Download Early Childhood Caries - Dr. Mary Louise Bove, ND

Early Childhood Caries
Mary Bove ND
Early Childhood Caries
• Defined 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.
http://www.ada.org
Severe Early Childhood Caries (S-ECC)
• Children younger than 3 years of age, any sign
of smooth-surface caries is indicative of S-ECC
• Ages 3-5, one or more cavitated, missing (due
to caries), or filled smooth sur-faces in primary
maxillary anterior teeth or a decayed, missing,
or filled score of greater than or equal to four
(age 3), greater than or equal to five (age 4),
or greater than or equal to six (age 5) surfaces
also constitutes S-ECC
Early Childhood Caries
• The biology of ECC may be modified by several
factors unique to young children, related to
the implantation of cariogenic bacteria,
immaturity of the host defense systems, as
well as behavioral patterns associated with
feeding and oral hygiene in early childhood
• A transmissible infectious disease and which is
responsive to preventive strategies
Etiology of ECC
• Dental caries is a common chronic infectious
transmisible disease resulting from toothadherent specific bacteria, primarily mutans
streptococci (MS), that metabolize sugars to
produce acid which, over time, demineralizes
tooth structure.
Loesche WJ.,Microbiol Rev 1986;50(4):353-80
Etiology of ECC
• ECC is caused by mutans streptococci that
ferment dietary carbohydrates to produce acid
attacks on susceptible teeth over a period of
time
• Sugared beverages are readily metabolized by
MS and lactobacilli into organic acids that can
demineralize enamel and dentin
Early Childhood Caries
• Common causative agents are mutans
streptococci (MS), including Streptococcus
mutans, Streptococcus sobrinus,
Streptococcus salivarius, Streptococcus mitis,
Streptococcus sanguis
• Lactobacilli also participate in the
development of caries playing an important
role in lesion progression, but not its initiation
• Salivary gland hypofunction
Etiology of ECC
• The major reservoir of MS is the mother, from
whom the child acquires it during a window
period of around 2 years of age
• Mothers with dense salivary reservoirs of MS
are at high risk of infecting their infants very
early in life [Pediatric Dentistry, vol. 28, no. 2, pp. 106–109, 2006.]
• Poor maternal oral hygiene and higher daily
frequencies of snacking and sugar exposure
increase the likelihood of transmission of the
infection from mother to child [Journal of Dental Research,
vol. 82, no. 7, pp. 504–508, 2003.]
ECC
• The time span between MS colonization and
caries lesion development is approximately
13–16 months
• Prenatal and perinatal malnutrition/under
nutrition lead to hypoplasia.
• A consistent association has been reported
between enamel hypoplasia and ECC
Cesarean Section vs Vaginal Birth
• Infants delivered by CS acquire S. mutans
earlier than vaginally delivered infants
• Vaginal delivery may expose newborns to
early protection against S. mutans
colonization by exposure to numerous
bacteria earlier and with great intensity,
affecting the pattern of microbial acquisition
• CS infants have an atypical microbial
environment that may increase susceptibility
to subsequent early S. mutans colonization
Cows Milk vs Breast milk
• Cow milk is essentially noncariogenic because
of its mineral content and low level of lactose
• Human milk promoted the development of
smooth-surface caries and was significantly
more cariogenic than cow milk*
• Breast feeding and its duration were
independently associated with an increased
risk for ECC*
*Canadian Journal of Public Health, vol. 91, no. 6, pp. 411–417, 2000.
Caries Process
• The presence of a fermentable carbohydrate
(e.g., sucrose, glucose, fructose, cooked
starch) and biofilms on the teeth
• Support the metabolism of acidogenic
microorganisms, leading to acidic substances
• Hydrogen ions dissolve the carbonated
hydroxyapatite crystal lattice of enamel,
cementum, and dentin
• Continued demineralization results in
cavitation of the tooth enamel surface
ECC and Other Health Issues
• Infants with ECC grow at a slower pace
• Young children with ECC may be severely
underweight because of associated pain and
their disinclination to eat
• ECC may also be associated with iron
deficiency
http://dx.doi.org/10.1155/2011/725320
Standard Dental Treatments
• Prevention (People remain susceptible to the
disease throughout their lives)
• Fluoride (2x/d brushing fluoridated paste with
eruption of 1st tooth)
• Topical Antimicrobial Therapy
• Casein Phosphopeptide-Amorphous Calcium
Phosphate (CPP-ACP)
• Dental Fluorosis
• Restoration or the surgical removal (40%
reoccurrence in 1st year)
Topical Antimicrobial Therapy
• Povidone-iodine has suppressive effects on
