Children's Oral Health: The Silent Crisis

Early Childhood Caries

Inappropriate feeding of children can lead to a typical nursing pattern decay. One term used for this type of caries is Baby Bottle Tooth Decay (BBTD), others include nursing bottle caries, nursing caries, bottle caries, infant caries, etc…
Early Childhood Caries (ECC) has established itself as the most widely accepted recent terminology.

This is a very devastating type of tooth decay for the young patients, their parents, and the pediatric dentist. Overall water fluoridation and other methods of fluoride application have resulted in reduction of caries rates. ECC persists as a decay pattern and requires our special attention.

Early recognition and intervention are essential to successful treatment and prevention of disease progression.

Caries is an infectious disease. Several factors need to be combined to develop caries.

teeth need to be present
bacteria need to be present
a substrate (food for the bacteria) needs to be present
caries requires time to develop

These are the major factors involved in the caries process. The combination of the factors leads to disease, if one or more factors are missing disease may not develop.

Teeth

Primary teeth usually start to erupt in the first year of life. The first teeth to erupt at approximately 6 months are the lower central incisors followed by the upper central incisors. At 12 months usually all lower incisors and all upper incisors are erupted. The eruption time is highly variable and I am not concerned about variations of up to 6 months.

Bacteria

One of the important bacteria in dental caries is streptococcus mutans. S. mutans does not appear in the oral cavity of infants until after tooth eruption. S.mutans itself does not adhere to the teeth very well, it requires other plaque forming bacteria for initial colonization. Most likely infants become infected from their parents, siblings or other individuals with close contact. Usually the mother is considered to be the source. Infants whose mothers harbor very high levels of s.mutans (mothers that have a very high caries risk and rate) become colonized more readily than infants of mothers with low s.mutans levels in their saliva.

A minimum infective dose is necessary to develop caries. Disease prevention should include preventive therapy for the parents. "We all have bad teeth" may actually mean we all have the same bacteria.

Taking care of your child's teeth begins prior to birth. You should have dental check-ups before your baby is born. If dental treatment is necessary during pregnancy you should try to schedule it during the second trimester of your pregnancy.

Substrate

The substrate for s.mutans comes from juice, milk, formula, or any other liquid sweetened with fermentable carbohydrates. Commercially available sugar teas lead to rampant infant caries in Germany in the 70s and 80s ("Zuckerteekaries"). A favorite trick among parents in the UK used to be to thicken vitamin syrups with honey or other sugar syrup to ensure long feeding. The pacifier dipped in honey is another bad habit. Honey needs to be avoided in the first year of life. It has been associated with cases of infantile botulism. The botulism spores have also been detected in commercial corn syrups.

One thing I see here in the U.S. are baby bottles with soda labels. This may encourage parents to give their children a nursing bottle with carbonated sodas. Unfortunately we indeed see children with soda or juice in their bottle.

soda baby bottles in a local
supermarket at "rock bottom prices"

Time

Bacteria and substrate need to be present for a prolonged time to allow demineralization and caries progression. The bottle at nap time or bedtime is most dangerous. Fluids may pool around the teeth for hours. The teeth primarily affected by that are the maxillary incisors. Lower teeth are in general less affected since they are covered by the tongue.

Nursing pattern decay has also been reported with prolonged and unrestricted nighttime breast-feeding. The stagnation of milk about the neck of anterior teeth and the fermentation of the disaccharide lactose, a sugar found in milk, may contribute to this caries process. Under usual feeding regimens neither bottle nor breast milk predispose to caries. Breastfeeding has many beneficial effects, but the specific advantages for oral health are unknown and further research is necessary.

The typical high risk child will use a nursing bottle far beyond the first birthday. If infants are allowed prolonged access to the bottle its use may become habitual. The result is the toddler that is never seen without a bottle. These children may have a very high inappropriate caloric intake or the high fluid intake may cause the child to keep away from other foods, which leads to an overall poor nutritional outcome.

Weaning from the bottle or breast during the "terrible twos" can be extremely challenging. This struggle can be avoided by making the transition to the cup earlier in life, preferably shortly before or after the first birthday. At 4 to 6 months of age infants develop muscle control to close the mouth and may be introduced to nonliquid foods and the cup.

Bottle feeding past 12 months of age leads to a drastically increased caries risk.

Typical BBTD pattern with caries on
maxillary incisors

In this case primary first molars are
also severely affected, canines have
less decay. This is explained by the
eruption sequence of primary teeth:
the primary first molars erupt prior
to the primary canines and are
consequently more damaged. They
were exposed to the cariogenic fluids
for a longer time.

infants should not be put to sleep with a bottle containing a liquid other than water
infants should be encouraged to drink from a cup prior to their first birthday
infants should be weaned from the bottle at 12-14 months of age
infants should start to supplement their diet with nonliquids at 4-6 months of age
juices should only be offered from a cup
oral hygiene should be started with eruption of the first primary tooth
within six month of eruption of the first tooth (no later than the first birthday) it is time for the first dental visit

Treatment

The treatment options for established ECC vary depending on how far the disease has progressed.

Very early detection of demineralization on teeth, chalky white spots or lines, may allow to remineralize teeth with fluoride application and diet modification. The first dental visit will help to evaluate your child's caries risk . Your pediatric dentist will discuss methods of disease prevention.

If obvious decay is present full coverage of the teeth with stainless steel crowns or veneered crowns is indicated. Adhesive fillings (white plastic) have generally a very poor prognosis on anterior primary teeth as far a retention and recurrent decay are concerned.

If decay reaches the pulp chamber pulp therapy (nerve treatment, "baby root canal") or extractions will need to be considered. Space maintenance is in general not necessary (anterior primary teeth are usually spaced, space maintenance is a concern for posterior primary teeth).

Young pre-cooperative children may need sedation or general anesthesia to accomplish treatment. Your pediatric dentist will be able to discuss with you which behavior management option is the best for your child.

In this case the primary incisors are decayed to the gumline. The two yellowish areas above the teeth are not erupting permanent teeth. They are puddles of pus from draining infection.

Extraction is treatment of choice for a case in this advanced stage.

After extraction of the anterior incisors the remaining dentition was isolated with a rubber dam and first primary molars were restored with stainless steel crowns, second primary molars received fluoride releasing glass-ionomer restorations. Canines did not require any treatment. Again caries distribution correlated with eruption sequence. The longer the teeth are exposed to cariogenic fluids the worse the decay.