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S UPPLEMENT April 2006 Journal de l’Ordre des dentistes du Québec Early Childhood Caries
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Supplement - Early Childhood Caries

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Page 1: Supplement - Early Childhood Caries

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Journal de l’Ordre des dentistes du Québec

EarlyChildhood

Caries

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Summarywww.ordredesdentistesduquebec.qc.ca

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The High Incidence of Early Childhood Caries in Kindergarten-age ChildrenJean-Marc Brodeur, DDS, MSc, PhDChantal Galarneau, DMD, MSc, PhD

Importance of Early Diagnosis of Early Childhood CariesSouad Msefer, DCD, DSO, Cert. Pedo.

Prevention of Early Childhood Caries (ECC)Daniel Kandelman, DDSNabil Ouatik, DMD

Pit and Fissure Sealants: An Important Adjunct in the Control of Childhood CariesCharles Dixter, BSc, DDS, Cert. Pedo.Aaron Dudkiewicz, BSc, DDS, Cert. Pedo.Irwin Fried, DDS, MS, Cert. Pedo, FRCD(C)

The Cariogenic Nature of Childhood Bedtime RitualsChantal Galarneau, DMD, MSc, PhDJean-Marc Brodeur, DDS, MSc, PhDLise Gauvin, PhD

Dietary Recommendations for Healthy Teeth in ChildrenMonique Julien, MSc, MPH, Dr PH

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1 Give a short definition of early childhood caries (ECC).

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2 What children are most affected by ECC?

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3 What are the telltale signs of ECC?

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4 What are the consequences of ECC?

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5 What steps are recommended to prevent ECC?

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Name: ____________________________________________________

Permit No.: ______________________________

Continuing Dental Education ProgramTest Your Knowledge

The Ordre des dentistes du Québec offers its members a chance to earn three continuing dental education credits by correctly answering thefollowing questions. Write your answers legibly and concisely. Keep this answer sheet and submit it with your continuing dental education annualdeclaration when required by the Order.

Cover page design:Bronx Communications Inc.

Illustration:Marc Mongeau

Production:Public Affairs andCommunications Ordre des dentistes du Québec

Translation:Lorena Ermacora

Graphic design:Studio Artbec Inc.

Impression:Litho Mag

ISBN 2-923500-00-8

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Journal de l’Ordre des dentistes du Québec

EarlyChildhood

Caries

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Scientific Article

Key Words• Definition

• Early childhood caries

• Epidemiology

• Prevention

The High Incidence of Early ChildhoodCaries in Kindergarten-age Children

Jean-Marc Brodeur, DDS, MSc, PhD1

Chantal Galarneau, DMD, MSc, PhD2

Early childhood caries in pre-school children hasbeen discussed extensively in the scientific literatureover the past 40 years. A review of the most recentstudies shows that the dental community is lookingat the problem with renewed interest1 and that moreinformation is needed in regard to the epidemiology,etiology, diagnosis, prevention and treatment ofcaries in children ages 0 to 5 years. This articlepresents a definition of caries in pre-school childrenand discusses related epidemiological data from a1998-99 study2 on the oral health of Québecschoolchildren in the 5-6 and 7-8 age ranges, inwhich 2,512 kindergarten students who were conside-red representative of their peers in Québec werechosen at random. The examinations were performedby 13 dentists/examiners who previously had receivedtheoretical and practical training on WHO criteria fordiagnosing caries for epidemiological inquiries.

Different terms to designate early childhoodcaries The multitude of terms to describe caries in childrenages 0 to 5 is emblematic of the confusion that existsin the literature. The following expressions are usedinterchangeably: baby bottle tooth decay, earlychildhood caries, early childhood dental decay, earlychildhood tooth decay, comforter caries, nursingcaries, maxillary anterior caries, rampant caries, andmany more3,4,5,6. Some of these designations are usedspecifically to illustrate the causes of tooth decay inpreschool children3. Baby bottle tooth decay is usedin the literature to identify inappropriate baby bottleuse as the main cause of caries disease5. Otherauthors prefer the term nursing caries because itdesignates inappropriate bottle use and nursingpractices as the causal factors4,7. However, the termearly childhood caries is becoming increasinglypopular with dentists and dental researchers alike1,3,6.This broader term encompasses other, lessunderstood, practices as etiological factors, such asmalnutrition, cariogenic childhood foods, andbacterial transmission from mothers or caregivers tochildren6.

Definition of early childhood caries A group of experts designated by the NationalInstitutes of Health to develop and adopt aconsensus regarding a clinical definition anddiagnostic criteria for these types of caries has alsoadopted the term early childhood caries to describecaries in preschool-age children1. The followingclinical definition of early childhood caries (ECC) hasbeen proposed:

The presence of one or more decayed(non-cavitated or cavitated lesions),missing (due to caries) or filled toothsurfaces in any primary tooth in apreschool-age child between birthand 71 months of age.

More specifically, experts recommend using the termSevere Early Childhood Caries (SECC) to designate allcaries considered atypical, progressive, acute orrampant. This category thus includes baby bottletooth decay, nursing caries, maxillary anterior caries,labial caries, comforter caries, and rampant caries.Gagnon8 considers that SECC are merely anincidence of ECC under special or specific conditions.

Which teeth are the most susceptible tocaries?ECC affect the primary teeth of infants and pre-schoolchildren. In their severest form, they sometimesappear as quickly developing lesions on the surfaceof teeth with low susceptibility to caries, following theusual eruption sequence9,10. Typically, the maxillaryprimary incisors are hit the hardest, followed by thefirst primary molars. The mandibular incisors normallyare spared because they are covered by the tongueduring suction movements and are thus bufferedagainst cariogenic liquids4,6,7,10. Saliva produced bynearby sublingual and submaxillary glands alsobuffers the mandibular incisors against acidsproduced by dental plaque. When the mandibularincisors are affected it is usually an indication that thecaries are caused by inappropriate pacifier use, orsimply that the child has a classic case of rampantcaries4,6,7,10. Similarly, the primary canines and second

1 Dr. Jean-Marc Brodeur is a Professor at theDepartment of social andpreventative medicine anda researcher at GRIS,Université de Montréal. Address correspondence to:C.P. 6128 Succursale Centre-villeMontréal (Québec) H3C 3J7or to [email protected]

2 Dr. Chantal Galarneau is adental consultant with theDirection de la santépublique de laMontérégie.

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primary molars, because of their later eruption, are usuallyspared or little affected by ECC. The ECC attack patterntherefore depends on three factors: the timing of the tootheruption, the time span of the harmful oral habit, and the typeof muscle movements the child makes when sucking7.

Many authors agree that the attack pattern of ECC changes atage three, when it begins to affect the first and second primarymolars3,11,12,13. These results suggest that a caries attack patternshould be established for different age categories of childrenages 0 to 71 months. Drury et al1 recommend the use of sixcategories: under 12 months, 12-23 months, 24-35 months,36-47 months, 48-59 months and 60 to 71 months. In fact,according to Milnes and Bowen10, practical experience hasshown that the cariogenicity of the foods parents use to nourishor soothe their infants is a reliable indication of a child’spredisposition for subsequent caries when their diet changesfrom liquids to solids. The type of solid or liquid food could wellexplain the differences in the ECC attack patterns at differentages.

Is there a high incidence of early childhood cariesamong the general population?The 1998-1999 study on the oral health of Quebec childrenages 5 and 6 reveals that upon entering kindergarten, 42% ofchildren already had ECC on their primary teeth, with, onaverage, 3.9 carious surfaces2. In the same vein as theprovincial study, Corbeil et al14 reported that in 1994-1995,nearly 40% of children living in the Montérégie area had carieson their primary teeth and an average of 3.4 carious surfacesor absent or filled teeth. By kindergarten, the children hadnearly 70% of all the caries that would form on their temporaryteeth2. While it may be informative to compare the prevalenceof ECC in Québec with international statistics, the obvious lackof standardization in defining and establishing diagnosticcriteria for ECC makes such comparisons impossible.

Which children are more prone to early childhoodcaries?As is the case with other health problems15, oral health is afactor of social inequality. While 58% of kindergarten childrenhave no caries on their temporary teeth, a small group ofkindergarten children (24%) have five or more affectedtemporary surfaces, which account for 90% of all affectedsurfaces on temporary dentition for this age group (Fig. 1).

The children with a high risk for caries have an average DMFSof 14.9, a rate six and a half times higher than that of childrenwith lower risk factors (DMFS=1 to 4). As for treatment needsfor caries on temporary dentition, 11.7% of kindergartenchildren have three or more surfaces requiring treatment, aswell as the majority (83%) of all surfaces requiring treatmentin that age group, while 77% of the children have notemporary surface requiring treatment (Fig. 2).

An important fact to note is that children with a high incidenceof caries, and those who require extensive caries treatment, aremainly from poor families.

Which teeth and surfaces have a higher incidence ofearly childhood caries?Figure 3 illustrates the percentage of temporary teeth inkindergarten-age children at the time of the exam that wereaffected by caries.

The most affected teeth were the four second molars and themandibular first molars, with an incidence of 21% to 24%respectively, followed by the maxillary second molars (15%)and the maxillary incisors (4% to 8%). The mandibular incisorsand the four canines were little affected. In addition, 45.7% ofthe carious temporary surfaces were pits and fissures, andwere mostly occlusal (Fig. 4).

