic status, previous caries experience
  • Microbial risk markers: mutans streptococci (MS) and Lactobacillus species
• Health-related risk factors
  • Developmental delay—oral hygiene difficult
  • Cerebral palsy—crowded dentition, difficult to brush
  • Conditions requiring frequent, high-nutrient oral feedings (PediaSure^®)
  • Conditions treated with medications that dry the mouth—psychiatric conditions

GENERAL PREVENTION

• Parental education and counseling on the importance of a healthy microbiome and diet in infancy should be conducted as early as possible. This includes discontinuing baby bottle and breastfeeding beyond 12 months.
• Children should have their first dental visit 6 months after the eruption of their first tooth, or around 1 year of age. This first visit establishes the dental home, assesses for dental caries risk factors, and allows for appropriate anticipatory guidance to the parent with the goal of preventing ECC.
• Dental caries essentially results from sugar exposure over time.
  • Prevention of dental caries should focus on eliminating or minimizing frequency of juice/sugary beverages/snacks, and brushing (with fluoridated toothpaste) and flossing after as many meals/medication administrations as possible.
  • A smear of fluoridated toothpaste should be used for children <3 years of age.
  • A pea-sized amount of fluoridated toothpaste for children aged 3 to 6 years.
• Periodic preventive visits (at least every 6 months) are essential throughout childhood as the dentition and habits develop.
• Fluoride varnish can be used to help prevent or slow down tooth decay. A primary care provider can apply varnish to children (with teeth) as young as 6 months of age at well-child visits.
  • Varnish is applied on the top and sides of each tooth.
  • Children can have varnish applied 2 to 4 times per year until they are 5 years old.
• Fluoride supplements (dosages below based on fluoride ion) are also recommended for children who live in communities with fluoride-deficient (<0.6 ppm F) water.
  • Infants <6 months of age should not receive fluoride supplementation.
  • For communities with <0.3 ppm F, the recommended fluoride supplement for children
    • 6 months to 3 years: 0.25 mg/24 h
    • 3 to 6 years: 0.5 mg/24 h
    • 6 to 16 years: 1 mg/24 h
  • For communities with 0.3 to 0.6 ppm F, the recommended fluoride supplement for children
    • 6 months to 3 years: zero
    • 3 to 6 years: 0.25 mg/24 h
    • 6 to 16 years: 0.5 mg/24 h
  • For communities with >0.6 ppm F, the recommended fluoride supplement for children
    • 6 months to 3 years: zero
    • 3 to 6 years: zero
    • 6 to 16 years: zero
• Supplemental fluoride is available as liquid drops, chewable tablets, or lozenges.
• The Centers for Disease Control and Prevention (CDC) provide a web-based resource for clinicians to determine if a community has fluoride deficient water. See: https://nccd.cdc.gov/doh_mwf/default/default.aspx

PATHOPHYSIOLOGY

Dental caries develops when oral bacteria, primarily MS, ferment carbohydrates into organic acids, over time demineralizing tooth enamel. Continuous demineralization of tooth enamel leads to enamel cavitation.