S UPPLEMENT April 2006 J ournal del’OrdredesdentistesduQuébec Childhood Caries Early Journal de l’Ordre des dentistes du Québec Summarywww.ordredesdentistesduquebec.qc.ca Early Childhood 3 The High Incidence of Early Childhood Caries in Kindergarten-age Children Caries Jean-Marc Brodeur, DDS, MSc, PhD Chantal Galarneau, DMD, MSc, PhD
6 Importance of Early Diagnosis of Early Childhood Caries Souad Msefer, DCD, DSO, Cert. Pedo. UPPLEMENT S April 2006 9 Prevention of Early Childhood Caries (ECC) Daniel Kandelman, DDS Nabil Ouatik, DMD
14 Pit and Fissure Sealants: Cover page design: An Important Adjunct in the Control of Childhood Caries Bronx Communications Inc. Charles Dixter, BSc, DDS, Cert. Pedo. Aaron Dudkiewicz, BSc, DDS, Cert. Pedo. Illustration: Marc Mongeau Irwin Fried, DDS, MS, Cert. Pedo, FRCD(C)
Production: Public Affairs and Communications 17 The Cariogenic Nature of Childhood Bedtime Rituals Ordre des dentistes du Québec Chantal Galarneau, DMD, MSc, PhD
Translation: Jean-Marc Brodeur, DDS, MSc, PhD Lorena Ermacora Lise Gauvin, PhD
Graphic design: Studio Artbec Inc. 20 Dietary Recommendations for Healthy Teeth in Children Impression: Monique Julien, MSc, MPH, Dr PH Litho Mag
ISBN 2-923500-00-8 Continuing Dental Education Program Test Your Knowledge
The Ordre des dentistes du Québec offers its members a chance to earn three continuing dental education credits by correctly answering the following questions. Write your answers legibly and concisely. Keep this answer sheet and submit it with your continuing dental education annual declaration when required by the Order.
1 Give a short definition of early childhood caries (ECC). 4 What are the consequences of ECC? ______
2 What children are most affected by ECC? 5 What steps are recommended to prevent ECC? ______
3 What are the telltale signs of ECC? Name: ______Permit No.: ______
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Jean-Marc Brodeur, DDS, MSc, PhD1 Chantal Galarneau, DMD, MSc, PhD2
The High Incidence of Early Childhood Caries in Kindergarten-age Children
Early childhood caries in pre-school children has Definition of early childhood caries been discussed extensively in the scientific literature A group of experts designated by the National over the past 40 years. A review of the most recent Institutes of Health to develop and adopt a studies shows that the dental community is looking consensus regarding a clinical definition and 1 at the problem with renewed interest and that more diagnostic criteria for these types of caries has also Key Words information is needed in regard to the epidemiology, adopted the term early childhood caries to describe • Definition etiology, diagnosis, prevention and treatment of caries in preschool-age children1. The following • Early childhood caries caries in children ages 0 to 5 years. This article clinical definition of early childhood caries (ECC) has • Epidemiology presents a definition of caries in pre-school children been proposed: • Prevention and discusses related epidemiological data from a 2 1998-99 study on the oral health of Québec The presence of one or more decayed schoolchildren in the 5-6 and 7-8 age ranges, in (non-cavitated or cavitated lesions), which 2,512 kindergarten students who were conside- missing (due to caries) or filled tooth red representative of their peers in Québec were surfaces in any primary tooth in a chosen at random. The examinations were performed preschool-age child between birth by 13 dentists/examiners who previously had received and 71 months of age. theoretical and practical training on WHO criteria for diagnosing caries for epidemiological inquiries. More specifically, experts recommend using the term Severe Early Childhood Caries (SECC) to designate all caries considered atypical, progressive, acute or Different terms to designate early childhood rampant. This category thus includes baby bottle caries tooth decay, nursing caries, maxillary anterior caries, The multitude of terms to describe caries in children labial caries, comforter caries, and rampant caries. ages 0 to 5 is emblematic of the confusion that exists Gagnon8 considers that SECC are merely an in the literature. The following expressions are used incidence of ECC under special or specific conditions. 1Dr. Jean-Marc Brodeur interchangeably: baby bottle tooth decay, early is a Professor at the childhood caries, early childhood dental decay, early Which teeth are the most susceptible to Department of social and preventative medicine and childhood tooth decay, comforter caries, nursing caries? a researcher at GRIS, caries, maxillary anterior caries, rampant caries, and ECC affect the primary teeth of infants and pre-school Université de Montréal. 3,4,5,6 many more . Some of these designations are used children. In their severest form, they sometimes Address specifically to illustrate the causes of tooth decay in correspondence to: appear as quickly developing lesions on the surface 3 C.P. 6128 preschool children . Baby bottle tooth decay is used of teeth with low susceptibility to caries, following the Succursale Centre-ville in the literature to identify inappropriate baby bottle usual eruption sequence9,10. Typically, the maxillary Montréal (Québec) 5 H3C 3J7 use as the main cause of caries disease . Other primary incisors are hit the hardest, followed by the or to authors prefer the term nursing caries because it first primary molars. The mandibular incisors normally jeanmarc.brodeur@ designates inappropriate bottle use and nursing are spared because they are covered by the tongue umontreal.ca 4,7 practices as the causal factors . However, the term during suction movements and are thus buffered early childhood caries is becoming increasingly against cariogenic liquids4,6,7,10. Saliva produced by 2Dr. Chantal Galarneau is a 1,3,6 dental consultant with the popular with dentists and dental researchers alike . nearby sublingual and submaxillary glands also Direction de la santé This broader term encompasses other, less buffers the mandibular incisors against acids publique de la understood, practices as etiological factors, such as Montérégie. produced by dental plaque. When the mandibular malnutrition, cariogenic childhood foods, and incisors are affected it is usually an indication that the bacterial transmission from mothers or caregivers to caries are caused by inappropriate pacifier use, or 6 children . simply that the child has a classic case of rampant caries4,6,7,10. Similarly, the primary canines and second
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primary molars, because of their later eruption, are usually Which children are more prone to early childhood spared or little affected by ECC. The ECC attack pattern caries? therefore depends on three factors: the timing of the tooth As is the case with other health problems15, oral health is a eruption, the time span of the harmful oral habit, and the type factor of social inequality. While 58% of kindergarten children 7 of muscle movements the child makes when sucking . have no caries on their temporary teeth, a small group of kindergarten children (24%) have five or more affected Many authors agree that the attack pattern of ECC changes at temporary surfaces, which account for 90% of all affected age three, when it begins to affect the first and second primary surfaces on temporary dentition for this age group (Fig. 1). molars3,11,12,13. These results suggest that a caries attack pattern should be established for different age categories of children The children with a high risk for caries have an average DMFS 1 ages 0 to 71 months. Drury et al recommend the use of six of 14.9, a rate six and a half times higher than that of children categories: under 12 months, 12-23 months, 24-35 months, with lower risk factors (DMFS=1 to 4). As for treatment needs 36-47 months, 48-59 months and 60 to 71 months. In fact, for caries on temporary dentition, 11.7% of kindergarten 10 according to Milnes and Bowen , practical experience has children have three or more surfaces requiring treatment, as shown that the cariogenicity of the foods parents use to nourish well as the majority (83%) of all surfaces requiring treatment or soothe their infants is a reliable indication of a child’s in that age group, while 77% of the children have no predisposition for subsequent caries when their diet changes temporary surface requiring treatment (Fig. 2). from liquids to solids. The type of solid or liquid food could well explain the differences in the ECC attack patterns at different An important fact to note is that children with a high incidence ages. of caries, and those who require extensive caries treatment, are mainly from poor families. Is there a high incidence of early childhood caries among the general population? Which teeth and surfaces have a higher incidence of The 1998-1999 study on the oral health of Quebec children early childhood caries? ages 5 and 6 reveals that upon entering kindergarten, 42% of Figure 3 illustrates the percentage of temporary teeth in children already had ECC on their primary teeth, with, on kindergarten-age children at the time of the exam that were 2 average, 3.9 carious surfaces . In the same vein as the affected by caries. provincial study, Corbeil et al14 reported that in 1994-1995, nearly 40% of children living in the Montérégie area had caries The most affected teeth were the four second molars and the on their primary teeth and an average of 3.4 carious surfaces mandibular first molars, with an incidence of 21% to 24% or absent or filled teeth. By kindergarten, the children had respectively, followed by the maxillary second molars (15%) nearly 70% of all the caries that would form on their temporary and the maxillary incisors (4% to 8%). The mandibular incisors 2 teeth . While it may be informative to compare the prevalence and the four canines were little affected. In addition, 45.7% of of ECC in Québec with international statistics, the obvious lack the carious temporary surfaces were pits and fissures, and of standardization in defining and establishing diagnostic were mostly occlusal (Fig. 4). criteria for ECC makes such comparisons impossible.
