EARLY

CHILDHOOD Dr. Eser Rengin Nalbantoğlu

CARIES Department of Pediatric Dentistry
RAMPANT CARIES

Chai HH, Gao SS, Chen KJ, Duangthip D, Lo ECM, Chu CH. A Kindergarten-Based Oral Health
Preventive Approach for Hong Kong Preschool Children. Healthcare. 2020; 8(4):545.
https://doi.org/10.3390/healthcare8040545
Early Childhood Caries

Early childhood caries (ECC) is a unique form of severe dental

caries affecting infants and young children.

La mélanodontie infantile

Nursing Bottle Mouth

Baby Bottle Caries

Early Childhood Caries (ECC)

Early Childhood
Caries
American Academy of Pediatric
Dentistry (AAPD):
The disease of early childhood
caries is the presence of 1 or more
•decayed (cavitated or non-
cavitated lesions),
•missing (due to caries) or
•filled tooth surfaces in any primary
tooth
in a child 71 months of age or
younger.
 • In children younger than 3, any sign of
smooth surface caries indicates severe early
childhood caries (S-ECC).
Early
Childhood Decayed-missing-filled tooth score-(DMFT),
•3 years old≥4,
Caries •4 years old ≥5
•5 years old ≥6
 Early Childhood Caries

Teeth with ECC are often left untreated.

The progression of the decay causes

an increase in pain

a decrease in chewing and eating skills.

lower weight
Early Childhood Caries

If ECC is too advancedà it causes primary tooth loss

occlusion disorders and speech disorders

•Studies have reported that early childhood caries have adverse effects
on the quality of life of children, as well as causing sleep disorders and
concentration problems.
Early Childhood
Caries
• EEC is typical for children in the 0-
3 age group and follows a
particular path.
• Primarily, the upper jaw begins in
the gingival triple part of the
labial face of the anterior teeth.
The initial lesion appears as a
white decalcification band along
the gingiva or is consistent with
plaque distribution on the
occlusal surface.
 •If left untreated, the lower and upper first molars are also
affected. Caries in molars start from the pit and fissure areas
Early or the gingival area of the buccal surface.
•Caries can develop in the pits and fissures of the primary
Childhood molars and the approximal surfaces of the teeth with contact.

Caries •Canine and second molar teeth are less affected because
during the period these teeth are erupting, the child usually
quits the feeding bottle and sucking habit. The front teeth of
the lower jaw are not affected by ECC due to the cleansing
effect of the tongue.
 Developmental Stages of ECC

Stage Clinical Age Features

Situation
1. Reversible 10-18 •Chalky white demineralization in the
cervical and interproximal areas.
initial stage months •No pain
•Lesions are reversible in this stage.
 Developmental Stages of ECC
Stage Clinical Age Features
Situation
2. Damaged 18-24 • A lesion in the maxillary anterior
carious stage months teeth, which may spread to the
dentine and exhibit yellowish-brown
discoloration, has been observed.
• Consuming cold food causes pain.
 Developmental Stages of ECC

Stage Clinical Age Features

Situation
3. Deep 24-36 • Depending on time of eruption and the
lessions months frequency of consumption of cariogenic
foods, this stage can be reached in 10-14
months also.
• Molars are also affected
• Frequent complaint of pain
• Pulpal involvement in maxillary incisors
 Developmental Stages of ECC
Stage Clinical Age Features
Situation
4. Traumatic 36-48 • Teeth weakened by caries can fracture
Stage months under relatively small forces.
• Molars are now commonly associated
with pulpal problems.
• Additionally, maxillary incisors may
become non-vital.
 • Early childhood caries frequently impacts the
upper incisors, which are among the first teeth
to erupt and thus are exposed to caries attacks
for extended periods.
• Furthermore, liquids consumed from a bottle
tend to pool between the upper incisors.
Early • On the other hand, the lower incisors are less
Childhood affected due to protection from the tongue
and saliva produced by the submandibular and
Caries sublingual salivary glands.
• Additionally, the forward extension of the
tongue during sucking prevents liquids in the
bottle from accumulating around the lower
incisors.
Prevalence of Early
Childhood Caries
• In industrialized countries, the incidence of
severe Early Childhood Caries (ECC) is 28%,
while in non-industrialized countries, it rises
to 82%. Additionally, 50% of children from
low socioeconomic groups experience severe
ECC.
• Children who develop caries early are more
likely to suffer from caries in their mixed and
permanent dentition in the future.
 Etiology of Early Childhood Caries

