Management of early childhood caries and rampant caries

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MANAGEMENT OF
EARLY CHILDHOOD CARIES
& RAMPANT CARIES
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TABLE OF CONTENTS
 INTRODUCTION
 EARLY CHILDHOOD CARIES
 HISTORY
 ETIOLOGY
 CLINICAL FEATURES
 IMPACT OF ECC ON GENERAL HEALTH

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 MANAGEMENT
 TREATMENT
 PREVENTIVE MODALITIES
 PUBLIC HEALTH APPROACHES TO ECC

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 RAMPANT CARIES
 HISTORY
 ETIOLOGY
 CLINICAL FEATURES
 MANAGEMENT
 TREATMENT
 PREVENTION
 SUMMARY AND CONCLUSIONS
 REFRENCES

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INTRODUCTION
 Dental caries is one of the most common diseases
affecting mankind.
 Almost every individual is susceptible to dental
caries.
 However, caries is more prevalent in the younger
population and considered as a disease of childhood.

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 Early Childhood Caries (ECC), a distinctive pattern
of severe tooth decay in infants and young children.
 An emerging awareness of the nature and severity of
Early Childhood Caries (ECC) and its serious
implications for General health has made it
imperative that all health professionals engage more
actively in oral health promotion and disease
prevention.

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 Early Childhood Caries (ECC) is a particularly
virulent form of dental caries that is characterized by
an overwhelming infectious challenge and is
associated with unusual dietary practices.
 ECC is a public health problem that continues to
affect babies and preschool children worldwide.
Causes, Treatment and Prevention of Early Childhood Caries: A
Microbiologic Perspective; J Can Dent Assoc 2003; 69(5):304–7

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DEFINITION
The American Pediatric Dental Association
(APDA) defines ECC as:
"The presence of one or more decayed (non-
cavitated or cavitated lesions), missing (due to
caries) or filled tooth surfaces in any primary
tooth in a preschool-age child between birth and
71 months of age”
American Academy of Pediatric Dentistry 2008-09
Definitions, Oral Health Policies, and Clinical Guidelines

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PREVALENCE
 The prevalence of ECC, however, has been shown to
be overwhelmingly high among low income and
minority populations.
 The prevalence rate is from 1-12% in some developed
countries,
 In some developing countries and some
disadvantaged populations of developed countries,
the prevalence rate is as high as 70%.
Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment
Options; Council on Clinical Affairs Review Council; Revised 2003, 2007, 2008

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 Significant prevalence of ECC worldwide
 18% of 2-4 yr olds
 52% of 6-8 yr olds
 87% of adolescents
 40% of children will have ECC by kindergarten
 Despite this ECC is very prevalent especially in
certain populations
 i.e. 70% of ECC in 20% of population
 Li et al, J Dent Res 2002 American Academy of Pediatric Dentistry Clinical
Guidelines 2004

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TERMINOLOGY
 Baby Bottle Tooth
Decay,
 Early Childhood Caries,
 Early Childhood Dental
decay,
 Early Childhood Tooth
decay,
 Comforter caries,
 Nursing caries,
 Maxillary Anterior
caries, and many more
There are multitude of terms to describe caries in
children ages 0 to 5 that exists in the literature:

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 Baby Bottle Tooth Decay is used in the literature to
identify inappropriate baby bottle use as the main
cause of caries disease.
 Other authors prefer the term Nursing Caries
because it designates inappropriate bottle use and
nursing practices as the causal factors.
 However, the term Early Childhood Caries is
becoming increasingly popular with dentists and
dental researchers alike.
Jean-Marc Brodeur, Chantal Galarneau; The High Incidence of Early Childhood
Caries in Kindergarten-age Children; JODQ - Supplement - April 2006

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 The Centers for Disease Control (CDC) discarded
the terms "bottle-mouth" and "nursing caries" in
1994, thereby acknowledging ECC as an infectious
disease not caused by breast- or bottle-feeding.
 This broader term encompasses other, less
understood, practices as etiological factors, such as
 Malnutrition,
 Cariogenic childhood foods, and
 Bacterial transmission from mothers or caregivers
to children.

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Terminologies Author
and Year
Definition
Nursing caries Winter et
al, 1966
An unique pattern of dental
decay in young children due to
prolonged nursing habit
Nursing bottle mouth Kroll et
al,1967
A syndrome characterized by a
severe caries pattern beginning
with the maxillary anterior
teeth in a healthy bottle fed
infant or toddler
Nursing bottle
syndrome
Bottle caries
Labial caries
Comforter caries
Shelton et
al, 1977
A devastating condition that
may render young children
dentally crippled

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Night bottle syndrome
Baby bottle caries
Nursing mouth
Dilley et
al, 1980
A unique pattern of dental caries
in young children
Baby bottle mouth
Nursing mouth decay
Croll, 1984 A very dectructive carious
process which can effect infants
and toddlers
Nursing bottle caries Tsamtsouri
s, 1986
Caries caused by a prolonged
use of a bottle filled with any
liquid other than the water
Baby bottle tooth
decay
Mim Kelly
et al,
1987
A caries caused by bottle
feeding only not by breast
Feeding
Milk bottle syndrome
Infancy caries
Soother caries
Circular caries
Ripa, 1988 A specific form of rampant
decay of the primary teeth of
infants

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Tooth Cleaning
Neglect
Moss,
1996
Baby bottle decay is renamed
to shift the emphasis away
from the bottle to the need for
cleaning
RIECDD (Rampant
Infant and Early
Childhood Dental
Decay)
Horowitz,
1998
It does define the age group
the usual rapidity of its
development
Early Childhood
Caries
Davies,
1998
A complex disease involving
maxillary primary incisor
within a month after eruption
and spread rapidly to involve
other primary teeth

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ETIOLOGY
 During naptime or bedtime, the substrate (sugar) and
the infectious agent (bacteria) are present on the teeth
for a prolonged time, allowing demineralization and
caries progression.
 When associated with use of the bottle, ECC has
been shown to first affect the primary maxillary
anterior teeth, followed by involvement of the
primary molars.

