口腔指南共识汇总

REVIEW ARTICLE

OPEN

Expert consensus on early childhood caries management

Jing Zou1, Qin Du2, Lihong Ge3, Jun Wang4, Xiaojing Wang5, Yuqing Li

6, Guangtai Song7, Wei Zhao8, Xu Chen9, Beizhan Jiang10,

Yufeng Mei11, Yang Huang12, Shuli Deng13, Hongmei Zhang14, Yanhong Li15 and Xuedong Zhou16✉

Early childhood caries (ECC) is a significant chronic disease of childhood and a rising public health burden worldwide. ECC may

cause a higher risk of new caries lesions in both primary and permanent dentition, affecting lifelong oral health. The occurrence of

ECC has been closely related to the core microbiome change in the oral cavity, which may be influenced by diet habits, oral health

management, fluoride use, and dental manipulations. So, it is essential to improve parental oral health and awareness of health

care, to establish a dental home at the early stage of childhood, and make an individualized caries management plan. Dental

interventions according to the minimally invasive concept should be carried out to treat dental caries. This expert consensus mainly

discusses the etiology of ECC, caries-risk assessment of children, prevention and treatment plan of ECC, aiming to achieve lifelong

oral health.

International Journal of Oral Science (2022) 14:35

; https://doi.org/10.1038/s41368-022-00186-0

INTRODUCTION

Early childhood caries (ECC), formerly referred to as nursing bottle

caries and baby bottle tooth decay remains a significant chronic

disease of childhood and public health problems. ECC is defined

as the presence of one or more decayed (non-cavitated or

cavitated), missing (as a result of caries), or filled tooth surfaces in

any primary tooth in a child 71 months of age or younger. The

American Academy of Pediatric Dentistry (AAPD) also specifies

that, in children younger than 3 years of age, any sign of smooth-

surface caries or a dmfs (decayed, missing, or filled surfaces) score

of greater than or equal to four (age 3), greater than or equal to

five (age 4), or greater than or equal to six (age 5) is indicative of

severe early childhood caries (S-ECC)1 (Fig. 1).

The experts of dental caries generally agreed that ECC was not

solely associated with poor feeding practices, the term ECC better

reflects its multifactorial etiology. These factors include susceptible

teeth due to enamel hypoplasia, oral colonization with elevated

levels of cariogenic bacteria, especially Streptococcus Mutans

(S.mutans), and the metabolism of sugars by tooth-adherent

bacteria to produce acid which, over time, demineralizes tooth

structure2. Reducing the number of cariogenic microorganisms

and establishing a balanced oral microenvironment will promote

the remineralization of tooth and limit the disease progression.

Thus, arresting caries requires behavioral modifications of the

patient or caregiver and relies on the individual’s compliance in

making necessary modifications3.

The consequences of ECC often include a higher risk of new

caries lesions in both the primary and permanent dentition,

hospitalizations and emergency room visits, high treatment

costs, loss of school days, and diminished oral health-related

quality of life.1

EPIDEMIOLOGY OF ECC

World Health Organization (WHO) mentioned that ECC is a highly

prevalent global disease public health problem. The American

Dental Association identified that ECC was found throughout the

general child population, and was a significant public health

problem in deprived communities.4

Firstly, the prevalence and incidence of ECC is very high, it is an

early-onset, aggressive form of dental caries that affected around

1.76 billion children with primary teeth worldwide.5 The results of an

Received: 24 April 2022 Revised: 15 June 2022 Accepted: 15 June 2022

1State Key Laboratory of Oral Diseases & National Clinical Research Centre for Oral Diseases & Department of Pediatric Dentistry, West China Hospital of Stomatology, Sichuan

University, Chengdu, China; 2Department of Stomatology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China;

3Department of Pediatric Dentistry, Peking University School and Hospital of Stomatology, Beijing, China; 4Ninth People’s Hospital, School of Medicine, Shanghai Jiao Tong

University, Department of Pediatric Dentistry, Shanghai Key Laboratory of Stomatology, Shanghai, China; 5State Key Laboratory of Military Stomatology, National Clinical Research

Center for Oral Diseases, Shanxi Key Laboratory of Military Stomatology, Department of Pediatric Dentistry, School of Stomatology, Fourth Military Medical University, Xi’an,

China; 6State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, West China School of Stomatology, Sichuan University, Chengdu, China;

7Department of Pediatric Dentistry, School and Hospital of Stomatology, Wuhan University, Wuhan, China; 8Department of Pediatric Dentistry, Guanghua School of Stomatology,

Guangdong Provincial Key Laboratory of Stomatology, Sun Yat‑Sen University, Guangzhou, China; 9Department of Pediatric Dentistry, School and Hospital of Stomatology, China

Medical University, Shenyang, China; 10Department of Pediatric Dentistry, School and Hospital of Stomatology, Tongji University, Shanghai Engineering Research Center of Tooth

Restoration and Regeneration, Shanghai, China; 11Department of Pediatric Dentistry, Affiliated Stomatological Hospital, Nanjing Medical University, Nanjing, China; 12Department

of Pediatric Dentistry, Hospital of Stomatology, Jilin University, Changchun, China; 13The Affiliated Hospital of Stomatology, School of Stomatology, Zhejiang University School of

Medicine, and Key Laboratory of Oral Biomedical Research of Zhejiang Province, Hangzhou, China; 14Department of Pediatric Dentistry, The Affiliated Stomatological Hospital of

Chongqing Medical University, Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences, Chongqing, China; 15Department of Pediatric and Preventive Dentistry, The

Affiliated Stomatology Hospital of Kunming Medical University, Kunming, China and 16State Key Laboratory of Oral Diseases & National Clinical Research Centre for Oral Diseases

& Department of Cariology and Endodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China

Correspondence: Xuedong Zhou (zhouxd@scu.edu.cn)

