REVIEW - Early Childhood Caries: Risk and Prevention in Underserved Populations

Abstract

Early Childhood Caries (ECC) is a chronic and infectious oral disease of young children, most commonly seen in poor and minority populations. Factors such as improper feeding practices, familial socioeconomic background, lack of parental education and dental knowledge, and lack of access to dental care can contribute to and explain why the prevalence of ECC is so great in these select populations. Current research has shown that parents and caretakers have a huge impact on the success of preventative methods and the prevention of ECC altogether. Preventative methods include restorative dental care that focuses on the disease component of ECC, and behavioral and educational programs that advocate individualistic changes so that parents and caretakers can detect and avoid the reoccurrence of caries in their children.

Introduction

Early Childhood Caries (ECC) is a rampant dental disease that affects mostly young children. The American Dental Association (ADA) defines ECC as "the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a preschool-age child between birth and 71 months of age."

For the last fifty years, dentists and researchers have struggled to clearly define ECC , it has been referred to as "baby bottle tooth decay," "nursing bottle syndrome," and "rampant caries lesions" (Huntington, Kim, & Hughes, 2002). Certainly, defining ECC has proven challenging and for this reason, prevalence rates of ECC have varied by definition. The prevalence of ECC, however, has been shown to be overwhelmingly high among low income and minority populations such as Native Americans, Hispanics, and African Americans in the United States. Hispanics have the highest rate of ECC in both developed and developing countries with an average prevalence of 13%-29%, second only to Native Americans (Huntington, et al., 2002).

ECC is an alarming problem because the disease is so common and widespread amongst young children. In fact, the prevalence of ECC in children, ages three to five years, in US Head Start programs is as high as 90% (Tinanoff & O'Sullivan, 1997). In developing countries ECC is a critical problem as well, heightened by extraneous factors such as low income or malnutrition. The prevalence of ECC in these countries is reported to be as high as 70%.

Overall, defining ECC is problematic because the true nature of the syndrome is not clear. Thus, subsequent recommendations for prevention and treatment may be limited. This review describes and models the nature of ECC so that effective and efficacious decisions about its prevention may be recommended.

ECC is a syndrome with both disease and behavioral components. The colloquial term for ECC is "Baby Bottle Tooth Decay" because it is common in young children; a baby bottle, filled with liquids containing sugars, is used as a pacifier in aiding sleep or quietness. Though this disease can occur in all children, ECC is most prevalent in minority and poorer populations. In 1993-1994, the California Oral Health Needs Assessment of Children in the Head Start Program demonstrated that 30%-33% of Asian and Latino/Hispanic children had ECC, with 49% to 54% of who presented with untreated caries (Shiboski, Gansky, Ramos-Gomez, Ngo, Isman, & Pollick, 2003).

Untreated caries may lead to early loss of the primary dentition and affect the growth and maturation of the secondary, adult dentition. In fact, decay in the primary detention is the best predictor for decay in the secondary dentition; poor dental health and disease often persist to adulthood, affecting speech articulation, growth, and dietary practices (Weintraub, 1998). At the most extreme of cases, ECC can also lead to rampant decay, infection, pain, abscesses, chewing problems, malnutrition, gastrointestinal disorders, and low self-esteem (Ramos-Gomez, Weinstraub, Gansky, Hoover, & Featherstone, 2002). Additionally, children with ECC are shown to have an elevated risk for new lesions as they get older, both in the primary and permanent dentitions (Tinanoff & O'Sullivan, 1997).

For this review paper, online searches were performed using PubMed, Google, and various college research search engines. Peer-review papers from scientific journals including Community Dentistry and Oral Epidemiology, The Journal of Clinical Pediatric Dentistry, The Journal of the American Medical Association, and Pediatric Dentistry were reviewed. Sources of information from various websites including those about fluoride prevention, dental sealants, and general ECC and pediatric dentistry information were also used.

Disease Process

Biologically, ECC is an infectious process catalyzed by the frequent and prolonged exposure of sugars, such as those present in milk, formula, and fruit juice, to the teeth's surface. The early, ongoing practice of putting a child to sleep using the bottle at naptime or bedtime exposes sugary fluids that may pool around a baby or child's teeth for hours. The longer that the sugary liquids come into contact with the tooth's enamel, the more likely it is for these sugars to combine with bacteria , those like mutans streptococci that become present after the first tooth emerges , in the mouth. Thus, sugars are indicated in the initiation and progression of this disease. Children with ECC typically have extremely high levels of mutans streptococci, bacteria that come from mothers (Tinanoff & O'Sullivan, 1997). Demineralization of the tooth's enamel and dentin is caused by the acids that bacteria, mutans streptococci and lactobacilli, produce. Specifically, the bacteria, acid, food debris, and saliva combine to form a sticky substance called plaque that adheres to teeth. The bacteria and plaque feed from the sugars, producing waste products like lactic acids that cause demineralization or tooth decay. If plaque is not removed thoroughly and regularly, tooth decay will not only present itself, but will continue to flourish.