Scientific Article

The High Incidence of Early Childhood Caries...

Figure 1. Percentage of children according to the number of affected temporarysurfaces (dmfs)

Figure 2. Percentage of kindergarten children with 0, 1 or 2, or 3 or moretemporary surfaces requiring treatment, and percentage of all surfaces requiringtreatment in each of these three groups

Percentage of children Percentage of caries

DMFS = 0 DMFS = 1 to 4 DMFS = 5 or +Average = 2.3 Average = 14.9

Percentage of children

cs = 0 cs = 1 to 2 cs = 3 or +Average = 1.4 Average = 6.8

Percentage of surfaces requiringtreatment

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ConclusionCarious activity involving temporary dentition begins early anddevelops rapidly. By kindergarten age, the incidence of ECC isalready high. Furthermore, it is mainly concentrated among asmall, vulnerable group of children who mostly come fromdisadvantaged backgrounds. These data demonstrate howimportant it is for dental health care providers to encourage theirpatients to take their children to the dentist beginning at around12 months so that caregivers can be more informed aboutpreventing ECC as soon as possible and the most disadvantagedclients can be given advice consistent with their challenges. Theliterature moreover advocates standardizing the terminology,

diagnostic criteria, and definition of caries in preschool-agechildren with a view to making better comparisons of theprevalence of caries in children around the world1,3.

AcknowledgementsThis study was made possible by the support of the Directiongénérale de la santé publique du Québec. Detailed resultswere published in the “analyses et surveillance” collection ofthe Ministère de la Santé et des Services sociaux du Québec2001, Vol. 18. This document is also available in thepublications section of the Web site of the Ministère de laSanté et des Services sociaux, at www.msss.gouv.qc.ca

Scientific Article

The High Incidence of Early Childhood Caries...

Figure 3. Percentage of carious temporary teeth in mouth in kindergarten children

(Percentage of modified DMFS of 96 surfaces)

Smooth surfaces54.3%

Surfaces of pits and fissures

45.7%

(buccal fissure on mandibular molars and lingual fissure on maxillary molars)

Occlusal surfaces

6.3%

39.4%

Other

Figure 4. Location of caries on the surfaces of pits and fissures and smoothsurfaces

Bibliography

1 Drury TF, Horowitz AM, Ismail AI, Maertens MP, Rozier RG, Selwitz RH.Diagnosing and reporting early childhood caries for research purposes. Areport of a workshop sponsored by the National Institute of Dental andCraniofacial Research, the Health Resources and Services Administration,and the Health Care Financing Administration. J Public Health Dent. 1999Summer ; 59(3) : 192-7.

2 Brodeur JM, Olivier M, Benigeri M, Bedos C, Williamson S. Étude 1998-1999sur la santé buccodentaire des élèves québécois de 5-6 ans et de 7-8 ans.Collection Analyse et Surveillance no18. Québec : ministère de la Santé et desServices sociaux. Direction générale de la santé publique ; 1999.

3 Ismail AI, Sohn W. A systematic review of clinical diagnostic criteria of earlychildhood caries. J Public Health Dent. 1999 Summer ; 59(3) : 171-91.

4 Dilley GJ, Dilley DH, Machen JB. Prolonged nursing habit: a profile of patientsand their families. ASDC J Dent Child. 1980 Mar-Apr ; 47(2) : 102-8.

5 Lacroix I, Buithieu H, Kandelman D. La carie du biberon. Journal dentaire duQuébec. 1997 ; XXXIV : 360-374.

6 Tinanoff N, O'Sullivan DM. Early childhood caries: overview and recentfindings. Pediatr Dent. 1997 Jan-Feb ; 19(1) : 12-6.

7 Ripa LW. Nursing caries: a comprehensive review. Pediatr Dent. 1988 Dec ;10(4) : 268-82.

8 Gagnon PF. Les habitudes alimentaires de la première enfance et l'apparitionde la carie rampante. Journal dentaire du Québec. 1984 avril : 119-122.

9 Berkowitz RJ, Turner J, Hughes C. Microbial characteristics of the human den-tal caries associated with prolonged bottle-feeding. Arch Oral Biol. 1984 ;29(11) : 949-51.

10 Milnes AR, Bowden GH. The microflora associated with developing lesions ofnursing caries. Caries Res. 1985 ; 19(4) : 289-97.

11 Dini EL, Holt RD, Bedi R. Comparison of two indices of caries patterns in 3-6year old Brazilian children from areas with different fluoridation histories. IntDent J. 1998 Aug ; 48(4) : 378-85.

12 Mayanagi H, Saito T, Kamiyama K. Cross-sectional comparisons of caries timetrends in nursery school children in Sendai, Japan. Community Dent OralEpidemiol. 1995 Dec 23(6) : 344-9.

13 Seow WK, Amaratunge A, Bennett R, Bronsch D, Lai PY. Dental health ofaboriginal pre-school children in Brisbane, Australia. Community Dent OralEpidemiol. 1996 Jun ; 24(3) : 187-90.

14 Corbeil P, Brodeur JM, Noiseux M. Enquête sur la santé dentaire des écoliersde maternelle, deuxième et sixième année en Montérégie. Rapport final.Québec : Direction de la santé publique de la RRSSS de la Montérégie ; 1996.

15 Evans RG, Barer MR, Marmor TR. Why are some people healthy and othersnot?: the determinants of health of populations. New York : A. de Gruyter ;1994.

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Scientific Article

Dr. Souad Msefer is a dentalsurgeon, doctor ofodontological sciences, and pedodontic specialist, and a former professor at theUniversity of Casablanca. She is currently a PhDcandidate in public health at the Université de Montréal. Address correspondence to:5390 Decelles, Suite 2Montréal (Québec)H3T 1V9

Importance of Early Diagnosisof Early Childhood Caries

1. Terminology

Early childhood caries (ECC) is a particularly virulenttype of dental caries that can destroy the primarydentition of babies and pre-school children. EEC isconsidered a severe and rampant disease of theprimary teeth that begins immediately after tootheruption.

The term baby-bottle tooth decay was commonlyused to denote caries of the primary teeth in veryyoung children, caused by prolonged use of a babybottle at bedtime or even during the daytime.

For some years now, the term early childhood carieshas had widespread use. This term better reflects themulti-factor etiological process of the disease1,2.

Among the other factors implicated are prolonged,on-demand breastfeeding, frequent consumption—i.e., more than three times per day—of cariogenicsnacks (cookies, candy, cake, and so forth), pediatricsyrups, lack of fluoride toothpaste use, and theabsence of fluoride in drinking water3,4.

It has also been recognized that cariogenic bacteriacan be transmitted from mother to child throughcertain practices, for example, tasting the baby’s foodwith the same spoon, or testing the temperature ofthe nipple. In addition, poor oral hygiene in mothershas been associated with a higher concentration ofmicro-organisms in the mouth of their children5.

2. Diagnosis

Early childhood caries is a serious and sometimespainful disease characterized by early onset and veryrapid progression. The caries develop quickly, usuallyright after the teeth erupt. Several teeth may beaffected, beginning with the maxillary incisors, at thejunction near the gums, followed by the canines. Ifthe disease continues to progress, the molars are

affected too, while only the mandibular incisors arespared.

There are four stages in the development of ECC6

• The initial stage is characterized by theappearance of chalky, opaque demineralizationlesions on the smooth surfaces of the maxillaryprimary incisors when the child is between theages of 10 and 20 months, or sometimes evenyounger. A distinctive whitish line can bedistinguished in the cervical region of thevestibular and palatal surfaces of the maxillaryincisors.

At this stage, the lesions are reversible but arefrequently unrecognized by parents or the firstphysicians to examine the mouths of these veryyoung children. Moreover, the lesions can bediagnosed only after the affected teeth have beenthoroughly dried.

• The second stage occurs when the child isbetween the ages of 16 and 24 months. Thedentin is affected when the white lesions on theincisors develop rapidly, causing the enamel tocollapse. The dentin is exposed and appears softand yellow. The maxillary primary molars presentinitial lesions in the cervical, proximal and occlusalregions (Photo 1).

At this stage, the child begins to complain of greatsensitivity to cold. The parents sometimes notice thechange of colour on their own and becomeconcerned.

• The third stage, which occurs when the child isbetween 20 and 36 months, is characterized bylarge, deep lesions on the maxillary incisors, andpulpal irritation. The child complains of pain whenchewing or getting his teeth brushed, and ofspontaneous pain during the night.

Souad Msefer, DCD, DSO, Cert. Pedo.

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At this point, the maxillary primary molars are at stage 2,while stage 1 can be diagnosed on the mandibular primarymolars and the maxillary canines.

• The fourth stage, which occurs between the ages of 30 and48 months, is characterized by coronal fractures of theanterior maxillaries as a result of amelodentinal destruction(Photo 2). At this stage the maxillary incisors are usuallynecrotized, and the maxillary primary molars are at stage 3.The secondary molars and maxillary canines and the firstmandibular molars are at stage 2. Some young childrensuffer but are unable to express their toothache complaints.They experience sleep deprivation and refuse to eat.

A positive diagnosis is established on the basis of questions toparents regarding risk factors and a clinical endo-oralexamination, completed by x-rays.