These authors contributed equally: Jing Zou, Qin Du

www.nature.com/ijos

International Journal of Oral Science

1234567890();,:

assessment of 193 United Nations published data between 2007 and

2017 showed that the mean ECC prevalence was 23.8 and 57.3% in

children younger than 3 years and children aged 3 to 6 years,

respectively.6 The summary paper presented at the International

Association of Pediatric Dentistry Conference on ECC in 2018,

showed that the ECC prevalence was 17, 36, 43, 55, and 63% in

children aged 1, 2, 3, 4, and 5 years, respectively.7 A systematic

review with a sample size of 80,405 children showed the prevalence

of dental caries in primary teeth was 46.2% (95% CI: 41.6%–50.8%).8

A systematic review using the WHO criteria, showed a combined ECC

prevalence of 48%, and ECC prevalence in decades was 55% in the

1990s, 45% in the 2000s, and 49% in the 2010 decade respectively,

with no significant change observed from 1990 to 2019.9

Secondly, although ECC is prevalent around the world, it is, in

particular, growing rapidly in low- and middle-income countries.10

The result of the fourth National Oral Health Survey in the

Mainland of China showed that the prevalence of deciduous tooth

caries in 5-year-old children was 71.9%, which was 5.9% higher

than that of 10 years ago, and the mean dmft (decay, missing, or

filled teeth) score was 4.24.11 With a combined global ECC

prevalence of 48%, the ECC prevalence varied both between and

within countries. Ranged from 16 %(Singapore) to 89% (China),

the prevalence by continent was 30% in Africa, 48% in the

Americas, 52% in Asia, 43% in Europe, and 82% in Oceania, which

indicated the distribution of ECC is not homogeneous.9 The

variation could be explained by mixed factors, such as macro-

economic,12 socioeconomic,13 genetic factors,14,15 ethnic minority

populations,16 the availability of fluoride in drinking water17 or

toothpaste,18 interventions with evidence of effectiveness for

caries prevention,19 universal health coverage, growth of gross

national income,6 high expenditure on health care, et al..20

Thirdly, the untreated primary caries remains high. ECC is still a

global public health burden, medically, socially, and economic-

ally.21 Globally, approximately 532 million cases (95% UI, 443 to

622 million) had untreated caries in primary teeth in 2017, and

between 1990 and 2017, the percentage change in the number of

prevalent cases decreased in high- and upper-middle-income

countries

and

increased

in

low-

and

lower-middle-income

countries.22 A systematic review supported the meta-regression

review showed that the prevalence of untreated caries affected

9% of children (95% CI 8.7, 9.4) in 2010 and has remained

relatively unchanged for 30 years.9,23 Therefore, we face a huge

challenge in the prevention and management of ECC.

RESEARCH PROGRESS OF ECC

ECC is a chronic infectious disease that occurs in primary teeth,

which is characterized by microbiome dysbiosis with increased

cariogenic bacteria. According to the fourth Chinese national oral

health epidemiological survey report (2018), the prevalence of ECC

in 3–5 years old children in China is ~62.5%, which is the highest

chronic infectious disease in children and affects the oral and even

the general health of children.

Etiological research of ECC

The primary tooth is constricted in the cervical portion, which

brings difficulty to cleaning. The primary tooth also has a lower

calcium content and mineralization degree than the permanent

tooth. These factors contribute to its susceptibility to dental caries.

The caries microbiome plays a critical role and is the primary

etiology in dental caries development. Endogenous bacteria

produce weak acids as a by-product of the metabolism of

fermentable carbohydrates within the formed biofilm, which

causes local pH values to fall and results in the demineralization of

tooth hard tissues. Therefore, the etiological study of ECC is mainly

focused on oral microecological unbalance, caries core micro-

biome, and their relationships with host genetic factors, which

contributes to the pathogenesis study of ECC and provides the

theoretical basis for ecological prevention and treatment of ECC.

ECC core microbiome.

It refers to microorganisms in dental

plaque or saliva related to the occurrence of caries. Nowadays, it is

well known that not only Streptococcus spp., Lactobacillus spp.,

and Actinomycete spp., but also previously unrecognized species

are involved in the progression of ECC. The significant difference

in microbial community structure between caries and caries-free

children has been revealed, including Veillonella spp., Granulica-

tella spp., Fusobacterium spp., Neisseria spp., Selenomonas spp., and

Campylobacter spp. Teng et al. detected that Veillonella spp. and

Prevotella spp. were the main trigger of ECC instead of S.mutans in

a 3-year cohort study.24–26 Scardovia wiggsiae, isolated from ECC,

has been associated with initial carious lesions with high acid

production and tolerance.27 A recent study found that the

acquisition of the arginine deiminase system benefits Sacchar-

ibacteria and their host bacteria against the acidic microenviron-

ment in the plaque biofilm.28 Not only bacteria but also fungi have

been linked to ECC with interkingdom interactions and the

abundance of Candida albicans is markedly higher in children with

ECC than in the caries-free children.29

As the specific pathogen, S. mutans has long been the research

hotspot of caries etiology. Transcription factors EpsR, StsR, RcrR,

and AdcR regulate bacterial biofilm formation, sugar transporta-

tion, and zinc homeostasis.30–33 Gtfs acetylation modification

plays an important role in biofilm formation and cariogenic

virulence.34 As the second messengers, c-di-AMP and Ap4A are

also

involved

in

biofilm

formation.35,36

CRISPR/Cas

system

regulates bacterial biofilm formation and cariogenic virulence

of clinically isolated strains.37,38 EzrA is involved in the bacterial

division,

morphology

maintenance,

biofilm

formation,

and

interspecies competition.39

Although S. mutans is a specific caries-associated bacterium in

the initiation and progress of caries, its presence or absence is

not always consistent with the severity of caries. A study

explored the possible correlation of S. mutans and other

microorganism

levels

on

caries-concordant

and

discordant

populations. The results found that salivary microbial commu-

nities significantly clustered based on S. mutans levels and

independent of their caries experience. In high S. mutans levels

groups, Veillonella spp., Streptococcus spp., and Prevotella spp.

were significantly increased.40 It highlights that other species

should be considered in the health/caries conditions, as well as

their conjunction with S. mutans.

Candida albicans (C. albicans) is a Gram-positive fungal

microorganism, which exists in human oral, intestinal, and

vaginal mucosa.41 It can invade dentinal tubules and secrete

acidic substances to promote enamel demineralization. It could

Fig. 1

Clinical manifestation of ECC

Expert consensus on early childhood caries management

Zou et al.

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International Journal of Oral Science (2022) 14:35

adhere to the hydroxyapatite matrix and dissolve crystals by

releasing calcium ions. C.albicans was detected in the oral

cavity of young children with dental caries.42 C.albicans can

adapt

to

a

high

acidic

environment

and

produce

high

concentrations of acetic acid and pyruvate. The interaction

between C. albicans and S. mutans can promote the occurrence

and development of ECC.43

ECC and genetic factors.

Individuals’ susceptibility to ECC is

associated with genetic and environmental factors. The twins

model makes it possible to identify the effect of genetic factors

on oral microbial composition. The oral microbial composition of

twins is more similar to each other and also showed a high

similarity with their mother. In addition, there is no significant

difference between the oral microbial compositions of mono-

zygotic

and

dizygotic

twins.44

These

results

showed

that

environmental factors may have a stronger effect on the

composition of oral microbiota in ECC children compared with

genetic factors.

Predictors and biomarkers for ECC

In health, the oral microbiome has a symbiotic or eubiotic

relationship and forms a stable dynamic balance with the host.

