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Caries as a Biosocial Disease
The understanding that caries is an infectious bacterial disease was placed on a firm scientific foundation by W.D. Miller in 1890 through his landmark book The Microorganisms of the Human Mouth.1 Recently, socioeconomic status has been shown to be a major risk factor for caries incidence. Further, the relationship between oral hygiene behaviors and diet contributes to the manifestation of dental disease burden differently among populations. The surgeon general’s report Oral Health in America,2 published in 2000, identified a “silent epidemic of caries” among certain disadvantaged populations. These groups include immigrant and ethnic clusters as well as low-income families. The differences in disease rates are dramatic: 80% of dental caries occurs in 20% of the population.3 Children living in poverty represent a large population of high-risk individuals who have undiagnosed and untreated disease coupled with limited access to care. The factors that contribute to this situation are complex and include both behavioral and environmental components. Central to this situation is the presence of large numbers of pathologic organisms in certain social groups, inadequate oral hygiene practices, and significant amounts of simple sugars in the diet.4 While improvements in access to care and availability of prevention products and services are important, fundamental changes in social behaviors, such as daily oral hygiene practices and dietary choices, are essential to improvements in oral health for at-risk children.
The Caries Balance
In the daily practice of dentistry, it is tempting to think of caries as an event rather than a process. During routine examinations, a tooth either has a cavity or does not have a cavity, and this observation is the basis for dental charting and the development of a treatment plan. A stroke is an event, a myocardial infarction is an event, but caries is a process. With some finesse and perhaps with the aid of magnification, the early signs of enamel demineralization can be discovered as white spot lesions on the enamel surface. If a patient remains in the same practice for some time, it becomes possible to observe lesions changing. Through careful discussions with the parent, dentists can uncover the behaviors that are contributing to changes in the structure of the tooth. John Featherstone described this phenomenon eloquently as the caries balance.5 The process of demineralization of tooth structure is controlled by a number of factors, which either promote disease or protect against it. In every individual, a continuing equilibrium of these factors leads to either disease or wellness. Protective factors are the presence of a noncariogenic oral biofilm, good oral hygiene practices, healthy saliva composition and flow rate, a diet that is low in simple sugars, and appropriate preventive interventions including fluoride products. Disease-promoting factors include a pathologic or cariogenic oral biofilm, a diet that is high in simple sugars, poor oral hygiene, poor quality and quantity of saliva, and a lack of fluoride.6 The factors that influence states of disease and health are in a constant balance with one another, hence the name caries balance. Over time, changes in any of these factors may tip the balance toward health or disease. Should destructive factors persist for any significant period, a cavitated lesion will develop, which will require surgical intervention. However, early destruction of enamel by organic acids may be reversed through the application of remineralization products.7
CAMBRA has entered the dental nomenclature in recent years. The concepts of the caries balance and the evaluation of risk factors that produce disease are starting to be integrated into dental education curriculums throughout the world. Adopting CAMBRA philosophy into restorative practice is becoming the standard of care.8 CAMBRA has become a guiding principle in the development of treatment plans for patients with a wide variety of dental conditions. The foundation of CAMBRA lies in identifying specific disease indicators and risk factors, and concluding with a risk assessment that represents a strategy for the development of an individualized treatment plan. Disease indicators include visible cavitations or white spot lesions, recent history of restored lesions, and active caries in mother/ caregiver and family unit. Risk factors include diet, frequent intake of high-sugar foods and candy, regular bottle/milk use and/or sleeping with a bottle containing fermentable carbohydrates, poor oral hygiene, inflamed gingivae, poor saliva flow, multiple medications that affect quality of saliva, developmental disabilities, limited access to dental care, inadequate fluoride supplementation, and lower socioeconomic status. Children with one or more positive disease indicators or risk factors are considered to be at high risk for developing lesions in the future.9
Managing the Child’s Psychology
Managing caries in a high-risk young child represents a remarkably complex situation. First, the caries risk factors need to be determined. If high-risk conditions or behaviors are present, they must be confronted appropriately. Confrontation entails communication with the parents and/or caregivers in such a way that they understand the disease and become motivated to encourage healthy choices and the abandonment of disease-promoting practices. Telling a 4-year-old child to stop eating gummy bears during a brief evaluation in the dental office will have minimal success. Explaining to caregivers how bacteria that live on the surface of the tooth convert sugars into acids is important. The author recommends using a metaphor: Sugar going in the mouth repeatedly is like throwing gasoline on a fire.
