22

Nursing and early

childhood caries
SUMMARY
Kelly-Ann is only 3. She has been brought to the
dentist by her mother because her upper front teeth
are wearing away (Fig. 22.1). What has caused this
and how may it be treated?
History
The teeth apparently never came through properly and
were never white like the rest of her teeth. There has been
no pain from the teeth and Kelly-Ann is eating and drinking
normally.
Medical history
Kelly-Ann is a healthy infant. She has had all her vaccina-
tions and has had no illnesses. She has never been on any
medication.
Examination
Extraorally there is no swelling and no facial asymmetry.
Intraorally she is in the full primary dentition with the
second primary molars having just erupted. There is caries
affecting the upper incisors and cavitation in all rst primary
molars.
What is the cause of this pattern of decay?
Nursing caries, or nursing bottle mouth or bottle mouth
caries.
What can cause this?
Consumption of a sweetened drink or fruit-avoured drink
from a bottle or dinky feeder, especially if the feeder is
constantly in the mouth or the child falls asleep with it in the
mouth.
Persistent on-demand breastfeeding at night after 12 months
of age (child is allowed to sleep on the breast) may cause
caries in exceptional circumstances. There are many biological
and social variables that confound this complex relationship.
As can be seen, the term nursing caries is probably the most
accurate as it encompasses both breastfeeding and bottle
feeding.
Why are the teeth afected in this pattern?
Teeth become carious in the order in which they erupt (Fig.
22.2) with the exception of the lower primary incisors,
which are protected by two major mechanisms: the position
of the submandibular ducts that open adjacent to these
teeth; the position of the tongue in suckling, which covers
the lower incisors.
What additional factors make the upper primary incisors
more predisposed to caries?
High bow-shaped upper lip in infants which does not cover
the upper incisors and results in an increased evaporation of
any saliva on these teeth.
Gravity, which keeps submandibular saliva pooled around the
lower incisors and less likely to reach the upper incisors.
Any liquid with sugar that is allowed to bathe the teeth
on a frequent basis will cause caries. This is especially so at
night when the protective function of saliva reduces as less
saliva is produced. Even breast milk, formula milk or cows
milk with their lowered natural sugars can still be cario-
genic on this basis.
Fig. 22.1 Early cavitation in nursing caries.
Fig. 22.2 Classical distribution of aected teeth in nursing caries
in upper arch.
Key point
Nursing caries:
Afects teeth in order of eruption.
Lower incisors are protected by saliva.
Can be caused by any sugar-containing liquid.
22 N U R S I N G A N D E A R LY C H I L D H O O D C A R I E S
101

What should be your advice about night-time feeding?

Only water should be given during the night after 12 months
of age.
The term early childhood caries (ECC) is an additional
term used to describe any caries presenting in the primary
dentition of young children. Some children present with
extensive caries that does not follow the nursing caries
pattern and have multiple carious teeth, and may be slightly
older at 3, 4 or 5 years of age at initial presentation.
How could you identify pre-school children in need of
dental care?
Encourage parents to bring their children for a dental
check-up as soon as the child has teeth.
Make contact with local health visitors, baby clinics, and
mother and baby groups via the local general medical
practice.
Treatment
Kelly-Ann is in a high risk for caries group. List all the main
factors you can think of for placing someone in the high
risk group for dental caries.
See Table 22.1.
What fuoride regimen would you suggest to Kelly-Anns
mother?
Fluoride paste. As a high risk subject, she should be given a
1000 or 1450 ppm uoride paste rather than 450600 ppm
childrens paste.
Fluoride supplements. These should be considered in high risk
of caries subjects and in children in whom dental disease
would pose a serious risk to general health (e.g. risk of
infectious endocarditis). Such supplementation is only
eective if given long term and regularly.
What information is essential before prescribing fuoride
supplements?
The amount of uoride in the local water. Telephone the
local water supplier for this information.
What is the currently recommended fuoride
supplementation regimen in the UK?
See Table 22.2.
Table 22.1 High-risk factors for caries
Risk factor Aetiology
Clinical evidence New lesions
Premature extractions
Anterior caries or restorations
Multiple restorations
No ssure sealants
Fixed appliance orthodontics
Partial dentures
Dietary habits Frequent sugar intake
Social history Social deprivation
High caries in siblings
Low knowledge of dental disease
Irregular attendance
Ready availability of snacks
Low dental aspirations
Use of uoride Drinking water not uoridated
No uoride supplements
No uoride toothpaste
Plaque control Infrequent, ineective cleaning
Poor manual control
Saliva Low ow rate
Low buering capacity
High Streptococcus mutans and Lactobacillus counts
Medical history Medically compromised
Physical disability
Intellectual disability
Xerostomia
Long-term cariogenic medicine
Table 22.2 Recommended dosage schedule for uoride
supplements in areas where the water supply contains less than
0.3 ppm uoride
Age Fluoride per day (mg)
6 months to 3 years 0.25
36 years 0.50
6 years 1.00
Professionally applied fuorides
Site-specic application of uoride varnish can be very
valuable in the management of early, smooth surface and
approximal carious lesions. Recent evidence suggests that
passage of oss through a contact point between primary
molars by parents can greatly enhance prevention and early
treatment of approximal lesions. The most commonly used
varnish 5% sodium uoride has 22 600 ppm and should
be applied very sparingly to specic areas three times a
year.
Why can Kelly-Ann not have fuoride mouthwash?
These are contraindicated in children less than 6 years
of age because more than half the mouthwash will be
swallowed.
What other forms of preventive care does she need?
Toothbrushing instruction
Pre-school children need help from their parents if effective
oral hygiene is to be maintained. Brushing needs to start as
soon as the rst tooth erupts. Standing or kneeling behind
the child in front of a sink or mirror is often the best way to
brush a young childs teeth. Supervision of brushing is
important so that an appropriate amount of paste is placed
on the brush to prevent/reduce ingestion of paste. Teeth
should be cleaned at least once a day.
Diet analysis
The only way to effectively do this is by a 3- or 4-day written
analysis. It is important to try to obtain 1 days history from
22 N U R S I N G A N D E A R LY C H I L D H O O D C A R I E S