When the balance of the oral microbiome is perturbed, it is known

as “dysbiosis” and is linked to diseases. On the one hand, dysbiosis

is accompanied by changes in the composition of the oral

microbiome. For example, there is a higher abundance of

Corynebacterium durum in caries-free children than in ECC

children. The abundances of Prevotella denticola, Megasphaera

micronuciformis, and Dialister invisus in ECC children are higher

than in caries-free children.45 On the other hand, oral microbiome

dysbiosis will affect the biomolecule components in saliva, as part

of the host’s defense system. The identity and concentration of

changing proteins are highly correlated with ECC.46 Thus, the

changes in oral microbiota and salivary proteins in this process

can be predictors and biomarkers for assessing the caries risk in

children and forecasting the progress of ECC. Recently, Li et al.

found that BCG-polystyrene/polyvinylpyrrolidone (BCG-PS/PVP)

electrospun fibrous membrane visually detects the pH point with

sensitive and fast response, which has potential application value

in the monitoring and prevention of ECC.47

Therapeutic strategies targeting cariogenic biofilm

The biofilm formation covering the tooth surface lays the

foundation for cariogenic microorganisms to initiate the caries

process. Cariogenic microorganisms live in biofilm as micro-

colonies

that

are

encapsulated

in

an

organic

matrix

of

exopolysaccharides, protein, and DNA, which protects from

desiccation, host defenses and provides resistance to antimicro-

bials. Consequently, biofilm formation is not interrupted and

together with the absorbed saccharides from the diet leads to

cariogenic microenvironments. Therefore, therapeutic strategies

targeting biofilm will be effective to disrupt the pathogenic niche

and prevent the progression of ECC. Multiple regulatory path-

ways have been demonstrated to regulate biofilm formation,

including a two-component system (TCS), quorum sensing (QS)

system, CRISPR/Cas system, and c-di-AMP signal system, etc.48,49

Inhibitors have been developed to impair the biofilm formation

by targeting glucosyltransferases (Gtfs) and consequential poly-

saccharide synthesis: oxazole derivatives, quinoxaline derivatives,

trimetrexate (TMQ), and so on.50–54 In addition, Lactobacillus

plantarum K41 isolated from pickles showed high inhibitory

ability against biofilm formation.55 With the development of

dental materials, the anti-caries approaches will be further

expanded. Liang et al. reported that TA@RAs, new “smart” anti-

caries resin adhesives that trigger activation in response to acidic

pH, showed an anti-biofilm effect and increased the microorgan-

ism’s diversity.56

MANAGEMENT OF EARLY CHILDHOOD CARIES

Caries-risk assessment models for children

Caries-risk assessment (CRA) is an important part of children’s

dental health care. It refers to the identification and analysis of

certain factors that are considered to be related to dental caries

and to propose personalized preventive and therapeutic strategies

for individuals to decrease the risk of dental caries.57 CRA involves

a comprehensive analysis of protective factors, such as fluoride

use; risk factors such as the presence of caries lesions, and social,

cultural factors such as social status.58,59 Several CRA models

related to ECC have been developed worldwide, including caries-

risk assessment tool (CAT), caries management by risk assessment

(CAMBRA), American Dental Association (ADA) caries-risk assess-

ment, and Cariogram (Table 1).

CAT was developed in April 2002 by AAPD to assess caries risk

in

children

and

to

aid

clinical

decision-making

regarding

diagnostic, fluoride, dietary, and restorative protocols.60,61 CAT is

a qualitative model, that defined dental caries risk as high,

moderate, and low and is mostly used for CRA in infants, children,

and adolescents.62 CAT consists of two tables, one for children

aged 0–5 and another for ≥6 years old.

CAMBRA 31was developed in 2002 by Calif Dent Assoc, ref. 63

and ref. 64 further completed it in 2007 and updated since

then.65,66 CAMBRA is a qualitative model, but in the latest vision,

quantitative components were added to better determine the

caries-risk level.67 CAMBRA evaluation indicators cover risk

factors, protective factors and disease indicators, and defined

dental caries risk as extreme, high, moderate, and low risk. It also

consists of two tables, one for 0–6 years old and another for over

6 years old (Table 2).

ADA caries-risk assessment37 is a qualitative model, that

defied dental caries risk as high, moderate, and low. The

assessment has two forms, one is for patients of age 0–6, and

the other is for patients over 6. The form mainly includes three

aspects: (1) contributing conditions, such as fluoride exposure;

sugary foods or drinks; eligibility for government programs, etc.

(2) general health conditions. (3)clinical conditions, such as

carious lesions, visible plaque, dental/orthodontic appliances

present, salivary flow, etc.

Cariogram is a computer-based caries-risk assessment system

developed by Swedish scholar Petersson et al..68 Cariogram is a

quantitative model for caries-risk assessment. Ten caries-related

factors were evaluated.68 By inputting seven or more indicators, a

pie chart can be obtained through program operation, and the

possibility of individual caries in the future can be predicted.69

Management of perinatal and infant oral health

Oral health management for pregnant and lactating women.

Changes in diet, living habits, and hormone levels during

pregnancy increase the risk of dental diseases, such as gingivitis,

pregnancy epulis, periodontitis, wisdom tooth periodontitis, caries,

etc. These diseases not only affect the nutrition and health status

of women themselves, but also impact the normal growth and

development of the fetus, which are correlated with adverse

outcomes in pregnancy such as

prematurity, fetal growth

restriction, and pre-eclampsia.70,71

There is a close relationship between prenatal oral health care

and children's ECC. By giving prenatal oral health education or

intervention, a positive ECC prevention outcome was achieved.72,73

When mothers were subjected to prenatal oral health promotion

through education and intervention, the incidence of ECC and S.

mutans carriage in their children may be reduced.74

Therefore, prenatal dental examination and education are

necessary for pregnancy. Dental treatment should be carried out

before pregnancy to prevent the occurrence of dental diseases

during pregnancy. The dental history including diet and fluoride

use, preexisting oral conditions, current oral hygiene habits,

tobacco, and other substance use should be recorded.75,76

Expert consensus on early childhood caries management

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International Journal of Oral Science (2022) 14:35

During pregnancy, women are advised to brush their teeth

twice a day using Bass Brushing Method with fluoride tooth-

paste, floss daily, and visit the dentist regularly, have a balanced

diet with high-quality protein, trace elements, and vitamins.

Folic acid, choline, and omega-3 fatty acids are also needed.77

In addition, pregnant women need to be aware of diabetes,

which has been correlated with congenital defects such as cleft

lip and palate.78 Brushing should be avoided soon after

vomiting in cases of morning sickness, as this practice exposes

the teeth to gastric acid. For neutralization of the acid, it is

recommended to rinse with a diluted solution of one cup of

water and one teaspoon of baking soda.79 Due to the uncertain

side effect, bleaching should be avoided during pregnancy.80 In

the third trimester of pregnancy, puerperium and infant oral

hygiene advice should be provided. The second trimester is the

best time for dental therapy, and treatments may focus on

relieving acute symptoms. All radiographic procedures should

be conducted in accordance with radiation.76 In the third

trimester of pregnancy, puerperium and infant oral hygiene

advice should be provided.

