Early childhoodcaries: overviewand recent findings

Norman Tinanoff, DDS, MS David M. O’Sullivan, BS

arly childhood caries (ECC) is a relatively new among certain populations will have nursing caries term that describes rampant dental caries in in- (Table), there have been recent challenges to the con- E 1 fants and toddlers. In many cases, it is thought ventional wisdom that inappropriate bottle use and to be initiated and exacerbated by inappropriate feed- high levels of oral with mutans streptococci ing with a nursing bottle. The condition, when associ- are the sole etiologic factors of this condition. Such con- ated with the bottle habit, has been characterized as cerns have given impetus to replacing the language as- first affecting the primary maxillary anterior teeth, fol- sociating cause and effect with the term early childhood lowed by involvement of the primary molars. Man- caries, which reflects a less certain understanding of the dibular incisors generally are not affected, reportedly etiology2 While the basic concepts of early infection due to the child’s tongue in the suckling position pro- with mutans streptococci and inappropriate feeding tecting these teeth from the cariogenic challenge. 2, 3 with a cariogenic diet remain important factors in the Fass is credited with first using the term nursing bottle etiology of ECC, the exclusive focus of a child sleep- mouth to describe this caries pattern. 4 Terms to de- ing with a bottle containing milk or other -con- scribe this condition have evolved during the last two taining substances is being explored. This review ex- decades to include nursing caries, nursing bottle car- amines these controversies and recent information ies, and baby bottle caries. In 1985, the term baby regarding the etiology, implications, and prevention of bottle was proposed by the Healthy Moth- dental caries in infants and toddlers. ers-Healthy Babies Coalition as an alternative that Etiology would be more appropriate for patient acceptance and It is widely accepted that the group of cariogenic would focus attention on the potential damage of us- microorganisms, mutans streptococci, is associated ing a nursing bottle, s, 6 with ECC. Children with ECC reportedly have elevated Although the combination of infection with mutans oral levels of mutans streptococci, 7-9 which generally streptococci and the caretaker-reported practice of tak- are acquired from their mothers. 1°-12 Such high numbers ing a bottle to bed may be a good predictor of who of acidogenic microorganisms combine with fre- quent intake to produce abundant acid TABLE. AN EXAMPLEOF THE ABILITY OF BOTTLE USE AND MUTANS that lowers plaque pH for extended periods and STREPTOCOCCI(MS) INFECTION TO IDENTIFY AND PREDICT CARIES" demineralizes the child’s teeth. Since most of these microbiological studies were conducted on a limited Caries~ number of subjects using bacterial samples collected Yes No Total well after the disease process began, the age at which Yes 30 4 34 children become infected with mutans streptococci Bottle Use & MS¢ No 7 73 80 is not well understood. Determining the age of in- Total 37 77 114 fection is critical to understanding the disease pro- cess, the efficacy of microbial screening tests at dif- sensitivity = 81.1% specificity = 94.8% ferent ages, and the optimal period during which to PPV = 88.2% intervene with preventive strategies. NPV = 91.3% One recent report suggested that mutans strep- ¯ tococci are acquired during a window of infectivity Unpublisheddata from a longitudinalstudy to identify cariesrisk between ages 19 and 31 months. ~3 However, earlier factors in preschoolchildren that wasconducted on inner-city Head Start children in Hartford,Connecticut between 1991 and 1993. For studies have found colonization of mutans strepto- detailed populationdescription and methods, see reference 42. cocci in the oral cavity at younger ages. One study * Anyform of cariespresent at third examination. showed that children as young as 11 months were 14 * At baselineexamination, 1) parentreported that the child hadtaken infected with mutans streptococci; another found a bottle to bed,and 2) child hadmutans streptococci infection > 50 that 12 of 42 children at the same developmental cfu per MSKBplate. stage were infected with mutans streptococci, 1° and

