INTRODUCTION

Caries is the irreversible, microbial disease of the calcified tissues of the teeth, characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth which often leads to cavitations. Caries activity is the sum of new carious lesions and the enlargement of existing cavities during a certain time period; it is the speed with which the teeth are destroyed by caries. Caries susceptibility is an inherent property of the host and tooth to be affected by carious process; it refers to the number of new lesions that may develop in an individual over a period of time.

a) Susceptibility of teeth: Primary : 2nd molars > 1st molar > canine > lateral incisor > central incisor Permanent: 1st molars>2nd molars>upper 2nd premolar>upper 1st premolar and lower 2nd premolar>upper central and lateral incisors>upper cuspids and lower 1st premolars>lower cuspids, central and lateral incisors

b) Susceptibility of surfaces (primary): Occlusal>molar interproximal area>incisor interproximal area

HIGH RISK VS LOW RISK GROUPS

High risk 1. Social history low socioeconomic status - High caries in siblings - Poor dental awareness - Low motivational level 2. Medical history - Handicapped - Medical condition predisposing to xerostomia - Long term cariogenic medicines - Traumatic delivery 3. Dietary habits - Frequent sugar intake (solid exposure >3, liquid > 5) - Refined carbohydrate intake - Pacifier habit/ prolonged breast feeding 4. Fluoride - Deficient - No fluoride supplements, toothpaste 5. Oral hygiene - Poor with excessive plaque accumulation 6. Saliva - Low buffering capacity - S. mutans count >105 - Lactobacillus count <10 000/ ml saliva Low risk Middle or upper class - Low - Conscious of dental health - High

- No medical problem - No handicap or salivary deficiency

- Normal birth

- Sugar intake within limits - Less - No such history

- Optimum water fluoride level - Used

- Fair

- High - <105 - <1000/ ml saliva

MANAGEMENT
AIMS Management of existing emergency Arrest and control of carious process Institution of preventive procedures Restoration and rehabilitation

FACTORS AFFECTING Extent of lesion Age of patient Behavioral problems due to young age

TREATMENT PROPER I. FIRST VISIT 1. Treatment of lesion - All lesions should be excavated and restored; gross excavation of each lesion is done in 1 appointment when the condition is rampant - Then filled with ZOE (IRM) or GIC - Advantage: temporarily arrest caries process, prevent rapid progression to dental pulp : gives time to dentist to take medical and dental history and complete tests to determine cause of rapid destruction : opportunity to outline a preventive and restorative approach to bring about permanent control of problem - Drainage if abscess is present - Advise x ray to assess succedaneous teeth - Collect saliva to determine flow and viscosity 2. Parenteral counseling Question them of the childs feeding habits, especially regarding the use of nocturnal bottles, demand for breast feeding etc Parents should be asked to try to wean the child from using the bottle as pacifier when in bed
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Suggest the use of plain water if there is emotional dependence Parents should be instructed to clean the childs teeth after every feed They are advised to maintain a diet record of the child for 1 week which includes time, amount of food given, type of food and number of sugar exposures

II. -

SECOND VISIT Scheduled 1 week after the 1st visit Diet chart is analysed Determine the adequacy of diet and amount of freely fermentable carbohydrate Number of servings of food in each of the 5 basic food groups should be determined and compared with the recommended outline To evaluate adequacy of diet, basic analysis form is helpful:

Certain guides are designed for individuals who are school age and older : Food guide pyramid by National Academy of Sciences and United States Department of Agriculture Guide to Good Eating by National Dairy Council (NDC)

Explain the disease process to parent or child in the form of simple equation:

Fermentable carbohydrates + oral bacteria within plaque

acid in plaque

Acid + susceptible tooth

tooth decay

Isolate sugar factors from diet chart and control sugar exposure
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If needed, reassess and redo restoration Caries activity test can be started and repeated at monthly intervals to monitor the success of treatment

III. -

THIRD AND SUBSEQUENT VISIT Restoring all grossly decayed teeth Endodontic treatment as required Extraction in unrestorable teeth, followed by space maintenance Crowns given for grossly decayed or endodontically treated teeth Review and recall after every 3 months

PREVENTION
I. Main strategy is to create awareness and alert prospective parents about the condition and its causes

II. Use of fluorides Maximal benefit is through the use of multiple visits

1. General considerations for fluoride regimen in children. a. Should be custom-designed for each individual patient; Children above 3 years Topical application will give significant benefit Home use preparation in the form of dentrifices only are recommended Caution to minimize fluoride ingestion Use only in pea-size amount Pediatric fluoride supplements are prescribed if child is not ingesting fluoride from another source b. Fluoride effects are additive. No single treatment or procedure provides maximal disease control Dental office and home use of fluoride are recommended Since it has the potential to produce dental fluorosis and systemic overdose, all forms of fluoride must be used with care under professional supervision Be aware of its content in drinking water and other sources before prescribing dietary fluoride supplements Always consider patients age Multiple fluoride therapy includes: Systemic fluorides Topical fluorides