Onset

The onset of ECC has four necessary components: susceptible teeth, bacteria, a substrate or food for bacteria, and time for caries to develop. During naptime or bedtime, the substrate (sugar) and the infectious agent (bacteria) become present on the teeth for a prolonged time, allowing demineralization and caries progression. When associated with use of the bottle, ECC has been shown to "first affect the primary maxillary anterior teeth, followed by involvement of the primary molars" (Tinanoff & O'Sullivan, 1997). Thus, it is common to observe children with ECC having decay predominantly around the central and lateral incisors, and canines of the maxillary. The tongue "protects" the bottom teeth by serving as a barrier from sugars and bacteria, and consequently, the bottom teeth are less affected and suffer less decay.

Disease States

Depending on the progression of caries, there are various disease states of which each requires appropriate treatment. A very early sign of caries development is the beginnings of tooth demineralization, the slight penetration into tooth enamel, which is typically visualized by chalky white spots or lines. In this premature stage, white spots or lines can be reversible and caries progression can be avoided with proper care; fluoride application and diet changes are likely to be beneficial to the remineralization and protection of teeth. Further decay of the teeth from the enamel to the dentin is, obviously, more critical.

Treatment

Once a tooth becomes cavitated, a restoration or filling is usually required. Even more significant decay to the teeth may require treatment as serious as steel or veneer crowns, in which the decayed or weakened area is removed and repaired with a cap' or crown that is fitted over the remainder of the tooth. Crowns are applied if decay is extensive and there is limited tooth structure that may cause weakened teeth.

Dental caries are generally painless until the decay becomes very large inside the tooth and destroys the nerves and blood vessels in the tooth. If the decay is left untreated, a tooth abscess can develop and the internal structures of the tooth, the pulp, can be destroyed. Decay to the tooth's inner pulp is extremely critical because the pulp is made up of nerves, connective tissue, and blood vessels that help nourish the tooth. A toothache or tooth pain is equated with damage to the tooth's pulp; the pulp is the most sensitive area of the tooth. Treatment for decay to the tooth's pulp requires either pulp therapy or extraction, which is typically accompanied with general anesthesia or sedation and followed by more complex fillings and crowns to restore the teeth. A root canal is recommended if the nerve in a tooth dies from decay. During a root canal the center of the tooth, the nerve and blood vessel tissue or the pulp, is removed along with decayed portions of the tooth. The roots are then filled with a sealing material and the tooth is filled. A crown may be placed over the tooth if needed.

Restorative care and, if necessary, tooth extraction are methods that certainly work, but the cost for restoring the health of teeth is extremely high. Tinanoff and O'Sullivan (1997) estimate the cost of restoring the teeth, alone, to be $1,000 or higher per child. They state an additional $1,000-$6,000 can be included for the cost of general anesthesia or sedation. Aside from the monetary aspects, the restorative process can be potentially painful and frightening for young children. Because this dental visit is likely to be one of the children's first, any negative impressions from this experience can potentially affect how children interact with and adhere to dental care in the future. Perhaps the most damaging effect, however, is that restorative care reinforces the idea to the parent or caretaker that dental professionals have the ability to quickly alleviate all dental problems. That is, the parent or caretaker's perception becomes that dental professionals have the responsibility of fixing caries; caries are "a static or isolated problem" (Weinstein, 1998). Undoubtedly, restorative care is convenient; it effectively and temporarily solves the problem of ECC. Instead of reaching the point in which massive and immediate restorative care becomes necessary, however, dental professionals encourage children to regularly visit the dentist, starting as early as six months to one year. The American Academy of Pediatric Dentistry (AAPD) recommends a dental check-up at least twice a year for most children and more frequent visits for other children as needed. Regular check-ups and proper brushing and flossing habits are essential in dental caries prevention.

