Early childhood caries

Early childhood caries (ECC), also known as baby bottle caries, baby bottle tooth decay, and bottle rot, is a disease characterized by severe decay in the teeth of infants or young children. Early childhood caries is a very common bacterial infection. It occurs in all areas of the world. In the US rates are highest in minority and rural populations, at times infecting over 70% of the children. ECC occurs more often in children from the lower end of the socioeconomic scale.[1] A large body of scientific evidence indicates that ECC is an infectious and transmissible disease, with Streptococcus mutans the primary microbiological agent in the disease. The disease process begins with the transmission of the bacteria to the child, usually from the primary caretaker. Caretakers with untreated dental disease present a very high risk to their children.


Frequent consumption of liquids containing fermentable carbohydrates (e.g., juice, milk, formula, soda) increases the risk of dental caries due to prolonged contact between sugars in the liquid and cariogenic bacteria on the teeth. Poor feeding practices without appropriate preventive measures can lead to a distinctive pattern of caries in susceptible infants and toddlers commonly known as baby bottle tooth decay (BBTD), a form of severe early childhood caries (ECC). Frequent bottle feeding at night, and extended and repetitive use of a no-spill training cup are associated with ECC. Children experiencing caries as infants or toddlers have a much greater probability of subsequent caries in primary and permanent teeth.

According to the American Dental Association, "As soon as a baby's first teeth appear—usually by age six months or so—the child is susceptible to decay. This condition is often referred to as Baby Bottle Tooth Decay or Early Childhood Caries (cavities).

In some unfortunate cases, infants and toddlers have experienced severe tooth decay that has resulted in dental restorations or extractions. The good news is that decay is preventable.

"Decay occurs when sweetened liquids are given and are left clinging to an infant's teeth for long periods. Many sweet liquids cause problems, including milk, formula and fruit juice. Bacteria in the mouth use these sugars as food. They then produce acids that attack the teeth. Each time your child drinks these liquids, acids attack for 20 minutes or longer. After many attacks, the teeth can decay."

The ADA adds, "It's not just what you put in your child's bottle that causes decay, but how often — and for how long a time. Giving your child a bottle of sweetened liquid many times a day isn't a good idea. Allowing your child to fall asleep with a bottle during naps or at night can also harm the child's teeth."

The primary culprit for ECC is a group of bacteria called Streptococcus mutans. The American Academy of Pediatric Dentistry, in their Clinical Guideline for Infant Oral Healthcare, advises that "Caries results from an overgrowth of specific organisms that are part of normally occurring human oral flora. Streptococcus mutans and Lactobacillus species are considered to be principal indicator organisms of those bacteria responsible for caries. Human oral flora is site specific, and an infant is not colonized with normal oral flora until the eruption of the primary dentition at approximately 6 to 30 months of age. The vertical colonization of S. mutans from mother to infant is well documented."

Research on preventing or delaying maternal transmission of these bacteria to children suggest that a comprehensive program of counseling, oral hygiene instruction, fluoride treatments, and restorative care are effective. Xylitol products also are promising. It is a form of childhood disease


Babies’ and toddlers’ teeth and gums should be cleaned after every feeding or meal, starting from their teeth's first emergence. Preventive programs with young children should begin at the earliest time possible. Fluoridated water will have a very positive effect on this disease. Other chemotherapeutics found to be effective include topical fluoride (fluoride varnish), fluoridated toothpaste, and PVP-iodine.

Parental tooth cleaning, especially with a very small amount of fluoridated dentifrice, is helpful when accomplished at least once a day. Twice a day is even better. Given that fermentable carbohydrates provide fuel for the harmful bacteria, dietary interventions are appropriate, but very difficult to implement. A counseling approach, providing the parent with choices has been found effective. The sugar substitute xylitol has been found to be effective at reducing levels of harmful micro-organisms in the mouth, and has recently been promoted as a cavity reducing agent in the form of disposable wipes.

According to an article in the Journal of the Canadian Dental Association, "Primary prevention of ECC has largely been restricted to counselling parents about caries-promoting feeding behaviours. This approach has also had minimal success. Newer strategies addressing the infectious component through use of topical antimicrobial therapy appear promising."[2]


  1. Watt RG, Listl S, Peres MA, Heilmann A, editors. Social inequalities in oral health: from evidence to action. London: International Centre for Oral Health Inequalities Research & Policy; www.icohirp.com
  2. Berkowitz RJ (May 2003). "Causes, Treatment and Prevention of Early Childhood Caries: A Microbiologic Perspective". JCDA. 69 (5).

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