Early Childhood Caries: Persistent Public Health Challenge

Early childhood caries ( ECC), formerly known as baby bottle caries, is defined as the presence of ≥1 decayed (non-cavitated or cavitated), or missing (as a result of cavities) or filled tooth surfaces, on any primary tooth. in a child ≤71 months.

The American Academy of Pediatric Dentistry (AAPD) also specifies that in children <3 years, any sign of smooth surface caries or a dmfs score (decayed, missing, and filled teeth index) ≥4 (3 years), ≥5 ( 4 years) or ≥6 (5 years) is indicative of severe ICC.

In general, dental caries experts have agreed that early childhood caries (ECC) is not solely associated with poor feeding practices, so the term early childhood caries is the term that best reflects the multifactorial etiology. . These factors include sensitivity of the teeth due to enamel hypoplasia, oral colonization with increased levels of cariogenic bacteria, especially Streptococcus Mutans , and the metabolism of sugars by bacteria attached to the tooth that produce acid and, over time, demineralize dental structures.

Reducing the number of cariogenic microorganisms and establishing a balanced oral microenvironment will promote tooth remineralization and limit disease progression.

Therefore, stopping caries requires modifying the patient’s or caregiver’s behaviors based on compliance with the necessary modifications.

The consequences of early childhood caries (ECC) include increased risk of actual cavities in both primary and permanent dentition, hospitalizations and emergency room visits, increased therapeutic costs, loss of school days, and decreased quality of life related to oral health.

The WHO mentioned that it is a prevalent public health problem worldwide. The American Dental Association (ADA) mentions that CPI was found in the entire general child population, which it considered a significant public health problem in disadvantaged communities.

Firstly, the prevalence and incidence are very high, it has an aggressive presentation and appears early. The results of an evaluation of 193 data published by the United Nations between 2007 and 2017 showed that the average prevalence of early childhood caries was 23.8 and 57.3% in children <3 years of age and children aged 3 to 6 years. , respectively.

The abstract presented at the International Association of Pediatrics Dentistry Conference on early childhood caries in 2018 showed that the prevalence was 17%, 36%, 43%, 55% and 63% in children ages 1, 2, 3, 4 and 5 years, respectively.

A systematic review, with a sample of 80,405 children, showed that the prevalence of dental caries in primary teeth was 46.2%. A systematic review using WHO criteria showed a pooled prevalence of 48% while the prevalence of ICC by decade was 55% in the 1990s, 45% in the 2000s and 49% in the 2010s. respectively, without significant changes being observed between 1990 and 2019.

Second, although early childhood caries (ECC) is prevalent worldwide, that growth is particularly rapid in low- and middle-income countries. The result of the Fourth National Oral Health Survey in mainland China showed that the prevalence of caries in 5-year-old children was 71.9%, which was 5.9% higher than that 10 years earlier while the average dmft (decay, loss or filled teeth) was 4.24. With a combined global prevalence of 48%, the prevalence of ICC varied between and within countries. It ranged from 16% (Singapore) to 89% (China).

The prevalence by continent was 30% in Africa, 48% in America, 52% in Asia, 43% in Europe and 82% in Oceania, indicating that the distribution of ICCs is not homogeneous. The variation could be explained by mixed factors, such as macroeconomic, socioeconomic, genetic, populations, ethnic minorities, availability of fluoride in drinking water or toothpaste, interventions with evidence of effectiveness for the prevention of cavities, universal health coverage, income growth national, high health spending, and others.

Third, untreated ICC remains high and a global public health, medical, social and economic burden. The percentage change in the number of prevalent cases decreased in high- and upper-middle-income countries and increased in low- and lower-middle-income countries. A systematic review supported meta-regression and showed that the prevalence of untreated caries affected 9% of children in 2010 and has remained relatively unchanged for 30 years. Therefore, we face an enormous challenge in the prevention and management of ICC.

Early childhood caries (ECC) is a chronic infectious disease that occurs in primary teeth, characterized by dysbiosis of the microbiome with an increase in cariogenic bacteria. According to the Oral Health Epidemiological Survey of the Fourth Chinese National Conference in 2018, the prevalence of ICC in children aged 3 to 5 years in China is ~62.5%, the highest among chronic infectious diseases in children and affects oral health and even the general health of children.

The temporary tooth is constricted in the cervical portion, which makes it difficult to clean. The primary tooth also has a lower part that contains less calcium and degree of mineralization than the permanent tooth. These factors contribute to your susceptibility to tooth decay.

The caries microbiome plays a critical role and is the main etiology in the development of dental caries.

