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Getting to the root of the problem
Dental caries in children can be aggressive if it is not diagnosed and treated in a timely manner. Dr Bien Lai Wen Pui says early dental visit at age one and preventive advice for parents are recommended before dental caries occur.

Oral diseases are a common problem found in children, in both developed and developing countries, affecting quality of life. Dental caries (or tooth decay) is the most common chronic disease affecting children globally, five times more common than childhood asthma and four times more common than childhood obesity.

In children under 6 years old, dental caries is termed Early Childhood Caries (ECC). In a study conducted by the National University of Singapore in 2009, 40% of children under 6 in Singapore were found to have ECC. Severe early childhood caries (SECC) is the more serious form of ECC and can affect even children below 3 years of age. SECC is an aggressive disease and can progress quickly in young children if undiagnosed and untreated.

Dental caries is caused by bacteria that grow naturally in the mouth and on the teeth. When allowed to accumulate, these bacteria form dental plaque.

Dental plaque is a sticky film of bacteria that constantly forms on the teeth surfaces. These bacteria feed on sugars from drinks and food to form acids which attacks and dissolves tooth enamel, which is the outermost surface of teeth, resulting in a loss of minerals over time. During the early stage of the disease, the loss of minerals, termed demineralisation, presents as White Spot Lesions (WSL) on tooth surfaces.

These WSL appear as white chalky areas on the enamel surface and are commonly found under a thick layer of dental plaque. Dental caries at this stage (WSL) is reversible if diagnosed and treated early. If not addressed, the demineralization progresses to form cavities in the tooth structure. Untreated cavities can continue to increase in size and deep cavities can affect nerve endings at the center of the tooth, resulting in a toothache. A deep cavity can also allow bacteria to enter the tooth and result in a dental infection. This infection of the nerves and blood vessels in a tooth can cause a dental abscess which may present as a gum or facial swelling.

Signs, symptoms and consequences of dental caries

SECC is an aggressive form of dental caries in children. Without timely diagnosis and intervention, untreated cavities can result in pain and infection. This is a common reason for an emergency room visit in the middle of the night with a screaming child. Furthermore, this can result in damage to the developing permanent teeth, affects a child’s nutritional intake, growth and development, and severely impacting their overall quality of life.

In cases of severe disease, the child will require more extensive and costly treatments, such as pulp therapy (baby root canal), crowns and extractions. In addition, young children affected by SECC may not be able to tolerate traditional dental treatment on a dental chair due to behaviour. As such, advanced pharmacological behavioural management, such as sedation or general anaesthesia, is often necessary to carry out dental treatment.

Significance of deciduous teeth

Unfortunately, many people have the belief that baby (deciduous) teeth are not important. Although deciduous teeth will ultimately be replaced by adult permanent teeth, they are essential for function, aesthetics, jaw and face development in the child’s growing years. It is especially noteworthy that the change from deciduous to adult dentition takes place from age six to 12, and does not occur all at once. Typically, anterior teeth will be replaced at about six to eight years old, while the last posterior deciduous tooth may exfoliate only at around 12 years old with slight variation between the genders and among individuals. This means that a three-year-old with a hole in the back tooth may only get a new one when they turn 12.

Causes of dental caries

There are many factors involved in the development of ECC. These causes include, but are not limited to:

  1. Poor oral hygiene resulting in the accumulation of dental plaque
  2. Prolonged exposure to sugars during night feeds without implementing the appropriate oral care measures (E.g. prolonged use of milk bottle filled with milk or sweetened liquids or on-demand breastfeeding throughout the night)
  3. Dietary factors such as increased frequency of sugary snacks or drinks, or pouching food for a prolonged period of time
  4. A child who harbors virulent strains of SM (transmitted
    through saliva) may develop dental caries if other environment factors are favourable. Streptococcus Mutans (SM) is the main caries-causing bacteria present in the oral cavity.
  5. Compromised tooth structures due to genetic or environmental factors make some children more susceptible to dental caries

Preventing dental caries

While dental caries is prevalent, it is also highly preventable if high-risk children are identified early and the appropriate preventive measures carried out. Therefore, to be successful in preventing dental caries, dentists must begin preventive interventions at an early age. Despite the high prevalence of ECC in preschool children, the oral health awareness of Singapore caregivers can be improved. In a local survey published in 2014, only 8% of children age three to six years and 3% of children aged 18-48 months received regular dental care. In addition, a mere 1% of parents were aware of the age-one dental visit recommendation by American Academy of Pediatric Dentistry (AAPD).

The American Dental Association and the AAPD recommend scheduling a child's first dental visit as soon as the first tooth erupts and/or no later than his or her first birthday. The rationale of the age-one dental visit is to assess the child’s caries risk levels and to educate caregivers on personalized preventive measures to prevent and arrest progression of the disease. With early and timely intervention, it is possible to eliminate or reduce future tooth decay, which in turn, can reduce the child’s dental-related discomfort and treatment costs.

A two-year early preventive oral health programme for infants and toddlers at the National Dental Centre Singapore (NDCS) was found to be successful in reducing SECC. Children who did not see a dentist at an early age were three times more likely to have SECC compared to those who were enrolled in a baby oral health programme (0-18 months-old).

Only 7.8% of children who participated in the baby oral health programme had SECC, compared to 31.3% in the group who did not participate. Furthermore, there was greater severity of dental caries in the group who did not see a dentist by 18 months. These results reinforced the AAPD’s recommendation of the age-one dental visit.

Prevention is the best option in the management of ECC. While more studies with a larger sample and better study design are required to draw a more definitive conclusion on age-one dental visit, caregivers should consider bringing their child for early preventive dental visit before any disease sets in.

What’s hot now

In recent decades, there is a paradigm shift from surgical intervention (drilling and filling) to a medical and minimally invasive approach, such as the use of topical fluoride, chlorhexidine-containing agents and probiotics to contain and arrest carious lesions. One such example is Silver Diamine Fluoride (SDF), which has been used as a caries arresting agent in many parts of the world. It has received Food and Drug Administration (FDA) approval in the United States in 2014, and was brought in to Singapore in 2016. SDF has a higher preventive fraction than traditional fluoride varnish. Its efficacy in caries prevention and arrest has been proven in primary and permanent dentition as high as 60%. It provides a non-surgical alternative treatment for asymptomatic deep caries lesions. Being a minimally invasive agent, it does not require local or general anesthesia, and it does not involve tissue removal. This gives an alternative option for parents with young children and who are not keen on local or general anaesthesia.

In conclusion, the old adage “prevention is better than cure” really rings true in the case of early childhood caries.

About the Author

Dr Bien Lai graduated from National University of Singapore (NUS) in 2006 with a Bachelor of Dental Surgery (BDS). She was awarded the Ministry of Health (MOH) Overseas scholarship in 2008 to receive post graduate training in the University of North Carolina Chapel Hill, specializing in Paediatric Dentistry. She graduated with a Master of Science (Pediatric Dentistry) in 2011 and completed her American Board certification in 2012. She has obtained her specialist accreditation in Singapore in 2014 and is appointed as the Associate Programme Director of the NUS Paediatric Dentistry Post-graduate programme. She is currently Consultant and Head of Paediatric Dentistry unit in the National Dental Centre Singapore (NDCS). Her research interest includes baby oral health and health service research related to early preventive dental care.

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