A differential diagnosis is based on observations of hereditarytooth structure anomalies such as infantile melanodontia7,which primarily affects the maxillary incisors, and amelogenesisimperfecta, which affects the enamel of every tooth, and is ahereditary disease of the dentin, characterized by anopalescent, brownish tooth colour, and typical short roots.Enamel hypoplasia caused by malnutrition during the perinatalperiod or by a deficit in Vitamin A promotes a high cariessusceptibility and is often associated with early childhoodcaries2.

3. Repercussions

Early childhood caries can have serious general and localrepercussions in the short and long terms.

Following pulp necrosis, infection spreads to the pulpal-periodontal region in one of two clinical forms: the acute form,characterized by cellulitis, adenopathy and mobility of theaffected teeth, and the chronic form, which is the mostcommon, characterized by abcesses and interdental septumsyndrome. Depending on the severity of the disease, infectioncan spread to the buds of the permanent teeth, causingirreversible lesions. Complications from subsequent infectionscan occur in children already compromised by a generallyweakened state of health8.

Contrary to popular belief, the effects of caries in youngchildren extend beyond the mouth. Tooth loss is sometimesinevitable, and it can cause not only orthodontic and estheticproblems, but more importantly, difficulties in pronunciation.Esthetic problems and pronunciation difficulties may result inpsychological and relationship problems. In addition, childrenwith ECC usually weigh less and are shorter than average9,10.Their growth is affected because they have difficulty sleepingand eating as a result of the infection and pain, and their qualityof life is greatly diminished11.

Scientific Article

Importance of Early Diagnosis...

Photo 1. Vestibular caries (stage1 and stage 2) in a three-year-old child(Department of Pedodontics, Casablanca)

Photo 2. Destruction of maxillary primary incisors with abscess facing 51(stage 4) (Department of Pedodontics, Casablanca)

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Furthermore, it is very complicated and costly to treat caries invery young children, who must undergo general anesthesia.ECC is therefore a burden both for parents and society3.

Intervention at the early stage is necessary to prevent thedestruction of the crown and stop the caries from progressing.It involves simple techniques to remineralize the enamel, suchas topical applications of fluoride, fluoride solutions andfluoride varnishes12,14.

In conclusion, early diagnosis of early childhood caries and theidentification of risk factors are essential to the implementationof preventative and curative measures to mitigate compli-cations and the repercussions of the disease. Physicians andnurses have more opportunities to see expectant mothers andtheir newborns than dentists do. It is therefore vital toemphasize parental awareness of the seriousness of ECC sothat proper attention is placed on early detection and theelimination of risk factors.

Scientific Article

Importance of Early Diagnosis...

Bibliography

1 American Academy of Pediatric Dentistry. 1997. Conference on earlychildhood caries, Bethesda, Md, Community Dent Oral Epidemiol.

2 Horowitz HS. Research issues in early childhood caries. Community DentOral Epidemiol. 1998 ; 26(suppl) : 67-81.

3 Berkowitz Robert J. Causes, traitement et prévention de la carie de la petiteenfance : perspective microbiologique. J Can Dent Assoc. 2003 ; 69(5) :304-7.

4 Seow WK. Biological mechanisms of early childhood caries. CommunityDent Oral Epidemiol. 1998 ; 26(suppl) : 8-27.

5 Milgrom P. Psychosocial and behavioral issues in early childhood caries.Community Dent Oral Epidemiol.1998 ; 26(suppl) : 45-8.

6 Veerkamp JS, Weerheim KL. Nursing caries bottle: the importance of adevelopmental perspective. J Dent Child. 1995 ; 22(6) ; 381-386.

7 Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhoodcaries. Community Dent Oral Epidemiol. 1998 ; 26(suppl) : 32-44.

8 Morrier JJ. La carie et ses complications chez l'enfant. Encycl. Med. Chir.Odontologie. 1998 ; 23 : 410-C-30.

9 Ayhan H, Suskan E, Yildirim S. The effect of nursing or rampant caries onheight, body weight and head circumference. J. Clin. Pediat. Dent. 1996 ;20(3) : 209-212.

10 Thomas C, Primosch R. Changes in incremental weight and well-being ofchildren with rampant caries following complete dental rehabilitation.Pediatr Dent. 2002 ; 24 : 109-113.

11 Low W, Tan S, Schwartz S. The effect of severe caries on the quality of life inyoung children. Pediatr Dent 1999 ; 21 : 325-326.

12 American Academy of Pediatric Dentistry (2004-2005). Clinical Guideline onInfant Oral Health Care. Clinical Guidelines.

13 Donald W. Lewis and Amid I. Ismail (1995). Prévention de la carie dentaire,groupe d`étude canadien sur les soins de santé préventifs.

14 Ismail Amid I. Prevention of early childhood caries. Community Dent OralEpidemiol. 1998 ; 26(suppl) : 49-61.

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Scientific Article

1 Dr. Daniel Kandelman isthe departmental Directorand a Professor at theDepartment of oral health,Faculty of dentistry,Université de Montréal. Address correspondence to: C.P. 6128 Succursale Centre-villeMontréal (Québec) H3C 3J7or [email protected]

2 Dr. Nabil Ouatik is aresident in pediatricdentistry and a graduatestudent at the Faculty ofdentistry, Université deMontréal.

Prevention of Early Childhood Caries(ECC)

Daniel Kandelman, DDS1

Nabil Ouatik, DMD2

Early childhood caries (ECC) unfortunately is still acommon disease in young children. It is definedclinically as the presence of one or more decayed(non-cavitated or cavitated lesions) that can developextremely quickly and lead to the widespread andsometimes painful deterioration of the primarydentition1,2,3.

The etiology of ECC is multifactorial and has beenwell established. ECC is frequently associated with apoor diet4 and bad oral health5 habits.

Severe ECC quickly destroys the smooth surfaces ofteeth that are usually considered low risk6; recentstudies have underscored the infectious nature ofthis disease and its transmission from mother tochild7,8. One study showed that streptococcus mutansgenotypes in children were similar to those of theirrespective mothers in 71% of cases among 34mother-child pairs9. However, this study was unableto highlight the father-child transmission indices butdid reveal a possible transfer of microorganismsamong children in daycare settings10.

The most common transmission modes weremother and child using the same spoon, contactbetween the mother’s saliva and the child’s mouth,improper baby bottle use, and family members usingthe same toothbrush.

ECC most frequently affects people in low socio-economic levels11. A longitudinal study on the development of Quebec children (ELDEQ) revealedthat living in disadvantaged conditions from birthincreases a child’s risk of developing caries by 112%,as compared to growing up in wealthier circum-stances12.

In view of the infectious nature of ECC and thetransmission mode of the microorganisms respon-sible for the development of caries7,8, it is importantto develop a hygiene education and prevention planwith parents during the first visits. This plan shouldtake into account the family’s living conditions andsociocultural environment.

I Prevention of ECC at the dentist’s officeand community centres

Working together with other stakeholders in thecommunity gives dentists access to skills and toolsthat aid in the prevention of ECC13,14. A dental healthpromotion program presented in books, brochures,stickers or videos and made available in dentists’offices and community centres can potentially lowerthe incidence of ECC in communities at high risk forcaries16.

This type of dental health promotion program mustbe geared to expectant parents or the parents of veryyoung children. The dentist’s office can become thecentre of a new prevention concept aimed atfamilies17,18 as the dentist acts in tandem with otherhealth professionals to meet the full range of familyneeds. The dentist could make the pediatricians inhis area aware of the importance of preventing EECand being on the lookout for the disease during thechild’s first visits (for instance, during vaccinationappointments). In addition, practitioners can work incooperation with the public dental health network.Multidisciplinary collaborations of this nature areessential to an effective program.

II Preventing ECC before conception andduring pregnancy

The expectant mother should be monitored fordental problems during pregnancy and given theappropriate prevention recommendations before thebirth of her baby. This step is all the more necessarybecause the parents will not be seeing the dentistagain for several months, when bad habits may beentrenched and already causing a proliferation ofcarious lesions at advanced stages of decay. Anevaluation of individual risk for caries is verynecessary, as it is the first step in defining andoptimizing preventive and therapeutic strategies. Thisstep should only be carried out when the dentist hasnoted poor oral health and/or eating habits or whenthere is a high incidence of active caries in theexpectant mother or her family.

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The evaluation of the risk for caries during pregnancy must takethe following into account:

• The presence of carious lesions and the degree of cariesactivity.

• A quantitative and qualitative evaluation of dental plaque(colour, number of streptococcus mutans and/orlactobacillus colonies).

• Evaluation of the salivary pH, the saliva’s buffering effect,and salivary flow.

• An analysis of the mother’s diet.• Evaluation of the extent of individual resistance by looking

at the morphological structure of the teeth, the presence ofnumerous initial carious lesions, and past fluoride use.

Together, these tests will help confirm the dentist’s clinicalimpressions, determine the existence of one or morepreponderant risk factors (bacteria, nutrition, saliva or individualresistance) and prepare a preventive and therapeutic strategythat will provide a more targeted and effective response to theetiological factors identified19. At this stage, the provider willhave to control the bacteria and eliminate the sources ofinfection, in view of the risk of bacterial transmission.

The bacteria control phase consists in reducing the number ofbacteria, and more specifically, reducing the amount ofstreptococcus mutans on the surface of the teeth. A numberof treatments are available for this purpose, including theapplication of varnishes with a high fluoride concentration orchlorhexidine varnishes (with or without a mouthguard)20.

