General Anaesthesia–assisted Comprehensive Dental Management of Severe Early Childhood Caries in an Uncooperative Child: A Case Report

INTRODUCTION

Early childhood caries (ECC) is a common, chronic, and multifactorial disease affecting the primary dentition of infants and young children and continues to pose a significant public health concern worldwide. The American Academy of Pediatric Dentistry (AAPD) defines ECC as “the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth” in a child less than 72 months of age.¹ Severe early childhood caries (S-ECC) is defined as: 1) any sign of smooth-surface caries in a child younger than 3 years of age; 2) from ages 3 through 5 years, one or more cavitated, missing (secondary to caries), or filled smooth surfaces in primary maxillary anterior teeth; or 3) a decayed, missing, or filled score of greater than or equal to 4 (age 3), greater than or equal to 5 (age 4), or greater than or equal to 6 (age 5)¹. The development of ECC results from a complex interplay of dietary practices, oral hygiene habits, early colonization by cariogenic microorganisms, host-related factors, and socioeconomic determinants. Due to the relatively thinner enamel and dentin of primary teeth, the disease often progresses rapidly, leading to extensive tooth destruction at an early age.

Ripa described a characteristic pattern of involvement in early childhood caries , wherein the distribution of carious lesions closely follows the chronology of tooth eruption, with the maxillary primary incisors being the earliest and most severely affected teeth, often shortly after their eruption.² In contrast, the mandibular incisors are usually spared during the initial stages due to the protective positioning of the tongue and the cleansing action of saliva from the submandibular and sublingual glands. Carious lesions typically begin on the smooth surfaces of the maxillary anterior teeth, particularly in the cervical region.

A defining feature of early childhood caries is the “burrowing pattern” of carious destruction, as described by Ripa, wherein caries rapidly penetrates the enamel and spreads laterally along the dentino-enamel junction, resulting in extensive dentinal involvement beneath a relatively intact enamel surface.² This pattern ultimately leads to undermining of enamel and sudden crown fracture. The high organic content of primary dentin, wider dentinal tubules, and reduced mineralization further accelerate disease progression. With continued exposure to etiologic factors, posterior teeth—particularly primary molars—may also become involved, often leading to early pulpal pathology and widespread breakdown of the primary dentition.³

Children affected by early childhood caries commonly present at a very young age and are often lacking cooperative ability to tolerate routine dental procedures, making comprehensive dental management challenging using conventional non-pharmacological behaviour guidance techniques. If left untreated, the condition can result in pain, infection, impaired mastication and speech, aesthetic concerns, and adverse effects on nutrition, growth, and overall quality of life.^4,5 In such circumstances, general anaesthesia (GA) serves as an effective behaviour guidance modality, enabling complete oral rehabilitation to be performed safely in a single visit. The AAPD recommends the use of GA in young children who lack cooperative ability when extensive dental treatment is required.^6,7

This case report describes the comprehensive dental rehabilitation of a young child diagnosed with nursing bottle caries and extensive tooth destruction, successfully managed under general anaesthesia.

CASE REPORT

A female child aged two and a half years reported to the Department of Paediatric and Preventive Dentistry with the chief complaint of multiple decayed teeth, noticed by the parents for over one year. The delay in seeking dental care was attributed to parental perception that the affected teeth were temporary in nature and would eventually exfoliate, along with the absence of pain and apprehension regarding the child’s young age and anticipated lack of cooperation during dental treatment.The parents reported the presence of numerous carious lesions involving the maxillary anterior and posterior teeth, as well as the mandibular posterior teeth. Although there was no history of pain, the parents expressed concern regarding the child’s reduced food intake

Diet history revealed prolonged bottle-feeding with milk for more than one and a half years, particularly during bedtime, along with frequent consumption of a sticky, cariogenic diet including biscuits and chocolates. The child did not present with any relevant past dental or medical history.

General physical examination revealed a well-nourished child with normal vital signs and no significant systemic findings. Behavioural assessment demonstrated an extremely anxious and uncooperative child, and the behaviour was rated as Frankl’s definitely negative. Extraoral examination did not reveal any abnormalities. Intraoral examination revealed a complete set of primary dentition with grossly decayed maxillary primary central incisors (51, 61) associated with sinus openings. Smooth surface carious lesions were observed involving 52, 53, 62, and 63, while multisurface caries affected 54, 64, 74, and 84, as shown in Figure 1a, 1b, and 1c.Based on the clinical findings and detailed dietary history, a diagnosis of early childhood caries was established, and full mouth rehabilitation was planned.

During the first two working appointments, the child exhibited severe anxiety and apprehension, continuing to fall under the definitely negative category of the Frankl Behaviour Rating Scale, making conventional dental treatment impossible. Considering the extent of dental disease, the need for comprehensive rehabilitation, and the child’s lack of cooperative ability, the parents were counselled regarding the necessity of performing dental treatment under general anaesthesia, to which they consented.

No emergency intervention was required. As part of the preventive phase, oral hygiene instructions and dietary counselling were provided to the parents. A detailed pre-anaesthetic evaluation was conducted during the preparatory phase, which included complete blood count, random blood sugar levels, bleeding time, clotting time, liver and kidney function tests, electrocardiography, chest radiography, and viral markers (HIV, HCV, and HBV). The pre-anaesthetic assessment revealed physiological narrowing of the upper respiratory tract, and therefore a time constraint was advised due to the risk of oedema associated with prolonged intubation.

