Early Childhood Caries: New Knowledge Has Implications for Breastfeeding Families

Anne Altshuler, RN, MS, IBCLC

Madison WI USA
From: LEAVEN, Vol. 42 No. 2, April-May-June 2006, pp. 27-31.

Research over the past decade has led to a new understanding of Early Childhood Caries. Formerly known as Baby Bottle Tooth Decay or
Nursing Caries, Early Childhood Caries is defined as the presence of one or more cavities in deciduous teeth in a child aged 71 months or
less. If unchecked, decay proceeds to the upper molars and canines. In some cases, the lower teeth may become involved as well (1, 3, 4).
Dental caries is now recognized to be an infectious disease caused by an overgrowth of microorganisms that are part of our normal oral
flora. The bacteria Streptococcus-mutans (S. mutans) is thought to be a primary cause (3, 5). Dental caries has been a serious health
problem for the past 200 years and is seen around the world (6, 1). In the United States, dental care is the largest unmet health need among
children (1).

How Is Early Childhood Caries Acquired?

Three factors are necessary for Early Childhood Caries to occur (7):

1. A susceptible tooth. Some variables make teeth more vulnerable to decay. Genetics may influence the pitting and grooving of teeth, alter
the tooth enamel, and affect the pH level (degree of acidity) of the saliva. Factors during the mother's pregnancy such as fever or other
illness, malnutrition, iron deficiency, lead exposure, stress, or antibiotic use may cause developmental defects in the baby's tooth enamel,
known as hypoplasia (1, 5, 6). There is some evidence that babies born by cesarean section (8), born preterm or small for gestational age
(2), or who are children of smokers (9), are also at increased risk of dental caries.

2. The presence of cariogenic (cavity causing) bacteria. There is a natural microbial succession that occurs in the mouth during the first year
or two of life.

Within the mouth, microbial biofilms form; they are composed of many commensal bacterial species and usually exist in equilibrium with host
defenses. But when the composition of the biofilm and the metabolic activities within it are disturbed, the proportion of disease-causing
bacteria increases, usually at the expense of other biofilm inhabitants (5).

Although it is thought that there is a whole constellation of organisms that interact within the plaque biofilm to cause caries formation, S.
mutans is known to be a major culprit (3, 4). It is most often acquired by the infant from the mother, but possibly also from other adult
caregivers, siblings, or playmates (4). When adults share food, eating utensils, or put pacifiers in their mouths, bacteria may be transmitted
to the infant. The same is true when babies put their fingers into the mouths of others and then into their own.

Reducing the level of bacteria in a mother's mouth may reduce transmission to her baby. Xylitol, a natural carbohydrate sugar substitute that
interferes with bacteria's ability to stick to the tooth surface, has been shown to be effective in reducing the caries risk for children of mothers
with high levels of S. mutans (10). It has been incorporated into a chewing gum which may be given to pregnant women with high oral
bacterial counts (11, 12). Mothers have also been treated with chlorhexidine rinses to reduce their level of oral S. mutans, again resulting in
a lower number of caries in their children (3, 5).

Studies show that a newborn's mouth is sterile at birth and colonized with adult levels of bacteria within one or two days of life (1). There are
also two distinct "windows of infectivity." Between 19 and 36 months (but possibly as early as three months for some children) and six to
eight years, during periods of tooth eruption, S. mutans is best able to gain a foothold (5, 1). Once a stable biofilm develops, the conditions
for colonization are no longer ideal and the window of high infectivity closes. While continuous care is prudent, vigilant awareness and care
are especially needed at these times.

3. The presence of acid. The normal, neutral pH in the mouth is 6.4 to 7.0 tending toward acidity. The lower (or more acidic) the pH
becomes, the more likely it is that dental caries will develop. S. mutans is able to break down sugar to use for energy, forming an acidic
environment and leading to a process of demineralization and etching of the teeth (5). The more frequently sugars or fermentable
carbohydrates are present in the mouth, the more often the acid-forming cycle occurs, with potential for harm to the teeth. Babies who suck
on bottles containing anything but water throughout the day or night, and toddlers who carry around sippy cups of juice, milk, or other
beverages are continually creating acidic conditions ripe for causing decay (4, 13).

