Caries management in young children

Prathip Phantumvanit
Thammasat University, Thailand
Former Vice-Chair, Public Health Committee, FDI

Overview
Dental caries status in primary teeth
Caries classification & management matrix
Caries control after first tooth eruption (6
mo)
Caries control at Well-baby clinic
Caries control in child care center
Caries management at all prevention levels

Child caries management 2015

Malaysia

5/9/16

Caries prevalence in primary

teeth
country
Age (yrs)
prevalence
Year
Japan

(%)
24.4

Nepal

5-6

57.5

2004

Malaysia

76.2

2005

Thailand

3 (5)

51.7 (78.5)

2012

Mongolia

3-5

87.8

2007

Vietnam

6-8

92.2

2007

Cambodia

93.1

2011

Laos

96.1

2010

Philippine
s

97.1

2006

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2005

Caries in primary teeth at 6

yrCountry
Year
dmft
Singapore

2005

2.03

Nepal
Korea
Sri Lanka
Malaysia
Thailand (5 yr)

2004
2012
2011
2007
2012

2.7
2.8
3.5
3.7
4.4

Vietnam

2007

6.3

Lao PDR

2010

6.3

Philippines

2006

8.4

Cambodia

2011

9.0

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Mean no. of carious teeth by age

(month) in Southern part of Thailand
2.74

9
12
18

no. of teeth

0.73
0.05

age (months)
Tithisommakul S et al. 2003
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Prevalence of primary teeth

caries

Prevalence of ECC rose sharply from

2.0% at 9 months to 68.1% at 18
months. (Thitasomakul et al., 2006)

In 15-19month-old children, the

prevalence of ECC was 82.8% (42.0%
noncavitated + 40.8% cavitated lesions)
(Vachirarojpisan et al. 2003)

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dmft of 3 yr olds Thai

3.6

2.7

0.07
0.05

0.03

3.5

2001

f
m
d

3.2

2012

Thailand National Oral Health Survey,

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Dental Caries Status in 6 yr-old

dmft

dt

mt

ft

Japan

%
caries
42.1

1.84

0.89

0.95

Malaysia

74.5

3.7

3.5

0.2

Thailand
(5)
Myanmar

78.5

4.37

3.98

0.13

0.26

89

4.34

4.16

0.18

Vietnam

84.9

5.4

5.07

0.31

0.02

Lao PDR

88.6

7,95

7.92

0.03

Cambodia

93.1

9.0

8.9

0.1

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Untreated caries

Korea National ORH Survey (2012)

5 years old, dft was 2.79 but 1.83 filled (65.6%)
Japan (Survey of MCH 2011)
5 years old, dft was 1.84 with 0.95 filled (51.6%)
England NHS Oral health Survey (2008)
5 years old, dmft was 3.45 and Care Index 14%
(restoration carious teeth)
Malaysia NOHSS (2007)
6 years old, dft was 3.7 and 0.5 filled (13.5%)
Thailand National Oral Health Survey (2012)
at 5 years old, dmft was 4.4 and only 0.26 filled (6.8%)
Vietnam (Hanoi, 2007)
6-8 years old, dmft was 5.7 and only 0.11 filled (1.9%)
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Untreated caries in children: Why?

Less important due to expected exfoliation of

primary teeth

Severity of carious lesions due to non-early

detection and care

Dental fear in children due to sound and water

from aeroter drilling machine & injection

Child management problem in general dentists

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Dental caries in primary teeth

of 3 yr olds Thai children
LOWER

UPPER

40
% children
35
30
25
20
15
10
5
0

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Severe Early childhood

caries (sECC)

Definition:
Rampant caries in
primary dentition
especially in the
upper anterior teeth,
as early as in
toddlers and
young children,
mostly in the underprivileged family.