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1: The Tooth
 ECC has a characteristic pattern of formation related
to the emergence sequence of the primary teeth.
 Typically, the maxillary primary incisors are hit the
hardest, followed by the first primary molars.
 Lower teeth not usually affected due to protective
pooling of saliva and tongue position during feeds.
 Saliva produced by nearby sublingual and
submaxillary glands also buffers.
Jean-Marc Brodeur, Chantal Galarneau; The High Incidence of Early Childhood
Caries in Kindergarten-age Children; JODQ - Supplement - April 2006

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Proportion of caries on the surfaces of pits &
fissures and smooth surfaces

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2: The Bacteria
 The associated bacteria are Mutans Streptococci.
 Streptococcus mutans regularly exceeded 30% of the
cultivable plaque flora.
 Conversely, S. mutans typically constitutes less than
0.1% of the plaque flora in children with negligible or
no caries activity.

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WINDOW OF INFECTIVITY
 In 1993, Page Caufield and Colleagues presented a
paper with evidence to support a discrete “window of
infectivity” for MS colonization
 38 of 46 infants acquired MS at median of 26
months
 25% by 19 months
 75% by 31 months
Initial Acquisition of Mutans Streptococci by Infants: Evidence for a
Discrete Window of Infectivity; J Dent Res 72(1):37-45, January, 1993

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When does the “Window” end?
 Window appears to close after all primary teeth erupt
 Once a stable plaque or biofilm covers the tooth
surface, MS is less likely to be established
 Children ages 2-6 have been shown to be less
susceptible to MS infection

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3: The Substrate – Sucrose
 Sucrose is the major environmental contributor to
ECC.
 Mutans strep possess glucosyltransferases that utilize
sucrose as an energy source.
 The use of nursing bottles and “sippy cups” during
sleep enhances the frequency of exposure. This type
of feeding behavior intensifies the risk of caries, as
oral clearance and salivary flow rate are decreased
during sleep.

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CLINICAL FEATURES
There are four stages in the Development of ECC:
 The initial stage is characterized by the appearance
of chalky, opaque demineralization lesions on the
smooth surfaces of the maxillary primary incisors
when the child is between the ages of 10 and 20
months, or sometimes even younger.

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 A distinctive whitish line can be distinguished in the
cervical region of the facial and palatal surfaces of the
maxillary incisors.
 At this stage, the lesions are reversible but are
frequently unrecognized by parents or the first
physicians to examine the mouths of these very
young children.
 Moreover, the lesions can be diagnosed only after the
affected teeth have been thoroughly dried.

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 The second stage occurs when the child is between
the ages of 16 and 24 months.
 The dentin is affected when the white lesions on the
incisors develop rapidly, causing the enamel to
collapse.
 The dentin is exposed and appears soft and yellow.
 At this stage, the child begins to complain of great
sensitivity to cold.

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 The third stage, which occurs when the child is
between 20 and 36 months, is characterized by large,
deep lesions on the maxillary incisors, and pulpal
involvement.
 The child complains of pain when chewing or getting
his teeth brushed, and of spontaneous pain during the
night.

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 The fourth stage, which occurs between the ages of
30 and 48 months, is characterized by coronal
fractures of the anterior maxillaries as a result of
amelodentinal destruction
 Some young children suffer but are unable to express
their toothache complaints.
 They experience sleep deprivation and refuse to eat.
Importance of Early Diagnosis of Early Childhood Caries Souad Msefer,
DCD, DSO, Cert. Pedo. JODQ - Supplement - April 2006

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1. Treatment modalities
2. Prevention of ECC
Acute
ECC
Non-Acute
ECC
Dietary
Counseling
Fluoride
Therapy
Caregiver
Education
Role of the
Pediatrician

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ALGORITHM FOR
MANAGEMENT OF ECC

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Acute S-ECC
Immediate treatment
 Children with acute ECC often present with pain,
discomfort and infection, and may require medication
for relief of pain.
 Severe cases may require hospitalization prior to
definitive treatment.
 Systemic infection resulting from a local focus of
dental infection, should be treated with antibiotics.