12 American Academy of Pediatric Dentistry Pediatric Dentistry - 19:1, 1997 a third found these microorganismsin five of 25 tod- Another controversial yet poorly documented car- dlers having six to 10 primary teeth, is a tooth devel- ies risk is the potential cariogenicity of at-will breast opmental stage corresponding to an age range of 12 feeding. There are case reports associating prolonged to 16 months.16 Moreover, a child as young as 11 or night-time breast feeding and ECC.3°-3B However, months has been reported to have frank carious le- one unpublished report surveying more than 1,000 sions27 Clearly, additional research is required to bet- children breast-fed ad libitum for I to 4 years found a ter understand when children of various caries risk 5%prevalence of maxillary anterior caries. 3~ Onecan- acquire mutans streptococci. not dismiss a possible association between reported Prolonged and night-time bottle-feeding practices in rampant caries in these cases and dietary practices infants and toddlers generally are thought to provide other than breast feeding. Further study is required to the carbohydrate source that promotes high acid pro- determine the prevalence of ECCin exclusively breast- duction by mutans streptococci. Yet evidence suggests fed children, and whether other child-rearing practices, that blaming sleeping with a bottle of milk mayover- such as lack of restriction in eating snacks,Bs could con- simplify the cause of rampant caries. Several studies tribute to caries in breast-fed children as well as in have reported that the majority of U.S. preschool popu- bottle-fed children. lations take, or have taken, a bottle to bed2s, 19 In one Children with caries in the primary maxillary ante- study of U.S. HeadStart children, 86%of children with rior teeth, independent of their ages, generally are re- caries of the maxillary anterior incisors were reported garded as having nursing bottle caries. 2, 3, 36 Although to have taken a bottle to bed, but surprisingly, 69%of it is likely that the disease is due, at least in part, to a those whodid not have maxillary anterior caries also prolonged use of the baby bottle, other causes of car- reportedly took a bottle to bed.2° In another study, 90% ies affecting the anterior teeth cannot be ruled out. of children in a population with and without caries Children whoare 4 and 5 years old, an age by which were bottle-fed between 12 and 18 months of age, yet bottle use generally has been discontinued, may de- the prevalence of nursing caries was only 20%.21 Since velop caries in the maxillary anterior teeth. This late this feeding pattern is pervasive, it follows that parents involvement of the maxillary anterior teeth is charac- of children with ECCoften answer "yes" to the ques- terized by a higher prevalence of mesial lesions on the tion,2° "Do you put your child to bed with a bottle?". central incisors than when ECCis diagnosed at a Thus, it is logical that the bottle-to-bed habit is inferred younger age (Figure). Data from developing countries as the cause of early childhood caries. also suggest that caries on anterior primary teeth can- In addition to the lack of a clear association between not, in all cases, be attributed to inappropriate bottle feeding patterns and all cases of early childhood car- use. For example, in Beijing, China, where the preva- ies, there is controversyregarding the effect of various lence of caries in maxillary anterior teeth has been re- bottle contents on the carious process. Of course, there ported to be 45%in 4-year-old children, By baby bottles is no cariogenic challenge if the bottle contains only generally are not available. Perhaps other etiologies in water. However,the majority of 6-month- to 5-year-old developing countries, such as linear hypoplasia of pri- children are put to bed with a bottle with contents other maryteeth associated with malnutrition, Bs maycontrib- than water.TM It is well recognized that liquids in the ute to the prevalenceof this condition. It is interesting bottle that contain are cariogenic, yet the po- to speculate that visible or subclinical enamelhypopla- tential cariogenicity of the most commonbottle con- sia maybe a factor for the high caries prevalence found tents--milk and infant formulas--remains unclear. in the primary teeth of U.S. preschoolers from families Althoughnot tested in humans,rats fed milk as the sole of low socioeconomic status. source of nutrition do not developcaries, 22, 23 and rats given sucrose-milk solutions had fewer caries than Implicationsof early childhoodcaries those24 given sucrose-water solutions. The seriousness and societal costs of ECCare enor- Several reports suggest whymilk maybe less cari- mous, especially amongracial or ethnic minorities. The ogenic than other sugar-containing liquids. Phosphop- prevalence of caries in 3- to 5-year-old U.S. HeadStart roteins in milk have been shownto inhibit enamel dis- children39 has been reported to range as high as 90%. solution,2S, 26 antibacterial factors in milk interfere with There is considerable evidence that children who ex- the oral microbial flora, a7 and cariogenic may perience ECCcontinue to be at high risk for newlesions not be able to utilize lactose as an energy source as as they get older, both in the primary and permanent readily as sucrose.2s Additionally, milk has been shown dentitions. 4°~3 Perhaps the high levels of infection by to remineralize artificially demineralized enamel in cariogenic microorganisms, or the establishment of vitro. 29 Whilethe cariogenicity of milk per se is unclear, poor nutritional practices, maybe determinants of car- it maybe the vehicle for more cariogenic substances. ies~4 progression. Parents are known to combine milk or milk/formula Treatment of ECCis expensive, often requiring ex- with other food products or sugar.26 Worse, nutritional tensive restorative treatment and extraction of teeth at information labels show that sucrose is an ingredient an early age. Estimates of the cost of restoring the teeth in someinfant formulas. alone mayexceed $1,000 per child. 4s In addition to these

