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CASE REPORT
Management of Early Childhood Caries under Conscious Sedation A Case Report
Nanjunda Swamy K.V., Sumanth M. Shetty
Abstract
The American Academy of Pediatric Dentistry (AAPD) defines early childhood caries (ECC) as the presence of one or
more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in
a child under the age of six. Untreated, ECC can irreversibly destroy the dentition, cause abscesses, and lead to serious illness. This paper reports the management of a Type2 ECC lesion in a three year old female child under conscious sedation.
Key Words: Early Childhood Caries; Caries; Conscious sedation

In the initial treatment regimen and home care instructions

included oral hygiene measures and diet counseling to the
parents.4 The parents were asked to keep a five-day food dairy,
to follow-up the diet counseling. Gross excavation of all lesions as an initial approach was done in the first sitting.5, 6 APF
Topical solution of 1.23% Fluoride was applied and temporization was done. In the second visit, the food dairy was checked
and the patient was found to be adhering to the counseled
diet changes and the oral hygiene measures were reinforced.
Under conscious sedation using Nitrous oxide and oxygen

Figure 1. Intraoral photograph showing Early childhood caries, Figure 2. Placement of Pedo-strip crowns, Figure 3. Post treatment photograph.

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The type of treatment based for each patient with ECC depends
on patients and parents motivation towards dental treatment,
the extent of the decay and the age and cooperchild. This pa-

Case Report
A three year old female child patient accompanied with her
parents were reported to the Department of Pedodontics
and Prevent with a chief complaint of decayed upper anterior teeth and pain in the molar teeth. Patient had a history of
improper oral hygiene maintenance and frequent intake of
sweets. On examination, crowns of all maxillary anteriors revealed cavities girdling the necks of teeth in brownish collar
(Figure 1). The primary molars also showed similar brownish
discoloration. Extensive cavitations with no pulpal involvement were observed. The case was diagnosed as Type 2 ECC
and a two stage treatment plan was formulated; Initial preventive therapy with strategies forand final therapeutic intervention. The success of multiple restorations may be influenced
by the childs level of cooperation during treatment. So it was
decided that conscious sedation may provide optimal conditions to perform the restorative procedures as with a less risk
potential than general anesthesia.

Johnston and Messer classify ECC into 3 patterns: a) developmental defects; b) smooth surface lesions; c) rampant caries.
Verkamp and Weerheijm use 4 stages to classify the ECC: initial, damaged, deep and traumatic lesions.1 Wyne suggested
the following classification for ECC: Type 1 ECC -mild to moderate- the existence of isolated carious lesion(s) involving molars
and / or incisors, Type 2 ECC-moderate to severe -labiolingual
carious lesions affecting maxillary incisors, with or without
molar caries depending on the age of the child and stage of
the disease, and unaffected mandiblular incisors, Type 3 ECC
severe-carious lesion affecting almost all the teeth including
the lower incisor. The condition is rampant and involves tooth
surfaces which are usually unaffected by caries.3

per reports the management of a three year old female child

patient with Type 2 ECC under conscious sedation.

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Introduction
Early childhood caries is a relatively new term that describes
rampant dental caries in infants and toddlers.1 The Early Childhood Caries (ECC) is a severe form of caries, defined in 2004
by the American Academy of Pediatric Dentistry, which affects
children of 25 years of age and which is characterized by precise topographical and clinical parameters. The decay pattern
of ECC is characteristic and pathognomonic of the condition.
The four maxillary incisors are most often affected. The lower
primary incisors are intact and the primary cuspids can be occasionally affected. In very severe cases the mandibular incisors are also affected.1 The academy also specifies that, in children younger than 3 years of age, any sign of smooth-surface
caries is indicative of early childhood caries.2

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Swamy et al
analgesia, the anterior lesions were restored by Strip-Crown
method.7 A strip crown was used and the crowns were reconstructed using composite resin (Figure 2).

I N T E R N AT I O N A L J O U R N A L O F D E N TA L C L I N I C S

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Stainless steel preformed crowns were used successfully to