Saliva is a first line of defense. It acts protectively to wash away food debris and bacteria and serves as a buffer to acid formation. Saliva
may also have a bacteriostatic effect, inhibiting the growth of bacteria without destruction of the bacteria. It further contains calcium and
phosphate, which are needed in remineralization of the tooth enamel. Iron deficiency or prenatal exposure to lead can impair salivary gland
function and put the child at greater risk for caries (5). If the oral pH falls below 5.5, saliva is no longer able to counter acid effects, and
demineralization of the teeth begins to occur (14). Conditions such as mouth breathing or the use of medications like antihistamines or drugs
for asthma that reduce saliva flow interfere with this buffering effect. Saliva flow is also lessened during sleep, when the salivary glands do
not secrete spontaneously (7). Frequent and/or prolonged night feedings may thus become a risk factor for susceptible children.

Certain foods or beverages may contribute to an acidic environment. Carbonated beverages are especially high in acid as well as sugar.
One can of soda contains the equivalent of as much as 11 or 12 teaspoons of sugar. Even carbonated diet drinks that have no sugar content
still contain acid and therefore are harmful to the teeth (15, 16, 17, 18). Pacifiers that have been dipped in sweet solutions, juices, or other
sweetened drinks, and liquid medications in sugar syrups are other precursors to acid production. Nearly 100 percent of pediatric
medications contain sucrose, some as much as 80 percent of their volume (7). Even breads and cereals that don't appear to be sweet
contain fermentable carbohydrates that can be converted to acid, and the digestive enzymes present in saliva can convert these foods into
sugar directly within the mouth.

What Are the Consequences of Early Childhood Caries?

Decayed teeth can be very painful and abscesses can develop. Some children who develop Early Childhood Caries learn to live with chronic
pain and don't know what it is like to live pain-free. The ability to chew and eat is compromised.

Children with Early Childhood Caries show slowed growth rates and may be diagnosed with failure-to-thrive (3). Speech can also be
affected. If primary molars are lost due to decay, malocclusion may occur. Emotional health may be compromised. Children may smile less
often and their self-esteem may be affected by others' reactions to their browned, decayed, or missing teeth, or a mouthful of silver caps.
Dental repair is an arduous and expensive prospect for young children, often requiring hospitalization, general anesthesia, and intravenous
antibiotics to treat, repair, or extract the affected teeth.

Ignoring the situation in hopes that secondary teeth will come in unaffected is not a good option since having Early Childhood Caries is a
strong predictor of decay in permanent teeth (3).

An earlier Scandinavian study has shown that S. mutans levels can usually be drastically reduced by removing any caries and maintaining
excellent oral hygiene. They found that chemicals rarely had to be used (39).

Recognizing Early Childhood Caries

Dental health care providers have developed a campaign called "Lift the Lip" to help parents check for signs of Early Childhood Caries (19).
Once the primary teeth have erupted, parents can lift the baby's upper lip and visually check both front and back of the four upper front teeth
at least once a month.

Checking a child's teeth takes only a minute. It is helpful to have one adult hold the baby while a second adult looks at the teeth. A small
dental mirror can help in viewing the back surfaces of the teeth. White spots on the surface of the upper front teeth or whitish lines at the
base of the teeth along the gum line are indicators of Early Childhood Caries. If a parent notices any white spots on the teeth, a dentist visit
is warranted. At this stage, Early Childhood Caries may still be reversible with prompt treatment. If left unchecked, the "white spot" lesions
can rapidly develop to brown spots and general decay of the teeth. Ideally, all children should be seen by a dental health care provider within
six months of the eruption of the first tooth, and no later than 12 months of age.