DMFS = 0 DMFS = 1 to 4 DMFS = 5 or + cs = 0 cs = 1 to 2 cs = 3 or + Average = 2.3 Average = 14.9 Average = 1.4 Average = 6.8
Percentage of children Percentage of surfaces requiring Percentage of children Percentage of caries treatment
Figure 1. Percentage of children according to the number of affected temporary Figure 2. Percentage of kindergarten children with 0, 1 or 2, or 3 or more surfaces (dmfs) temporary surfaces requiring treatment, and percentage of all surfaces requiring treatment in each of these three groups
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39.4% Occlusal Smooth surfaces Surfaces of pits surfaces 54.3% and fissures 45.7%
6.3% Other (buccal fissure on mandibular molars and lingual fissure on maxillary molars) (Percentage of modified DMFS of 96 surfaces)
Figure 4. Location of caries on the surfaces of pits and fissures and smooth surfaces
Figure 3. Percentage of carious temporary teeth in mouth in kindergarten children
Conclusion diagnostic criteria, and definition of caries in preschool-age Carious activity involving temporary dentition begins early and children with a view to making better comparisons of the 1,3 develops rapidly. By kindergarten age, the incidence of ECC is prevalence of caries in children around the world . already high. Furthermore, it is mainly concentrated among a small, vulnerable group of children who mostly come from Acknowledgements disadvantaged backgrounds. These data demonstrate how This study was made possible by the support of the Direction important it is for dental health care providers to encourage their générale de la santé publique du Québec. Detailed results patients to take their children to the dentist beginning at around were published in the “analyses et surveillance” collection of 12 months so that caregivers can be more informed about the Ministère de la Santé et des Services sociaux du Québec preventing ECC as soon as possible and the most disadvantaged 2001, Vol. 18. This document is also available in the clients can be given advice consistent with their challenges. The publications section of the Web site of the Ministère de la literature moreover advocates standardizing the terminology, Santé et des Services sociaux, at www.msss.gouv.qc.ca
Bibliography 8 Gagnon PF. Les habitudes alimentaires de la première enfance et l'apparition de la carie rampante. Journal dentaire du Québec. 1984 avril : 119-122. 9 Berkowitz RJ, Turner J, Hughes C. Microbial characteristics of the human den- 1 Drury TF, Horowitz AM, Ismail AI, Maertens MP, Rozier RG, Selwitz RH. tal caries associated with prolonged bottle-feeding. Arch Oral Biol. 1984 ; Diagnosing and reporting early childhood caries for research purposes. A 29(11) : 949-51. report of a workshop sponsored by the National Institute of Dental and 10 Milnes AR, Bowden GH. The microflora associated with developing lesions of Craniofacial Research, the Health Resources and Services Administration, nursing caries. Caries Res. 1985 ; 19(4) : 289-97. and the Health Care Financing Administration. J Public Health Dent. 1999 Summer ; 59(3) : 192-7. 11 Dini EL, Holt RD, Bedi R. Comparison of two indices of caries patterns in 3-6 year old Brazilian children from areas with different fluoridation histories. Int 2 Brodeur JM, Olivier M, Benigeri M, Bedos C, Williamson S. Étude 1998-1999 Dent J. 1998 Aug ; 48(4) : 378-85. sur la santé buccodentaire des élèves québécois de 5-6 ans et de 7-8 ans. Collection Analyse et Surveillance no18. Québec : ministère de la Santé et des 12 Mayanagi H, Saito T, Kamiyama K. Cross-sectional comparisons of caries time Services sociaux. Direction générale de la santé publique ; 1999. trends in nursery school children in Sendai, Japan. Community Dent Oral Epidemiol. 1995 Dec 23(6) : 344-9. 3 Ismail AI, Sohn W. A systematic review of clinical diagnostic criteria of early childhood caries. J Public Health Dent. 1999 Summer ; 59(3) : 171-91. 13 Seow WK, Amaratunge A, Bennett R, Bronsch D, Lai PY. Dental health of aboriginal pre-school children in Brisbane, Australia. Community Dent Oral 4 Dilley GJ, Dilley DH, Machen JB. Prolonged nursing habit: a profile of patients Epidemiol. 1996 Jun ; 24(3) : 187-90. and their families. ASDC J Dent Child. 1980 Mar-Apr ; 47(2) : 102-8. 14 Corbeil P, Brodeur JM, Noiseux M. Enquête sur la santé dentaire des écoliers 5 Lacroix I, Buithieu H, Kandelman D. La carie du biberon. Journal dentaire du de maternelle, deuxième et sixième année en Montérégie. Rapport final. Québec. 1997 ; XXXIV : 360-374. Québec : Direction de la santé publique de la RRSSS de la Montérégie ; 1996. 6Tinanoff N, O'Sullivan DM. Early childhood caries: overview and recent 15 Evans RG, Barer MR, Marmor TR. Why are some people healthy and others findings. Pediatr Dent. 1997 Jan-Feb ; 19(1) : 12-6. not?: the determinants of health of populations. New York : A. de Gruyter ; 7 Ripa LW. Nursing caries: a comprehensive review. Pediatr Dent. 1988 Dec ; 1994. 10(4) : 268-82.
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Souad Msefer, DCD, DSO, Cert. Pedo.
Importance of Early Diagnosis of Early Childhood Caries
1. Terminology affected too, while only the mandibular incisors are spared. Early childhood caries (ECC) is a particularly virulent 6 type of dental caries that can destroy the primary There are four stages in the development of ECC dentition of babies and pre-school children. EEC is considered a severe and rampant disease of the • The initial stage is characterized by the primary teeth that begins immediately after tooth appearance of chalky, opaque demineralization eruption. lesions on the smooth surfaces of the maxillary primary incisors when the child is between the The term baby-bottle tooth decay was commonly ages of 10 and 20 months, or sometimes even used to denote caries of the primary teeth in very younger. A distinctive whitish line can be young children, caused by prolonged use of a baby distinguished in the cervical region of the bottle at bedtime or even during the daytime. vestibular and palatal surfaces of the maxillary incisors. For some years now, the term early childhood caries has had widespread use. This term better reflects the At this stage, the lesions are reversible but are multi-factor etiological process of the disease1,2. frequently unrecognized by parents or the first physicians to examine the mouths of these very Among the other factors implicated are prolonged, young children. Moreover, the lesions can be on-demand breastfeeding, frequent consumption— diagnosed only after the affected teeth have been i.e., more than three times per day—of cariogenic thoroughly dried. snacks (cookies, candy, cake, and so forth), pediatric syrups, lack of fluoride toothpaste use, and the • The second stage occurs when the child is absence of fluoride in drinking water3,4. between the ages of 16 and 24 months. The dentin is affected when the white lesions on the Dr. Souad Msefer is a dental It has also been recognized that cariogenic bacteria incisors develop rapidly, causing the enamel to surgeon, doctor of can be transmitted from mother to child through collapse. The dentin is exposed and appears soft odontological sciences, and yellow. The maxillary primary molars present and pedodontic specialist, certain practices, for example, tasting the baby’s food and a former professor at the with the same spoon, or testing the temperature of initial lesions in the cervical, proximal and occlusal University of Casablanca. the nipple. In addition, poor oral hygiene in mothers regions (Photo 1). She is currently a PhD has been associated with a higher concentration of candidate in public health at 5 the Université de Montréal. micro-organisms in the mouth of their children . At this stage, the child begins to complain of great Address correspondence to: sensitivity to cold. The parents sometimes notice the 5390 Decelles, Suite 2 2. Diagnosis change of colour on their own and become Montréal (Québec) concerned. H3T 1V9 Early childhood caries is a serious and sometimes painful disease characterized by early onset and very • The third stage, which occurs when the child is rapid progression. The caries develop quickly, usually between 20 and 36 months, is characterized by right after the teeth erupt. Several teeth may be large, deep lesions on the maxillary incisors, and affected, beginning with the maxillary incisors, at the pulpal irritation. The child complains of pain when junction near the gums, followed by the canines. If chewing or getting his teeth brushed, and of the disease continues to progress, the molars are spontaneous pain during the night.
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Photo 1. Vestibular caries (stage1 and stage 2) in a three-year-old child Photo 2. Destruction of maxillary primary incisors with abscess facing 51 (Department of Pedodontics, Casablanca) (stage 4) (Department of Pedodontics, Casablanca)
At this point, the maxillary primary molars are at stage 2, 3. Repercussions while stage 1 can be diagnosed on the mandibular primary molars and the maxillary canines. Early childhood caries can have serious general and local repercussions in the short and long terms. • The fourth stage, which occurs between the ages of 30 and 48 months, is characterized by coronal fractures of the Following pulp necrosis, infection spreads to the pulpal- anterior maxillaries as a result of amelodentinal destruction periodontal region in one of two clinical forms: the acute form, (Photo 2). At this stage the maxillary incisors are usually characterized by cellulitis, adenopathy and mobility of the necrotized, and the maxillary primary molars are at stage 3. affected teeth, and the chronic form, which is the most The secondary molars and maxillary canines and the first common, characterized by abcesses and interdental septum mandibular molars are at stage 2. Some young children syndrome. Depending on the severity of the disease, infection suffer but are unable to express their toothache complaints. can spread to the buds of the permanent teeth, causing They experience sleep deprivation and refuse to eat. irreversible lesions. Complications from subsequent infections can occur in children already compromised by a generally A positive diagnosis is established on the basis of questions to weakened state of health8. parents regarding risk factors and a clinical endo-oral examination, completed by x-rays. Contrary to popular belief, the effects of caries in young children extend beyond the mouth. Tooth loss is sometimes A differential diagnosis is based on observations of hereditary inevitable, and it can cause not only orthodontic and esthetic 7 tooth structure anomalies such as infantile melanodontia , problems, but more importantly, difficulties in pronunciation. which primarily affects the maxillary incisors, and amelogenesis Esthetic problems and pronunciation difficulties may result in imperfecta, which affects the enamel of every tooth, and is a psychological and relationship problems. In addition, children hereditary disease of the dentin, characterized by an with ECC usually weigh less and are shorter than average9,10. opalescent, brownish tooth colour, and typical short roots. Their growth is affected because they have difficulty sleeping Enamel hypoplasia caused by malnutrition during the perinatal and eating as a result of the infection and pain, and their quality period or by a deficit in Vitamin A promotes a high caries of life is greatly diminished11. susceptibility and is often associated with early childhood caries2.