Oral health management for the infant.

Infants have under-

developed salivary glands and less saliva secretion, also the

primary teeth have a lower mineralization extent than permanent

teeth, all these factors contribute to dental caries.

Breastfeeding:

Breastfeeding is a highly effective health-

promoting habit. Although breastmilk can decrease the pH

value of s dental plaque and lead to its dissolution, it is less

effective than infant formula.81 ECC may not be caused solely

by breastfeeding. However, frequent feeding will elevate

the cariogenic potential due to reduced salivary flow during

sleep.82,83 Breastfeeding combined with other carbohydrates

was shown to be significantly cariogenic in an in vitro study.84

The protective effect of breastfeeding during infancy has been

revealed, which may be correlated with decreased carbohy-

drate intake and delay in the use of the bottle.85 Some

studies suggested that prolonged breastfeeding for more than

12,83 18,83 or 24 min,86,87 increases the caries risk, but others

suggested

that

breastfeeding

duration

was

not

related

to the high likelihood of developing dental caries, even when

breastfeeding

time

is

over

24 min.88

However,

reducing

frequent and nocturnal breastfeeding82,89 from the second

year may decrease caries risk. The recommended duration of

breastfeeding by the American Academy of Pediatrics is the

first year while WHO encourages mothers to breastfeed for

up to 2 years.90

Early caring:

New parents may be aware of the necessity of

personal oral health and the possibility of cariogenic bacteria from

parent/ primary caregiver transmission to the infant. A few days

after birth, daily cleaning of the infant’s gums with a clean, moist

gauze pad, or a washcloth should be initiated. Brushing teeth

twice daily should begin as early as when the first tooth grows. A

smear or a rice-size amount of fluoride toothpaste is the standard

amount that should be considered. Limit sugar consumption in

meals and beverages; avert night bottle feeding with milk or

sugary drinks.91

Dental visit:

Infants may have their first dental examination

following the growth of their first tooth, and establish a

personal dental health file, which should not exceed 1 year of

age at the latest(Dental Home);92 after that, routine dental

examinations are carried out every 3 to 6 months, including

dental development, Whether there are bad oral habits, caries,

malocclusion, etc., and CRS is the focus.93 Early dental visits

may also make children adapt to the medical environment

and dental examination process, minimizing the occurrence of

dental phobia.

Management of caries for 0–6-year-old children

Fluoride.

Fluoride has played a key role in decreasing dental

caries, and its use for caries prevention and management is both

safe and significantly effective.94

Low fluoride levels in plaque and saliva help remineralize

demineralized enamel and prevent sound enamel demineraliza-

tion. It also prevents caries via the mechanism of influencing

cariogenic bacteria metabolic activity.95 Fluoride at high levels

causes a transient calcium fluoride layer-like substance on the

surface of the enamel. In the case where the value of pH was

decreased due to acid formation, fluoride is liberated and can be

used to remineralize enamel or affect bacterial metabolism.

The most cost-effective means to deliver fluoride to the

community is through fluoridation of drinking water. In the United

States,

water

fluoridation

is

carried

out

at

the

level

of

0.7–1.2 mg·L−1. The U.S. Department of Health and Human Services

has recommended standardizing all water to the 0.7 mg·L−1

level.94 In China, the optimal fluoridation level of drinking water

is recommended as 0.7–1.0 mg·L−1.96

Topical fluoride therapies applied professionally are efficient in

decreasing the incidence rate of dental caries. Topical fluoride

therapies should be performed after completing the caries-risk

assessment and by dental professionals.94 High-risk children

should receive fluoride treatment at an interval of 3 months, and

biannual treatment should be conducted for children with a

Table. 1.

Factors of assessment tools for patients ≤6

Caries-risk assessment tool (CAT) (0–5)

Caries management by risk assessment

(CAMBRA) (0-6)

American Dental Association

(ADA) caries-risk assessment

(0–6)

Cariogram

Protective

factors

Fluoride exposure; regular dental care

Fluoride exposure, Daily dental care

Fluoride exposure;

dental home

fluoride program;

Risk

factors

Mother or caregiver has active dental

caries; poverty, low health literacy;

frequent exposure to sugary snacks;

frequent bottle/nonspill cup use;

special health care needs; new

immigrant

Frequent snacking; bottle/nonspill cup

use; the family has low socioeconomic

and or low health literacy status;

medications that induce hyposalivation

Eligible for government

programs; caries experience

of mother or caregiver;

special health care needs

diet contents; diet

frequency;

Clinical

findings

Non-cavitated caries or enamel defects;

visible cavities, filling or missing teeth

due to caries; visible plaque;

Plaque; decay or white spots; recent

restorations

Carious lesions; Non-

cavitated carious lesions;

missing teeth due to caries;

Orthodontic Appliances;

Salivary flow

Caries experience;

plaque amount;

Streptococcus Mutans;

saliva secretion; buffer

capacity

Expert consensus on early childhood caries management

Zou et al.

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International Journal of Oral Science (2022) 14:35

moderate risk.97The most frequently used agents for professional

fluoride treatments are 5% sodium fluoride varnish (NaF,

22 600 mg·L−1 F)

and

acidulated

phosphate

fluoride

(APF,

12 300 mg·L−1 F). 5% sodium fluoride varnish in unit dosages is

the only professional topical fluoride that is suitable for children

under six.98 Clinical trials have also shown that applications for

less than four minutes are noneffective. 38% silver diamine

fluoride (SDF) is recommended to inhibit the progress of

cavitated caries lesions in primary teeth. SDF prevents caries by

acting as an antibacterial agent and by remineralization of

enamel and dentin.99

Children’s home-use fluoride products should be used in a

low-dose and higher-frequency manner.97 Fluoride toothpaste is

indicated twice a day, and rinsing after brushing should be

minimized or avoided entirely.100 In China, the national standard

of toothpaste fluoride level is 0.05%–0.11%.96 For children aged

less than 3 years, using an amount smaller than a smear or rice-

size amount of fluoride toothpaste may reduce the incidence risk

of fluorosis. Children aged 3 to 6 should use a dosage smaller

than a pea-size of fluoride toothpaste.91 Home-use fluoride gels

and pastes and prescribed strength home-use fluoride mouth

rinse are efficacious as well in dental caries reduction98 (Table 3).

Oral hygiene.

A few days after birth, parents are advised to

begin to clean infants’ gums using a clean, moistened gauze pad,

or washcloth daily. Brush teeth twice a day as soon as the first

tooth erupts. Brush teeth using the Bass method. Fluoride

toothpaste should be used in an amount not exceeding a smear

or rice-size amount.

