NURSING

BOTTLE
CARIES AND
RAMPANT
CARIES

CONTENTS
NURSING BottlE CARIES

INtroduction
Terminologies and Definitions
RAMPANT CARIES
Classification
Etiological agents
Clinical features
EARLY CHILDHOOD CARIES
DEFINITION
ETIOLOGY
CLINICAL FEATURES
DIAGNOSIS
Treatment
prevention

Introduction
Acc. To SHAFERS, dental caries is
an irreversible microbial disease
of calcified tissues of the
teeth,characterized by
demineralization of inorganic
portion and destruction of
organic portion of the tooth.

NURSING BOTTLE
CARIES

Terminologies and definitions

Winter et al,1960
Nursing caries is a unique pattern of dental
decay in young children due to prolonged nursing
habit.
Kroll et al,1967
Nursing bottle mouth is a syndrome
characterized by a severe caries pattern beginning
with the maxillary anterior teeth in a healthy bottle
fed infant or toddler
Shelton et al,1977
Nursing bottle syndrome is a devastating
condition that may render young children dentally
crippled.
Other names are Bottle propping caries,Labial

TERMINOLOGIES
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NURSING CARIES- WINTER ET AL, 1968

NURSING BOTTLE MOUTH- KROLL ET AL,1967
NURSING BOTTLE SYNDROME- SHELTON ET AL,1977
BABY BOTTLE CARIES-DILEY ET AL,1980
BABY BOTTLE MOUTH-CROLL,1984
NURSING BOTTLE CARIES-TSAMTSOURIS,1986
BABY BOTTLE TOOTH DECAY-MIM KELLY ET AL,1987
MILK BOTTLE SYDROME-RIPA,1988
EARLY CHILDHOOD CARIES-DAVIES,1998

RAMPANT CARIES

1)CLASSIFICATION
1)Based on anatomic site

Crown caries

PIT AND
FISSURE
CARIES

SMOOTH
SURFACE
CARIES

Root caries

1)Based on progression of the lesion

PROGRESSIVE CARIES

ARRESTED CARIES

RAPIDLY
PROGRESSING
NURSING CARIES

RADIATING
CARIES

SLOWLY
PROGRESSING

Based on virginity of lesion

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Primary caries
Secondary caries
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Based on chronology

Early childhood caries

Adult caries
Adolescent caries

Based on type of dentition

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Caries in primary dentition

Caries in mixed dentition
Caries in permanent dentition

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BASED ON SEVERITY
INCIPIENT CARIES
HIDDEN CARIES
CAVITATIONS

ETIOLOGY
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1.)Salivary deficiency
Due to radiation therapy
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Xerostomia
2.)Feeding habits
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Feeding with sweetened milk
in the night
l Pacifiers
3)Diet
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Composed of sugary foods

CLINICAL APPEARANCE
Pattern: primary dentition
related to order of
eruption
Mandibular incisors are most resistant

INITIAL LESION:
Labial surface of maxillary incisors
Whitish area of decalcification/pitting of
enamel surface

EARLY CHILDHOOD CARIES

Acc. To DAVIES,1998
It is a complex disease
involving maxillary primary
incisors within a month after
eruption and spread rapidly to
involve other primary teeth.

CLASSIFICATION
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Type 1- MILD TO
MODERATE ECC
Isolated lesions
involving molars and
incisors
Cause is a combination
of cariogenic semisolid
food and poor oral
hygiene
Found commonly in 2-5
yr.

Type 2- MODERATE
TO SEVERE ECC
Labio lingual
carious lesions
involving maxillary
incisors,
with/without molar
involvement.
Etiology is feeding
bottle or at will
brEast feeding and
poor oral hygiene
Occurs after
st

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Type 3- Severe ECC

Affects all teeth
including mandibular
incisors
Implicated cause is a
combination of
cariogenic diet and poor
oral hygiene
Rapidly prOgressing
condition
Involves the surfaces
that are usually
considered caries
resistant.

