ISSN :0975-8437

CASE REPORT
Management of Early Childhood Caries under Conscious Sedation A Case Report
Nanjunda Swamy K.V., Sumanth M. Shetty

Abstract

The American Academy of Pediatric Dentistry (AAPD) defines early childhood caries (ECC) as “the presence of one or
more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in
a child under the age of six.” Untreated, ECC can irreversibly destroy the dentition, cause abscesses, and lead to serious ill-
ness. This paper reports the management of a Type2 ECC lesion in a three year old female child under conscious sedation.

Key Words: Early Childhood Caries; Caries; Conscious sedation

Introduction per reports the management of a three year old female child

Early childhood caries is a relatively new term that describes
rampant dental caries in infants and toddlers.1 The Early Child-
hood Caries (ECC) is a severe form of caries, defined in 2004
by the American Academy of Pediatric Dentistry, which affects
children of 2–5 years of age and which is characterized by pre-
cise topographical and clinical parameters. The decay pattern
of ECC is characteristic and pathognomonic of the condition.
The four maxillary incisors are most often affected. The lower
primary incisors are intact and the primary cuspids can be oc-
casionally affected. In very severe cases the mandibular inci-
sors are also affected.1 The academy also specifies that, in chil-
dren younger than 3 years of age, any sign of smooth-surface
caries is indicative of early childhood caries.2
Johnston and Messer classify ECC into 3 patterns: a) develop-
mental defects; b) smooth surface lesions; c) rampant caries.
Verkamp and Weerheijm use 4 stages to classify the ECC: ini-
tial, damaged, deep and traumatic lesions.1 Wyne suggested
the following classification for ECC: Type 1 ECC -mild to moder-
ate- the existence of isolated carious lesion(s) involving molars
and / or incisors, Type 2 ECC-moderate to severe -labiolingual
carious lesions affecting maxillary incisors, with or without
molar caries depending on the age of the child and stage of
the disease, and unaffected mandiblular incisors, Type 3 ECC
I N T E R N AT I O N A L J O U R N A L O F D E N TA L C L I N I C S
patient with Type 2 ECC under conscious sedation.
Case Report
A three year old female child patient accompanied with her
parents were reported to the Department of Pedodontics
and Prevent with a chief complaint of decayed upper anteri-
or teeth and pain in the molar teeth. Patient had a history of
improper oral hygiene maintenance and frequent intake of
sweets. On examination, crowns of all maxillary anteriors re-
vealed cavities girdling the necks of teeth in brownish collar
(Figure 1). The primary molars also showed similar brownish
discoloration. Extensive cavitations with no pulpal involve-
ment were observed. The case was diagnosed as Type 2 ECC
and a two stage treatment plan was formulated; Initial preven-
tive therapy with strategies forand final therapeutic interven-
tion. The success of multiple restorations may be influenced
by the child’s level of cooperation during treatment. So it was
decided that conscious sedation may provide optimal condi-
tions to perform the restorative procedures as with a less risk
potential than general anesthesia.
In the initial treatment regimen and home care instructions
included oral hygiene measures and diet counseling to the
parents.4 The parents were asked to keep a five-day food dairy,

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– severe-carious lesion affecting almost all the teeth including to follow-up the diet counseling. Gross excavation of all le-

2012 Volume 4 Issue 1

the lower incisor. The condition is rampant and involves tooth
surfaces which are usually unaffected by caries.3
The type of treatment based for each patient with ECC depends
on patients and parents motivation towards dental treatment,
the extent of the decay and the age and cooperchild. This pa-
sions as an initial approach was done in the first sitting.5, 6 APF
Topical solution of 1.23% Fluoride was applied and temporiza-
tion was done. In the second visit, the food dairy was checked
and the patient was found to be adhering to the counseled
diet changes and the oral hygiene measures were reinforced.
Under conscious sedation using Nitrous oxide and oxygen

Figure 1. Intraoral photograph showing Early childhood caries, Figure 2. Placement of Pedo-strip crowns, Figure 3. Post treat-
ment photograph.

