Preventing Early Childhood Caries
Early childhood caries (ECC) is the presence of one or more decayed, missing, or filled (dmf) surfaces in any primary tooth of a child up to age 6.
Early childhood caries (ECC) is the presence of one or more decayed, missing, or filled (dmf) surfaces in any primary tooth of a child up to age 6. ECC continues to be the most common chronic disease in children, occurring five times to eight times more frequently than asthma. ECC is a multifactorial disease with etiological factors being enamel hypoplasia, elevated levels of cariogenic bacteria, and the metabolism of fermentable carbohydrates, which produce acid to demineralize teeth. Furthermore, statistics reveal that socioeconomic status is the prevalent factor regarding ECC. While race, culture, ethnicity, lifestyle, diet, and oral hygiene practices play a significant role, socioeconomic status outweighs all these factors.
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Strategies continue to evolve to combat this invasive disease. Primarily, the dental hygienist is the key player in prevention. Use of motivational interviewing (MI) and collaboration with other health care providers can create a patient-centered approach to treatment. Other strategies, such as fluoride therapy, including silver diamine fluoride; proper self-care; nutritional evaluation; risk assessment; reduction of MS; and restorative interventions, if necessary; are all part of an effective ECC prevention program.
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Dental hygienists are educators at the core. In addition to preventive strategies, teaching methodologies need to be refined to produce behavioral modifications. MI is one such methodology. Colvara et al assessed the effectiveness of MI in prevention of ECC. Results showed MI was more effective in reducing ECC than conventional oral health education. MI is based on the premise that individuals make behavioral changes on their own by taking responsibility for those changes.
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The principal approaches to prevent or reduce ECC in high-risk children include altering dietary patterns and implementing fluoride protocols. Nutritional counseling aims to help parents change their children’s dietary behaviors to favor low or noncariogenic snacks, increase use of community fluoridated water, and limit sweet foods to mealtimes. Such recommendations must be realistic and based on the dietary behaviors of the family. Evidence shows that nutritional counseling can be effective for families at high caries risk. Two landmark studies show that nutritional counseling and reinforcement resulted in reduced caries incidence. Use of water instead of juices, especially in bottles or sippy cups, and avoiding frequent consumption of fermentable carbohydrates should be encouraged. Limiting on-demand breastfeeding after the eruption of the first tooth and after dietary carbohydrates are introduced, and weaning from bottle use after 12 months are recommended.
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First Line of Defense
Fluoride is the first line of defense in the prevention of ECC. The US Food and Drug Administration recognizes fluoride as the only compound that prevents dental caries. In the US, community fluoridated water, toothpastes, and mouthrinses are the primary sources of fluoride. Other sources include office gels, varnishes, and silver diamine fluoride (SDF).
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Twice-a-day toothbrushing is essential in controlling ECC, and guidelines for toothpaste use have been updated. Previously, fluoride toothpaste was not recommended for infants. However, in 2014, the recommendation changed to twice-daily brushing with fluoride toothpaste for all children in optimally-fluoridated and fluoride-deficient communities. Risk vs benefit is the key issue in preventing dental disease over mild fluorosis occurrences. The AAPD recommendation is now a smear or rice-sized amount for children younger than age 3 (0.1 mg fluoride) and a pea-sized amount for children ages 3 to 6 (0.25 mg fluoride) (Figure 6). For children at high risk of caries, prescription home-fluoride use should be recommended. Fluoride concentrations from 900 ppm to 5,000 ppm are suggested.