ETIOLOGY
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Pathologic microorganisms
Substrate(fermentable carbohydrates)
Host
Time
Other predisposing factors

PATHOLOGIC
MICROORGANISM
l STREPTOCOCCUS
MUTANS- main microbe
that colonizes teeth after it
erupts in oral cavity.
l It is transmitted to infants
mouth through mother.
l It is more virulent because- it colonizes the teeth
- it produces large
amount of acid
- it produces large
amount of extracellular
polysaccharides that favour
plaque formation.

CARBOHYDRATES
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Carbohydrates are converted

into dextrans by microorganisms
In infants & toddlers, the main
sources of fermentable
carbohydrates are:
i. Bovine milk or infant
formulas
ii. Human milk (breastfeeding at will)
iii. Fruist juices & other sweet
liquids
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iv. Sweet syrups like vitamin
preparations
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v. Pacifiers dipped in honey
or sugar solution
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vi. Chocolates or other sweet

HOST
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Teeth act as host for

microorganisms
Hypomineralisation or
hypoplasia of teeth
increases the
susceptibility of child to
caries
Thin enamel in primary
teeth is one of the
reasons for early spread
of lesions
Developmental grooves
also may act as plaque
retentive areas.

TIME
More the time child
sleeps with bottle in the
mouth the higher is the
risk of caries because
the salivary flow and the
swallowing
reflex
decrease, thus providing
more
time
for
accumulation
of
carbohydrates in the
mouth which are acted
upon by microbes to
produce acid leading to
caries.

OTHER PREDISPOSING FACTORS

Overindulgence of parent
Crowded homes
Child who has less sleep
Malnutrition
Low weight infants
(<2500 gms)

CLINICAL FEATURES
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Maxillary central incisors: facial,

lingual,mesial,distal
Maxillary lateral incisors: facial,lingual,
mesial, distal
Maxillary 1st molars : facial, lingual, occlusal,
proximal
Maxillary canines and 2nd molars:
facial,lingual,proximal surfaces.

Mandibular anterior teeth

are usually spared because
of:
1.Protection by tongue
2.Cleansing action of saliva
due to presence of the
orifice of the duct of
sublingual glands very
close to lower incisors.

l Harris and Garcia Godoy

(1999) classified ECC
according to its clinical
picture of the stages of
development .
l This was initially given by
Veerkamp(1995) as the
Developmental perspective
of nursing bottle caries.

STAGE 1 - very mild

or initial stage
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appearance of chalky
opaque demineralization
lesions on smooth
surfaces
Between 10-20 months of
age
Distinctive white lines can
be distinguished
Lesions are reversible at
this stage.
But frequently go
unrecognized by the
patient.

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STAGE 2- MILD

Shows demineralization in
gingival third of the tooth
and moderate cavitation.
Dentin gets involved when
the rapid development
cause the enamel to
collapse
Exposed dentin appears
soft and yellow
Child is 16-24 months of
age
He complains of sensitivity
to temerature change.

STAGE 3-MODERATE
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Frank cavitation of
multiple tooth surfaces is
seen.
With large deep lesions
on maxillary incisors and
pulpal irritation.
Age group affected is 2036 months.
History of spontaneous
pain.
Frequent cases of pulpal
involvement.

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STAGE 4: SEVERE
Clinically widespread destruction
of the tooth and partial to
complete loss of clinical crown.
Characterized by coronal
fracture of anterior maxillaries
due to amelodentinal
destruction
Maxillary incisors are usually
necrotized.
Occurs between 30-48 months
Child experiences severe pain
and discoMfort.

DIAGNOSIS
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Like every other disease, early diagnosis

increases the chances of adequate disease
control and reverting back to normal
condition.
The catch lies in the fact that clinically it is
difficult to detect the initial lesion as it is
visible to only when the tooth is thoroughly
dry.
A positive diagnosis is based on the
questions asked to parents regarding

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Maternal history
Feeding habits
Exposure to risk factors
Clinical endo oral examination,completed by
radiographs
DiFFerential diagnosis is based on observation
of hereditary anomalies such as
Infantile melnodontia
Amelogenesis imperfecta

TREATMENT
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Before onset of any treatment it is

mandatory to individually review every
child under following parameters.
CHILD FACTORS
PARENT FACTORS
Age
Cooperation
Chief complaint
Socioeconomic
status
Behavior
Physical and mental health

