Set them up for success: Treating Early Childhood Caries with Glass Ionomers

Early childhood caries (ECC) isn’t child’s play. It’s a highly prevalent, serious disease affecting millions of preschool children worldwide that, unfortunately, often goes overlooked and untreated. Thankfully, ECC is preventable, treatable, and doesn’t always require invasive intervention – if the right strategies and materials are selected.

Early Childhood Caries

To increase understanding of ECC, and mobilize collaborations to reduce the disease, a group of international pediatric experts issued a widely accepted definition of ECC, called the IAPD Bangkok Declaration.¹ According to this declaration, ECC is defined as, “the presence of one or more decayed (non-cavitated or cavitated lesions) missing or filled (due to caries) surfaces, in any primary tooth of a child under six years of age.”¹ The condition presents itself as dull, white demineralized enamel (white spot lesions) that quickly advances to decay along the gingival margin. Typically, the primary maxillary incisors are affected first, followed by the four maxillary anteriors, and the lesions can appear on either or both sides of the tooth (labial or lingual).² And as with any form of decay, if the disease is allowed to continue, caries can progress and lead to devastating consequences.

Risk factors

While many factors contribute to the progression of ECC, such as socioeconomic background and microbiological factors, the main contributors of the disease are diet and insufficient oral hygiene. A high-sugar, high carbohydrate diet that involves frequent, prolonged, or nocturnal bottle use or breastfeeding exposes enamel to increased caries-causing bacteria. These feeding practices can also impact saliva production, hindering the mouth’s natural cleansing ability. Plus, many parents simply don’t know how to properly maintain infant oral health or best hygiene practices, which can set the child up for issues down the line.

Consequences

Dental professionals know that poor oral health can affect more than just your smile, regardless of age. But for children, the physical, social, and psychological consequences of ECC can have immediate and life-long repercussions that should be addressed as soon as possible.

Children that have untreated caries suffer from pain, discomfort, and infections, which in turn can affect appetite and eating habits. It hurts to bite and chew, which makes it difficult to ensure sufficient nutrition or healthy habits. The discomfort can also affect sleep habits, which can cause the child to suffer socially and academically. Plus, if the decay is located on the incisors, not only can it affect the esthetics of the tooth, but also impair speech development – making it difficult to pronounce “s” and “z”– both of which can reduce self-esteem.

Beyond the oral cavity, oral diseases, like ECC, can cause and exacerbate other conditions throughout the body, particularly for immunocompromised children. Primary teeth are vital to children’s development and every effort should be made to retain these teeth for as long as possible. If left untreated, defects may appear in the developing permanent dentition – setting them down an unhealthy, difficult path. We tell parents, “If you treat this caries now, their new teeth won’t come in like tissue.”

Managing ECC

There are several different ways to approach managing ECC, all of which depend on the progression of the disease, the child’s age, as well as their unique social, behavioral, and medical history. However, the end goal of any management strategy is to preserve and protect the child’s primary dentition for a long as possible.

Primary prevention

ECC treatment actually begins long before the disease – with education and proper hygiene. Parents and caregivers need to know many different things to ensure their children are happy and healthy, and most of that information comes from healthcare workers – not from dental professionals. That’s why it’s so important to promote interprofessional collaboration, so that no child slips through the cracks. From there, it’s vital that the conversation includes nutrition, feeding practices and hygiene – as well as the consequences of not addressing them as soon as possible.

• Nutrition: Limit sugary foods and drinks, particularly in children under two years old.
• Feeding practices: There’s a reason ECC is also referred to as “Baby Bottle Tooth Decay” – most studies have shown a correlation between ECC and prolonged and/or overnight bottle use with sweet content (such as lactose).³ And while breastmilk contains the ideal nutrition for infants, frequent and prolonged contact with human milk can results in “acidogenic conditions” and softened enamel.² That’s why it’s important to counsel against overnight breastfeeding and breastfeeding beyond the child’s first year.
• Oral hygiene: Many parents don’t know that they should begin start brushing their child’s teeth as soon as they erupt – but the practice is vital to getting a good start on strong oral health. Just like adults, children need their teeth brushed twice a day with an age-appropriate amount of fluoridated toothpaste (containing at least 1000 ppm fluoride) – a “smear” for children under 3, and a “pea-size” amount for children 3-6.^1,4 It can be helpful to offer activity books or daily trackers to parents to help educate and motivate children as they get older. Establishing these practices early help build healthy habits for life.
• As detailed above, the repercussions of untreated ECC can be devastating for the child, but they can also impact the family as a whole. As the condition worsens, it becomes more difficult to treat – and the cost of treatment increases. By treating the condition early, parents can protect their children and their budget.

