Long-Term Treatment of Early Childhood Caries (ECC)

“Early childhood caries (ECC) is an infectious disease affecting
the primary dentition in infants and children younger than 6 years...


Introduction/Literature Review
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, 1988-1994and NHANES III, 1999-2004. 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 [5]. Numerous studies indicate that Hispanic and Native American children are among the high-risk North American populations [6]. 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][7][8]. Vertical transmission of Streptococcus mutans from caregiver to child has been demonstrated [9]. 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 [10].
Being born preterm or small for gestational age [11], 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 [14]. Complete destruction of the crown can potentially follow if the disease continues [15]. The spread of caries to primary maxillary molars is seen in moderate cases and primary mandibular molars are involved in severe stages [16].
Greater probability of subsequent caries in both the primary [17] and the permanent18 dentitions is observed among the children who experienced caries as infants or toddlers [18]. Missing anterior teeth causes poor phonetics, unpleasant appearance, hardship in sociological and psychological adjustment, and nonefficient mastication [19]. Several studies have demonstrated the considerable negative impact ECC has on the health-related quality of life of children [20].
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

Treatment objectives
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.

Treatment progress
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

Discussion
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