the oral colonization of MS and prevented
dental caries
• Povidone-iodine has strong
bactericidal/virucidal effects and demolishes
normal flora in the pharynx and the oral
cavity, which interfere with pathogenic viral
invasion
• Therefore, povidone-iodine should not be
Pediatric Dentistry, vol. 24, no. 3, pp. 204–206, 2002
routinely used
Topical Antimicrobial Therapy
• Topical 0.12% chlorhexidine gluconate could
significantly reduce MS levels
• Chlorhexidine therapy was much less effective
at reducing the levels of lactobacilli in the
human mouth
Casein Phosphopeptide-Amorphous
Calcium Phosphate (CPP-ACP)
• Shown to reduce demineralization and
promote remineralization of carious lesions
• CPP-stabilized amorphous calcium fluoride
phosphate had a greater remineralizing effect
than fluoride or CPP-ACP individually
• CPP-ACP used as a self-applied topical coating,
after the teeth have been brushed with a
fluoridated toothpaste
Caries Research, vol. 38, no. 6, pp. 551–556, 2004
Fluoride supplements recommended
for preventing caries
• Evidence of effectiveness of supplements in
caries prevention in primary teeth is weak
• For permanent teeth daily use of supplements
prevented dental caries
• Supplements during the first 6 years of life,
and especially during the first 3 years, is
associated with an increase in fluorosis
• Fluoride supplement should not be given to
infants
http://dx.doi.org/10.1155/2011/725320
AAPD Preventive Measures
Decrease transmission of cariogenic bacteria
• Reduce parent/sibling MS levels
• Minimizing saliva-sharing activities (eg,
sharing utensils)
• Implement oral hygiene measures no later
than the first primary tooth eruption
• Brush BID (age-related dose of fluoride
toothpaste)
AAPD Preventive Measures
• Establishing a dental care within six months of
eruption of the first tooth and no later than 12
months of age
– conduct a caries risk assessment
– provide parental education
AAPD Preventive Measures
• Avoiding high frequency consumption of
liquids and/or solid foods containing sugar.
– sugar-containing beverages (eg, juices, soft drinks,
sweetened tea, milk with sugar added) in a baby
bottle or no-spill training cup
– infants should not be put to sleep with a bottle
filled with milk or liquids containing sugars
AAPD Preventive Measures
• Avoid ad libitum breast-feeding after the first
primary tooth begins to erupt and other
dietary carbohydrates are introduced
• Encouraged infants to drink from a cup as they
approach their first birthday
• Infants should be weaned from the bottle
between 12 to 18 months of age.
Therapeutic Strategies for EEC
• Dysbiosis of the mouth
– Oral hygiene
– Shift oral microbiota
• Immune System
– Oral mucosal tissue
– Immature Systemic Host Defense
• Microbiome Challenge
– Microbiota Environment of Body
Therapeutic Strategies for EEC
• Improve the intraoral environment
• Reduce Mutan Strep species
• Shift oral environment to reduce strep and
lactobacilli affects on demineralization
• Increase helpful oral strains of microbes
• Support immune regulation of oral
environment
Probiotic Streptococcus salivarius
strain M18
• Produces bacteriocins targeting the cariogenic
species Streptococcus mutans, as well as the
enzymes dextranase and urease
• RDBPC study of 100 dental caries-active
children for 3 months
• Plaque scores were significantly lower for
children in the M18-treated group
• Concluded that S. salivarius M18 can provide
oral health benefits when taken regularly
J Med Microbiol (2013 Jun) 62(Pt 6):875-84
Lactobacillus rhamnosus GG
• Has shown antagonism to many bacteria
including mutans streptococci
• LGG was found to reduce the risk of caries
• Milk containing the probiotic LGG bacteria
may have beneficial effects on children’s
dental health and reducing the risk of caries
Caries Res 2001;35:412–420 (DOI: 10.1159/000047484)
Lactobacillus reuteri
• Evaluate the effect on the oral health of 9 year
olds after:
• Daily oral supplementation with the probiotic
Lactobacillus reuteri, strain ATCC 55730, to
mothers during the last month of gestation
and to children through the first year of life
• A single-blind, placebo-controlled, multicenter
trial of 113 children: 60 in the probiotic and 53
in the placebo group
Caries Res 2014;48:111-117 (DOI: 10.1159/000354412)
Lactobacillus reuteri
• Saliva and plaque similar in both groups for
mutans streptococci (MS) and lactobacilli (LB)
in saliva and plaque as well as salivary
secretory IgA (SIgA)
• Within the limitation of this study it seems
that daily supplementation with L. reuteri
from birth and during the first year of life is
associated with reduced caries prevalence and
gingivitis score in the primary dentition at 9
years of age.