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Overview
Dental caries status in primary teeth
Caries classification & management matrix
Caries control after first tooth eruption (6
mo)
Caries control at Well-baby clinic
Caries control in child care center
Caries management at all prevention levels

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Caries Classification and

Management Matrix FDI 2012

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1W
2W

1B

Detection system: Each of

the 7 scores are illustrated
with an example

2B

1W
SOUND

OPACITY
with airdrying:
WHITE,
BROWN

OPACITY
without airdrying:
WHITE,
BROWN

SURFACE
INTEGRITY
LOSS

UNDERLYING
GREY
SHADOW

DISTINCT
CAVITY

EXTENSIVE
CAVITY

Score
0

Scores
1

Scores
2

Score
3

Score
4

Score
5

Score
6

Sound

Ekstrand et al., (1997) modified by ICDAS (Ann Arbor), 2002 and again in 2004
(Baltimore)
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ICDAS/ICCMS for caries

management

ICDAS/ICCMS in research, dental education,

public health and dental practices:
prevention as a priority, surgical intervention only
used as a last resort
where surgery is indicated, use minimal removal
of tooth tissue
cavity size and selection of material are governed
by preservation of tooth tissue destruction and
healthy patient outcomes
(NB Pitts1 and KR Ekstrand. Community Dent Oral Epidemiol
2013; 41: e41e52)

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ICDAS score 1-2 or ICCMS score a

(non-cavitated enamel)
Fluoridated toothpaste
Score 1 or a: OPACITY with airdrying: WHITE, BROWN

Score 2 or a: OPACITY without airdrying: WHITE, BROWN

Pitts N, 2007
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ICDAS score 3 or
ICCMS score b (cavitated enamel)
Fluoride varnish or silver diamine fluoride

Score 3 or b: SURFACE
INTEGRITY LOSS

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ICDAS score 4 or
ICCMS score c (non-cavitated dentine)
sealant with GIC

Score 4 or c: UNDERLYING
GREY SHADOW

Pitts N, 2007
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ICDAS score 5&6 or ICCMS score d

(frank open cavity)
Partial caries removal and GIC
restoration
Score 5 DISTINCT
CAVITY

Score 6 EXTENSIVE
CAVITY
Pitts, 2007
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Overview
Dental caries status in primary teeth
Caries classification & management matrix
Caries control after first tooth eruption (6
mo)
Caries control at Well-baby clinic
Caries control in child care center
Caries management at all prevention levels

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Malaysia

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Oral health start at first

primary tooth eruption

Home visit

Tooth

cleaning
routinely right after
the first primary tooth
eruption
Tooth-brushing with
smear amount of
fluoride toothpaste,
twice daily after 6
month old
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Clean toddles mouth and

teeth

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Effective Fluoride Toothpaste

Use
(Zero DT, Marinho VCC & Phantumvanit P 2012; ADR 24:16-21)
Concentration:

range 1000 1500 ppm fluoride

(minimum of 800 ppm F bioavailable)
Brushing Frequency At least twice per day
Amount of F toothpaste:
6 mo 2 yr: thin smear, half a pea (0.05 - 0.1 g)
2 6 yr: pea size or width of toothbrush (0.25 g)
6 and older: full length of toothbrush (1 1.5 g)

Brushing

Time Minimum of two minutes

Post brushing behaviors Spit out the toothpaste
and minimize rinsing behaviors with water.
Timing Ideally after meals in the morning and
immediately before bed
Fluoride toothpaste is safe to use irrespective of low,
normal, or high fluoride exposure from other
sources, if used as recommended
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Cochrane Database of Systematic

reviews: (Walsh T et al 2010)
confirm the benefits of using fluoride
toothpaste in preventing caries in children
and adolescents
only significantly for fluoride
concentrations of 1000 ppm and above
caries preventive effects of fluoride
toothpastes of different concentrations
increase with higher fluoride
concentration

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Effectiveness of parental hand-on

toothbrushing with fluoride
toothpaste
Thai children age 9-18 months, 1 year
follow-up study
Study group with instruction to parental
hand-on tooth-brushing with Fluoride
toothpaste showed caries increment
dmfs/dmft as 3.3/1.3
Control group demonstrated caries
increment dmfs/dmft as 18.9/7.4

(Thanakanjanaphakdee & Triratvorakul 2010, J Dent

Assoc Thai 60:83-93)
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Overview
Dental caries status in primary teeth
Caries classification & management matrix
Caries control after first tooth eruption (6
mo)
Caries control at Well-baby clinic
Caries control in child care center
Caries management at all prevention levels

Child caries management 2015

Malaysia

5/9/16

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Oral health at well child clinic