Both the parent and the patient should be involved in oral

hygiene counseling. Initially, the parent oversees the oral

hygiene of the child. As the child develops, home dental care

should be taken by both the parent and the child. When the

child demonstrates knowledge and competence to perform

personal hygiene techniques, the child should also be counseled

by a healthcare professional. At each dental visit, the effective-

ness of home care should be assessed.101–103

Diet habits.

Diet habit is closely related to ECC, healthy diets

such as lean protein and vegetable intake will promote dental

health. However, unhealthy diet habits (e.g., frequent intake of

sugars and/or juices) were risk factors for ECC.104,105 For infants,

human breastmilk is recommended.106 But parents should be

aware

that

breastfeeding

is

significantly

cariogenic

when

combined with other carbohydrates.84 A healthy diet is necessary

for children, including drinking plenty of water; eating various

kinds of foods (whole grain, fruits, vegetables, protein, and low-

fat/fat-free dairy foods); limiting the number and frequency of

Sugary

Snacks;

balancing

meals

consumed

with

physical

activity to maintain an appropriate Body Mass Index (BMI);

Table. 2.

Caries management recommendations for patients ≤6 by CAT and CAMBRA

Category

Model

Low risk

Moderate risk

High risk

Extreme high risk

Recall

CAT

6–12 months

6 months

3 months

CAMBRA 6–12 months

6 months

3 months

monthly

Radiographs

CAT

12–24 months

6–12 months

6 months

CAMBRA 12–24 months

6–12 months

6 months

6 months

Fluoride

CAT

optimally

fluoridated

water/twice-daily

brushing with

fluoridated

toothpaste

optimally fluoridated water/

twice-daily brushing with

fluoridated toothpaste/fluoride

supplements/professional

topical fluoride every 6 months

optimally fluoridated water/

twice-daily brushing with

fluoridated toothpaste/

Professional topical fluoride

treatment every 3 months/SDF

on cavitated lesions

/

CAMBRA twice-daily

brushing with

fluoridated

toothpaste

optimized fluoride intake/twice-

daily brushing with fluoridated

toothpaste/ Fluoride varnish

every 6 months

optimized fluoride intake/twice-

daily brushing with fluoridated

toothpaste/ Fluoride varnish

every 3 months

optimized fluoride intake/

three times daily brushing

with fluoridated toothpaste,

spitting the toothpaste with

no rinsing/ Fluoride varnish

every 1–3 months

Dietary counseling

CAT

Yes

Yes

Yes

/

CAMBRA No

Yes

Yes

Yes

Sealants

CAT

Yes

Yes

Yes

/

CAMBRA No

On enamel defects and pits and

fissures at-risk

On enamel defects and pits and

fissures at-risk

All pits and fissures

Restorative

CAT

Surveillance

Active surveillance of non-

cavitated /Restoration of

cavitated or enlarging

caries lesion

Active surveillance of non-

cavitated/Restoration of

cavitated or enlarging

caries lesion

/

CAMBRA /

Active surveillance for

developing lesions

Remineralize enamel-only lesion;

restoration of cavitated lesions or

non-surgical caries; ITR; SDF;

Caries control before

surgical treatment;

remineralize enamel-only

lesion; restoration of

cavitated lesions or non-

surgical caries; ITR; SDF;

Self-managements

CAT

/

/Yes

/Yes

/

CAMBRA No

Yes

Additional therapies

CAT

/

/

/

/

CAMBRA /

/

/

use of baking soda/xylitol,

ACP/CPP paste

Expert consensus on early childhood caries management

Zou et al.

5

International Journal of Oral Science (2022) 14:35

maintaining a caloric intake adequate to sustain normal growth

and development.107

The public and the parents should be informed about the

correlation between frequent carbohydrate intake and caries,

and other hazards linked to over intake of simple carbohydrates,

saturated fat, and sodium.106

Pit and fissure sealant.

Since the 1960s, pit and-fissure sealants

have been employed108 to prevent and control dental caries on

primary and permanent teeth. Pit and fissure sealant may protect

molars from the pit and fissure lesions of occlusal surfaces, and

also inhibit the growth of non-cavitated carious lesions.109 At 1,

2, 3, and 4 years of follow-up, studies have demonstrated

that comparing resin sealant versus no sealant achieved highly

significant outcomes.108,110

According to AAPD guidelines, it is recommended that

sealants should be applied in permanent molars with both

sound occlusal surfaces and non-cavitated occlusal caries in

children and adolescents.110 Dental sealants are a cost-

effective solution when antecedent caries is present. The

efficiency of several types of sealants, such as resin-based

sealants, resin-modified GI sealants, GI cement, and polyacid-

modified resin sealants, could not be assessed owing to

inadequate evidence.108,110

Sealing of at-risk pits and fissures should be conducted as

promptly as feasible.103 Generally, it is recommended to have

sealant for pits and fissures of primary molars at age 3–4, have

sealants for pits and fissures of permanent first molars at age 6–8,

and have sealants for pits and fissures of permanent second

molars and premolars at age 10–12. The necessity for placing a

sealant should be reevaluated at periodic prevention care

sessions. Checking of sealants regularly should be conducted

and fixed or changed when necessary.110,111

Dental home.

The American Academy of Pediatrics proposed the

concept of the medical home in 1993, from which the dental

home concept is present. It is described as “the ongoing

relationship between the dentist and the patient, inclusive

of all aspects of oral health care delivered in a comprehensive,

continuously

accessible,

coordinated,

and

family-centered

way.“.112 It is intended to provide preventative, acute, and holistic

oral health care, as well as referrals for patients, when necessary,

and should be initiated as early as 6 months but not after 1

year.113,114 The determination of reappointment frequency is

dependent on caries-risk assessment.92,115

Studies have well-illustrated that health-related outcomes and

costs can be efficiently improved by early dental visits.116,117 A

dental home is a useful pattern for preventing ECC. Children who

lack accessibility to a dental home are exposed to a greater risk

of ECC and dental treatment under general anesthesia, as shown

in a Canadian study.118 It has been proved that conducting a

dental home improves health outcomes in children, particularly

those at risks of developing periodontal disease or ECC.104 In

low-income groups, the development of a dental home reduces

the incidence of ECC.119

Pediatric restorative dentistry

Clinical techniques of caries management for toddlers

Atraumatic restorative technique (ART):

The University of Dar es

Salaam initiated a community-based primary oral health program

referred to as ART during the mid-1980s in Tanzania.120 It is

characterized by the removal of carious tissue by only hand

devices and restoring the cavity by primarily glass ionomer.

