Lecture 11

Dr- Khaled Al-Haddad

.Caries in children and treatment strategies II(advanced lesion)
:Variables contributing to the development of dental caries .1
A. Teeth.

C. Substrate

.B. Micro- organisms

D. Time

:Nursing caries .2
.a. Definition
.b. Etiologic factors
.c. Characteristic
.d. Consequence of habit in the child
.e. Precaution on and treatment
:Rampant caries .3
.a. Definition
.b. Characteristic
.c. Cause
:Control of dental caries .4
.a. Control of all active carious lesion
.b. Reduction in the intake of freely fermentable carbohydrate
c. Reduction in the number of oral micro- organism plaque control
.brush + floss
.d. Patient motivation to maintain good oral hygiene
e. Multiple fluoride therapy:
.1. Systemic fluorides (pediatric fluoride supplement)
.Topical office applied gel or solution .2
.Self applied rinse paste _ brush in -

:Currently accepted theories of the cause of dental caries

.The proteolysis theory .The proteolytic- chelation theory .The chemoparasitic or acidogenic theory :Variables contributing to the development of dental caries
a. Teeth

c. Substrate

.b. Micro-organisms

d. Time
A

:A. The tooth

:Anatomic characteristic of the teeth .1
a. Calcification of enamel is incomplete at the time of eruption of the
teeth and additional period of a bout 2 years is required for the calcification
process to be completed by exposure to saliva. From studies it was shown
that the surface fluoride level of newly erupted teeth is equal to 800 p.p.m.
in comparison to teeth with longer exposure time to oral fluids. Surface
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fluoride level of adults is 1,500-2000 p.p.m., it was pointed out that enamel
.surface fluoride level of 1,000 p.p.m. is required for caries resistance
.b. Development defect
.c. Spacing or crowding
:Hereditary factors .2
Environmental factors have a greater influence on dental caries than
genetic factors but the genetic factor also contribute to the causation of
.dental disease
It was shown in laboratory studies on rats that heredity is a factor in
determining resistance or susceptibility to dental caries. By selective
breeding two distinct strains of albino rats were produced. One susceptible
and the other caries resistant. The caries resistant rats were studied for many
generations and continued to be free of the disease even when fed caries
.producing diet
:Genetic influence on caries expression
Caries resistant teeth

Caries prone teeth

Spacing normal contour

crowding, abnormal .1

contour, deep shallow fissure

fissures

Good salivary buffering

poor salivary buffering .2

High salivary phosphate

low salivary phosphate .3

Serous, copious saliva

viscous, low flowing .4

High salivary I G A

low salivary I G A .5

:B. Micro organism

A number of micro organisms can produce acid to decalcify tooth
structure. The main agent of caries production is to streptococci including S.
mutans, S. sanguis and S. salivarus, and lactobaccili. S. mutans has been
.implicated as the major and most virulent of the caries producing organisms
It has been demonstrated that immoculation of the streotococal micro
organisms isolated from carious rodent teeth would initiate caries in germ
free rats provided that the diet was rich in sucrose. Same results were
.obtained in human to rat study
:Traits of S. mutans
.Inability to adhere to soft tissue .1
.Colonization on occur in sheltered areas .2
Strong adherence to enamel due to heavy amount of extra-cellular .3
.glucan produced as by product of source of metabolism
S. mutan is not present in the oral cavity of infants at birth and can be
.detected only after the primary teeth begin to erupt
S. mutans play a primary role in smooth surface caries. Colonization of
teeth by s- mutans occur on very specific areas that are sheltered and free
from mechanical action once colonies becomes established it posses high
adherence to the tooth surface. Other bacteria particularly strains of
streptpccoci and lactobacilli play a secondary role in the pathogenesis of
.dental caries due to their incapability to induce heavy plaque formation
Lactobacilli comes to prominence within plaque only after acid
.conditions becomes concentrated PH below 5.5
The role of lactobacilli may be of greater significance with regard to pit
and fissure caries. The sheltered niches provided by anatomical grooves and
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sulci would appear to enhance the establishment of lactobacilli without the

.necessity of prior plaque build-up
:C.D.

