Pediatric Dentistry - a Clinical Approach, 3ed.

CHAPTER 10. Dental Caries in Children and Adolescents

Marit Slåttelid Skeie, Anita Alm, Lill‐Kari Wendt, and Sven Poulsen

Dental caries is the most common chronic disease among children and adolescents [1], and thus the one most often affecting both oral and general health [2,3]. Untreated cavitated dentine lesions may also negatively influence children’s quality of life [4]. The impact of caries on oral and general health is associated with the age the child, when lesions appear, the depth of the lesions, and the location of the lesions in the dentition. The impact of the disease is more serious in younger children, in children with chronic health conditions, and in children living in countries with poor access to adequate dental health services.

Childhood dental caries as a health problem

“Health is a state of complete physical, mental and social wellbeing, not merely the absence of disease and infirmity.” This definition of health by World Health Organization, which dates back half a century, although criticized for its shortcomings [5] (Chapter 1), has been a starting point for today’s generally accepted holistic approach to health [3]. As oral health is an integrated part of general health, it is natural to use this concept even when describing caries and its sequelae in children and adolescents [6].

Dental caries has impacts on both oral and general health (Box 10.1), and when left untreated, often leads to pain, and consequently a reduced ability to chew and eat [2]. Limitations in choice of foods, loss of appetite, and reduced pleasure from eating [2] are some of the reasons why untreated severe caries may be associated with reduced body weight and impaired growth [6–8]. However, when restorative treatment was so extensive that general anaesthetic was indicated, some studies showed that children afterwards often gain weight rapidly [8]. Research also indicates that restorative rehabilitation of young children with severe caries experience is associated with substantial and highly significant improvements in their parent‐assessed oral‐health‐related quality of life [9,10].

Box 10.1 Childhood dental caries has impacts on both oral and general health, including quality of life

Physical

·     Pain and discomfort due to infection and abscess formation

·     Invasive dental treatment with risk of procedural pain

·     Disturbed development of permanent teeth

·     Negative impact on future oral health

·     Disturbed occlusal development with risk of future orthodontic problems

·     Retarded growth due to loss of appetite and reduced intake of food

·     Disturbed sleep

·     Special problems in children with chronic health conditions

Psychological and emotional

·     Dental fear and anxiety

·     Reduced aesthetics with lowered self‐esteem as a consequence

·     Being teased by other children due to aesthetics or speech difficulties

Behavioral

·     Behavior management problems

·     Lack of regular attendance to dental care

Social

·     Interruption of daily functions

·     Embarrassment while eating and speaking in front of others

An Irish study concluded that almost half of all hospital dental emergencies were due to caries sequelae [11]. Candida, osteomyelitis or sepsis due to infected teeth are reported in countries that have poor access to adequate dental or general health services [3]. Even in the Western world, for some children with chronic health conditions (Chapter 23), dental infections and to some extent the treatment of carious lesions may represent a threat to life [12].

Caries with onset early in life indicates an increased risk of future caries development [13–15], a topic that will be covered in more detail later in this chapter. Insufficient oral hygiene around a tooth with caries also often induces additional gingival problems [16]. Furthermore, deep carious lesions constitute a risk for endodontic complications and abscess development [17], which often leads to infection, abscess formation with swelling and further pain and discomfort during chewing. A high number of untreated decayed teeth is found to be related to dental sepsis as well [18]. For some children, hospitalizations and emergency dental visits are the consequences [19]. As use of antibiotics is common in dentistry [20,21], the risk for antibacterial drug resistance is another problem which should be considered. Regarding infected primary teeth, there is a risk for potential injuries to the permanent tooth such as enamel opacities, hypoplasia or developmental disturbances [12].