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ANALGESICS FOR IMMEDIATE TREATMENT
FOR CHILDREN 1 YEAR AND OLDER
Analgesics
Dosage Frequency Route of
administ
ration
Paracetamol
15
mg/kg/dose
4-6 hourly (max
4g/day)
Oral
Ibuprofen
5-10
mg/kg/dose
6-8 hourly Oral
Diclofenac 1 mg/kg/dose 8-12 hourly Oral
Naproxen*
5-10
mg/kg/dose 8-12 hourly Oral

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ANTIBIOTICS FOR SYSTEMIC
INFECTION
Antibiotics Dosage Frequency Route of
administration
Amoxycillin*
10-25
mg/kg/dose
8 hourly Oral
Penicillin V*
7.5-15
mg/kg/dose
6 hourly Oral
Erythromycin 10 mg/kg/dose 6 hourly Oral
Metronidazole 7.5 mg/kg/dose 8 hourly Oral

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Stabilization of Dentition
 It is the process of instituting preventive and
interventive procedures to control the progression of
active caries in the oral cavity.
 It involves instruction in
 Oral hygiene procedures,
 Diet counselling,
 Fluoride therapy and
 Placement of Intermediate restorations such as
Glass-ionomer Cement.

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 Caries progresses rapidly through the thin dentine of
primary and young permanent teeth and may rapidly
endanger the pulp (Levine, 2002; Kidd & Pitts,
1990).
 In providing initial treatment, the following need to
be considered:
 Identification and extraction without delay of teeth
that are unrestorable, or are not to be preserved for
other reasons
 Temporization prior to definitive treatment of teeth
that are to be preserved.

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Definitive
Treatment
 Extraction of primary teeth is one of the treatment
options in managing children with ECC (Alsheneifi
& Hughes, 2001; Tickle, 2002; Holt, 992; Vinckier,
2001, Jamjoom 2001).
 General anesthesia should be considered in every
child, especially where several teeth have to be
extracted whilst others need complicated restorative
treatment, as it is less stressful.

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 The decision to extract should only be made after
considering both general and local factors below:
General Factors
 Patient’s cooperation (Harris & Coley-Smith, 1998)
 Medical condition (Harris & Coley-Smith, 1998)
 Dental infection - may increase patient’s morbidity
(Harris & Coley- Smith, 1998)
 Immunocompromised condition (Fayle, 1992)
 Bleeding disorder (Harris & Coley-Smith, 1998)

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Local factors
 Restorability (Fayle, 2001)
 Extent of caries which may involve the pulp and roots
 Potential for malocclusion or disturbances in
development of the dentition - balancing and
compensating extraction may be considered (Rock,
2002)

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Restorative Treatment
 The principal role of restorative treatment is to
eliminate cavitations, that make plaque removal
difficult, and thus promote caries extension.
 Restorative treatment should always be used in
conjunction with preventive therapy, based on the
child’s risk factors and age (Al-Malik, 2001).

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 The choices of restorative materials are influenced
by the following:
 Site and Extent of caries
 Child’s ability to cooperate (Kilpatrick, 1993)
 Duration for which the restoration is required to
last
 Type of analgesia used in providing treatment

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 Initial caries control and
stabilization can be achieved by
using the following:
 Glass Ionomer cement
 Silver cement or
 Zinc Oxide Eugenol cements
(Harris & Coley-smith, 1998; Kandelman, 1990)

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 The commonly used materials to restore primary teeth
are as follows:
 Dental Amalgam
 Resin Based Composites
 Glass Ionomer Cements
 Stainless Steel /
Nickel Chrome Extra-coronal
Crown
(Harris & Coley-Smith, 1998; Walker, 1996 ; Johnston 1994;
Gray & Paterson, 1994; Kilpatrick, 1993; Ripa, 1988)

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Follow–up
 Children with ECC must be reviewed to detect any
changes.
 Children with obvious signs of active oral disease
or its predisposing factors should be reviewed at 4-
monthly intervals until well controlled

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 Compromised children should be reviewed depending
on the severity of their underlying impairment and
oral findings.
 Reinforcement of appropriate preventive strategies
for remineralisation and arrest of carious lesions
should be carried out.
 Review should be carried out by the same clinician,
where possible.

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NON-ACUTE ECC
Conservative Treatment
 In non-acute ECC, the child may be symptomless and
the carious lesion may be arrested.
 In such cases, no therapy is required. However, the
caries should be monitored to ascertain that it remains
in the nonprogressive stage until exfoliation (Levine,
2002).

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Preventive Treatment
 Prevention of ECC requires a Mutifactorial
approach.
 The strategies for preventing demineralization and
promoting re-mineralization are crucial and should be
reinforced from time to time.
 These include the following:
 Oral prophylaxsis
 Diet counselling (Al-Malik, 2001; Shantinath,
1996; Eronat & Eden, 1992)

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 Topical fluoride application (Schwatz, 1998;
Stookey, 1993)
 Professional application of fluoride varnishes
(Autio-Gold, 2001; Weinstein, 1994; Peyron, 1992)
 Sugar free chewing gum (Autio, 2002; Makinen,
1995; Makinen, 1996; Birkhed, 1994; Kandelman,
1990)
 Health Education on Oral Health

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PREVENTIVE STRATEGIES
 Oral hygiene measures should be implemented by the
time of eruption of the first primary tooth to prevent
dental caries in children (Council on Clinical Affairs,
2005)
 Wean from bottle at 12 to 14 months of age (Council
on Clinical Affairs, 2005).
 Avoid putting infants to sleep with a bottle
 Avoid nocturnal breastfeeding after the first primary
tooth begins to erupt.

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 Encourage parents to teach their infants to drink
from a cup as they approach their first birthday
(Council on Clinical Affairs, 2005) and avoid
consumption of juices from the bottle.
 Advise parents and children on:
 Regular brushing of teeth, as soon as children
have teeth, after breakfast and before bedtime,
using children’s toothbrush and pea-sized
toothpaste containing fluoride.