Endogenous bacteria produce weak acids, as a by-product of the metabolism of fermentable carbohydrates within the formed biofilm, which causes local pH values ​​to be low resulting in demineralization of the hard tissues of the teeth. Therefore, the etiological study of ICC is mainly focused on the oral microecological imbalance, the core microbiome of caries and its relationships with host genetic factors, which contributes to the study of the pathogenesis of ICC and provides the theoretical basis. for the prevention and etiological treatment of ICC.

ICC core microbiome . It refers to microorganisms in dental plaque or saliva related to the appearance of cavities. Nowadays it is well known that not only Streptococcus spp ., Lactobacillus spp . and Actinomycete spp . They are also species that had not previously been recognized in the progression of ICC. The significant difference in microbial community structure between children with caries and caries-free children include Veillonella spp ., Granulicatella spp ., Fusobacterium spp ., Neisseria spp ., Selenomonas spp . and Campylobacter spp .

In a cohort study of 3-year-old children, Teng et al. detected that Veillonella spp . and Prevotella spp . were the main triggers of CPI and not S. mutans . The bacteria Scardovia wiggsiae was also isolated in the CPI. It has been associated with initial carious lesions, with a high acid content well tolerated. A recent study found that the acquisition of the arginine deiminase system benefits Saccharibacteria and its host bacteria against the acidic microenvironment in plaque biofilm. Not only bacteria but also fungi have been linked to ICC, with cross-kingdom interactions and abundance of Candida albicans notably higher in children with ICC than in caries-free children. As a specific pathogen, S. mutans has long been the hotspot of caries etiology research.

Transcription factors EpsR, StsR, RcrR, and AdcR regulate bacterial biofilm formation, sugar transport, and zinc homeostasis. Modification of gulosyltransferase acetylation plays an important role in biofilm formation and cariogenic virulence. As second messengers, c-di-AMP and Ap4A also participate in biofilm formation.

The CRISPR/Cas system regulates bacterial biofilm formation and cariogenic virulence of clinically isolated strains. EzrA is involved in division, maintenance of morphology, biofilm formation, and competition between species. Although S. mutans is a specific bacteria associated with caries in its onset and progression, its presence or absence is not always consistent with the severity of the caries.

One study explored the possible correlation of S. mutans and other microorganism levels in concordant and discordant caries populations and found that the structure of salivary microbial communities are significantly clustered according to S. mutans levels, independently of caries. Today it is known that not only S. mutans , Veillonella spp ., Streptococcus spp . and Prevotella spp . They are significantly increased.

It is highlighted that it is necessary to consider other species in health/cavity conditions , as well as their conjunction with S. mutans . C. albicans is a Gram-positive fungus that exists in the human oral cavity, intestine, and vaginal mucosa. It can invade the dentinal tubules and secrete acidic substances, promoting enamel demineralization. It could adhere to the hydroxyapatite matrix and dissolve the crystals releasing calcium ions. C. albicans was detected in the oral cavity of young children with dental caries. C. albicans can adapt to a very acidic environment and produce high concentrations of acetic acid and pyruvate. The interaction between C. albicans and S. mutans can promote the emergence and development of CPI.

Early Childhood Cares and Genetic Factors . People’s susceptibility to ICC is associated with genetic and environmental factors . Twin models allow us to identify the effect of genetic factors on oral microbial composition. The oral microbial composition of the twins is more similar to each other, also showing a great similarity to their mother. Furthermore, there is no significant difference between the oral microbial compositions of monozygotic and dizygotic twins. These results showed that environmental factors may have a stronger effect on the composition of the oral microbiota in children with ICC compared to genetic factors.

Predictors and biomarkers of CPI . In health, the oral microbiome has a symbiotic or eubiotic relationship and forms a stable dynamic equilibrium with the host. When the balance of the oral microbiome is disturbed, it is known as “dysbiosis” and is linked to disease. On the one hand, dysbiosis is accompanied by changes in the composition of the oral microbiome. For example, there is a greater abundance of Corynebacterium durum in caries-free children than in children with CPI.

The abundance of Prevotella denticola , Megasphaera micronuciformis and Dialister invisus in children with ICC is higher than in caries-free children. On the other hand, dysbiosis of the oral microbiome will affect the components of the salivary biomolecule, as part of the host defense system.

The identity and concentration of the changing proteins are highly correlated with the CPI. Therefore, changes in the oral microbiota and salivary proteins in this process may be predictors and biomarkers to evaluate the risk of caries in children, and predict the progression of ICC. Recently, Li et al. found that electrospun with BCG-polystyrene/polyvinylpyrrolidone (BCG-PS/PVP) polymeric fibrous membranes visually detects the pH point with a sensitive and rapid response, which has potential application value in the monitoring and prevention of ICC.