Extractions of primary teeth due to caries at an early age may lead to reduced dental arch length, tooth displacement, tilting, and rotations [22]. If several teeth with important phonetic functions are extracted, normal language development may be compromised [23]. Having to perform operative restorative treatment of caries in children at an early age may also affect future oral health negatively. About one‐third of fillings in primary teeth will need replacement between the ages of 7–12 years [24]. It has also been documented [25,26] that approximal cavity preparations may damage two‐thirds or more of the neighboring sound surfaces, making them more susceptible to caries. Children with caries experience at 6 years of age had three and a half times more treatments performed (i.e., new restorations, replacement of restorations, or other treatment such as disking or extraction) in primary teeth from 7 to 12 years compared to children without previous caries experience at the age of 6 years [27].

A well‐documented consequence of severe caries with pain is the reduction of the individual’s quality of life [4,6]. Disturbed sleeping, concentration problems [1,28,29] and interruption in play and schoolwork [2,30] may induce emotional stress with anger and irritability. Because of aesthetics and/or phonetic problems, there is also a risk that children will be teased, which again may negatively influence their self‐esteem, resulting in the child acquiring a silent demeanor or avoiding smiling and laughing [31].

Experiences of pain during dental treatment during childhood are well documented to increase the risk of developing dental behavioral management problems and dental anxiety later in life [32]. A study has shown that more than every third child with more than 10 carious lesions at age 5 years presented with dental anxiety 5 years later [33], indicating that painful experiences during restorative treatment are a major risk factor for development of dental anxiety. A higher prevalence of missed dental appointments among children who have had dental treatment in connection with toothache has also been documented [34]. Neglected oral health may be the consequence, and also increased economic treatment costs later in life, both for the individual and for society.

Epidemiology of dental caries in children and adolescents

Epidemiology is defined as “The study of the occurrence and distribution of health‐related states or events in specified populations, including the study of the determinants influencing such states, and the application of this knowledge to control the health problems” [35]. From this definition it is obvious that understanding and interpretation of epidemiologic data are an essential part of managing pediatric dental care. More specifically, epidemiology has two important applications in pediatric dental care: to describe the distribution of caries in the population, and to describe changes in caries prevalence over time. It is important to define certain basic epidemiologic terms in order to understand epidemiologic data on dental caries in children and adolescents (Box 10.2). Epidemiologic data can be used, for example, to provide information on:

·     The prevalence of caries in the population, according to age, gender, socioeconomic and ethnic background. This is important in order to determine the magnitude of the problem and the distribution of the burden of disease in the population.

·     The incidence of caries in the population. This will give information as to the future level of disease in the population.

·     Oral health strategic planning for caries control, e.g., how to use the existent personnel resources efficiently, how to evaluate child dental care, and how to inform the dental health authorities responsible for the financing of health care.

·     Formulation of goals and determination of whether these goals are fulfilled or not.

Box 10.2 Important epidemiologic terms used in describing occurrence of dental caries

Prevalence

The number of persons in a population with a disease or a condition at a specified point in time (point prevalence) or during a specified period (period prevalence)

Incidence

The number of new events, e.g. new cases, of a disease in a defined population within a specified period of time

dmft/dmfs (defs/deft)

Decayed, missing (extracted due to caries) and filled primary teeth (t) or tooth surfaces (s)

DMFT/DMFS

Decayed, missing (extracted due to caries) and filled permanent teeth (T) or tooth surfaces (S)

Thus, epidemiologic data are important in quality development and quality control of pediatric dental care.

Epidemiologic data on dental caries

During recent years increasing emphasis has been placed on the dynamics of the carious lesion as developing from a subclinical lesion through an initial, noncavitated lesion to a manifest lesion, eventually resulting in complete destruction of the tooth. It is now generally accepted that arrest and even reversal of initial, noncavitated carious lesions can occur [36]. This has resulted in the development of interceptive strategies in children and adolescents in the management of these kinds of lesions (see Chapter 12). An important aspect of these strategies is the need to inform the parents that appropriate preventive measures may allow a natural arrest of lesion progression while it is confined to the enamel. As guardians, they have the right to be informed about this. Parents should be shown the sites of enamel lesions and given advice for future optimal oral health behaviors. Dentists not taking this task seriously may be at future risk to encounter demands. The best period for such prevention and to reach and motivate caregivers, is during eruption of the primary teeth [37]. It might be expected in the future that operative intervention, not a treatment of the caries disease, but its consequences, will be chosen only as a secondary alternative only when nonoperative intervention methods have failed [38]. The previous traditional “care” concept, meaning operative treatment as restorations and extractions, is nowadays changed to also include nonoperative treatment in the disease management.