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 Decreasing quantity and frequency of sugar
intake , avoiding sweet snacks between meals and
immediately before bedtime.
 Avoiding frequent consumption of liquids
containing fermentable carbohydrates (Council on
Clinical Affairs, 2005).
 Encourage substitution of sugar-free liquid medicines
wherever appropriate.

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RECOMMENDATIONS
 AAPD encourages professional and at-home
preventive measures including age-appropriate
feeding practices that do not contribute to a child's
caries risk. These include:
1. Reducing the mother’s/primary caregiver’s/sibling's
MS levels (ideally during the prenatal period) to
decrease transmission of cariogenic bacteria.
2. Minimizing saliva-sharing activities (e.g., sharing
utensils) between an infant or toddler and his
family/cohorts.

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3. Implementing oral hygiene measures no later than
the time of eruption of the first primary tooth.
If an infant falls asleep while feeding, the teeth
should be cleaned before placing the child in bed.
Tooth brushing of all dentate children should be
performed twice daily with a fluoridated
toothpaste and a soft, age-appropriate sized
toothbrush.

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Parents should use a ‘smear’ of toothpaste to brush
the teeth of a child less than 2 years of age. For the
2-5 year old, parents should dispense a ‘pea-size’
amount of toothpaste and perform or assist with
their child’s tooth brushing.
Flossing should be initiated when adjacent tooth
surfaces can not be cleansed by a toothbrush.

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4. Establishing a dental home within 6 months of
eruption of the first tooth and no later than 12 months
of age to conduct a caries risk assessment and provide
parental education including anticipatory guidance
for prevention of oral diseases.
5. Avoiding caries-promoting feeding behaviors: In
particular: Infants should not be put to sleep with a
bottle containing fermentable carbohydrates.
 At will breast-feeding should be avoided after the
first primary tooth begins to erupt and other dietary
carbohydrates are introduced.

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ECC AS A PUBLIC
HEALTH PROBLEM
A COMMUNITY BASED APPROACH

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 Early childhood caries is an important public health
problem of which the dental manifestations are
nothing but a manifestation of underlying maternal
and pediatric disorder.
 The management of ECC should receive high public
health priority.
 While the literature is clear that parenting practices
influence ECC, results from specific practices are
strongly influenced by cultural, ethnic and familial
variables among population.

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Failure of Existing Interventions
 Interventions that are not congruent with existing
parenting practices and beliefs have limited
efficiency.
 Most traditional health educational approaches focus
on bottle as a risk factor and recommend immediate
substitution by 12 months.
 Clearly, this approach is not acceptable to mothers,
caregivers.
 It is difficult to execute especially for single parents
and those with limited social support.

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 Another recommendation was the use of fluoride
supplements. It has been recommended in communities
without adequate water fluoridation.
 Providing aggressive repair as initial therapy is a problem
because , while the restorative care is convenient for the
parent and the professional, eliminates pain and has
economic incentives, it reinforces the patients perception
that caries is static or isolated problem.
 Follow up visits are missed or preventive counsel ignored.

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Possible Public Health Approaches
to ECC
1. Community Based Education
2. Behavioral Interventions - changing parenting
practices
3. Water Fluoridation
4. Maternal and Child Health & Nutrition
5. Working with the Community

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6. Chemotherapeutics
7. Educational policies - directed towards the
professional
8. Providing priority dental care to pregnant
women
9. Reversing/ arresting carious process

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Community Based Education
 The goal of education is to increase the knowledge of
the mother about ECC and to improve dietary and
nutritional habits of the infant and the mother.
 It is assumed that an increase in the knowledge of the
mother and caregiver will influence their self care and
dietary practices and in turn improve the dietary and
oral hygiene habits of infants leading to prevention of
ECC.

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 There is evidence that modestly positive change can be
achieved in dietary and personal health behavior.
 However, this limited success requires significant
investments in community organizations and promotion.
 Although current evidence does not support a wide scale
implementation of educational programs to prevent ECC,
there is still need to provide information to encourage
behavioral changes.
Educational programs may be still recommended for
high risk groups in communities.

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Behavioral Interventions - Changing Parenting Practice
 Parenting practices can be protective or may put the
child to additional risk.
 Protective behavior like controlling the child's diet,
instituting oral hygiene and appropriate fluoride regimen
is controlled entirely by the parents of the young child.
 Additional risks of parental practices are due to lack of
knowledge and disregarding the harmful effects of some
practices.

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 Providing information can help some parents to be
open to the possibility of changing their behavior.
 According to the above theory, the move from
precontemplative status to contemplative status.
Therefore , when trying to change the behavior one
should focus on positives and then overcoming the
negatives.
 The parent should be encouraged to identify more
than one option to reduce caries risk.

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Water fluoridation
 All infants and toddlers regardless of their risk status
could benefit from water fluoridation.
 It has been found to be highly effective in preventing
caries in primary dentition.
 It has been found to be more useful in preventing
dental caries in children with lower SES than those
with higher SES.

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 Water fluoridation provides the only means of
prevention that does not require a dental visit or
parental motivation.
 However, there is no evidence that it has a direct
effect on ECC although reduction in caries in 5-year
old children is reported to be high.

