Assessment of ECC Affecting Anterior Teeth in Children Visiting University Dental Hospital in India

Anupama Deepak1, Subramaniam EMG2, Ganesh Jeevanandan*2, Jeevitha M3 1Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India 2Department of Pediatric and Preventive Dentistry, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India 3Department of Periodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical And Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India


INTRODUCTION
ECC or early childhood caries is the most prevalent disease in children. It is de ined as presence of one or more decayed, missed or illed tooth surfaces in children of 72 months or younger. It is a virulent form of dental caries. ECC can begin early in life and keeps rapidly progressing (Weinstein, 1994;Grindejord et al., 1995). They are also known as baby bottle caries, rampant caries, nursing caries etc., commonly seen in pre-school children. They are generally seen affecting the maxillary anterior teeth. This is mainly due to the feeding patterns and improper dietary snacking patterns (Dilley et al., 1980;Weinstein, 1994;Grinde jord et al., 1995), with S.mutans and S.sobrinus as the etiologic agents (Tanzer et al., 2001;Weinstein, 1994;Grinde jord et al., 1995). ECC is directly related to poor oral habits and poor diet (Berkowitz, 2003).
Feeding practices such as improper use of baby bottles and its prolonged bedtime use is a main cause of this disease (Hallett and Rourke, 2002). Studies have shown that high frenal attachment can lead to midline diastema in children leading to increased space in between the tooth (Christabel, 2015). Increasing this time per day can shift the fermentable carbohydrates from re-mineralisation to demineralisation (Hallett and Rourke, 2002;Ramos-Gomez, 2010). ECC is also associated with poor socioeconomic status of the family. ECC is more commonly found in children belonging to poor economic conditions (Davies, 1998;Cau ield and Griffen, 2000). Children also show prevalence of enamel hypoplasia and insuf icient exposure to luorine. Optimum luoride content in water is 0.7-1.2 ppm, if decreased can lead to dental or skeletal luorosis and whereas use of luoridated toothpaste can prevent the progression for caries (Somasundaram, 2015;Govindaraju, 2017;Ramakrishnan and Bhurki, 2018). In case of luoride de iciency, leading to defect in enamel and prone for caries, this can be treated by systematically applied luoride in drinking water to reduce the severity of dental decay (JAMA, 2008). The main common cause for ECC is dental neglect where the parent or guardian fails to meet the child's basic oral health needs (Gurunathan and Shanmugaavel, 2016).
ECC is associated with infections leading to dificulty in chewing, malnutrition and dif iculty in sleeping (Finlayson et al., 2007). This can also be related to environmental factors like premature birth/ low birth weight and poor parental education. High sugar diet leads to caries formation. Lactobacilli along with S.mutans play a role in caries progression (Kawashita et al., 2011;Weinstein, 1994;Grinde jord et al., 1995). Few non-mutans streptococci having acidogenic and aciduric properties are associated with caries. Saliva has a protective role against dental caries formation and decrease in salivary rate, buffering capacity and reduced antimicrobial properties can predispose to caries development (Jiang et al., 2016). Therefore, the main aim of this study is to assess the prevalence of ECC affecting the anterior teeth in children.

Study Design
This is a cross-sectional study conducted at a university setting. The data was collected from a digital case sheet record. The sample size of the study is 282 subjects from a total of 731 case sheet records. The pros of the study are similar ethnicity and cons are geographic limitations. The ethical approval was by the ethics committee and the data was reviewed by 2 viewers. 731 cases sheets were reviewed of age group 2-6 years, irrespective of gender. Simple random technique was used to minimise sampling bias. Internal validity was the anterior teeth caries and external validity is that it can be generalizable.

Data Collection/ Tabulation
Data collected from the case sheet record was then transferred to MS Excel Sheet. Coding of data was done. Tabulation was done in excel spreadsheet. Data was then imported to SPSS by variable de inition process.

Analytics
Data was analysed using SPSS IBM version 20.0. Descriptive and inferential statistics was used. List of dependent variables are caries in anterior teeth and those of independent variables are age and gender. Chi-square test was followed and data transferred to the host computer and graphical illustration was done.