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Swamy et al
analgesia, the anterior lesions were restored by Strip-Crown
method.7 A strip crown was used and the crowns were recon-
structed using composite resin (Figure 2).
Stainless steel preformed crowns were used successfully to
restore the primary firsocclusion was checked and after the
removal of, resto interferences. Final finishing and polish-
ing of the restoration was performed using soflex tips and a
post-operative photograph was taken (Figure 3). Immediate
recall check up was scheduled after one week followed by the
second recall check up after three months. Third month recall
showed no new lesions and the restorations were well main-
tained. Another round of Topical Fluoride therapy was given.
Recall check up after every six months was scheduled to track
the maintenance status of oral hygiene and diet.
2012 Volume 4 Issue 1
Discussion
Discusit™The premature loss or unsightly appearance of
grossly decayed primary anterior teeth (nursing bottle caries,
Early childhood caries) may physically handicap, embarrass
and psychologically traumatize a young child.8, 9 The untreat-
ed decayed teeth may cause pain and infection which results
the damage to the developing permanent tooth4 and feelings
of personal inadequacy.9 Treatment of these badly decayed
teeth will prevent pain and infection and assist the child to a
better social and emotional adjustment.10, 11 To perform treat-
ment effectively and efficiently while instilling a positive den-
tal attitude, the practitioner caring for a child with ECC often
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must employ advanced behavior guidance technique. These
I N T E R N AT I O N A L J O U R N A L O F D E N TA L C L I N I C S
may include protective stabilization and/or sedation or gen-
eral anesthesia. The success of restorations may be influenced
by the child’s level of cooperation during treatment. NO/O2
analgesia was the preferred mode of sedation in this patient
as it is effective, safe and easy to administer.12
Nitrous oxide is effective to perform short and relatively pain-
less procedures, with few, light and transitory side effects.12
Restorative treatment modalities for early childhood caries
are directly related to stage of advancement of lesions. Type
1 lesions suffice with glass ionomer or composite restorations
while Comprehensive treatment strategies for Type 2 ECC also
include Pedo strip crowns, or acrylic and/or stainless steel
crowns. Type 3 lesions require either pulpotomy/pulpectomy/
extraction followed by crowns / space maintainers / partial
or complete dentures as indicated. The placement of crowns
provides a satisfactory means of restoring anterior teeth.7, 8, 12
Acrylic jacket crowns offer excellent aesthetics, are insoluble
in oral fluids and resist surface staining.13 However, the mate-
rial wears away rapidly, is expensive and the process requires
long dental appointments.7
Composite resin (tooth colored filling material) can be success-
fully used for full coronal coverage to crown severely damaged
primary teeth.7, 14 These composite resin crowns [Pedo strip
crowns] look just like normal teeth wear well, prevent the de-
velopment of a tongue thrust and bad speech habits, prevent
the formation of fibrotic tissue with delayed permanent tooth
eruption, prevent loss of space and the child cannot loose or
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fail to wear the crown.8 Composite resin can be polished to a
smooth luster thereby decreasing plaque accumulation. This
cost effective treatment option does not require long dental
appointments and lasts the life of the primary tooth and is
thus the treatment of choice when restoring decayed primary
anterior teeth.8 Ripa has reviewed that, restorative dentistry is
expensive and by itself is not a complete cure for ECC. When
children with maxillary anterior caries were compared with
.increased risk of caries in other primary teeth by, O’Sullivan,16
it was found that these children are three times at greater risk
of developing molar caries than children without anterior car-
ies. The initial preventive therapy measures will help deter-
mine the ultimate success or failure of the case by correlating
with the re-emergence of decay if any.
Conclusion
In conclusion,the treatment of such extensive lesions under
conscious sedation offers a risk-free complete oral rehabilita-
tion in a short span of time, allowing immediate relief of pain
with only little / no cooperation from the child. However, more
importantly oral health, diet and acceptance of routine dental
care should be maintained and monitored to ensure complete
success of the treatment.
Authors Affiliations
1. Nanjunda Swamy K.V. MDS, Professor and Head, 2. Sumanth
M. Shetty MDS, Associate Professor, Department of Pedodon-
tics, Sri Aurobindo Dental College, Indore, Madhyapradesh,
India.
References
1. Luzzi V, Fabbrizi M, Coloni C, Mastrantoni C, Mirra C, Bossù
M, et al. Experience of dental caries and its effects on early
dental occlusion: a descriptive study. Annali di stomatologia.
2011;2(1-2):13–8.
2. Jin BH, Ma DS, Moon HS, Paik DMI, Hahn SH, Horowitz AM.
Early childhood caries: prevalence and risk factors in Seoul, Ko-
rea. Journal of public health dentistry. 2003;63(3):183-8.
3. Wyne AH. Early childhood caries: nomenclature and case
definition. Community dentistry and oral epidemiology.
2007;27(5):313-5.
4. Navit S, Katiyar A, Samadi F, Jaiswal J. Rehabilitation of se-
verely mutilated teeth under general anesthesia in an emo-
tionally immature child. Journal of Indian Society of Pedodon-
tics and Preventive Dentistry. 2010;28(1):42-4.
5. Twetman S, Fritzon B, Jensen B, Hallberg U, StÅhl B. Pre‐and
post‐treatment levels of salivary mutans streptococci and lac-
tobacilli in pre‐school children. International Journal of Paedi-
atric Dentistry. 1999;9(2):93-8.
6. Johnsen D. Response to Horowitz: research issues in early
childhood caries. Community dentistry and oral epidemiolo-
gy. 1998;26(1):82-3.
7. Croll T. Primary canine full coronal restoration: new consid-
 ISSN :0975-8437