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Maternal and Child Health and Nutrition
 Prenatal and postnatal environmental insults may confer
increased susceptibility to ECC.
 Poor nutritional status of the mother may lead to
developmental defects of dental hard tissues.
 Malnourished children have delayed eruption and
decreased resistance to repeated infections.
 Policies towards improving maternal and child nutrition
and health must be undertaken as an important
community measure in controlling ecc.

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Working with the Community
 The reorientation of public health clinics cannot be
successful without engaging the community itself.
 The assistance of private dental sectors and medical,
nursing professionals in the community is essential.
 Dental auxiliaries can be trained to screen cases and
provide primary care especially in outreach
situations.
 Moreover, when the lay community is engaged,
public support often through the testimony of
community leaders will follow

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 Only through an engaged community can the
expectations and norms of dental behavior of the
community change over time.
 Public resources need to be used not solely to deliver
dental care but to deal with the factors that interfere
with the delivery of preventive care to the
disadvantaged.

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CHEMOTHERAPEUTICS
 While topical fluoride especially fluoride varnish
have shown to be effective in older children, there is
limited data or no knowledge of optimal regimen
for young children.
 Antimicrobials like povidine, chlorhexidine gels as
well as pacifiers which slowly release caries
preventive agents like fluoride or xylitol may hold
some promise.

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Educational policies - directed towards the
Dental Health Professionals
 It is addressed towards the problem of decreased
availability of dentists appropriately trained to
meet the needs of infants and toddlers with ECC.
 It involves:
1. Predoctoral training in pediatric dentistry and
infant oral health
2. Pediatric dentistry specialist training
3. Continuing dental education and auxiliary
education.

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Providing Priority Dental Care to pregnant women
 Chemotherapeutics, counseling and other interventions
reduce maternal MS levels as well as lowered
incidence of MS transmission.
 Although the interventions with mother are successful
in improving the health of their children, a much
broader program focusing on oral health of mother and
her attitudes to and experience in receiving dental
services is desirable.

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Reversing / Arresting carious process
 Topical fluoride application can cause reversal of
initial lesions
 Minimal interventional techniques such as use of GIC
and ART may result in better patient compliance.
 Such treatments often facilitate the establishment of
an ongoing relationship with the parents thus causing
a change both in their home care and follow up.

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OBSTACLES IN CARE SETTINGS
 These are:
1. Persistent under reporting of childhood caries in policy
documents and dental literature.
2. Caries in sub population varies widely with a
disproportionate percentage of disease and problems
related to access to services.
3. Oral health professionals have lesser access to young
children and their mothers as compared to Medical and
other health professionals .
4. Public health clinics where the disadvantaged are
treated focus most of their resources on providing
episodic, impersonal emergency services

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RECOMMENDATIONS
 ECC must be considered as a pediatric problem rather
than a dental disease.
 Conceptualizing ECC as a dental problem
significantly limits the community interest as it
reduces the likelihood of meaningful attention.
 Continue to promote water fluoridation.
 Develop a national ECC and rampant caries registry.

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 Link oral health screening and easily implemented,
low cost interventions with immunizations and public
health activities.
 Increase opportunities for community based
interventions conducted by dental hygienists.
 Dental schools should give greater emphasis their
curricula to management of oral health problems of
preschoolers including ECC.

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 The term 'Rampant Caries' has prompted numerous
definitions and synonyms within dentistry.
 Generally it can be described as decay that spreads
quickly, destroying the crowns of many or all of the
erupted teeth.
 Destruction is frequently both rapid and extensive,
because of this rampant caries poses a challenging
management problem for dentists and patients.

02/07/19 85
 Rampant caries is a severe form of tooth decay that
can affect milk teeth or permanent teeth.
 It is characterized by its speed of onset and
progression, by the pattern of attack and its cause.
 Many teeth are affected often starting with the upper
incisors.
 The lower incisors are usually, but not always
spared. Sites which are normally at low risk of decay
may be attacked.

02/07/19 87
DEFINITION
 Massler in 1945 defined it as:
“Suddenly appearing, widespread, rapidly
burrowing type of caries resulting in early
involvement of pulp and affecting those teeth or
surfaces usually regarded as immune to dental
decay.”

02/07/19 88
 G.B Winter, M.C. Hamilton and P.M.C. James
in1966 defined it as:
“A lesion of acute onset involving many or all
the erupted teeth, rapidly destroying coronal
tissue often in surfaces normally immune to decay
leading to early involvement of dental pulp”

02/07/19 89
 James et al (1951) called it as ‘labial caries’ because
labial surface of the maxillary incisors are first
attacked.
 The term "rampant caries" has been used since the
early part of last century to describe an aggressive
and rapidly progressing type of disease (Silverstone
et al, 1981).
 Rampant caries is defined as a rapid carious attack
involving several teeth, including teeth and tooth
surfaces that are usually at low risk of caries
(Mitchell and Mitchell, 1991).

02/07/19 90
HISTORY
 Harries (1911) blamed comforters as direct cause of
rampant caries while
 Pitts (1927) correlated rampant caries to the sugar
coating of the comforters.
 Beltramie and Romien (1939) called it as
Melanodontic Infantile (black teeth in children),
presumably because of the dark brown colouration of
the arrested lesion.