According to the WHO’s manual, ART can be used when the

dentine has a cavity and it is accessible by hand equipment. It

should not be employed in cases where there is swelling or

fistula, the pulp is exposed, pain and inflammation symptoms

develop, or the cavity cannot be accessed by hand equip-

ment.121

ART

is

a

minimal

cost,

physiologically

friendly

approach requiring little cavity preparation,122–124 which lowers

the

need

of

performing

further

endodontics

and

tooth

extraction procedures.125

It has been shown that ART has a high success rate, especially

for one-surface restoration. For instance, 3-year research in

Zimbabwe found an 85.3% survival rate for one-surface ART

restorations.126 Another meta-analysis has revealed that the rate

of survival for single-surface ART restoration of the primary

posterior teeth reached 94.3% in 2 years, and 87.1% in permanent

posterior teeth in 3 years.127 Also, studies have found that ART

may efficiently minimize pain and dental anxiety compared with

traditional therapies.128–131

Combined use of ART and dentin conditioner/chemo-mechanical

method have been developed these days. Combined use of dentin

conditioner may have a better result,132,133 since dentin conditioner

may clean the bonding surface and seal the dentinal tubules.134 The

use of hand instruments in combination with chemo-mechanical

methods will enhance the elimination of carious tissues. In addition,

they may minimize pain posed by the dental treatments, making

ART more suitable for children.135,136

Interim therapeutic restoration (ITR):

ITR was first developed by

AAPD in 2001,137 it utilizes a technique similar to ART, but has

different therapeutic purposes. ART was introduced in low-income

nations as a treatment approach, where more appropriate

treatment may not be available.138 ART used hand instruments

only and is a definitive restoration. ITR is a temporary restoration

that entails removing caries by both hands or slow-velocity rotary

devices and then restoring with temporary adhesive restorative

material (GIC). ITR is effective in managing dental caries of young

patients, non-cooperative patients, patients with special health

needs, and in situations where the conventional cavity preparation

and placement are not feasible. ITR may also be used for caries

control in children with multiple carious lesions before definitive

restoration of the teeth.131,139–141 The adoption of ITR is effective

in decreasing the levels of oral cariogenic bacteria promptly after

its placement.142,143 However, if no further treatment is adminis-

tered in 6 months, the bacteria counts may revert to pretreatment

levels,143 so ITR should be changed with a more definitive

restoration within 6 months. ITR is an appropriate treatment

option for ECC since it slows down the deterioration of caries and

enables more children to be treated.144,145

Table. 3.

Recommended fluoride usage

Systemic use of fluoride

Professional topical use of fluoride

Home-use fluoride

Water fluoridation

Fluoride varnish

SDF

Fluoride toothpaste*

Fluoride gels/pastes

Fluoride mouth rinse

0.7–1.0 mg·L−1

NaF (22 600 mg·L−1 F) *

38% SDF

NaF

NaF (5 000 mg·L−1 F)

NaF (900 mg·L−1 F) (weekly)

APF (12 300 mg·L−1 F)

SMFP

APF (5 000 mg·L−1 F)

NaF (230 mg·L−1 F) (daily)

Stannous Fluoride

SnF2 (1 000 mg·L−1 F)

*Recommended for children ≤6

Expert consensus on early childhood caries management

Zou et al.

6

International Journal of Oral Science (2022) 14:35

Chemo-mechanical caries removal (CMCR):

CMCR is a procedure

that uses a solution to chemically soften carious tissue to facilitate

its easier removal. The caries tissues were then removed by hand

devices. CMCR is one of the minimal invasion caries removal

techniques. This method was firstly applied in the 1970s with the

aid of different reagents including ethylene diamine tetra-acetic

acid (EDTA),146 collagenase,147,148 and sodium dodecyl sulfate.147

CMCR agents can now be grouped as enzyme-based agents and

ethyl sodium hypochlorite (NaOCl).149

Carisolv

is

the

best-known

NaOCl-based

CMCR

agent.

Papacarie is the commercially available Enzyme-based CMCR

agent and consists of the papain enzyme, toluidine blue,

chloramine, salts, a thickener, stabilizers, preservatives, and

deionized water.150

Compared with the traditional caries removal method, CMCR

showed a significant reduction of pain response and the need for

local anesthesia,151,152 it is a useful caries removal method for

anxious, disabled, and pediatric patients.149 However, other

studies had shown that CMCR needs more clinical and technical

effort and treatment time than the traditional method. This may

increase fear in subjects of CMCR.153,154

Laser application:

Neodymium-yttrium-aluminum-garnet (Nd:

YAG) laser was the first laser innovation to be adopted in the

treatment of dental problems. This laser was emerged in 1987

and got licensure in 1990 from the U.S. Food and Drug

Administration.155

Lasers can eliminate caries efficiently with minimal disruption of

adjacent tooth structure because there is a high-water content in

the caries-affected tissue than in healthy tissues.155 The utilization

of the traditional high-velocity dental equipment induces pain,

discomfort, and anxiety among the pediatrics by producing

vibration and noise during dental restorative procedures.156–158

Erbium lasers are contactless with the hard tissue and do not

generate vibrations like the handpiece devices.156–158 Therefore,

they have been discovered to exert a pain-relieving effect on the

target hard tissues, minimizing the usage of anesthesia and

injections during tooth preparations.159–161

Restoration

Preventive resin restoration (PRR):

PRR is a restorative method

first proposed by ref. 162 in 1978 for the management of pits and

fissures that have minimal or questionable caries. Indications for

PRR are questionable caries, or an explorer caught in a pit or

fissure; minimal, shallow pit and fissure caries; deep pits and

fissures that could inhibit complete penetration of sealant

material or could be carious at their bases; deep pits and fissures

with obvious supplemental fissuring and limited areas of decay;

and an opaque, chalky appearance along with pits and fissures

that could indicate early-stage caries. PRR is contraindicated for

large, deep, or multisurface carious lesions.163–165 It is character-

ized by only removing a small number of teeth, repairing early

carious lesions, and protecting the unprepared area from

secondary caries. Classic PRR were prepared with a small round

bur and the procedure was completed with composite resin and

pit and fissure sealant. The success rate of PRR is high, even after

a long period of time.166,167 Nowadays, PPR has been combined

with other technologies, such as Laser application to produce

better long-term results.

Resin-based composite (RBC) restoration:

As an essential com-

ponent in pediatric restorative dentistry, RBCs are composed of

chemically bonded fillers and a resin matrix168 and are classified

according to the size of their fillers, since the fillers influence the

esthetics/polish ability, polymerization shrinkage, depth, and

physical features. Hybrid resins involve different particle sizes to

enhance strength while retaining esthetics.169 The larger filler

particles enhance strength whereas the smaller particles improve

esthetics/polish ability. In comparison with hybrid resins, flowable

resins have a smaller volumetric filler percentage.170 RBC may be

utilized in PRR, Class II restorations in both the primary171,172 and

permanent dentition,173–175 and indirect RBC restorations in both

the primary and permanent dentition.176,177

Operator expertize, restoration size, and tooth position are all

factors that have the potential to promote the durability of resin

composites.71 Resins are more sensitive to the technique in

contrast to amalgams. If the patient is uncooperative or there is

an isolation problem, the usage of RBC may not be the best

choice.178,179 Before the operation, a caries-risk assessment must

be taken, and children at high caries risk are also not good

candidates for RBC.