The sources of infection21 must be eliminated as soon aspossible by debriding the carious lesions and placingtemporary fillings (zinc oxide eugenol, calcium hydroxide, orglass ionomer cements) in order to stabilize the patient’scondition and lower contamination risks. Further restorationsshould not be contemplated until the level of carious activityhas been fully controlled.

The mother could use substitutes like xylitol (gum or candy)during the pregnancy. She may continue this habit after thebirth as well22. Every member of the family should take part inan oral hygiene education program if a high risk for caries ispresent. Naturally, this should be accompanied by routinemaintenance and reinforcement programs.

Given hormone fluxes that occur during pregnancy andregardless of the risk level for caries, it is important toperiodically monitor the dental health of expectant mothers.However, fluoride supplements are not recommended beforethe baby is born23,24.

Once the baby’s first tooth erupts, the child’s mouth must becleaned with a wet cloth25 or with a child’s toothbrush and asmall amount of fluoride toothpaste (about the size of a grain

of rice)26. Parents should be taught how to brush their baby’steeth, either by resting the baby against them, or laying thebaby on their lap with his head between their legs. Thesepositions will give them the control they need to accomplishthe task. When the baby reaches the age of one, his teethshould be brushed twice a day with a small toothbrush andwater and fluoride toothpaste (about the size of a pea)26.Between the ages of 18 and 24 months, the child can learn tobrush his teeth under adult supervision.

In addition, parents should not try to soothe a crying or agitatedbaby with candy, a pacifier dipped in sugar, or a bottlecontaining a sweet drink.

Lastly, it is important to talk to expectant parents about theimportance of the first dentist’s visit.

III After the birth

Baby’s first dental visit should be during the first year of life,preferably during the first six months following the eruption ofhis first teeth, but no later than his first birthday25,27. During thefirst visit, the dentist will examine the baby’s mouth and givespecific oral care advice for preventing ECC.

It is important to talk with parents about the following points:

• Verifying and reinforcing the information and advice givenduring pregnancy.

• Reinforcing that the child should not be given cariogenicsubstances in his bottle at bedtime.

• Encouraging healthy eating and limiting sugary foods bysuggesting other types of sweeteners.

• Cleaning the child’s teeth as soon as they begin to erupt. • Encouraging the child to drink out of a cup around his first

birthday, and then progressively limiting the use of thebottle between the ages of 12 and 16 months26.

• Observing the baby’s early habits such as thumb sucking,so that the caregiver can receive timely instructions incorrecting it28, even if that means giving the child a pacifier.No connection has been noted between pacifier use (aslong as it has not been dipped in a sweetener) and ECC29.

If the provider notices ECC once the primary teeth haveerupted, he must evaluate the child’s risk for caries just as hedid with the expectant mother.

He must also prepare a personalized prevention program andchoose a fluoride therapy (systemic and topical) according tothe caries risk and the patient’s age in order to enrich thefluoride of the budding teeth’s enamel and increase the cariesresistance of the teeth that have already erupted.

Fluoride supplements (0.25 mg) are not recommended forlow-risk children under the age of three. For high-risk children,

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fluoride tablets (0.25 mg) are recommended beginning at theage of 6 months, i.e. when the child first visits the dentist30.

In all cases, before prescribing it is very important to:

• Evaluate the risk for caries• Ensure that the child is not drinking fluoridated water or

taking fluoride supplements (in vitamins) • Adjust the dosage schedule in consultation with the

attending pediatrician• Evaluate other possible sources of systemic ingestion (total

daily ingestion must not exceed 0.05-0.07 mg F-/ kg31)

The success of fluoride therapy depends on the parent’smotivation and participation, regular check-ups and adjustingthe dose depending on the dosage schedule.

Brushing the teeth with a fluoride toothpaste must immediatelybe added to the child’s daily oral health regimen as soon as hisfirst primary tooth erupts.

The use of topical fluoride in the form of a varnish or gel isbeneficial but not recommended before the child turns one. Itcould be used to foster the protection of the smooth surfacesof primary teeth and the remineralization of the first cariouslesions32,33.

Chlorhexidine varnishes can be used in children between theages of 3 and 4 with a high risk for caries, in order to reducethe quantity of streptococci within the dental plaque and as atool for the bacterial control phase. This may be a preferredmethod when traditional methods are not enough34,35.Unfortunately, these products are not available in Canada.

Sealing agents are evidently entirely indicated to preventocclusal caries of the primary molars36,37, and should be usedbeginning at age 3 after consideration of the caries risk andclinical recommendations.

Substituting sugar with xylitol22,38 or other artificial sweeteners(sorbitol and mannitol) in candy, and the recent appearance ofproducts made with casein phosphopeptide or amorphouscalcium phosphate39,40,41,42 (in chewing gum and toothpaste)will have interesting applications in preventing EEC in thefuture. These products may help remineralize teeth by bindingthemselves to the biofilm, the dental plaque and the hard andsoft tissues of the mouth and liberating calcium and phosphateions into the saliva. Further research will be necessary todetermine optimal frequency of use and the recommendedapplications according to age.

Lastly, it would be important to schedule children at risk forregular three-month check-ups and to stay in touch withparents in order to provide proper follow-up.

IV The challenges ahead

Despite a dental health provider’s efforts to implement aprevention program, sometimes the outcome does not meetexpectations43.

The prevention program must be accompanied by individualcounselling of the parents. A psychological approach should beemphasized, one that provides feedback on performance andencourages children to be proactive (by learning andintegrating oral health techniques and adopting a healthy dailydiet)44.

The collaboration of practitioners with the public healthnetwork, particularly with respect to coordinating anddeveloping dental health promotion activities, must bestrengthened so that greater numbers of parents and/orchildren will receive advice and preventive care under theprograms of the public dental health care network45.

Conclusion

The etiological factors of EEC are known, and there is anarsenal of preventive and curative therapies available to helppractitioners prevent and properly control EEC.

EEC prevention is an essential component in any dental healthpromotion program, providing a solid foundation for theoptimal development of children.

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Age During 6-12 12-24 2-6pregnancy months months years

Dental exam Periodical X X X

X-rays of dental and bone development X

Meeting with the pediatrician X X X

Evaluation of bad habits (thumb sucking) X X X

Prevention of childhood dental injuries and traumas X X X

Evaluation of caries risk through bacterial and saliva tests

High risk X X X X

Low risk

Infection control and elimination of infection sources

High risk X X2 X X

Low risk

Systemic fluoride

High risk X X X

Low risk X1

Topical fluoride

High risk X X X

Low risk X3

X4 X X

Learning about oral hygiene and monitoring oral hygiene routines

Mother and other family members X X X X

Baby X2 X X

Artificial sweeteners—chewing gum or candy

(High caries risk) X X

Sealants for pits and fissures in primary teeth X

SUMMARY OF THE SUGGESTED RECOMMENDATIONS FOR PREVENTING EARLY CHILDHOOD CARIES

1 Starting at age 3 • 2 When first tooth erupts • 3 Fluoride toothpaste and mouthwash • 4 Fluoride toothpaste • 5 Chlorhexidine varnish

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Bibliography

1 American Academy of Pediatric Dentistry. Definition of Early ChildhoodCaries (ECC). Reference Manual 2004-2005, Chicago, 1 p.

2 Kaste LM, Drury TF, Horowitz AM, Beltran E. An evaluation of NHANES IIIestimates of early childhood caries. J Public Health Dent 1999 ; 59(3) : 198-200.

3 Drury TF, Horowitz AM, Ismail AI, Maertens MP, Rozier RG, Selwitz RH.Diagnosing and reporting early childhood caries for research purposes. Areport of a workshop sponsored by the National Institute of Dental andCraniofacial Research, the Health Resources and Services Administration,and the Health Care Financing Administration. J Public Health Dent 1999 ;192-7.

4 Davies GN. Early childhood caries-a synopsis. Community Dent OralEpidemiol 1998 ; 26(1 Suppl) : 106-16.

5 Berkowitz RJ. Causes, treatment and prevention of early childhood caries: amicrobiologic perspective. J Can Dent Assoc 2003 ; 69(5) : 304-7.

6 Ismail AI, Sohn W. A systematic review of clinical diagnostic criteria of earlychildhood caries. J Public Health Dent 1999 ; 59(3) : 171-91.

7 Davey AL, Rogers AH. Multiple types of the bacterium Streptococcus mutansin the human mouth and their intra-family transmission. Arch Oral Biol 1984 ;29(6) : 453-60.

8 Berkowitz RJ, Jones P. Mouth-to-mouth transmission of the bacteriumStreptococcus mutans between mother and child. Arch Oral Biol 1985 ;30(4) : 377-9.

9 Li Y, Caufield PW. The fidelity of initial acquisition of mutans streptococci byinfants from their mothers. J Dent Res 1995 ; 74(2) : 681-5.

10 Mattos-Graner RO, Li Y, Caufield PW, Duncan M, Smith DJ. Genotypic diversityof mutans streptococci in Brazilian nursery children suggests horizontaltransmission. J Clin Microbiol 2001 ; 39(6) : 2313-6.

11 Brodeur JM, Olivier M, Benigeri M, Bedos C, Williamson S. Étude 1998-1999sur la santé buccodentaire des élèves québecois de 5-6 ans et de 7-8 ans.Québec : Ministère de la Santé et des Services sociaux, Direction générale dela santé publique ; 2001.