Therapeutic strategies targeting the cariogenic bioppoelicle . The formation of the biofilm that covers the tooth surface establishes the basis for cariogenic microorganisms to initiate the caries process. Cariogenic microorganisms live in biofilms as microcolonies that are encapsulated in an organic matrix of exopolysaccharides, proteins and DNA, which protects from desiccation and host defenses and provides resistance to antimicrobials. Consequently, biofilm formation is not interrupted and together with saccharides absorbed from the diet leads to cariogenic microenvironments. Therefore, therapeutic strategies targeting biofilm will be effective in disrupting the pathogenic niche and preventing ICC progression.

Multiple pathways have been demonstrated that regulate biofilm formation, including a 2-component system, the quorum sensing system, the CRISPR/Cas system and c-di-AMP signal system and others. Inhibitors have been developed to prevent biofilm formation targeting the synthesis of glucosyltransferases and the consequent polysaccharides: oxazole derivatives, quinoxaline derivatives, trimetrexate and so on.

On the other hand, Lactobacillus plantarum K41 isolated from pickles showed a high inhibitory capacity against biofilm formation. With the development of dental materials, anti-caries approaches will become even more widespread. Liang et al. reported that TA@RAs, new “smart” anticaries resin adhesives that trigger activation in response to acidic pH, showed an antibiofilm effect and increased the diversity of microorganisms.

> Caries risk assessment models for children

Caries risk assessment is an important part of dental health care.

It refers to the identification and analysis of certain factors that are considered related to dental caries and proposes personalized preventive and therapeutic strategies for people to reduce the risk of dental caries. It involves a thorough analysis of protective factors, such as fluoride use; risk factors such as the presence of caries lesions, social and cultural, such as social status. Several CPI-related models have been developed around the world, including the Caires Assessment Tool , caries management by risk assessment, the American Dental Association (ADA) caries risk assessment, and the Cardiogram.

The Caries Assessment Tool was developed in April 2002 to assess caries risk in children and to assist in clinical decision making regarding diagnostic, fluoride, dietary, and restorative protocols. It is a qualitative model, which defines the risk of dental caries as high, moderate and low and is mainly used for the assessment of caries risk in infants, children and adolescents. The tool consists of 2 tables, one for children from 0 to 5 years old and another for children ≥6 years old. CAMBRA is a qualitative model that is being updated. In the latest revision, quantitative components were added to better determine the level of caries risk. The CAMBRA assessment indicators cover risk factors and protective factors and disease indicators. It defines the risk of dental caries as extreme, high, moderate and low. It also consists of 2 tables, one for children from 0 to 6 years old and another for >6 years.

The ADA Caries Risk Assessment is a qualitative model that defines dental caries risk as high, moderate, and low. It has 2 forms, one is for patients from 0 to 6 years old and the other is for patients >6 years old. The form mainly includes 3 aspects: 1) contributing conditions, such as fluoride exposure; sugary foods or drinks; eligibility for government programs, etc.; 2) general health conditions; 3) clinical conditions, such as carious lesions, visible plaque, presence of dental/orthodontic appliances, salivary flow, etc.

The Cardiogram is a computer system for evaluating caries risk. The Cariogram is a quantitative model for the evaluation of caries risk. 10 factors related to caries were evaluated. By entering ≥7 indicators, a pie chart can be obtained through the operation of the program, and predict the possibility of individual caries in the future.

>  Management of perinatal and infant oral health

Oral health management for pregnant and lactating women. Changes in diet, lifestyle habits and hormonal levels during pregnancy increase the risk of dental diseases, such as gingivitis, pregnancy epulis, periodontitis, wisdom teeth periodontitis, cavities, etc. These diseases not only affect the nutrition and health status of the women themselves but also the normal growth and development of the fetus, which correlates with adverse effects on pregnancy, such as prematurity, fetal growth restriction and preeclampsia. There is a close relationship between prenatal oral health care and ICC in babies.

A positive outcome of ICC prevention was achieved through prenatal health education or intervention. When mothers received prenatal oral health promotion through education and intervention, the incidence of ICC and the presence of S. mutans in their children could be reduced. Therefore, it is necessary to do dental treatment before pregnancy, to prevent the appearance of dental diseases during pregnancy. The dental history should record tooth history, diet and fluoride use, pre-existing oral conditions, current oral hygiene habits, tobacco and other substance use.

During pregnancy , it is recommended to brush your teeth 2 times/day using the Bass brushing method, with fluoride toothpaste, floss daily and visit the dentist regularly, have a balanced diet with high-quality proteins, trace elements and vitamins. Folic acid, choline and omega-3 fatty acids are also needed. You also have to consider diabetes , which has been correlated with birth defects such as cleft lip and palate.

Brushing soon after vomiting should be avoided in cases of morning sickness, as this practice exposes the teeth to gastric acid.

