Oral Health Group

Early Childhood Caries: The Dental Disease of Infants

January 1, 2010
by Michelle S. Ezer, BSc(Hon), DDS, Natalie A. Swoboda, BSc(Hon), DDS and David R. Farkouh BSc, DMD, MS


Early childhood caries (ECC) is a major health concern that continues to negatively affect the oral health of infants and children today. Dental caries is a chronic disease that in children is five times more common than asthma and seven times more common than hay fever.1 Even with caries prevalence declining in the permanent dentition, decay prevalence in primary teeth is on the rise.2 Approximately 40% of children have dental caries by the age of five, and 8% of two year old children have some form of decay or previous restoration(s).1-2 Left untreated, carious lesions can lead to expensive treatment, disruption of growth and development, pain, and life threatening infections.

Early Childhood Caries

By definition, early childhood caries is the presence of one or more decayed, missing or filled tooth surfaces in any primary tooth in a child 71 months of age or younger.3 The multi-factorial nature of ECC encompasses but is not restricted to commonly used terms including “nursing caries”, “baby bottle caries”, and “baby bottle tooth decay” as inappropriate nursing and baby bottle use are often implicated but are not the sole etiological factors of this condition. In infants, ECC often follows a characteristic pattern of development: maxillary incisors are affected first followed by maxillary then mandibular molars, and due to the protective nature of the tongue, the mandibular incisors are often spared.4 Further progression of caries in infants depends on the child’s eruption chronology and habit duration.

Risk Factors of Early Childhood Caries

Risk factors associated with ECC should be recognized in infants in order to provide appropriate preventative counselling, anticipatory guidance and management. Multiple variables have been shown to be associated with an increased risk of ECC and must be addressed in order to identify high risk infants.

Mutans Streptococci Transmission

A significant risk factor associated with ECC is the early acquisition of cariogenic bacteria. Mutans Streptococci (MS) are bacteria that adhere to enamel and metabolize fermentable carbohydrates producing acid. Consequently, acid produced by MS lowers the intraoral pH and promotes demineralization of tooth structure. Prolonged decrease in pH causes demineralization that eventually results in cavitation.6 Though MS is typically found on enamel surfaces, it has the ability to colonize intra-orally prior to the eruption of the first tooth and earlier acquisition of MS has been associated with increased caries risk.7-8 MS in infants is commonly acquired from the child’s primary caregiver, most often the mother, via infected saliva.9 While the mechanism of transmission is unclear, contributing factors may include intimate contact, sharing of utensils or food, and poor oral hygiene and/or open carious lesions in the primary caregiver.9-10

Poor Dietary and Feeding Habits

Repeated exposure to fermentable carbohydrates lowers pH intra-orally for prolonged periods of time and thus increases the risk of caries.11 Therefore, ad libitum feedings, repetitive consumption of any liquid containing fermentable carbohydrates from a bottle or sippy cup and frequent snacking should be avoided.11 Of particular concern is the significant risk associated with feedings while the child is asleep due to a reduction in salivary flow. Feeding while the child is asleep allows any food or liquid present in the mouth to be in prolonged contact with tooth structure in the presence of MS.11

Clinical Findings

Developmental defects on tooth structure allow for additional plaque accumulation and increase the risk of caries.12 Enamel hypoplasia may form as a result of developmental disturbances related to pregnancy, such as preterm births, low birth weight or maternal smoking and complications during the pre- or postnatal period including illness, infection, malnutrition or under-nutrition.6-7 A detailed medical history is imperative in revealing these risk factors.

It is important to be aware that in comparison to permanent teeth, enamel and dentin of primary teeth are inherently thinner and caries progression can more rapidly involve the pulp. In addition, teeth emerge with immature enamel that continues to mature throughout eruption by incorporating intra-oral minerals and ions, one of which includes fluoride. Thus, newly erupted teeth are at an increased risk of caries until complete maturation occurs.7

Socioeconomic Status

Evidence suggests an association between lower socioeconomic status and ECC. One Canadian survey demonstrated an association between parents with higher levels of education, higher incomes and dental insurance, with children who presented with lower incidence of and less severe caries. In contrast, children of parents with lower levels of education and lower incomes were at an increased risk of caries.13 In the United States, it has been reported that 80% of dental disease occurs in 20% of children of who were from low income families.2

Systemic Disease and Medications

Congenital or acquired conditions may indicate an increased risk for caries. Special needs children may have decreased motor coordination and/or ability to cooperate limiting oral hygiene. Other risk factors include conditions (ie. cancer and radiation) that may reduce salivary flow or for which chronic use of sugar-containing oral liquid medications is indicated.12,14

Consequences of Early Childhood Caries

Early childhood caries has detrimental effects on the health and quality of life of the child as well as a financial impact on the family. The direct consequences of ECC are pain and infection. These can affect the child’s ability to eat and studies have shown that children with ECC are at risk of weighing less than 80% of their ideal weight, fitting into the criteria of failure to thrive.15 Nutritional deficiencies in a growing child may have lifelong impacts on neural development and somatic growth.15 Normal growth and development may also be delayed due to pain and sleep disturbances.15 In addition, caries in the primary dentition has been indicated as a risk factor for future dental caries in the primary and permanent dentition.16

The treatment of ECC has many repercussions as it is expensive, invasive and time-consuming. One study indicated that the cost of restoring teeth afflicted with ECC will likely exceed $1,000 per child. In addition, young children often lack the ability to cooperate with dental procedures and consequently general anaesthesia or sedation is often required, which can further increase the cost of treatment to nearly $6,000.4 These figures do not include the indirect costs of time lost from work or school with repeated dental visits. ECC also results in increased hospitalization and emergency room visits which can be stressful for the parents and a burden on the health care system.17 Nearly 20% of all dental emergency visits are attributed to ECC and these visits were the child’s first contact with a dentist in more than half of patients below the age of 4.17 Furthermore, it is these patients who more often required restraint for procedures and multiple extractions, increasing the stress for patient, parent and practitioner.


Prevention is best accomplished by the timely identification of risk factors and appropriate intervention.18 The Canadian Dental Association advocates that the first dental visit occur within six months of the eruption of the first primary tooth and no
later than twelve months of age. The purpose of this early visit is to assess the risk of dental disease, initiate a preventive program and provide anticipatory guidance on issues concerning diet, oral hygiene and fluoride use.19 As well, this visit establishes a dental home for the child where future care may be provided to ensure good oral health.

Dental disease can impact the total well-being of a child and is largely preventable; thus, a healthy mouth with a full dentition should be the goal for each and every child.20 Health care professionals, through everyday patient encounters, can provide understanding of risk factors, consequences, prevention approaches and appropriate referral information.21 Through early detection, proper counselling and the involvement of health professionals and caregivers, the consequences of this disease can be minimized and hopefully, in future, completely eliminated. oh

Dr. Michelle S. Ezer is currently a dental resident in the Department of Dentistry at The Hospital for Sick Children, Toronto, Ontario.

Dr. Natalie A. Swoboda is currently a dental resident in the Department of Dentistry at The Hospital for Sick Children, Toronto, Ontario.

Dr. David R. Farkouh is a staff pediatric dentist in the Department of Dentistry at The Hospital for Sick Children, Toronto, Ontario.

Oral Health welcomes this original article


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