Early Childhood Caries

Early childhood caries is the presence of one or more decayed, missing or filled primary tooth surfaces in a child under 6 years of age. Severe early childhood caries is any smooth surface caries in a child under 3 years, or a decayed, missing and filled surface score of 4 or more at age 3, 5 or more at age 4, and 6 or more at age 5.

It is the commonest chronic disease of childhood. In high risk groups it begins as white spot lesions on the upper incisors and progresses to cavitation of upper incisors and molars, and in severe disease to destruction of the crowns.

Pathophysiology. Frequent sugar intake feeds acidogenic biofilm bacteria, mainly Streptococcus mutans and Lactobacillus species, producing acid that demineralises the immature enamel of primary teeth, which is thinner and less mineralised than permanent enamel.

Risk factors: bottle or breast feeding at night or on demand after tooth eruption, sugar sweetened drinks, frequent snacking, poor plaque control, no fluoride exposure, enamel defects, maternal caries, low socioeconomic status and poor access to care.

Chalky white spot lesions along the gingival margin of the upper incisors, progressing to yellow, brown and black cavitation, breakdown of the crown and pulp exposure. Pain, sleep disturbance, difficulty eating, irritability and weight faltering occur in advanced disease.

Gingival swelling, a sinus tract, facial swelling and fever indicate abscess and spreading infection. Check the pattern of feeding, drink contents, brushing frequency and fluoride toothpaste use.

Facial swelling extending to the eye or neck, trismus, drooling, fever with lethargy or inability to feed or swallow need emergency hospital assessment. Persistent untreated disease with missed appointments in a young child raises the question of dental neglect and needs a safeguarding discussion.

• Visual and tactile examination in good light with a dry tooth surface and a blunt probe.
• Bitewing radiographs when the child is able to cooperate, and a periapical radiograph for a suspected abscess.
• Caries risk assessment: dietary sugar frequency, fluoride exposure, plaque, previous caries, medical and social factors.
• Diet history over 3 days, and assessment of nutrition and growth in severe disease.
• Swab or imaging only for suspected spreading infection or osteomyelitis.

Differential diagnosis.

• Enamel hypoplasia and molar incisor hypomineralisation
• Dental fluorosis
• Amelogenesis imperfecta and dentinogenesis imperfecta
• Extrinsic and intrinsic tooth staining
• Dental trauma
• Erosion from reflux or acidic drinks

• Prevention and non-operative control form the first step: tooth brushing twice daily from eruption of the first tooth with a smear of toothpaste containing 1000 to 1450 ppm fluoride for under 3 years of age and a pea sized amount for ages 3 to 6, supervised by an adult, spitting and not rinsing.
• Fluoride varnish 5% sodium fluoride (22 600 ppm) applied to all teeth every 3 to 4 months in high risk children and at least every 6 months otherwise, with a dose of about 0.25 mL for the primary dentition. Do not give a child more than the labelled amount.
• Silver diamine fluoride 38% applied to cavitated, asymptomatic lesions without pulp involvement, 1 drop for a few lesions, once or twice yearly (2 applications 1 week apart in the first year in some regimens), with warning of permanent black staining and a metallic taste. Avoid with silver allergy, ulcerative gingivitis or stomatitis, and pulp exposure.
• Diet advice: stop bottles of sugary drinks and night feeding after the first tooth eruption, stop bottle use by 12 to 18 months, offer only milk or water between meals, and reduce sugar frequency to meal times.
• Restoration: glass ionomer cement or resin modified glass ionomer for small cavities, stainless steel crowns using the Hall technique (cementing without caries removal or local anaesthetic) for molars, and strip crowns or extraction for incisors.
• Extraction under local anaesthetic or general anaesthetic for teeth that cannot be restored, with pulp therapy for restorable molars, and general anaesthesia for young or anxious children with extensive disease.
• Antibiotics only for spreading infection or systemic upset: amoxicillin 125 mg orally three times daily at 1 to 11 months, 250 mg three times daily at 1 to 4 years and 500 mg three times daily at 5 to 11 years (double in severe infection), for 5 days, with metronidazole 7.5 mg/kg three times daily for severe infection. Reduce amoxicillin when eGFR is under 30. In penicillin allergy use clarithromycin, dosed by age and weight.
• Paracetamol 15 mg/kg every 4 to 6 hours, with a maximum of 4 doses in 24 hours and 75 mg/kg daily, and ibuprofen 5 to 10 mg/kg every 6 to 8 hours, avoided in dehydration and asthma exacerbation.

Special groups. Children with congenital heart disease, immunosuppression or bleeding disorders need coordinated care with the specialist team before extractions and anaesthesia.

Monitoring. Recall every 3 months for high risk children and every 6 months otherwise, with reassessment of lesions, plaque, diet and fluoride use. Re-apply fluoride varnish at each visit, every 3 to 4 months in high risk children and at least every 6 months otherwise.

Referral and escalation. Refer to paediatric dentistry for extensive disease, general anaesthesia, medical complexity or poor cooperation. Emergency referral for facial swelling, airway or feeding compromise and fever, and to child protection services when neglect is suspected.