12 Paquet G, Hamel D. Des alliés pour la santé des tout-petits vivant au bas del'échelle sociale. Étude longitudinale du développement des enfants duQuébec (ÉLDEQ 1999-2002) 2005 ; 3(4) : 7-8.

13 Harrison R. Oral health promotion for high-risk children: case studies fromBritish Columbia. J Can Dent Assoc 2003 ; 69(5) : 292-6.

14 Hamilton FA, Davis KE, Blinkhorn AS. An oral health promotion programmefor nursing caries. Int J Paediatr Dent 1999 ; 9(3) : 195-200.

15 Alsada LH, Sigal MJ, Limeback H, Fiege J, Kulkarni GV. Development andtesting of an audio-visual aid for improving infant oral health throughprimary caregiver education. J Can Dent Assoc 2005 ; 71(4) : 241.

16 Bruerd B, Kinney MB, Bothwell E. Preventing baby bottle tooth decay inAmerican Indian and Alaska native communities: a model for planning.Public Health Rep 1989 ; 104(6) : 631-40.

17 Porangannel L, Titley KC, Kulkarni GV. Establishing a dental home: A programfor promoting comprehensive oral health starting from pregnancy throughchildhood. Oral health 2006 ; 96(1) : 3-4.

18 Nowak AJ, Casamassimo PS. The dental home: a primary care oral healthconcept. J Am Dent Assoc 2002 ; 133(1) : 93-8.

19 Kandelman D. La dentisterie préventive de l'an 2000. L'Information Dentaire1999 ; 81(31) : 2185-89.

20 Achong RA, Briskie DM, Hildebrandt GH, Feigal RJ, Loesche WJ. Effect ofchlorhexidine varnish mouthguards on the levels of selected oralmicroorganisms in pediatric patients. Pediatr Dent 1999 ; 21(3) : 169-75.

21 Kohler B, Bratthall D. Intrafamilial levels of Streptococcus mutans and someaspects of the bacterial transmission. Scand J Dent Res 1978 ; 86(1) : 35-42.

22 Isokangas P, Soderling E, Pienihakkinen K, Alanen P. Occurrence of dentaldecay in children after maternal consumption of xylitol chewing gum, afollow-up from 0 to 5 years of age. J Dent Res 2000 ; 79(11) : 1885-9.

23 Driscoll WS. A review of clinical research on the use of prenatal fluorideadministration for prevention of dental caries. ASDC J Dent Child 1981 ;48(2) : 109-17.

24 Sa Roriz Fonteles C, Zero DT, Moss ME, Fu J. Fluoride concentrations inenamel and dentin of primary teeth after pre- and postnatal fluorideexposure. Caries Res 2005 ; 39(6) : 505-8.

25 American Academy of Pediatric Dentistry. Clinical Guideline on Infant OralHealth Care. Reference Manual 2004-2005, Chicago, 4 p.

26 Doré N, Le Hénaff D, Turcotte P. Mieux vivre avec notre enfant de lanaissance à deux ans : Guide pratique pour les mères et les pères ; Chapitresur les soins de la bouche et des dents. Québec ; 2006, p. 351-363.

27 Kowash MB, Pinfield A, Smith J, Curzon ME. Effectiveness on oral health ofa long-term health education programme for mothers with young children.Br Dent J 2000 ; 188(4) : 201-5.

28 American Academy of Pediatric Dentistry. Policy on Oral Habits. ReferenceManual 2004-2005, Chicago, 2 p.

29 Peressini S. Pacifier use and early childhood caries: an evidence-based studyof the literature. J Can Dent Assoc 2003 ; 69(1) : 16-9.

30 Limeback H, Ismail A, Banting D, DenBesten P, Featherstone J, Riordan PJ.Canadian Consensus Conference on the appropriate use of fluoridesupplements for the prevention of dental caries in children. J Can Dent Assoc1998 ; 64(9) : 636-9.

31 Swan E. Dietary fluoride supplement protocol for the new millennium. J CanDent Assoc 2000 ; 66(7) : 362.

32 American Academy of Pediatric Dentistry. Clinical Guideline on FluorideTherapy. Reference Manual 2004-2005, Chicago, 2 p.

33 Donly KJ. Fluoride varnishes. J Calif Dent Assoc 2003 ; 31(3) : 217-9.34 Almeida AG, Roseman MM, Sheff M, Huntington N, Hughes CV. Future caries

susceptibility in children with early childhood caries following treatmentunder general anesthesia. Pediatr Dent 2000 ; 22(4) : 302-6.

35 Alaki SM, Loesche WJ, da Fonesca MA, Feigal RJ, Welch K. Preventing thetransfer of Streptococcus mutans from primary molars to permanent firstmolars using chlorhexidine. Pediatr Dent 2002 ; 24(2) : 103-8.

36 American Academy of Pediatric Dentistry. Clinical Guideline on PediatricRestorative Dentistry. Chicago (IL) : American Academy of Pediatric Dentistry2004. 9 p.

37 Tinanoff N, Douglass JM. Clinical decision-making for caries management inprimary teeth. J Dent Educ 2001 ; 65(10) : 1133-42.

38 Hujoel PP, Makinen KK, Bennett CA, Isotupa KP, Isokangas PJ, Allen P, et al.The optimum time to initiate habitual xylitol gum-chewing for obtaininglong-term caries prevention. J Dent Res 1999 ; 78(3) : 797-803.

39 Cross KJ, Huq NL, Stanton DP, Sum M, Reynolds EC. NMR studies of a novelcalcium, phosphate and fluoride delivery vehicle-alpha(S1)-casein(59-79)by stabilized amorphous calcium fluoride phosphate nanocomplexes.Biomaterials 2004 ; 25(20) : 5061-9.

40 Itthagarun A, King NM, Yiu C, Dawes C. The effect of chewing gumscontaining calcium phosphates on the remineralization of artificial caries-likelesions in situ. Caries Res 2005 ; 39(3) : 251-4.

41 Reynolds EC. Remineralization of enamel subsurface lesions by caseinphosphopeptide-stabilized calcium phosphate solutions. J Dent Res 1997 ;76(9) : 1587-95.

42 Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC. Remineralization of enamelsubsurface lesions by sugar-free chewing gum containing caseinphosphopeptide-amorphous calcium phosphate. J Dent Res 2001 ; 80(12) :2066-70.

43 Tinanoff N, Daley NS, O'Sullivan DM, Douglass JM. Failure of intensepreventive efforts to arrest early childhood and rampant caries: three casereports. Pediatr Dent 1999 ; 21(3) : 160-3.

44 Tinanoff N, O'Sullivan DM. Early childhood caries: overview and recentfindings. Pediatr Dent 1997 ; 19(1) : 12-6.

45 Ministère de la Santé et des Services sociaux, Plan stratégique 2005-2010,Axe promotion et prévention, Québec, 2005, p. 27.

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Scientific Article

The dental literature clearly supports the use of pit and fissure sealants as a safe and effective, althoughunderused, treatment in caries prevention. It is best used for high caries risk populations and it requiresdiagnosis and application by trained dental personnel paying close attention to proper protocol.

Sealant application requires periodic follow-up examinations and repair to ensure its efficacy and its costeffectiveness.

»Summary

1 Dr. Charles Dixter is apediatric dentist in privatepractice in Montréal.Address correspondence to4141, rue SherbrookeOuest, suite 350Montréal (Québec) H3Z 1B8.

2 Dr. Aaron Dudkiewicz is an Assistant Professor atthe Faculty of Dentistry,McGill University. He alsomaintains a private practicein Montréal.

3 Dr. Irwin Fried is theDirector of the Division of Pediatric Dentistry andan Assistant Professor atthe Faculty of Dentistry,McGill University. He alsomaintains a private practicein Montréal.

Key Words• Dental caries

• Fissure sealants

• Pediatric dentistry

• Preventive dentistry

Pit and Fissure Sealants: An Important Adjunct in the Control of Childhood Caries

Charles Dixter, BSc, DDS, Cert. Pedo.1, Aaron Dudkiewicz, BSc, DDS, Cert. Pedo.2

Irwin Fried, DDS, MS, Cert. Pedo, FRCD(C)3

Although the occlusal surface is only one of fivecoronal tooth surfaces, it accounts for more than two-thirds of the dental caries experienced by children1.This statistic, along with the rise in dental caries inQuebec, requires that we use all available treatmentmodalities to control decay. Among these is theapplication of pit and fissure sealants into theocclusal fissures of caries-susceptible teeth thusforming a bonded protective layer preventingnutrients from reaching caries-producing bacteria2.This treatment was first reported by Cueto andBuonocore in 19673 and has been highly recom-mended in dentistry. Recent studies have showedthat after eight years about 80% of the sealedfissures had sealant retention and no caries, andanother 16% of the sealed occlusal surfaces hadpartial sealant retention and no caries. After ten yearsonly 6% of the sealed occlusal surfaces showed anycaries or restorations4. These results clearlyunderscore that sealants are a very effectivetreatment in the control of dental decay, and yet only18.5% of U.S. children aged 5-17 years had sealantson their permanent teeth3.

The task at hand is to revisit this treatment andreintegrate pit and fissure sealants into our practices.Sealants should be used for caries prevention in at-risk caries-free teeth and as therapy for incipientcarious lesions limited only to enamel5. Caries that

have extended into dentin are more appropriatelytreated with conservative preventive resinrestorations which incorporate sealants, compositeresin, or amalgam restorations1.