To neutralize the acid, it is recommended to rinse with a diluted solution of one cup of water and one teaspoon of baking soda . Due to the uncertainty of the side effect, bleaching should be avoided during pregnancy. Oral hygiene advice should be provided in the third trimester of pregnancy, the postpartum period and breastfeeding. The second trimester is the best time for dental therapy, and treatments can focus on relieving acute symptoms. All radiographic procedures must be done with radiation in mind. In the third trimester and the postpartum period, advice on children’s oral hygiene should be provided.

Management of infant oral health . Babies have underdeveloped salivary glands and less saliva secretion, and primary teeth also have a lower degree of mineralization than permanent teeth. These are factors that contribute to tooth decay.

Breastfeeding : is a highly effective health promoter. Although breast milk can lower the pH of dental plaque and lead to its dissolution, it is less effective than infant formula. ICC cannot be caused solely by breastfeeding. However, frequent feeding will elevate the cariogenic potential due to reduced salivary flow during sleep. In an in vitro study, breastfeeding combined with other carbohydrates was significantly cariogenic.

It has been shown that there is a protective effect of breastfeeding during infancy that may be correlated with decreased carbohydrate intake and delayed bottle use. Some studies suggested that prolonged breastfeeding for more than 24 min increases the risk of caries, but others suggested that the duration of breastfeeding was not related to a high probability of developing dental caries, even when the duration of breastfeeding is longer than 24 min. However, reducing the frequency and night feeding from the second year onwards can reduce the risk of cavities. The duration recommended by the AAPD is the first year, while the WHO encourages mothers to breastfeed for up to 2 years.

Early care : New parents may be aware of the need for personal oral health and the possibility of transmission of cariogenic bacteria from the parent/primary caregiver to the baby. A few days after birth, daily cleaning of the baby’s gums should begin with a clean, damp cloth, gauze or washcloth. Brushing your teeth twice a day should begin as soon as the first tooth grows. Fluoride toothpaste is the standard and the recommended amount is that of one grain of rice. Limit sugar consumption in foods and drinks; Avoid nighttime bottle feeding with milk or sugary drinks.

Visits to the dentist : Babies can have their first dental exam after the growth of their first tooth, and have a personal dental health record, which should not exceed the first year of life at the latest. After that, routine dental examinations will be done every 3-6 months, including dental development, whether there are bad oral habits, cavities, malocclusion, etc.

Early dental visits can also help children adjust to the medical environment and the dental examination process, minimizing the onset of dental phobia.

Management of caries in children from 0 to 6 years. Fluoride . Fluoride has played a key role in decreasing cavities, and its use for cavity prevention and control is both safe and significantly effective. Low levels of fluoride in plaque and saliva help remineralize demineralized enamel and prevent demineralization of healthy enamel. It also prevents cavities by acting on the metabolic activity of cariogenic bacteria. At high levels, fluoride causes a transient substance similar to a layer of calcium fluoride on the enamel surface. In the event that the pH decreases due to acid formation, fluoride is released, which can be used to remineralize enamel or affect bacterial metabolism. The most cost-effective means of providing fluoride to the community is through drinking water fluoridation. In the US, water fluoridation is done at a level of 0.7–1.2 mg·l−1. The US Department of Health and Human Services has recommended standardizing all water to 0.7 mg·l−1. In China, the optimal level of fluoridation of drinking water is 0.7–1.0 mg·l−1. Professionally applied topical fluoride therapies are effective in decreasing the incidence rate of dental caries.

Topical fluoride. Therapies should be done after dental professionals have completed the cavity risk assessment. High-risk children should receive fluoride treatment at 3-month intervals. For children at moderate risk, monitoring should be done every 6 months.

Most used agents for professional use. Fluoride treatments are 5% sodium fluoride varnish and acidulated phosphate fluoride (APF 12,300 mg·l−1 F). Sodium Fluoride Varnish 5% Unit Dosage is the only professional topical fluoride suitable for children <6 years. Clinical trials have also shown that applications <4 minutes are not effective. The use of 38% silver diamine fluoride is recommended to inhibit the progress of cavitated caries lesions in primary teeth. Prevents cavities by acting as an antibacterial agent and promoting the remineralization of enamel and dentin.

Household fluoride products for children should be used at low doses and high frequency. Fluoride toothpaste is indicated 2 times/day, and rinsing after brushing should be minimized or avoided completely. In China, the national standard of fluoride level of toothpaste is 0.05% to 0.11%. For children <3 years of age, applying less than a smear or a grain of rice of fluoride toothpaste may reduce the incidence of fluorosis risk. Children ages 3 to 6 should use a smaller, pea-sized dose of fluoride toothpaste. Fluoride gels and pastes for domestic use. The use of pastes and rinses in doses prescribed for home use are also effective in reducing tooth decay.

