Early childhood caries

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Early childhood caries (ECC), formerly known as nursing bottle caries, baby bottle tooth decay, night bottle mouth and night bottle caries, is a disease that affects teeth in children aged between birth and 71 months. [1] [2] ECC is characterized by the presence of 1 or more decayed (non cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth. [3] ECC has been shown to be a very common, transmissible bacterial infection, usually passed from the primary caregiver to the child. [2] [4] The main bacteria responsible for dental cavities (dental caries) are Streptococcus mutans (S.mutans) and Lactobacillus . [4] There is also evidence that supports that those who are in lower socioeconomic populations are at greater risk of developing ECC. [5] [6]

Contents

Dental caries (tooth decay) as seen on a child Dental Caries Cavity 2 (cropped).JPG
Dental caries (tooth decay) as seen on a child

Aetiology

Early childhood caries (ECC) is a multifactorial disease,   with risk factors including but not limited to, cariogenic bacteria, diet practices and socioeconomic factors. [6]   Deciduous teeth begin to erupt at 6 months of age , once  visible in the oral cavity they are susceptible to tooth decay or dental caries. [1] This can result in the child experiencing severe pain, and needing extensive dental restorations or tooth extractions.

Microbial factors

The primary cariogenic bacteria involved in ECC are S. mutans and Lactobacillus. [6] The transfer of S. Mutans from mother to infant is well documented. Over time the combination of food debris and bacteria form a biofilm on the tooth surface called plaque. [2] In plaque, the cariogenic microorganisms produce lactic acid as a by-product from fermentable carbohydrates. Examples of these fermentable carbohydrates include fructose, sucrose and glucose. [6] Cariogenic bacteria thrive on these sugars and help to weaken the adjacent tooth surface by causing loss of tooth structure (minerals) due to the loss of minerals due to acid production. A poor oral care routine and a diet that is high in fermentable carbohydrates favor acidic attack in the oral cavity. This prolonged acidic exposure allows the net loss of minerals from the tooth. [6] This diminishes the strength of the tooth and is called demineralization. For the outer layer of the tooth (enamel) to reach cavitation, there is a breakdown of the enamel structure  that allows the influx of the cariogenic bacteria. As cavitation progresses into dentine, the dental caries lesion becomes more severe, and this may cause tooth pain .

Dietary factors

Diet plays a key role in the process of dental caries. The type of foods along with the frequency at which they are consumed can determine the risk  for  developing carious lesions.  Infants and young children may  consume fermentable carbohydrates, in the form of liquids such as: fruit juices, and soda pop. [1] These consumables have the potential to increase the risk of dental caries due to prolonged contact between sugars in the liquid and cariogenic bacteria on the tooth surface. Poor feeding practices without appropriate preventive measures can lead to  ECC. [1] Frequent and long duration bottle feeding, especially at night, is associated with ECC. This finding can be attributed to the fact that there is less salivary flow at night and hence less capacity for buffering and remineralization. [2] Each time a child drinks these liquids, acids attack for 20 minutes or longer. A parent's education and health awareness has a major influence on the caries experience of their child’s feeding practices, dietary habits and food choices. [1]

Socioeconomic factors

Dental caries still today, remains the most prevalent disease worldwide. [7] burdening millions of children and continuing  into adulthood with pain and potentially lower quality of life. There are several studies by Locker and Mota-Veloso reporting that there is a two-way relationship that exists between dental caries and levels of education, household income that affect quality of life and social positioning. [4] Locker suggested that the relationship between oral disease and health-related quality of life outcomes can be mediated by personal and environmental variables. More health promotion initiatives and policy-making that collaborate directly with the community to increase meeting their needs, should be implemented. [3]

While the primary etiology is due to microbial factors, it is also largely influenced by the social, behavioral and economic determinants in which children are surrounded  including living in a low income earning family. Secondly, having limited access to healthcare and education where important messages about the consumption of cariogenic foods are not being transferred to children or their parents. [6] [1] Efforts should be made to reach rural and remote communities to implement health promotion strategies to increase awareness about diet and oral hygiene.