Preventative Measures

Fluoride

Caries do not completely form at one time; rather it takes months or even years before they appear. Thus, it is important to implement prevention methods when dealing with caries, particularly at an early age. Perhaps the most proven and effective method in the prevention of caries is the regular use of fluoride. Fluoride is essential when it comes to maintaining the health of teeth, predominantly in young children. Indeed, it has become so important in the United States that certain foods, toothpastes, mouthwashes, and even tap water are fluoridated. Water fluoridation is particularly important in dental prevention because it is an effective, safe, and low-cost way to prevent and protect against the occurrence of tooth decay. Fluoride protects the teeth when they first begin to erupt and as they continue to develop over time. It bonds with enamel, the tooth's outer surface, thus making it more resistant to sugars and plaque or invading bacteria colonies that lead to decay. Because the caries process is constantly changing, demineralization can be followed by remineralization; fluoride can repair tooth decay at its earliest stages (Seow, 1998). Using topical fluoride applications, such as fluoride toothpastes, fluoride varnishes, or fluoride rinses, can also aid in remineralization.

But Mouridian, Wehr, and Crall (2000) report that only 62% of water supplies are fluoridated; lack of fluoridation tends to affect poor and minority children who are already likely to receive little dental intervention. In fact, many developing countries and poorer areas do not have ready access to water fluoridation. These are the areas that are at highest risk for ECC and tend to also have the highest rates of ECC prevalence. Weinstein (1998) states that even with the recommendation of fluoride supplements in these areas, compliance with using fluoride supplements typically diminishes with time. That is, the presence of adherers is low and most people, for whatever reasons, become less rigid in implementing the practice of fluoride supplements with the passing of time. This trend is problematic because adherers to fluoride supplements already tend to have higher socioeconomic status and tend to practice dental health measures more regularly than non-adherers.

Dental Sealants

The chewing surfaces at the back of the teeth, the molars, are where decay often occurs. A dental sealant or a pit and fissure sealant is a professionally-applied, safe plastic material that is placed on the chewing surfaces of back teeth to protect and prevent against caries. Sealants smooth the chewing surfaces of teeth by filling the grooves of back teeth that are especially susceptible to trapped food and bacteria. Acting as a physical barrier between bacteria and the tooth's enamel, dental sealants prevent invading bacteria from causing tooth decay. Sealants are typically applied in young children and are recommended for use beginning at the age of six, when the first permanent molars erupt. Thus, sealants cannot be used to prevent ECC which occur in children from birth to 71 months of age, when children still have their primary teeth. Rather, dental sealants work in protecting against future caries, specifically those that occur in the permanent dentition. Sealants, however, do not and cannot replace fluoride treatments. Because fluoride works best when teeth surfaces are smooth and without grooves and pits, the use of both dental sealants and fluoride can successfully prevent most tooth decay in children.

Behavioral Component

Dietary Practices

Unquestionably, sugar plays a huge role in the development and progression of ECC. It is, after all, the sugar that acts as a substrate for the bacteria to begin its decay process. Feeding children sweetened beverages coupled with poor hygiene habits are detrimental to the health of children's teeth; sucrose, fructose, and glucose found in fruit juices and vitamin C beverages are the main sugars associated with infant caries. These sugars cause a drop in pH and catalyze demineralization. Evidence of the cariogenic nature of cow milk, breast milk, and milk formula varies and is still very much inconclusive (Seow, 1998). Seow (1998) reports that the increase of sucrose intake raises the plaque acidity and enhances the establishment and dominance of mutans streptococci. Saliva clears food and oral bacteria; it is the main buffering system used to neutralize acids. The sleep-time consumption of sugars during a child's naptime or at nighttime affects the ability of saliva to clear foods. In sleep, the low salivary flow decreases oral clearance of sugars and increases the contact time between plaque and substrates, thus considerably increasing the cariogenicity of the substrate (Seow, 1998).

Lack of Education and Dental Knowledge

A study of 149 predominantly Hispanic children in the San Francisco area showed a significant correlation (inverse) between mother's level of education and presence of ECC; 73% of the children had parents with less than high school education (Ramos-Gomez, et al., 2002). A study in Canada shows children of parents with university education had less than half the average number of mean Decayed, Missing, and Filled Teeth (dmft) scores of children who had parents with only elementary school education (Ismail, 2003). In another study of families with children with ECC, only 22% of parents reported having knowledge of or information regarding ECC , despite the presence of ECC in one or more of their children (Huntington, et al., 2002). Thus, both education and knowledge of dental caries are vital in prevention of ECC. Ismail (2003) indicates the importance that health literacy plays in the onslaught of the ECC process. Certainly, whether a parent or caretaker has the ability to read and thus, understand and learn about the dangers of sugar intake, general facts about ECC and its prevention methods can affect what practices a parent implements on the dental health of her children. Weinstein (1998) states, "Providing parents with information, especially about the benefits of changing parenting practices and the norms of behavior, will help some parents be open to the possibility of changing their behavior." Further, Weinstein (1998) believes that educating the parent or caretaker on "self-examination" techniques on children is important. That is, training parents and caretakers to determine decay or decalcification in children's teeth can be important in secondary prevention. For instance, in a study at Women, Infant, and Children Program (WIC) centers, a sample of 77 persons were able to reliably examine baby's teeth after watching only a five minute video called "Lift the Lip" (Weinstein, 1998).