• Early Childhood Caries (ECC) is a multifactorial

disease caused by cariogenic microorganisms
and fermentable carbohydrates, such as those
found in fruit juice, milk, sugar, and cooked
starch, coupled with improper dietary habits.
• While the etiology of ECC is similar to that of
other types of coronal smooth surface caries,
its biology may differ in certain aspects.
• The bacterial flora and host defense systems
are still developing in young infants. The tooth
surfaces are newly erupted and immature,
potentially exhibiting hypoplastic defects.
Etiology of Early Childhood Caries
• Cariogenic bacteria
• Diet
• Oral hygiene (tooth brushing
frequency and quality)
• Child
• Low saliva flow rate at night
• Newly erupted non-mature
teeth
• Medical conditions
• Number of filled-extracted
teeth
• Social factors
• Parental education
• Parental caries amount
• Socio-economic status
 Cariogenic Bacteria
• Like other types of coronal dental decay,
the primary bacteria implicated in Early
Childhood Caries (ECC) are from the
group now referred to as 'mutans
streptococci.’
• Streptococcus mutans and Streptococcus
sobrinus are the most commonly isolated
in human dental caries.
• The initial colonization of S. mutans in an
infant's mouth occurs through tooth
eruption.
• Typically, a child is first infected with S.
mutans from their mother, often through
close contact such as kissing and sharing
food.
 Carbohydrates
• Sucrose, widely used in various foods, is
considered the most significant
carbohydrate-forming dental caries.
• A common characteristic among children
with Early Childhood Caries (ECC) is sugar
consumption during sleep.
• The reduced saliva flow during sleep
decreases sugar clearance from the tooth
surface, prolonging the contact time
between plaque and carbohydrates.
• As a result, the risk of caries significantly
increases, particularly on the labial
surfaces of the maxillary incisors and the
buccal surfaces of the mandibular
molars.
 • Bovine Milk: Bovine milk contains casein particles that
facilitate the formation of stable calcium and phosphate
molecules. These proteins adhere to the tooth surface,
forming a protective layer that helps prevent
Cariogenicity demineralization. Additionally, the non-cariogenic
of Food properties of bovine milk enhance calcium and
phosphate concentrations in dental plaque, increasing
its buffering capacity against acids. This not only helps
reduce enamel demineralization but also accelerates
remineralization.
Cariogenicity
of Food
• Human milk: Bovine milk has 3%
lactose and human milk has 7%.
Compared to bovine milk, human
milk has a higher concentration of
lactose and lower levels of protein
and minerals. Studies indicate that
prolonged and excessive
breastfeeding can increase the
prevalence of caries in children by
between 5% and 10%.
Cariogenicity
of Food
• The American Academy of
Pediatric Dentistry recommends
breastfeeding for at least one year.
• However, they also note that
although breast milk is crucial for
infant development, frequent and
prolonged nighttime breastfeeding
after the eruption of primary teeth
can cause a rapid and significant
decrease in plaque pH, leading to
early childhood caries.
 Cariogenicity
of Food
• Fruit Juices: Acids in fruit juices
and soft drinks lower saliva pH,
and excessive consumption can
lead to enamel loss in children.
Adding sugar to these beverages