The education, occupation and income of families also greatly affects the quality of life. Children greatly rely on their parents or guardians for help concerning their health and well-being. [7] Studies have shown that families of lower socioeconomic status are less likely to regularly attend the dentist and access preventive dental resources. ECC also has an accumulative effect for those that live in rural areas. [8]

Prevention

Early childhood caries can be prevented through the combination of the following: adhering to a healthy nutritional diet, optimal plaque removal, use of fluoridation on the tooth surface once erupted, care taken by the mother during the prenatal and perinatal period and regular dental visits. The following are recommendations to help prevent ECC.

Adequate diet

Dietary habits and the presence of cariogenic bacteria within the oral cavity are an important factor in the risk of ECC. ECC is commonly caused by bottle feeding, frequent snacking and a high sugar diet. [9]

In regards to preventing ECC through bottle feeding, it is fundamental not to allow the child to sleep using 'sippy cups' or bottles as this is a large factor contributing to baby bottle decay/caries. [7] This is highly encouraged as it prevents continuous exposure to non-milk extrinsic sugars and therefore the potential progression of caries – this means the oral cavity can return to a neutral pH and therefore decreased acidity. [1] These researches also suggest trying to introduce cups to children as they approach their first birthday and to reduce the use of a bottle. A low-sugar and high nutritional diet is recommended for both the mother and the child especially during breastfeeding, and it is also recommended to avoid frequent snacking. [9]

A 2019 Cochrane review concluded that there is a 15% drop in risk of developing ECC when mothers with infants or pregnant women are given advice on a healthy child diet and feeding practices. [10]

Optimal plaque removal

On eruption of the first primary tooth in a child, tooth brushing and cleaning should be performed by an adult. [1] This is important as the plaque that attaches to the surface of the tooth has bacteria that have the ability to cause caries (decay) on the tooth surface. It is recommended to brush children's teeth twice daily using a soft bristled, age and size appropriate toothbrush and if indicated age appropriate amount of fluoridated toothpaste. [11] It is suggested that it is suitable to brush children's teeth until they reach the approximate age of 6 years; when they will begin to develop  adequate dexterity and cognition needed for adequate brushing by themselves. It is encouraged to watch children brushing their teeth until they are competently able to brush.

Fluoride

Fluoride is a natural mineral that naturally occurs throughout the world – it is also the active ingredient of many toothpastes specifically for its remineralizing effects on enamel, often repairing the tooth surface and reducing the risk of caries. [11] The use of fluoridated toothpaste is highly recommended by dental professionals; whereby studies suggest that the correct daily use of fluoride on the dentition of children has a high caries-preventive effect and therefore has potential to prevent ECC. [8] However, it is important to use fluoridated toothpastes correctly; in children under the age of three years, a smear or rice-sized amount of fluoridated toothpaste should be used. In children between the ages of three and six, a pea-sized amount of fluoridated toothpaste should be used. The child should be monitored until they can brush well. The child should be taught to spit the toothpaste out after brushing. [1]

Pre-natal and peri-natal period

Prevention of early childhood caries begins before the baby is born; women are advised to maintain a well-balanced diet of high nutritional value during pregnancy. [9] This is important since teeth start developing before birth  if the diet is not sufficient, a  condition called developmental dental defect may occur  including enamel hypoplasia. [12] Enamel hypoplasia is a developmental defect of enamel that occurs during tooth development, mainly pre-natal or during early childhood. Teeth affected by enamel hypoplasia are at a higher risk of caries since there is an increased loss of minerals and therefore the tooth surface is able to breakdown more easily in comparison to a non-hypoplastic tooth.

Dental visits

It is recommended thar parents and caregivers take their children to a dental professional for examination at six months of age and no later than the child’s first birthday. [1] The dental professional will examine  the child’s teeth and provide recommendations to the parents or caregivers regarding the best way to prevent ECC and what actions to take. [1] Studies suggest that children who have attended visits within the first few years of life (an early preventive dental visit) potentially experience less dental related issues and incur lower dental related costs throughout their lives. [13]

Treatment

Early detection and risk assessment

The approach to managing Early Childhood Caries involves a combination of restoring or removing the decayed teeth. Dentists also focus heavily on early intervention strategies, which include the application of protective fluoride treatments directly to the teeth, guiding families through proper dental care routines, and offering nutritional advice to prevent further decay. During the initial dental visit, which plays a pivotal role, the dentist evaluates the child's dietary and oral hygiene habits. By doing so, they can identify behaviours that may contribute to tooth decay. These assessments take into account the child’s age and their social, behavioural, and medical background.