Glass-ionomer cement (GIC) restoration:

GIC have been used in

dentistry as restorative materials since the early 1970s.180 GIC

have several features that enhance its usage among pediatrics:

the ability to chemically bond to both dentin and enamel,

biocompatibility,

uptake

and

release

of

fluoride

lower

moisture sensitivity than resins, and relative thermal expansion

ability

to

teeth

structures.181

However,

they

have

poor

resistance to wear, unfavorable mechanical properties as well

as poor esthetics.182

Fluoride is released from the GIC and taken up by the

surrounding dental structures.183 Studies have shown that conven-

tional GIC is suitable for Class I restorations in primary molar,184 as

conventional GIC has a median failure time of 1.2 years,185 and has

poor anatomical form and marginal integrity.186

Resin-modified glass-ionomer cements (RMGICs) contain hydro-

xyethyl methacrylate (HEMA) and can be light cured.187 It has

better

mechanical

qualities188

and

improved

resistance

to

moisture contamination compared to traditional GIC, while the

fluoride release stays constant.189 RMGICs are efficient in primary

teeth and can be used for both Class I and Class II restorations in

the primary dentition.

GICs are also used in ART and ITR technologies and are a

suitable base or liner when RBC is used as the restorative material.

Giomer restoration:

Giomer is a new type of hybrid material

that was first introduced in the early 2000s,190 it is made up of

pre-reacted glass ionomer (PRG) filler particles within a resin

matrix.191 PRG filler is generated by an acid-base reaction

between fluoride-containing glass particles (fluoro-boro-alumi-

nosilicate glass filler) and polyalkenoic acid with water before

integration into the resin.192

Giomer has the features of both glass ionomers and resin

composites such as the capacity of releasing and recharging

fluoride, biocompatibility, and good esthetics.

In vivo clinical studies reveal that the morphological, mechan-

ical integrity, and functional properties of the giomer restorations

can

be

compared

favorably

with

resin

composite

restora-

tives.193,194 Studies have also shown that Giomer has a high

success restoration rate. A clinical trial used Giomer as Class I and

Class II restoration in a permanent molar and showed that the

8-year success rate reached 100%,192 and the 13-year success rate

is still pretty high.195

Stainless steel crown (SSC) for primary molar:

SCC are prefabri-

cated crown forms that are adjustable to a patient’s tooth and

cemented with a biocompatible luting agent. SCC has shown

greater longevity than amalgam196 and RMGIC197 restorations.

SSCs continue to offer the advantage of full coverage in the fight

against recurrent dental caries and provide strength and extended

durability with minimal maintenance requirements, which are

favorable for high-risk pediatrics.181 Evidence from retrospective

research studies shows that preformed metal crown restorations

last longer in comparison to resin-based restorations or amalgam

in caries in primary teeth treatment. Therefore, the use of SSCs on

Expert consensus on early childhood caries management

Zou et al.

7

International Journal of Oral Science (2022) 14:35

high-risk pediatric with extensive or multisurface cavitated or non-

cavitated lesions on deciduous molars is recommended, particu-

larly in the case when children need behavioral guidance

approaches advancements, such as general anesthesia to provide

restorative dental care181(Fig. 2).

Hall Technique (HT) was first developed by a general dental

practitioner, Dr. Norna Hall in 1997.198 HT is a noninvasive

treatment, applying SCC to a caries primary molar by separating

teeth rather than removing caries tissues and preparing the

tooth, so HT may need no local anesthesia, caries removal, or

tooth preparation.196 HT avoids the discomfort from local

anesthesia and caries removal provides a treatment option for

anxious children.199 Also, avoiding caries removal may prevent

pulpal exposure.200,201 When HT is used, decay is sealed under

SSC, denying biofilm microbes their source of nutrition, dietary

carbohydrate, and removing this access prevents the progression

of caries.202 Studies have shown that HT had a similar success

rate with conventional crowns203 and has a favorable restoration

longevity.201,204 Another RCT study compared the 36-month

outcome of HT and ATR showed that HT had almost three times

higher survival rates for restoring primary molars than ART130

Both HT and ART are well-accepted among children and their

parents.205 Therefore, HT may be used when conventional

crowns are not feasible.181

Anterior esthetic restoration in primary incisors:

Anterior restora-

tion of primary incisors can be cumbersome in pediatrics due to

small teeth size, minimal surface area for bonding, proximity

between teeth pulp and surface, and the child’s behaviors.206

The following are indications for full coronal restoration of

carious primary incisors: caries is extensive on the surfaces;

involvement of the incisal edge; extensive cervical decalcification;

pulpal therapy is recommended; the presence of minor caries with

poor oral hygiene; or unfavorable child’s behavior that hinders

moisture control.207

Retrospective research has revealed that at least 80% of strip

crowns were completely retained after 3 years while those that

were partially retained accounted for 20%, with none being

lost.208 Another retrospective study showed 80% retention of

strip crowns after 24–74 months.209 For full coronal coverage

restorations in primary anterior teeth, strip crowns are a

treatment option (Fig. 2).

Deep caries and vital pulp therapy

Indirect pulp therapy (IPT).

IPT is a procedure that leaves the

deepest caries adjacent to the pulp undisturbed to avoid pulp

exposure. Then, a biocompatible material is used to cover caries-

affected dentin to provide a biological seal.210 A dentin bonding

agent like calcium hydroxide, resin-modified glass ionomer, or

MTA is usually used on the remaining carious dentin, to trigger

dentin’s repair and healing process. The tooth then is restored

with a dental material. IPT is indicated in primary teeth with deep

caries that exhibit no pulpitis or with reversible pulpitis when the

deepest carious dentin is not removed to avoid pulp exposure.

James A. Coll et al. reviewed articles and found that the success

rate for IPT was 94.4% at 24 months, and liner material (Calcium

hydroxide liners versus bonding agent liners) did not affect the IPT

success.211 Successful IPT is possible under defined conditions

(symptom-free tooth, no pulp exposure) and appropriate sealing

of the cavity with an effective dentine seal.

Pulpotomy.