PediatricDentistry - 19:1,1997 AmericanAcademy of PediatricDentistry 13 expenses, general anesthesia or deep sedation may be Another commoneducational approach to alter ECC required because such young children lack the ability is individual parent counseling. A small study was to cope with the procedures. General anesthesia to fa- performedwith 17 mothers of infants with initial signs cilitate dental treatment adds between $1,0006 and of ECC. The self-reports on stopping the use of the $6,000~ to the cost of dental care. bottle, substitution of noncariogenic substrate in the One study also implicates ECCas contributing to bottle, and use of the fluoride gel showedthat the care- other health problems. Children with ECCwere shown takers generally could not, or would not, comply with to weigh less than 80%of their ideal weight, and to be the preventive regimen. Additionally, a presurvey in the lowest 10th percentile for weight.46 Perhaps the showed that 12 of the 17 caretakers admitted being pain or associated with ECCmay make it aware of the potential cariogenicity of sweet liquids in difficult for affected children to eat. Alternatively, poor the~ bottle. nutritional practices may be responsible for both the Strategies to reduce the transmission of cariogenic reduced body weight and the caries. Thus, the conse- microorganisms to offspring also have been studied as quences of ECCare a significant problem not only in methods to prevent ECC. In one study, 37 first-time monetary terms to parents and federal or state agen- mothers with high levels of mutans streptococci were cies paying for the care, but in potential risks to health given a preventive regimen, including use of and discomfort of the child with the disease. The po- chlorhexidine, to reduce their levels of mutans strepto- tential association of ECCwith growth lags is an im- cocci infection. Follow-up data showedthat the mutans portant observation that requires additional study. streptococci level of the 3-year-old children of these moth- ers was 41%, compared with 70%in the control group. Prevention of early childhood caries Moreimportantly, the caries prevalence was 16%in the ECCprevention has focused on educational pro- test groupversus 43%in the control group.49, 50 In a simi- grams to alter children’s feeding practices and to re- lar study, 70 motherswith high levels of mutansstrepto- duce levels of mutans streptococci infection. However, cocci were given a semiannualtreatment of chlorhexidine there has been surprisingly little scientific effort to test and sodiumfluoride. After three years, the children of the methodsfor reducing the prevalence of this disease. An mothers in the experimental group had a lower coloni- intensive education program using training aids-- zation of mutansstreptococci and lower caries incidence manuals, counseling booklets, posters, and bumper than those in the control groups.5~ In contrast to these fa- stickers with messages about preventing baby bottle vorable findings, a recent report attempted to reduce tooth decay--was employed in 16 Native American transmission of mutans streptococci to infants by giving communitiesin an attempt to alter child feeding prac- the mothers’ dentitions six applications of I2-NaFat the tices. Surveys of ECCprevalence before and after the time of the child’s tooth eruption. This study found that intensive educational programs showed that ECCde- mutans streptococci colonization and caries experience creased47 to 43%from 57%. of the test group did not differ from controls22

1100%

children who developedEGG: oOO/oJ llrl I [] at baseline ¯ 1 and 2 yrs later 40%

2O%

O% Dis Buc Lin Mes Dis Buc Lin Mes Mes Lin Buc Dis Mes Lin Buc Dis 52/d 51/e 61/f 62/g

maxillary anterior surface Figure.Patterns of early childhoodcaries in HeadStart childrenfrom the inner-cityof Hartford,Connecticut. Children (meanbaseline age, 3.8 years)were examined for dentalcaries once annually for 3 years.Baseline refers to children whowere determined to haveearly childhood caries at first examination;1 and 2 yearslater refers to childrenwho weredetermined not to haveearly childhoodcaries at first examinationbut did haveit at secondor third examination.