2. Office fluoride regimen a. Propphylaxis Should be administered only if needed Prophy paste functions to clean, polish and replenish fluorides that is lost from enamel

b. In office topical application 2% sodium fluoride 8% stannous fluoride 1.23% acidulated phosphate fluoride (APF) c. Frequency of application: Rampant caries: 4-5 application during 4-6 week period; repeat single application every 3 months until caries is under control : should brush teeth with fluoridated dentrifice immediately before receiving fluoride treatment Moderate caries: single application at 2-3 month interval Minimal or none: single application every 6 months

3. Topical fluoride measures for home use a. Fluoride dentrifices Contains 0.10- 0.11% or 1000- 1100 ppm fluoride At least 25% caries reduction can be expected Increased benefit from 2-3 brushings/day b. Fluoride mouth rinse 35% reduction with daily or weekly rinses Recommended for patients with rampant caries or high risk patients Daily use Rinse after thorough brushing with fluoridated dentrifice c. Fluoride gels 0.4% SnF2 1.1% NaF Applied with toothbrush before going to bed and immediately brushing with fluoride dentrifice

4. Systemic fluoride measures a. Communal fluoridation Refers to the addition of low concentration of fluoride to the public water supply 1 ppm is considered as optimum (in India) Single most effective public health procedure for caries prevention b. School water fluoridation Optimal concentration is 4.5X more than city water supply; due to less water consumption in schools Overall reduction by 40% c. Pediatric fluoride supplements Fluoride or fluoride-vitamin preparation Only given if water content is <70% of optimal concentration Only prescribe fluoride-vitamin preparation if the child is really in need of vitamins

III. Sealing of all caries free pits and fissures Indication: o newly erupted primary molars and permanent bicuspids and molars with complete recession of pericoronal operculum and with open and/or sticky grooves and fissures o Stained pits and fissures with minimum decalcification or opacification and no softness at the base of the fissures o The tooth in question should have erupted less than 4 years ago Selection of patients: o 3-4 yrs: primary molars o 6-7 yrs: 1st permanent molars o 11-13 yrs: 2nd permanent molars and premolars

IV. Parents education How and when to feed the child during the earliest stages of the child When and how to introduce solid foods Breastfeeding should be encouraged; breast milk is highly adapted to the human infant and is almost a complete source of all required nutrients V. Oral hygiene
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a. Office procedure - The use of hand instruments and motor driven brushes and cups with mild abrasives at 3-6 month interval - Is of little significance in the control of tooth decay; its major contribution is in the prevention of periodontal health b. Home treatment

Mechanical aids Manual toothbrush and dentrifice Powered toothbrush Dental floss Disclosing agents Tongue scrappers oral irrigators

Chemotherapeutic aids Antiseptic mouthwash Antibiotics Enzymes Plaque modifying agents Sugar substitutes Plaque attachment interference agents

Manual toothbrush and dentrifice - Use of Fones technique; due to lack of muscle development for techniques that require more coordination - Tooth brushing should remove dental plaque from the outer, inner and chewing surfaces including the tongue - Toddlers and preschoolers: horizontal scrub brush was found efficacious - School going: Bass method - Dentrifices: o Select fluoridated toothpaste for any child above 36 month of age with low abrasive content o Not used below 36 months due to increased risk of systemic ingestion o Use only pea-size amount for those below 7 years - Twice daily brushing Powered toothbrush - Greater plaque removal - Children tend to brush longer

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Dental floss - Advised to use waxed floss in children; ease of passing between adjacent tooth surface - Fluoride-coated to prevent caries from occurring in adjacent tooth surfaces - Floss holders allows parents to help children - Technique: o Take 12-18 inches, grasp such that there is a few inches of taut floss between hands o Slip the floss between teeth and gums as far as it will go o 8-10 vertical stokes o At least once a day especially before bed o Before or after brushing is fine Plaque disclosing agents - Allows visualization of plaque to facilitate education and removal Chemotherapeutic aids - Mainly for patients who are unable, unwilling or untrained to practice routine effective mechanotherapy - Are adjuncts in plaque control - Most commonly used are antiseptic mouthwashes - Care to prevent swallowing - Recommended for children above 7 years of age

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REFERENCES

Textbook of Pedodontics by Shobha Tandon, 2nd Edition Dentistry for the Child and Adolescent by Ralph E. McDonald, 6th Edition

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Thank you

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