102
a weekend as they are invariably different from weekdays.
In modern society it is common for most parents to work
and the child to be looked after by a carer or nursery. It is
critical to establish who is the carer on weekdays and week-
ends. Advice needs to be clear at all times, but if it has to
be relayed from a parent in the surgery to a carer then it
needs to be clear, succinct and written. Frequent consump-
tion of sugar-containing drinks and feeds is the key aetio-
logical feature in many pre-school children with caries.
Reducing the frequency of sugar-containing snacks is the
key message. If the child is a poor eater there is need to
build up the amount of food at mealtimes and, therefore,
reduce the need for frequent snacking. Children do not need
lots of zzy drinks or fruit-based drinks. They often take
them to make up for calories missed at mealtimes. Only
milk and water should be taken between meals. A small
amount of fruit-based drink can more safely be taken with
a meal. As mentioned above, it is critical to stop the night-
time bottle.
In your dietary advice you must be practical, personal and
positive. Avoid making the parent feel excessively guilty but
concentrate on practical strategies. It is probably unreason-
able to give out more than four pieces of written advice.
These should concentrate on day-time drinks, night-time
drinks, between-meal snacks, and making sure the child has
no food or drink for 1 hour before going to bed and then
cleans the teeth just before bed.
Kelly-Ann has the early cavitation on her upper incisors
that you see in Figure 22.1. She also has early cavitated
occlusal caries in her rst primary molars.
How would you restore the upper incisors?
These can be restored with a compomer or a composite.
Both have a good bond strength to enamel and dentine.
Compomers have good mechanical properties and in this
situation will be as durable as composite.
How would you restore the early cavitation in the frst
primary molars?
Compomer or resin-modied glass ionomer cement similarly
will be the restorative materials of choice.
All this work, because it is not extensive, could probably be
achieved with a slow handpiece and excavator. However, if
Kelly-Ann is apprehensive of the drill then an alternative way
of caries removal will have to be found.
What method of caries removal, without a handpiece, may
be applicable here?
Carisolv, which accomplishes caries removal by chemo-
mechanical means. Carisolv consists of a pink gel that con-
tains mainly the amino acids leucine, lysine and glutamic
acid, and hypochlorite. In addition there is cellulose and a
colouring agent, erythrocin. The amino acids and hypochlo-
rite work to separate carious dentine from sound dentine
and the carious dentine is removed with the aid of special
hand instruments that have different cutting edges and
hand actions to excavators. They are used in a whisking,
rotating, or up and down movement. Because the sound
dentine is not stimulated by the temperature or vibration of
a handpiece, or the temperature changes of a 3 in 1 spray,
it is a painless procedure. The cavity should be dried by
saline-dampened cotton wool, then dry cotton wool, prior
to restoring with an adhesive material. Bond strengths to
adhesive materials are the same as conventionally prepared
cavities.
How is pain relief best achieved in the child with nursing
caries in Figure 22.2?
This is a case where general anaesthesia for tooth removal
is justied. This is covered in Chapter 26.
Recommended reading
Ripa LW 1988 Nursing caries: a comprehensive review.
Paediatr Dent 10:268282.
For revision, see Mind Map 22,
page 184.
41

184
MI N D MA P 2 2
Nursing and
Early Childhood Caries
fluoride topical-varnish
toothpaste 1100 / 1450 ppm
restoration
extraction
SSC posteriors
strip crowns on anteriors
adhesive material
systemic supplement age + F

in water-dependent Treatment
toothbrushing instructions parent and child
diet diary (3 day)
Risk assessment
clinical evidence
dietary factors
social history
use of fluoride
plaque control
saliva
medical history
sugar
Aetiology
Pattern of caries
eruption sequence
submandibular ducts
bow upper lip
gravity
tongue position
frequency