Tailored treatment based on caries risk

For children identified as having a low risk of tooth decay, the focus is on monitoring and preventive care rather than immediate dental treatments. Regular dental visits are encouraged to identify any new signs of decay early on. Early stages of decay (white spots) and initial enamel damage are managed with non-invasive preventive methods and are closely watched over time. High-risk children typically need more intensive treatment. This may include early restorative work to repair and address any existing decay to prevent further deterioration of the teeth. Since ECC affects children under the age of 5 years, dental treatments under general anesthesia may be necessary in select cases. [14] However, there's a notable concern with this method: despite the initial success of the treatment, decay can recur, with some cases reported as early as 6 months post-treatment. [15]

Silver diamine fluoride

In managing Early Childhood Caries, dental professionals also have Silver Diamine Fluoride (SDF), a dual-action liquid that combats tooth decay. SDF combines the bacteria-battling power of silver with the tooth-strengthening properties of fluoride. This solution is brushed directly onto the affected areas, eliminating the immediate need for drilling and making it a less invasive treatment option.

SDF is known for its cost-effectiveness and ease of application. It effectively halts decay but does not rebuild the tooth structure; hence, a tooth treated with SDF may still require a filling or crown to restore its shape and function. One notable downside is the black staining of the decayed areas after SDF application. Despite this, the discoloration can be masked with a white filling material, a cosmetic concern that may be less significant for baby teeth that will eventually be replaced by permanent teeth.

The quick application process of SDF makes it particularly beneficial for young children and patients who find it difficult to remain still during dental procedures, potentially reducing the need for sedation or general anesthesia. However, the usage of SDF is not without debate. Further high-quality research is required to fully understand its effectiveness, necessity, and potential adverse effects. [16] [17] This consideration gains importance in the context of FDA advisories regarding the use of general anesthetics and sedation in young children. [18] Nonetheless, the American Dental Association endorses SDF as an effective means to manage dental decay in a conservative manner. [19]

Stainless steel crowns

When it comes to repairing teeth affected by Early Childhood Caries, the extent of tooth decay will guide the choice of treatment. For moderate to severe decay, stainless steel crowns are a common option. These crowns are ready-made and can be tailored to fit over a child’s primary molar. The crowns are then fixed in place to restore the tooth. An alternative method for fitting these crowns is the Hall Technique, which does not require the decayed parts of the tooth to be removed first.

Atraumatic restorative treatment (ART)

For less invasive treatments, Atraumatic Restorative Treatment (ART) is an option. ART involves the partial removal of decayed tooth material with hand tools and sealing the cavity with a bonding material. This approach is particularly suitable for young patients because it is quicker and less likely to cause distress. It’s also beneficial when maintaining a tooth is important for spacing in the mouth, paving the way for permanent teeth to erupt properly in the future. However, it’s important to note that while ART is a valuable treatment, especially in areas where dental facilities are limited, studies suggest that fillings done with ART may be more prone to failure compared to those done with more traditional methods. Despite this, ART remains a recommended practice for managing tooth decay in young children under challenging conditions. [20]

Related Research Articles

<span class="mw-page-title-main">Toothpaste</span> Substance to clean and maintain teeth

Toothpaste is a paste or gel dentifrice used with a toothbrush to clean and maintain the aesthetics and health of teeth. Toothpaste is used to promote oral hygiene: it is an abrasive that aids in removing dental plaque and food from the teeth, assists in suppressing halitosis, and delivers active ingredients to help prevent tooth decay and gum disease (gingivitis). Owing to differences in composition and fluoride content, not all toothpastes are equally effective in maintaining oral health. The decline of tooth decay during the 20th century has been attributed to the introduction and regular use of fluoride-containing toothpastes worldwide. Large amounts of swallowed toothpaste can be poisonous. Common colors for toothpaste include white and blue.

<span class="mw-page-title-main">Tooth enamel</span> Major tissue that makes up part of the tooth in humans and many animals

Tooth enamel is one of the four major tissues that make up the tooth in humans and many animals, including some species of fish. It makes up the normally visible part of the tooth, covering the crown. The other major tissues are dentin, cementum, and dental pulp. It is a very hard, white to off-white, highly mineralised substance that acts as a barrier to protect the tooth but can become susceptible to degradation, especially by acids from food and drink. In rare circumstances enamel fails to form, leaving the underlying dentin exposed on the surface.