The most powerful tool for gaining cooperation for treatment is the creation of positive and informative experiences in the dental setting so that the child develops confidence and trust in the dental team and the treatment environment. Modeling of positive behaviors by an older sibling while the younger child watches can be very powerful. Further, gaining the cooperation and participation of parents and/or caregivers during the initial examination is crucial. If a child has been prepared with a negative message, such as “if you don’t behave the dentist is going to give you a big shot,” there is an almost insurmountable obstacle to successful interaction between the child and the dental team. In this situation, it might be better to spend some one-on-one time with the adult caregiver and postpone the examination of the child until a positive expectation has been established. The decision to have the parent in the room during treatment is a complex one. Both highly successful dentists and those with less positive results have strong opinions on this subject that often are in complete disagreement. Reality lies somewhere in the middle, and dentists should remain flexible and adapt the treatment scenario to the unique needs of the individual child and the adult caregivers.
Much too often, a child’s first visit to the dentist is when extensive disease with symptoms is present. This can be a truly challenging situation; a 3- or 4-year-old child may present with one or more abscessed teeth that require extraction. When negative stereotypes have been introduced about the dental experience, there is no time to build positive reinforcements. For these situations, a variety of pharmacologic options are available to enable dental treatment and also protect the developing psyche of the child. Examples of such therapies include hospital dentistry with general anesthesia, parenteral and oral sedation, and nitrous oxide. Managing a sedated child requires a team of professionals with high levels of training. Although extensive, this level of effort can positively influence the child’s relationship with oral healthcare for a lifetime.
One painful and fear-inducing experience by a child in the dental office may take months or years to overcome. Many adult dental phobics report a negative dental experience as a child to be the source of their phobia.10 A chart entry at each visit should describe the child patient’s anxiety, level of cooperation, and any behavior modification methods used. This information allows practitioners to see how specific interventions have worked over time.
The diagnosis of caries continues to be a controversial subject.11 A wide range of opinions exist, but a common goal is to diagnose caries correctly at an early stage to avoid extensive damage to the tooth and the need for very invasive procedures. Traditionally, clinicians have relied on visual and tactile clues, along with radiographic evidence. Recently, new technologies have appeared on the market to assist in caries diagnosis. Some examples include products that use quantitative light-induced fluorescence,12 laser fluorescence, or light-emitting diode (LED) reflection and refraction. Other technology includes digital fiber-optic transillumination and digital radiography with software programs designed to improve visualization of the caries lesion. Whatever devices are used, it is important to remember that input from a variety of sources is necessary to make a correct diagnosis and determine what type of intervention is warranted for caries.
Principles of Phased Care
The concept of moving a patient through distinct phases of care has been part of dentistry since the beginnings of the profession. Certainly, G.V. Black articulated this concept in his early writing.13 Tom Limoli expanded on this theme and defined four distinct phases of care through which each patient should pass sequentially for treatment to be effective and for disease to be eliminated.14
Phase 1: The consideration of all urgent conditions. This includes elimination of all acute infective processes in both the dentition and the periodontium. This type of treatment includes the extraction of an unrestorable, abscessed tooth and a pulpectomy of a tooth that is in danger of abscess.
Phase 2: Preventive practices and behaviors that avoid the establishment or return of infective processes. Examples of these interventions include oral prophylaxis, hygiene instruction, sealants, and fluoride application. Caries control and caries arrest procedures also fit under this heading. This phase should be ongoing because it may require several steps and some time to establish adequate plaque control and dietary modifications, as well as to eliminate pathologic biofilms and active disease.
Phase 3: Basic restorative services, such as fillings and stainless steel crowns.
Phase 4: Extensive restorative services, such as crowns and bridges, orthodontics, implants, and cosmetic dental procedures. Note: Most restorative procedures for children will fit under Phase 3.
