Baby bottle syndrome, now known as early childhood caries (ECC), is defined as the presence of 1 or more decayed teeth or missing teeth (resulting from dental caries) or filled tooth surfaces in any primary tooth between birth and 71 months of age.
Tooth decay or dental caries is the single most common chronic childhood disease worldwide, 5 times more common than asthma, 7 times more common than hay fever, 4 times commoner than childhood obesity, and 20 times commoner than juvenile diabetes. According to the American Academy of Pediatric Dentistry, it is today an international public hazard in both developing and developed nations. It is an infectious disease that can begin as early as the teeth erupt, usually around 6 months, and can progress rapidly causing immense pain and discomfort to the child.[1][2][3]
The multifactorial nature of ECC encompasses but is not restricted to certain other terminologies such as "nursing caries," "comforter caries," and "baby bottle tooth decay," as improper nursing is not the only causative factor as they would suggest.[4][5][6] Presently, the term "early childhood caries" is used as the best description.[5][7] This term was coined at a workshop sponsored by The Center for Disease Control and Prevention 1994. The goal to comprehend the causative factors behind the genesis of this malady. Attention was drawn to various psychosocial, economic, ethnic, and cultural factors that contribute to the widespread increase in the incidence of this disease worldwide.[8]
In infants, ECC often follows a characteristic pattern of development. It affects maxillary incisors first, followed by the maxillary and then the mandibular molars, and because of the protective nature of the tongue, the mandibular incisors are often spared. Progression in infants depends on the chronology in which the dentition erupts and the dietary habits.
Actual causation is the interaction of microbes like Streptococcus mutans on sugary foodstuffs or fermentable carbohydrates producing lactic acid which erodes the tooth enamel causing demineralization.[9] Left untreated, the repercussions on the child’s health and quality of life, and can create serious social and economic consequences.
A multitude of factors contribute toward the genesis of early childhood caries, as listed below[10]:
Despite the best of dental care and awareness of dental hygiene in developed countries, ECC has remained an increasing problem today in both developing and developed nations. The incidence of the disease varies area-wide and country-wide, with varying prevalence depending on socioeconomic strata, ethnicity, and dietary patterns. In developed nations, it is between 1% to 12%; whereas, in economically backward nations it is as high as 70%. One study reported a prevalence of 11.4% in Sweden, 7% to 19% in Italy, 76% in Palestine and 83% in the UAE. In another study, a stark contrast was seen between incidences in Swedish children to being 2.1% as against 85.5% in their counterparts in rural China. National surveys of some nations have revealed the following prevalence: India 51.9%, Israel 64.7%, Brazil 45.8%, Greece 36%, and the United States 3% to 6%. Not many studies have demonstrated differences in gender ratios, but one study of 3- and 4-year-olds showed boys to be more prominently affected than girls.
The genesis of dental caries depends on a triad of essential factors, namely:
Evidence has linked Streptococcus mutans to dental caries, and it has been proven that strains of this species can produce lactic acid which is implicated in the genesis of caries. Although the incidence is of Streptococcus sobrinus infection is lower, it is a closely-related, lactic-acid producing species linked to causing dental caries. Lactobacillus species also play a role in the progression of caries but not in its initiation. Actinomyces species, especially Actinomyces gerencseriae are thought to be responsible for root surface caries and deep-seated caries caused by Bifidobacterium species. Candida albicans is also said to cause dental caries. Molecular methods for bacterial identification now make it possible to pinpoint the specific microbes associated with dental caries, and DNA sequencing is used to identify closely-related species difficult to trace through traditional techniques. Bacteriocin typing studies were used to isolate Streptococcus mutans from mothers and infants, and results demonstrated identical patterns, proving the concept of vertical transmission from mother to offspring.[27][28][29] Chromosomal DNA patterns or identical plasmids are nowadays used to prove this theory.[30][31][32]
A typical history depends on the age of the child and the extent of dental damage. Usually, a child with dental caries suffers from severe pain which hinders eating or speaking. As a result, there may be a history suggestive of delayed milestones due to malnutrition and inability to concentrate on studies, poor memory, stunted growth, difficulties in speech and articulation, and lowered self-esteem.[33][34][35][36]
On physical examination, typically dull white or brown spots on the demineralized enamel on the maxillary incisors along the gingival margin are seen. This progresses to destruction of the crown. White spots or pits or fissures on the enamel close to the gingival margin could be precursors of caries and should be examined with an index of suspicion.[37][38] In later stages, spread to maxillary and mandibular molars occurs, leaving stumps or a large yellow-brown cavity. In an older child with fully erupted primary dentition, extensive dental destruction may be evident.
