The impact of neglect and failed treatment of early childhood caries

Summary

Introduction: Early childhood caries and its complications have the negative impact on both oral and general health of the affected child. Dental caries in early childhood is defined as the presence of any decayed, filled tooth surface or missed primary tooth due to caries of a child under 71 months of age. The treatment of dental caries in small children is complicated due to limited cooperation, morphological and biological differences of primary teeth and caries lesion progression.

Presentation: The purpose of the treatment of dental caries in young children is to repair and limit further damage of dental hard tissue, protect the remaining healthy tissue, restore the masticatory function, improve the aesthetics, prevent the inflammatory complications and facilitate the daily oral hygiene practice. Inappropriate and failed treatment of primary teeth may disadvantage these children; increase the risk of inflammatory complications in terms of pulp diseases and subsequent spreading of inflammation into surrounded tissues, general diseases and social problems. This disease has an impact on the quality of life of children and their families and is unnecessary burden to society. The aim of this paper is to review the consequences of neglect and failed treatment of early childhood caries.

Conclusion: Prevention of dental caries would be preferable on individual and community level, because the main aetiological factors of dental caries are well defined. But the high level of untreated caries world-wide suggests that the current preventive approaches are not sufficient and are proof of collision of risk factors and inappropriate life style associating with social, educational, behavioural and economic inequalities.

Keywords:

complications – dental caries – primary teeth – treatment

INTRODUCTION

Early childhood caries (ECC) is defined as the presence of one or more cavitated or non-cavitated carious lesions, filled or extracted tooth due to caries and its complications in children younger than 71 months. Severe early childhood caries (S-ECC) is smooth surface caries in a child younger than 36 months [1]. ECC develops and progresses due to some specific mechanisms, typical for oral cavity of small child, as microbial colonization of oral cavity, immaturity of local oral defense reactions (low level of secretory IgA), low enamel resistance to acids of teeth shortly after eruption, and frequent consumption of sweetened drinks in baby bottle or sippy cup before bed time and at night [2]. After carbohydrates are ingested, especially sucrose, there is a rapid fall of pH in tooth adherent biofilms to 5.0 or below. The lower pH leads to a so‐called dysbiotic microbiome that is characterized by an increase in the proportion of acidic biofilm species and changes in the composition of the biofilm matrix. Frequent sugar exposure thus leads to sustained acid production and consequent demineralization of the tooth structure. The biofilm alone does not produce disease, but exposure to dietary sugars is a determining factor as well as an individual's ability to overcome the ecological challenges [3, 4]. ECC shares common risk factors with other non-transferable diseases associated with excessive sugar consumption such as cardiovascular disease, diabetes, and obesity.

Although ECC is preventable, affects recently more than 600 million of children worldwide and remains largely untreated. The treatment of ECC is neglected, doubt on effectiveness, with the apparent rationale that they shed before causing symptoms [5]. Such approach must be strictly disclaimed. Inappropriate or no treatment of primary teeth handicaps these children. Dental caries in early childhood is unacceptable burden for children, families, and society [6].

THE PHILOSOPHY OF CARE OF PRIMARY DENTITION

The long-term successful treatment of primary dentition is determined by cooperation of the child and parents. This relationship is necessary to build up very soon. The first dental visit is recommended before the child´s first birthday. This visit is oriented to obtaining the important anamnestic data related to caries risk assessment (CRA), important primary preventive advice, and the first contact of the child with the dentist and dental office. Early diagnosis of initial stages of caries attack is the next important issue, together with the establishment of the individual treatment care based on child´s need and primary preventive approaches. In case of treatment, the child must be able to manage it [7].

The aim of the treatment of primary teeth is to repair the damaged dental tissue, minimize the risk of further progression of the lesion, save the remaining healthy tissue, renew masticatory function and aesthetics, prevent inflammatory complications and facilitate the oral hygiene [2].