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Importance of Early Diagnosis...
Furthermore, it is very complicated and costly to treat caries in In conclusion, early diagnosis of early childhood caries and the very young children, who must undergo general anesthesia. identification of risk factors are essential to the implementation ECC is therefore a burden both for parents and society3. of preventative and curative measures to mitigate compli- cations and the repercussions of the disease. Physicians and Intervention at the early stage is necessary to prevent the nurses have more opportunities to see expectant mothers and destruction of the crown and stop the caries from progressing. their newborns than dentists do. It is therefore vital to It involves simple techniques to remineralize the enamel, such emphasize parental awareness of the seriousness of ECC so as topical applications of fluoride, fluoride solutions and that proper attention is placed on early detection and the fluoride varnishes12,14. elimination of risk factors.
Bibliography 8 Morrier JJ. La carie et ses complications chez l'enfant. Encycl. Med. Chir. Odontologie. 1998 ; 23 : 410-C-30. 9Ayhan H, Suskan E, Yildirim S. The effect of nursing or rampant caries on 1 American Academy of Pediatric Dentistry. 1997. Conference on early height, body weight and head circumference. J. Clin. Pediat. Dent. 1996 ; childhood caries, Bethesda, Md, Community Dent Oral Epidemiol. 20(3) : 209-212. 2 Horowitz HS. Research issues in early childhood caries. Community Dent 10 Thomas C, Primosch R. Changes in incremental weight and well-being of Oral Epidemiol. 1998 ; 26(suppl) : 67-81. children with rampant caries following complete dental rehabilitation. 3 Berkowitz Robert J. Causes, traitement et prévention de la carie de la petite Pediatr Dent. 2002 ; 24 : 109-113. enfance : perspective microbiologique. J Can Dent Assoc. 2003 ; 69(5) : 11 Low W, Tan S, Schwartz S. The effect of severe caries on the quality of life in 304-7. young children. Pediatr Dent 1999 ; 21 : 325-326. 4 Seow WK. Biological mechanisms of early childhood caries. Community 12 American Academy of Pediatric Dentistry (2004-2005). Clinical Guideline on Dent Oral Epidemiol. 1998 ; 26(suppl) : 8-27. Infant Oral Health Care. Clinical Guidelines. 5 Milgrom P. Psychosocial and behavioral issues in early childhood caries. 13 Donald W. Lewis and Amid I. Ismail (1995). Prévention de la carie dentaire, Community Dent Oral Epidemiol.1998 ; 26(suppl) : 45-8. groupe d`étude canadien sur les soins de santé préventifs. 6Veerkamp JS, Weerheim KL. Nursing caries bottle: the importance of a 14 Ismail Amid I. Prevention of early childhood caries. Community Dent Oral developmental perspective. J Dent Child. 1995 ; 22(6) ; 381-386. Epidemiol. 1998 ; 26(suppl) : 49-61. 7 Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Community Dent Oral Epidemiol. 1998 ; 26(suppl) : 32-44.
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Daniel Kandelman, DDS1 Nabil Ouatik, DMD2
Prevention of Early Childhood Caries (ECC)
Early childhood caries (ECC) unfortunately is still a I Prevention of ECC at the dentist’s office common disease in young children. It is defined and community centres clinically as the presence of one or more decayed (non-cavitated or cavitated lesions) that can develop Working together with other stakeholders in the extremely quickly and lead to the widespread and community gives dentists access to skills and tools sometimes painful deterioration of the primary that aid in the prevention of ECC13,14. A dental health dentition1,2,3. promotion program presented in books, brochures, stickers or videos and made available in dentists’ The etiology of ECC is multifactorial and has been offices and community centres can potentially lower well established. ECC is frequently associated with a the incidence of ECC in communities at high risk for poor diet4 and bad oral health5 habits. caries16.
Severe ECC quickly destroys the smooth surfaces of This type of dental health promotion program must teeth that are usually considered low risk6; recent be geared to expectant parents or the parents of very studies have underscored the infectious nature of young children. The dentist’s office can become the this disease and its transmission from mother to centre of a new prevention concept aimed at child7,8. One study showed that streptococcus mutans families17,18 as the dentist acts in tandem with other genotypes in children were similar to those of their health professionals to meet the full range of family respective mothers in 71% of cases among 34 needs. The dentist could make the pediatricians in mother-child pairs9. However, this study was unable his area aware of the importance of preventing EEC to highlight the father-child transmission indices but and being on the lookout for the disease during the did reveal a possible transfer of microorganisms child’s first visits (for instance, during vaccination among children in daycare settings10. appointments). In addition, practitioners can work in cooperation with the public dental health network. The most common transmission modes were Multidisciplinary collaborations of this nature are 1Dr. Daniel Kandelman is mother and child using the same spoon, contact essential to an effective program. the departmental Director between the mother’s saliva and the child’s mouth, and a Professor at the improper baby bottle use, and family members using II Preventing ECC before conception and Department of oral health, Faculty of dentistry, the same toothbrush. during pregnancy Université de Montréal. Address ECC most frequently affects people in low socio- The expectant mother should be monitored for correspondence to: 11 C.P. 6128 economic levels . A longitudinal study on the dental problems during pregnancy and given the Succursale Centre-ville development of Quebec children (ELDEQ) revealed appropriate prevention recommendations before the Montréal (Québec) that living in disadvantaged conditions from birth birth of her baby. This step is all the more necessary H3C 3J7 increases a child’s risk of developing caries by 112%, or to because the parents will not be seeing the dentist daniel.pierre.kandelman@ as compared to growing up in wealthier circum- again for several months, when bad habits may be umontreal.ca stances12. entrenched and already causing a proliferation of carious lesions at advanced stages of decay. An 2Dr. Nabil Ouatik is a In view of the infectious nature of ECC and the resident in pediatric evaluation of individual risk for caries is very dentistry and a graduate transmission mode of the microorganisms respon- necessary, as it is the first step in defining and student at the Faculty of sible for the development of caries7,8, it is important optimizing preventive and therapeutic strategies. This dentistry, Université de to develop a hygiene education and prevention plan Montréal. step should only be carried out when the dentist has with parents during the first visits. This plan should noted poor oral health and/or eating habits or when take into account the family’s living conditions and there is a high incidence of active caries in the sociocultural environment. expectant mother or her family.