02/07/19 91
 Toth & Szabo (1959) ascribed it as ‘circular caries’,
as the advanced lesion circumscribes the tooth.
 Because of the close relation to nursing bottle many
authors also named it ‘nursing bottle mouth’(Fass
1962); ‘milk bottle caries’(Kotlow 1977);’nursing
bottle caries’, “nursing bottle syndrome”, “bottle
propping caries” (Shelton et al 1977), ‘bottle baby
syndrome’and ‘bottle mouth caries’(Ripa 1978).

02/07/19 92
ETIOLOGY
The etiology of rampant disease is very complex. It is
multifactorial and has a close relationship to a number
of risk factors.
Environmental factors: The major environmental
factor is diet-sucrose. This may result from an increase
in refined carbohydrate consumption or simply from
decreased use of fluoride at home.
 Occasionally rampant caries may occur from repeated
exposure of teeth to erosive acids leading to frequent
pH drop at the tooth surface.

02/07/19 93
 The rate of caries progression is likely to increase with
increasing imbalance between de- and re-mineralisation
levels.
 The caries-rampant group was characterized by
insufficient intake of vegetables and relatively low intake
of fresh fruit with cod liver oil supplements in only half
of the subjects.
 In all instances, there was a considerable amount of
sweets and fermentable carbohydrates ingested daily
Effects of Dietary Modifications on Caries in Humans, IRWIN D.
MANDEL, J Dent Res Supplement to No. 6

02/07/19 94
 Overuse of cariogenic foods and unsuitable patterns
of infant feeding were the most important risk factors
associated with rampant caries.
Chin J Dent Res. 1999 May;2(2): 58-62 ; Epidemiological study of the
risk factors of rampant caries in Shanghai children, Ye W, Feng XP,
Liu YL

02/07/19 95
Salivary Factors: Decreased flow of saliva in
children having pyrexia and dehydration predisposes
to rampant caries.
 There is no immunological compromise, but children
with rampant caries have lower Ig G to Ig A ratio
than caries free children.
 Adults on prolonged xerostomic drugs, debilitation
and poor oral hygiene are susceptible to rampant
caries.

02/07/19 96
 Sjogren's Syndrome is a possible predisposing
cause of rampant dental caries in children.
Int J Paediatr Dent. 1995 Sep;5(3):173-6.Primary Sjogren's syndrome
and rampant dental caries in a 5-year-old child, Nathavitharana KA,
Tarlow MJ, Bedi R, Southwood TR
 Patients who receive cancer radiotherapy, which may
develop xerostomia are at increased risk to develop
rampant dental caries.
Oral Surg Oral Med Oral Pathol. 1989 Oct;68(4):401-5.Chlorhexidine
rinse in prevention of dental caries in patients following radiation
therapy,Epstein JB, Loh R, Stevenson-Moore P, McBride BC,Spinelli
J

02/07/19 97
 The presence of carious lesions in mandibular
incisors, particularly when their severity exceeds
those present elsewhere in the mouth, should alert the
clinician to the possibility that salivary glands may be
absent.
Int J Paediatr Dent. 1995 Dec;5(4):253-7. Absence of salivary glands in
children with rampant dental caries: report of seven cases.Gelbier MJ, Winter
GB

02/07/19 98
 The irradiant cervico-facial therapy produces
numerous complications in maxillo-facial territory,
among which the most frequent are: xerostomia,
osteonecrosis, mucosal degeneration and severe
rampant caries.
Rev Med Chir Soc Med Nat Iasi. 1996 Jul-Dec;100(3-4):198-202.Clinical and
therapeutical aspects of rampant caries in cervico-facial irradiated
patients,Lăcătuşu S, Frâncu L, Frâncu D

02/07/19 99
Genetic and Congenital factors:
 The role of hereditary has not been established but
maternal illness during pregnancy, problematic
childbirth, illness during infancy can produce defects
in tooth structure and enamel which may predispose
to rampant caries.
Behavioral factors:
 Parental over indulgence in a sick child & pampering,
Emotional disturbances, repressed fears, traumatic
school experience and anxiety has also been observed
in children and adults with rampant caries.

02/07/19 100
 Rampant caries reflects an acute lack of tooth
protection to counterbalance the caries causing
factors.
 Although the etiology of caries is understood, factors
that modify risk and severity of rampant caries are
not understood.
 patients with rampant caries select nutritionally
inadequate diets, consumed more sugared beverage
intakes, have higher rates of substance abuse, use
more xerostomic medications and have lower socio-
economic status than patients without rampant caries.

02/07/19 101
This study suggests that
 Unhealthy lifestyle behaviors including smoking,
recreational drug use and
 Irregular meal patterns;
 Consumption of regular soda pop; and lack of water
consumption
increase risk of rampant caries.
Risk factors for rampant caries: a pilot study R. REVELL, T.A.
MARSHALL, S. GUZMAN-ARMSTRONG, and F. QIAN

02/07/19 102
 Patients with orofacial lesions of or suggestive of
HIV/AIDS were examined and they showed a
high prevalence of candidiasis, Kaposi's sarcoma,
salivary gland disease, non-Hodgkin's lymphoma,
cancrum oris and rampant caries.
HIV/AIDS orofacial lesions in 156 Zimbabwean patients at referral oral and
maxillofacial surgical clinics ,MM Chidzonga ,Journal of oral diseases,volume 3
issue 6,page 317-322

02/07/19 103
 It is very interesting to note that higher phosphorus
concentration and alkaline phosphatase activity were
found in patients with rampant caries as compared to
that with non rampant/control group.
J Pedod. 1990 Spring;14(3):144-6.Relation of salivary phosphorus and
alkaline phosphatase to the incidence of dental caries in
children,Pandey RK, Tripathi A, Chandra S, Pandey A.