The treatment plan should include also the evaluation of the developmental stage of the dentition (dental age versus biological age), CRA and parents’ cooperation and their interest in dental treatment and the ability of the child to undergo the treatment. Dental caries of primary upper incisors represents the risk for primary molars, which are usually affected by caries within 12 months. Untreated carious primary teeth present also risk of early caries of permanent teeth [8, 9].

THE SPECIFIC ASPECTS OF ECC

The mechanism of caries development of primary teeth does not differ significantly from permanent teeth. Initial subsurface enamel lesion is the first step of the lesion in both cases which can arrest or further progress to the cavitated lesion. What is different in primary teeth, is rapidity of caries progression and clinical symptomatology, due to thinner enamel and dentine, less mineral content in both tissues and irregular dentinal tubules. Clinical symptoms are present more likely in primary molars in case of approximal caries. This can be explained by the large pulpal cavity of primary molars extending up to the cusps and dentinal margin. The cavitated lesion localized on approximal surface of primary molar causes early chronic inflammatory changes of the dental pulp with no or minimal symptoms like a pain. These are present when the whole pulp is inflamed [10, 11]. Primary incisors manifest symptoms frequently after the pulp became necrotic with subsequent inflammatory complications [12]. Parents thus do not find the dentist because of no pain and if so, dentists often consider the treatment useless, as “there is no pain”.

THE IMPACT OF FAILED DENTAL TREATMENT OF PRIMARY TEETH

Early childhood caries has health, social and psychological impact on the child and family (Fig. 1). ECC has negative consequences not only for the teeth of the affected child, but also for the child´s general health, morbidity and mortality [13].

Pain

The perception of pain is unpleasant discomfort for both children and adults. The child unlikely understands the reason, having problems with its interpretation. The affected child is bed-tempered, has sleeping difficulties and stop playing. Some children may report eating problems and grow failure. Shepherd et al. interviewed 589 eight-year-old children and found that almost 50% had suffered dental pain. The pain was of such severity that 73% of those affected had been unable to eat, 31% had been unable to sleep, 27% had stopped playing, and 11% had not been able to go to school [14]. Although this study interviewed children older than 6 years, data were alarming. Levine et al. published a retrospective study of 481 children suffered from dental caries of primary teeth, where 18% of unrestored primary teeth had caused pain, most often molars [10].

Inflammatory complications

The inflammatory complications related to untreated carious primary teeth can manifest either as local inflammation (submucous abscess), Fig. 2 or diffuse inflammation (cellulitis), Fig. 3 or even sepsis [15]. A study by Pine et al., in which almost 7,000 Scottish children with ECC were examined, has revealed that 5% of children had dental sepsis [16]. The gangrenous pulp of upper primary teeth can be the cause of spreading of inflammation into orbit in 50% of cases. The treatment of these serious complications always requires systemic antibiotic therapy, hospitalization of the child and invasive surgery. The progression of infection to the periodontal tissues and osteitis of dental origin lead to bacteremia, which may have the great impact on general health of the affected child. In case of local complication of spreading of infection into surrounding periodontium there is a risk of developmental defects of the enamel of permanent successor. The affected tooth is hypoplastic, in severe cases second-rate quality from the aesthetic, functional and prosthetic point of view and must be extracted. The psychological impact leads to negative attitude to dental treatment and poor cooperation for many years [7].

Space loss

Premature loss of primary molars may contribute to problems such as deviation of mid-line, crowding, dental impaction, ectopic eruption, and cross-bite formation. The reduction in arch length is more severe in maxilla and in case of second primary molar [17, 18]. Space maintainers may help to prevent change in arch length, following early loss of primary molars, however supporting their use is limited. The disadvantage of space maintainers are that they are plaque retentive, may irritate soft tissues, fracture or be lost. The unwillingness of the child to wear the maintainer and need of frequent check-ups may be the next complication.