<span class="mw-page-title-main">Tooth decay</span> Deformation of teeth due to acids produced by bacteria

Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating. Complications may include inflammation of the tissue around the tooth, tooth loss and infection or abscess formation.

<span class="mw-page-title-main">Water fluoridation</span> Addition of fluoride to a water supply to reduce tooth decay

Water fluoridation is the controlled adjustment of fluoride to a public water supply solely to reduce tooth decay. Fluoridated water contains fluoride at a level that is effective for preventing cavities; this can occur naturally or by adding fluoride. Fluoridated water operates on tooth surfaces: in the mouth, it creates low levels of fluoride in saliva, which reduces the rate at which tooth enamel demineralizes and increases the rate at which it remineralizes in the early stages of cavities. Typically a fluoridated compound is added to drinking water, a process that in the U.S. costs an average of about $1.26 per person-year. Defluoridation is needed when the naturally occurring fluoride level exceeds recommended limits. In 2011, the World Health Organization suggested a level of fluoride from 0.5 to 1.5 mg/L, depending on climate, local environment, and other sources of fluoride. Bottled water typically has unknown fluoride levels.

<span class="mw-page-title-main">Fluorine deficiency</span> Medical condition

Fluoride or fluorine deficiency is a disorder which may cause increased dental caries and possibly osteoporosis, due to a lack of fluoride in diet. Common dietary sources of fluoride include tea, grape juice, wine, raisins, some seafood, coffee, and tap water that has been fluoridated. The extent to which the condition truly exists, and its relationship to fluoride poisoning has given rise to some controversy. Fluorine is not considered to be an essential nutrient, but the importance of fluorides for preventing tooth decay is well-recognized, despite the effect is predominantly topical. Prior to 1981, the effect of fluorides was thought to be largely systemic and preeruptive, requiring ingestion. Fluoride is considered essential in the development and maintenance of teeth by the American Dental Hygienists' Association. Fluoride incorporates into the teeth to form and harden teeth enamels. This makes the teeth more acid resistant, as well as more resistant to cavity forming bacteria. Caries-inhibiting effects of fluoride were first noticed 1902, when fluoride in high concentrations was found to stain teeth and prevent tooth decay.

<span class="mw-page-title-main">Dental abrasion</span> Medical condition

Abrasion is the non-carious, mechanical wear of tooth from interaction with objects other than tooth-tooth contact. It most commonly affects the premolars and canines, usually along the cervical margins. Based on clinical surveys, studies have shown that abrasion is the most common but not the sole aetiological factor for development of non-carious cervical lesions (NCCL) and is most frequently caused by incorrect toothbrushing technique.

<i>Streptococcus mutans</i> Species of bacterium

Streptococcus mutans is a facultatively anaerobic, gram-positive coccus commonly found in the human oral cavity and is a significant contributor to tooth decay. It is part of the "streptococci", an informal general name for all species in the genus Streptococcus. The microbe was first described by James Kilian Clarke in 1924.

<span class="mw-page-title-main">Fluoride therapy</span> Medical use of fluoride

Fluoride therapy is the use of fluoride for medical purposes. Fluoride supplements are recommended to prevent tooth decay in children older than six months in areas where the drinking water is low in fluoride. It is typically used as a liquid, pill, or paste by mouth. Fluoride has also been used to treat a number of bone diseases.

<span class="mw-page-title-main">Dental fluorosis</span> Medical condition

Dental fluorosis is a common disorder, characterized by hypomineralization of tooth enamel caused by ingestion of excessive fluoride during enamel formation.

<span class="mw-page-title-main">Tooth brushing</span> Act of scrubbing teeth with a toothbrush

Tooth brushing is the act of scrubbing teeth with a toothbrush equipped with toothpaste. Interdental cleaning can be useful with tooth brushing, and together these two activities are the primary means of cleaning teeth, one of the main aspects of oral hygiene. The recommended amount of time for tooth brushing is two minutes.