Prevention

Non-breastfeeding infants are at a higher risk for tooth decay when compared to breastfed babies (2, 20). Components present in human
milk play a protective role. Immune factors such as Secretory IgA and IgG can slow the growth of the specific types of streptococcus mutans
colonizing the child's mouth (21, 22). Lactoferrin in mothers' milk has a bacteriocidal effect (destroying bacteria), as well (6). Dr. Pamela
Erickson studied the decay potential of various liquids (23, 24). Water had a decay potential of 0.00 and a 10 percent sucrose solution had a
decay potential of 1.00. Human milk had a decay potential of 0.01, close to that of plain water. Various formulas differed in their ability to
lower the pH, to support the growth of S. mutans, and to dissolve tooth enamel. Human milk did not lower the pH in plaque (the sticky
usually colorless film on teeth that is formed by and harbors bacteria), and did not support the growth of S. mutans. Additionally, calcium and
phosphorus in human milk were actually deposited on the tooth enamel. However, when 10 percent sucrose was added to human milk, the
decay potential rose to 1.30. It was concluded that human milk by itself is not cariogenic.

Once the first teeth erupt and additional foods and fluids have been added to the diet at around six months of age, breastfed babies, like
other babies, are susceptible to caries development (25, 26, 27, 28). Also, when a baby is fed mother's milk via a bottle, the protective
mechanisms of active breastfeeding are compromised. An actively sucking baby at the breast is also swallowing, so milk does not pool in the
mouth and against the teeth, as it does when a child falls asleep while drinking from a bottle (29, 30). The natural secretion action of the
salivary glands directly behind the lower front teeth is also beneficial.

Fluoride is a mineral that occurs naturally on the earth's surface in rock, air, vegetation, and groundwater. Fluoride is incorporated into the
baby's developing teeth and increases the quality and strength of the tooth enamel, forming a more acid-resistant surface. It can also help to
re-mineralize teeth and repair early decay. The presence of fluoride may lower the incidence of dental caries by 50 to 70 percent (31, 32).
Many health experts are strong in their support of fluoride as a weapon in the fight against dental caries (32). Families that derive their
drinking water from a well can have the water tested to determine the amount of fluoride present.

Households that use bottled water or filter their water should be aware that the level of fluoride may not be sufficient to deter caries
formation. Fluoride supplements may be recommended for infants over one year of age who do not have access to fluoridated water
supplies. Some susceptible children may need topical applications of fluorides by a dental health care provider. Fluoride in toothpaste can be
beneficial for children over two years of age.

Good oral hygiene is an important part of every baby's care. The gums may be gently cleaned with water and a soft cloth or gauze pad as
part of bath time or after feedings. This helps a baby become accustomed to oral care. Once the primary teeth erupt, parents should clean
them at least twice daily with a small, soft toothbrush. Parents may need to supervise and assist children with tooth brushing until they are
about seven years old and have enough manual dexterity to brush effectively on their own, about the time that they can tie their own
shoelaces (33). Brushing disrupts the bacterial biofilm matrix on the teeth, interfering with acid production and slowing the decay process.
Children with developmental disabilities or special health care needs such as Down Syndrome, cleft lip and/or palate, or cerebral palsy are at
higher risk for Early Childhood Caries and may need additional help with oral care.

A healthy diet aids in building strong teeth and is important for both mothers and children. The more frequently we eat during the day and
night, the more frequently the damaging cycles of acid formation occur. Babies and young children have small stomachs and need to eat
more frequently than older children and adults. For good dental health, it is helpful to offer three distinct meals and two to three snacks per
day, rather than allowing continuous snacking that leads to an increased frequency of destructive acid formation (2). Snacking on healthy
fruits and vegetables is always a good choice. Cheese, for example, has an anticariogenic effect because it causes salivary glands to retain
calcium and phosphates, which are needed for remineralization of the tooth surfaces. It may also increase salivary flow (7).