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The evaluation of the risk for caries during pregnancy must take of rice)26. Parents should be taught how to brush their baby’s the following into account: teeth, either by resting the baby against them, or laying the baby on their lap with his head between their legs. These • The presence of carious lesions and the degree of caries positions will give them the control they need to accomplish activity. the task. When the baby reaches the age of one, his teeth • A quantitative and qualitative evaluation of dental plaque should be brushed twice a day with a small toothbrush and (colour, number of streptococcus mutans and/or water and fluoride toothpaste (about the size of a pea)26. lactobacillus colonies). Between the ages of 18 and 24 months, the child can learn to • Evaluation of the salivary pH, the saliva’s buffering effect, brush his teeth under adult supervision. and salivary flow. • An analysis of the mother’s diet. In addition, parents should not try to soothe a crying or agitated • Evaluation of the extent of individual resistance by looking baby with candy, a pacifier dipped in sugar, or a bottle at the morphological structure of the teeth, the presence of containing a sweet drink. numerous initial carious lesions, and past fluoride use. Lastly, it is important to talk to expectant parents about the Together, these tests will help confirm the dentist’s clinical importance of the first dentist’s visit. impressions, determine the existence of one or more preponderant risk factors (bacteria, nutrition, saliva or individual III After the birth resistance) and prepare a preventive and therapeutic strategy that will provide a more targeted and effective response to the Baby’s first dental visit should be during the first year of life, etiological factors identified19. At this stage, the provider will preferably during the first six months following the eruption of have to control the bacteria and eliminate the sources of his first teeth, but no later than his first birthday25,27. During the infection, in view of the risk of bacterial transmission. first visit, the dentist will examine the baby’s mouth and give specific oral care advice for preventing ECC. The bacteria control phase consists in reducing the number of bacteria, and more specifically, reducing the amount of It is important to talk with parents about the following points: streptococcus mutans on the surface of the teeth. A number of treatments are available for this purpose, including the • Verifying and reinforcing the information and advice given application of varnishes with a high fluoride concentration or during pregnancy. chlorhexidine varnishes (with or without a mouthguard)20. • Reinforcing that the child should not be given cariogenic substances in his bottle at bedtime. The sources of infection21 must be eliminated as soon as • Encouraging healthy eating and limiting sugary foods by possible by debriding the carious lesions and placing suggesting other types of sweeteners. temporary fillings (zinc oxide eugenol, calcium hydroxide, or • Cleaning the child’s teeth as soon as they begin to erupt. glass ionomer cements) in order to stabilize the patient’s • Encouraging the child to drink out of a cup around his first condition and lower contamination risks. Further restorations birthday, and then progressively limiting the use of the should not be contemplated until the level of carious activity bottle between the ages of 12 and 16 months26. has been fully controlled. • Observing the baby’s early habits such as thumb sucking, so that the caregiver can receive timely instructions in The mother could use substitutes like xylitol (gum or candy) correcting it28, even if that means giving the child a pacifier. during the pregnancy. She may continue this habit after the No connection has been noted between pacifier use (as birth as well22. Every member of the family should take part in long as it has not been dipped in a sweetener) and ECC29. an oral hygiene education program if a high risk for caries is present. Naturally, this should be accompanied by routine If the provider notices ECC once the primary teeth have maintenance and reinforcement programs. erupted, he must evaluate the child’s risk for caries just as he did with the expectant mother. Given hormone fluxes that occur during pregnancy and regardless of the risk level for caries, it is important to He must also prepare a personalized prevention program and periodically monitor the dental health of expectant mothers. choose a fluoride therapy (systemic and topical) according to However, fluoride supplements are not recommended before the caries risk and the patient’s age in order to enrich the the baby is born23,24. fluoride of the budding teeth’s enamel and increase the caries resistance of the teeth that have already erupted. Once the baby’s first tooth erupts, the child’s mouth must be cleaned with a wet cloth25 or with a child’s toothbrush and a Fluoride supplements (0.25 mg) are not recommended for small amount of fluoride toothpaste (about the size of a grain low-risk children under the age of three. For high-risk children,
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Prevention of Early Childhood Caries...
fluoride tablets (0.25 mg) are recommended beginning at the Lastly, it would be important to schedule children at risk for age of 6 months, i.e. when the child first visits the dentist30. regular three-month check-ups and to stay in touch with parents in order to provide proper follow-up. In all cases, before prescribing it is very important to: IV The challenges ahead • Evaluate the risk for caries • Ensure that the child is not drinking fluoridated water or Despite a dental health provider’s efforts to implement a taking fluoride supplements (in vitamins) prevention program, sometimes the outcome does not meet • Adjust the dosage schedule in consultation with the expectations43. attending pediatrician • Evaluate other possible sources of systemic ingestion (total The prevention program must be accompanied by individual 31 daily ingestion must not exceed 0.05-0.07 mg F-/ kg ) counselling of the parents. A psychological approach should be emphasized, one that provides feedback on performance and The success of fluoride therapy depends on the parent’s encourages children to be proactive (by learning and motivation and participation, regular check-ups and adjusting integrating oral health techniques and adopting a healthy daily the dose depending on the dosage schedule. diet)44.
Brushing the teeth with a fluoride toothpaste must immediately The collaboration of practitioners with the public health be added to the child’s daily oral health regimen as soon as his network, particularly with respect to coordinating and first primary tooth erupts. developing dental health promotion activities, must be strengthened so that greater numbers of parents and/or The use of topical fluoride in the form of a varnish or gel is children will receive advice and preventive care under the beneficial but not recommended before the child turns one. It programs of the public dental health care network45. could be used to foster the protection of the smooth surfaces of primary teeth and the remineralization of the first carious Conclusion lesions32,33. The etiological factors of EEC are known, and there is an Chlorhexidine varnishes can be used in children between the arsenal of preventive and curative therapies available to help ages of 3 and 4 with a high risk for caries, in order to reduce practitioners prevent and properly control EEC. the quantity of streptococci within the dental plaque and as a tool for the bacterial control phase. This may be a preferred 34,35 EEC prevention is an essential component in any dental health method when traditional methods are not enough . promotion program, providing a solid foundation for the Unfortunately, these products are not available in Canada. optimal development of children. Sealing agents are evidently entirely indicated to prevent occlusal caries of the primary molars36,37, and should be used beginning at age 3 after consideration of the caries risk and clinical recommendations.
Substituting sugar with xylitol22,38 or other artificial sweeteners (sorbitol and mannitol) in candy, and the recent appearance of products made with casein phosphopeptide or amorphous calcium phosphate39,40,41,42 (in chewing gum and toothpaste) will have interesting applications in preventing EEC in the future. These products may help remineralize teeth by binding themselves to the biofilm, the dental plaque and the hard and soft tissues of the mouth and liberating calcium and phosphate ions into the saliva. Further research will be necessary to determine optimal frequency of use and the recommended applications according to age.
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SUMMARY OF THE SUGGESTED RECOMMENDATIONS FOR PREVENTING EARLY CHILDHOOD CARIES
Age During 6-12 12-24 2-6 pregnancy months months years Dental exam Periodical X X X X-rays of dental and bone development X Meeting with the pediatrician X X X Evaluation of bad habits (thumb sucking) X X X Prevention of childhood dental injuries and traumas X X X Evaluation of caries risk through bacterial and saliva tests High risk X X X X Low risk Infection control and elimination of infection sources High risk X X2 XX Low risk Systemic fluoride High risk X X X Low risk X1 Topical fluoride High risk X X X
3 Low risk X X4 XX Learning about oral hygiene and monitoring oral hygiene routines Mother and other family members X X X X Baby X2 XX Artificial sweeteners—chewing gum or candy (High caries risk) X X Sealants for pits and fissures in primary teeth X
1 Starting at age 3 • 2 When first tooth erupts • 3 Fluoride toothpaste and mouthwash • 4 Fluoride toothpaste • 5 Chlorhexidine varnish