Socioeconomic Status

There is a strong inverse correlation between incidence of ECC in children and the socioeconomic status of the families of those children. That is, children with ECC tend to come from low-income or lower socioeconomic backgrounds (Weinstein, 1998). In fact, one San Francisco study of 149 children showed 71% of the families earned less than $15,000 a year. Weinstein (1998) emphasizes the discrepancy in ECC prevalence rate: 1-12% in developed countries while as high as 70% in developing countries or within select immigrant or ethnic minority populations. Tang, Altman, Robertson, O'Sullivan, Douglass, and Tinanoff (1997) confirm that children with parents in the lowest income group had mean Decayed, Missing, and Filled Teeth (dmft) scores four times as high as children with parents in the highest income group. The cost of ECC treatment, particularly in ECC cases in which restoration or extraction is needed, is extremely high for these low-income families , oftentimes these families are unable to make dental care a priority over what is seen as more pertinent day-to-day costs. Thus, children in families with lower socioeconomic status are more likely to have their caries left untreated or are likely to have incomplete dental care. Ismail (2003) adds that socioeconomic status can also have a considerable impact on environment, availability of foods, access to proper health care, and education of children. These are all factors that can potentially and negatively affect whether a child develops ECC or not. Weinstein (1998) reasons that extraneous factors including number of children in a family, single-parent status, or child care options play a role in ECC and the success of prevention methods as well.

Access to Dental Care

Dental care is the most prevalent unmet health need in children living in the United States (Mouradian, et al., 2000). This fact suggests that only a minority of poor children have proper access to dental care; and children from low-income and minority families are at highest risk for poor oral health. In a study of 149 predominantly Hispanic children and their families, 63% of children had never seen a dentist before. There was a statistically significant correlation between lack of dental insurance for children and ECC , children without dental insurance were twice as likely to have ECC (Ramos-Gomez, et al., 2002). In fact, the National Early Periodic Screening, Diagnosis, and Treatment Program (EPSDT) reports that less than one in five Medicaid eligible children received any sort of dental care while three-fourths of our states served less than 30% of these children. And only 16% of children, ages one to five, report to have received dental care (Weinstein, 1998). Ismail (2003) states that Medicaid's dental program has several problems: it is not well funded in a majority of states, it is bureaucratically difficult to deal with for health professionals, and it is highly unpopular among dental providers , even the private dental sector has failed to provide proper dental care to low-income children (Weinstein, 1998). Mouradian, et al. (2000) report that children from poor families who qualify for dental coverage are less likely to seek dental services than middle- or upper-income counterparts. Poorer children have fewer dental visits and seek less dental services in general. In addition, most public health clinics, where the majority of disadvantaged people are treated, only offer "episodic, impersonal, emergency services" (Weinstein, 1997). This ineffective and irregular dental treatment of children can lead to mistrust and hesitation, affecting the desire in which families of children with ECC seek dental care.

Mouradian, et al. (2000) suggest that some of the problems in dental care could be largely due to the separation between medical and dental care. Mouradian, et al. (2000) say that medical professionals have to understand the connected role that dental care has in the medical field; teeth have a great function and effect in the individual and his management of health. Because medical professionals have a greater ability to come into contact with children, they "need to be trained to work with dental teams to prevent and control ECC" (Weinstein, 1998). Weinstein (1998) believes that dentists, too, have to make improvements by better understanding the needs of young children and treating them appropriately while still being sensitive to their concerns.

Preventative Measures

ECC prevention has evolved to be much more than just immediate fixes like restorative care; educational programs have been established in hopes of reducing the prevalence of ECC in the future. Undoubtedly, the internal mechanisms, such as the bacteria and the susceptible tooth (or teeth) of the child, are what cause the infection and onslaught of ECC. But because infants and young children are dependent on adults, parents or caregivers, for their daily needs, behaviors to prevent ECC truly rests on the responsibility of the parent or caregiver. Programs that teach change in diet, programs that encourage the decrease of sugar from a child's nutritional practices, and programs that counsel parents and caregivers really focus on educating the adult.

