REFERENCE MANUAL V 37 / NO 6 15 / 16

50 ORAL HEALTH POLICIES

Policy on Early Childhood Caries (ECC):

Classifications, Consequences, and Preventive
Strategies
Originating Group
A collaborative effort of the American Academy of Pedodontics and the American Academy of Pediatrics
Review Council
Council on Clinical Affairs
Adopted
1978
Revised
1993, 1996, 2001, 2003, 2007, 2008, 2011, 2014*
Purpose
The American Academy of Pediatric Dentistry (AAPD) recog-nizes early childhood caries [(ECC); formerly termed nursing
bottle caries, baby bottle tooth decay] as a significant public health problem. 1 The AAPD encourages oral health care pro-viders
and caregivers to implement preventive practices that can decrease a childs risks of developing this devastating disease.
Methods
This document is a revision of the previous policy, last revised in 2008. The update used electronic and hand searches of English
written articles in the dental and medical literature within the last 10 years, using the search terms infant oral health, infant oral
health care, and early childhood caries. When data did not appear sufficient or were inconclusive, recommendations were based
upon expert and/or consensus opinion by experienced researchers and clinicians.
Background
In 1978, the American Academy of Pedodontics released Nursing Bottle Caries, a joint statement with the Amer-ican Academy of Pediatrics,
to address a severe form of caries associated with bottle usage. 2 Initial policy recommendations were limited to feeding habits, concluding that
nursing bottle caries could be avoided if bottle feedings were discontinued soon after the first birthday. An early policy revision added ad libitum
breastfeeding as a causative factor. Over the next two decades, however, recognizing that this distinctive clinical pre-sentation was not
consistently associated with poor feeding practices and that caries was an infectious disease, AAPD adopted the term ECC to reflect better its
multifactoral etiology.
Dental caries is a common chronic infectious transmissible disease resulting from tooth-adherent specific bacteria, primarily
Mutans Streptococci (MS), that metabolize sugars
to produce acid which, over time, demineralizes tooth struc-ture.3 The disease of ECC is the presence of one or more de-cayed (noncavitated or
cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of six. In children younger than
three years of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC). From ages three through five, one or
more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, miss-ing, or filled score of
greater than or equal to four (age 3), greater than or equal to five (age 4), or greater than or equal to six (age 5) surfaces also constitutes S-ECC.4
Epidemiologic data from national surveys clearly indicate that ECC is highly prevalent and increasing in poor and near poor US preschool
children and is largely untreated in children under age three. 5 Those children with caries experience have been shown to have high numbers of
teeth affected. Conse-quences of ECC include a higher risk of new carious lesions in both the primary and permanent dentitions,6,7
hospitalizations and emergency room visits,8,9 increased treatment costs,10 risk for delayed physical growth and development, 11,12 loss of school
days and increased days with restricted activity,13,14 diminished ability to learn,15 and diminished oral health-related quality of life.16
Dental caries is a transmissible infectious disease and understanding the acquisition of cariogenic microbes improves preventive
strategies. Microbial risk markers for ECC include MS and Lactobacillus species. 17 MS maybe transmitted vertically from
caregiver to child through salivary contact, affected by the frequency and amount of exposure. Infants whose mothers have high
levels of MS, a result of untreated caries, are at greater risk of acquiring the organism earlier than chil-dren whose mothers have
low levels.18 Horizontal transmission (eg, between other members of a family or children in daycare) also occurs. 18 Eliminating
saliva-sharing activities (eg, sharing utensils, orally cleansing a pacifier) may help decrease an infants or toddlers acquisition of
cariogenic microbes.18
* The 2014 revision is limited to use of fluoride toothpaste in young children.
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

