Bahram Ghassemi1*, Maryam Maghsoudloo2 and Sepehr Maghsoudloo3
Received: April 09, 2020; Published: June 11, 2020
*Corresponding author: Bahram Ghassemia, Department of Dentistry, Tufts University School of Dental Medicine, Boston, MA
Abbreviations: ECC: Early childhood caries; CDC: Center for Disease Control; NHANES: National Health and Nutrition Examination Surveys
Early childhood caries (ECC) is an infectious disease affecting the primary dentition in infants and children younger than 6 years of age. Despite being a largely preventable condition, ECC remains a major public health problem in both developing and developed countries, with nearly 1.8 billion new cases diagnosed each year globally [1,2]. In the United States, Center for Disease Control and Prevention (CDC) reported a 15.2% increase in the prevalence of dental caries among the nation’s youngest children, aged 2-5, comparing the findings of two National Health and Nutrition Examination Surveys, NHANES II, 1988–1994 and NHANES III, 1999–2004 [3,4]. A comprehensive epidemiological review of ECC showed that although the overall ECC prevalence varies from population to population, the socio-economically disadvantaged and minority groups are most at risk . Numerous studies indicate that Hispanic and Native American children are among the high-risk North American populations . ECC is multifactorial in its etiology and has been associated with a multitude of risk factors including inappropriate and prolonged bottle or breast feeding, frequent consumption of fermentable carbohydrates, and poor oral hygiene [6-8]. Vertical transmission of Streptococcus mutans from caregiver to child has been demonstrated . A previous study has shown that S. mutans or S. sobrinus alone may not be the only indicators for high risk of caries, but the prevalence of S. oralis in saliva may be a risk factor for increased caries activity in severe ECC forms . Being born preterm or small for gestational age , improper oral health practices, higher birth order, low fluoride in drinking water, poor saliva buffering capacity and behavioral factors are other risk factors [12,13]. The initial clinical presentation of ECC appears as white-spot lesions in the upper primary incisors along the margin of the gingiva . Complete destruction of the crown can potentially follow if the disease continues . The spread of caries to primary maxillary molars is seen in moderate cases and primary mandibular molars are involved in severe stages . Greater probability of subsequent caries in both the primary  and the permanent18 dentitions is observed among the children who experienced caries as infants or toddlers . Missing anterior teeth causes poor phonetics, unpleasant appearance, hardship in sociological and psychological adjustment, and nonefficient mastication . Several studies have demonstrated the considerable negative impact ECC has on the health-related quality of life of children .
Maintaining the primary dentition in a healthy condition has innumerable benefits, therefore dental caries management in children is pivotal. Treatment options include the restoration or extraction of the carious teeth although the importance of preventative and preservative measures cannot be overstated. Construction of orthodontic appliances such as space maintainers or prosthetic management may be needed in some cases. The following case demonstrates the use of the Nance appliance and the Hyrax expander in addition to conventional orthodontic treatment over the course of nine years in order to obtain a Class I (Angle) canine and molar relationship in a child with severe early childhood caries.
The patient was a four-year-old Hispanic female that presented with the chief complaint of “missing frontal and some back teeth having difficulty chewing and speaking.” No remarkable medical findings were noted. A facial evaluation revealed a symmetric face. She had a unilateral posterior cross bite with flush terminal deciduous molar relationship (Figure 1).
The primary objectives of treatment were to maintain the space and replace the missing anterior teeth, to obtain a Class I (Angle) canine and molar relationship, with ideal overjet and overbite, and to improve facial esthetics. The complementary treatment objectives were to establish good functional and stable occlusion, to avoid crowding and lack of space of the upper incisors and premolars, while improving smile characteristics and eliminating lip incompetence.
The treatment of choice was utilization of Nance appliance followed by conventional orthodontic treatment. After consultation with the patient and her parents, informed consent was obtained and treatment was begun. All components of the appliances were submitted to a dental laboratory for fabrication. Modified Nance appliances was fit on deciduous maxillary first molars at the age of four and a half Figure 2. The Hyrax appliance was fixed on teeth #3 and #14 when the patient was 11 years old Figure 3. The appliance’s screw was turned twice a day until proper palatal expansion was achieved Figure 4. Treatment was followed by comprehensive orthodontic treatment lasting approximately 30 months Figure 5(A&B). Immediate Essix retainers were placed at the deboning appointment Figure 6.
Excellent facial and occlusal results were achieved with the nine-year treatment rendered. The most significant changes were the correction of the unilateral cross-bite malocclusion of the deciduous teeth and prevention of mesial shifting of posterior teeth in order to achieve both a molar and canine Class I (Angle) relationship of permanent dentition. The change in appraisal posttreatment also demonstrated normal occlusion with proper alignment of anterior teeth.
Utilization of Nance appliance to avoid any further mesial shifting of posterior teeth was a pivotal part of the treatment. Reconstruction of anterior teeth helped the patient improve her speech and have a more desirable smile. Construction of a removable partial denture could be a different way to approach treatment in this case. It must be noted, however, that removable partial dentures have certain disadvantages such as presence of extra material in the mouth and increased speech difficulty for the child. They may be broken or lost easily and are ineffective to maintain space if not used properly. Since children are not competent to wear removable appliances, the ideal treatment option was a fixed non-functional appliance. The Hyrax appliance is a fixed functional appliance which was used during the treatment to correct the unilateral posterior cross bite and to expand the narrow maxillary arch. The alternative choice of appliance was the Haas expander. The latter option was not chosen due to requiring a more demanding oral hygiene regimen while offering the same treatment outcome as the Hyrax appliance in this case. Conventional orthodontic treatment was an inevitable part of the treatment plan to obtain Class I (Angle) canine and molar relationship, with ideal overjet and overbite which helps the patient to have proper tooth position in jaws, improve facial esthetics and reduce dental caries risk and future complications. Relying on conventional orthodontic treatment alone without the use of an expansion would not have been the proper approach since the Hyrax appliance helped with the expansion of the maxillary arch prior to the complete closure of the mid-palatal suture.
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