home

  Case Study One - Milly  **Description of patient** Milly is 5 and 1/2 years old and you are seeing her for the first time. She is going to be a flower girl in a wedding in a few weeks and her mother wants the 'aesthetics' of her front teeth improved.

**Clinical presentation**
 * All deciduous teeth present (maxillary and mandibular arch E to E)
 * The maxillary anterior teeth (52,51,61,62) and mandibular first molar (84) are affected by caries
 * Maxillary (54 and 64) and mandibular first molars (74 and 84) are affected by incipient lesions
 * Frosty, dull and white appearance therefore could be active rampant caries

**Characteristics of bottle induced early childhood caries (which can also be seen in Milly's case):**
 * Rampant caries (multiple active carious lesions, usually including caries free surfaces) affecting the maxillary anterior teeth
 * Lesions appear later on posterior teeth, both the maxillary and mandibular first primary molars
 * Canines are affected less than first molars because later eruption
 * Mandibular anterior teeth are unaffected because the salivary flow and the position of the tongue

<span style="display: block; font-family: Arial,Helvetica,sans-serif;">**Etiology of the clinical problem** <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Early childhood caries- Bottle caries When infants fall asleep with a bottle containing a liquid other than water (e.g milk or juice), the liquid accumulates around the maxillary incisors (Muthu & Sivakumar, 2009). The sucrose contained within the milk provides cariogenic substrate for cariogenic bacteria - mutans streptococci (Schroten & Wirth, 2007)
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Extensive periods of exposure, usually held to at the palatal surfaces of the maxillary anterior teeth up to 8 hours, to cariogenic substrate such as milk, fermentable carbohydrate and drinks containing vitamin C from a feeding bottle.

Ecc generally follows tooth eruption patterns excluding the mandibular incisors as these are protected from the lower lip and are continually bathed in saliva from the submandibular and sublingual glands. Therefore, carious lesions develop on As, Bs, Ds, Cs followed by Es. (Berg & Slayton, 2009)

<span style="display: block; font-family: Arial,Helvetica,sans-serif;">**Factors which may have contributed to the situation - Duncan to expand**
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Frequently snacking on cariogenic foods and drinks between meals
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">The use of feeding cups and sipper bottles constantly
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">The bottle is frequently used to pacify infant/children to sleep
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Low salivary flow at night, decline in buffering capacity
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Hyposalivation
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Prolonged breastfeeding ( Darby & Walsh, 2010)
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Parental history especially the mother of active and untreated caries
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Poor oral hygiene
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Malignant tumours treatment (causes acute reduction in salivary flow)

<span style="display: block; font-family: Arial,Helvetica,sans-serif;">**Further information you would/might need to help arrive and a diagnosis and aid in treatment planning**
 * More research required**

Provide further DHE to the parent to prevent the occurence of carious on Milly's permanent teeth and prevent occurence of ECC on any other younger siblings which Milly may have (Schroten & Wirth, 2007).
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Diet diary
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Radiographs to see the extension of the caries and lesions
 * Fluoride exposure

Treatment plan which reflects a holistic approach to the care of the patient
 * Restorative materials for patient's needs and concerns** Consider risk and aesthetics
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Stopping the habit by eliminating the bottle habit by gradually decreasing the amount of sugar in the bottle, for example diluting with water.
 * Introduce training cup instead of bottle. Ensure trainer cup does not have a valve.
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Dietary advice regarding feeding bottle habit
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Duraphat application once every 3 months
 * Oral health education to alter oral health behaviour.
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Maybe brush twice daily with adult toothpaste (1000ppm). Provide mother with 1000ppm tooth paste as Milly is almost 6 y.o.
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Restorations: Composite resin to restore the maxillary anterior teeth and glass ionomer restorations could be considered for the posterior teeth??
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Extractions may be needed during the extension of the caries
 * <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Educating the parents and giving them advice - acknowledge that teeth will exofliate and permanent teeth will erupt. Explain to parent that permanent teeth may appear discoloured in comparison to deciduous teeth.
 * Provide mother with 1000ppm tooth paste as Milly is almost 6 y.o.
 * Treatment under general anesthesia is often required for small children
 * Explain further consequences of diesease - not only impacts on the oral cavity but may also lead to slower growth rate due to poorer eating habits and experiencing pain (Muthu, 2009)

<span style="display: block; font-family: Arial,Helvetica,sans-serif;">**Provides an evidence base for their diagnosis and treatment planning** A systematic review in the Cochrane library by Davies et al (2005), indicated that a multi-stage intervention involving oral hygiene practices can alter oral health behaviour. The intervention included, brushing with fluoridated toothpaste, use of an appropriate trainer cup and drinking less sugary drinks. There were two groups in the review, an intervention and a control group. The authors reported a decrease in ECC between the intervention group and the control group.


 * More references required**

<span style="display: block; font-family: Arial,Helvetica,sans-serif;">References

<span style="display: block; font-family: Arial,Helvetica,sans-serif;">Cameron A.C, Widmer R.P, 2008, Handbook of Pediatric Dentistry 3rd Edn, Mosby Elsevier, Canberra, Australia. <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Berg J & Slayton R, 2009, Early Chilhood Oral Health, Wiley Blackwell, USA

<span style="display: block; font-family: Arial,Helvetica,sans-serif;">Kidd E, 2005, Essentials of dental caries 3rd Edn, Oxford, United States. <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Muthu M & Sivakumar N, 2009, Pediatric Dentistry - Principles and Practice, Elsevier, Delhi, India <span style="display: block; font-family: Arial,Helvetica,sans-serif;">Darby M & Walsh M, 2007, Pediatric Infectious Diseases Revisted, Birkhauser Verlay, Basel, Switzerland.