Every child with ECC has to be evaluated and examined in detail. Poor dental health often extends beyond the oral cavity. As caries can affect the child’s mastication and phonetics, the ability to eat, drink, speak, or gain acceptance of peer groups may affect physical, mental, and psychosocial development. Manifesting as severe nutritional deficiencies and growth retardation, a lowered immune status predisposes the patients to a multitude of infections throughout the body. A thorough dental examination is carried out with IOPA radiography, or an OPG if required, and other investigations like a complete blood count (CBC), x-ray of the chest, among others.
The treatment of ECC is complex and is determined by a multitude of factors, including the age of the child, the extent of dental damage, co-existence of other complications, and the financial capacity of the parents.
In low-risk cases of white spots and enamel proximal lesions, extensive restoration may not be needed, and the clinician can prevent further decay and spread through parent education, diet counseling, and counseling the patient on the use of preventive agents such as topical chemotherapeutic agents. Topical fluoride is very popular in this regimen as a varnish with a resin base.[39] Toothpaste, foams, gels, rinses, and drops containing fluoride have a brief effect; whereas, fluoride varnish hardens on the tooth enamel after application and remains intact for about a week, longer on demineralized tooth surfaces than on healthy teeth.[40] This offers excellent protection against demineralization.[41] Chlorhexidine varnish can also be applied to protect the tooth surface. Likewise, bimonthly application of 10% povidone-iodine has been recommended by some for its antimicrobial effect against most cariogenic Streptococcus mutans.
Application of CPP or casein phosphopeptide stabilizes the calcium and phosphate and preserves them in an amorphous or soluble form called ACP (amorphous calcium phosphate). In the presence of CPP, calcium, and phosphate form highly insoluble complexes. These CPP-ACP complexes enhance fluoride action and improve remineralization of enamel.
In moderately severe to advanced cases or those at great risk, restoration with surgical extraction of teeth with pulpotomy or pulpectomy is required. In these cases, deep sedation or general anesthesia with its inherent complications is needed due to lack of compliance with the age group involved. Restoration is done with prefabricated stainless steel crowns for primary or permanent teeth with caries.[42][43]
Other conservative techniques used are the removal of carious tooth tissues and restorations with adhesive restorative materials like GIC, composites or traditional amalgams.[44] These are inexpensive, quick, and easy to perform. They obviate the need for general anesthesia and its inherent risks, so the safety profile is higher, and the cost of treatment suits the majority of the population involved which comes from a lower socio-economic background.[45][46][47][48]
Poor dental health translates into unhealthy teeth and gums and has far-reaching ramifications. The child’s inability to eat, chew, drink, and swallow food because of the pain and disfigured teeth can leave them malnourished and stunted. This may alter the appearance and disturb interactions with peers, leaving patients socially and psychologically affected. The condition may affect scholastic performance, and patients may be socially ridiculed due to disfigurement.[33][34][35][36] Often, these are children of poor, uneducated parents who are grappling with finances and cannot pay for the treatment, subjecting the child to further neglect.[49][50] Unchecked, neglected caries can progress to pulpitis and severe dental abscesses, which can affect erythropoiesis by affecting inflammation induced metabolic pathways leading to chronic anemia and growth retardation.[51][52][53] In children with special needs, who are already physically or mentally challenged, ECC may pose further health issues. In severe cases, it serves as a potential nidus of streptococcal infection which could cause the potentially lethal endocarditis if it spreads to a defective heart valve. It could also spread to other organs causing fever, pneumonia, and urinary tract infection.
Given the levels of ignorance about the importance of dental hygiene and oral health worldwide, many times, children have never visited a dentist until medical problems arise. A child should visit a dentist, preferably a pediatric dentist for an early evaluation by the first birthday. The pediatric dentist will screen the child and counsel parents about preventive measures against caries. After this initial visit, an annual checkup is recommended.
ECC is the commonest chronic, infectious, childhood disease globally, and a health matter of highest concern. The disease is the product of a lack of education, low hygiene levels, and concurrent poverty and malnourishment. Certain socio-cultural and ethnic dietary practices encourage the growth of cariogenic microorganisms. Healthcare professionals should adopt the following measures in the systematic prevention of ECC:
Since ECC is the world’s largest chronic infectious disease of childhood, it is an international health hazard with a grave prognosis. Despite the increasing awareness of dental care, ECC is a problem of global concern.