further decreases the pH,
increasing enamel
demineralization. If children are
to consume fruit juice, it should
be limited to 4-6 times a day and
served in a glass. Eating whole
fruits is recommended over
drinking fruit juice.
 • When consumed from a bottle as the baby sleeps, cariogenic
foods can accumulate around the maxillary incisors, leading to
rapid and severe tooth decay. In breastfed babies, the prolonged
presence of the nipple in the mouth restricts saliva flow to the
Cariogenicity upper jaw teeth.
• The danger of using a bottle at night is linked to a diminished
of Food saliva neutralization capacity due to reduced saliva flow.
• This leads to food accumulation on the teeth and prolonged
contact with fermentable carbohydrates.
 • The American Association of Pediatric Dentistry
advises against bottle-feeding children at night and
recommends limiting nighttime breastfeeding
Cariogenicity following the eruption of the first primary tooth.
• Parents are encouraged to help their children
of Food transition to drinking from a glass as they near their
first birthday. A bottle should be discontinued
between 12 to 14 months of age.
Medicines
• Long-term use of sweetened medical
preparations due to chronic or recurrent
diseases increases the risk of caries in
children.
• Frequent use of sweetened medicines,
particularly when syrups are taken more
than a week per month for at least one year,
contributes to the etiology of Early
Childhood Caries (ECC).
• A study involving Turkish children found a
high tendency towards self-medication and
irregular syrup use, which may increase the
incidence of lesions and ECC.
Medicines
• The severity of Early Childhood Caries (ECC) is
exacerbated by the use of beta-2 agonists,
powdered inhalers, and oral medications that
contain sugar.
• Powdered inhalers often include sugars like lactose,
which can increase the frequency of caries. It is
recommended that children rinse their mouths
after each inhalation of steroids.
• Additionally, using beta-2 antagonists is linked to a
reduced saliva flow rate.
Socioeconomic
Factors
• The socioeconomic environment
in which children are raised
influences their development of
oral hygiene routines.
• The socioeconomic status and
educational attainment of parents
shape oral hygiene status.
• Children who have experienced
tooth decay, as well as their
mothers, are classified as being at
high risk.
 Primary Etiological Factors of Early Childhood Caries:
• Prolonged breastfeeding beyond one year without
adequate oral hygiene practices.
• Extended nighttime bottle feeding, especially if it lasts
Primary throughout the night.
• Sweeteners like honey, sugar, or molasses can be
Etiological introduced into nighttime bottle feedings.
Factors of Early • Offering pacifiers to infants after dipping them in jam or
honey.
Childhood • Providing acidic fruit juices in bottles as part of the
Caries child's diet.
Primary • Excessive intake of sugary foods and drinks.
Etiological • Failure to prioritize the care of primary teeth
under the assumption that they will naturally be
Factors of Early replaced.
Childhood • The decay-promoting impact of sugar present in
Caries medications taken regularly by children.
 • In infancy, indications of caries may manifest as early as
the first year. During this crucial stage, educating
parents on maintaining proper oral hygiene is
Prevention and imperative.