02/07/19 104
Clinical Features
 Initial lesion may present as an area of whitish
decalcification on the labial surfaces of maxillary
anteriors.
 Less commonly the lesion may appear on the palatal
surface and in florid cases , may involve the incisal
edges as the tooth emerges.
 This soon progresses to yellow discoloration
followed by lateral extensions into the approximal
areas and may circumscribe the entire tooth.

02/07/19 105
 Epidemiological surveys consider a case of rampant
caries if more than 50% of teeth erupted are
involved in caries as decayed, missing or filled or an
increment of 10 DMFT per year is seen.
 The distinguishing character of rampant caries are the
involvement of the proximal surfaces of the lower
anteriors and the development of cervical type of
caries.

02/07/19 106
 Pulpal involvement is early leading to multiple
abscesses and pathological fracture of weakened
tooth structure.
 The disease usually proceeds in the following pattern:
first to be involved are the labial surface of maxillary
anteriors followed by first molars: Maxillary slightly
before the Mandibular.
 This is followed by rapid involvement of the canines
and the mandibular incisors.

02/07/19 107
The patient with rampant caries may present with the
following signs and symptoms:
 The patient may present with a history of frequent
replacement and/or new fillings or a recent change
in social or medical history or medication use;
 Multiple lesions at different stages of progression,
from early enamel decalcification to larger lesions
and frank cavitation;

02/07/19 108
 The dentinal base of cavities is usually soft and of
yellowish brown colour. These characteristics
differentiate rampant caries from arrested or slowly
progressing caries where the dentinal base is firmer
and usually dark in colour;
 Lesions can develop anywhere often including
surfaces that are usually at low risk of caries;
 Dentinal sensitivity from untreated carious lesions

02/07/19 109
Management of Rampant Caries
 DISEASE CONTROL PHASE
 REHABILITATION PHASE
DISEASE CONTROL PHASE –
to help them decrease the caries risk
and activity.
Journal of Dental Education ■ Volume 71, Number 6

02/07/19 110
 Disease control phase has three important components:
 Caries Risk Assessment evaluation and
reevaluation throughout their treatment, in which
individual risk factors are identified and
recommendations are made.
 Caries Removal and placement of transitional
restorations using fluoride release restorative
materials (glass ionomers).
 Chemotherapeutic agents and preventive
treatment in which a therapeutic regimen for
prevention and nonsurgical treatment is established
according to each patient’s individual risk factors.

02/07/19 111
The first component, Acute/Emergency Treatment,
such as root canal therapy, is provided only if necessary
to address emergency needs.
 Extractions are also completed for any tooth that
cannot be restored.

02/07/19 112
Operative treatment, the second component, is based
on caries management by individual risk assessment.
 This phase consists of:
CARIES RISK
ASSESSMENT
CARIES REMOVAL
and
PLACEMENT OF
TRANSITIONAL
RESTORATIONS,
AND SEALANTS

02/07/19 113
CARIES RISK ASSESSMENT
 CARIES RISK ASSESSMENT is absolutely
necessary to select optimal therapeutic regimens for the
prevention, diagnosis, and management of caries as an
infectious disease.
 It is done to identify the risk factors that may contribute
to dental caries as well as any protective factors.
 Factors include plaque accumulation, oral hygiene
practices, dietary habits, attitude, health beliefs,
presence of physical, mental, or social factors, saliva
quality and quantity, systemic disease or medication,
alcohol, drug abuse, fluoride exposure, education level,
SES, and tooth morphology

02/07/19 114
Caries Removal
 Caries removal and placement of transitional
restorations is accomplished by working on one
quadrant or arch at each appointment.
 This rapid caries removal and temporization is
designed to eliminate the infection as quickly as
possible, but also provides a method of diagnosis that
allows for a more accurate assessment of restorability
and prognosis for each individual tooth.
Journal of Dental Education ■ Volume 71, Number 6

02/07/19 115
 The transitional restorations are placed after the
removal of all carious tissue using rotary and hand
instruments.
 Adhesive transitional fluoride releasing restorative
material (Fuji IX, GC America, Alsip, IL, USA) is used.
 In a very few cases, some demineralized dentin is left
close to the floor of the cavity, as part of a Stepwise
excavation protocol in an attempt to avoid pulpal
complications during disease control.
 After six to eight months, teeth treated in this manner
are re-entered, all remaining demineralized dentin is
removed, and a final treatment is provided as
appropriate, either a final restoration or endodontic
therapy.

02/07/19 116
Excavation of caries
Restoration with GIC
Patient with Rampant Caries

02/07/19 117
 Sealants are placed in deep and retentive pits and
fissures of all surfaces that are otherwise sound and
unrestored.
 It is very important to seal all retentive tooth surfaces
to prevent any new lesions from developing during
the initial phase of treatment.

02/07/19 118
 In the Third component — Chemotherapeutic
agents and Preventive treatment:
 Individualized prevention is provided at both the
dental visit and through home care.
 Individualized home-based caries prevention
regimens include many of the following.