<span class="mw-page-title-main">Dental public health</span>

Dental Public Health (DPH) is a para-clinical specialty of dentistry that deals with the prevention of oral disease and promotion of oral health. Dental public health is involved in the assessment of key dental health needs and coming up with effective solutions to improve the dental health of populations rather than individuals.

<span class="mw-page-title-main">Oral hygiene</span> Cleaning the mouth by brushing the teeth and cleaning in between the teeth

Oral hygiene is the practice of keeping one's oral cavity clean and free of disease and other problems by regular brushing of the teeth and adopting good hygiene habits. It is important that oral hygiene be carried out on a regular basis to enable prevention of dental disease and bad breath. The most common types of dental disease are tooth decay and gum diseases, including gingivitis, and periodontitis.

<span class="mw-page-title-main">Fluoride varnish</span> Highly concentrated form of fluoride

Fluoride varnish is a highly concentrated form of fluoride which is applied to the tooth's surface, by a dentist, dental hygienist or other health care professional, as a type of topical fluoride therapy. It is not a permanent varnish but due to its adherent nature it is able to stay in contact with the tooth surface for several hours. It may be applied to the enamel, dentine or cementum of the tooth and can be used to help prevent decay, remineralise the tooth surface and to treat dentine hypersensitivity. There are more than 30 fluoride-containing varnish products on the market today, and they have varying compositions and delivery systems. These compositional differences lead to widely variable pharmacokinetics, the effects of which remain largely untested clinically.

<span class="mw-page-title-main">Remineralisation of teeth</span>

Tooth remineralization is the natural repair process for non-cavitated tooth lesions, in which calcium, phosphate and sometimes fluoride ions are deposited into crystal voids in demineralised enamel. Remineralization can contribute towards restoring strength and function within tooth structure.

<span class="mw-page-title-main">Enamel hypoplasia</span> Medical condition

Enamel hypoplasia is a defect of the teeth in which the enamel is deficient in quantity, caused by defective enamel matrix formation during enamel development, as a result of inherited and acquired systemic condition(s). It can be identified as missing tooth structure and may manifest as pits or grooves in the crown of the affected teeth, and in extreme cases, some portions of the crown of the tooth may have no enamel, exposing the dentin. It may be generalized across the dentition or localized to a few teeth. Defects are categorized by shape or location. Common categories are pit-form, plane-form, linear-form, and localised enamel hypoplasia. Hypoplastic lesions are found in areas of the teeth where the enamel was being actively formed during a systemic or local disturbance. Since the formation of enamel extends over a long period of time, defects may be confined to one well-defined area of the affected teeth. Knowledge of chronological development of deciduous and permanent teeth makes it possible to determine the approximate time at which the developmental disturbance occurred. Enamel hypoplasia varies substantially among populations and can be used to infer health and behavioural impacts from the past. Defects have also been found in a variety of non-human animals.

<span class="mw-page-title-main">Dentistry for babies</span>

Dentistry for Babies is a branch of Pediatric dentistry related to the dental treatment provided to children from birth to around 36 months of age, aiming to maintain or re-establish a good oral health status, at the same time as it creates a positive attitude of parents and children about Dentistry. Although concerns about dental treatment directed to babies have been reported at the beginning of the twentieth century, only recently has the dental community started to focus on this area of Dentistry, due to the high dental caries (decay) prevalence observed in young children. The first setting for providing dental care exclusively to babies started in 1986, at Londrina's State University (Brazil), changing the concept from early treatment of carious lesions and their consequences to early educative-preventive attention. These concepts were disseminated throughout the entire country introducing new clinics with a similar philosophy such as the Baby Clinic of Araçatuba Dental School, São Paulo State University (UNESP), and also abroad.

<span class="mw-page-title-main">Tooth pathology</span> Medical condition

Tooth pathology is any condition of the teeth that can be congenital or acquired. Sometimes a congenital tooth disease is called a tooth abnormality. These are among the most common diseases in humans The prevention, diagnosis, treatment and rehabilitation of these diseases are the base to the dentistry profession, in which are dentists and dental hygienists, and its sub-specialties, such as oral medicine, oral and maxillofacial surgery, and endodontics. Tooth pathology is usually separated from other types of dental issues, including enamel hypoplasia and tooth wear.

