Early childhood caries (ECC) is a chronic disease defined as the presence of one or more decayed, missing, or filled surfaces in any primary tooth of a child under the age of six. It is a major public health concern worldwide, affecting hundreds of millions globally. Primary teeth are necessary for clear speech development and establishing proper chewing function. Losing these teeth prematurely due to decay can compromise the space needed for adult teeth to erupt correctly, leading to future alignment problems.
Defining the Condition and Progression
ECC is sometimes referred to as “baby bottle tooth decay” due to its association with prolonged feeding practices. ECC typically affects the upper front teeth first, as these are the least protected by saliva flow and are bathed in liquid during bottle feeding. The lower front teeth are generally spared.
The decay process begins with the loss of minerals from the tooth enamel, appearing as a dull, white spot near the gumline. This demineralization is an active lesion that may be reversible. If the process continues, the enamel breaks down, turning the area yellowish or brownish. Finally, the decay forms a cavitation, a visible hole in the tooth structure. Without intervention, this decay can rapidly destroy the entire crown.
The Underlying Causes and Risk Factors
ECC is a multifactorial disease resulting from an interaction between specific bacteria, fermentable carbohydrates, and a susceptible tooth surface. The primary organism involved is Streptococcus mutans, an acid-producing bacterium that colonizes the dental plaque biofilm. These bacteria are commonly transmitted from the primary caregiver to the infant through saliva-sharing behaviors, such as sharing spoons or cleaning a pacifier with the mouth.
Once established, Streptococcus mutans consumes fermentable carbohydrates, such as sucrose, glucose, and fructose, converting them into lactic acid. This acid lowers the \(\text{pH}\) level in the mouth, dissolving minerals from the tooth enamel in a process known as demineralization. The bacteria thrive in this low \(\text{pH}\) environment, which drives the decay process.
A significant risk factor is the prolonged use of bottles or sippy cups containing milk, formula, or juice, especially at bedtime. During sleep, salivary flow is reduced, removing the mouth’s natural buffering capacity. This allows sugary liquid to pool around the teeth, creating an acidic environment that drives rapid demineralization. Frequent consumption of sugary snacks or beverages also increases the risk by constantly providing fuel for the bacteria.
Comprehensive Prevention Strategies
Prevention relies on establishing consistent habits that address the bacterial, dietary, and host factors of the disease. Oral hygiene must begin as soon as the first primary tooth erupts, typically around six months of age. Caregivers should brush the child’s teeth twice daily using a soft-bristled, child-sized toothbrush and fluoridated toothpaste.
Oral Hygiene and Fluoride Use
The amount of toothpaste used is specific to the child’s age to balance prevention with the risk of dental fluorosis. For children younger than three years old, use only a smear, the size of a grain of rice. This amount increases to a pea-sized dab for children aged three to six years. Caregivers should supervise brushing until the child is capable of doing a thorough job, usually around seven or eight years old.
Dietary Management and Professional Care
Dietary habits should be managed by limiting the frequency of sugar exposure, as repeated acid exposure increases risk. Weaning the child onto a cup by their first birthday prevents prolonged contact between sugars and the teeth. If a bottle is used at bedtime, it should contain only water.
Professional preventive care begins with establishing a “Dental Home,” meaning the child should have their first dental visit within six months of the first tooth erupting or no later than their first birthday. This early visit allows the dentist to conduct a caries risk assessment and provide guidance. The professional may also apply topical fluoride varnish to strengthen the enamel and offer extra protection.
Diagnosis and Treatment Options
Diagnosis begins with a thorough visual and tactile examination by a dental professional, often supplemented by radiographic imaging. Bitewing radiographs are useful for detecting decay between the back teeth, which cannot be seen during a clinical exam. Detecting lesions early allows for less invasive treatment options.
Treatment depends on the severity of the decay. For early-stage, non-cavitated white spot lesions, the process can often be reversed or arrested with non-invasive treatments like fluoride varnish. Another minimally invasive option is Silver Diamine Fluoride (SDF), a liquid applied directly to the decayed area that arrests the lesion’s progression by hardening the softened tooth structure. SDF permanently stains the arrested decay black.
When decay has progressed to a moderate or severe stage, restorative treatment is necessary to remove the damaged structure and restore function. This may involve traditional fillings for smaller lesions or the placement of stainless steel crowns (SSCs) for teeth with extensive decay or following pulp therapy. SSCs are durable, full-coverage restorations that seal the tooth and protect it until it naturally falls out. For young or anxious children with extensive needs, treatment may require sedation or general anesthesia.