02/07/19 119
Rehabilitation Phase
 Permanent restorative treatment should ideally not
commence until there is evidence of reduction in
caries activity, which hopefully can be observed at
the first three month recall visit.
 This phase consists of the replacement of the
missing / extracted teeth with a suitable phase.
 The permanent restorations are done for the teeth
which are given temporary or intermediatey6
restorations.

02/07/19 120
PREVENTION
 It is the responsibility of the dental professional to put
together an appropriate preventive approach that is
tailored for the individual patient's needs.
 No two patients are the same and no two preventive
treatment plans will look alike.
 Preventive programs need to be individualized and
based on the needs and the goals of the patient.

02/07/19 121
 Practitioners stand little chance of managing disease
if they cannot influence the patient to modify the
harmful habits.
 Dietary patterns may be difficult to alter: Clinicians
need to be prepared to provide patients with
achievable options for healthier foods and eating
patterns.
Frequent use of fluoridated toothpaste is one of the
easiest and simplest ways to increase exposure to
fluorides.

02/07/19 122
 For In-office procedures, there are:
 Pit and Fissure sealants,
 Topical Fluoride procedures, and
 Counselling patients to change to preventive dental
behaviours.

02/07/19 123
 In addition to these home-based measures, in-office
preventive treatment for Rampant caries patients
consists of three steps.
 First, patients attend a consultation appointment for
diet evaluation and receive individual nutritional
counseling.
 Second, patients receive a Fluoride varnish which is
an in-office method of providing high concentration
fluoride to the teeth (5% NaF in an alcohol
suspension of natural resins, 22.000 ppm).

02/07/19 124
 Six-month applications have resulted in a 37 percent
caries inhibition in children with high caries risk.
 Rampant caries patients have fluoride varnish
application at least twice a year. Two or more
applications of fluoride varnish a year have shown to
be effective in preventing caries in high risk
populations.
 Third, risk factors and recommendations are
discussed with the patient, and findings are
documented in the patient’s record.

02/07/19 125
 Parents should be encouraged to have infants drink
from a cup as they approach their first birthday.
Infants should be weaned from the bottle at 12 to 14
months of age.
 Repetitive consumption of any liquid containing
fermentable carbohydrates from a bottle or no spill
training cup should be avoided.
 Between-meal snacks and prolonged exposures to
foods and juice or other beverages containing
fermentable carbohydrates should be avoided.

02/07/19 126
SUMMARY AND CONCLUSION
 Although extensive measures and research have been
invested into the prevention of ECC and Rampant
caries, better ways of implementing preventive
methods and programs are needed.
 The etiological factors of EEC and Rampant caries,
are known, and there is an arsenal of preventive and
curative therapies available to help practitioners
prevent and properly control EEC.

02/07/19 127
 Treatment decisions vary from patient to patient
depending upon the severity of the case, extent of the
lesion, the patients age and financial status, patient
motivation, and the patient's esthetic concerns.
 Glass ionomer cements used as restorative materials
can be extremely useful in delivering fluoride to a
patient without having to worry about patient
compliance.
 Prevention is an essential component in any dental
health promotion program, providing a solid
foundation for the optimal development of children.

02/07/19 128
 The dental community is looking at the problem with
renewed interest and that more information is needed
in regard to the epidemiology, etiology, diagnosis,
prevention and treatment of early childhood and
rampant caries.

02/07/19 129
REFERENCES
 Causes, Treatment and Prevention of Early Childhood
Caries: A Microbiologic Perspective; J Can Dent Assoc
2003; 69(5): 304–7
 Management of severe early childhood caries:
CLINICAL PRACTICE GUIDELINES; December
2005
 Robert J. Berkowitz; Causes, Treatment and Prevention
of Early Childhood Caries: A Microbiologic
Perspective: Journal of the Canadian Dental
Association; May 2003, Vol. 69, No. 5

02/07/19 130
 Policy on Early Childhood Caries (ECC):
Classifications, Consequences, and Preventive
Strategies; Council on Clinical Affairs: Adopted
1978; Revised 1993, 1996, 2001, 2003, 2007, 2008
 EARLY CHILDHOOD CARIES RESOURCE
GUIDE; Second Edition: national maternal and child
oral health resource center

02/07/19 131
 Ye W, Feng XP, Liu YL; Epidemiological study of
the risk factors of rampant caries in Shanghai
children: Chin J Dent Res. 1999 May;2(2):58-62.
 Gelbier MJ, Winter GB; Absence of salivary glands
in children with rampant dental caries: report of seven
cases: Int J Paediatr Dent. 1995 Dec;5(4):253-7.
 Lăcătuşu S, Frâncu L, Frâncu D; Clinical and
therapeutical aspects of rampant caries in cervico-
facial irradiated patients: Rev Med Chir Soc Med Nat
Iasi. 1996 Jul-Dec;100 (3-4):198-202.

02/07/19 132
ACKNOWLEDGEMENTS
 Dr S. S. Hiremath, Dean Cum Director.
 Dr Manjunath Puranik, Professor.
 Dr Yashoda R, Assistant Professor.
 Dr Namita Shanbhag, Senior Lecturer.
 Dr Sowmya, Senior Lecturer.
 Dr Uma S R, Senior Lecturer.
 All Post Graduate Students.
 Department of Preventive & Community Dentistry,
Government Dental College & Research Institute,
Bangalore.

Management of early childhood caries and rampant caries

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Management of early childhood caries and rampant caries