How can La Leche League Leaders Support Families Dealing with Early Childhood Caries?

We can listen in a nonjudgmental manner to mothers' concerns and requests for help. We can assist them in finding accurate, up-to-date
information about Early Childhood Caries. We can support their efforts to find community resources for dental care that are child-friendly and
knowledgeable about breastfeeding and recognize that weaning is not required to prevent and treat Early Childhood Caries (37). We can
assist with information to help children who must undergo hospitalization or general anesthesia as part of their treatment, sharing La Leche
League printed and Web site resources. We can demonstrate healthy eating behaviors by the kinds of snacks we bring for our children at
meetings. Information about Early Childhood Caries fits well into Series Meeting 4, Nutrition and Weaning, or could be a good topic for an
Enrichment Meeting. Group Libraries can include Mothering Your Nursing Toddler by Norma Jane Bumgarner, which has a good discussion
on dental caries (38). By sharing information and raising awareness, we can play a role in preventing this serious, widespread infectious
disease.
Editor's Note: It is noteworthy that some health care professionals disagree with the American Dental Association's position that dental
caries is a fluoride-deficiency condition, and that there is an optimal amount of fluoride. There are professionals who hold that fluoride is not
a nutrient in humans and teeth have no requirement for fluoride. There are professionals who feel situations exist where fluoride application
can be used to treat dental caries, but are concerned by published statistics from many countries that show epidemic levels of toxic effects
from preventive fluoride use in the form of fluorosis, a developmental defect of enamel.

La Leche League International makes no endorsement of any treatment mentioned in this article, as to do so is beyond the scope of its
expertise.

References

1. Caufield, P.W. and Griffen, A.L. Dental caries: An infectious and transmissible disease. The Pediatric Clinics of North America 2000;
47(5):1001-19.

2. National Maternal and Child Oral Health Resource Center. Open Wide: Oral Health Training for Health Professionals. 2005.
www.mchoralhealth.org/Open Wide/index.htm

3. Tinanoff, N. and O'Sullivan, D.M. Early childhood caries: Overview and recent findings. Pediatric Dentistry 1997; 19(1):12-16.

4. Berkowitz, R.J. Causes, treatment and prevention of early childhood caries: A microbiologic perspective. Journal of the Canadian Dental
Association2003; 69(5):304-07.

5. Slavkin, H.C. Streptococcus mutans, early childhood caries and new opportunities. JADA 1999; 130(12):1787-92.

6. Palmer, B. Breastfeeding and infant caries: No connection. ABM News and Views 2000; 6(4):27, 31.

7. Schafer, T.E. and Adair, S.M. Prevention of dental disease. The Pediatric Clinics of North America 2000; 47(5):1021-42.

8. Li, Y., Caufield, P.W., Dasanayake, A.P. et al. Mode of delivery and other maternal factors influence the acquisition of streptococcus
mutans in infants.Journal of Dental Research 2005; 84:806-11.

9. Aligne, C.A., Moss, M.E., Auinger, P. et al. Association of pediatric dental caries with passive smoking. JAMA 2003; 289(10):1258-64.

10. Bickmore, M. Breastfeeding and oral health issues. NEW BEGINNINGS 2005 Sept-Oct; 22(5):211-12.

12. American Academy of Pediatrics. Policy Statement: Oral health risk assessment timing and establishment of the dental
home. Pediatrics 2003; 111(5):1113-16.

13. Peterson, D. and Johnston, L. Baby Bottle Tooth Decay or Early Childhood Caries (ECC). 1998-2005.
www.dentalgentlecare.com/baby_bottle_decay.htm.

14. Nowak, A.J. and Warren, J.J. Infant oral health and oral habits. The Pediatric Clinics of North America 2000; 47(5):1043-66.