Secondary prevention (noninvasive treatment):

Secondary prevention is focused on effective control of lesions prior to cavitation and arresting more advanced lesions where possible. This means utilizing remineralizing agents, such as fluoride containing products, more frequently. Fluoride treatments, combined with improved home oral care routines with fluoridated toothpaste, is effective in arresting or remineralizing non-cavitated lesions. Silver diamine fluoride can be successfully used in dentin lesions.⁵ In pits and fissures, composite resin materials can be used as preventive sealants and for minimally invasive restorations.⁶ Unfortunately, this area is only a small part of pediatric dentistry, as more often than not, children have already progressed to the need for tertiary prevention.

Tertiary prevention (invasive treatment):

Tertiary prevention comes into play when the lesions are cavitated and ideally involves non-invasive, tooth-preserving restorative procedures. In deciding which treatment is best, consider a less invasive treatment approach to caries management, e.g., controlling and inactivating the caries process with selective caries removal – to preserve the tooth as long as possible.⁷ However, as with most restorative procedures, the best solution will depend on the progression of the disease and how much tooth structure has been lost. In any case, restoring children’s teeth comes with its own set of challenges, and the approach as well as material choice should be carefully considered.

Restoring ECC

A visit to the dentist can be difficult at any age, but for children the prospect can be traumatic before you even consider restorative treatment. However, there are methods and materials that can help make the experience easy for patient and practitioner alike.

Treatment options:
Carious Tissue Removal:

There are two different approaches to carious tissue removal – complete (CCR) and selective carious tissue removal (SCR). The first
approach removes all demineralized dentin until the hard dentin is reached, while the second removes only the soft dentin to reduce pulp exposure.⁸

No Carious Tissue Removal (Hall Technique, HT):

In contrast to traditional methods of caries removal and restorative treatment, the Hall Technique (HT) follows a non-invasive approach. The principle of HT is to seal in caries using preformed metal crowns. Thus, the bacteria will be sealed away from the oral environment and consequently slow or stop the caries process.⁹

Alternative treatment options:
Atraumatic Restorative Treatment (ART):

Atraumatic Restorative Treatment (ART) is a treatment option based on removing carious tissue with hand instruments alone – no drilling involved – before restoration with a cement, composite, or prefabricated crown.¹⁰ While ART isn’t commonly used worldwide, it offers a variety of benefits for uneasy or difficult pediatric patients that make it a valuable tool worth exploring. Because you don’t have to drill, you can reduce patient anxiety and discomfort, as well as make treatment easier for those who may suffer from dental phobias. Plus, ART requires no electricity or anesthesia, making it a viable option when the child has other health conditions that may make anesthesia unsafe. Overall, the technique is simple, less frightening, less painful, and can be more cost effective than other approaches. And it has been shown that utilizing ART with highly viscous glass ionomers is an adequate option to treat single-surface
carious lesions in primary teeth.¹¹

Material options: The Glass Ionomer opportunity:

After caries removal, there are several different materials you can use to restore the tooth, however, glass ionomer restorative materials (GIs) have distinct advantages for pediatric patients.

To start, GIs are biocompatible and chemically bond to natural tooth structure – no etchants, adhesives, or time-consuming extra steps necessary. This means an easier, quicker procedure for fussy patients, and an excellent bond. But more than simply restoring, GIs actually help support healthy teeth. These unique materials contain a number of ions that support natural dentition, including fluoride, calcium and phosphate. As dental professionals well know, fluoride is key to healthy teeth. It holds onto calcium and phosphate, the building blocks of teeth, and replaces enamel’s normal crystalline composition hydroxyapatite with more decay-resistant fluorapatite.

In addition to releasing a significant amount of fluoride, GIs act as reservoirs for the ion – providing a prolonged ion-release. This means that every time the patient drinks fluoride-rich water, brushes their teeth or uses a fluoride rinse, their restoration absorbs more fluoride – which it will then release when it’s most needed. This makes GIs particularly useful for young patients at a high risk for caries. Phosphate and calcium are crucial to remineralization as well, being one of the key minerals in enamel, hydroxyapatite. By releasing these ions along with fluoride, teeth get a much-needed boost. And because GIs are water-based, these ions can move in and out of the material to where they’re needed most.

In addition, GIs are incredibly versatile – they can be used as full restorative materials, but also as liners and bases for resin-based composites. They can act as sealants or bonding agents (including for orthodontic brackets) and are flowable enough to seal sensitive dentin tubules. And because of their moisture tolerance, they’re particularly excellent for sealing early erupting molars – GIs are less technique sensitive, set rapidly, and can be placed with less-than-ideal clinical tooth isolation. However, GIs cannot be recommended for stress-bearing Class II restorations or for the restorations of the incisal section of incisors due to compressive strength and fracture issues. All of this together adds up to a material that’s ideal for pediatric patients and ECC.

CONCLUSION

ECC is incredibly common and can have a major impact on children, their parents, and the future of their oral health. That’s why it’s so important to do all that we can to prevent, protect and treat ECC as early as possible. By making an effort to educate parents, and exploring appropriate materials and techniques, you could help set up children for a healthier future. GIs in particular present an excellent opportunity to restore in difficult situations, while supporting conservative or atraumatic caries removal.