RAMPANT

CARIES AND
EARLY
CHILDHOOD
CARIES
 Rampant Caries

Defined as suddenly appearing widespread,

rapidly spreading, burrowing type of caries,
resulting in early involvement of pulp and
affecting those teeth which are usually
regarded as immune to decay.
Winter 1966

Massler 1945

Caries of acute onset involving many

or all the teeth in areas that are not
usually susceptible.
 Clinical features
• Related to the order of tooth eruption
• Initial lesion – labial surface of upper incisors
close to gingival margin as a whitish area of
decalcification or pitting of enamel surface soon
after eruption
• Become pigmented to light yellow or brown
• Extend laterally to proximal areas, down to incisal
edge
• At times begin on palatal / incisal area
• Advanced stage – entire circumference of the
tooth → pathological fracture of tooth
Early Childhood Caries (ECC)
Terms formerly used for ECC are
Sequence of events in causation of ECC
Stages of ECC
Second stage/Damaged (carious): occurs when the
child is between the ages of 18 and 24 months.

Continuity of enamel is broken. The dentin is exposed

and appears soft and yellow to brown.

The maxillary primary molars present initial lesions in

the cervical, proximal and occlusal regions.

At this stage, the child begins to complain of great

sensitivity to cold. The parents sometimes notice the
change of color on their own and become concerned.
Deep Lesion/stage 3

• Lesions in maxillary anterior teeth are large. (24 - 36

months or earlier too)
• The primary molars are all affected.
• Complaints of pain during tooth brushing or eating,
especially while biting are frequent.
• Incidentally, pulp problems in the maxillary incisors can
occur (spontaneous pain during the night; and pain
after hot or cold drinks, lasting for several minutes)
• Abscess may be seen
• In this stage the diagnosis could be made easily, even
without actually seeing the child’s teeth
Traumatic stage

• 36-48 months
• Neglecting all the previous symptoms, the teeth
(starting with maxillary incisors) can become so
weakened by caries that relatively small forces
suffice to fracture them.
• Destruction of crown: Root stumps seen
clinically.
• The maxillary incisors already have become non
vital in most of the cases.
Early childhood Types of dental caries in young children:-
caries can be
classified as: • Type I – mild to moderate, isolated lesions on
(Wayne H) • upper molars and incisors

• Type II – moderate to severe, any teeth other

than lower incisors

• Type III – severe, all teeth

Type I ECC (Mild to moderate)

• Carious lesion involving the molars and incisors

• Seen between 2-5yrs of age
• Cause is usually a combination of cariogenic semisolid or solid food and lack
of oral hygiene
• Number of affected teeth usually increases as the cariogenic challenge
persists.
Type II ECC (Moderate to severe)

• Labiolingual carious lesion affecting the maxillary incisors with or

without molar caries depending on the age.
• Seen soon after the 1st tooth erupts.
• Unaffected mandibular incisors.
• Cause is usually inappropriate use of feeding or combination of both
poor oral hygiene.
• Unless controlled may proceed to an advanced stage.
Type III ECC (severe)

• Carious lesion involves almost all the teeth including mandibular

incisors.
• Usually seen in 3-5 years of age (dmfs >= 4 for 3yrs,>= 5 for 4ys or >=6
for 5yrs)
• Cause is a combination of factors and poor oral hygiene.
• Rampant in nature and involves immune tooth surface.
 • Pain and infection

• Sleeping and eating difficulties

• Poor nutrition and growth delay

Implication or
consequences of • Risk for permanent dentition getting involved

ECC • Other health problems (oral health impact on

general health)

• Speech defect

• Habit development
 Absence from school

Hospitalization and emergency

managements

Implication or Altered behavior

consequences of
ECC Distraction from normal activities

Psychological problems including poor

self esteem

Financial burden
 Difference between ECC and Rampant Caries
ECC Rampant Caries
Specific form of rampant caries Acute, widespread caries with early pulpal involvement of
teeth, which are usually immune to decay
Age of Occurrence Infant and toddlers All ages, including adolescence
Dentition involved Primary dentition Primary and permanent dentition
Characteristic Maxillary incisors followed by molars. Surfaces considered immune to decay are involved. Thus,
feature Mandibular incisors are not affected mandibular incisors are involved.
Rapid progression of new lesion.
Etiology Bottle feeding before sleep More multifactorial
Pacifies dipped in honey/ other Frequent snacking, excessive sticky refined carbohydrate
sweeteners intake
Prolonged at will breastfeeding Decreased salivary flow
Genetic background
Treatment Initial lesions – Topical fluoride Multiple pulp exposure will require pulp therapy
application and education Long term treatment required when permanent dentition
Maintenance till transition occurs involved
Prevention Parents education Dental health education at a mass level involving people
of all ages
Etiology
Etiology

1) Pathogenic microorganism
₋ Most common – S. mutans.
₋ Not detectable till first tooth
erupts.
₋ Presence indicates primary
infection.
• Main source – mother.
• S.mutans – 60% of all cultivable
flora. In caries free children, it is less
than 1% of flora.
• Colonizes tooth fast, more acid
production, produce more
extracellular polysaccharides
• Other org – Veillonella, Lactobacillus
 Window of
infectivity
• 7- 31 months: Teeth
erupt
Provides virgin habitat for
bacteria

• Second window of
infectivity
6-12yrs: Permanent teeth
erupt
Provides new habitat for
bacteria
Window of infectivity
• In 1993, Caufield et al described a discrete “window of infectivity” during which infants
acquired mutans streptococci (MS) from their maternal host.

• It is defined as the period of initial acquisition of mutans streptococci (MS) by infants.