Oral hygiene . A few days after birth, parents are advised to begin cleaning babies’ gums daily, with a clean gauze or moistened washcloth. Brush your teeth 2 times/day as soon as the first tooth eruption has occurred. Brush your teeth with the Bass method. Fluoridated toothpaste should be used in an amount that does not exceed a spot or an amount the size of a grain of rice.

Both parent and patient should be involved in oral hygiene counseling. Initially, the parent supervises the child’s oral hygiene. As the child develops, home dental care should be done together, you and the child. When the child demonstrates knowledge and competence in performing personal hygiene techniques, the child should also be counseled by a health professional. At each dental visit, the effectiveness of home care should be evaluated.

Dietary habits . Dietary habit is closely related to early childhood caries (ECC). Healthy diets such as eating lean proteins and vegetables will promote dental health. However, unhealthy eating habits (e.g., frequent intake of sugars and/or juices) were risk factors for ICC.

For infants, human breast milk is recommended, but parents should be aware that breastfeeding is significantly cariogenic when combined with other carbohydrates.

A healthy diet is necessary for children, including drinking plenty of water; eat several types of foods (whole grains, fruits, vegetables, proteins, and low-fat/fat-free dairy products); limit the number and frequency of sugary snacks; balance meals consumed with physical activity to maintain an appropriate body mass index, maintain adequate caloric intake to support normal growth and development. The public and parents should be informed about the correlation between frequent carbohydrate intake and tooth decay, as well as other dangers related to excessive consumption of simple carbohydrates, saturated fat, and sodium.

Pit and fissure sealant . Since the 1960s, these sealants have been used to prevent and control dental caries in primary and permanent teeth. They can protect against pit and fissure lesions of occlusal surfaces, and also inhibit the growth of non-cavitated carious lesions. Studies with 1, 2, 3 and 4 years of follow-up have shown that resin sealant achieved highly significant results compared to no sealant. The AAPD recommends that sealants should be applied to permanent molars with both healthy occlusal surfaces and noncavitated occlusal cavities in children and adolescents. Dental sealants are a cost-effective option when there is a history of cavities. The efficiency of various types of resin-based, resin-modified GI, GI cement, polyacid-modified resin-based sealants could not be evaluated due to inconclusive evidence.

Sealing of pits and fissures at risk should be carried out as soon as practicable. In general, it is recommended to have pit and fissure sealants for primary molars for children aged 3-4 years, as well as for first permanent molars at 6 to 8 years of age, and for permanent second molars and premolars at 10 years of age. -12 years. The need for sealant placement should be reevaluated at regular preventive care sessions. Sealants should be checked periodically and fixed or replaced when necessary.

Dental home . The American Academy of Pediatrics proposed the concept of Medical Home in 1993, since which the concept of home is present. It is described as “the continuous process of relationship between the dentist and the patient, including all aspects of oral health care in a comprehensive, continuously accessible, coordinated and family-centered manner." Its objective is to provide preventive, acute and holistic oral health care, as well as referral of patients, when necessary. Should be started at 6 months, but not after the first year of life. Setting the frequency of new visits depends on the caries risk assessment.Studies have shown that health-related outcomes and costs can be efficiently improved by early dental visits.Dental home is a useful pattern to prevent ICC.

Children who lack access to a dental home are at increased risk of CPI and dental treatment under general anesthesia, as shown in a Canadian study. Dental home practice has been shown to improve health outcomes in children, particularly those at risk of developing periodontal disease or ICC. In low-income groups, the development of a dental home reduces the incidence of CPI.

>  Clinical caries management techniques for young children

Atraumatic Restorative Techniques ( ART): A community-based primary oral health program, known as ART, was initiated by the University of Dar es Salaam in the mid-1980s in Tanzania. It is characterized by the removal of carious tissue only with manual devices and the restoration of the cavity, mainly with glass ionomer. According to the WHO manual, ART can be used when the dentin has a cavity and is accessible with hand-held equipment. It should not be used in cases where there is swelling or fistula, the pulp is exposed, there are symptoms of pain and inflammation or the cavity cannot be accessed with manual equipment. ART has minimal cost, the approach is physiologically friendly requiring little cavity preparation, which reduces the need for further endodontics and tooth extraction procedures.

ART has been shown to have a high success rate, especially for single surface restoration. For example, a 3-year investigation in Zimbabwe found a survival rate of 85.3% for single-surface ART restorations. A meta-analysis has revealed that the survival rate for single-surface ART restoration of primary posterior teeth reached 94.3% at 2 years, and 87.1% for permanent posterior teeth over 3 years. Furthermore, studies have found that ART can efficiently minimize dental pain and anxiety compared to traditional therapies.