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Bibliography 23 Driscoll WS. A review of clinical research on the use of prenatal fluoride administration for prevention of dental caries. ASDC J Dent Child 1981 ; 48(2) : 109-17. 1 American Academy of Pediatric Dentistry. Definition of Early Childhood 24 Sa Roriz Fonteles C, Zero DT, Moss ME, Fu J. Fluoride concentrations in Caries (ECC). Reference Manual 2004-2005, Chicago, 1 p. enamel and dentin of primary teeth after pre- and postnatal fluoride 2 Kaste LM, Drury TF, Horowitz AM, Beltran E. An evaluation of NHANES III exposure. Caries Res 2005 ; 39(6) : 505-8. estimates of early childhood caries. J Public Health Dent 1999 ; 59(3) : 198- 25 American Academy of Pediatric Dentistry. Clinical Guideline on Infant Oral 200. Health Care. Reference Manual 2004-2005, Chicago, 4 p. 3 Drury TF, Horowitz AM, Ismail AI, Maertens MP, Rozier RG, Selwitz RH. 26 Doré N, Le Hénaff D, Turcotte P. Mieux vivre avec notre enfant de la Diagnosing and reporting early childhood caries for research purposes. A naissance à deux ans : Guide pratique pour les mères et les pères ; Chapitre report of a workshop sponsored by the National Institute of Dental and sur les soins de la bouche et des dents. Québec ; 2006, p. 351-363. Craniofacial Research, the Health Resources and Services Administration, and the Health Care Financing Administration. J Public Health Dent 1999 ; 27 Kowash MB, Pinfield A, Smith J, Curzon ME. Effectiveness on oral health of 192-7. a long-term health education programme for mothers with young children. Br Dent J 2000 ; 188(4) : 201-5. 4 Davies GN. Early childhood caries-a synopsis. Community Dent Oral Epidemiol 1998 ; 26(1 Suppl) : 106-16. 28 American Academy of Pediatric Dentistry. Policy on Oral Habits. Reference Manual 2004-2005, Chicago, 2 p. 5 Berkowitz RJ. Causes, treatment and prevention of early childhood caries: a microbiologic perspective. J Can Dent Assoc 2003 ; 69(5) : 304-7. 29 Peressini S. Pacifier use and early childhood caries: an evidence-based study of the literature. J Can Dent Assoc 2003 ; 69(1) : 16-9. 6 Ismail AI, Sohn W. A systematic review of clinical diagnostic criteria of early childhood caries. J Public Health Dent 1999 ; 59(3) : 171-91. 30 Limeback H, Ismail A, Banting D, DenBesten P, Featherstone J, Riordan PJ. Canadian Consensus Conference on the appropriate use of fluoride 7 Davey AL, Rogers AH. Multiple types of the bacterium Streptococcus mutans supplements for the prevention of dental caries in children. J Can Dent Assoc in the human mouth and their intra-family transmission. Arch Oral Biol 1984 ; 1998 ; 64(9) : 636-9. 29(6) : 453-60. 31 Swan E. Dietary fluoride supplement protocol for the new millennium. J Can 8 Berkowitz RJ, Jones P. Mouth-to-mouth transmission of the bacterium Dent Assoc 2000 ; 66(7) : 362. Streptococcus mutans between mother and child. Arch Oral Biol 1985 ; 30(4) : 377-9. 32 American Academy of Pediatric Dentistry. Clinical Guideline on Fluoride Therapy. Reference Manual 2004-2005, Chicago, 2 p. 9 Li Y, Caufield PW. The fidelity of initial acquisition of mutans streptococci by infants from their mothers. J Dent Res 1995 ; 74(2) : 681-5. 33 Donly KJ. Fluoride varnishes. J Calif Dent Assoc 2003 ; 31(3) : 217-9. 10 Mattos-Graner RO, Li Y, Caufield PW, Duncan M, Smith DJ. Genotypic diversity 34 Almeida AG, Roseman MM, Sheff M, Huntington N, Hughes CV. Future caries of mutans streptococci in Brazilian nursery children suggests horizontal susceptibility in children with early childhood caries following treatment transmission. J Clin Microbiol 2001 ; 39(6) : 2313-6. under general anesthesia. Pediatr Dent 2000 ; 22(4) : 302-6. 11 Brodeur JM, Olivier M, Benigeri M, Bedos C, Williamson S. Étude 1998-1999 35 Alaki SM, Loesche WJ, da Fonesca MA, Feigal RJ, Welch K. Preventing the sur la santé buccodentaire des élèves québecois de 5-6 ans et de 7-8 ans. transfer of Streptococcus mutans from primary molars to permanent first Québec : Ministère de la Santé et des Services sociaux, Direction générale de molars using chlorhexidine. Pediatr Dent 2002 ; 24(2) : 103-8. la santé publique ; 2001. 36 American Academy of Pediatric Dentistry. Clinical Guideline on Pediatric 12 Paquet G, Hamel D. Des alliés pour la santé des tout-petits vivant au bas de Restorative Dentistry. Chicago (IL) : American Academy of Pediatric Dentistry l'échelle sociale. Étude longitudinale du développement des enfants du 2004. 9 p. Québec (ÉLDEQ 1999-2002) 2005 ; 3(4) : 7-8. 37 Tinanoff N, Douglass JM. Clinical decision-making for caries management in 13 Harrison R. Oral health promotion for high-risk children: case studies from primary teeth. J Dent Educ 2001 ; 65(10) : 1133-42. British Columbia. J Can Dent Assoc 2003 ; 69(5) : 292-6. 38 Hujoel PP, Makinen KK, Bennett CA, Isotupa KP, Isokangas PJ, Allen P, et al. 14 Hamilton FA, Davis KE, Blinkhorn AS. An oral health promotion programme The optimum time to initiate habitual xylitol gum-chewing for obtaining for nursing caries. Int J Paediatr Dent 1999 ; 9(3) : 195-200. long-term caries prevention. J Dent Res 1999 ; 78(3) : 797-803. 15 Alsada LH, Sigal MJ, Limeback H, Fiege J, Kulkarni GV. Development and 39 Cross KJ, Huq NL, Stanton DP, Sum M, Reynolds EC. NMR studies of a novel testing of an audio-visual aid for improving infant oral health through calcium, phosphate and fluoride delivery vehicle-alpha(S1)-casein(59-79) primary caregiver education. J Can Dent Assoc 2005 ; 71(4) : 241. by stabilized amorphous calcium fluoride phosphate nanocomplexes. Biomaterials 2004 ; 25(20) : 5061-9. 16 Bruerd B, Kinney MB, Bothwell E. Preventing baby bottle tooth decay in American Indian and Alaska native communities: a model for planning. 40 Itthagarun A, King NM, Yiu C, Dawes C. The effect of chewing gums Public Health Rep 1989 ; 104(6) : 631-40. containing calcium phosphates on the remineralization of artificial caries-like lesions in situ. Caries Res 2005 ; 39(3) : 251-4. 17 Porangannel L, Titley KC, Kulkarni GV. Establishing a dental home: A program for promoting comprehensive oral health starting from pregnancy through 41 Reynolds EC. Remineralization of enamel subsurface lesions by casein childhood. Oral health 2006 ; 96(1) : 3-4. phosphopeptide-stabilized calcium phosphate solutions. J Dent Res 1997 ; 76(9) : 1587-95. 18 Nowak AJ, Casamassimo PS. The dental home: a primary care oral health concept. J Am Dent Assoc 2002 ; 133(1) : 93-8. 42 Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC. Remineralization of enamel subsurface lesions by sugar-free chewing gum containing casein 19 Kandelman D. La dentisterie préventive de l'an 2000. L'Information Dentaire phosphopeptide-amorphous calcium phosphate. J Dent Res 2001 ; 80(12) : 1999 ; 81(31) : 2185-89. 2066-70. 20 Achong RA, Briskie DM, Hildebrandt GH, Feigal RJ, Loesche WJ. Effect of 43 Tinanoff N, Daley NS, O'Sullivan DM, Douglass JM. Failure of intense chlorhexidine varnish mouthguards on the levels of selected oral preventive efforts to arrest early childhood and rampant caries: three case microorganisms in pediatric patients. Pediatr Dent 1999 ; 21(3) : 169-75. reports. Pediatr Dent 1999 ; 21(3) : 160-3. 21 Kohler B, Bratthall D. Intrafamilial levels of Streptococcus mutans and some 44 Tinanoff N, O'Sullivan DM. Early childhood caries: overview and recent aspects of the bacterial transmission. Scand J Dent Res 1978 ; 86(1) : 35-42. findings. Pediatr Dent 1997 ; 19(1) : 12-6. 22 Isokangas P, Soderling E, Pienihakkinen K, Alanen P. Occurrence of dental 45 Ministère de la Santé et des Services sociaux, Plan stratégique 2005-2010, decay in children after maternal consumption of xylitol chewing gum, a Axe promotion et prévention, Québec, 2005, p. 27. follow-up from 0 to 5 years of age. J Dent Res 2000 ; 79(11) : 1885-9.
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Charles Dixter, BSc, DDS, Cert. Pedo.1, Aaron Dudkiewicz, BSc, DDS, Cert. Pedo.2 Irwin Fried, DDS, MS, Cert. Pedo, FRCD(C)3
Pit and Fissure Sealants: An Important Adjunct in the Control of Childhood Caries
»Summary The dental literature clearly supports the use of pit and fissure sealants as a safe and effective, although Key Words underused, treatment in caries prevention. It is best used for high caries risk populations and it requires • Dental caries diagnosis and application by trained dental personnel paying close attention to proper protocol. • Fissure sealants Sealant application requires periodic follow-up examinations and repair to ensure its efficacy and its cost •Pediatric dentistry effectiveness. • Preventive dentistry
Although the occlusal surface is only one of five have extended into dentin are more appropriately coronal tooth surfaces, it accounts for more than two- treated with conservative preventive resin thirds of the dental caries experienced by children1. restorations which incorporate sealants, composite This statistic, along with the rise in dental caries in resin, or amalgam restorations1. Quebec, requires that we use all available treatment modalities to control decay. Among these is the The teeth selected to be sealed are typically first and application of pit and fissure sealants into the second permanent molars, pre-molars and then occlusal fissures of caries-susceptible teeth thus primary molars3. The caries risk assessment of both forming a bonded protective layer preventing the patient and the tooth are important determinants 1Dr. Charles Dixter is a nutrients from reaching caries-producing bacteria2. of the need for sealants. The risk of caries in fissures pediatric dentist in private This treatment was first reported by Cueto and extends beyond early childhood and post-eruptive practice in Montréal. 3 Address correspondence to Buonocore in 1967 and has been highly recom- age alone should not be considered a major criterion 4141, rue Sherbrooke mended in dentistry. Recent studies have showed for sealant application. The caries risk level of our Ouest, suite 350 Montréal (Québec) that after eight years about 80% of the sealed patient population and the absence or presence of H3Z 1B8. fissures had sealant retention and no caries, and fluoride programs are key determinants to be another 16% of the sealed occlusal surfaces had considered5. The indiscriminate use of sealants in 2Dr. Aaron Dudkiewicz is partial sealant retention and no caries. After ten years low-caries risk situations reduces the cost an Assistant Professor at the Faculty of Dentistry, only 6% of the sealed occlusal surfaces showed any effectiveness of the treatment and should not be 4 McGill University. He also caries or restorations . These results clearly directed to all occlusal surfaces nor to all teeth with maintains a private practice underscore that sealants are a very effective fissures1,5. Appropriate decisions include past caries in Montréal. treatment in the control of dental decay, and yet only history, present oral hygiene, fluoride history, sound 18.5% of U.S. children aged 5-17 years had sealants clinical examination and appropriate dental 3Dr. Irwin Fried is the 3 Director of the Division on their permanent teeth . radiographs. of Pediatric Dentistry and an Assistant Professor at the Faculty of Dentistry, The task at hand is to revisit this treatment and Key to Sealant Success McGill University. He also reintegrate pit and fissure sealants into our practices. maintains a private practice Sealants should be used for caries prevention in at- in Montréal. The key factor to completing successful sealants is risk caries-free teeth and as therapy for incipient proper tooth isolation. Wherever possible, a rubber 5 carious lesions limited only to enamel . Caries that dam should be used. This will aid in both moisture
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Pit and Fissure Sealants: An Important Adjunct...
