Chapter 4: Pediatric Dentistry Introduction

Section A: Etiology of Dental Caries in Children

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Section A: Etiology of Dental Caries in Children


Early childhood caries (ECC) is defined as any dental cares in children less than 3 years of age. It can be caused by several factors. These factors include:

  • inappropriate bottle feeding (baby bottle tooth decay)

  • ad libitum breast feeding (nursing caries)

  • a highly cariogenic diet (rampant caries)

  • absent or insufficient preventive measures

  • high maternal s. mutans levels

Note: The importance of ECC and baby bottle tooth decay (BBTD) to the IHS cannot be overemphasized. Research has shown that most children who develop ECC continue to have higher decay rates into adult life. Children with ECC should be considered at higher risk for the development further of dental caries and have access to additional preventive programs and services.

Baby Bottle Tooth Decay (BBTD)


BBTD is a common problem in the child population at IHS facilities. It is a condition that is most often recognized in the very young (age 1 to 3 years). Due to the devastation of the dentition and patient management considerations, treating BBTD/ECC can be a difficult and frustrating experience.


Prolonged cariogenic bottle feeding at night is a major risk factor. The contents of the bottle may include substances such as milk, formula, juice, or sweetened drinks.

Decay is thought to occur due to the distinctive swallowing process which infants display:

  • The child lies in bed with a bottle in its mouth; the nipple resting against the palate while the tongue contacts the lower lip, covering the mandibular incisors.

  • As the child falls asleep, the flow of saliva decreases, and the liquid in the mouth pools and remains in the oral cavity. This permits carbohydrates to remain in contact with microorganisms on the teeth for an extended period of time.

Pattern of Decay

The causative behaviors produce a distinctive pattern of decay in the primary dentition. The age of the child when the teeth erupt also plays a role. Typically, BBTD involves the facial and lingual surfaces of the maxillary incisors. Also, the occlusal surfaces of the maxillary and mandibular first molars are decayed. In advanced stages, the second molars might also display occlusal decay. Mandibular incisors rarely have decay due to the protective position of the tongue.

Nursing Caries

A decay pattern similar to BBTD may be predicted when children sleep with the mother and are allowed to nurse at will throughout the night. This is not a common problem with breastfeeding, but it should be a part of breastfeeding promotion and education. Although breast milk alone is not thought to be cariogenic, other dietary carbohydrates, along with the breast milk, contribute to this pattern.

Rampant Decay


Rampant decay is also a common problem in young children at IHS facilities. The caries pattern is generalized, rather than affecting mostly the maxillary teeth.


Rampant decay is the widespread, rapidly advancing type of caries resulting in early involvement of the pulp and affecting surfaces of teeth usually regarded as immune from decay.


The factors most frequently present in cases of rampant decay are

  • a diet high in refined carbohydrates

  • virulent microorganisms

  • poor oral hygiene

Pattern of Decay

The pattern of rampant decay in a young child is distinct from BBTD. Smooth surfaces of all primary teeth are susceptible in rampant decay; however, it is the interproximal surface decay that predominates. Interproximal decay on the maxillary and mandibular incisors is indicative of rampant decay. Maxillary and mandibular molars may also have large occlusal and interproximal lesions.

Other Sources of Decay


There are many other etiologies of decay present in the child population. It is not uncommon to see ECC in a child who has never used the bottle. The causes and variations of ECC are not well understood or quantified.

Risk Factors

ECC is a multi-factorial process involving many potential risk factors. These may include the following:

  • frequency of feeding

  • contents of the diet

  • quality and quantity of saliva

  • virulence and makeup of the oral flora

  • maturity of the enamel

  • inappropriate feeding practices

  • maternal transmission of pathogenic organisms

  • exposure to fluoride



Dental caries in the very young child is a preventable condition. There are programs available to assist in prevention efforts, and many steps can be taken on an individualized basis.

Community Preventive Measures

Some examples of community preventive measures are:

Clinical Preventive Measures

Some examples of clinical preventive measures are:

  • increasing access to children between 1 and 2 years of age

  • developing a High-Risk-for-Caries Prevention Program

  • early screening and identification of children with ECC/BBTD

  • appropriate topical fluoride therapy (i.e., varnish)

  • conservative preventive restorations (i.e., ART)

  • prevention programs designed to slow progression of caries until patient maturity and cooperation allow treatment

  • supplying infants and toddlers with “sippy” cups

  • prenatal WIC counseling

  • oral hygiene instructions

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