Nordic countries have, for administrative purposes, established data collection systems to monitor the level of dental caries. The data collected in some of these systems are the numbers of already placed restorations and/or the number teeth which according to the dentist’s judgment, need restorative treatment. Today’s shift to a more conservative treatment philosophy [39] may in this system compromise valid comparisons between studies from different time periods. An example of one exception is the system implemented by the National Board of Health in Denmark [40]. Caries data are collected by this institution according to written epidemiologic criteria, and noncavitated carious lesions are recorded as a separate caries diagnosis. Over the last few decades, several other epidemiologic projects in the Nordic countries have been carried out, using similarly detailed diagnosis criteria. These studies have shown that noncavitated carious lesions constitute a large proportion of the total number of carious lesions (Figure 10.1). In teenagers, it is reported that approximal noncavitated carious lesions may make up as much as 80–90% of the total number of carious lesions [14,41]. This actually underlines previous arguments from other researchers [42,43] that national reports considerably underestimate the total number of lesions. Additionally, by not including enamel caries, the need for modern nonoperative treatment will not be demonstrated. Thus, for a number of reasons it is very important to make explicit the criteria used for diagnosis, when presenting, interpreting, and making use of data on the occurrence of caries in children and adolescents (Box 10.3).

Three pie graphs illustrating the contribution of initial and manifest lesions, filled and missing surfaces of the total caries index in Norwegian children aging 5 (left), 12 (middle), and 18 years old (right).

Figure 10.1 Contribution of initial and manifest lesions, filled and missing (due to caries) surfaces of the total caries index in Norwegian children.

Source: Amarante et al. 1998 [42]. Reproduced with permission of John Wiley & Sons.

Box 10.3 Important aspects of using the initial, noncavitated caries lesion as diagnostic cutoff point

It is important to differentiate between initial, noncavitated caries lesions and manifest caries lesions when collecting epidemiological data because

·     Early intervention can arrest or reverse the noncavitated caries lesion, and is more gentle to the child than restoration at a later stage of development of the lesion

·     Noncavitated caries lesions can be arrested or reversed through self‐care. The parents should be informed about appropriate dental health care and appropriate diet for the child

·     Initial, noncavitated caries lesions can be treated by other dental personnel than dentists

However, the different caries measurement systems capable of incorporating noncavitated carious lesions vary in detail, in the way they are used, and in terminology (Box 10.4). A common trait is ambiguity and incompatibility in caries diagnostic thresholds around the dentino‐enamel border. Although detailed caries diagnostic systems should be considered as a step forward in the field of epidemiology, measures of caries activity are still relatively poorly developed [44]. However, Nyvad argues that additional information related to caries diagnostic decision can be obtained if carious lesions were dichotomized into “inactive” and “active” lesions [45].

Box 10.4 Diagnosis of early caries lesions has attracted considerable attention during recent years [128]. Below are excerpts of references describing such criteria based on clinical and/or radiographic evaluation (see also Chapter 12).

Example 1. Initial caries in pits and fissures, clinical diagnostic criteria [129]

Initial loss of tooth substance appearing as chalky spots in the enamel surface layer without breakdown of the surface in the form of cavitation when explored with the probe.

Example 2. Changes in enamel in pits and fissures (ICDAS) [130]

Code 1: A visible carious opacity or discoloration that is not consistent with the clinical appearance of sound enamel, seen either after prolonged air drying OR on wet enamel.

Code 2: A carious opacity and/or brown carious discoloration which is wider than the natural fissure/fossa and not consistent with the clinical appearance of sound enamel (tooth seen wet).

