Disease, trauma and developmental defects can occur in the mouths of young children. One of the most prevalent and most common diseases found in young children is dental caries, which refers to both the destructive disease process leading to cavitations of a tooth and the resulting condition of the tooth. Dental caries is often called “tooth decay” or “cavities.” Though it is an infection that is transmissible from parents and other caregivers, dental caries are preventable and manageable. If tooth decay starts before six years of age, it can be particularly damaging to the teeth and compromising to the child’s well being. For the oral health of young children, preventing tooth decay in primary teeth must be a major goal for parents/caregivers and the community. Childhood injuries are another major concern since up to 30 percent of children injure their primary teeth. The consequences of oral injury include pain, infection, damaged bone and soft tissue, loose/discolored teeth, impaired speech, and high treatment costs that may extend over several years. Prevention involves sharing and modeling safe behaviors for children and counseling parents/caregivers how to respond to oral injury, such as managing a dislodged tooth. Oral injury can be an important marker for child abuse and neglect. There are other oral and dental diseases/conditions that affect young children, such as cleft lip and/or palate, malformed teeth, poorly aligned teeth and bite, lesions from oral infections and early gum disease. This report will focus on preventing and controlling early childhood tooth decay because it is such a common and demanding problem for families, health care and dental providers, and communities.
Tooth decay (dental caries) is caused by certain bacteria. These bacteria together with food particles and mucus are found in dental plaque, a soft and sticky substance that builds up on teeth. Infants are first infected with bacteria that cause tooth decay through saliva, typically from the mother or primary caregiver. Frequent ingestion of sugar and poor dental hygiene will allow bacteria to grow. The bacteria ingest sugar and produce acid that dissolves tooth structure, resulting in tooth decay. When a tooth surface is first damaged by acid, it appears as a “white spot.” Further acid damage breaks down tooth structure and leads to a cavity in the tooth. If the disease process is left unchecked, the bacteria will advance into the nerve and blood vessels of the tooth further advancing the infection. Since the dental enamel (the harder outer layer) of a primary tooth is thin, tooth decay can progress rapidly in a child. A young child’s exposure to excess sugary liquids during bottle feeding, and habits such as dipping a pacifier in honey, corn syrup or “jello water,” can increase his/her risk for tooth decay. Allowing a child to use a bottle continuously throughout the day or sleeping with a bottle can also lead to advanced decay. For a preschooler who no longer uses a bottle, a diet with high intake of sugars, especially for prolonged periods of time, continues the risk of caries.
Strategies to Prevent and Control Early Childhood Tooth Decay
Strategies to prevent and control early childhood tooth decay should address the dental disease, systems of care that support children during their early developmental years, and public health practices. For the preventing and controlling the dental disease, strategies should:
Stop/delay the onset of tooth decay in the primary teeth. This requires primary prevention that begins with the mother and seeks to reduce her bacterial load or control her transmission of the bacteria that causes tooth decay before, during and after her pregnancy. Prevention includes assessing a child’s risk for tooth decay. Identify and recognize early signs of tooth decay. Observing signs of tooth decay such as “white spots” will allow early use of measures to arrest decay and minimize subsequent treatment. Treat tooth decay early. Professional care is needed to arrest the disease at the earliest “white spot” phase to prevent further damage. If caries has progressed (e.g., resulting cavities), restore damaged teeth to proper form, function and esthetics.
Prevent new and recurrent tooth decay. If prevention and restorative treatment do not manage the underlying disease process, a child is likely to experience new and/or recurrent caries. Addressing risk factors prevents decay in new and restored areas of the teeth. Provide an adequate and competent workforce to promote early childhood oral health and manage all stages of tooth decay. Trained professionals at all levels are needed to assess risk, identify tooth decay, manage the disease process, manage a young child’s behavior for safe treatment, and deliver care to restore oral health. Integrate oral health and coordinate dental care services with care systems supporting young children (e.g., medical, developmental and educational systems). Professionals working in these systems can help identify those at risk and facilitate early preventive/restorative dental care.
For developing public health practices, strategies should:
Utilize population-based approaches. The Institute of Medicine noted that public health “is what we, as a society, do collectively to assure the conditions for people to be healthy.” Public health focuses on the health of the population rather than individuals, such as obtaining a high level of oral health throughout society. Population-based approaches use a community perspective, population-level data and evidence-based practices, with an emphasis on prevention and effective outcomes. Community water fluoridation (a population-based strategy to prevent tooth decay) is recognized by medical authorities as one of the ten great public health achievements in the 20th century. Population based interventions complement individual interventions e.g., use of community water fluoridation and fluoridated toothpaste. Population-based approaches should strive to achieve national, state or local oral health objectives.
Promote public and private partnerships. Determinants of health are the province of many governmental agencies e.g., agencies concerned with health and child welfare and many non-governmental institutions e.g., managed care organizations, community-based groups, and academic institutions. The National Call to Action to Promote Oral Health acknowledges the need for public-private partnerships at all levels of society. For example, public-private partnerships are needed to raise the public profile on the epidemic of tooth decay and its consequences among vulnerable children/families, and leverage communities to address the problem.