Oral health examination

and caries risk assessment
(plaque/diet/
toothbrushing/F use)
Milk and food instruction
Training parent to brush
the childs teeth
F varnish in high risk group
Follow up individually
every 6 months

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Appropriate oral health

care
Early

oral health
examination, white
spot lesion caries in
primary dentition

Fluoride

varnish in
high risk group

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Caries control during

vaccination
Early caries detection (careful)
Continuing tooth-brushing with fluoride
toothpaste under parents close supervision
Fluoride varnish as primary and/or seondary
prevention in infant from 9 months old
followed at 12, 15, 18, 24 and 36 during
vaccination period (Thailand Well-Baby
Clinic)

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Eruption times and lifespan of

deciduous teeth (in years)*
Deciduous Permanent
eruption
eruption
times
times

Lifespan

Central incisor

0.5

6.5

Lateral incisor

0.75

7.25

1.5

9/12a

7.5/10.5a

First
molar/premolar
Second
molar/premolar

10

11

*Kidd, van Amerongen, van Amerongen; 2008

Canine

Upper/lower arch

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Overview
Dental caries status in primary teeth
Caries classification & management matrix
Caries control after first tooth eruption (6
mo)
Caries control at Well-baby clinic
Caries control in child care center
Caries management at all prevention levels

Child caries management 2015

Malaysia

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Fluoride toothpaste use in

young children

Tooth-brushing with
pea size or width of
tooth-brush amount
of fluoride
toothpaste, 1,000
ppmF, twice daily after
full primary teeth
eruption (2 yr old)

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Effective Fluoride Toothpaste

Use
(Zero DT, Marinho VCC & Phantumvanit P 2012; ADR 24:1621)

Concentration:

range 1000 1500 ppm fluoride

(minimum of 800 ppm F bioavailable)
Brushing Frequency At least twice per day
Amount of F toothpaste:
6 mo 2 yr: thin smear, half a pea (0.05 - 0.1 g)
2 6 yr: pea size or width of toothbrush (0.25 g)
6 and older: full length of toothbrush (1 1.5 g)

Brushing

Time Minimum of two minutes

Post brushing behaviors Spit out the toothpaste and
minimize rinsing behaviors with water.
Timing Ideally after meals in the morning and
immediately before bed
Fluoride toothpaste is safe to use irrespective of low,
normal, or high fluoride exposure from other sources, if
used as recommended
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Oral health promotion activities

in Day Care Center
1. After lunch
toothbrushing
with fluoride
toothpaste
2. Provide nutritious
snack
3. Oral health
examination

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Type of treatment needed in primary

teeth of 3 year olds Thai children
0.36

0.91

5
4
teeth/person

0.31

RCT

1.56

Crown

1.13

1.44

0.67

Extraction

2001

2+ surface
1 surface

2.5

PRR
Sealant

2007

Thailand National Oral Health Survey

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Glass ionomer sealants

Glass ionomer cements and resin-based exhibited

significant caries preventive effects (Yengopal V et
al 2009)

Recommendations away from resin and toward glass

ionomer for sealant programs (Niederman R 2010)
glass ionomer is moisture-forgiving
glass ionomer contains and slowly releases fluoride
glass ionomer flows more deeply into pits and
fissures, providing protection even as abrasion
wears away the occlusal surfaces
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Child caries management 2015

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NEXT
When

the disease is beyond

primary prevention, the secondary
prevention and tertiary prevention
or care are required accordingly.

However, the secondary prevention and

the tertiary prevention or care cannot be
rendered merely; they must be performed
together with the primary prevention in
order to stop recurrent disease.
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Caries management for primary teeth

Fluoride

and non-operative therapy

for initial enamel caries
Sealants with Glass Ionomer Cement
for non-cavitated caries lesion
involving dentine
Conservative DEJ caries removal and
GIC restorations for deep carious
cavities SMART
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GI in primary teeth
restorations

A 1-yr evaluation of the success rate of Cl I

& II restorations of the primary molars
restored with high-viscosity GI was 94%
(Yilmaz Y et al 2006)

After 1 yr, the overall survival restorations

of GI was 95% for Cl I and 82% for Cl II
restorations Simplifed, Modified ART or
SMART (Phonghanyudh A et al 2012)

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Practical Caries management for primary teeth

