The early childhood caries epidemic

I was attending to the care of a 2 1/2-year-old child with Beckwith-Weidemann syndrome. He lived in a low-income family, and temporarily had fallen through the health insurance safety net. For some reason, his Medicaid insurance had lapsed, and here he was in my office appearing very ill with a temperature of 40° C (104° F). His left maxillary area was quite swollen and dusky red. I looked in his mouth, and not surprisingly, found an infected first left upper molar surrounded by a very erythematous gingiva. His teeth were riddled with cavities.

Fortunately, I was able to urgently admit him to the county hospital through a colleague in the emergency room. He did well with IV antibiotics, and was discharged four days later on oral clindamycin, and referred for outpatient extraction of the tooth by the oral surgery department through the county health department. This case, including EMS transport, hospital services, and outpatient dental surgical intervention, resulted in an $8,000 cost to the health care system. The parents had to absorb some of this cost, and are still making monthly payments to the hospital.

After this experience, I began to look at the teeth of young children a little more carefully. It soon became apparent to me that more than half of my patients had dental caries! During this time, I supervised a teaching clinic and had medical students rotating through daily. As a teacher and clinician, I knew that I needed to improve my knowledge on the diagnosis and management of dental disease in children, to better inform and educate my students, and my patients' parents.

At the top of its class

The American Academy of Pediatric Dentistry's (AAPD) most recent definition of early childhood caries (ECC) is paraphrased as follows: ECC is the presence of one or more decayed (noncavitated or cavitated), missing (due to decay), or filled tooth surface in any primary tooth in a child younger than six years (71 months or younger).¹ More serious cases are classified as severe early childhood caries, or S-ECC, previously known as "bottle rot" or "nursing caries." Characteristics of S-ECC include any sign of smooth-surface caries in children younger than 3; or, in the 3- to 5-year-old age group, any cavitated, missing, or filled smooth surfaces in the primary maxillary anterior teeth. Additionally, S-ECC may be defined as an overall decayed, missing, or filled (DMF) score as follows: age 3 with DMF ≥ 4, age 4 ≥ 5, or age 5 ≥ 6.¹

In terms of incidence, the numbers are staggering. ECC is the most common chronic disease among American children, affecting more than half of all 7-year-olds. It is three times more prevalent than obesity, and five times more prevalent than asthma (Figure 1).²

Recently, the Centers for Disease Control and Prevention reported that the prevalence rate of tooth decay is actually rising among 2- to 5-year olds, from 24% in a 1990-1994 survey, to 28% in the most recent 2000-2004 NHANES III survey.⁶ This 15% increase represents 600,000 additional preschoolers with the disease as compared to caries levels in the 1990s. This recent and rapid rise in ECC incidence is the basis for the claim that we are now facing an early childhood caries disease epidemic. This is despite steady expansion of the use of fluoridated waters and dentifrices over the past 30 years, the increased use of dental sealants in primary teeth, as well as many other dental public health initiatives. Given the significance of this epidemic, all medical and dental organizations now recommend that children have their first dental visit by age 1. However, financial and health care workforce constraints continue to make this an unrealized goal.

The roots of ECC/S-ECC

Unless the plaque in and around these white spots is actively removed by brushing, allowing for salivary calcium and phosphorus to diffuse back into the damaged tissue, the erosions will often progress to cavities that may need restorative treatment by the dentist. It is crucial that providers (and parents) understand that white-spot lesions represent early and potentially reversible areas of dental decay, and that missing or downplaying the existence of these spots can prove to be costly-both medically and financially.