The etiological basis of ECC is multifactorial and has nutritional, socioeconomic, cultural, and educational foundations. The virulent form of dental caries is an entirely preventable disease. It begins soon after dental eruption, affects the smooth enamel of the tooth and progresses rapidly, permanently impacting the upcoming dentition. As dental health involves having healthy teeth, it is important to note that poor dental health translates into a child’s inability to eat, chew, drink, and gain proper nourishment. All this may manifest as physical malnutrition and stunted growth, deficiencies, poor scholastic performance, and disfigurement that may lead to a negative body image, psychological trauma, and social ridicule.[33][34][35][36] It can affect the family adversely, as a child who lives in a lower socioeconomic and educational background suffers further if the family cannot afford the expensive treatment needed.[49][50][56][57]
[1] | Livny A,Assali R,Sgan-Cohen HD, Early Childhood Caries among a Bedouin community residing in the eastern outskirts of Jerusalem. BMC public health. 2007 Jul 24 [PubMed PMID: 17650296] |
[2] | Grindefjord M,Dahllöf G,Modéer T, Caries development in children from 2.5 to 3.5 years of age: a longitudinal study. Caries research. 1995 [PubMed PMID: 8556747] |
[3] | Weinstein P,Domoto P,Koday M,Leroux B, Results of a promising open trial to prevent baby bottle tooth decay: a fluoride varnish study. ASDC journal of dentistry for children. 1994 Sep-Dec [PubMed PMID: 7897002] |
[4] | Dilley GJ,Dilley DH,Machen JB, Prolonged nursing habit: a profile of patients and their families. ASDC journal of dentistry for children. 1980 Mar-Apr [PubMed PMID: 6928858] |
[5] | Ismail AI,Sohn W, A systematic review of clinical diagnostic criteria of early childhood caries. Journal of public health dentistry. 1999 Summer [PubMed PMID: 10649590] |
[6] | Ripa LW, Nursing caries: a comprehensive review. Pediatric dentistry. 1988 Dec [PubMed PMID: 3078603] |
[7] | Drury TF,Horowitz AM,Ismail AI,Maertens MP,Rozier RG,Selwitz RH, Diagnosing and reporting early childhood caries for research purposes. A report of a workshop sponsored by the National Institute of Dental and Craniofacial Research, the Health Resources and Services Administration, and the Health Care Financing Administration. Journal of public health dentistry. 1999 Summer [PubMed PMID: 10649591] |
[8] | Schroth RJ,Brothwell DJ,Moffatt ME, Caregiver knowledge and attitudes of preschool oral health and early childhood caries (ECC). International journal of circumpolar health. 2007 Apr [PubMed PMID: 17515255] |
[9] | Douglass JM,Douglass AB,Silk HJ, A practical guide to infant oral health. American family physician. 2004 Dec 1 [PubMed PMID: 15606059] |
[10] | Harel-Raviv M,Laskaris M,Chu KS, Dental caries and sugar consumption into the 21st century. American journal of dentistry. 1996 Oct [PubMed PMID: 9545901] |
[11] | Tanzer JM,Livingston J,Thompson AM, The microbiology of primary dental caries in humans. Journal of dental education. 2001 Oct [PubMed PMID: 11699974] |
[12] | Nurelhuda NM,Al-Haroni M,Trovik TA,Bakken V, Caries experience and quantification of Streptococcus mutans and Streptococcus sobrinus in saliva of Sudanese schoolchildren. Caries research. 2010 [PubMed PMID: 20714152] |
[13] | Schafer TE,Adair SM, Prevention of dental disease. The role of the pediatrician. Pediatric clinics of North America. 2000 Oct [PubMed PMID: 11059348] |
[14] | Caufield PW,Griffen AL, Dental caries. An infectious and transmissible disease. Pediatric clinics of North America. 2000 Oct [PubMed PMID: 11059347] |
[15] | Loesche WJ, Nutrition and dental decay in infants. The American journal of clinical nutrition. 1985 Feb [PubMed PMID: 3918434] |
[16] | Ercan E,Dülgergil CT,Yildirim I,Dalli M, Prevention of maternal bacterial transmission on children's dental-caries-development: 4-year results of a pilot study in a rural-child population. Archives of oral biology. 2007 Aug [PubMed PMID: 17321488] |