After completing the 4 phases of dental care, the patient enters into the recall and maintenance program and returns at intervals determined by his or her unique circumstances. Children with high caries risk factors should be seen more frequently than caries-free children. There is no one-size-fits-all recall program.
Recently, therapies have emerged that may be termed probiotic, which means the intervention has been designed to consider the complex biologic factors that lead to disease. Generally, when probiotic concepts are applied to caries treatments, the dynamics of oral biofilms are well thought out and the treatment is meant to influence biofilm evolution away from disease-producing states and toward benign health-promoting states. This approach to care holds great promise, especially in the arena of complex biosocial diseases, such as dental caries.
The 1-Year-Old Child without Caries
Both the American Academy of Pediatrics and the American Academy of Pediatric Dentistry recommend that a child’s first dental visit occur at 1 year of age or when the first tooth erupts.15,16 This practice is not commonly understood or accepted by either the dental profession or parents. Often, dentists first see an infant with a family group during a sibling’s treatment. This represents a perfect opportunity to explain to the parent that the baby’s first examination should be at 1 year.
The very young child is best examined using a knee-toknee lap examination technique,17 partnering with a parent or caregiver (Figure 1). An excellent multimedia presentation on this technique can be obtained through the University of Washington School of Dentistry (www.abcd-dental.org). The 1-year-old patient who presents without caries represents an ideal opportunity to prevent caries lesions from ever occurring. The risk factors for caries should be reviewed by the dentist with the parents. Careful discussion of the cause of dental disease and the importance of proper feeding practices together with proper oral hygiene supervision by an adult should be stressed. This is an opportunity to provide a fluoride varnish, as well. If the child is living in an environment that places him or her at risk for developing caries, the author recommends 3-month reevaluations and fluoride varnishes. If the child is at low risk for caries, the author recommends 6-month reevaluations and fluoride varnishes.
The 1- to 2-Year-Old Child with Early Caries
Traditional restorative treatment for a very young child is extraordinarily difficult. Every effort should be made to bring about a change in the environment that is causing the disease. This means identifying improper feeding practices and/or oral hygiene issues and correcting them. Early white spot lesions and small cavitations will arrest if risk factors are eliminated.18 Brushing teeth and using products that contain chlorhexadine, povodine iodine, or xylitol may be helpful (Figure 2). In the author’s practice, the protocol consists of applying fluoride treatments and assessing risk factors at the initial examination visit, at 2 weeks, at 4 weeks, and at 8 weeks. If candy is being given to the child by a different caregiver, a prescription is sent home stating no more candy, written in the appropriate language (Figure 3).
At each visit, the dental team should try to create a positive experience for the child. Anxious children can be told that the dentist is putting medicine on their teeth with a little brush that won’t hurt. At 8 weeks the situation should be reevaluated. If the caries process is arrested and remineralization is successful, the patient can be placed on a 3-month recall and varnish protocol. If caries is present into dentin and arrest is not achieved, the dentist should consider placing a resin-modified glass ionomer, using a minimally invasive or Atraumatic Restoration Technique (ART).19
This approach allows for the removal of obvious carious dentin using hand instruments and sealing with a resin-modified glass ionomer fluoride-releasing product. It is important to communicate to the parents that this is a form of caries control rather than a permanent restoration.20 As the child matures and additional positive-reinforcing experiences in the dental setting occur, a more conventional restoration may be considered. It is common that a 2-yearold child will present with caries and be uncooperative for the examination. Traditional restorative care should not be considered without sedation of some kind. After 3 months of simple and easy visits and “putting medicine” on the tooth, the child’s behavior should improve to the point that a more invasive procedure becomes possible.
The 2-Year-Old Child with Extensive Caries
This presentation is classic Early Childhood Caries (ECC), when 6 or more of 20 teeth are decayed (Figure 4). If any abscesses are present, the author recommends 1 week of antibiotics and removal of the tooth.21 When a child’s first dental visit is associated with pain and a potentially uncomfortable procedure, many future “happy visits” will be required to rebuild rapport and trust. After 1 week of antibiotics, it is usually possible to obtain adequate anesthesia for removal of a single tooth. Many practitioners report that local anesthetics are more effective when the acute phase of a bacterial infection has passed after administration of antibiotics. The use of a Molt mouth prop and caregiver assistance with gentle restraint helps guarantee control of the situation for the limited time necessary for removal of the tooth.