Treatment of • Additionally, professional preventive programs should

be instituted for children at high risk of developing
Early caries.

Childhood • These programs encompass various interventions such

as fluoride treatments, fissure sealants, applications of
Caries silver diamine fluoride, nutritional guidance, and, when
warranted, the utilization of chlorhexidine agents.
 Prevention and Treatment of Early Childhood Caries

Alshammar A, Almukrin A. Parental perceptions and acceptance of silver diamine fluoride treatment in Kingdom of Saudi Arabia. Int J Health Sci 2019; 13(2):25-29.
 • The conventional approach to addressing early
childhood caries involves restoring the affected
tooth's function and appearance through fillings
after eliminating all infected tissues.
• Early childhood caries (ECC) frequently occurs in
Treatment families with lower educational attainment, and
delayed detection often necessitates more
of Early complex treatment procedures.
Childhood • Young children often face significant challenges
when it comes to adapting to lengthy and
Caries complex dental procedures. These challenges
often necessitate costly interventions like
general anesthesia and sedation. Furthermore,
studies have shown that approximately 50% of
children treated under general anesthesia
develop new instances of caries post-treatment.
Prevention and
Treatment of Early
Childhood Caries

• Given these challenges, halting the

progression of caries has gained significant
importance today.
• While arrested caries may not be
aesthetically pleasing, they are preferred as
they effectively prevent pain and infection
in children.
• Additionally, more intricate treatments may
be pursued if the child is cooperative, or
the family can afford them.
Prevention of Early Childhood
Caries
Prevention of early childhood caries necessitates several
measures:
1.Educating families about oral hygiene practices, including regular teeth
cleaning.
2.Implementing early protective measures to safeguard dental health.
3.Discouraging the habit of sleeping with a bottle in the mouth at night.
4.Ensuring the child is put to sleep after feeding rather than during.
5.Avoid adding sweeteners such as honey and molasses to milk in the bottle.
Treatment of Early
Childhood Caries

6. Rinsing the child's mouth with water after feeding.

7. Cleaning the teeth after nighttime and morning feedings
during infancy.
8. Encouraging the mother to chew gum containing xylitol
can reduce the population of S. mutans.
9. Implementing fluoride applications, ideally every three
months, for children at high caries risk.
10.Brushing the child's teeth with toothpaste appropriate
for their age.
11. Recommending casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP) preparations for dental care.
Treatment of Early Childhood Caries

Topical antimicrobial treatments:

• Topical antimicrobial treatments such
as povidone-iodine are believed to
be effective against the oral
colonization of S. mutans and can
help prevent dental caries.
• However, due to its potent
bactericidal and virucidal properties,
povidone-iodine can also disrupt the
normal flora in the oral cavity and
pharynx.
• As a result, it should not be routinely
used.
Treatment of Early
Childhood Caries
Topical antimicrobial treatments:
• It has been reported that applying 40%
chlorhexidine varnish for six months reduced
caries formation by 37.3%, with no observed
side effects. This efficacy is comparable to
fluoride varnish.
• Nowadays, chlorhexidine preparations available
in the market are predominantly in the form of
mouthwash.
Treatment of Early
Childhood Caries

Restorative Treatments
• Early childhood caries (ECC)
management in children varies
depending on factors such as the
severity of the lesions, the child's
age, behavioral characteristics, and
the level of parental cooperation.
• Left untreated, ECC can lead to
complications, including abscess
formation, pain, and malocclusion.
• Therefore, early intervention and
appropriate treatment are crucial to
prevent these adverse outcomes.
Treatment of Early Childhood
Caries
Restorative Treatments
• Restorative treatment for teeth affected by early childhood caries (ECC)
typically involves filling decayed teeth. In more severe cases, extraction
of decayed teeth may be necessary.
• However, even after these treatments, secondary caries and new decay
can develop in the restored teeth if the child's oral care is inadequate.
• The rate of recurrence within a year following dental treatment has been
reported to be as high as 40%. Therefore, minimal restorative procedures
should be pursued whenever possible in cases requiring treatment.
• For non-cooperative children, dental treatment may need to be
performed under sedation or general anesthesia to ensure safety and
effectiveness.
Treatment of Early Childhood Caries
Treatment of Early Childhood Caries

Restorative Treatments
• Achieving painless treatment for caries is paramount during the initial dental appointment
for pediatric patients. Various treatment options are available, including:
1.Compomer/composite restorations: These tooth-colored materials are commonly used for
restoring decayed teeth, providing both aesthetic appeal and functional restoration.
2.Glass ionomer restorations: These restorations release fluoride and are often used in
primary teeth due to their ability to bond to the tooth structure and release fluoride, aiding
in caries prevention.
3.Stainless steel crowns: These crowns are durable and commonly used for restoring
extensively decayed primary teeth, providing long-term protection and functionality.
4.Zirconia prefabricated crowns: They are esthetically pleasing and durable, making them
suitable for restoring primary teeth with extensive decay or structural damage.
5.Space maintainer applications: These devices help preserve space in the dental arch
following premature loss of primary teeth, preventing misalignment of permanent teeth.
Treatment of Early Childhood Caries
Treatment of Early Childhood Caries