[17] | Türksel Dülgergil C,Satici O,Yildirim I,Yavuz I, Prevention of caries in children by preventive and operative dental care for mothers in rural Anatolia, Turkey. Acta odontologica Scandinavica. 2004 Oct [PubMed PMID: 15841811] |
[18] | Köhler B,Andréen I,Jonsson B, The earlier the colonization by mutans streptococci, the higher the caries prevalence at 4 years of age. Oral microbiology and immunology. 1988 Mar [PubMed PMID: 3268743] |
[19] | Van Loveren C, Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic effects? Caries research. 2004 May-Jun [PubMed PMID: 15153702] |
[20] | van Palenstein Helderman WH,Soe W,van 't Hof MA, Risk factors of early childhood caries in a Southeast Asian population. Journal of dental research. 2006 Jan [PubMed PMID: 16373687] |
[21] | Birkhed D, Sugar substitutes--one consequence of the Vipeholm Study? Scandinavian journal of dental research. 1989 Apr [PubMed PMID: 2704975] |
[22] | Misra S,Tahmassebi JF,Brosnan M, Early childhood caries--a review. Dental update. 2007 Nov [PubMed PMID: 18087926] |
[23] | Rajab LD,Hamdan MA, Early childhood caries and risk factors in Jordan. Community dental health. 2002 Dec [PubMed PMID: 12489836] |
[24] | Davies GN, Early childhood caries--a synopsis. Community dentistry and oral epidemiology. 1998 [PubMed PMID: 9671208] |
[25] | Slavkin HC, Streptococcus mutans, early childhood caries and new opportunities. Journal of the American Dental Association (1939). 1999 Dec [PubMed PMID: 10599184] |
[26] | Weerheijm KL,Uyttendaele-Speybrouck BF,Euwe HC,Groen HJ, Prolonged demand breast-feeding and nursing caries. Caries research. 1998 [PubMed PMID: 9438571] |
[27] | Davey AL,Rogers AH, Multiple types of the bacterium Streptococcus mutans in the human mouth and their intra-family transmission. Archives of oral biology. 1984 [PubMed PMID: 6589988] |
[28] | Berkowitz RJ,Jordan HV, Similarity of bacteriocins of Streptococcus mutans from mother and infant. Archives of oral biology. 1975 Nov [PubMed PMID: 1061524] |
[29] | Berkowitz RJ,Jones P, Mouth-to-mouth transmission of the bacterium Streptococcus mutans between mother and child. Archives of oral biology. 1985 [PubMed PMID: 3857909] |
[30] | Caufield PW,Childers NK,Allen DN,Hansen JB, Distinct bacteriocin groups correlate with different groups of Streptococcus mutans plasmids. Infection and immunity. 1985 Apr [PubMed PMID: 2984124] |
[31] | Caufield PW,Ratanapridakul K,Allen DN,Cutter GR, Plasmid-containing strains of Streptococcus mutans cluster within family and racial cohorts: implications for natural transmission. Infection and immunity. 1988 Dec [PubMed PMID: 3182079] |
[32] | Kulkarni GV,Chan KH,Sandham HJ, An investigation into the use of restriction endonuclease analysis for the study of transmission of mutans streptococci. Journal of dental research. 1989 Jul [PubMed PMID: 2632600] |
[33] | Petersen PE,Estupinan-Day S,Ndiaye C, WHO's action for continuous improvement in oral health. Bulletin of the World Health Organization. 2005 Sep [PubMed PMID: 16211149] |
[34] | Acs G,Lodolini G,Kaminsky S,Cisneros GJ, Effect of nursing caries on body weight in a pediatric population. Pediatric dentistry. 1992 Sep-Oct [PubMed PMID: 1303533] |
[35] | Acs G,Shulman R,Ng MW,Chussid S, The effect of dental rehabilitation on the body weight of children with early childhood caries. Pediatric dentistry. 1999 Mar-Apr [PubMed PMID: 10197335] |
[36] | Acs G,Lodolini G,Shulman R,Chussid S, The effect of dental rehabilitation on the body weight of children with failure to thrive: case reports. Compendium of continuing education in dentistry (Jamesburg, N.J. : 1995). 1998 Feb [PubMed PMID: 9656863] |
[37] | Steiner M,Helfenstein U,Marthaler TM, Dental predictors of high caries increment in children. Journal of dental research. 1992 Dec [PubMed PMID: 1452896] |
[38] | van Palenstein Helderman WH,van't Hof MA,van Loveren C, Prognosis of caries increment with past caries experience variables. Caries research. 2001 May-Jun [PubMed PMID: 11385198] |