These days the combined use of ART and dentin/chemo-mechanical conditioner has been developed. The combined use of conditioner may have a better result as it can clean the bonding surface and seal the dentinal tubules. The use of manual instruments in combination with chemo-mechanical methods will improve the removal of carious tissues. Furthermore, they may minimize the pain posed by dental treatments, making ART more suitable for children.

Interim therapeutic restoration (ITR): Uses a technique similar to ART, but has different therapeutic purposes. ART was introduced to families in low-income countries as a therapeutic approach, although this treatment is not always available. ART used only hand instruments and is a definitive restoration. ITR is a temporary restoration that involves removing cavities with both hands or low-speed rotary devices and then restoring with temporary adhesive restorative material. ITR is effective in the management of dental caries in young or uncooperative patients, or with special health needs, and in situations where conventional cavity preparation and placement are not feasible. ITR can also be used for caries control in children with multiple caries lesions, before definitive tooth restoration. The adoption of RTI is effective in decreasing the levels of oral cariogenic bacteria immediately after its placement. However, if no further treatment is given within 6 months, bacterial counts may return to pretreatment levels, so ITR should be changed with more definitive restoration within 6 months. IRT is a suitable treatment option for ICC, as it slows the deterioration of caries, allowing more children to be treated.

Chemomechanical cavity removal : This is a procedure that uses a solution to chemically soften decayed tissue to make it easier to remove. The decay tissues are then removed using hand-held devices. It is one of the techniques for eliminating tooth invasion cavities. This method was first applied in the 1970s with the help of different reagents, including ethylenediaminetetraacetic collagenase and sodium dodecyl sulfate. The agents used can now be grouped as enzyme-based agents and ethyl sodium hypochlorite. Carisolv is the best-known chemomechanical elimination agent based on sodium hypochlorite. Papacarie is based on commercially available enzymes, composed of the enzyme papain, toluidine blue, chloramine, salts, a thickener, stabilizer, preservatives and deionized water. Compared with the traditional method of caries removal, the one discussed here showed a significant reduction in pain response and the need for local anesthesia, it is a useful caries removal method for anxious, disabled and pediatric patients. However, other studies have shown that the chemomechanical method requires more clinical dedication and treatment time than the traditional method. This can increase fear in subjects subjected to this technique.

Laser application : Neodymium-yttrium-aluminum-garnet. Lasers can efficiently remove cavities with minimal disruption to adjacent tooth structure, because the water content in cavity-affected tissue is higher than in healthy tissues. The use of traditional high-speed dental equipment induces pain, discomfort and anxiety among pediatricians by producing vibration and noise during dental restoration procedures. Erbium lasers do not contact hard tissue and do not generate vibrations like handpiece devices. Therefore, they have been found to exert an analgesic effect on hard tissues, minimizing the use of anesthesia and injections during dental preparations.

>  Restoration

Preventive resin restoration : This is a restorative method applied as early as 1978 for the management of pits and fissures that have minimal or questionable cavities. Indications are questionable cavities, or a probe stuck in a pit or fissure; minimal and shallow pit and fissure caries; deep pits and fissures that could inhibit complete penetration of the sealant material or could be decayed at their bases; deep pits and fissures with obvious supplementary fissures and limited areas of decay; and a dull, chalky appearance along with pits and fissures, which could indicate early-stage cavities. Preventive resin restoration is contraindicated in large, deep or multi-surface carious lesions. It is characterized by the extraction of only a small number of teeth, early repair of carious lesions, and protection of the unprepared area from secondary caries. The classic shape is prepared with a small round lathe and the procedure is completed with composite resin and pit and fissure sealant. Its success rate is high, even after a long period of time. Currently, it is combined with other technologies, such as laser application, to produce better long-term results.

Composite resin-based restoration : As an essential component in pediatric restorative dentistry, this restoration is composed of chemically consolidated fillings and a resin matrix and is classified according to the size of its fillings, since they influence the esthetics/polishability , polymerization shrinkage, depth and physical characteristics. Hybrid resins involve different particle sizes to improve strength while preserving aesthetics. Larger filler particles improve strength while smaller particles improve aesthetics and polishability.

Compared to hybrid resins, flowable resins have a smaller volumetric fill percentage. This restoration can be used in preventive restoration with resin, Class II restorations in both primary and permanent dentition. Indirect restorations with composite resins can be applied to primary and permanent teeth. Operator experience, restoration size, and tooth position are factors that have the potential to promote composite resin durability. Resins are more sensitive to the technique in contrast to amalgams. If the patient is uncooperative or there is an isolation problem, use of this restoration may not be the best choice. Before the operation, a caries risk assessment should be done, and children at high risk of caries are also not good candidates for it.

