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Knowledge Base

Early Childhood Caries

Early childhood caries (ECC), formerly referred to as nursing bottle caries and baby bottle tooth decay, remains a significant public health problem.1  The American Academy of Pediatric Dentistry (AAPD) encourages healthcare providers and caregivers to implement preventive practices that can decrease a child’s risks of developing this disease.

Current best practice to reduce the risk of ECC includes twice-daily brushing with fluoridated toothpaste for all children in optimally-fluoridated and fluoride-deficient communities.

To decrease the risk of developing ECC, the AAPD encourages professional and athome preventive measures that include:

  1. avoiding frequent consumption of liquids and/or solid foods containing sugar, in particular:
    • sugar-sweetened beverages (e.g., juices, soft drinks, sports drinks, sweetened tea) in a baby bottle or no-spill training cup.
    • ad libitum breast-feeding after the first primary tooth begins to erupt and other dietary carbohydrates are introduced.
    • baby bottle use after 12-18 months.
  2. implementing oral hygiene measures no later than the time of eruption of the first primary tooth. Toothbrushing should be performed for children by a parent twice daily, using a soft toothbrush of age-appropriate size. In children under the age of three, a smear or rice-sized amount of fluoridated toothpaste should be used. In children ages three to six, a pea-sized amount of fluoridated toothpaste should be used.
  3. providing professionally-applied fluoride varnish treatments for children at risk for ECC.
  4. establishing a dental home within six months of eruption of the first tooth and no later than 12 months of age to conduct a caries risk assessment and provide parental education including anticipatory guidance for prevention of oral diseases.

Definition of Dental Caries

Dental caries is a disease caused by an ecological shift in the composition and activity of the bacterial biofilm when exposed over time to fermentable carbohydrates, leading to a break in the balance between demineralization and remineralization.

How much FLUORIDE?

Current best practice to reduce the risk of ECC includes twice-daily brushing with fluoridated toothpaste for all children in optimally-fluoridated and fluoride-deficient communities.  When determining the risk-benefit of fluoride, the key issue is mild fluorosis versus preventing dental disease. A smear or rice-sized amount of fluoridated toothpaste (approximately 0.1 mg fluoride; see Figure in PDF) should be used for children less than three years of age. A pea-sized amount of fluoridated toothpaste (approximately 0.25 mg fluoride) is appropriate for children aged three to six.  Parents should dispense the toothpaste onto a soft, age-appropriate sized toothbrush and perform or assist with toothbrushing of preschool-aged children. To maximize the beneficial effect of fluoride in the toothpaste, rinsing after brushing should be kept to a minimum or eliminated altogether.

Professionally-applied topical fluoride treatments also are efficacious in reducing prevalence of ECC. The recommended professionally-applied fluoride treatments for children at risk for ECC who are younger than six years is five percent sodium fluoride varnish (NaFV; 22,500 ppm F).   Evidence increasingly suggests that preventive interventions within the first year of life are critical.

SEALANT; What is it, how is it done and what for?

Pit-and-fissure sealants have been used for nearly 5 decades to prevent and control carious lesions on primary and permanent teeth.

We use the Resin-based sealants which are toothcolored, or white liquid like material. It is simply painted on the pits and grooves of the tooth and then it hardens up instantly when we light cure it when we point a light of a specific wavelength and intensity to the sealant.

From a primary prevention perspective, anatomic grooves or pits and fissures on occlusal surfaces of permanent molars trap food debris and promote the presence of bacterial biofilm, thereby increasing the risk of developing carious lesions. Effectively penetrating and sealing these surfaces with a dental material—for example, pit-and-fissure sealants—can prevent lesions and is part of a comprehensive caries management approach.

From a secondary prevention perspective, there is evidence that sealants also can inhibit the progression of noncavitated carious lesions.

When a tooth has a cavity, Why do we have to remove the tooth decay and on top of that why do we have to restore the tooth back to it's original shape?

Historically, the management of dental caries was based on the belief that caries was a progressive disease that eventually destroyed the tooth unless there was surgical and restorative intervention.  It is now recognized that restorative treatment of dental caries alone does not stop the disease process, and restorations have a limited lifespan. Conversely, some caries lesions may not progress and, therefore, may not need restoration. Contemporary management of dental caries includes identification of an individual’s risk for caries progression, understanding of the disease process for that individual, and active surveillance to assess disease progression and manage with appropriate preventive services, supplemented by restorative therapy when indicated.

The benefits of restorative therapy include: removing cavitations or defects to eliminate areas that are susceptible to caries; stopping the progression of tooth demineralization; restoring the integrity of tooth structure; preventing the spread of infection into the dental pulp; and preventing the shifting of teeth due to loss of tooth structure.

Primary teeth may be more susceptible to restoration failures than permanent teeth.  Additionally, before restoration of primary teeth, one needs to consider the length of time remaining prior to tooth exfoliation.

What are some of the restorations that are available for children dentistry?