Figure 1. Figure 2.
control and keeping oral structures away from the teeth being 6. Rinse thoroughly treated. Alternatively, maintaining a dry field of operation can 7. Acid etch the surface with phosphoric acid for 15–20 be accomplished by using a four-handed dentistry technique seconds (both permanent and primary teeth) (Figure 2) which is recommended when other methods of isolation such 8. Rinse well for 15 seconds as cotton rolls, dry angles or Garmers clamps are used. 9. Air dry the surface thoroughly to ensure a frosty white, Teeth being selected for sealant application should be chalky enamel (Figure 3) caries–free. Both a clinical and radiographic examination are 10. Where required, apply a drying agent/bonding agent required. Any dentin decay present precludes the use of a (depending on which system is used ) sealant and alternative treatment such as preventive resin 11. Re-dry the tooth restoration, composite resin, and possibly amalgam restoration 12. Apply a thin layer of sealant-tease the sealant through the should be considered. Enamel with suspect fissures involving grooves with a brush or explorer (Figure 4) incipient enamel decay should be prepared and the suspect 13. Cure the sealant for 20-30 seconds grooves cleaned of all decay prior to the sealant application. Enamel preparation can be carried out by use of a slow-speed 14. Check the sealant for voids or defects, if necessary add round bur, air abrasion, or a high-speed fissurotomy bur. This more preparation of the tooth and removal of unsupported enamel 15. Verify the occlusion has shown to increase bond strength and retention of the 16. Where required, adjust the occlusion and polish the sealants. sealant with a multi-fluted finishing bur 17. Reevaluate the sealant at recall appointments Protocol for Sealant Placement Sealants have shown excellent success and retention rates4. 1. Examine tooth clinically and radiographically The most important cause for failure is poor tooth isolation and 2. Apply rubber dam, or other tooth isolation (Figure 1) the ensuing saliva contamination. Other causes of failure 3. Prepare tooth include poor tooth surface preparation and/or failure of the sealant bond resulting in microleakage. This can lead to sealant Reassess the presence or absence of decay 4. loss and the potential for overt caries6. 5. Clean the fissures with a brush with/without pumice
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Pit and Fissure Sealants: An Important Adjunct...
Figure 3. Figure 4.
Conclusions treatment is highly technique sensitive. This treatment, as all dental treatments, is most effective when proper recall Pit and fissure caries are responsible for the greatest share of examination is performed and where necessary, resealing is the dental caries experience in childhood. The dental literature done to ensure the maximum protection against dental caries. clearly supports the placement of pit and fissure sealants on surfaces judged to be at high risk or on surfaces that exhibit The authors wish to thank Dr. Erle Schneidman for the use of incipient enamel caries. The success and cost effectiveness of his photographs in the preparation of this article. sealants require that careful attention be paid to protocol as the
Bibliography
1Waggoner WF, Siegal M. Pit and fissure sealant application: updating the technique. JADA 1996 ; 127 : 351-361. 2 Simonsen RJ. Pit and fissure sealant: review of the literature. Pediatric Dentistry 2002 ; 24 (5) : 393-414. 3 Primosch RE, Barr ES. Sealant use and placement techniques among pediatric dentists. JADA 2001 ; 132 (10) : 1442-1451. 4Wendt LK, Koch G, Birkhed D. On the retention and effectiveness of fissure sealants in permanent molars after 15-20 years: a cohort study. Community Dent Oral Epidemiol. 2001 ; 29 (4) : 302-307. [OVID]. 5Feigal RJ. The use of pit and fissure sealants. Pediatric Dentistry 2002 ; 24(5) : 415-422. 6 Bryant CL. Point of care. JCDA 2005 ; 71 (6) : 417-418.
16 JODQ - Supplement - April 2006 Scientific Article
Chantal Galarneau, DMD, MSc, PhD1 Jean-Marc Brodeur, DDS, MSc, PhD2, Lise Gauvin, PhD3
The Cariogenic Nature of Childhood Bedtime Rituals
Perinatal educators teach parents to develop an conducted with 776 mothers of children between evening ritual to help their children go to sleep1. As a the ages of 15 and 18 months. Data was gathered result, mothers use a variety of bedtime strategies, though a self-administered 36-question survey. Key Words which sometimes involve giving the child sugar. This • Early childhood caries practice increases their child’s risk for caries, Frequency of bedtime rituals and their • Prevention particularly because salivary flow diminishes at night, cariogenicity 2 • Soothing reducing its buffering and cleansing effect . Parents Figure 2 shows the various ways mothers comfort are more inclined to settle for caries-causing rituals at their children at bedtime. Among some of the bedtime because of their own fatigue at the end of strategies that involve little or no cariogenic activity, the day. The goals of this article are illustrated in four routines are the most popular with mothers: Figure 1: First, we provide an overview of different 57% rock their child, 47% put on music or use a bedtime rituals that mothers use, followed by a mobile, 33% read a story, and 23% stay by the description of cariogenic practices. child’s bedside until he falls asleep.
We then try to determine the extent to which caries- Twenty-nine percent of mothers expose their children causing soothing rituals have become a public health to dental caries by putting them to bed every night problem by analyzing data from a study carried out in with a bottle of milk. Studies4 have shown that when 2002 in the Montérégie3 (a large region southwest of the oral flora comes into contact with lactose with the island of Montréal, whose residents adequately increasing frequency and for longer periods of time, represent the rest of the population). The study was the cariogenic bacteria metabolize the lactose quickly,
1Dr. Chantal Galarneau is a dental consultant at the Direction de la santé publique de la Montérégie. Address correspondence to: 1255 rue Beauregard Longueuil (Québec) J4K 2M3 or to c.galarneau@ rrsss16.gouv.qc.ca
2Dr. Jean-Marc Brodeur is a professor at the Department of social and preventive medicine and a researcher at GRIS, Université de Montréal.
3Dr. Lise Gauvin is a professor at the Department of social and Est-ce un problème preventive medicine and a researcher at GRIS, de santé publique ? Université de Montréal, and at Centre Léa-Roback sur les inégalités sociales de santé de Montréal Figure 1. Soothing routines used by mothers at their child’s bedtime
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The Cariogenic Nature of Childhood...
Figure 2. Frequency of soothing routines used by mothers at their child’s bedtime and risk of caries in children
thereby causing a risk for the development of early childhood mothers from wealthier backgrounds. In all, 60% of mothers caries (ECC). According to researchers4, daily use of a baby from disadvantaged backgrounds use caries-causing soothing bottle with cow’s milk at bedtime may be sufficient to routines. These statistics suggest that these cariogenic practices demineralize the enamel, while its occasional use does not are spawning a major public health problem because children seem to increase the risk for ECC. Despite the efforts of dental are ingesting sugars that harm their teeth, the practices are care providers to raise parental awareness of the role of sugar sufficiently widespread, and they occur widely among mothers in the development of ECC, some mothers still resort to using from disadvantaged backgrounds. sugary foods to soothe their children at bedtime: 9% give a sweet treat, 9% give a highly cariogenic drink either in a cup or What is the role of dentists in preventing early in a bottle that is taken directly to bed, while 2% give candy. childhood caries associated with soothing routines? And although these mothers use cariogenic foods to soothe In summary, the data speaks for itself: there is a clear need for their children, most of them also use other strategies that do early intervention. Parental practices that begin in the early not involve cariogenic foods, as described in Figure 2. stages of a child’s life forge the child’s early food preferences, and even dictate their long-term ones5,6. We believe that as Are caries-causing rituals a public health problem? dental health providers, we can help prevent ECC associated Mothers use a variety of bedtime rituals that have different with caries-causing soothing routines by recommending that levels of cariogenicity. Figure 3 classifies mothers according to our very young patients first visit the dentist as soon as their the cariogenicity level of the methods they use. first tooth erupts, or no later than their first birthday. During this visit, parents should be made aware of ECC and encouraged to Sugary foods known to be highly cariogenic are used in the adopt healthy soothing routines at the child’s bedtime. soothing routines of 16% of the mothers surveyed. Twenty-five percent of mothers do not use sugary foods but include a baby However, we must be understanding with families in poor bottle in their daily soothing routine. In all, a total of 41% of circumstances. Their daily life is such that cariogenic practices mothers include caries-causing practices in their bedtime are well-entrenched at bedtime, and they see a real problem rituals. Poverty tends to lead to increased use of sugary foods. in stopping their soothing strategies. It is our duty to ensure About one out of three mothers in difficult socio-economic that the child is sufficiently exposed to fluoride in order to circumstances expose their children to highly cariogenic foods minimize the risk of ECC associated with these soothing to help them fall asleep, as compared to one out of six routines. According to Burt and Pai7, the ingestion of sugars
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The Cariogenic Nature of Childhood...
