Basics
Description
Dental caries is the process of tooth structure demineralization, ultimately leading to cavitation (cavities). Bacterial metabolism of carbohydrates produces acid, leading to tooth demineralization over time. The presence of 1 or more decayed, missing, or filled primary tooth surfaces in children younger than 6 years old constitutes "early childhood caries"� (ECC). �
Epidemiology
- 28% of 2-5-year-olds suffer from ECC, which is most prevalent in disadvantaged populations, with those younger than 3 years old largely untreated.
- ECC may lead to increased emergency room visits and admissions, delayed growth and development, and diminished ability to learn.
Risk Factors
Dental caries is multifactorial: �
- Factors increasing duration of sugar on teeth: frequent consumption of sugars (including prolonged bottlefeeding), sugary beverages, sticky sugars, medications sweetened with sucrose, inconsistent brushing/flossing after meals, pouching of food, tightly spaced teeth that are difficult to clean
- Factors leading to dry mouth (less saliva, less acid buffering): mouth breathing, albuterol inhalers, psychiatric medications
- Factors leading to weaker tooth enamel: lack of systemic or topical fluoride, developmental enamel defects
- Epidemiologic factors (e.g., low socioeconomic status, previous caries experience)
Pathophysiology
Dental caries develops when oral bacteria, primarily mutans streptococci (MS), ferment carbohydrates into organic acids, over time demineralizing tooth enamel. Continuous demineralization of tooth enamel leads to enamel cavitation. �
Alert
MS has been shown to be vertically transmitted from caregiver to child, leading to the concept of ECC as an infectious disease. �
Diagnosis
History
- Reactive tooth pain to cold or hot foods, sweets, or biting. Spontaneous pain may be a sign of advanced caries and infection.
- Frequent carbohydrate challenge (bottle, juice, snacks, sweets, meds, etc.)
- Inconsistent brushing and flossing after meals
Alert
Spontaneous or nocturnal pain (waking up at night) may be a sign of advanced caries and dental infection. See chapter on "Dental Infections."� �
Physical Exam
- Tooth discoloration: chalky white (initial caries demineralization), yellow, or brown (advanced cavitation)
- Locations on teeth: in-between (interproximal) front incisors, biting surfaces (occlusal) of molars, at gum line (cervical)
- Soft tissue swelling (advanced caries with infection)
- Dental instrument exploration necessary to help confirm diagnosis
- To document and communicate the location of the lesion, a Universal Numbering System is used to identify the specific tooth/teeth involved (Appendix; Figure 2). Each tooth has a unique letter or number.
- Primary teeth are identified by uppercase letters (A-T).
- Permanent teeth are identified by numbers (1-32).
Diagnostic Tests & Interpretation
Lab
None �
Imaging
Intraoral radiographs (bitewing and periapical views) help to identify radiolucent/carious tooth structure. �
Other
Tooth percussion testing and hot and cold testing (inconsistent diagnostic potential) help to identify extent of caries and/or infection. �
Diagnostic Procedures/Other
None �
Differential Diagnosis
Developmental tooth hard tissue defects such as �
- Hypoplastic or hypomineralized enamel
- Dental fluorosis
Treatment
Medication
Acetaminophen or ibuprofen for symptomatic pain management. See antibiotic therapy in the chapter "Dental Infections."� �
Additional Therapies
- Timely restorative care (fillings, crowns) by a pediatric dentist
- Supplemental topical fluoride (high concentration, prescription only, dentifrice, mouthwash, gel, varnish) with the goal of temporarily arresting caries
- Tooth extraction or root canal of infected teeth
Ongoing Care
Follow-up Recommendations
- Dental caries essentially results from sugar in addition to time. Prevention of dental caries should focus on minimizing frequency of sugary beverages/ snacks and brushing (with fluoridated toothpaste) and flossing after as many meals/medication administrations as possible.
- Children should have their first dental visit 6 months after the eruption of their first tooth, or around 1 year of age. This first visit is to assess for dental caries risk factors and give appropriate anticipatory guidance to the parent with the goal of preventing ECC.
- Dental caries can advance quickly, therefore periodic preventive visits (at least every 6 months) are recommended throughout childhood.
Prognosis
- Timely caries risk assessment as well as restoration of tooth structure and function will minimize the child's caries experience and its consequences.
- Initial signs of caries (chalky white demineralization) may be remineralized with excellent oral hygiene and fluoride supplementation. Untreated advanced dental caries leads to irreversible pulpitis, dental infection, and tooth extraction.
Additional Reading
- American Academy of Pediatric Dentistry. 2014-15 Definitions, oral health policies, and clinical guidelines. http://www.aapd.org/policies/. Accessed March 16, 2015.
- Kawashita �Y, Kitamura �M, Saito �T. Early childhood caries. Int J Dent. 2011;2011:725320.
- Meyer-Leuckel �H, Paris �S, Elkstrand �KR. Caries Management-Science and Clinical Practice. New York, NY: Thieme Medical Publishers; 2013.
- U.S. Department of Health and Human Services, U.S. Public Health Service. Oral health in America: a report of the surgeon general (Executive Summary). http://www.nidcr.nih.gov/datastatistics/surgeongeneral/report/executivesummary.htm. Accessed March 16, 2015.
Codes
ICD09
- 521.00 Dental caries, unspecified
- 522.0 Pulpitis
- 522.5 Periapical abscess without sinus
- 522.4 Acute apical periodontitis of pulpal origin
ICD10
- K02.9 Dental caries, unspecified
- K04.0 Pulpitis
- K04.7 Periapical abscess without sinus
SNOMED
- 80967001 Dental caries (disorder)
- 32620007 Pulpitis (disorder)
- 196339009 Periapical abscess without a sinus (disorder)
- 427898007 infection of tooth (disorder)
FAQ
- Q: When should I refer my patient for his/her first dental visit?
- A: Children should have their first dental visit 6 months after the eruption of their first tooth, or around 1 year of age. This first visit is to assess for dental caries risk factors and give appropriate anticipatory guidance to the parent, with the goal of preventing ECC.
- Q: Why do baby teeth need to be treated if they are just going to fall out?
- A: Dental pain can affect a child's daily activities, leading to delayed growth and development and diminished ability to learn. Premature primary tooth loss due to infection and extraction can lead to eruption and crowding issues in the permanent dentition.