Preventing Early Childhood Caries

Dental caries, while preventable, is a chronic condition that continues to globally impact young children. Early childhood caries (ECC) is present when one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces appears in a deciduous tooth among children ages 6 and younger.¹ Similarly, severe early childhood caries (S-ECC) is the development of smooth-surface caries lesions before age 3.¹

While several preventive measures, such as national policies, school-based programs, and expanded eligibility for public health insurance, have been implemented in the United States, not all children have benefitted at the same rate. For example, disparities exist among certain races, ethnicities, and income groups.

National data from 2011-2016 show that 23% of children ages 2 to 5 had dental caries in primary teeth. Among the same age group, 10% had untreated dental caries in primary teeth.² Further, Mexican-American children had a higher percentage of dental caries and untreated dental caries (33%, 15%) than Black, non-Hispanic (28%, 15%) and white, non-Hispanic children (18%, 7%), respectively.

In terms of income, children from households < 100% federal poverty level (FPL) had a higher percentage of dental caries (34%) than those from higher FPLs 100% to 199% (24%) and > 200% (16%).² The same pattern persisted for untreated dental caries, with children from lower income households reporting a higher percentage than children from higher income households.² While disparities and inequities in childhood dental caries exist among certain demographic groups, the dental caries process and its transmission are complex.

Causes and Risk Factors

The Keyes model explains three main intersecting factors related to dental caries: the host (saliva and teeth), microflora (bacteria), and substrate (diet).^3,4 It also recognizes confounding factors such as time, plaque, fluoride, sociodemographic characteristics, behaviors, knowledge, and attitudes.⁵

The Fisher-Owen et al conceptual model of children’s oral health incorporates the original Keyes factors while including the level of influences (eg, child, family, community influences) and five domains (eg, genetics and biology, social environment, physical environment, health-influencing behaviors, and medical and dental care).⁶

The microflora is established during the developmental stages and infants are susceptible to Streptococcus mutans from their mother via vertical transmission.⁷ As the child enters the late infant to toddler stages, feeding practices and the introduction of foods and snacks are additional risk factors for parents and caregivers to consider. For example, research has shown that sleep feedings and the frequency of feedings including, human milk beyond age 12 months, may increase the child’s risk for dental caries.⁸

Frequent exposure to foods and beverages high in added sugars also increases the risk of dental caries.⁹ Feeding practices before age 2 are critical to reducing the risk of ECC or S-ECC. For example, frequent bottle feedings of sugary beverages during meals or while sleeping increase the risk of dental caries and most often impact the anterior teeth among children ages 1 to 2.¹⁰

As the child ages and tooth eruption occurs, additional primary teeth are susceptible to dental caries. Further, around ages 3 to 4, the maxillary central incisors and mandibular second molars may be susceptible. At age 5, the maxillary central incisors, maxillary second molars, and mandibular first and second molars are at risk. These causes and risk factors should be explained to mothers and caregivers during the perinatal and post-natal periods, in addition to well-child visits.

Transmission and Familial Factors

Dental caries transmission occurs through two primary modes in young children. The most common transmission during infancy and toddler stages are vertical and horizontal. Vertical transmission is the exchange of saliva between the mother/caregiver and the child.⁷ Horizontal transmission may occur among groups such as family members or peers. Other modes of transmission may be through utensil sharing, testing food, cleaning of pacifiers, and sharing oral hygiene aids.⁷

Parents and caregivers play an important role in the transmission of early childhood dental caries. Familial factors, such as education level and socioeconomic status, oral health literacy, and oral health behaviors of caregivers, impact the risk of dental caries among children.^11–13

Caregivers with low oral health literacy were found to be less likely to maintain good oral health behaviors for the child.¹¹ A combination of low oral health literacy and lack of resources can increase the risk of dental caries among children.^13,14 Caregivers are primarily responsible for the dietary and oral hygiene behaviors of their children. Parental oral health behaviors, such as frequency of brushing, time spent brushing, and frequency of dental visits, contribute to the child’s risk for dental caries.¹³

Children are more likely to experience dental caries if their parent/caregiver has a high caries experience.¹³ Parents/caregivers who do not engage in caries-prevention behaviors, such as healthy oral health practices or routinely visiting the dental office, may increase their children’s caries risk.

Prevention During Perinatal Period Through Early Childhood

Prevention of dental caries among children begins during the perinatal period. The World Health Organization Expert Consultation on Public Health Intervention Against Early Childhood Caries recommends that the most appropriate time to prevent ECC is pregnancy through the child’s first 2 years.¹⁰ Mothers must be educated about the importance of continued dental care both during pregnancy and after birth. Further, providers should promote continued dental care during the perinatal period and stay up-to-date with the national guidelines and policies.¹¹

Preventive dental care is safe and encouraged during the perinatal and post-natal periods. Data from the 2016-2020 Pregnancy Risk Assessment Monitoring System showed that in 2020, 40% of pregnant women had a prophylaxis by a dentist or dental hygienist.¹² Preventive oral health behaviors should start during pregnancy and continue with the child after birth. Parents and caregivers need to be provided with educational materials related to good oral health and caries prevention.¹³

When the child’s first tooth erupts or the first birthday occurs, a dental visit and dental home should be established. The American Academy of Pediatric Dentistry recommends parents and caregivers establish a dental home for the child by the age of 12 months.¹⁴

Preventive dental visits with oral health professionals aid in providing age-appropriate anticipatory guidance for parents/caregivers. These recommendations include assisting the child with oral hygiene behaviors until age 10, role modeling oral behaviors, and promoting healthy dietary behaviors.¹⁴ Moreover, an assessment of the child’s and parent’s/caregiver’s dental caries risk should be conducted to determine the need for at-home fluoride or professional treatment. The preventive dental visits and anticipatory guidance should continue throughout the child’s development.