Based on these parameters the

following modalities can be selected
Treatment under general anesthesia
Too young to comprehend the
instructions.
Mentally/physically challenged
Moderate high socioeconomic status
Multiple quadrant/teeth requiring
invasive treatment

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Treatment under quadrant

Age and mental/physical health allow
understand.
Parent cooperation for multiple
appointment
Multiple teeth involved
In this situation 2 options can be
followed:
First,where the chief complaint is dealt
with first
severely debilitating condition of child
due to that tooth

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Secondly,where minor treatment is

started first
First dental visit
Cooperative but apprehensive child
Allows development of trust between
child and dentist.
The treatment of ECC is usually restricted to
surgical removal or restoration of carious
teeth coupled with recommendations
regarding feeding habits.

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treatment protocol for ECC

Incipient or white spot lesions
Topical fluoride and observation
Fissure sealant application
Carious lesion in enamel and dentin
Preventive resin restoration
Glass ionomer filling
Composite restoration
Stainless steel crown

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Carious lesion with pulp involvement

Pulp therapy
exodontia

PREVENTION
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INFANT ORAL HEALTH

It is the professional intervention
within 6 months after the eruption of
first primary tooth with history taking
directed to pre and post natal factors
affecting the oral cavity and
counseling about oral diseases risk
and providing anTicipatory guidance

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ORAL HYGIENE MEASURES

Prior to tooth eruption the gum
pads shoulD be meticulously
cleaned with a gauze piece
wrapped around the index
finger.
Care should be taken to ckean
the dorsal surface of the
tongue
This should be doe 3 times a
day.
After the eruption of tooth, the
parent shouLd be instructed to

FLUORIDE THERAPY
Topical
- tooth paste:up to 2 yrs- rice grain size
up to 5 yrs.- pea grain size
(under parent supervision)
-professional application
Systemic
-water fluoridation
-Salt fluoridation

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FEEDING HABITS
Breast fed the child even on demand
during first six months of life.
If the child is bottle fed,it should be I the
caregivers arms and ten put to bed
once he falls asleep without a bottle or
sweetener.
At all other times the child should be
given water to drink without added
sugars.
The use of fruit juice should be limited.
When the child reaches 6 months of age
he should be encouraged to drink using

At the age of one the child should stop

using the bottle and start using only
the training cup.
Faster swallowing reduces the cond
perio with the liquid.
DO NOT GIVE teething biscuits.They
provide no real benefit and are a food
of choice for bacteria.

WEANING
It is essentially expansion of diet.
It is integral part of nutritional development
in infancy
Defined as the process of exanding the
diet to include food and drinks other than
breast mild or infant food
Timing-no earlier than 4 months and no
later than 6 months of age.
The eruption of primary dentition usually
starts during or after establishment of
weaning.
Thus weaning may directly or indirectly

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FOODS THAT DO NOT HARM

It is important to know that food is
composed of proteins and fats cannot
be used by bacteria to produce acids.
They tend to increase the pH levels
and neutralize the acid that may have
been produced.eg. Nuts and seeds
They stimulate saliva and it easily
neutralizes the acids produced. eg.
Raw or uncooked vegetables.
Milk prevents dissolution of enamel by
providing calcium and phosphate ions

TIPS FOR PARENTS

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The American Academy of Pediatric Dentistry, the

American Dental Association, and the Academy of

General Dentistry recommend that children visit a dentist
within six months of the eruption of the first tooth, and no
later than 12 months of age.
Infants should not be put to sleep with a bottle. Breastfeeding at night should be avoided after 12 months of
age.
Infants should be weaned from the bottle at 12-14
months of age.
Consumption of juice from a bottle or sippy cup should be
avoided. Juice should be offered to a child only in a cup.
Infants and toddlers should drink no more than 6 ounces
of juice per day.
Cleansing of the baby teeth should be started by the time
of eruption of the first primary tooth. A small piece of

DIFFERENCE BEWEEN NURSING BOTTLE

AND RAMPANT CARIES

THANK YOU