Silver diammine fluoride (SDF), also known as silver diamine fluoride in most of the dental literature, is a topical medication used to treat and prevent dental caries and relieve dentinal hypersensitivity. It is a colorless or blue-tinted, odourless liquid composed of silver, ammonium and fluoride ions at a pH of 10.4 or 13. Ammonia compounds reduce the oxidative potential of SDF, increase its stability and helps to maintain a constant concentration over a period of time, rendering it safe for use in the mouth. Silver and fluoride ions possess antimicrobial properties and are used in the remineralization of enamel and dentin on teeth for preventing and arresting dental caries.

The dental care in adolescent Australians is overall good. Studies have shown that the majority of the children in some regions of Australia are receiving the dental care that they need. However, other studies have shown that the children and young adults still encounter poor quality dental care, and some do not have access to a dentist due to financial barriers. Children in the lower income groups were the most likely to not receive the dental care they needed because of the cost of the treatment. There are several things that the adolescents can do in order to stay proactive in healthy dental hygiene. Young Australians today have less tooth decay because of fluoride. Natural fluoride found in water has significantly increased the dental health of the adolescents, and decreased the tooth-aches. For those that do not have access to water with fluoride due to the area in which they live in, they can use alternatives such as toothpaste that does contain fluoride.

Topical fluorides are fluoride-containing drugs indicated in prevention and treatment of dental caries, particularly in children's primary dentitions. The dental-protecting property of topical fluoride can be attributed to multiple mechanisms of action, including the promotion of remineralization of decalcified enamel, the inhibition of the cariogenic microbial metabolism in dental plaque and the increase of tooth resistance to acid dissolution. Topical fluoride is available in a variety of dose forms, for example, toothpaste, mouth rinses, varnish and silver diamine solution. These dosage forms possess different absorption mechanisms and consist of different active ingredients. Common active ingredients include sodium fluoride, stannous fluoride, silver diamine fluoride. These ingredients account for different pharmacokinetic profiles, thereby having varied dosing regimes and therapeutic effects. A minority of individuals may experience certain adverse effects, including dermatological irritation, hypersensitivity reactions, neurotoxicity and dental fluorosis. In severe cases, fluoride overdose may lead to acute toxicity. While topical fluoride is effective in preventing dental caries, it should be used with caution in specific situations to avoid undesired side effects.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 Policy on early childhood caries (ECC): Consequences and preventive strategies. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:88-91.https://www.aapd.org/globalassets/media/policies_guidelines/p_eccconsequences.pdf
  2. 1 2 3 4 Fejerskov O, Edwina A, Kidd M. Dental Caries: The Disease and its Clinical Management. 2nd ed. Oxford; Ames, Iowa: Blackwell Munksgaard;2008.
  3. 1 2 Locker, David (2007). "Disparities in oral health‐related quality of life in a population of Canadian children". Community Dentistry and Oral Epidemiology. 35 (5): 348–356. doi:10.1111/j.1600-0528.2006.00323.x. PMID   17822483.
  4. 1 2 3 Mota-Veloso, Isabella; Soares, Maria Eliza C.; Alencar, Bruna Mota; Marques, Leandro Silva; Ramos-Jorge, Maria Letícia; Ramos-Jorge, Joana (2016-01-01). "Impact of untreated dental caries and its clinical consequences on the oral health-related quality of life of schoolchildren aged 8–10 years". Quality of Life Research. 25 (1): 193–199. doi:10.1007/s11136-015-1059-7. ISSN   1573-2649. PMID   26135023. S2CID   19164652.