Substrait / Time

Sucrose has been established as extremely conducive to both plaque

formation and rampant caries in both experimental and humans. Dietary
sucrose is the single most important predisposing dietary factors in the
establishment of a carious environment. Studies have proven that dental
caries activity is directly related to frequency of intake and consistency of
carbohydrate. Also, acid production within the dental plaque shows that
deminieralizing concentration are reached within 4 minutes and maintained
for an average of 20 minutes after the ingestion of carbohydrate containing
.meal
A cariogenic type of plaque is responsible for an environment conducive
:to demineralization in two ways
It provides a rather prolonged period of low PH values due to .1
constant fermentation activities of dietary sucrose plus catabolic breakdown
.of strong polysaccharides
The thick gel-like consistency of plaque acts as limiting membrane .2
.to prevent diffusion of acidic products into saliva

:Nursing caries

Previously, clinical terms such as nursing caries and bottle caries were
used to describe a form of rampant caries affecting primary incisor and
molar

teeth

of

infants

and

preschool

children.

However,

most

epidemiological studies of preschool children have been limited to specific

indigenous, ethnic and lower socioeconomic groups. This unique pattern of
dental caries affecting the primary maxillary incisor and first molar teeth and
sparing the mandibular incisor teeth in most cases is thought to be related to
the chronology of primary tooth eruption and subsequent acquisition of
cariogenic bacteria, namely mutans streptococci. In certain ethnic groups,
children with caries before 2.5 years of age usually have decayed smooth
surfaces of maxillary incisor and occlusal fissures of the first molar teeth.
By 3.5 years of age, caries progresses to the smooth surfaces of the
maxillary canine and occlusal fissures of the second primary molar teeth and
by 5 years the approximal surfaces of all primary molar teeth are usually
involved. However, standardized diagnostic criteria for reporting nursing
caries and bottle caries have been lacking in the dental literature. A
workshop, convened by the National Institutes of Health (NIH) in 1999,
proposed that the term early childhood caries (ECC) be used to describe the
presence of one or more decayed (noncavitated or cavitated lesions), missing
(because of caries), or filled tooth surfaces on any primary tooth in children
up to 71 months of age. Baby bottle syndrome or nursing caries syndrome is
a type of rampant caries that is associated with prolonged exposure to
cariogenic agent. This is often, but not always a substance in the baby bottle.
Sweetened comforter and breast feeding have been attributed to the same
condition but to a lesser degree. Reduced salivary flow and sucking reflex
during sleep time lead to stagnation of milk or sweetened beverage. In
addition to exposure to cariogenic agent local factors and tooth susceptibility
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seem to play important roles in the occurrence of this condition. Besides

direct effects which govern the general health and psychological well being
of the child; malnutrition due to pain associated with chewing, bacterial and
viral susceptibility due to dehydrated and inflamed tissues, tongue
.illustrating abnormal swallowing habits
:Measure for prevention
.From birth, the infant should be held while feeding .1
The child who falls asleep while nursing should be burped and then .2
.placed in bed
.The parent should start cleaning the childs teeth as soon as they erupt .3
The child should be weaned from nursing as soon as he can drink from .4
.a cup. At approximate 12 to 15 months of age
Children should have their first dental check up by 9 months of age. .5
The parent should be cautioned a bout prolonged frequent infant feeding
.habits
:Treatment of children with nursing caries
Motivating the parent to wean the child if the child is above 15 months .1
.or modify the habit of nocturnal or irregular feeding
.Gross excavation of decay and placement of temporary filling .2
Arrest dental caries by using multiple fluoride regimens and maintain .3
good oral hygiene. Daily use of fluoride supplement such as 0.5% A.P.F.
.gel on a brush until caries is arrested
In the very young, general anesthesia or premedication may be .4
.necessary to restore the teeth
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Restoration of teeth which might include full coverage, pulp therapy and .5
.in some instance extraction
:Older children above 3-years of age
:Office fluoride regimen
Acidulated phosphate fluoride A.P.F. 1.23 % (fluoride ion) gel 4 or 5
apllication during 4 to 6 weeks period. Repeat single application every 3
.month
:Home regimen
Brushing teeth after meals using fluoride dentifrice especially that .1
.contain NaF (Crest)
At night brushing. Acidulated phosphate fluoride gel on brush. A thin .2
ribbon than the child expectorate but not rinse. Repeat this until caries
.is arrested
:Systemic fluoride supplement
Before prescribing fluoride, we should analyze the fluoride content of
.community water
Drops for infant. Chewable tablets for above 3-years of age. This will have
.local and systemic effect