RESULTS AND DISCUSSION
In Figure 1, X-axis representing the age and Yaxis representing the percentage of subjects treated. Majority of the subjects belonged to 2-4 years of age (80.5%). In Figure 2, X-axis representing the gender and Y-axis representing the percentage of subjects treated. Majority of the subjects were males (54.6%) whereas 45.4% were females. In Figure 3, X-axis representing the tooth site and Y-axis representing the percentage of subjects treated. Majority of the subjects had ECC treated in the maxilla (87.6%), whereas 7.1 % of subjects had treatments done in both mandible and maxilla and 5.3% in the mandible. In Figure 4, X-axis representing the age and Y-axis representing the percentage of patients treated. For subjects in the 2-4 years of age group, treatment was predominantly done in both mandible and maxilla (blue) (95%) whereas in 5-6 years of age group, treatment was predominantly done in mandible (red) (33.3%) giving a pvalue of 0.307 (>0.05) which is statistically not signi icant, which means there is no signi icant association between age and the site of treatments done in patients with ECC. In Figure 5, X-axis representing the gender and Y-axis representing the percentage of subjects treated. In females, treatment was predominantly done in mandible (red) (60.0%) whereas in males, treatment was predominantly done in maxilla (green) (55.9%) giving a p-value of 0.379 (>0.05) which is statistically not signi icant, which means there is no signi icant association between gender and the site of treatment done, in patients with ECC.
A total of 282 subjects were included in this study  Figure 1, with X-axis as age and Y-axis as percentage treated, it is seen that 80.5% affected by ECC are in the age group 2-4 years and 19.5% are in 5-6 years of age. From Figure 2, with X-axis as gender and Y-axis as percentage treated it is seen that males (54.6%) are more affected than females. From Figure 3, with X-axis as the tooth site and Y-axis as percentage treated, it is seen that 87.6% of treatments were done in maxilla, 5.3% in mandible and 7.1% done in both maxilla and mandible. From Figure 4, on comparison between age and tooth site based on independent samples t-test, it is seen that 2-4 years age group (95%) is commonly affected by ECC with mean value of (2.7 ±0.57) with a p-value of 0.307. From Figure 5, on comparison between gender and tooth site on independent samples t-test, it is seen that females are commonly affected by ECC (60%) with a mean value of (2.77±0.57) with p-value 0.379. The comparisons were done using the chi-square test and were found to be statistically not signi icant as p-value was more than 0.05.
Prevalence of ECC is seen in the maxillary anterior region. Dental caries in toddlers and infants have a de inite pattern. Primary maxillary incisors are generally affected than the four central maxillary anterior teeth (van Houte et al., 1982;Weinstein, 1994;Grinde jord et al., 1995). The pattern of destruction by ECC is generally seen along the gingival margin. Carious lesions are found on the labial or lingual surfaces of the teeth or arising the proximal areas (Kelly and Bruerd, 1987). Studies show that severity is more for 3 year olds ranging from 36 to 85% (Tsai et al., 2006). Our results were comparable and in concordance with their studies. Another study conducted in Kuwait showed children with caries-free or even more less lesions in 4-5 year olds (Al-Mutawa, 2010). The signi icant increase in oral morbidity in this age group is primarily due to the poor rate of unmet treatment needs. Treatment and management of EEC can be achieved by intervention depending on disease progression. Children at low risk don't need any restorative therapy. Commonly done restorative treatments are class I GIC, Class I LCR, Root canal therapy, Pulpectomy/ Pulpotomy. These treatments are commonly done in children to prevent further progression of disease. Stainless steel crowns are the prefabricated crowns which can be adapted to the primary teeth mainly for molars and strip crowns for anteriors (Kindelan et al., 2008).
There are other studies conducted related to ECC, its management and prevention. Traumatic injuries can be one of the reasons for caries progression, one of the complications being the ranula, which is an extravasation cyst occurring rarely in children (Packiri, 2017;Ravikumar et al., 2017;Grindejord et al., 1995). Studies have proven that MDA (salivary malondialdehyde) levels were high in children with ECC (Subramanyam et al., 2018). One of the foremost treatments for anterior teeth being the pulpectomy and root canal treatment is carried out by rotary instrumentation using the Ni-Ti iles and Kedo iles (Govindaraju et al., 2017c,a;Jeevanandan and Govindaraju, 2018). Few other studies showed that cleaning (Govindaraju et al., 2017b;Jeevanandan, 2017) and shaping of the canals were more ef icient with the rotary system besides the conventional hand instrumentation technique (Nair et al., 2018;Panchal et al., 2019). Various complications encountered by dentists are the stresses during the endodontic treatment in cases of uncooperative children (Aishwarya and Gurunathan, 2017).

CONCLUSION
Primary dentition is required for proper mastication, aesthetics, phonetics and space maintenance. Therefore prevention of ECC is important and can be achieved by educating parents regarding tooth decay by maintaining oral hygiene. Within the limitations of this study such as the geographic limitations and small sample size, it can be concluded that ECC is highly prevalent in maxillary anterior teeth in children, commonly occurring in 2-4 years old.