Code 3: In addition to the criteria of Code 2, and after dried once for approximately 5 s, a carious loss of tooth structure at the entrance to or within the pit or fissure/fossa, is seen. The dentin is NOT visible in the walls or base of the cavity/discontinuity.

Example 3. Diagnostic criteria, incorporating location of the caries lesions [131]

Criteria are described for

·     Pits and fissures

·     Vestibular and lingual smooth surfaces

·     Radiographic evaluation of proximal surfaces

Type 1: Enamel surface contour is broken; a shadow between the enamel surface and a border not more than one‐fourth through the enamel

Type 2: Shadow has reached dentino‐enamel junction

Example 4. Diagnostic criteria for enamel approximal caries, radiographic diagnostic criteria [132]

Grade 1 (A1): Radiolucency in outer half of enamel.

Grade 2 (A2): Radiolucency in inner half of enamel.

Example 5. Initial approximal caries, radiographic diagnostic criteria [14]

Di a: A caries lesion in the enamel that has not reached the dentino‐enamel junction or a lesion that reaches or penetrates the dentino‐enamel junction, but does not appear to extend into the dentine.

Example 6. Definition of pre‐cavitation caries (“iceberg model”) [93]

D1: Clinically detectable enamel lesions with “intact” surfaces.

D2: Clinically detectable “cavities” limited to enamel.

Example 7. Diagnostic criteria, differentiating between active and inactive caries lesions at noncavitated levels [133]

·     Active caries with intact surface

·     Active caries with surface discontinuity

·     Inactive caries with intact surface

·     Inactive caries with surface discontinuity

Table 10.1 lists a number of Nordic surveys on which the description, the patterns of caries in children and adolescents in this chapter is based. Descriptive epidemiologic data from these surveys are not presented because, as previously discussed, differences in diagnostic criteria hamper comparison of data.

Table 10.1 Nordic surveys of caries in children and adolescents on which the description in the present chapter is based

Author (year of publication)

Country

Age (month/year)

Seppä et al. (1989) [79]

Finland

Follow‐up (6–13 yr)

Wendt et al. (1991, 1992) [57,134]

Sweden

1 yr, 3 yr

Grindefjord et al. (1993,1995) [13,135]

Sweden

1 yr, 3.5 yr

Amarante et al. (1995) [136](136)

Norway

5 yr, 12 yr, 18 yr

Petersen (1996) [113]

Denmark

2–3 yr, 7 yr

Vehkalathi et al. (1997) [85]

Finland

5 yr, 15 yr

Mattila et al. (1998) [51]

Finland

Follow‐up (3–5 yr)

Mejàre et al. (1998, 1999, 2000) [90,91,137]

Sweden

Follow‐up (6–12 yr), (11–22 yr) and (12–18 yr)

Wendt et al. (1999) [78]

Sweden

Follow‐up (3–6 yr)

Poulsen & Pedersen (2002) [138]

Denmark

5 yr, 7 yr, 12 yr, 15 yr

Stenlund et al. (2002) [89]

Sweden

Follow‐up (11–22 yr)

Wennhall et al. (2002) [61]

Sweden

3 yr

Sundby & Petersen (2003) [112]

Denmark

3 yr, 5 yr

Ruottinen et al. (2004) [139]

Finland

Follow‐up (7 mo–10 yr)

Skeie et al. (2004, 2006) [76,40]

Norway

Follow‐up (5–10 yr)

Stécksen‐Blicks et al. (2004, 2008, 2014) [62,84,141]

Sweden

4 yr

Hugoson et al. (2005, 2008) [73,81]

Sweden

3 yr, 5 yr, 10 yr, 15 yr, 20 yr.