The teeth selected to be sealed are typically first andsecond permanent molars, pre-molars and thenprimary molars3. The caries risk assessment of boththe patient and the tooth are important determinantsof the need for sealants. The risk of caries in fissuresextends beyond early childhood and post-eruptiveage alone should not be considered a major criterionfor sealant application. The caries risk level of ourpatient population and the absence or presence offluoride programs are key determinants to beconsidered5. The indiscriminate use of sealants inlow-caries risk situations reduces the costeffectiveness of the treatment and should not bedirected to all occlusal surfaces nor to all teeth withfissures1,5. Appropriate decisions include past carieshistory, present oral hygiene, fluoride history, soundclinical examination and appropriate dentalradiographs.

Key to Sealant Success

The key factor to completing successful sealants isproper tooth isolation. Wherever possible, a rubberdam should be used. This will aid in both moisture

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control and keeping oral structures away from the teeth beingtreated. Alternatively, maintaining a dry field of operation canbe accomplished by using a four-handed dentistry techniquewhich is recommended when other methods of isolation suchas cotton rolls, dry angles or Garmers clamps are used.

Teeth being selected for sealant application should becaries–free. Both a clinical and radiographic examination arerequired. Any dentin decay present precludes the use of asealant and alternative treatment such as preventive resinrestoration, composite resin, and possibly amalgam restorationshould be considered. Enamel with suspect fissures involvingincipient enamel decay should be prepared and the suspectgrooves cleaned of all decay prior to the sealant application.Enamel preparation can be carried out by use of a slow-speedround bur, air abrasion, or a high-speed fissurotomy bur. Thispreparation of the tooth and removal of unsupported enamelhas shown to increase bond strength and retention of thesealants.

Protocol for Sealant Placement

1. Examine tooth clinically and radiographically2. Apply rubber dam, or other tooth isolation (Figure 1)3. Prepare tooth4. Reassess the presence or absence of decay5. Clean the fissures with a brush with/without pumice

6. Rinse thoroughly7. Acid etch the surface with phosphoric acid for 15–20

seconds (both permanent and primary teeth) (Figure 2)8. Rinse well for 15 seconds9. Air dry the surface thoroughly to ensure a frosty white,

chalky enamel (Figure 3)10. Where required, apply a drying agent/bonding agent

(depending on which system is used )11. Re-dry the tooth12. Apply a thin layer of sealant-tease the sealant through the

grooves with a brush or explorer (Figure 4)13. Cure the sealant for 20-30 seconds14. Check the sealant for voids or defects, if necessary add

more15. Verify the occlusion16. Where required, adjust the occlusion and polish the

sealant with a multi-fluted finishing bur17. Reevaluate the sealant at recall appointments

Sealants have shown excellent success and retention rates4.The most important cause for failure is poor tooth isolation andthe ensuing saliva contamination. Other causes of failureinclude poor tooth surface preparation and/or failure of thesealant bond resulting in microleakage. This can lead to sealantloss and the potential for overt caries6.

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Figure 1. Figure 2.

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Conclusions

Pit and fissure caries are responsible for the greatest share ofthe dental caries experience in childhood. The dental literatureclearly supports the placement of pit and fissure sealants onsurfaces judged to be at high risk or on surfaces that exhibitincipient enamel caries. The success and cost effectiveness ofsealants require that careful attention be paid to protocol as the

treatment is highly technique sensitive. This treatment, as alldental treatments, is most effective when proper recallexamination is performed and where necessary, resealing isdone to ensure the maximum protection against dental caries.

The authors wish to thank Dr. Erle Schneidman for the use ofhis photographs in the preparation of this article.

Bibliography

1 Waggoner WF, Siegal M. Pit and fissure sealant application: updating thetechnique. JADA 1996 ; 127 : 351-361.

2 Simonsen RJ. Pit and fissure sealant: review of the literature. PediatricDentistry 2002 ; 24 (5) : 393-414.

3 Primosch RE, Barr ES. Sealant use and placement techniques amongpediatric dentists. JADA 2001 ; 132 (10) : 1442-1451.

4 Wendt LK, Koch G, Birkhed D. On the retention and effectiveness of fissuresealants in permanent molars after 15-20 years: a cohort study.Community Dent Oral Epidemiol. 2001 ; 29 (4) : 302-307. [OVID].

5 Feigal RJ. The use of pit and fissure sealants. Pediatric Dentistry 2002 ;24(5) : 415-422.

6 Bryant CL. Point of care. JCDA 2005 ; 71 (6) : 417-418.

Figure 3. Figure 4.

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Scientific Article

Key Words• Early childhood caries

• Prevention

• Soothing

The Cariogenic Nature of ChildhoodBedtime Rituals

Chantal Galarneau, DMD, MSc, PhD1

Jean-Marc Brodeur, DDS, MSc, PhD2, Lise Gauvin, PhD3

Perinatal educators teach parents to develop anevening ritual to help their children go to sleep1. As aresult, mothers use a variety of bedtime strategies,which sometimes involve giving the child sugar. Thispractice increases their child’s risk for caries,particularly because salivary flow diminishes at night,reducing its buffering and cleansing effect2. Parentsare more inclined to settle for caries-causing rituals atbedtime because of their own fatigue at the end ofthe day. The goals of this article are illustrated inFigure 1: First, we provide an overview of differentbedtime rituals that mothers use, followed by adescription of cariogenic practices.

We then try to determine the extent to which caries-causing soothing rituals have become a public healthproblem by analyzing data from a study carried out in2002 in the Montérégie3 (a large region southwest ofthe island of Montréal, whose residents adequatelyrepresent the rest of the population). The study was

conducted with 776 mothers of children betweenthe ages of 15 and 18 months. Data was gatheredthough a self-administered 36-question survey.

Frequency of bedtime rituals and theircariogenicity Figure 2 shows the various ways mothers comforttheir children at bedtime. Among some of thestrategies that involve little or no cariogenic activity,four routines are the most popular with mothers:57% rock their child, 47% put on music or use amobile, 33% read a story, and 23% stay by thechild’s bedside until he falls asleep.

Twenty-nine percent of mothers expose their childrento dental caries by putting them to bed every nightwith a bottle of milk. Studies4 have shown that whenthe oral flora comes into contact with lactose withincreasing frequency and for longer periods of time,the cariogenic bacteria metabolize the lactose quickly,

Figure 1. Soothing routines used by mothers at their child’s bedtime

1 Dr. Chantal Galarneau is adental consultant at theDirection de la santépublique de laMontérégie. Address correspondence to: 1255 rue BeauregardLongueuil (Québec) J4K 2M3 or to [email protected]

2 Dr. Jean-Marc Brodeur is aprofessor at theDepartment of social andpreventive medicine and aresearcher at GRIS,Université de Montréal.

3 Dr. Lise Gauvin is aprofessor at theDepartment of social andpreventive medicine and aresearcher at GRIS,Université de Montréal,and at Centre Léa-Robacksur les inégalités socialesde santé de Montréal

Est-ce un problèmede santé publique ?

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thereby causing a risk for the development of early childhoodcaries (ECC). According to researchers4, daily use of a babybottle with cow’s milk at bedtime may be sufficient todemineralize the enamel, while its occasional use does notseem to increase the risk for ECC. Despite the efforts of dentalcare providers to raise parental awareness of the role of sugarin the development of ECC, some mothers still resort to usingsugary foods to soothe their children at bedtime: 9% give asweet treat, 9% give a highly cariogenic drink either in a cup orin a bottle that is taken directly to bed, while 2% give candy.And although these mothers use cariogenic foods to soothetheir children, most of them also use other strategies that donot involve cariogenic foods, as described in Figure 2.

Are caries-causing rituals a public health problem?Mothers use a variety of bedtime rituals that have differentlevels of cariogenicity. Figure 3 classifies mothers according tothe cariogenicity level of the methods they use.

Sugary foods known to be highly cariogenic are used in thesoothing routines of 16% of the mothers surveyed. Twenty-fivepercent of mothers do not use sugary foods but include a babybottle in their daily soothing routine. In all, a total of 41% ofmothers include caries-causing practices in their bedtimerituals. Poverty tends to lead to increased use of sugary foods.About one out of three mothers in difficult socio-economiccircumstances expose their children to highly cariogenic foodsto help them fall asleep, as compared to one out of six

mothers from wealthier backgrounds. In all, 60% of mothersfrom disadvantaged backgrounds use caries-causing soothingroutines. These statistics suggest that these cariogenic practicesare spawning a major public health problem because childrenare ingesting sugars that harm their teeth, the practices aresufficiently widespread, and they occur widely among mothersfrom disadvantaged backgrounds.

What is the role of dentists in preventing earlychildhood caries associated with soothing routines?In summary, the data speaks for itself: there is a clear need forearly intervention. Parental practices that begin in the earlystages of a child’s life forge the child’s early food preferences,and even dictate their long-term ones5,6. We believe that asdental health providers, we can help prevent ECC associatedwith caries-causing soothing routines by recommending thatour very young patients first visit the dentist as soon as theirfirst tooth erupts, or no later than their first birthday. During thisvisit, parents should be made aware of ECC and encouraged toadopt healthy soothing routines at the child’s bedtime.