30 000$ et plusmoins de 30 000$ Tous * Does not exclude the use of other practices with potential, low or no cariogenicity. ** Does not exclude the use of other practices with low or no cariogenicity Figure 4.
Figure 3. Classification of mothers according to the caries-causing soothing routines used at their child’s bedtime and their annual family income
represents a moderate to low risk in children with sufficient Acknowledgements exposure to fluoride, but a high risk for those with no fluoride This study was made possible by a grant from the Réseau de exposure. recherche en santé buccodentaire du Québec, the technical and financial support of the Direction de la santé publique de Brushing with fluoride toothpaste before bedtime should be la Montérégie, and a PhD scholarship awarded to Dr. recommended, particularly when sugary foods are ingested Galarneau by the FRSQ. right before sleep. Toothbrushing dislodges dental plaque and exposes the teeth to fluoride. The introduction of fluoride toothpaste is now recommended as soon as the first teeth Bibliography erupt, as this will allow the fluoride to work topically and 1 systemically . For very young children at risk for dental caries, or 1 Institut national de santé publique du Québec. Mieux vivre avec notre enfant : parents who have considerable difficulty brushing their de la naissance à deux ans : guide pratique pour les mères et les pères. Montréal : Institut national de santé publique du Québec ; 2004-2005. children’s teeth, and for children who do not like the taste of 2 Ripa LW. Nursing caries: a comprehensive review. Pediatr Dent. 1988 ; Dec toothpaste, fluoride supplements or fluoride varnishes are 10(4) : 268-82. good ways to reduce the risk of ECC associated with soothing 3 Galarneau, C. Habitudes d’apaisement cariogènes utilisées par les mères au routines that have caries-causing effects. moment de coucher leur enfant pour la nuit. Thèse de doctorat. Université de Montréal ; 2006. 4 Birkhed D, Imfeld T, Edwardsson S. pH changes in human dental plaque Lastly, if there is one thing we should remember about from lactose and milk before and after adaptation. Caries Res. 1993 ; preventing ECC associated with caries-causing soothing 27(1) : 43-50. routines, it is that we must broach the subject with our patients 5 Rossow I, Kjaernes U, Holst D. Patterns of sugar consumption in early at the earliest opportunity. This will give them a good start in childhood. Community Dent Oral Epidemiol. 1990 Feb ; 18(1) : 12-6. 6 Grindefjord M, Dahllof G, Nilsson B, Modeer T. Stepwise prediction of dental introducing healthy soothing techniques, and help them avoid caries in children up to 3.5 years of age. Caries Res. 1996 ; 30(4) : 256- harmful routines that are difficult to stop. 66. 7 Burt BA, Pai S. Sugar consumption and caries risk: a systematic review. J Dent Educ. 2001 Oct ; 65(10) : 1017-23.
19 JODQ - Supplement - April 2006 Scientific Article
Monique Julien, MSc, MPH, Dr PH
Dietary Recommendations for Healthy Teeth in Children
The food industry is constantly flooding the market under normal conditions. Rather, the appearance of with increasingly processed products. Now that we caries is precipitated by the way the young child is have more knowledge and techniques to control the fed, and particularly by what is in the baby bottle and risk factors for caries than ever before, is it still how it is given. appropriate and/or enough to tell our children to stay away from candy? To answer this question, we will As time goes on, the child’s stomach can still handle first consider the foods necessary for tooth growth only small meals, so they must be rich in nutrients. and briefly review the main characteristics in foods The child should be trained to stop his activities to that contribute to cariogenicity. Lastly, we will learn to take time to eat and taste the food. Avoid developing recognize the foods that do the most harm to our the habit of grazing and drinking out of a bottle teeth, so we can guide children in their own choices. throughout the day, which can have detrimental health implications throughout life. For children, the A short history of teeth best snack is a glass of milk or fresh fruit, with or Our teeth have their genesis while we are in our without cheese or yogourt. The most detrimental mother’s womb. The embryonic development of our elements in a child’s diet are too many drinks of 2 mouth and its neighbouring structures is closely all kinds, even when given in a bottle. linked to the availability of nutrients during the entire course of fetal development. Because of the intensity Fermentable carbohydrates of metabolic activity, undernutrition or any other The first foods implicated in the development of deficiency in protein, calcium, and particularly, caries contained sugar, mostly naturally occurring vitamin D intake, leads to irreversible changes in the sucrose (dried fruit), or added sugar (cane sugar). structure of developing cells. These changes can be Throughout history, the prevalence of caries observed not only in tooth enamel, but also in the increased with the wider availability of sugary foods. salivary glands. The systemic influence of nutrition We should remember that all the populations in continues when permanent teeth are formed and which this phenomenon was observed traditionally even when the last permanent molar comes in. had a diet rich in starch, in the form of minimally Dr. Monique Julien is a processed grain products. It appears, therefore, that Professor at the Department of From birth until around the age of 6 months, a child starch was not a factor in the origin of caries. oral health, Faculty of dentistry, Université de Montréal. receives all the nutrients he needs (except vitamin D) Address correspondence to: from mother’s milk. The suction movements required With the industrial age, grain products were ground C.P. 6128 to extract the milk provide optimal development for finer. Individuals with fructose intolerance were Succursale Centre-Ville 3 Montréal (Québec) the maxillaries, thus ensuring that there is sufficient reported to have a lower caries incidence in H3C 3J7 space for each tooth and that the teeth will not comparison with other healthy members of their or to overlap. Bottle-feeding does not offer this advantage. family, and sometimes no caries at all. [email protected] First caries and how to prevent them Today, milling is producing increasingly finer textures, Usually, caries begin to appear when the child is and foods are subject to various cooking methods, between the ages of 18 and 24 months. It is often at very high temperatures, and sometimes with important to remember, however, that young sugar. Thus processed, the starch molecules become children will not necessarily get caries even when all smaller (dextrins) and therefore more likely to be the right conditions are present. Although lactose is a broken down into the glucose stage by the salivary sugar and its concentration in mother’s milk is slightly amylase. In addition, the cooking stage changes the higher than in cow’s milk, it is nevertheless the least product’s texture so that it becomes sticky after cariogenic of all sugars and does not cause caries contact with saliva, and it adheres particularly to the
20 JODQ - Supplement - April 2006 Scientific Article
Dietary Recommendations...
TIPS TO AVOID CARIES IN YOUNG CHILDREN • Breastfeed the child1, even on demand, during the first six months of life. • When the child reaches the age of six months, he should be able to drink out of a training cup. Give him his daily juice with the training cup, which • If the child is bottle-fed, he should be taken into the caregiver’s arms for reduces the time his teeth are in contact with the acid. the feeding, and then put to bed once he falls asleep, without a bottle or sweetened pacifier. • If properly done (gradual reduction of frequency with the addition of other foods), breastfeeding or bottle-feeding can be continued after six • Outside of breastfeeding or bottle-feeding times, give a child water to months. At the age of one, the child should stop using the bottle and be drink without added sugar. using the training cup. Faster swallowing reduces the contact period with • Limit the use of fruit juice to the amount required to balance the child’s the liquid. diet. A few ounces a day are enough for a young child. Additional Do not give teething biscuits. They provide no real benefit and are a food amounts should be in the form of fresh fruit. • of choice for bacteria. • Between bottle feedings, do not give additional bottles containing fruit When the child begins to have a varied diet, do not give him cookies, juice, fruit punch or soft drinks. Their natural acidity fosters • candy, pastries, fruit juices, or sweet drinks during the day. Pieces of fruit, decalcification by erosion. This is also true for diet soft drinks, which have cheese, some vegetables, and small sandwiches are better for his health. an acid pH.
inter-dental spaces and beneath the gums. When bacteria can Thus we can conclude that starch, when processed in the metabolize starch and reduce it to sugar, they can produce forms commonly consumed today, is potentially cariogenic. acid, and the starch becomes a “fermentable carbohydrate”. If, However, traditional foods such as potatoes, rice, pasta, furthermore, even a small quantity of sucrose is added, the legumes and bread, whose texture requires thorough chewing, caramelization that occurs when the starch is cooked together and which are all sources of starch, can be considered non- with the sugar increases the stickiness of the food’s texture to cariogenic, particularly because they are usually eaten with create a substrate that remains available longer to the existing non-carbohydrate foods (proteins and fats) that are not bacteria, thus prolonging the period during which the acid is harmful to teeth. produced and is able to attack the enamel. In a study conducted with animals, Grenby4,5 demonstrated that adding sugar to starch makes the mixture more cariogenic than sucrose alone.
Figure 1. Figure 2.
21 JODQ - Supplement - April 2006 Scientific Article
Dietary Recommendations...
Figure 3. Figure 4.