Pulpotomy is performed in a primary tooth when

caries removal results in a pulp exposure in a tooth with a healthy

pulp or reversible pulpitis and there is no radiographic sign of

infection or pathologic resorption. The coronal pulp is amputated,

pulpal hemorrhage controlled, and the remaining vital radicular

pulp tissue surface is treated with a long-term clinically-successful

medicament.212 The meta-analysis showed that the 2-year overall

success rate of pulpotomy was 82.6%.211 MTA is the only

recommended medication for teeth to be retained for 2 years or

longer.210 Then the tooth is restored with a restoration material

(such as glass-ionomer cement, resin-based composite, giomer, or

stainless steel if necessary) to prevent the tooth from microleakage.

Management of ECC begins at the mother’s pregnancy. Early

establishment of healthy dietary habits, oral hygiene habits, and

dental home is essential to children’s dental health. An individua-

lized ECC management plan should be made based on the

assessments of caries risk and the clinical evaluation of caries

lesions (Fig. 3).

ASSESSMENT AND MANAGEMENT AFTER TREATMENT FOR

ECC

Dental caries intervention is insufficient alone in halting the

progression of the disease.62 Therefore, after treatment for ECC,

a

b

c

d

Fig. 2

Application of Stainless steel crown and Anterior esthetic restoration, a Primary molars with multisurface caries, b Primary molars

restored with Stainless steel crown restoration, c Primary incisors with multisurface caries, d Primary incisors restored with strip crowns

Expert consensus on early childhood caries management

Zou et al.

8

International Journal of Oral Science (2022) 14:35

continuous assessment and management of the health status

of the patient should be performed to manage oral health in the

long term.

CRA is a key component of current preventive care for infants,

children, and adolescents. It should begin as soon as the first

primary tooth emerges and be reevaluated regularly by dental

and medical practitioners,62,213 and 12‐month anticipation is more

accurate than a long-term duration.7

Secondary caries

Secondary caries is the most common cause for the replacement

of dental restorations in clinical settings, no matter what kind of

material is chosen, secondary caries cannot be completely

avoided.214 A number of factors may be responsible for secondary

caries: (1) clinical technique,214 moisture control, visual inspection,

and for children, behavioral management, etc. are all clinical

factors that may predispose the development of secondary caries.

(2) microleakage at the tooth-restoration interface.215 Until now,

no material can completely eliminate microleakage around the

restoration. Immediately after the use of adhesives, a gap of

6–10 μm is formed between the tooth tissue and the restora-

tion.216 Furthermore, the level of microleakage was not affected

by conventional or chemical-mechanical methods of caries

removal,217 (3) microbiological change of restoration area,218

(4) restoration material properties,214 Fluoride-releasing restora-

tive materials such as GIC or giomer may have advantages over

resin-based materials,214 (5) oral hygiene is also closely related to

the occurrence of secondary caries.219 The prevention methods of

secondary

caries

include

using

fluoride-releasing

materials;

microleakage control, adequate plaque removal, especially the

gingival part of the restoration by toothbrushing and interdental

flossing,

and

adequate

fluoride

contact

will

help

prevent

secondary caries.

Ecological balance

The human and symbiotic microbes form a complex ecosystem

whose dynamic balance is significantly correlated with physical

health. Frequent dietary carbohydrate consumption may result in

dysbiosis of the oral microbial community from an overproduction

of acid with selection for elevations in acidogenic, acid-tolerant

bacteria.220,221 For example, S.mutans, Scardovia wiggsiae, Slackia

exigua, Granulicatella elegans, and Firmicutes were found to be

predominant in the plaque biofilms of carious lesion. In contrast,

bacteria such as Streptococcus cristatus, S. gordonii, S. sanguinis,

Corynebacterium matruchotii, and Neisseria flavescens were com-

mon in plaque biofilm of noncarious, healthy, tooth surfaces.222

Therefore, rebalancing the caries microbiome dysbiosis after ECC

treatment is of importance.

ECC patients

Chief compliant

History collection (Diet/Oral hygiene/Dental visit etc.)

Clinical examinations

Caries risk assessment

Caries severity assessment

low risk

Moderate risk

High risk

Extreme high risk

Non-cavitated

Cavitated

caries

caries

caries

Deep

Clinical

Clinical

Clinical

Clinical

intervention/

intervention/

intervention/

intervention/

Radiograph

Radiograph

Radiograph

Radiograph

(12-24

Fluoride/

Recall every

6-12 months

(6 months)/

(6 months)/

(6 months)/

Fluoride/

Fluoride/

Fluoride/

Dietary

Dietary

Dietary

counseling/

counseling/

counseling/

Sealants/

Sealants/

Sealants/

Recall every

Recall every

Recall every

6 months

3 months

Additional

therapies/

month

Topical

fluoride

application/

Pit and fissure

sealant/ACP-

CCP/Dental

home

Anterior

teeth

Posterior

teeth

IPT/

Pulpotomy

Minimally

Minimally

invasive

invasive

esthetic

restoration

restoration

(PRR/RBC/

GIC/Giomer/

SSC)

Recall and monitoring

months)/

Fig. 3

Management decision model of ECC

Expert consensus on early childhood caries management

Zou et al.

9

International Journal of Oral Science (2022) 14:35

Timely dental caries restoration, mechanical removal of dental

plaque, the use of antimicrobial compounds, diet modification,

and topical fluoride application may help with oral ecological

balance.223 As sugar intake influences microbiome dysbiosis, sugar

substitutes such as Xylitol and erythritol are encouraged to

prevent cariogenic bacteria transmission.224

CONCLUSION AND EXPECTATION

Until now, ECC is still a worldwide health challenge. The caries

microbiome plays a critical role in the occurrence of ECC. Based on

the etiological research of ECC, new biomarkers and therapeutic

strategies may be developed for the better prevention and

treatment of ECC. Maternal oral health and awareness of health

care are directly related to the oral health of infants and young

children. Oral health promotion, including education and healthcare

services during pregnancy, is necessary to improve infants' and

young children’s oral health. A dental home should be established at

an early stage of childhood and an individualized caries manage-

ment plan should be provided according to caries-risk assessment.

Active measurements adhering to the concept of minimum

intervention should be taken to treat dental caries. In China, the

prevalence of ECC is still increasing, whole-life-cycle caries manage-

ment should start at the very beginning of one’s life to effectively

prevent and treat caries to achieve the aim of lifelong oral health.

ACKNOWLEDGEMENTS

The study was supported by the National Natural Science Foundation of China

(82170947) and the International Science and Technology Innovation Cooperation

Projects of Science and Technology Office of Sichuan Province (2019YFH0025).

AUTHOR CONTRIBUTIONS

Conceptualization and Investigation, X.D.Z.; Supervision, X.D.Z.; Original draft, J.Z.,

Q.D., Y.Q.L.and Y.H.L.; Review and editing, L.H.G., J.W., X.J.W., G.T.S., W.Z., X.C., B.Z.J.,

Y.F.M., Y.H., S.L.D., and H.M.Z.

ADDITIONAL INFORMATION

Competing interests: The authors declare no competing interests.

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