The AAPD defines ECC as the presence of one or more decayed (non cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child aged 71 months or younger. Any sign of smooth surface caries in children younger than 3 years of age is indicative of severe ECC [5].

ECC leads to pain, possible infection, destruction of dental surfaces, deterioration of life quality of children (difficulties in speaking, eating, sleeping, delayed physical growth), and school and social disruption for kids and their caregivers if left untreated [67].

The most commonly used preventive measures in managing ECC, in addition to awareness and educational programs, remains the topical application of antimicrobial agents (such as fluoride gels, fluoride varnishes, sealants, chlorhexidine, xylitol, povidone iodine, and silver compounds) [8].

Extensively cavitated ECC lesions pose a growing challenge in terms of treatment. Where possible, minimally invasive techniques are advantageous [9]. There is no consensus as to the best conventional restorative technique despite advancements in dental materials and techniques [8]. Following pulp therapy, it is generally advised to seal teeth with a stainless steel crown.

Despite the wide array of treatments available, one major aspect of child management remains their acceptance of the proposed procedures in the dental chair without anxiety or perceiving dental visits as a threat. Children exhibit different attitudes and temperaments, which are influenced by their differences in physical, emotional, and social development. To provide the best possible painless and stress-free care under a conventional dental setting, behavioral management approaches have shifted in the second half of the 20th century to an increased emphasis on communication and empathy [10]. Dental practitioners have a range of non-pharmacological techniques to choose from that are dependent on their clinical training, experience, communication skills, patient specificities, and parents' involvement (Table 1). Under certain circumstances, the health provider is faced with challenges in the dental chair that may lead to ineffective strategies to combat the disease. Therefore, there has been a shift to pharmacological management to provide a safer environment for children and parents. At the end of the sedation continuum is the use of general anesthesia (GA) [11]. This type of individualized dental treatment has been used more often in the last decades as a means to provide high quality preventive or restorative treatment in one appointment.

When evaluating the outcome of a treatment, both the clinical impact and incidence on quality of life should be taken into account. OHRQoL is an emerging multidimensional construct recognized by the World Health Organization as an important segment of the Global Oral Health Program (2003) [48]. OHRQoL assessments are particularly important in survey research to examine trends, highlight population needs, and measure treatment efficacy to improve care through potential policies and protocols. But most importantly, OHRQoL allows a shift from a traditional clinical approach to the integration of the patient as an active participant by taking into account the impact of oral disease and care on their daily emotional, social, and physical experiences [49].

Studies with short-term follow up periods have indicated a significant improvement in the OHRQoL of children. Interestingly, one long-term study highlighted that it has deteriorated over time after an immediate improvement. This indicates that GA is a positive addition to ECC management; however, it is important to discuss the limitations of these measures. A loss of contact with participants post treatment might justify the short follow up periods in most studies; however long term assessment is necessary to judge the sustainability of results because an early follow up might not yet show the full quality of life gains from the treatment. Evaluating patient satisfaction through questionnaires might be affected by response bias or misinformation because most preschool children lack the linguistic and cognitive maturity required to answer the questions. This means that most responses rely on a proxy perspective via parents or caregivers. This might lead to a different perspective depending on family dynamics and personality traits. In addition, high parental satisfaction does not always match the post-operative outcome. Treatment choices (restorative, exodontia, and preventive) might also influence the scores. While these represent a positive overall effect, further studies are required to assess different treatment types and the application of age appropriate scores.

Most recent studies do not report different treatment choices, the restorative failure rate, or the caries relapse rate. These studies rely on parental satisfaction and overall quality of life as outcome measurements. Jang and Shen (2019) and Amin (2016) did report these factors and show similar findings to previous studies.

As early as 1991, O'Sullivan et al. [50] reported that the use of stainless steel crowns (SSCs) in the treatment of ECC under GA yielded better results than conventional restorations with amalgam and composite (3% vs. 29% failure rate). They reported a failure rate of 2% for vital pulpotomies. In line with this, El Eheideb et al. [51] reported that SSCs were more successful (95.5%) when compared with amalgam and composite restorations (50%) and pulpotomies showed a 97.1% success rate. In anterior teeth, strip crowns had a similar success rate when compared with composite resin materials and sealants had an increased average retention rate (68.3%). Further, Tate concluded that SSCs showed the most reliable results and blamed the failure of composite restorations on follow up length [52]. Eidelman et al. [53] compared the quality of restorations performed in young children with ECC under GA to those treated under sedation. They concluded that the frequent use of SSCs in the GA group is motivated by the extensive destruction of teeth and a reduced possibility for the requirement of further retreatment. Similarly, the absence of movement from the child allows for the use of sensitive strip crowns that provide better results in the GA group. Therefore, only 59% of patients under GA required a follow up, which is compared with 74% of patients under sedation.

Nonetheless, ECC is an aggressive and multifactorial disease with a high relapse rate and higher chance of developing caries in permanent dentition [212241]. Therefore, many children with ECC that are treated under GA exhibit high caries relapse rates. Almeida et al. [54] reported a 79% caries recurrence rate in children who underwent ECC treatment under GA; 17% of these patients required a repeat GA intervention within two years. Similar results were revealed by Kakaounaki et al. [55]: 8.9% of 484 children required a re-intervention under GA during a 6-year follow up period. Further, Berkowitz et al. [56] reported that over half the children in their study exhibited new smooth surface caries lesions after 6 months and most parents were unresponsive to later appointments. Similarly, Foster reported that half their patients had new caries within two years and this relapse was more likely when parents failed to attend follow up care [57]. Amin et al. (2010) reported a 22% relapse rate in patients attending a recall appointment within 1 year following surgery compared with a 51% relapse rate in the group attending their first recalls at 13–24 months post-surgery. Correspondingly, an increased relapse rate from 51% in the high attendance patients to 68% in patients with lower attendance rates was reported by El Batawi (2014). The aggressive dental approach of ECC under GA (extractions, pulp therapy, and SSCs) did not decrease caries relapse, which might indicate that this is better explained by a lack of follow up care and persistence of cariogenic habits post rehabilitation [5859].

Therefore, it is clear that GA might be a preferable option in certain cases for dealing with extensive ECC damage in uncooperative children; however, a strict compliance with post-operative plans is crucial to avoid the loss of any positive rehabilitation outcomes. Poor follow up compliance or loss of participants might indicate unreported caries recurrence. This highlights that the caregiver should be the primary recipient of information regarding the importance of follow up care and hygiene. An approach that treats the clinical outcome of caries alone without addressing or correcting the underlying risk factors of ECC will fail. Therefore, the role of the pediatric dentist goes beyond the surgical intervention because they are required to provide appropriate guidance and insist on regular follow up visits. Future research should focus on the tooth-based and patient-related factors of relapse. Procedure focused studies will have clinical significance in determining the preferred protocols for the restorations of specific teeth or surfaces and the success rate of each procedure. Taking into consideration patient related factors is important because it affects equally the choice and success of specific treatments.