However, we must be understanding with families in poorcircumstances. Their daily life is such that cariogenic practicesare well-entrenched at bedtime, and they see a real problemin stopping their soothing strategies. It is our duty to ensurethat the child is sufficiently exposed to fluoride in order tominimize the risk of ECC associated with these soothingroutines. According to Burt and Pai7, the ingestion of sugars

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Figure 2. Frequency of soothing routines used by mothers at their child’s bedtime and risk of caries in children

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represents a moderate to low risk in children with sufficientexposure to fluoride, but a high risk for those with no fluorideexposure.

Brushing with fluoride toothpaste before bedtime should berecommended, particularly when sugary foods are ingestedright before sleep. Toothbrushing dislodges dental plaque andexposes the teeth to fluoride. The introduction of fluoridetoothpaste is now recommended as soon as the first teetherupt, as this will allow the fluoride to work topically andsystemically1. For very young children at risk for dental caries, orparents who have considerable difficulty brushing theirchildren’s teeth, and for children who do not like the taste oftoothpaste, fluoride supplements or fluoride varnishes aregood ways to reduce the risk of ECC associated with soothingroutines that have caries-causing effects.

Lastly, if there is one thing we should remember aboutpreventing ECC associated with caries-causing soothingroutines, it is that we must broach the subject with our patientsat the earliest opportunity. This will give them a good start inintroducing healthy soothing techniques, and help them avoidharmful routines that are difficult to stop.

AcknowledgementsThis study was made possible by a grant from the Réseau derecherche en santé buccodentaire du Québec, the technicaland financial support of the Direction de la santé publique dela Montérégie, and a PhD scholarship awarded to Dr.Galarneau by the FRSQ.

Bibliography

1 Institut national de santé publique du Québec. Mieux vivre avec notre enfant :de la naissance à deux ans : guide pratique pour les mères et les pères.Montréal : Institut national de santé publique du Québec ; 2004-2005.

2 Ripa LW. Nursing caries: a comprehensive review. Pediatr Dent. 1988 ; Dec10(4) : 268-82.

3 Galarneau, C. Habitudes d’apaisement cariogènes utilisées par les mères aumoment de coucher leur enfant pour la nuit. Thèse de doctorat. Universitéde Montréal ; 2006.

4 Birkhed D, Imfeld T, Edwardsson S. pH changes in human dental plaquefrom lactose and milk before and after adaptation. Caries Res. 1993 ;27(1) : 43-50.

5 Rossow I, Kjaernes U, Holst D. Patterns of sugar consumption in earlychildhood. Community Dent Oral Epidemiol. 1990 Feb ; 18(1) : 12-6.

6 Grindefjord M, Dahllof G, Nilsson B, Modeer T. Stepwise prediction of dentalcaries in children up to 3.5 years of age. Caries Res. 1996 ; 30(4) : 256-66.

7 Burt BA, Pai S. Sugar consumption and caries risk: a systematic review.J Dent Educ. 2001 Oct ; 65(10) : 1017-23.

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The Cariogenic Nature of Childhood...

Figure 4.

Figure 3. Classification of mothers according to the caries-causing soothing routines used attheir child’s bedtime and their annual family income

* Does not exclude the use of other practices with potential, low or no cariogenicity.** Does not exclude the use of other practices with low or no cariogenicity

30 000$ et plus Tousmoins de 30 000$

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Scientific Article

Dietary Recommendations for HealthyTeeth in Children

Monique Julien, MSc, MPH, Dr PH

The food industry is constantly flooding the marketwith increasingly processed products. Now that wehave more knowledge and techniques to control therisk factors for caries than ever before, is it stillappropriate and/or enough to tell our children to stayaway from candy? To answer this question, we willfirst consider the foods necessary for tooth growthand briefly review the main characteristics in foodsthat contribute to cariogenicity. Lastly, we will learn torecognize the foods that do the most harm to ourteeth, so we can guide children in their own choices.

A short history of teethOur teeth have their genesis while we are in ourmother’s womb. The embryonic development of ourmouth and its neighbouring structures is closelylinked to the availability of nutrients during the entirecourse of fetal development. Because of the intensityof metabolic activity, undernutrition or any otherdeficiency in protein, calcium, and particularly,vitamin D intake, leads to irreversible changes in thestructure of developing cells. These changes can beobserved not only in tooth enamel, but also in thesalivary glands. The systemic influence of nutritioncontinues when permanent teeth are formed andeven when the last permanent molar comes in.

From birth until around the age of 6 months, a childreceives all the nutrients he needs (except vitamin D)from mother’s milk. The suction movements requiredto extract the milk provide optimal development forthe maxillaries, thus ensuring that there is sufficientspace for each tooth and that the teeth will notoverlap. Bottle-feeding does not offer this advantage.

First caries and how to prevent them Usually, caries begin to appear when the child isbetween the ages of 18 and 24 months. It isimportant to remember, however, that youngchildren will not necessarily get caries even when allthe right conditions are present. Although lactose is asugar and its concentration in mother’s milk is slightlyhigher than in cow’s milk, it is nevertheless the leastcariogenic of all sugars and does not cause caries

under normal conditions. Rather, the appearance ofcaries is precipitated by the way the young child isfed, and particularly by what is in the baby bottle andhow it is given.

As time goes on, the child’s stomach can still handleonly small meals, so they must be rich in nutrients.The child should be trained to stop his activities totake time to eat and taste the food. Avoid developingthe habit of grazing and drinking out of a bottlethroughout the day, which can have detrimentalhealth implications throughout life. For children, thebest snack is a glass of milk or fresh fruit, with orwithout cheese or yogourt. The most detrimentalelements in a child’s diet are too many drinks ofall kinds, even when given in a bottle.2

Fermentable carbohydratesThe first foods implicated in the development ofcaries contained sugar, mostly naturally occurringsucrose (dried fruit), or added sugar (cane sugar).Throughout history, the prevalence of cariesincreased with the wider availability of sugary foods.We should remember that all the populations inwhich this phenomenon was observed traditionallyhad a diet rich in starch, in the form of minimallyprocessed grain products. It appears, therefore, thatstarch was not a factor in the origin of caries.

With the industrial age, grain products were groundfiner. Individuals with fructose intolerance werereported3 to have a lower caries incidence incomparison with other healthy members of theirfamily, and sometimes no caries at all.

Today, milling is producing increasingly finer textures,and foods are subject to various cooking methods,often at very high temperatures, and sometimes withsugar. Thus processed, the starch molecules becomesmaller (dextrins) and therefore more likely to bebroken down into the glucose stage by the salivaryamylase. In addition, the cooking stage changes theproduct’s texture so that it becomes sticky aftercontact with saliva, and it adheres particularly to the

Dr. Monique Julien is aProfessor at the Department oforal health, Faculty of dentistry,Université de Montréal.Address correspondence to:C.P. 6128Succursale Centre-Ville Montréal (Québec) H3C 3J7 or [email protected]

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inter-dental spaces and beneath the gums. When bacteria canmetabolize starch and reduce it to sugar, they can produceacid, and the starch becomes a “fermentable carbohydrate”. If,furthermore, even a small quantity of sucrose is added, thecaramelization that occurs when the starch is cooked togetherwith the sugar increases the stickiness of the food’s texture tocreate a substrate that remains available longer to the existingbacteria, thus prolonging the period during which the acid isproduced and is able to attack the enamel. In a studyconducted with animals, Grenby4,5 demonstrated that addingsugar to starch makes the mixture more cariogenic thansucrose alone.

Thus we can conclude that starch, when processed in theforms commonly consumed today, is potentially cariogenic.However, traditional foods such as potatoes, rice, pasta,legumes and bread, whose texture requires thorough chewing,and which are all sources of starch, can be considered non-cariogenic, particularly because they are usually eaten withnon-carbohydrate foods (proteins and fats) that are notharmful to teeth.

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TIPS TO AVOID CARIES IN YOUNG CHILDREN

• Breastfeed the child1, even on demand, during the first six months of life.

• If the child is bottle-fed, he should be taken into the caregiver’s arms forthe feeding, and then put to bed once he falls asleep, without a bottle orsweetened pacifier.

• Outside of breastfeeding or bottle-feeding times, give a child water todrink without added sugar.

• Limit the use of fruit juice to the amount required to balance the child’sdiet. A few ounces a day are enough for a young child. Additionalamounts should be in the form of fresh fruit.

• Between bottle feedings, do not give additional bottles containing fruitjuice, fruit punch or soft drinks. Their natural acidity fostersdecalcification by erosion. This is also true for diet soft drinks, which havean acid pH.

• When the child reaches the age of six months, he should be able to drinkout of a training cup. Give him his daily juice with the training cup, whichreduces the time his teeth are in contact with the acid.

• If properly done (gradual reduction of frequency with the addition ofother foods), breastfeeding or bottle-feeding can be continued after sixmonths. At the age of one, the child should stop using the bottle and beusing the training cup. Faster swallowing reduces the contact period withthe liquid.

• Do not give teething biscuits. They provide no real benefit and are a foodof choice for bacteria.

• When the child begins to have a varied diet, do not give him cookies,candy, pastries, fruit juices, or sweet drinks during the day. Pieces of fruit,cheese, some vegetables, and small sandwiches are better for his health.

Figure 1. Figure 2.

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Acidic foodsIt is important to mention that there is a wide range of foodsreadily found in children’s diets whose inherent aciditycontributes directly to demineralization, whether or not theycontain sugar. They have a detrimental effect when ingested inconjunction with sugar.