Mattila et al. (2005b, 2005a) [124,127]

Finland

Follow‐up (0–7 yr) and (0–10 yr)

Skeie et al. (2005, 2006) [86,114]

Norway

3 yr, 5 yr

Wennhall et al. (2005) [142]

Sweden

Follow‐up (2–3 yr)

Alm et al. (2007, 2008) [14,58]

Sweden

Follow‐up (3–15 yr)

Wigen et al. (2009, 2011) [75,143]

Norway

5 yr

Ekbäck et al. (2012) [144]

Sweden

Follow‐up (3–19 yr)

Socialstyrelsen (2013) [63]

Sweden

3 yr, 6 yr, 12 yr, 19 yr

Isaksson et al. (2013) [59]

Sweden

Follow‐up (3–20 yr)

André Kramer et al. (2014) [74]

Sweden

Follow‐up (3–6 yr)

Dental caries in the young and the late primary dentition

Dental decay in infants and toddlers has a distinctive pattern. The definitions first used to describe this condition were related to etiology, with the focus on inappropriate use of nursing practices. This generated the terms “nursing bottle mouth,” “baby bottle tooth decay,” “nursing bottle syndrome,” and “nursing caries.” The current internationally accepted definition of caries with early onset is “early childhood caries” (ECC). This terminology encompasses a broader meaning, better fitting the understanding that unfavorable feeding practice is not the only important cause of ECC. However, pediatricians have not yet succeeded in agreeing on a mutual and uniform definition of ECC, and inconsistencies in the case definitions and diagnostic criteria still exist (Box 10.5) [46,47]. The definition of ECC used in this chapter is the occurrence of any sign of dental caries on any tooth surface during the first 3 years of life [48]. A more extensive form of ECC, severe ECC (S‐ECC), is defined of the basis of age, caries prevalence, and depth of the carious lesions. Typical for S‐ECC is a high caries progression rate. Grindefjord et al. have documented that children with early caries development, before 2.5 years of age, exhibited a high caries progression rate during the period up to 3.5 years of age [49].

Box 10.5 Nomenclature and definition of ECC

Early Childhood Caries (ECC)

Occurrence of any sign of dental caries on any tooth surface during the first 3 years of life

Source: Ismail 1998 [48]

Early Childhood Caries (ECC)

Presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries) or filled surfaces in any primary tooth in a child < 6 years.

Source: National Institute of Dental and Craniofacial Research (NIDCR) 1999

Severe Early Childhood Caries (SECC)

Children with “atypical”, “progressive” or “rampant” patterns of dental caries (described separately for each age group):

1.  < 3 years: any sign of dental caries in smooth surfaces

2.  3–5 years: ≥ 1 cavitated, missing (due to caries), or filled smooth surfaces in maxillary teeth or a dmfs score of 4, 5, and 6 surfaces for ages 3, 4, and 5 years respectively

Source: National Institute of Dental and Craniofacial Research (NIDCR) 1999

Dental caries has numerous biological, psychosocial, and behavioral risk factors, which vary from population to population and combine in different patterns to result in a carious lesion (Box 11.1). Patterns of behavior that affect dental health such as oral hygiene and dietary habits are established early in a child’s life and persist during childhood [50,51] as well as during adolescence [52]. It has been demonstrated that social, economic, and environmental factors have a fundamental impact on oral health [53,54]. The complexity of life social processes and the causal networks between social structure and dental disease have been discussed by Newton and Bower [55]. Parents with an overload of demands related to their daily living and survival may fail to take their children to the dentist [56]. Children who missed dental appointments at the 1‐year examination are also shown to have significantly more caries during childhood, adolescence, and even during young adulthood than those who did attend [57–60]. Although ECC is among the most prevalent health problems of infants and toddlers from immigrant or from low‐income families [61,62], little attention and few resources have been allocated to understanding why these children develop dental caries and why some of them are so severely affected. A recent study showed a decline in caries among Swedish 4‐year‐olds between 2007 and 2012. However, this decline was limited to non‐immigrant children [62]. Thus extra attention should be paid to children and their families who fail to attend oral health examinations and appointments and to children from immigrant, low‐income families, parents with low education level, and welfare‐dependent families [63]. Health professionals should work in multidisciplinary teams with these patients at an early age. Also of importance is to improve parents’ dental attitudes, as negative attitudes are shown to impact on caries increment during the age period 3–5 years [64].