15. Erickson, P.R., Alevizos, D.L., Rindelaub, D.J. Soft drinks: Hard on teeth. Northwest Dentistry 2001 Mar-Apr; 15-19.

17. Minnesota Dental Association 2003. Kids, Teens and Soft Drinks.
www.mndental.org/client_files/documents/Sip_All_Day_Presentation.pdf.

18. Marshall, T.A., Levy, S.M., Broffitt, B. et al. Dental caries and beverage consumption in young children. Pediatrics 2003, 112(3):e184-
e191.

19. Dental and oral health: Lift the Lip (preventing early childhood tooth decay). www.calgaryhealthregion.ca/hecomm/oral/liftlip.htm
20. Ribeiro, N.M.E. and Ribeiro, M.A.S. Breastfeeding and early childhood caries: A critical review. J Pediatr 2004; 80(5):s199-s210.

21. Eggert, F.M. and Gurner, B.W. Reaction of human colostral and early milk antibodies with oral streptococci. Infection and Immunity 1984;
44(3):660-64.

22. Oulis, C.J., Berdouses, E.D., Vadiakas, G. et al. Feeding practices of Greek children with and without nursing caries. Pediatric
Dentistry 1999; 21(7):409-416.

23. Erickson, P.R., McClintock, K.L., Green, N. et al. Estimation of the caries-related risk associated with infant formulas. Pediatric
Dentistry 1998; 20(7):395-403.

24. Erickson, P.R. and Mazhari, E. Investigation of the role of human breast milk in caries development. Pediatric Dentistry 1999; 21(2):86-
90.

25. Cox, R. Coping with dental caries. NEW BEGINNINGS 1997 Jan-Feb; 15(1):10-11.

26. Breastfeeding and dental caries. NEW BEGINNINGS 1994 Mar-Apr; 11(2):56-59.

27. Other experiences with dental caries. NEW BEGINNINGS 2002 Sept-Oct; 19(5):168-69.

28. Avoiding dental caries. NEW BEGINNINGS 2005 Sept-Oct; 22(1):216-19.

29. Palmer, B. Infant Dental Decay: Is It Related to Breastfeeding? October 2000. www.brianpalmerdds.com/pdf/caries.pdf (Slides 38, 39)

30. Fowler, J. Avoiding dental caries. NEW BEGINNINGS 2002 Sept-Oct; 19(5):164-67.

31. American Dental Association. Fluoridation Facts. Chicago, Illinois: ADA, 2005.

33. Hale, K.J. A pediatric dentist's perspective. NEW BEGINNINGS 1997 Jan-Feb; 14(1):11-12.

34. World Health Organization. Report of the Expert Consultation On the Optimal Duration of Exclusive Breastfeeding. Geneva, Switzerland,
2002.

35. Valaitis, R., Hesch, R., Passarelli, C. et al. A systematic review of the relationship between breastfeeding and early childhood
caries. Canadian Journal of Public Health 2000; 91(6):411-17.

36. Bowen, W.H. and Lawrence, R.A. Comparison of the cariogenicity of cola, honey, cow milk, human milk, and
sucrose. Pediatrics 2005;116(4):921-26.

37. Madison Department of Public Health. Breastfeeding and Early Childhood Caries: From 0 to 6 months, After 6
Months.www.cityofmadison.com/health/phn/breastfeeding.html.

38. Bumgarner, N.J. MOTHERING YOUR NURSING TODDLER, 3rd edition. Schaumburg, IL: La Leche League, International, 2000; 41-48.

39. Kohler, B., Andreen, J., and Jonsson, B. Preventive measures in mothers influence the establishment of the bacterium Streptococcus
mutans in their infants. Arch Oral Biol 1983; 28(3):225-31.