[39] | Weintraub JA, Fluoride varnish for caries prevention: comparisons with other preventive agents and recommendations for a community-based protocol. Special care in dentistry : official publication of the American Association of Hospital Dentists, the Academy of Dentistry for the Handicapped, and the American Society for Geriatric Dentistry. 2003 Sep-Oct [PubMed PMID: 14965184] |
[40] | ten Cate JM,Featherstone JD, Mechanistic aspects of the interactions between fluoride and dental enamel. Critical reviews in oral biology and medicine : an official publication of the American Association of Oral Biologists. 1991 [PubMed PMID: 1892991] |
[41] | Marinho VC,Higgins JP,Sheiham A,Logan S, Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents. The Cochrane database of systematic reviews. 2004 [PubMed PMID: 14973992] |
[42] | Tinanoff N,Douglass JM, Clinical decision-making for caries management in primary teeth. Journal of dental education. 2001 Oct [PubMed PMID: 11699990] |
[43] | Kindelan SA,Day P,Nichol R,Willmott N,Fayle SA, UK National Clinical Guidelines in Paediatric Dentistry: stainless steel preformed crowns for primary molars. International journal of paediatric dentistry. 2008 Nov [PubMed PMID: 18808544] |
[44] | Dülgergil CT,Soyman M,Civelek A, Atraumatic restorative treatment with resin-modified glass ionomer material: short-term results of a pilot study. Medical principles and practice : international journal of the Kuwait University, Health Science Centre. 2005 Jul-Aug [PubMed PMID: 15961941] |
[45] | Ercan E,Dülgergil CT,Soyman M,Dalli M,Yildirim I, A field-trial of two restorative materials used with atraumatic restorative treatment in rural Turkey: 24-month results. Journal of applied oral science : revista FOB. 2009 Jul-Aug [PubMed PMID: 19668990] |
[46] | Frencken JE,Pilot T,Songpaisan Y,Phantumvanit P, Atraumatic restorative treatment (ART): rationale, technique, and development. Journal of public health dentistry. 1996 [PubMed PMID: 8915958] |
[47] | Seale NS,Casamassimo PS, Access to dental care for children in the United States: a survey of general practitioners. Journal of the American Dental Association (1939). 2003 Dec [PubMed PMID: 14719761] |
[48] | da Franca C,Colares V,Van Amerongen E, Two-year evaluation of the atraumatic restorative treatment approach in primary molars class I and II restorations. International journal of paediatric dentistry. 2011 Jul [PubMed PMID: 21401749] |
[49] | Sheller B,Williams BJ,Hays K,Mancl L, Reasons for repeat dental treatment under general anesthesia for the healthy child. Pediatric dentistry. 2003 Nov-Dec [PubMed PMID: 14733468] |
[50] | Casamassimo PS,Thikkurissy S,Edelstein BL,Maiorini E, Beyond the dmft: the human and economic cost of early childhood caries. Journal of the American Dental Association (1939). 2009 Jun [PubMed PMID: 19491160] |
[51] | Sheiham A, Dental caries affects body weight, growth and quality of life in pre-school children. British dental journal. 2006 Nov 25 [PubMed PMID: 17128231] |
[52] | Means RT Jr, Recent developments in the anemia of chronic disease. Current hematology reports. 2003 Mar [PubMed PMID: 12901142] |
[53] | Means RT Jr,Krantz SB, Progress in understanding the pathogenesis of the anemia of chronic disease. Blood. 1992 Oct 1 [PubMed PMID: 1391934] |
[54] | Bratthall D,Hänsel-Petersson G,Sundberg H, Reasons for the caries decline: what do the experts believe? European journal of oral sciences. 1996 Aug [PubMed PMID: 8930592] |
[55] | Marinho VC, Evidence-based effectiveness of topical fluorides. Advances in dental research. 2008 Jul 1 [PubMed PMID: 18694869] |
[56] | Friedlaender EY,Rubin DM,Alpern ER,Mandell DS,Christian CW,Alessandrini EA, Patterns of health care use that may identify young children who are at risk for maltreatment. Pediatrics. 2005 Dec [PubMed PMID: 16322151] |
[57] | Valencia-Rojas N,Lawrence HP,Goodman D, Prevalence of early childhood caries in a population of children with history of maltreatment. Journal of public health dentistry. 2008 Spring [PubMed PMID: 18248339] |