14 AmericanAcademy of PediatricDentistry PediatricDentistry - 19:1,1997 Additional methods to foster preventive behaviors 8. Milnes AR, BowdenGHW: The microflora associated with in parents whose children are at high risk for ECCneed developinglesions of nursing caries. Caries Res 19:289-97, 1985. to be explored. Psychological approaches, such as self- 9. van HouteJ, GibbsG, Butera C: Oral flora of children with efficacy enhancement and performance feedback tech- nursing bottle caries. J DentRes 61:382-85,1982. niques, may increase parents’ confidence in their abil- 10. BerkowitzRJ, Turner J, GreenP: Primary oral infection of ity to carry out recommendations and perform oral infants with Streptococcusmutans. Arch Oral Bio125:221-24, health preventive behaviors for their children. Self-ef- 1980. 11. BrownJP, Junner C, LiewV: A study of Streptococcusmutans ficacy enhancement involves raising an individual’s levels in both infants with bottle caries and their mothers. confidence to perform certain behaviors. Performance Aust Dent J 30:96-98, 1985. feedback provides observable success in performing a 12. van HouteJ, YanoverL, BrecherS: Relationshipof levels of beneficial behavior. Although these techniques have the bacteriumStreptococcus mutans in saliva of children and not been applied to behavioral changes required to their parents. ArchOral Biol 26:381-86,198L 13. Caufield PW,Cutter GR,Dasanayake AP: Initial acquisition prevent ECC, considerable literature shows their effects 53 of mutansstreptococci by infants: evidence for a discrete in other health areas. windowof infectivity. J DentRes 72:37-45, 1993. Besides considering behavioral techniques to change 14. BrownJP, Junner C, LiewV: A study of Streptococcusmutans adverse health behaviors, perhaps intense preventive levels in both infants with bottle caries and their mothers. interventions that do not rely on patient compliance Aust Dent J 30:96-98, 1985. 15. Carlsson J, Grahn6nH, Jonsson G: Lactobacilli and strep- also should be examined as methods of reducing ECC. tococci in the mouthof children. Caries Res 9:333-39, 1975. In some groups, lack of preventive behaviors and 16. Lunt RC, LawDB: A review of the chronology of the erup- deeply entrenched feeding practices may be so difficult tion of deciduousteeth. J AmDent Assoc 89:872-79, 1974. to change that it would not be practical to alter these 17. Suher T, Savara BS, DicksonJP: Case report of rampantden- behaviors. Results from frequent professional tal caries at 11 monthsof age. Oral Surg Oral MedOral Pathol 6:882-85, 1953. toothbrushing or professional administration of an an- 18. Kaste LM,Gift HC:Inappropriate infant bottle feeding. Sta- timicrobial agent, or fluoride, have not been reported, tus of the Healthy People 2000 Objective Arch Pediatr and may need to be considered to reduce caries inci- Adolesc Med149:786-91, 1995. dence in such groups. The focus of such programs is to 19. PowellD: Milk...Is it related to rampantcaries of the early place the responsibility for caries prevention on the den- primarydentition? J Calif Dent Assoc4:58-63, 1976. 20. O’Sullivan DM,Tinanoff N: Social and biological factors tal health professional, rather than on the parent. contributingto caries of the maxillaryanterior teeth. Pediatr Dent 15:41-44, 1993. Summary 21. Serwint JR, MungoR, Negrete VF, DugganAK, Korsch BM: Early childhood caries is of epidemic proportions in Child-rearing practices and nursing caries. Pediatrics 92:233-37,1993. some U.S. minority populations and in developing 22. Dreizen S, Dreizen JOG,Stone RE: The effect of cowsmilk countries, yet a review of the literature reveals numerous on dental caries in the rat. J DentRes 40:1025-28,1961. conflicting reports and unanswered questions regarding 23. ShawJH, Ensfield BJ, WollmanDH: Studies on the relation the etiology and prevention of the disease. Better knowl- of dairy productsto dental caries in caries-susceptible rats. edge of the cause of early childhood caries and effective J Nutr 67:253-73,1959. 24. BowenWH, Pearson SK:Effect of milk on cariogenesis. Car- strategies to reduce its risk should produce enormous ies Res 27:461-66,1993. reductions in initial and long-term dental treatment costs, 25. ReynoldsEC, Riley PF, Storey E: Phosphoprotein inhibi- as well as the pain and suffering of affected children. tion of hydroxyapatitedissolution. Calcif Tiss Int 34:$52- This work was supported by NIH grant DE10592and by Delta 56, 1982. 26. Weiss ME,Bibby BG: Effects of milk on enamelsolubility. 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16 American Academyof Pediatric Dentistry Pediatric Dentistry - 19:1, 1997