Dental Amalgam

Dental amalgam has been the most commonly used restorative material in posterior teeth for over 150 years.  Amalgam contains a mixture of metals such as silver, copper, and tin, in addition to approximately 50 percent mercury.  Dental amalgam has declined in use over the past decade,  perhaps due to the controversy surrounding perceived health effects of mercury vapor, environmental concerns from its mercury content, and increased demand for esthetic alternatives.

With regard to safety of dental amalgam, a comprehensive literature review of dental studies published between 2004 and 2008 found insufficient evidence of associations between mercury release from dental amalgam and the various medical complaints.


Resin-based composite restorations were introduced in dentistry about a half century ago as an esthetic restorative material , and composites increasingly are used in place of amalgam for the restoration of carious lesions.  Composites consist of a resin matrix and chemically bonded fillers.

Several factors contribute to the longevity of resin composites, including operator experience, restoration size, and tooth position.  Resins are more technique sensitive than amalgams and require longer placement time. In cases where isolation or patient cooperation is in question, resin-based composite may not be the restorative material of choice.

Preformed metal crowns / Stainless Steel Crowns "SSC"

Preformed metal crowns also known as SSCs are prefabricated crown forms that are adapted to individual teeth and cemented with a biocompatible luting agent. Preformed metal crowns have been indicated for the restoration of primary and permanent teeth with extensive caries, cervical decalcification, and/or developmental defects (e.g., hypoplasia, hypocalcification), when failure of other available restorative materials is likely (e.g., interproximal caries extending beyond line angles, patients with bruxism), following pulpotomy or pulpectomy, for restoring a primary tooth that is to be used as an abutment for a space maintainer, for the intermediate restoration of fractured teeth, and for definitive restorative treatment for high caries-risk children.

For restoring primary anterior teeth with full coronal coverage,  there are different esthetically more acceptable options like Preveneered SSCs , all composite pedo jackets with no metal substructure, Zirconia crowns and more.


A pulpotomy is performed in a primary tooth with extensive caries but without evidence of radicular pathology when caries removal results in a carious or mechanical pulp exposure. The coronal pulp is amputated, and the remaining vital radicular pulp tissue surface is treated with a long-term clinically-successful medicament such as Buckley’s Solution of formocresol

After the coronal pulp chamber is filled with zinc/oxide eugenol or other suitable base, the tooth is restored with a restoration that seals the tooth from microleakage. The most effective long-term restoration has been shown to be a stainless steel crown.

Definition, types and different Management of the Frenulum in Pediatric Dental Patients

Frenulum attachments and their impact on oral motor function and development have become topics of emerging interest within the dental community as well as various specialties of healthcare providers. Studies have shown differences in treatment recommendations among pediatricians, otolaryngologists, lactation consultants, speech pathologists, surgeons, and dental specialists.

Typically, seven frenula are present in the oral cavity, most notable the maxillary labial frenulum, the mandibular labial frenulum, the lingual frenulum, and four buccal (cheek) frenula.  Their primary function is to provide stability of the upper lip, lower lip, and tongue.

Maxillary frenulum

A prominent maxillary frenulum in infants, children, and adolescents, although a common finding, is often a concern to parents. In severe instances, a restrictive maxillary frenulum attachment has been associated with breastfeeding and bottle-feeding difficulties among newborns in a number of studies. Surgical removal of the maxillary midline frenulum also is related to presence or prevention of midline diastema formation, prevention of post orthodontic relapse, esthetics

Lingual frenulum

Lingual frenula, in addition to the maxillary labial frenula, have been associated by some practitioners with impedance to successful breastfeeding, thereby leading to recommendations for frenotomy. The most common symp-toms babies and mothers experience from tongue- and lip-tie are poor or shallow latch on the breast or bottle, slow or poor weight gain, reflux and irritability from swallowing excessive air, prolonged feeding time, milk leaking from the mouth from a poor seal, clicking or smacking noises when nursing/feeding, and painful nursing.

Ankyloglossia (tongue-tie)

Ankyloglossia is a congenital developmental anomaly of the tongue characterized by a short, thick lingual frenulum resulting in limitation of tongue movement (partial ankyloglossia) or by the tongue appearing to be fused to the floor of the mouth (total ankyloglossia).

The tongue’s ability to elevate rather than protrude is the most important quality for nursing, feeding, speech, and development of the dental arch.

Ankyloglossia has been associated with breastfeeding and bottle-feeding difficulties among neonates, limited tongue mobility and speech difficulties, malocclusion, and gingival recession.  A short frenulum can inhibit tongue movement and create deglutition problems. During breastfeeding, a restrictive frenulum can cause ineffective latch, inadequate milk transfer and intake, and persistent maternal nipple pain, all of which can affect feeding adversely and lead to early cessation of breastfeeding.

When indicated, frenuloplasty, frenectomy, and frenotomy may be a successful approach in alleviating the problem. Each of these procedures involves surgical incision or excision, establishing hemostasis, and wound management

Frenectomy: excision of the frenulum left to heal by secondary intention.

Frenotomy: simple cutting or incision of the frenulum.

Frenuloplasty: excisions involving sutures releasing the frenulum and correcting the anatomic situation.