restore the primary firsocclusion was checked and after the
removal of, resto interferences. Final finishing and polishing of the restoration was performed using soflex tips and a
post-operative photograph was taken (Figure 3). Immediate
recall check up was scheduled after one week followed by the
second recall check up after three months. Third month recall
showed no new lesions and the restorations were well maintained. Another round of Topical Fluoride therapy was given.
Recall check up after every six months was scheduled to track
the maintenance status of oral hygiene and diet.
Discussion
DiscusitThe premature loss or unsightly appearance of
grossly decayed primary anterior teeth (nursing bottle caries,
Early childhood caries) may physically handicap, embarrass
and psychologically traumatize a young child.8, 9 The untreated decayed teeth may cause pain and infection which results
the damage to the developing permanent tooth4 and feelings
of personal inadequacy.9 Treatment of these badly decayed
teeth will prevent pain and infection and assist the child to a
better social and emotional adjustment.10, 11 To perform treatment effectively and efficiently while instilling a positive dental attitude, the practitioner caring for a child with ECC often
must employ advanced behavior guidance technique. These
may include protective stabilization and/or sedation or general anesthesia. The success of restorations may be influenced
by the childs level of cooperation during treatment. NO/O2
analgesia was the preferred mode of sedation in this patient
as it is effective, safe and easy to administer.12
Nitrous oxide is effective to perform short and relatively painless procedures, with few, light and transitory side effects.12
Restorative treatment modalities for early childhood caries
are directly related to stage of advancement of lesions. Type
1 lesions suffice with glass ionomer or composite restorations
while Comprehensive treatment strategies for Type 2 ECC also
include Pedo strip crowns, or acrylic and/or stainless steel
crowns. Type 3 lesions require either pulpotomy/pulpectomy/
extraction followed by crowns / space maintainers / partial
or complete dentures as indicated. The placement of crowns
provides a satisfactory means of restoring anterior teeth.7, 8, 12
Acrylic jacket crowns offer excellent aesthetics, are insoluble
in oral fluids and resist surface staining.13 However, the material wears away rapidly, is expensive and the process requires
long dental appointments.7
Composite resin (tooth colored filling material) can be successfully used for full coronal coverage to crown severely damaged
primary teeth.7, 14 These composite resin crowns [Pedo strip
crowns] look just like normal teeth wear well, prevent the development of a tongue thrust and bad speech habits, prevent
the formation of fibrotic tissue with delayed permanent tooth
eruption, prevent loss of space and the child cannot loose or

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fail to wear the crown.8 Composite resin can be polished to a

smooth luster thereby decreasing plaque accumulation. This
cost effective treatment option does not require long dental
appointments and lasts the life of the primary tooth and is
thus the treatment of choice when restoring decayed primary
anterior teeth.8 Ripa has reviewed that, restorative dentistry is
expensive and by itself is not a complete cure for ECC. When
children with maxillary anterior caries were compared with
.increased risk of caries in other primary teeth by, OSullivan,16
it was found that these children are three times at greater risk
of developing molar caries than children without anterior caries. The initial preventive therapy measures will help determine the ultimate success or failure of the case by correlating
with the re-emergence of decay if any.
Conclusion
In conclusion,the treatment of such extensive lesions under
conscious sedation offers a risk-free complete oral rehabilitation in a short span of time, allowing immediate relief of pain
with only little / no cooperation from the child. However, more
importantly oral health, diet and acceptance of routine dental
care should be maintained and monitored to ensure complete
success of the treatment.
Authors Affiliations
1. Nanjunda Swamy K.V. MDS, Professor and Head, 2. Sumanth
M. Shetty MDS, Associate Professor, Department of Pedodontics, Sri Aurobindo Dental College, Indore, Madhyapradesh,
India.
References
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M, et al. Experience of dental caries and its effects on early
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2. Jin BH, Ma DS, Moon HS, Paik DMI, Hahn SH, Horowitz AM.
Early childhood caries: prevalence and risk factors in Seoul, Korea. Journal of public health dentistry. 2003;63(3):183-8.
3. Wyne AH. Early childhood caries: nomenclature and case
definition. Community dentistry and oral epidemiology.
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posttreatment levels of salivary mutans streptococci and lactobacilli in preschool children. International Journal of Paediatric Dentistry. 1999;9(2):93-8.
6. Johnsen D. Response to Horowitz: research issues in early
childhood caries. Community dentistry and oral epidemiology. 1998;26(1):82-3.
7. Croll T. Primary canine full coronal restoration: new consid-

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erations. Quintessence international. 1985;16(2):143-7.
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11. Borjian H. Removable prostheses in preschool children.

The Journal of pedodontics. 1978;2(3):246-50.
12. Ryding HA, Murphy HJ. Use of nitrous oxide and oxygen for
conscious sedation to manage pain and anxiety. J Can Dent
Assoc. 2007;73(8):711.
13. Rao S. Removable partial dentures for children. Clinical
Paedodontics, Fourth Edition, Ed Finn, SB. 1973:271-85.
14. Webber DL, Epstein NB, Wong JW, Tsamtsouris A. A method of restoring primary anterior teeth with the aid of a celluloid crown form and composite resins. Pediatric dentistry.
1979;1(4):244-5.
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Dentistry. 1988;10(4):268-82.
16. Osullivan D, Tinanoff N. Maxillary anterior caries associated with increased caries risk in other primary teeth. Journal of
dental research. 1993;72(12):1577-80.
Address For correspondence

Dr. Nanjunda Swamy K.V. MDS,

Professor and Head,
Department of Pedodontics,
Sri Aurobindo Dental College,
Indore, Madhyapradesh, India.
Email: nanju_75@rediffmail.com

2012 Volume 4 Issue 1

Source of Support: Nil
Conflict of Interest: None Declared

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