Acidic foods Fruit punch, herbal teas and diet and regular soft 2,7,8 It is important to mention that there is a wide range of foods drinks are also foods that contain acids that risk eroding readily found in children’s diets whose inherent acidity tooth enamel. With the exception of herbal teas, their sugar contributes directly to demineralization, whether or not they content is comparable to that of natural fruit juice. In the contain sugar. They have a detrimental effect when ingested in presence of plaque, bacteria could use this sugar to produce conjunction with sugar. acid (caries). Given their low nutritional value, it would be beneficial to limit these drinks as much as possible and ensure Most fresh fruit have a sugar content of 10 to 15%, which is that they do not take the place of nutritional foods like milk sufficient to penetrate plaque and be used by bacteria to (Fig. 1). produce acids. In addition, fruit is an acid food that is able to demineralize the enamel if it remains in prolonged contact with Sports drinks, while also acidic, have a higher sugar content it. The erosion cases reported due to fruit consumption mainly than other sweet drinks and therefore have sugars that involved individuals who consumed as many as 20 fruit per penetrate plaque more easily and become more readily day, or who sucked on acidic fruit such as oranges or lemons, available to bacteria. In addition, because they are more which had the effect of placing their teeth in direct contact with viscous, they stay in longer contact with the teeth. Drinking the acidity of the fruit. This, however, is not the case when a sports drinks not only increases the risk of caries and erosion, few fresh fruit are eaten in a day, even bananas, which have a it also deprives children’s bodies of important nutrients, slightly higher sugar content and stickier texture. Although the particularly calcium. Another negative consequence of over- salivary flow that comes from ingesting fresh fruit is enough to consumption of sports drinks is their contribution in calories. neutralize the acid contained in most fruit, eating an apple, for Since the body does not compensate for the additional liquid example, does not clean the teeth6. A toothbrush and dental calories by ingesting less food, the surplus liquid calories 9,10 floss are still necessary. contribute to obesity. Recent studies have established a link between obesity in children and the consumption of soft One hundred percent natural fruit juices are acid and can drinks. cause erosion when drunk slowly or over long periods of time. If ingested in reasonable quantities (and as long as fresh fruit Are certain foods harmless to teeth? is not neglected, as per the recommendations of Canada’s It is appropriate to wonder whether the omnipresence of food guide) and fairly quickly, they do not cause damage carbohydrates in our diets makes it impossible for people to because of their low sugar content and fluid consistency. have a healthy diet these days, especially one that will not expose the teeth to caries. Fortunately, there are many easily identifiable foods that do not harm teeth and also provide many advantages for physical health in general.
22 JODQ - Supplement - April 2006 Scientific Article
Dietary Recommendations...
First of all, it is important to know that all foods mainly fruit. The nutritional value of yogourt, which is good at the composed of proteins and fats cannot be used by bacteria to outset, will be enhanced by the addition of vitamins and fibre. produce acid that attacks tooth enamel, even when they end up as debris between the teeth. This is case namely with Cheese not only has all the characteristics of milk, but also meat, game, poultry, fish and eggs, which are part of the usually contains more calcium and fat. Hard cheese requires meat and alternatives category of Canada’s food guide, and more chewing, which increases salivary flow and, which have a neutral pH in the mouth. As for nuts and seeds, consequently, the basic substances in plaque. Eating cheese which are also part of this group, they are low in carbohydrates will bathe the teeth in calcium, phosphate and bicarbonates, (starches) and are therefore not harmful because they contain which increases the pH of plaque and fosters remine- proteins and fats. In fact, if eaten after sugary foods, they tend ralization13,14. This is why it is good to eat cheese at the end of to increase the pH level and neutralize the acid that may have a meal that contains carbohydrates15. As for ice cream, it has been produced11. They are an excellent snack either eaten some of the desirable characteristics of milk, but in lesser alone or with a piece of fruit. The last item in this group is proportions (1/3 of the calcium, phosphate and casein). In legumes. Their composition is similar to that of nuts and seeds, addition, it contains more sugars and fats. Its soft consistency and they contain no processed starch. The sugars they contain and sugar content make it cariogenic, but at a lesser level than are mainly oligosaccharides, so they cause more flatulence other dessert foods. It is a dessert that can be given to children, than caries … preferably without a cone or sundae toppings (Fig. 3).
Secondly, taking a look at the vegetables and fruit group, some Now we turn to the most problematic group, grain products, vegetables, such as corn, contain starches and/or sugars like which contain carbohydrates that are processed at varying legumes. This is also the case with carrots, whose low degrees. These products vary widely, depending on how they starch/sugar content (< 5%) is not sufficient to penetrate were processed. Whole grain cereal, eaten with milk, and plaque. When carrots are eaten raw or undercooked, saliva is even with a small amount of sugar, does not pose a problem. stimulated by chewing and it easily neutralizes the small amount More chewing may be required due to its fibre content, which of acid produced. Cooked carrots are usually eaten together with increases salivary flow. The presence of organic phosphates pH-neutral foods from the meat and alternatives group. Earlier (phytates) hinders the dissolution of the enamel. As for the we saw that fresh fruit eaten in normal quantities, (fewer than benefits of other types of cereals, particularly flakes produced 10 per day), do not present a tangible danger for teeth. There is by cooking the product at very high temperatures, they are therefore no need to deprive oneself under the assumption that more doubtful because the starches have been hydrolyzed into fruit is acid and contains sugars (Fig. 2). smaller molecules of maltose and glucose, which are sugars that can be used by bacteria to produce acid. However, several In the milk products group, milk is the best food for healthy studies16 have concluded that when eaten with milk, these teeth. In fact, its content in lactose, which is the least cariogenic types of grains increase the sugar content of a child’s diet but of all sugars, is relatively low, and it contains calcium and do not appear to increase their risk for caries. However, cereal phosphate ions that prevent the dissolution of the enamel. bars cannot be considered a substitute for cereals. Their chewy Casein, a phosphoprotein in milk, adheres to the surface of the consistency breaks down their starches and sugars into the enamel and reduces its solubility. In addition, the fats form that is most readily available to bacteria. In addition, they contained in milk form a thin film on the teeth that, when are rather low in protein (Fig. 4). added to the effect of the casein, delay the penetration of sugars into the plaque. Chocolate milk contains sugar (about Whole-wheat breads and other bakery products (white 10%) and also cocoa, a substance that has been associated bread, bagels, pita bread and so forth) that require a lot of with a reduction in bacterial growth12. Added to the chewing pose no threat to teeth. Furthermore, pasta and rice characteristics of milk, which we have just mentioned, cocoa have not been linked to caries. The starches in these products neutralizes the negative effects of sugar and makes chocolate are not reduced to large quantities of dextrin, and they are milk a non-cariogenic food. usually eaten with neutral pH foods (meat, fish, cream sauces, etc.). Yogourt is a milk product with less lactose than milk, as a result of fermentation. With or without flavouring (vanilla, Foods that harm teeth lemon, etc.), it has the same characteristics as milk, which can Given that the food products on the market change constantly, compensate for the added sugar. Yogourt that contains fruit it is important to be able to easily spot those that may be jam is slightly cariogenic (owing to its consistency and sugar harmful to teeth. They are often attractively presented, if not by content). It is better to eat the first type of yogourt with their packaging than by their purported merits. homemade fruit puree or frozen berry compote, or with fresh
23 JODQ - Supplement - April 2006 Scientific Article
Dietary Recommendations...
QUESTIONS TO HELP DETERMINE THE CARIOGENICITY OF FOOD • What are its ingredients? If it contains mainly fats and/or protein, it is not • Does the product have a chewy consistency, which might make it adhere cariogenic. to the teeth and become lodged in places where it is difficult to remove? • If it contains carbohydrates, are they in the form of sugar or starch? • Is it an acidic food that can directly cause erosion? • What is the food’s sugar content? For example, 10g of sugar in a product • Is it eaten only occasionally or frequently? Can we avoid nibbling or that weighs 15g is a content of 66%. sipping it? • Does the product contain starch that has been cooked at high • Is it a food that is usually eaten alone? Can we eat cheese or nuts after temperatures? Does it also contain sugar, even in small quantities? eating this food in order to reduce its negative effects?
Our knowledge of the factors associated with the cariogenicity that can be harmful to teeth are also harmful to our health in of foods, coupled with the information on food labels (which general. They all contain fermentable carbohydrates and are have become mandatory on pre-packaged food since January concentrated sources of energy (for example, pastries and 2006) can help us select appropriate foods by supplying us candy). Since they contribute few or no essential nutrients, with the answers to a series of simple questions on the they should be passed up, and our health will be all the better composition of the food and the way we plan to eat it. for it. But if we do give in to these indulgences, we should limit how often we eat them and follow the above eating guide to The simplest and safest answer to all these questions is to minimize their harmful effects. choose foods that have been processed as little as possible, i.e., milk products, vegetables and fruit, and grain products. The worst offenders are: They are the best choices we can make for a healthy diet as • All types of cookies recommended by Canada’s Food Guide. Most of them have • Pastries and sticky bakery products excellent nutritional value and do not contribute the additional • Acidic drinks of all sorts, diet or not. Unfortunately, they calories that few people really need. Most require little or no seem to be taking the place of milk. cooking, which makes them the perfect fast foods. The foods
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