:Rampant caries

Some factor in the caries process seems to accelerate the process of

decalcification of teeth to the extent that it becomes uncontrollable and it is
.then referred rampant caries
When a patient has what is considered an excessive amount of tooth decay
it must be determined whether that person actually has a high susceptibility
and truly rampant caries of sudden onset or the oral condition represents
.years of neglect and inadequate dental care
:Characteristics
Suddenly appearing, widespread caries resulting in early involvement .1
.of the pulp and affecting those teeth usually regarded as immune to decay
.Rate of ten or more new lesions per year .2
Involve the proximal surface of the lower incisor teeth and cervical .3
.type of caries
.Observed in both children and adult .4
.It is not a deficiency disease or related to malnutrition .5
.It is caused by too much intake of sugar .6
Emotional disturbance may be a causative factor in some cases of .7
rampant caries. This condition may initiate an increase craving for sweet and
.marked reduction in salivary flow
:Treatment of rampant caries
A systematic understanding approach with patients or parents
cooperation and interest in maintaining the child teeth will influence the
result. A complete history should be taken to identify the cause of the
rampant caries whether it is due to systemic or local factor. Necessary
laboratory test should be taken. A treatment plan should be addressed to
eliminate the causative factor and to arrest the carious process and restore
.teeth to health
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:Control of all active carious lesion .1

.Gross excavation of each carious lesion and restoration with dycal + I R M
:Advantage of this procedure
.a. Arrest the caries process and prevent rapid progression to dental pulp
.b. Aids in the sterilization of the remaining caries materials
.c. Reduces the inflammation of the pulp
d. Elimination of food traps results in a reduction in the number of oral
.micro-organisms
:Reduction in the intake of freely fermentable carbohydrate .2
.a. Determination of eating habits
.b. Reducing between meal eating habits modify the snack
Discuss problem with parent and child to establish rapport which is critical
.for patient cooperation
:Reduction in the number of oral micro- organisms .3
Constant reinforcement is necessary to maintain effective plaque control
.especially in pre-school children
In school children the use of Chlorhexidine mouth wash as an
antimicrobial agent to suppress colonization of bacteria especially S. mutans
is recommended in adolescent also using brushing and dental floss to reduce
.the amount of plaque

:Patient motivation -4
:The full motivation including
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.Oral hygiene- to short period only -1

.Slides- after week or more -2
.Maternal- for week -3
.Reinforcement -4
.Multiple fluoride therapy -5
:Techniques of brushing
Brushing technique will differ according to the patient age and manual
.dexterity
.Types of brush: soft multi- tufted rounded nylon
.Primary dentition: scrubbing (horizontally)
.Mixed dentition: scrubbing and roll technique
.Permanent dentition: bass technique and roll
.Minimum time for brushing is 3 minutes
:Parents role in tooth brushing
The parents should continue to brush their children teeth until the age of 8
.especially at bed time
:Dentifrices
Sodium fluoride dentifrices have been proven to be more efficient than
.sodium monofluorophosphate
For infant brushing should be without dentifrices. In pre-school children a
.little amount as small as a peas should be put over the brush
:Use of fluoride
Types of fluoride as mentioned in previous lecture and according to studies
.the APF is more acceptable from children
I- APT

II- Stannous fluoride 8%

.acceptable taste.

1- bad taste -1
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.no staining or pigmentation.

2- pigmentation of arrested stain -2

.little blanching of tissue.

3- causes blanching of tissue -3

more effective than NaF

4- sames as APF -4

can be applied to both arches.

5- arrest incipent caries- applied -5

.in quadrent isolated arches

.potentially harmful if swallowed

6- same -6

.in large quantities

.gel form stable for 2 years.

7- not stable solution -7

:Frequency of topical application in rampant caries

application for 4-6 weeks period repeating single application every 3 4-5
.months

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