Restoration with glass ionomer cement : they have several characteristics that improve their pediatric use, ability to chemically bond to both dentin and enamel, biocompatibility, fluoride absorption and release, lower sensitivity to humidity than resins, and relative thermal expansion capacity. for tooth structures. However, they have poor wear resistance, unfavorable mechanical properties and poor aesthetics. Fluoride is released from the glass empire cement and absorbed by the surrounding tooth structures. Studies have shown that this cement is suitable for Class I restorations in primary molars, like conventional glass iomer cement, which has a median failure time of 1.2 years, and has poor anatomical shape and marginal integrity. Resin-modified glass ionomer cements contain hydroxyethyl methacrylate and may be light-cured. They have better mechanical qualities and greater resistance to moisture contamination compared to traditional glass iomer cement, while fluoride release remains constant. Resin-modified glass iomer cements are tooth-efficient and can be used for Class I and Class II restorations in the primary dentition. They are also used in ART and ITR technologies and are a suitable base or coating when composite resins are used as a restorative material.

Giomer Restoration : Giomer is a new type of hybrid material that came into use in the early 2000s and is composed of prereacted glass ionomer filler particles within a resin matrix. The prereacted glass iomer filler is generated by an acid/base reaction between fluoride-containing glass particles and polyalkenoic acid with water, before being integrated into the resin. Its characteristics are those of both glass ionomers and composite resin, such as the ability to release and recharge fluorine, biocompatibility and good aesthetics.

In vivo clinical studies reveal that the morphological changes, mechanical integrity, and functional properties of Giomer restorations compare favorably with composite resin restorers. Studies have also shown that Giomer has a high restoration success rate. A clinical trial used Giomer for Class I and Class II restoration on a permanent molar and showed that the success rate at 8 years reached 100%, and the success rate at 13 years is still quite high.

Stainless steel primary molar crowns – These are prefabricated crown forms adjustable to the patient’s tooth, which are cemented with a biocompatible luting agent. It has demonstrated greater longevity than amalgam restorations and resin-modified glass iomer cements. These crowns continue to offer the advantage of complete coverage in the fight against recurrent tooth decay and provide strength and increased durability with minimal maintenance requirements, which are favorable for high-risk pediatrics. Retrospective evidence from research studies shows that preformed metal crown restorations last longer compared to resin or amalgam based restorations in the treatment of cavities in primary teeth. Therefore, its use is recommended in high-risk children with extensive or multifaceted cavities or extensive noncavitated lesions or over primary molars, particularly when children require behavioral guidance or approaches such as general anesthesia.

Hall’s technique. This technique is a non-invasive method, applying metal crowns to a decayed primary molar, separating the teeth rather than removing decayed tissues, and preparing the tooth, so you may not need local anesthesia, cavity removal. or dental preparation. It also avoids the discomfort of anesthesia and cavity removal, providing a therapeutic option for anxious children. Likewise, avoiding caries removal can prevent pulp exposure. Its use causes the caries to be sealed under a metal crown, preventing the biofilm from being the source of nutrition for the microbes, with protection against diets rich in carbohydrates. Eliminating this bacterial access prevents the progression of cavities. It has been shown that the HaIl technique had a similar success rate to conventional crowns with favorable restoration longevity. Another study lasting 36 months compared the results of the Hall technique with TKA and showed that the former had 3 times higher survival rates for molar restoration. Both methods are well accepted by children and their parents. Therefore, the Hall technique can be used when crowns are not feasible.

Anterior aesthetic restoration in primary incisors : Restoration of primary incisors can be cumbersome in pediatrics due to small size of teeth, minimal surface areas for bonding, proximity between tooth pulp and surface, behavior of the child. The following are indications for full crown restoration of decayed primary incisors: extensive superficial caries; involvement of the incisal edge; extensive cervical decalcification. Pulp therapy is recommended.

Retrospective research has revealed that at least 80% of the band crowns were completely retained after 3 years while those that were partially retained accounted for 20%, with no loss. Another retrospective study showed 80% retention of band crowns after 24 to 74 months. For complete coronal coverage on primary anterior teeth, band crowns are therapeutic.

>  Deep caries and vital pulp therapy.

Indirect pulp therapy is a procedure that does not disturb the pulp of adjacent deeper cavities to avoid pulp exposure. A biocompatible material is then used to cover the decay-affected dentin to provide a biological seal. A dentin bonding agent such as calcium hydroxide, resin-modified glass ionomer, or MTA (NT: mineral trioxide aggregate) is usually used on the remaining carious dentin to trigger the dentin healing and repair process. The tooth is then restored with a dental material. Indirect pulp therapy is indicated in primary teeth with deep caries without pulpitis or with reversible pulpitis, when the deeper carious dentin is not removed to avoid exposure of the pulp. James A. Coll et al. reviewed articles and found that the success rate of this therapy was 94.4% at 24 months, and the coating material (calcium hydroxide coatings vs. bonding agent coatings) did not affect the success of the outcome. Its successful outcome is possible under defined conditions (tooth without symptoms, without pulp exposure) and adequate sealing of the cavity with effective sealing of the dentin.