For more information:

La Leche League International

www.lalecheleague.org/NB/NBdental.html
American Dental Association
www.ada.org

Brian Palmer, DDS

www.brianpalmerdds.com

Information on Xylitol
www.xylitol.com/info/history.asp

Minnesota Dental Association

www.mndental.org

National Maternal and Child Oral Health Resource Center

www.mchoralhealth.org/OpenWide/index.htm

Calgary Health Region "Lift the Lip" Campaign

www.calgaryhealthregion.ca/hecomm/oral/

Abstract by Harry Torney, DDS

www.babyfriendly.org.uk/pdfs/torney_abstract.pdf

Promoting Dental Health

Editor's Note: These suggestions for promoting dental health are from a variety of sources. LLLI does
not make any recommendations beyond exclusive breastfeeding for the first six months of a baby's life,
and eating a variety of foods in as close to their natural state as possible.

1. Reduce levels of oral S. mutans for all family members with good oral care:
o Avoid sharing of eating utensils or otherwise transmitting bacteria in saliva from parent
to child.
2. Strengthen the teeth:
o Ensure good prenatal care and nutrition during pregnancy.
o Avoid iron deficiency and lead exposure.
o Ensure optimal levels of fluoride intake.
o Keep babies and young children away from tobacco smoke.
3. Provide conscientious oral care for babies and young children:
o Clean the mouth with a clean soft cloth twice daily before teeth appear.
o Use a soft brush to gently clean erupted teeth at least twice a day, including at bedtime.
o Begin supervised use of fluoridated toothpaste at age two years.
4. Promote healthy eating:
o Exclusively breastfeed for the first six months of life, with the addition of appropriate
complementary foods after that.
o Breastfeed through the first two years and beyond that for as long as the mother and
child desire (34, 35).
o Strongly limit carbonated and sweetened beverages, and refined sugar in the diet (36).
o Give fruit juices only at meal times and limit them to two to four ounces per day for
young children (four to six ounces a day for older children) (18).
o Avoid sugary, sticky treats that are in contact with the teeth for long periods, such as
raisins, lollipops, cough drops, taffy, and hard candies.
o Encourage whole grains and fresh fruits and vegetables in a well-balanced diet.
 Provide three meals and two to three snacks daily as needed, but discourage continuous
o
snacking.
o Avoid use of sippy cups for beverages other than water, except at mealtimes.
o Teach babies to drink from a regular cup by age one year.
o Avoid putting babies to bed with a bottle containing anything other than water (36).
o If pacifiers are used, never dip them in sweetened substances.
o Consider limiting frequency of nursing at night for those with signs of Early Childhood
Caries. If this can't be done, try cleaning the baby's teeth with water on a cloth after night
nursings. Try detaching the sleeping baby from the breast (36).
5. Be vigilant for signs of Early Childhood Caries:
o Parents may do monthly "Lift the Lip" screening. See
www.calgaryhealthregion.ca/hecomm/oral/liftlip.htm for more information.
o Seek immediate care for any abnormalities.
o Visit a dental health professional within six months of eruption of the first tooth and by
age 12 months (12).
o Continue with good follow-up dental care for children and all family members.

Anne Altshuler has been a La Leche League Leader since 1988 and an IBCLC since 1994. She lives in Madison, WI, USA
with her husband, David Sulman. They are the parents of five grown children. This article was originally developed for the
"Keeping Up-to-Date" column by Anne Altshuler and Development/Contributing Editor, Norma Ritter. Articles and ideas for
"Keeping Up-to-Date" may be sent to Norma at 58 Antler Road, Big Flats, New York 14814 USA, or email LLLnormaR at
gmail.com. Special appreciation to Maureen Oostdik-Hurd, RDH, Madison, WI, USA; Cecille Sulman, MD, Chicago, IL, USA;
Harry Torney, BDS, Ireland; Geoff Cheyne, BDS, Australia; Brian Palmer, DDS, Kansas City, MO, USA; and Glori Enzor, DDS,
Sarasota, FL, USA who graciously reviewed and offered input on this article. Their time and expertise was extremely helpful.

Page last edited Sun Oct 14 09:31:14 UTC 2007.