Extensive operative dentistry in the very young child is a special challenge for the clinical team. The option of performing all necessary work while the child is under general anesthesia in the hospital environment should be considered carefully (Figure 5). It is becoming more common to have a dental anesthesiologist come to the office and provide sedation services during restorative care. Unfortunately this option is limited by the small number of dental anesthesiologists practicing in this country. Performing multiple operative visits with oral sedation must be considered only when the dental team has received advanced training in this modality of treatment. All children who receive extensive restorative care, whether it is in the hospital environment or not, should be placed on an accelerated recare schedule with frequent limited oral evaluations and fluoride varnish.22 At each of these visits, the importance of controlling the risk factors for disease should be emphasized and levels of cooperation should be documented.
The 6-Year-Old Child with Moderate Caries
Far too often, children of 4 to 6 years of age come to the dentist for a first visit because caries is obvious to the caregiver. At this age, children are able to begin to comprehend the dental treatment environment and participate in their care. Telling, showing, and doing are very effective at this age. Introduce the child to the treatment environment, using models and puppets. Although multiple treatment appointments may be necessary, it is important to create a positive experience at the start. Introducing the dental handpiece during a coronal polish is much better than starting with an operative visit. If during this initial visit, cues are obvious that the child is apprehensive and may be uncooperative for restorative treatment, introduce the nitrous oxide nosepiece. Show the child how to blow air into and out of the nosepiece to expand the balloon next to the bottles of “happy air.” Introduce the topical anesthetic on a cotton-tipped applicator, and rub a little inside his or her lip to demonstrate what happens when the lip goes to sleep. At this age, more traditional restorations are usually possible. If during treatment, the child becomes uncooperative, consider moving back to the option of ART restorations with resin-modified glass ionomer to stabilize the situation through caries control and gain time for the child to mature and to create a history of positive dental visits.
The first primary teeth are starting to be lost at this age, so it is time to apply the wiggle test: If the tooth wiggles and radiographs demonstrate the exfoliation is eminent, do not restore it. After the first primary teeth are lost, the primary molars and cuspids may be retained for another 5 years, so longer-term restorations are important in these teeth. The materials that qualify as long-term include resin-modified glass ionomer/resin-based composite used in the sandwich technique, resin-based composite, compomer, and silver amalgam. Resin-modified glass ionomer cement restorations have significant fluoride ion release and tooth structure uptake and can be recharged with intraoral fluoride sources. Marginal caries around tooth repair areas involving glass-ionomer systems is rare, even in poorly kept mouths. After restorations are placed, consider the child at high risk for new caries unless 2 years have passed with no new lesions. The high-risk protocol calls for an enhanced recare frequency and fluoride varnish program. At 6 years of age, the first permanent molars are emerging. Many parents do not know that these are permanent teeth and need to be advised of the importance of keeping them free from caries. Sealants are one of the most effective therapies in dentistry and should go on permanent first and second molars soon after eruption.23
When a 6-year-old child is uncooperative for placement of a resin sealant or has a large quantity of saliva, the author recommends placing a fluoride-releasing surface protectorant and explaining to the parent that it will protect the tooth until such a time when conventional resin sealants can be placed.24 No restoration can survive the constant onslaught of acid that is produced by a cariogenic biofilm combined with repeated dietary exposures to simple sugars. Therefore, in the author’s practice, teeth are not referred to as restored or fixed; they are treated with a bandage to help protect the tooth.
A primary objective of treating caries in children is the hope of preventing the disease from ever starting in their permanent dentition. Although it is unfortunate when a child has a caries lesion, protocols can be implemented to help prevent the infection from affecting the permanent teeth. Arresting the progress of tooth decay, eliminating dental caries, and controlling biofilms and diet during the period of primary dentition is crucial to achieving this goal. Successful treatment outcomes will depend on a complex set of skills that address the biological, biosocial, and technical restorative aspects of care.
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About the Author
Steven Duffin, DDS, Private Practice, Keizer, Oregon