Treatment Options for Dental Caries

Even with prevention strategies, children may develop caries. Therefore, the conversation of secondary (eg, early detection, fluoride varnish, sealants) and minimally invasive tertiary prevention (eg, atraumatic restorative treatment [ART]) should occur with the parent/caregiver.¹⁰ ART is restorative treatment completed without the use of electric drills and local anesthesia.¹⁵ Many of the nonrestorative dental treatment options for dental caries can be performed by a dental hygienist depending on the state’s dental practice act.

The most common nonrestorative treatment options are dental sealants and 5% NaF varnish. The American Dental Association (ADA) recommends the use of dental sealants plus the application of 5% NaF varnish every 3 to 6 months to arrest or reverse noncavitated carious lesions on the occlusal surfaces of primary and permanent teeth.¹⁶ For noncavitated lesions on facial and/or lingual surfaces, the application of 1.23% APF or 5% NaF varnish every 3 to 6 months is recommended.¹⁶ Early detection of carious lesions in children can prevent the need for restorative treatment.

Growing research supports the efficacy of silver diamine fluoride (SDF) as an additional nonrestorative treatment option for dental caries in children.^16–18 The silver in SDF has antibacterial effects that target the cariogenic bacteria, while the fluoride provides remineralizing effects to arrest and sometimes reverse the caries process (Figure 1, page 33).¹⁸

SDF should be considered, especially for children and those with special healthcare needs, because the application process is not as invasive as traditional restorative treatments. The ADA recommends the use of 38% SDF twice a year to arrest advanced cavitated lesions on the coronal surfaces of primary and permanent teeth.¹⁶

No acute adverse side effects have been noted; however, the silver byproducts in SDF stain dental tissues black, impacting the esthetic appearance.¹⁸ Clinicians must be cautious when applying SDF to ensure staining does not occur on the skin and gingival tissues. Note that regulations on dental hygienists applying SDF vary by state.¹⁹

Role of Oral Health and Medical Professionals

The child’s risk for developing dental caries must be determined to implement patient-centered preventive strategies. One tool commonly used to assess dental caries risk is caries management by risk assessment (CAMBRA). It analyzes an individual’s risk for dental caries based on disease indicators, biological and pathological risk factors, and protective factors.²⁰ The balance of these factors determines if the individual is at a low, moderate, high, or extreme risk for dental caries.

CAMBRA should be used on all new patients to determine initial caries risk. Subsequent assessments can be conducted at recare visits based on the clinician’s judgment and patient considerations. Multiple studies have been conducted on the validity of CAMBRA and found it to be a valid tool to determine future caries experience at follow up visits.²⁰

The efforts of oral health professionals alone are not sufficient to decrease the prevalence of dental caries among young children. An interprofessional approach is needed among all professionals and stakeholders who provide care or services for women, families, and children.

The US Department of Health and Human Services developed core clinical competencies for primary care clinicians to integrate oral health into primary care practice, one of which is the importance of interprofessional collaborative practice.²¹ Oral health professionals are encouraged to build relationships and increase communication with medical providers, especially pediatricians, obstetricians, and school nurses.

Pediatricians and obstetricians also need to collaborate with oral healthcare professionals to prevent ECC and S-ECC.²² Pediatricians and primary care providers see pediatric patients for well-child visits more frequently and sooner than oral healthcare professionals, making them ideal collaborators to address ECC.

These medical professionals can apply fluoride varnish and prescribe dietary fluoride supplements if indicated.²² Therefore, collaboration with oral health professionals is essential to enhance pediatricians’ and primary care providers’ comfort with implementing these services into their daily practice.

Obstetricians also play an important role in providing oral health education to expectant mothers about the importance of their oral health, as well as the oral health of their children. These collaborations are important to ensuring mothers, caregivers, and family members are aware of the contributing factors to dental caries to minimize risk.

Conclusion

Childhood dental caries is a complex process that requires education and prevention during the perinatal period and throughout the child’s lifetime. Interprofessional collaboration among oral healthcare and medical professionals is essential to increasing awareness of early childhood caries among caregivers and families.

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References

1. American Academy of Pediatric Dentistry. Definition of early childhood caries (ECC). Available at: aapd.org/assets/1/7/d_ecc.pdf. Accessed August 22, 2023.
2. United States Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. Available at: nidcr.nih.gov/research/data-statistics/dental-caries/children. Accessed August 22, 2023.
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From Dimensions in Dental Hygiene. September 2023; 21(8):32-35.