S. Karger AG, Basel; Caries Res 2014;48:111-117 (DOI: 10.1159/000354412)
Dietary Phenols
Support the microbiota
Inhibit non-beneficial bacteria while having little
effect on beneficial bacteria
Antioxidant activity
Tannins flavonoids, bioflavonoids, polyphenols,
phenolic acids
Fruits, berries, vegetable, herb, spices, cocoa,
red wine, dark chocolate
Huffnagle, G,. The Probiotic Revolution, Bantum Books, 2007 pg 274-277
Calcium and Probiotics
Aids probiotic bacteria to adhere to the
intestinal wall
Discourages harmful bacteria from adhering to
the intestinal wall
Avoid calcium carbonate
Food forms preferred
Huffnagle, G,. The Probiotic Revolution, Bantum Books, 2007 pg 257
Neem tree /Azadirachta indica
• Leaves Bark, and Seed oil
• Anti-microbial for many bacteria, virus,
fungus, parasitic organisms, antimalarial
• Immunomodulatory, antioxidant
• Anti-inflammatory, antiulcer
• Traditionally used in the treatment of
inflammation, infections, fever, skin diseases
and dental disorders
Neem
• Efficacious against caries-inducing
microorganisms
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Streptococcus mutans
Streptococcus salivarius
Streptococcus mitis
Streptococcus sanguis
• Neem extract at maximum concentrations
showed the maximum zone of inhibition
• Chewing neem sticks can be beneficial in
preventing caries
J Contemp Dent Pract (2012 Nov-Dec) 13(6):769-72
Cranberry
Vaccinium macrocarpon
Several compounds isolated from cranberry
juice inhibit the attachment of many oral
bacteria to the surface of the tooth thus
decreasing tooth decay
Cranberry eaten regularly
promotes both gastrointestinal
and oral health.
Oral health benefits of Cranberry
• Polyphenols have very promising properties
with respect to cariogenic bacteria
• Host inflammatory response
• Enzymes that degrade the extracellular matrix
• Inhibit acid production, adhesion, and biofilm
formation by Streptococcus mutans.
• Glucan-binding proteins, extracellular
enzymes, carbohydrate production, and
bacterial hydrophobicity
Crit Rev Food Sci Nutr (2008 Aug) 48(7):672-80,
J Can Dent Assoc (2010) 76:a130
Deglycyrrhizinated Licorice Root
Extracts (DG-LRE)
• Demonstrates antimicrobial activity against
Streptococcus mutans.
• Significantly inhibited biofilm formation by
Streptococcus mutans UA159
Anaerobe (2012 Dec) 18(6):590-6
Licorice Root /Glycyrrhiza glabra
• Glycyrrhizol A has strong antimicrobial activity
against cariogenic bacteria
• Two pilot human studies indicate that a brief
application of licorice lollipops (twice a day for
ten days) led to a marked reduction of
cariogenic bacteria in oral cavity among most
human subjects tested
Int J Oral Sci (2011 Jan) 3(1):13-20
Licorice Root /Glycyrrhiza glabra
• Licoricidin and licorisoflavan A shown to
inhibit oral pathogens
– Streptococcus mutans
– Streptococcus sobrinus
• Periodontopathogenic species
– Porphyromonas gingivalis
– Prevotella intermedia
Anti-Cariogenic Essential Oils
• Achillea ligustica-linalool, viridiflorol, beta-pinene, 1,8cineole and terpinen-4-ol
(Fitoterapia (2009 Sep) 80(6):313-9)
• Significant adhesion-inhibiting activity against
P. gingivalis and S. mutans.
– Manuka oil
– Tea Tree oil
– Eucalyptus oil
– Lavandula oil
– Romarinus oil
Anti-Cariogenic Essential Oils
• Macelignan isolated from Myristica fragrans
(nutmeg)- S. mutans, S. sobrinus, S. salivarius,
S. sanguis
Phytomedicine (2006 Mar) 13(4):261-6
• Lippia sidoides- thymol (56.7%) and carvacrol
(16.7%)
– 37 children ages 6-12,
– one application of .6-1% solution of EO
– significant MS reduction
Phytomedicine (2011 May 15) 18(7):551-6
Anti-Cariogenic Essential Oils
• Cinnamon oil was found to be more effective
than clove oil exhibiting broad spectrum of
antibacterial activity inhibiting all the ten test
bacterial species involved in dental caries.
• Inhibition zone of diameter of 24.0 mm
against Streptococcus mutans compared to
the clove oil zone of 13.0mm
Acta Biomed (2011 Dec) 82(3):197-9
Anti-Cariogenic Essential Oils
• Other Aromatic Plants which contain thymol
and carvacrol include:
– Thymus vulgaris
– Salvia officinalis
– Rosmarinus officinalis
– Zingiber officinale
– Origanum vulgare
Botanicals impacting SIgA
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Echinacea species
Andrographis paniculata
Astragalus membranaceus
Ulmus fulva
Althaea officinalis
Medicinal Mushroom Species
Nutrients for Intraoral Health
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Folic Acid
Co Q10
Vitamin D
Vitamin C
Vitamin B 2
Vitamin B3
Vitamin B12
Beta carotene
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Calcium
Phosphorus
Magnesium
Zinc
Iron
Potassium
Xylitol
• A sugar alcohol which has the ability to reduce
S. mutans in the mouth
– Chewing gum
– Mints
– Powder
– Toothpaste
Early Childhood Caries
• Prevention
– Mother
– Child
• Diet
• Oral Hygiene
• Improving the oral microbiome