Restorative Treatments
Total coronal restoration of primary incisors is required when:
•When caries are found on many surfaces
•When the incisal edge is involved in caries
•When there is advanced cervical decalcification
•When pulp treatments are required
•When the decay is small but oral hygiene is poor (in high-risk patients)
•Where the child's behavior makes it challenging to perform a Class II
restoration
Treatment of Early Childhood Caries
Treatment of Early Childhood Caries
Treatment of Early Childhood Caries
Treatment of Early Childhood Caries

Restorative Treatments:
• Crowns applied to teeth reduce the number of surfaces at risk of
secondary caries formation, decreasing the need for retreatment over
time compared to other treatment options.
• While crown restorations offer good aesthetics, their application is
challenging due to the required time and patient cooperation. This
makes them less satisfactory for families with high aesthetic
expectations.
• Despite various treatments, secondary or new caries may still be
observed during children's 6-month to 1-year follow-up visits.
• Therefore, it is essential not only to address the symptoms of the disease
but also to prioritize oral hygiene to prevent further decay and maintain
dental health.
Rampant Caries
 Rampant caries are characterized by:
• sudden onset
• affecting multiple teeth simultaneously and

Rampant • leading to rapid destruction of the dental crown.

• This form of caries often progresses swiftly,
Caries involving the pulp within a short period.
• It is typically observed on tooth surfaces not
commonly affected by traditional dental caries.
 • “Rampant caries is a suddenly appearing,
rapidly burrowing type of caries resulting in
early pulp involvement, in
Rampant which more than 10 new lesions appear
every year on healthy teeth surfaces which
Caries are generally immune to caries.”