ECC is also related to hereditary and acquired etiological factors. The presence of enamel hypoplasia, for example, is one developmental defect of enamel associated with an increased risk of ECC [65]. During recent years factors related to mothers’ background have been investigated as ECC predictors; mother’s weight and intake of sugar and fat in pregnancy [66], maternal salivary bacteria [67], maternal prenatal 25‐hydroxyvitamin D levels [68], mode of delivery correlation with mutans streptococci colonization [69], breastfeeding for 18 months or longer [70], nighttime breast feeding after the age of 12 months [71], and mothers’ oral health status [72].

At 1 year of age some children have already developed carious lesions and at 3 years of age about 30% have caries (noncavitated carious lesions included) [73,74]. The first sign of dental caries in infants with ECC is the appearance of white demineralized areas on the cervical part of the buccal surfaces of the maxillary anterior teeth, while the mandibular incisors usually remain unaffected [57]. The most frequently affected surfaces in older (3.5 years of age) pre‐school children are the occlusal surfaces of the second primary molars [49]. This is in accordance with André Kramer et al. who concluded that second primary molars carried the largest burden of caries disease, in term of initial and manifest carious lesions at 3 years of age [74]. At 5 years of age, the occlusal surfaces of the second primary molars are still most affected, but by this age it is followed by approximal surfaces between the primary molars [75]. Molar approximal lesions dominate the increment in the late primary dentition [76].

There is a strong correlation between ECC and later caries development in both the primary and permanent dentitions [77]. In one study, children with manifest carious lesions at 3 years of age experienced a mean caries increment of 4.5 tooth surfaces from 3 to 6 years, compared to 0.9 tooth surfaces for children who at baseline had no manifest carious lesions [78]. Furthermore, there is a strong relationship between caries in early childhood and caries development both in the primary dentition up to 10 years of age [76] and in the permanent dentition up to mid teenage [14] and young adulthood [59]. The dmft recorded at the age of 6 years (accumulated through childhood) seems to be better correlated to caries increment between 7 and 13 years of age than caries in permanent first molar [79]. These findings make infants and toddlers an important target group for preventive dental care. All this witnesses the importance of early identification of children with ECC or, even better, with a high risk of developing ECC. The importance of informing parents and even pregnant women of preventive dental health practices, implemented from an early age for their children, cannot be emphasized strongly enough. Such mother‐child caries preventive programs up to 6 years of age have been shown to have a prolonged effect even on dental caries in the permanent 1st molars in 9‐ to 10‐year‐old children [80].

The general trend of caries decline, observed among children and adolescents in the Nordic countries during the last decades, has been less marked for the primary dentition of preschool children. As an example, a series of cross‐sectional epidemiologic surveys carried out in the city of Jönköping in 1973, 1983, 1993, and 2003 have shown that while mean dmfs in 3‐ and 5‐year‐old children decrease between 1973 and 1993, there was no further decrease between 1993 and 2003 [81] (Figure 10.2). This is in line with a study from Denmark [82]. Furthermore, a study in Umeå, Sweden, showed that over a 30‐year period mean dmfs of 4‐year‐olds decreased from almost 8 to 2, but the decrease was largest at the beginning of the period. Since 1980 mean dmfs has been constant at about 2 [83]. However, after implementing a new preventive program at an early age, a decline in caries prevalence in 4‐year‐old children has taken place concomitantly with improved oral hygiene habits and a decreased sugar challenge [84].

Clustered bar chart illustrating the mean number of decayed and filled tooth surfaces according to age in 1973, 1983, 1993, 2003, and 2013.

Figure 10.2 Mean number of decayed and filled tooth surfaces according to age in 1973, 1983, 1993, 2003, and 2013, Jönköping, Sweden. For 3‐ and 5‐year‐olds only caries in primary teeth were recorded, while only caries in permanent teeth were recorded in subjects 10 years and older. Initial, noncavitated carious lesions were included.

Source: Norderyd et al. Oral health of individuals aged 3–80 years in Jönköping, Sweden during 40 years (1973–2013). II. Review of clinical and radiographic findings. Swed Dent J 2015;39:69–86.