Respond to emerging issues. Public health practice needs to be responsive to emerging issues that impact early childhood oral health. These issues at times demand urgent attention or action, and may support or threaten current practices.
Spectrum of Dental Treatment Tooth decay is a progressive disease. The earliest visible signs often appear as a “white spot” on a tooth, eventually breaking down tooth structure leading to a “cavity” and finally advancing into the nerve and blood vessels of the tooth. In young children, how tooth decay is treated depends on many factors including at what stage it is first diagnosed, the number of teeth affected, the severity of decay, and the level of cooperation of the child. For “white spot” lesions, fluoride varnish applications and lifestyle modifications may be adequate treatment. For decay that has progressed to the cavity stage and beyond, traditional restoration and/or extraction of the teeth are generally appropriate. Since tooth decay is an infectious disease, the potential use of antimicrobial agents to reduce the bacteria associated with the disease mirrors the approach used with other infectious diseases, but with some limitations as the mouth is also an external structure exposed to outside elements.
An emerging area of clinical practice is the use of chemotherapeutic agents for caries prevention and as an adjunct to traditional dental treatment. Treating tooth decay chemically is part of a paradigm shift in dental disease management. Chemotherapeutic agents interfere with the colonization, growth and metabolism of decay causing bacteria and should not decrease the ability of other agents to prevent caries. Fluoride can be considered a chemotherapeutic agent. There has been some research on preventing tooth decay on young children using other agents such as chlorhexidine varnish, xylitol, povidone iodine, and silver diamine fluoride. It is possible that in the future some chemotherapeutic agents will become a routine part of the management of tooth decay.
Growth and Development of Dental and Skeletal Tissue in children
Dental and skeletal development provide a measure of physiological age that can be used to predict the optimal timing for treatment in orthodontic, orthopaedic or paediatric clinical practice or to estimate chronological age of child skeletal remains in forensic or archaeological contexts. Because the environmental sensitivity of skeletal and dental development can affect the ability to predict treatment timing and accuracy of age estimations, it is important to understand how these two tissues respond differently to environmental insults, such disease or malnutrition. This paper reviews the literature that supports the general assertion that dental development is less affected by environmental quality than skeletal development. It is concluded that the environmental sensitivity of tooth formation (compared to tooth eruption) has been rarely assessed and that there is a paucity of studies that examine the development of both tissues against socioeconomic and nutritional status or non-genetic disease.
Determining the relationship between dental, skeletal and chronological age in children is fundamental for several disciplines, because it allows the researcher to understand variations in physiological or developmental age of children of the same chronological age. Since human growth shows a considerable variation in the chronological ages at which individual children reach similar developmental events, the developmental status of a child is best estimated relative to specific stages of physiological maturity. Some of the most common measures of physiological age rely on dental and skeletal maturation. Several methods have been proposed for assessing dental maturation. One general approach focuses on the number and kind of teeth present in the mouth.
Despite the simplicity of the approach there are some definite disadvantages because it relies on the timing of tooth emergence. Tooth emergence is a single, brief event in the continuous process of tooth eruption and the chance that the time of inspection coincides with the actual moment of emergence is, as a rule, small. The precision is also compromised by the fact that there are periods where no teeth erupt and others where several teeth erupt more or less simultaneously. In addition, tooth emergence may be influenced significantly by local exogenous factors, such as infection, obstruction, crowding, and premature extraction of the deciduous predecessor or adjacent permanent teeth.
Most of the disadvantages can be avoided by using stages of tooth Dental and skeletal development provide a measure of physiological age that can be used to predict the optimal timing for treatment in orthodontic, orthopaedic or paediatric clinical practice or to estimate chronological age of child skeletal remains in forensic or archaeological contexts. Because the environmental sensitivity of skeletal and dental development can affect the ability to predict treatment timing and accuracy of age estimations, it is important to understand how these two tissues respond differently to environmental insults, such disease or malnutrition. This paper reviews the literature that supports the general assertion that dental development is less affected by environmental quality than skeletal development. It is concluded that the environmental sensitivity of tooth formation has been rarely assessed and that there is a paucity of studies that examine the development of both tissues against socioeconomic and nutritional status or non-genetic disease. Key-words: dental development; skeletal development; disease; nutrition; socioeconomic status. Formation obtained from roentgenographic data on the calcification of teeth to determine dental maturity. Tooth formation is a progressive, continuous and cumulative process that ends only when tooth has been completely formed and is a measure of dental age that can be used throughout the entire growing period of an individual.
Since skeletal maturation comprises changes in bone size and ossification of the growth plates it implies the completion of skeletal growth and height. Therefore, because these two developmental processes are closely related, growth in height can be used as a proxy for linear skeletal growth. Skeletal maturation however, is a better measure of biological maturation than height because any given skeletal age indicates how far a child has reached in the process of maturation, which terminates with fusion of all epiphyses and any given height does not indicate how great a percentage of its final height the child has attained, as the adult height is not known until the growth in length is completed.