  5. ↑ Dülgergil, Çoruht; Dalli, Mehmet; Hamidi, Mehmetmustafa; Çolak, Hakan (2013). "Early childhood caries update: A review of causes, diagnoses, and treatments". Journal of Natural Science, Biology and Medicine. 4 (1): 29–38. doi: 10.4103/0976-9668.107257 . PMC   3633299 . PMID   23633832.
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  7. 1 2 3 Seminario, AL, Ivančaková R. Early childhood caries. Acta medica [Internet]. 2003 May;46(3):91-94. Retrieved from: ftp://orbis.lfhk.cuni.cz/Acta_Medica/2003/AM3_03.pdf
  8. 1 2 Twetman S. Caries prevention with fluoride toothpaste in children: an update. Eur Arch Paediatr Dent [Internet]. 2009 Sep 1;10(3):162-8. Available from: http://go.galegroup.com/ps/anonymous?p=AONE&sw=w&issn=18186300&v=2.1&it=r&id=GALE%7CA227281634&sid=googleScholar&linkaccess=fulltext&authCount=1&isAnonymousEntry=true
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  10. ↑ Riggs, Elisha; Kilpatrick, Nicky; Slack-Smith, Linda; Chadwick, Barbara; Yelland, Jane; Muthu, M S; Gomersall, Judith C (2019-11-20). Cochrane Oral Health Group (ed.). "Interventions with pregnant women, new mothers and other primary caregivers for preventing early childhood caries". Cochrane Database of Systematic Reviews. 2019 (11). doi:10.1002/14651858.CD012155.pub2. PMC   6864402 . PMID   31745970.
  11. 1 2 Colgate Australia. Dental fluoride - what is fluoride? [Internet]. Colgate-Palmolive Company; 2017. Available from: http://www.colgate.com.au/en/au/oc/oral-health/basics/fluoride/article/what-is-fluoride
  12. ↑ Caufield, P.W.; Li, Y.; Bromage, T.G. (2012). "Hypoplasia-associated Severe Early Childhood Caries – A Proposed Definition". Journal of Dental Research. 91 (6): 544–550. doi:10.1177/0022034512444929. PMC   3348067 . PMID   22529242.
  13. ↑ Savage, Matthew F.; Lee, Jessica Y.; Kotch, Jonathan B.; Vann, William F. (2004). "Early Preventive Dental Visits: Effects on Subsequent Utilization and Costs". Pediatrics. 114 (4): e418–e423. doi:10.1542/peds.2003-0469-f. PMID   15466066. S2CID   14276166.
  14. ↑ Weninger, Alyssa; Seebach, Erica; Broz, Jordyn; Nagle, Carol; Lieffers, Jessica; Papagerakis, Petros; Da Silva, Keith (2022-01-06). "Risk Indicators and Treatment Needs of Children 2–5 Years of Age Receiving Dental Treatment under General Anesthesia in Saskatchewan". Dentistry Journal. 10 (1): 8. doi: 10.3390/dj10010008 . ISSN   2304-6767. PMC   8775244 . PMID   35049606.
  15. ↑ Amin, M.; Nouri, R.; ElSalhy, M.; Shah, P.; Azarpazhooh, A. (2015-01-27). "Caries recurrence after treatment under general anaesthesia for early childhood caries: a retrospective cohort study". European Archives of Paediatric Dentistry. 16 (4): 325–331. doi:10.1007/s40368-014-0166-4. ISSN   1818-6300. PMID   25619862. S2CID   256369402.
  16. ↑ Crystal, Yasmi; Niederman, Richard (Jan 2019). "Evidence-Based Dentistry Update on Silver Diamine Fluoride". Dental Clinics of North America. 63 (1): 45–68. doi:10.1016/j.cden.2018.08.011. PMC   6500430 . PMID   30447792.
  17. ↑ Horst, Jeremy; Ellenikiotis, Hellene; UCSF Silver Caries Arrest Committee; Milgrom, Peter (Jan 2016). "UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications, and Consent". Journal of the California Dental Association. 44 (1): 16–28. doi:10.1080/19424396.2016.12220962. PMC   4778976 . PMID   26897901.
  18. ↑ U.S. Food &Drug Administration (18 June 2019). "FDA Drug Safety Communication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women". Food and Drug Administration . Retrieved 21 February 2020.
  19. ↑ American Dental Association Center for Evidence-Based Dentistry. "Nonrestorative Treatments for Carious Lesions Clinical Practice Guideline" . Retrieved 21 February 2020.
  20. ↑ Dorri, Mojtaba; Martinez-Zapata, Maria José; Walsh, Tanya; Marinho, Valeria Cc; Sheiham Deceased, Aubrey; Zaror, Carlos (December 28, 2017). "Atraumatic restorative treatment versus conventional restorative treatment for managing dental caries". The Cochrane Database of Systematic Reviews. 12 (3): CD008072. doi:10.1002/14651858.CD008072.pub2. ISSN   1469-493X. PMC   6486021 . PMID   29284075.
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