Pulpotomy . Pulpotomy is performed on a primary tooth when caries removal results in pulp exposure in a tooth with healthy pulp or reversible pulpitis and there are no radiographic signs of infection or pathological resorption. The coronal pulp is amputated, pulpal hemorrhage controlled, and the remaining vital root surface tissue is treated with medications, with long-term clinical success. A meta-analysis showed that the success rate of pulpotomy after 2 years was 82.6%. MTA is the only medication recommended for teeth that will be preserved for ≥2. years. The tooth is then restored with a restorative material (glass ionomer cement, resin-based composite, Giomer, or stainless steel, if necessary) to prevent microleakage from the tooth. Management of ICC begins in pregnancy. Early establishment of healthy eating habits, oral hygiene habits, and dental home habits are essential for children’s dental health. The ICC management plan should be made based on caries risk assessments and clinical evaluation of carious lesions.

Intervention of dental caries alone is insufficient to stop the progression of the disease. Therefore, continuous evaluation and management of the patient’s health status should be performed after treatment to manage long-term oral health. Caries risk assessment is a key component of today’s preventive care for infants, children, and adolescents. It should begin as soon as the first primary tooth emerges and be reevaluated regularly by both the dentist and doctor. Beginning preventive monitoring and treatment at 12 months is more accurate than later.

> Secondary caries

Secondary caries is the most common cause of replacement of dental restorations in clinical settings, regardless of the type of material chosen, secondary caries cannot be completely avoided. There may be a number of factors responsible for its appearance; 1) clinical technique, humidity control, visual inspection and, for children, behavior management, etc. All of these clinical factors can predispose to the development of secondary caries; 2) microleakage at the interface between the tooth and the restoration. So far, no material can completely eliminate microleakage around the restoration. Immediately after the use of adhesives, a space of 6–10 μm is formed between the dental tissue and the restoration.

On the other hand, the level of microleakage was not affected by conventional or chemical-mechanical methods of caries removal, microbiological changes of the restoration area; 4) restorative material properties, fluoride-releasing restorative materials such as GIC or Giomer, which may have advantages over resin-based materials; 5) Oral hygiene is also closely related to the appearance of secondary caries. Secondary caries prevention methods include the use of fluoride-releasing materials; control of microleakage, adequate removal of plaque, especially the gingival part of the restoration by interdental brushing, flossing and adequate contact with fluoride will help prevent secondary caries.

> Ecological balance

Human and symbiotic microbes form a complex ecosystem whose dynamic balance is significantly correlated with physical health. Frequent consumption of carbohydrates may result in dysbiosis of the oral microbial community, the overproduction of acid with selection for the elevation of acid-tolerant acidogenic bacteria. For example, S. mutans , Scardovia wiggsiae, Slackia exigua, Granulicatella elegans and Firmicutes were found to predominate in the dentobacterial plaque of carious lesions. Other bacteria, such as Streptococcus cristatus, S. gordonii, S. sanguinis, Corynebacterium matruchotii and Neisseria flavescens, were common in dentobacterial plaque on the surfaces of healthy, non-carious teeth. Therefore, it is important to rebalance the dysbiosis of the caries microbiome after ICC treatment.

Timely restoration of dental caries, mechanical removal of dental plaque, use of antimicrobial compounds, dietary modification, and topical application of fluoride can help maintain a careful oral ecological balance. . As sugar intake influences microbiome dysbiosis, the use of substitutes such as xylitol and erythritol is encouraged to prevent the transmission of cariogenic bacteria.

Until now, ICC remains a global health challenge. The caries microbiome plays a fundamental role in the development of ICC. Based on etiological investigations of ICC, new biomarkers and therapeutic strategies can be developed to improve the prevention and treatment of ICC.

Maternal oral health and health literacy are directly related to the oral health of infants and young children.

For the promotion of oral health, including education. Health care services are needed during pregnancy to improve the oral health of young children. A dental home should be established at an early stage of childhood while for individualized caries management a plan should be in place according to the caries risk assessment.

Active measures should be taken following the concept of minimal interventions to treat dental caries. In China, the prevalence of ICC continues to increase, caries management throughout the life cycle should start from the beginning of life to effectively prevent and treat caries and thus achieve the goal of lifelong oral health.