ORAL HEALTH POLICIES 51

Newly-erupted teeth, because of immature enamel, and teeth with enamel hypoplasia may be at higher risk of devel-oping
caries. Current best practice includes twice-daily brushing with fluoridated toothpaste for all children in optimally fluoridated and
fluoride-deficient communities. When determining the risk-benefit of fluoride, the key issue is mild fluorosis versus preventing
devastating dental disease. A smear or rice-size amount of fluoridated tooth-paste (approximately 0.1 mg fluoride; see Figure
1) shouldbe used for children less than three years of age. A pea-size amount of fluoridated toothpaste (approximately 0.25 mg
fluoride) is appropriate for children aged three to six. 19,20 Parents should dispense the toothpaste onto a soft, age-appropriate sized
toothbrush and perform or assist with toothbrushing of preschool-aged children. To maximize the beneficial effect of fluoride in
the toothpaste, rinsing after brushing should be kept to a minimum or eliminated altogether. 21
Professionally-applied topical fluoride treatments also are efficacious in reducing prevalence of ECC. The recommended
professionally-applied fluoride treatments for children at risk for ECC who are younger than six years is five percent sodium
fluoride varnish (NaFV; 22,500 ppm F).22 An associated risk factor to microbial etiology is high frequency consumption of sugars.
Caries-conducive dietary practices appear to be estab-lished by 12 months of age and are maintained throughout early
childhood.23,24 Frequent night time bottle feeding with milk and ad libitum breast-feeding are associated with, but not consistently
implicated in, ECC.25 Night time bottle feeding with juice, repeated use of a sippy or no-spill cup, and frequent in between meal
consumption of sugar-containing snacks or drinks (eg, juice, formula, soda) increase the risk of caries. 26While ECC may not arise
from breast milk alone, breast feeding in combination with other carbohydrates has beenfound in vitro to be highly cariogenic.27
Frequent consumption of between-meal snacks and beverages containing sugars in-creases the risk of caries due to prolonged
contact between sugars in the consumed food or liquid and cariogenic bacteria on the susceptible teeth. 28 The American Academy
of Pediatrics has recommended children one through six years of age consume no more than four to six ounces of fruit juice per
day, from a cup (ie, not a bottle or covered cup) and as part of a meal or snack. 29
Evidence increasingly suggests that preventive interven-tions within the first year of life are critical.30 This may be best
implemented with the help of medical providers who, in many cases, are being trained to provide oral screenings, apply preventive
measures, counsel caregivers, and refer infants and toddlers for dental care. 31
Policy statement
The AAPD recognizes caries as a common chronic disease resulting from an imbalance of multiple risk factors and protective factors
over time. To decrease the risk of develop-ing ECC, the AAPD encourages professional and at-home preventive measures that include:
1. Reducing the parents/siblings MS levels to decrease transmission of cariogenic bacteria.
2. Minimizing saliva-sharing activities (eg, sharing utensils) to decrease the transmission of cariogenic bacteria.
3. Implementing oral hygiene measures no later than the time of eruption of the first primary tooth. Toothbrush-ing should be
performed for children by a parent twice daily, using a soft toothbrush of age-appropriate size. In all children under the age of three,
a smear or rice-size amount of fluoridated toothpaste should be used. In all children ages three to six, a pea-size amount of
fluor-idated toothpaste should be used.
4. Providing professionally-applied fluoride varnish treat-ments for children at risk for ECC.
5. Establishing a dental home within six months of erup tion of the first tooth and no later than 12 months of age to conduct a
caries risk assessment and provide parental education including anticipatory guidance for prevention of oral diseases.
6. Avoiding high frequency consumption of liquids and/or solid foods containing sugar. In particular:
Sugar-containing beverages (eg, juices, soft drinks, sweetened tea, milk with sugar added) in a baby bottle or no-spill
training cup should be avoided.
Infants should not be put to sleep with a bottle filled with milk or liquids containing sugars.
Ad libitum breast-feeding should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates
are introduced.
Parents should be encouraged to have infants drink from a cup as they approach their first birthday. Infants should be
weaned from the bottle between 12 to 18 months of age. 32
7. Working with medical providers to ensure all infants and toddlers have access to dental screenings, counseling, and
preventive procedures.
Smear under 3 yrs. Pea-sized 3 to 6 yrs.
Figure 1. Comparison of a smear (left) with a pea-size (right) amount of toothpaste.
REFERENCE MANUAL V 37 / NO 6 15 / 16

52 ORAL HEALTH POLICIES

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