The distribution of dental caries among preschool children is today characterized by a marked positive skewness [75]. According to Vehkalahti et al. [85] 8% of the 5‐year‐olds accounted for 76% of the total number of teeth with current untreated caries in their age group. When enamel caries were also included in a sample of 3‐ and 5‐year‐olds, 67% of all carious surfaces were found in 10.7% of the children [86]. Thus, while dental caries is less of a burden than previously for most preschool children, it remains a significant problem for some children.

Caries in the permanent dentition

Caries in the permanent dentition has decreased considerably. As an example the epidemiologic surveys conducted in the city of Jönköping over 30 years have shown a decrease in DFS in age groups 10, 15, and 20 years between 1973 and 2003 [81] (Figure 10.2). From other data, such as those reported from 1988 to 2013 for 15‐year‐old Danish children, a marked shift to the left of the distribution according to DMFS (Figure 10.3) can be seen. Isakson et al. showed that 10% of a group of 20‐year‐olds had 62% of the initial lesions and 56% of the manifest lesions and restorations at approximal sites in premolars and molars [15].

Clustered bar chart illustrating the distribution of 15‐year‐old Danes according to DMFS (initial, noncavitated lesions not included) in 1988, 2006, and 2013.

Figure 10.3 Distribution of 15‐year‐old Danes according to DMFS (initial, noncavitated lesions not included) in 1988, 2006, and 2013.

Based on data from the Danish National Board of Health 2013.

The majority of the lesions are located to specific teeth and to tooth morphology types such as pits and fissures (occlusal surfaces). It has been described as a general pattern that when caries prevalence falls, the largest reduction is found on the least susceptible surfaces (proximal and free smooth surfaces) [87]. The least susceptible of all sites in the dentition are on the lower anterior teeth and canines. Independent of the age, such a location of the lesions indicates that the individual is extremely caries active, especially if the child belongs to a low‐caries population.

In the young permanent dentition the permanent first molars constitute the most caries‐susceptible teeth, and in line with what is described above, up to 12 years, pits and fissures are the most frequent sites for caries development [88]. The risk decreases as the time after eruption increases, suggesting that the first 4–5 years after eruption constitute risk ages for new approximal caries [89]. At the age of 12, the mesial surface of the first permanent molars account for the majority of approximal lesions [90], strongly correlated with past caries experience of the adjacent surface of the primary second molar [91]. At 21 years of age, the permanent first molar contributes considerably to the total caries burden, as the occlusal, mesial, and distal surfaces of this tooth account for 60% of all restored surfaces [92].

Above the age of 12 years, caries progression is generally slower. A radiographic study found that caries progression (from inner half of the enamel to outer half of the dentin) on the mesial surface of the first permanent molar was almost four times faster in a young age group (6–12 years) than in an older group (12–22 years) [90].

Caries in children and adolescents in a changing society

Not only society, but also the caries disease itself may be said to have been an object of change. The morphology is one example. As distinct from previous times, a clearly visually evident carious lesion is now often indicative of a considerable destruction of underlying tissue [93]. Caries distribution has become increasingly skewed, both at population, individual, and dentition level (teeth/surfaces). The same may be said for the distribution of caries determinants [94], which also are influenced by new trends in a changing society. Essentially, caries determinants, like other health risks, cannot be considered in isolation from the society to which the individual belongs [95]. All changes in the social situation for children should be monitored in order to search for possible associated new or changing caries determinants or caries risks [96]. Compared to the conditions today’s generation of parents and grandparents lived through when they were young, children nowadays experience a different everyday life, in both style of parenting and pattern of family life. During recent years children living with one parent have increased [97], and compared to children of two‐parent families, they are found to be more affected by caries [63]. There are also reasons to believe that some of the traits of modern lifestyle have led to caries‐promoting behaviors, such as irregular meals, “democratic negotiations” between child and parent, parental indulgence about children’s bedtimes, easily accessible fast food, increased intake of snacks and soft drinks, and so on. Many of the same behaviors are also associated with lifestyle diseases such as overweight and obesity [3] which today represent a frequent medical condition in children and adolescents [98–100]. The etiology of both childhood obesity and dental caries is multifactorial and includes dietary, social, and cultural factors [101,102]. Results of research into the relationship between obesity and dental caries in children have been both mixed and inconclusive [103]. However, in studies from Sweden, overweight and dental caries are significantly associated in children and adolescents [104,105]. Studies have also shown a relationship between the consumption of sugar‐sweetened drinks and childhood obesity [106,107]. Focusing on diet for example, the common risk factor approach, described by Sheiham and Watt, addresses the mutual etiologic factors of both dental caries as well as overweight and obesity [108]. It is notable that preschool children with low BMI are also shown to be at risk of caries development [109], and it is speculated that this relationship could be associated with poor eating habits.