Most fresh fruit have a sugar content of 10 to 15%, which issufficient to penetrate plaque and be used by bacteria toproduce acids. In addition, fruit is an acid food that is able todemineralize the enamel if it remains in prolonged contact withit. The erosion cases reported due to fruit consumption mainlyinvolved individuals who consumed as many as 20 fruit perday, or who sucked on acidic fruit such as oranges or lemons,which had the effect of placing their teeth in direct contact withthe acidity of the fruit. This, however, is not the case when afew fresh fruit are eaten in a day, even bananas, which have aslightly higher sugar content and stickier texture. Although thesalivary flow that comes from ingesting fresh fruit is enough toneutralize the acid contained in most fruit, eating an apple, forexample, does not clean the teeth6. A toothbrush and dentalfloss are still necessary.

One hundred percent natural fruit juices are acid and cancause erosion when drunk slowly or over long periods of time.If ingested in reasonable quantities (and as long as fresh fruitis not neglected, as per the recommendations of Canada’sfood guide) and fairly quickly, they do not cause damagebecause of their low sugar content and fluid consistency.

Fruit punch, herbal teas and diet and regular softdrinks2,7,8 are also foods that contain acids that risk erodingtooth enamel. With the exception of herbal teas, their sugarcontent is comparable to that of natural fruit juice. In thepresence of plaque, bacteria could use this sugar to produceacid (caries). Given their low nutritional value, it would bebeneficial to limit these drinks as much as possible and ensurethat they do not take the place of nutritional foods like milk(Fig. 1).

Sports drinks, while also acidic, have a higher sugar contentthan other sweet drinks and therefore have sugars thatpenetrate plaque more easily and become more readilyavailable to bacteria. In addition, because they are moreviscous, they stay in longer contact with the teeth. Drinkingsports drinks not only increases the risk of caries and erosion,it also deprives children’s bodies of important nutrients,particularly calcium. Another negative consequence of over-consumption of sports drinks is their contribution in calories.Since the body does not compensate for the additional liquidcalories by ingesting less food, the surplus liquid caloriescontribute to obesity. Recent studies9,10 have established a linkbetween obesity in children and the consumption of softdrinks.

Are certain foods harmless to teeth? It is appropriate to wonder whether the omnipresence ofcarbohydrates in our diets makes it impossible for people tohave a healthy diet these days, especially one that will notexpose the teeth to caries. Fortunately, there are many easilyidentifiable foods that do not harm teeth and also providemany advantages for physical health in general.

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Figure 3. Figure 4.

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First of all, it is important to know that all foods mainlycomposed of proteins and fats cannot be used by bacteria toproduce acid that attacks tooth enamel, even when they endup as debris between the teeth. This is case namely withmeat, game, poultry, fish and eggs, which are part of themeat and alternatives category of Canada’s food guide, andwhich have a neutral pH in the mouth. As for nuts and seeds,which are also part of this group, they are low in carbohydrates(starches) and are therefore not harmful because they containproteins and fats. In fact, if eaten after sugary foods, they tendto increase the pH level and neutralize the acid that may havebeen produced11. They are an excellent snack either eatenalone or with a piece of fruit. The last item in this group islegumes. Their composition is similar to that of nuts and seeds,and they contain no processed starch. The sugars they containare mainly oligosaccharides, so they cause more flatulencethan caries …

Secondly, taking a look at the vegetables and fruit group, somevegetables, such as corn, contain starches and/or sugars likelegumes. This is also the case with carrots, whose lowstarch/sugar content (< 5%) is not sufficient to penetrateplaque. When carrots are eaten raw or undercooked, saliva isstimulated by chewing and it easily neutralizes the small amountof acid produced. Cooked carrots are usually eaten together withpH-neutral foods from the meat and alternatives group. Earlierwe saw that fresh fruit eaten in normal quantities, (fewer than10 per day), do not present a tangible danger for teeth. There istherefore no need to deprive oneself under the assumption thatfruit is acid and contains sugars (Fig. 2).

In the milk products group, milk is the best food for healthyteeth. In fact, its content in lactose, which is the least cariogenicof all sugars, is relatively low, and it contains calcium andphosphate ions that prevent the dissolution of the enamel.Casein, a phosphoprotein in milk, adheres to the surface of theenamel and reduces its solubility. In addition, the fatscontained in milk form a thin film on the teeth that, whenadded to the effect of the casein, delay the penetration ofsugars into the plaque. Chocolate milk contains sugar (about10%) and also cocoa, a substance that has been associatedwith a reduction in bacterial growth12. Added to thecharacteristics of milk, which we have just mentioned, cocoaneutralizes the negative effects of sugar and makes chocolatemilk a non-cariogenic food.

Yogourt is a milk product with less lactose than milk, as aresult of fermentation. With or without flavouring (vanilla,lemon, etc.), it has the same characteristics as milk, which cancompensate for the added sugar. Yogourt that contains fruitjam is slightly cariogenic (owing to its consistency and sugarcontent). It is better to eat the first type of yogourt withhomemade fruit puree or frozen berry compote, or with fresh

fruit. The nutritional value of yogourt, which is good at theoutset, will be enhanced by the addition of vitamins and fibre.

Cheese not only has all the characteristics of milk, but alsousually contains more calcium and fat. Hard cheese requiresmore chewing, which increases salivary flow and,consequently, the basic substances in plaque. Eating cheesewill bathe the teeth in calcium, phosphate and bicarbonates,which increases the pH of plaque and fosters remine-ralization13,14. This is why it is good to eat cheese at the end ofa meal that contains carbohydrates15. As for ice cream, it hassome of the desirable characteristics of milk, but in lesserproportions (1/3 of the calcium, phosphate and casein). Inaddition, it contains more sugars and fats. Its soft consistencyand sugar content make it cariogenic, but at a lesser level thanother dessert foods. It is a dessert that can be given to children,preferably without a cone or sundae toppings (Fig. 3).

Now we turn to the most problematic group, grain products,which contain carbohydrates that are processed at varyingdegrees. These products vary widely, depending on how theywere processed. Whole grain cereal, eaten with milk, andeven with a small amount of sugar, does not pose a problem.More chewing may be required due to its fibre content, whichincreases salivary flow. The presence of organic phosphates(phytates) hinders the dissolution of the enamel. As for thebenefits of other types of cereals, particularly flakes producedby cooking the product at very high temperatures, they aremore doubtful because the starches have been hydrolyzed intosmaller molecules of maltose and glucose, which are sugarsthat can be used by bacteria to produce acid. However, severalstudies16 have concluded that when eaten with milk, thesetypes of grains increase the sugar content of a child’s diet butdo not appear to increase their risk for caries. However, cerealbars cannot be considered a substitute for cereals. Their chewyconsistency breaks down their starches and sugars into theform that is most readily available to bacteria. In addition, theyare rather low in protein (Fig. 4).

Whole-wheat breads and other bakery products (whitebread, bagels, pita bread and so forth) that require a lot ofchewing pose no threat to teeth. Furthermore, pasta and ricehave not been linked to caries. The starches in these productsare not reduced to large quantities of dextrin, and they areusually eaten with neutral pH foods (meat, fish, cream sauces,etc.).

Foods that harm teethGiven that the food products on the market change constantly,it is important to be able to easily spot those that may beharmful to teeth. They are often attractively presented, if not bytheir packaging than by their purported merits.

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Our knowledge of the factors associated with the cariogenicityof foods, coupled with the information on food labels (whichhave become mandatory on pre-packaged food since January2006) can help us select appropriate foods by supplying uswith the answers to a series of simple questions on thecomposition of the food and the way we plan to eat it.

The simplest and safest answer to all these questions is tochoose foods that have been processed as little as possible,i.e., milk products, vegetables and fruit, and grain products.They are the best choices we can make for a healthy diet asrecommended by Canada’s Food Guide. Most of them haveexcellent nutritional value and do not contribute the additionalcalories that few people really need. Most require little or nocooking, which makes them the perfect fast foods. The foods

that can be harmful to teeth are also harmful to our health ingeneral. They all contain fermentable carbohydrates and areconcentrated sources of energy (for example, pastries andcandy). Since they contribute few or no essential nutrients,they should be passed up, and our health will be all the betterfor it. But if we do give in to these indulgences, we should limithow often we eat them and follow the above eating guide tominimize their harmful effects.

The worst offenders are:• All types of cookies• Pastries and sticky bakery products• Acidic drinks of all sorts, diet or not. Unfortunately, they

seem to be taking the place of milk.

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QUESTIONS TO HELP DETERMINE THE CARIOGENICITY OF FOOD

• What are its ingredients? If it contains mainly fats and/or protein, it is notcariogenic.

• If it contains carbohydrates, are they in the form of sugar or starch?

• What is the food’s sugar content? For example, 10g of sugar in a productthat weighs 15g is a content of 66%.

• Does the product contain starch that has been cooked at hightemperatures? Does it also contain sugar, even in small quantities?

• Does the product have a chewy consistency, which might make it adhereto the teeth and become lodged in places where it is difficult to remove?

• Is it an acidic food that can directly cause erosion?

• Is it eaten only occasionally or frequently? Can we avoid nibbling orsipping it?

• Is it a food that is usually eaten alone? Can we eat cheese or nuts aftereating this food in order to reduce its negative effects?

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