Ideally, focus on programs for prevention should be successful, but it succeeds only if parents and caregivers adhere to the prevention methods being taught to them. According to a study of 17 mothers of infants with significant risk of developing ECC, success of specific prevention programs was slim. The self-reports showed that when it came to discontinuing the use of baby bottles, replacing sugary liquids, and using fluoride gels, caretakers typically could not or would not follow the prevention methods (Tinanoff & O'Sullivan, 1997). Another study regarding stopping the use of the bottle at one year also provided negative results. Failure of this preventative measure was attributed to the fact that the method, "appears to violate cultural norms and may be very difficult to execute, especially for single parents or caregivers, or those with limited social support or skills in changing behavior" (Weinstein, 1998). The fact is these individualistic based approaches all require, to some extent, a degree of compliance or even motivation on the part of the parent or caretaker. The problem of ECC cannot fully be solved without the joint effort from both parents or caretakers and those teaching prevention methods.

Public Health Approaches and Recommendations in Professional Care

Weinstein (1998) sees a three-fold solution to the problem of ECC, with the collaborative efforts of caregivers, health professionals, and the community. Researchers like Weinstraub (1998) reinforce the ideas of Weinstein, believing that public health approaches are more necessary and effective than individualistic or behavioral approaches. It is important to mention that the responsibility of possibly reducing the occurrence of ECC can also be alleviated by the way that dental care, itself, is approached. In fact, Ismail (2003) believes that oral health professionals like dentists and hygienists should be trained for skills as necessary for developing community-based advocacy and dental programs, maintaining knowledge of social beliefs and practices, and establishing and implementing dental prevention programs. Ismail (2003) boldly states, "The prevalence of ECC among all American children, regardless of their race, income, and where they live, should be nonexistent. This is the only ethical and public health policy for the dental profession."

Conclusion

ECC is a chronic and infectious, but preventable, disease , both in the behavioral and scientific senses. Although extensive measures and research have been invested into the prevention of ECC, better ways of implementing preventative methods and programs are needed. Young children depend on adults; parents and caretakers need to understand that they have the ability to control whether ECC is present in their children's lives or not. Such factors as insuring proper diet, establishing good oral hygiene practices, and giving access to necessary fluoride regimens are, ultimately, in their power. Lack of knowledge about ECC and following proper dental practices are things that parents can change -- but only if parents or caretakers are willing to make that change. Preventative measures cannot and will not work unless parents and caretakers follow and adhere to the prevention methods being taught to them. Dentists, other health professionals, and the public community must also recognize that ECC is not simply an individual problem. Rather, it takes a collaborative effort to make the necessary improvements for these young children to be able to receive the proper dental care that they deserve.

References

Huntington, N.L., I.J. Kim, and C.V. Hughes (2002). Caries-risk factors for Hispanic children affected by early childhood caries. Pediatric Dentistry, (24) 536-542.

Ismail, A.I. (2003). Determinants of health in children and the problem of early childhood caries. Pediatric Dentistry, (25) 328-333.

Mouradian, W.E., E. Wehr, and J.J. Crall (2000). Disparities in children's oral health and access to dental care. The Journal of the American Medical Association, (284) 2625-2631.

Ramos-Gomez, F.J., J.A. Weinstraub, S.A. Gansky, C.I. Hoover, and J.D. Featherstone (2002). Bacterial, behavioral and environmental factors associated with early childhood caries. The Journal of Clinical Pediatric Dentistry, (26) 165-173.

Seow, W.K. (1998). Biological mechanisms of early childhood caries. Community Dentistry and Oral Epidemiology, (26) 8-27.

Shiboski, C.H., S.A. Gansky, F.J. Ramos-Gomez, and L. Ngo, R. Isman, and H.F. Pollick (2003). The association of early childhood caries and race/ethnicity among California preschool children. Journal of Public Health Dentistry, (63) 38-46.

Tang, J.M., D.S. Altman, D.C. Robertson, D.M O'Sullivan, J.M. Douglass, N. Tinanoff (1997). Dental caries prevalence and treatment levels in Arizona preschool children. Public Health Reports, (112) 319-329.

Tinanoff, N. and D.M. O'Sullivan. (1997). Early childhood caries: overview and recent findings. American Academy of Pediatric Dentistry, (19) 12-15.

Weinstein, P. (1998). Public health issues in early childhood caries. Community Dentistry and Oral Epidemiology, (26) 84-90.

Weinstraub, J.A. (1998). Prevention of early childhood caries: a public health perspective. Community Dentistry and Oral Epidemiology, (26) 62-66.

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