Failure to thrive

This problem is related to eating difficulties. The child refuses the solid food or swallows un-chewed bites due to pain, leading to gastro-intestinal or nourishing problems. In other cases, the child prefers soft diet only what affects negatively dentition and gingiva. Self-cleaning process is not effective with the great risk of painful gingival inflammation. It was found that children´s weight with ECC is frequent below the 3rd percentile for age. Chronic inflammation affects growth via metabolic pathways. Cytokines (IL 1a and IL 1b) can induce inhibition of erythropoiesis [19, 20]. Failure to thrive due to reduced intake of food may affect glucosteroid production and growth [20].

Disruption of Quality of Life

Information used in OHRQoL questionnaires in children with ECC are not self-reported, obtained from parents or care givers, does not reflect the real child perception, intensity and character of pain. Children with ECC do not always complain of pain, but can manifest disruption of QoL in other ways, such as eating, sleeping, and behavior problems. Despite differences in measurement approaches to assessing OHQoL, there is ample evidence to support the validity and reliability of the various OHQoL measures in determining the burden of ECC on children's lives. Because of linguistic and cultural differences, OHQoL measures need to be adapted for use in other languages and cultures to facilitate cross-national and cross-cultural research on the impact of ECC globally [21].

The risk of new carious lesions

The carious primary dentition represents the great risk for further lesions of unaffected primary teeth, but also for erupting permanent teeth due to insufficient post-eruptive maturation of enamel and less resistance to caries attack. Grindefjord et al. demonstrated that 92% of 2.5-years-old children diagnosed with caries at baseline, developed new carious lesions over a 1-year period. Among children who were caries-free at baseline in only 29% developed caries during the study period. In case of occlusal caries of second primary molars, 64% of these lesions progress to aproximal caries within one year. Children with dental caries at the age of 2.5 years reported significantly more proximal caries compared to caries-free children [22].

Carious primary incisors significantly increases risk of the caries attack of primary molars [8, 9]. Other risk factors of ECC are untreated dental caries in mothers, early transmission of cariogenic bacteria, high sugar containing diet, lack of information on caries prevention and social and economic deprivation [24]. In a prospective, longitudinal study of 186 children, examined at ages 5 and 10 years, Skeie et al. found significant correlations between the caries experience in the primary and permanent dentitions [25]. Pine et al. concluded that caries developing on the mesial surface of mandibular first permanent molars is primarily due to the distal caries in second primary molars [16].

Social-economic impact

In term of cost to a community, care of ECC consumes a significant amount of health-care budgets, due to extend of the problem and the need for use of emergency, unplanned hospitalizations and general anaesthetic facilities [13]. No effective and regular fluoride prevention costs 7,000 euro per person each year during his life. Dental caries in children is the reason of 51 million of missed school lessons and 161 missed working hours of their parents. Dental caries and its complications are the 4th most common reason of hospital admission of children [13, 27]. Davis et al. reported the study from emergency out-patient unit, Minneapolis-St. Paul Hospital, US. They found that over a 1-year period there were over 10,000 visits for dental related problems, 2% by children aged less than 5 years, at an average cost of $460 per patient [28]. The similar data can be expected in Czech Republic, unfortunately the do not exist.

CONCLUSIONS

Early childhood caries remains a highly prevalent worldwide disease that has a major impact of parents’ and children's quality of life and is unnecessary burden to society. ECC has negative consequences not only for the teeth of the affected child, but also for the child´s general health.

Our first interest on both individual and community level should be prevention of dental decay because the main and supporting aetiology factors are well known. Preventive measures should be complex, on individual base and constantly performed. Appropriate management of ECC from informed patents, health professionals, and community health workers is important to reduce this burden of preventable disease. Prevention of caries would be preferable to treatment, but the high level of untreated caries in small children world-wide suggests that current preventive approaches are not sufficient. This can be explained by the collision of caries risk factors and incorrect life-style associated with social, educational, behavioural and economic factors.

The paper is supported by the grant PROGRES Q-29.

doc. MUDr. Romana Koberová, CSc.

Institute of Dental Medicine, Faculty of Medicine, Charles University and General University Hospital

Sokolská 581

500 05 Hradec Králové

e-mail: koberovar@lfhk.cuni.cz