• Namita, ; Rai, Rita. Adolescent rampant caries. Contemporary Clinical

Dentistry 3(Suppl1):p S122-S124, April 2012. | DOI: 10.4103/0976-237X.95122
Rampant Caries
• Rampant caries in primary dentition often correlate
with the order of tooth eruption, except for
mandibular incisors. This pattern is similarly
observed in permanent dentition.
• Rampant caries typically manifest as buccal and
lingual caries in premolars and molars, labial and
proximal caries in upper incisors, and proximal
caries in lower incisors.
• Enamel decalcification presents as a band encircling
the tooth in both primary and permanent
dentition. The carious lesion appears light yellow or
pink, contrasting with the typical dark brown hue
associated with caries.
Rampant Caries
• In rampant caries, the initial lesion typically starts
as a chalk-like decalcification on the labial surface
of the maxillary incisors near the gingival margin.
This lesion may later transition to a light-yellow
color and extend toward the proximal areas.
Sometimes, decalcification can begin on the
palatal surface or incisal edge, although this is less
common and usually occurs in severe cases.
• As the carious lesion progresses, it may encircle
the entire tooth, causing the crown to become
fragile and susceptible to damage even with
minimal trauma.
Rampant Caries
• The primary distinguishing feature of
rampant caries compared to early
childhood caries is its potential to occur
at any age. Early childhood caries is
considered a subtype of rampant caries.
• The primary contributing factors for
early childhood caries typically involve
bottle-feeding during sleep, prolonged
breastfeeding, or giving pacifiers dipped
in sugary substances. Conversely,
cariogenic snacks and sugary drinks are
often cited as a significant factor
contributing to rampant caries in
permanent teeth.
 Rampant Caries
• The etiology of rampant caries in children remains a topic of debate among
researchers. Several factors have been proposed as potential contributors:
1.Frequent sugar intake and reduced saliva flow: High sugar consumption
creates an environment conducive to bacterial growth, particularly S.
mutans, a key contributor to caries formation. Reduced saliva flow can
further exacerbate this process by diminishing the natural cleansing and
protective effects of saliva in the oral cavity.
2.Poor oral hygiene habits: Inadequate brushing and flossing can accumulate
plaque and bacteria on teeth, increasing the risk of caries.
3.Patients with dry mouth (xerostomia): Dry mouth can result from various
factors, such as medication use, certain medical conditions, or radiation
therapy. Decreased saliva production in dry mouth conditions reduces
saliva's protective effects, making teeth more susceptible to caries.
4.Psychological factors: Some psychological situations or disorders may
contribute to poor oral hygiene habits or increased consumption of
cariogenic foods and drinks, thereby influencing the development of
rampant caries.
 Rampant Caries
• Rampant caries can lead to various
complications, including:
1.Pain: As the carious lesions progress and affect the
deeper layers of the tooth, pain can develop,
particularly in response to stimuli such as hot,
cold, or sweet foods and drinks.
2.Infection: Untreated caries can result in bacterial
infection within the tooth, leading to abscess
formation, swelling, and potentially spreading
infection to surrounding tissues.
3.Tongue thrusting: Severe caries can alter the bite
and alignment of teeth, leading to abnormal
tongue thrusting habits as the tongue attempts to
compensate for the changes in dental structure.
4.Abnormal swallowing reflex: Discomfort or pain
associated with rampant caries may affect the
swallowing reflex, leading to difficulties in
swallowing or altered swallowing patterns.
5.Speech difficulties: Changes in dental alignment or
pain and discomfort from rampant caries can
interfere with proper articulation and speech
production, resulting in speech difficulties or
abnormalities.
 Rampant Caries
• Controlling rampant caries requires a comprehensive
approach that includes various protective procedures:
1.Dietary suggestions: Reducing sugar intake, especially sugary snacks
and drinks, can help mitigate the risk of caries development.
Encouraging a balanced diet rich in fruits, vegetables, and dairy
products can also support overall dental health.
2.Oral hygiene education: Teaching proper oral hygiene practices,
including brushing techniques, flossing, and fluoride toothpaste, is
crucial for preventing and managing caries. Emphasizing the
importance of regular brushing and flossing, especially after meals
and before bedtime, can help remove plaque and prevent decay.
3.Fluoride treatments: Utilizing fluoride-based products such as
fluoride varnish or fluoride mouthwash can strengthen tooth enamel
and make it more resistant to acid attacks, reducing the risk of caries
development.
4.Fissur sealants: Applying dental sealants to the occlusal surfaces of
permanent molars can create a protective barrier against bacteria
and food particles, reducing the likelihood of decay in these
vulnerable areas.
Rampant Caries
• Professional application of fluoride gel every
three months.
• Using fluoride tablets, fluoride toothpaste, or
fluoride mouthwashes.
• Applying fissure sealant to non-carious pits and
fissures.
• Cleaning and restoring all active caries lesions
and considering crown placement if needed.
Rampant Caries
Treatment
• Treatment approaches should be
tailored based on factors such as
age, motivation, cooperation, and
the extent of caries spread.
• Initially, preventive treatment
methods and establishing a
routine for regular oral hygiene
practices should be emphasized.
• Restorative treatments can be
initiated once rampant
caries is brought under control.
Rampant Caries
Treatment
• Compomer and composite resin
restorations and pedo-form strip
crowns may be the preferred choice
for anterior teeth due to their
superior aesthetic appeal. While
glass ionomer restorations are less
aesthetically pleasing, they are still
utilized because of their fluoride-
releasing properties.
• Composite/compomer resin
restorations, glass ionomer
restorations, and stainless-steel
crowns are commonly employed for
posterior teeth.
 Treatment
• Treatment options such as pulpotomy,
pulpectomy, root canal therapy, or
extraction may be considered depending on
the extent of the lesion.
• Space maintainers or prosthetics may be
Rampant necessary to preserve proper dental
alignment after treatment.
Caries • Patients should be scheduled for regular
check-ups every three months to monitor
oral health and ensure any issues are
promptly addressed.
Rampant Caries
Thank you!