Swamy et al

erations. Quintessence international. 1985;16(2):143-7.

8. Rosen M, Melman G, Cohen J. Changes in a light-cured com-

posite resin material used to restore primary anterior teeth: an
eighteen month in vivo study. The Journal of the Dental Asso-
ciation of South Africa.1990;45(6):251-5.

9. Fisher N. Restoration of anterior teeth: a transitional approach

for the young adult. British dental journal. 1985;158(12):445-9.

10. Laird W. Immediate dentures for children. The Journal of

prosthetic dentistry. 1970;24(4):358-61.

11. Borjian H. Removable prostheses in preschool children.

The Journal of pedodontics. 1978;2(3):246-50.

I N T E R N AT I O N A L J O U R N A L O F D E N TA L C L I N I C S
12. Ryding HA, Murphy HJ. Use of nitrous oxide and oxygen for
conscious sedation to manage pain and anxiety. J Can Dent
Assoc. 2007;73(8):711.

13. Rao S. Removable partial dentures for children. Clinical

Paedodontics, Fourth Edition, Ed Finn, SB. 1973:271-85.

14. Webber DL, Epstein NB, Wong JW, Tsamtsouris A. A meth-

od of restoring primary anterior teeth with the aid of a cel-
luloid crown form and composite resins. Pediatric dentistry.
1979;1(4):244-5.

15. Ripa LW. Nursing caries: a comprehensive review. Pediatric

Dentistry. 1988;10(4):268-82.

16. O’sullivan D, Tinanoff N. Maxillary anterior caries associat-

ed with increased caries risk in other primary teeth. Journal of
dental research. 1993;72(12):1577-80.

Address For correspondence

Dr. Nanjunda Swamy K.V. MDS,

Professor and Head,
Department of Pedodontics,

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Sri Aurobindo Dental College,
2012 Volume 4 Issue 1
Indore, Madhyapradesh, India.
Email: nanju_75@rediffmail.com

Source of Support: Nil

Conflict of Interest: None Declared

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