Another change in modern society is that not all young people manage to be fully integrated in the community and drop outside into societies where drug dependency is widespread. The lifestyle of addiction is shown to have negative impacts on oral health [110]. Further, the oral health of children of substance‐abusing parents should receive extra attention due to documentation of a high prevalence of ECC [111] in this group.

Migration is another phenomenon in modern society. During recent decades the Nordic countries have had an influx of immigrants from the non‐Western world, changing the Nordic societies to multicultural societies [84,112]. Immigrant children represent a major challenge to our oral health care, especially in very young children [62,84,113]. Dental health disparities between immigrant and nonimmigrant children and teenagers have during the last decade been documented by many Nordic studies [57,63,78,86,112,114]. A Danish study in Copenhagen by Christensen el al. documented a mean caries experience among 5‐ and 7‐year‐old children to be three to four times higher in children of non‐Danish mothers. Other factors associated with caries in the study were low family income, high number of children, and low maternal educational levels [115]. The previously mentioned study from a low‐income multicultural population in an urban area of Malmö, Sweden, found a caries prevalence (noncavitated carious lesions included) of 85% among 3‐year‐old children [61]. All these studies underline that although the public dental service is free and prevention‐oriented, inequalities still relate to caries experience in children and adolescents.

Immigrant children are not a homogeneous group, but with backgrounds from a wide range of countries. It has for long been accepted that cariogenic practices are culturally embedded [116]. Danish authors describe marked differences in dental caries prevalence between different ethnic minorities, and compared to Danish children. There were cultural differences in dental attendance, and self‐care practices of children and parents. These social‐behavioral factors may help to explain the differences in dental caries prevalence and severity [112,113]. Parental dental attitudes towards children’s oral health are affected by cultural and ethnic diversity [114,117]. In some minority groups and cultures, dental care is not always given priority, and this is especially true for the primary dentition [118]. Poor knowledge about dental‐health‐related matters, language problems, surrounding stress factors, and problems with resettlement may all be barriers overshadowing the need for dental care [119–121]. Besides problems caused by socially and culturally different backgrounds, immigrant families often live in low socioeconomic surroundings, thereby experiencing an additional caries risk factor [122]. Public dental health workers also have to communicate information on oral health practices to immigrant groups in a manner that is sensitive to their cultural background [123].

As those factors in society mentioned above are important determinants for oral health in children, it is important that the oral health‐care services as well as pediatric dentists are committed to consider not only the individual child, but also the entire child population, including the network around the child and its living conditions [124]. Studies have shown that the family is an important mediator of socialization and the development of health‐related behaviors even during adolescence [52,125]. Nicolau et al. [126] discussed a life‐course approach and stated that “the development of oral hygiene habits may be sensitive to the socioeconomic environment in which the people live during their childhood.” Although the etiological mechanisms for dental caries are well known, the early life events which may contribute to caries are not completely understood.

Almost all children are born with healthy teeth. It is therefore very important to involve parents and health‐care professionals during pregnancy, infancy, and preschool age to focus on health factors to maintain oral health during the lifetime. Lastly, the importance of a good co‐operation between professionals working in dental clinics and child health‐care centers must be stressed [127].

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