Fluoride

toothpaste, non-operative therapy, for noncavitated, initial, enamel caries

Fluoride

varnish for cavitated enamel caries

Sealants

with Glass Ionomer Cement for non-cavitated

dentine caries

Conservative,

(partial), caries removal and GIC

SMART restorations for frank open cavitated
dentine caries
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Overview
Dental caries status in primary teeth
Caries classification & management matrix
Caries control after first tooth eruption (6
mo)
Caries control at Well-baby clinic
Caries control in child care center
Caries management at all prevention levels

Child caries management 2015

Malaysia

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Comprehensive caries management

Primary

prevention
oral hygiene instruction
dietary control
fluoride toothpaste
fluoride mouth-rinse
Secondary prevention
early detection
fluoride varnish
glass ionomer sealant
silver fluoride application
high-fluoride toothpaste
Tertiary prevention
minimum intervention dentistry (ART)
SMART preventive restoration (partial caries removal +
capsulated GIC)
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Dynamic Process of Dental Caries

Plaque/Enamel Interface
(Zero 2011)
Undersaturated
demineralization conditions in oral fluids
8H+ + Ca10(PO4)6OH2
Supersaturated
conditions in oral
fluids

F-

6(HPO4)- - + 10Ca++ + 2H2O

remineralization

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Paradigms in Cariology

Old paradigm

Infectious disease
(mono-infectious
concept)
Fluoride create
enamel resistance

Operative treatment
Drill and fill restoration
Removing bacteria in
cavity

New paradigm
Dynamic process
leading to mineral
loss
Fluoride inhibits
demineralization and
enhances
remineralization
Preventive treatment
Minimum intervention
Pulp and reparative
dentine
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Effects of dental caries in

pre-school children

Severe untreated caries is very common in many

countries
Children with untreated ECC have significantly
poorer oral health-related quality of life
Following treatment of affected caries there is more
rapid weight gain and growth velocity in the treated
children
Comprehensive care makes significant difference to
the psychological and social aspects of the childs
life
British Dental Journal 2006; 201:625-6
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Pathways of care children with

dental caries

Deliverable treatment philosophy

leading children into adulthood with cavity-free
permanent teeth
responsibility and ability to care of their mouth and
teeth without fear of dental treatment

New approach to dentistry for children

changing attitudes and priorities

redressing the balance of prevention
understanding of dental caries
less invasive dental treatment which easier for children
to cope with
Innes N & Evans D 2009
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Approaches to treating carious

primary teeth

Specialists in pediatric dentistry

limited number

General dental practitioners

busy schedule work plan, child management

Public health dentists, dental therapists or

dental nurses
preventive restoration approach
less invasive dental treatment
changing attitudes and priorities
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Policy and national

program

Early caries detection for prevention

Oral health program + preventive

restoration with partial caries
removal (SMART) as an integral part of
the existing national health care delivery
system.
Service coverage to rural areas - an
equitable distribution of oral health services
Use of auxiliaries and other health
personnel besides dentists.

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Improved oral health and

enhanced quality of life

Oral

disease (dental caries) need to be

treated or prevented as to control pain
and discomfort and enhance the quality of
life.
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Oral health in young

children
Oral pain and general health
Good mastication and body weight
Mastication and brain growth
Tooth esthetics and personality
Healthy mouth and body
Oral health and quality of life of the child,
parents, family and community

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when

what

0-6 month

Where

who

how

suppor
t

diet counsel
home visit
early check-up
toothbrush F

parents
health
workers
dental
nurses

advocacy
training
community

dent
fund
LAO
MOH

-3 yr
vaccinatio
n

diet counsel
health
early check-up center
toothbrush F
F varnish
GI sealants
(SMART)

parents
health
workers
dental
nurses

advocacy
training
community
evaluation

dent
fund
LAO
MOH

3-5 yr

diet counsel
early check-up
toothbrush F
F varnish
GI sealants
SMART
sweet-enough

parents
health
workers
dental
nurses
teacher
nannies
dentists

advocacy
training
community
curriculum
evaluation
impact

dent
fund
LAO
MOH
schools
private

day care
center
pre-school
kindergarten

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Thank You

THANK YOU FOR

YOUR KIND
ATTENTION

prathipphan@gmail.com
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