Following completion of the systemic and preventive phases, the patient was admitted one day prior to the procedure at hospital. The treatment plan was thoroughly explained to the parents, and written informed consent was obtained.

Prophylactic antibiotic coverage was initiated prior to the induction of general anaesthesia. Full mouth rehabilitation was subsequently performed under general anaesthesia. Pulpectomy procedures were carried out in relation to teeth 51, 61, 52, and 62. Post and core restorations were placed in relation to teeth 51 and 61, followed by the placement of Bio Flx crowns (Kids-e-Dental) on 51 and 61. Full coronal restorations using Bio Flx crowns were placed on 52 and 62. Composite restorations were completed on teeth 53, 63, 54, 74, and 84. Due to multisurface carious involvement, a stainless steel crown was placed on tooth 64 after thorough caries excavation. The entire procedure was completed within approximately 1.5 hours, as shown in Figure 2a, 2b, and 2c.

Postoperatively, the patient was observed overnight to monitor recovery from general anaesthesia and to rule out any immediate complications. The child remained stable and was discharged the following day. A three-day course of antibiotics was prescribed considering the presence of multiple infected teeth and the extensive nature of the procedures performed, along with analgesics for pain control. Parents were instructed regarding oral hygiene maintenance, adherence to a soft diet, and the importance of follow-up. The patient was scheduled for review after one week.

At the three-month follow-up, the patient demonstrated improved cooperation and better dietary intake as reported by the parents. Intraoral examination revealed generalized surface wear of the BioFlx crowns in relation to teeth 51, 52, 61, and 62, with comparatively greater wear noted on teeth 61 and 62; all crowns, however, remained intact, well-adapted, and clinically satisfactory, as seen in Figure 3. Dislodgement of composite restorations was observed in relation to teeth 53, 63, and 54, whereas restorations in relation to 74 and 84, along with the stainless steel crown on 64, were found to be intact with good marginal integrity. Overall oral hygiene showed moderate improvement with partial dietary compliance. Re-restoration of the affected teeth was planned, and reinforcement of oral hygiene instructions and dietary counselling was provided, with advice for regular follow-up to ensure long-term treatment succes.

DISCUSSION

The successful management of early childhood caries requires a comprehensive approach that addresses not only the existing dental pathology but also the underlying etiological factors contributing to disease progression. In the present case, the severity and distribution of carious lesions reflected prolonged exposure to inappropriate feeding practices and a highly cariogenic diet, necessitating full mouth rehabilitation rather than isolated restorative intervention.³

Restorative treatment under general anaesthesia allowed for complete elimination of infection, preservation of remaining tooth structure, and restoration of both function and aesthetics in a single appointment. General anaesthesia is indicated in young children who lack cooperative ability and require extensive dental treatment, as it ensures safety, efficiency, and psychological well-being.^6,7 In addition, comprehensive dental care under GA has been shown to reduce the risk of repeated traumatic dental visits and improve overall treatment outcomes.⁸

Pulpectomy procedures were indicated in teeth with extensive coronal destruction and early pulpal involvement, enabling maintenance of arch length and prevention of premature tooth loss. In severely compromised maxillary incisors, post and core restorations were placed to provide adequate retention and structural support for full-coverage restorations. Such an approach is essential in cases where coronal tooth structure is insufficient to retain crowns independently.⁹

BioFlx crowns were selected for the restoration of anterior teeth owing to their favourable aesthetic properties, flexibility, and ability to closely mimic the natural morphology of primary teeth, making them a suitable full-coverage option in young children. Recent evidence has demonstrated that BioFlx crowns exhibit good clinical performance along with high levels of child and parental satisfaction when compared to zirconia and stainless steel crowns.¹⁰ However, observations from the three-month follow-up in the present case revealed generalized surface wear of the BioFlx crowns, with more pronounced wear in relation to teeth 61 and 62, suggesting that despite their aesthetic and adaptive advantages, their wear resistance may be comparatively moderate under functional and dietary stresses. This finding is supported by available evidence indicating that BioFlx crowns may demonstrate variable wear resistance compared to zirconia crowns, with material-dependent differences under occlusal loading conditions.¹¹ Nevertheless, despite the observed surface changes, the crowns maintained satisfactory colour stability and overall aesthetic appearance, with no significant discoloration or loss of translucency during the follow-up period. Collectively, these findings indicate that BioFlx crowns provide promising short-term aesthetic and functional outcomes; however, their long-term durability, particularly in terms of wear resistance, warrants further evaluation through longitudinal clinical studies.

Comprehensive dental rehabilitation in early childhood has been associated with significant improvements in mastication, speech development, nutritional intake, and overall quality of life.^4,5 However, the long-term success of such treatment depends largely on preventive strategies, including parental education, dietary modification, and reinforcement of oral hygiene practices.³ In the present case, emphasis was placed on preventive counselling and regular follow-up to minimize the risk of disease recurrence.

Early diagnosis, appropriate behaviour guidance, and timely intervention remain crucial in the management of early childhood caries. A multidisciplinary approach involving restorative care, preventive measures, and parental motivation is essential to ensure favorable long-term outcomes in affected children.

REFERENCES