• This “window” opened at 19 months and extended to 31 months, with a mean of 26

months.

• During this period, the prevalence of MS was seen to rise from 0% to 82%.

• Caufield hypothesized that the discrete nature of initial MS acquisition was directly related
to the presence of non desquamated hard surfaces, namely newly erupted teeth.
2. Diet/ Substrate – Fermentable
carbohydrates

• Forms Dextrans→ adherence of plaque

and formation of acids →
demineralization.
• Texture and frequency of diet
consumed more important than
amount consumed.
• Lower molecular weight sugars →
diffuses into plaque faster → more
cariogenic.
Fermentable carbohydrate main source for a child:-

• Human milk, Bovine milk and milk formulas

• Fruit juices and other sweet liquids
• Sweet syrups like vitamin preparations
• Pacifiers dipped in honey or sugar solutions
• Chocolates, candies, lollies
• Soda pop
• Powdered drink crystals
Milk and it’s cariogenicity

• Among all simple sugars – Lactose is less

cariogenic

Breast milk versus Bovine milk

• Breast milk is more cariogenic than bovine milk
because it is lighter in weight.
• Breast milk → high lactose → cariogenic
• Bovine→ more Ca and P → remineralization
4. Teeth – the host for microorganisms
What factors predispose tooth to caries:-
• Hypomineralization or hypoplasia
• Developmental grooves
• Enamel of primary tooth is thinner than
permanent means fast caries progression
 • Children with special health care needs
Other • Children with malnutrition
• Overindulgent parents
factors
• Crowded homes
• Impaired salivary gland function
• Low birth weight and/or premature babies
• Lack of routine oral hygiene
• Prolonged sweetened bottle feeding
• Recently vitamin D deficiency is related to occurrence of ECC.
Management
Aims
- Treat existing emergency
- Arrest and control carious process
- Institution of preventive procedures
- Restoration and rehabilitation
Factors affecting Management

• Extent of lesion
• Age
• Behavioral problems and cooperation
• Motivation of parents and patients
 Treatment Protocol

Management
of Rampant Preventive care Restorative care
and Early
childhood ✓ Professional care
caries: ✓ Home care
Preventive care
1a) Professional care
• Educating parents regarding importance of deciduous teeth
• Diet counselling
• Dental health education to parents regarding gum pads
cleaning, tooth brushing, frequent mouth rinsing.
• Advocating fluoride supplementation if needed
• Advocating fluoride containing dentifrices
• Applying fluoride varnish topically
• Application of fissure sealants in 1st & 2nd primary molars
• Regular recall for routine monitoring for dental health
• Reinforcing & motivating parents to continue supervised
home care
1b) Home care

- Elimination of cariogenic food items from the diet

- Substitution with tooth friendly food
- Discouraging bottle feeding at night
- Falling asleep with pacifiers should be stopped
- Cleaning of gum pads during infancy period is encouraged
- Digital or baby tooth brushing as the teeth erupts
- Initiating mouth rinsing habit after consuming any solid or liquid drinks
- Regular visit to dentist once in 6 months
 Restorative care
Incipient/white spot carious lesions
- Professional topical fluoride application & observation of lesion for reversal
- Fissure sealant application

Carious lesion in enamel & dentine

- Preventive resin restoration
- Glass ionomer filling
- Composite restoration in anterior teeth
- Posterior composite restoration
- Amalgam restoration in posterior teeth
- Nickel chrome stainless steel crown
- Strip crowns for anterior
Carious lesion with pulp involvement

- Pulp therapy with full coverage

restoration
or
- Extraction followed by space
management
 Treatment

1) Emergency treatment: Acute and severe signs and symptoms → Immediate

treatment
2) Initial treatment – provisional restorations, diet assessment, OHE, home and
professional F treatment
- Done before any comprehensive restorative treatment.
- Caries control and provisional restoration for symptom free teeth →
minimize risk of pulp exposure & improve function.
- Once caries is controlled, comprehensive restorative treatment done
 • First – Treatment of emergency,
identification of cause for counselling
parents.

Treatment may be • Second – Diet counselling,

Restorations
divided into three
visits: • Third – Restoring and rehabilitation,
follow-up diet charts, Further follow
up
 First visit - causes specific to the child
• All lesions excavated and restored
• If deep lesions, do IOPA
• Assess condition of underlying permanent tooth as well
• Any abscess → drained
• Estimate salivary flow and viscosity
• Fluoride application topical for early superficial lesions
• Introduce diet record – time, type of food, amount and number of exposure
• Question about feeding habits – nocturnal bottles, breast feeding, pacifier use
• OHE
First Visit
Second visit
Third visit
Conclusion

• ECC is a serious problem affecting children that progresses rapidly in

those at risk and often goes untreated.
• Have deleterious complications on child, family, and public health
systems.
• Early diagnosis, prompt treatment can save enhanced and complex
treatment needs
• Prevention is the key to healthy and shining smiles.
References

• Shobha Tandon. Textbook of Pedodontics. 3rd ed. India :Paras Medical Publisher;2018.
• Nikhil Marwah. Textbook of Pediatric Dentistry. 2nd ed. India : Jaypee Brothers Medical
Publishers (P) Ltd; 2009.
• Ralph E. Mc Donald, David R. Avery, Jeffrey A. Dean. Dentistry for children and adolescent. 8th
ed. India: Mosby; 2010.
• Jimmy Pinkham, Paul Casamassimo, Henry W. Fields, Arthur Nowak. Pediatric Dentistry:
Infancy Through Adolescence. 4th ed. India: Elsevier
Thankyou