Children’s Oral Health & the
Primary Care Provider
Epidemiology and Risk Factors for Early
Childhood Caries
Module 2
Module 2 Objectives:
 Discuss the epidemiology of Early Childhood
Caries (ECC)
 Discuss the factors that place children at higher
risk for developing ECC
 Discuss clinical findings that are predictive of
high ECC risk
How Do Cavities Develop?
Streptococcus mutans
Carbohydrates
Acid formation
Demineralization
Tooth destruction
Teeth
Sugar
Decay
Bacteria
How Do Cavities Develop?
Streptococcus mutans
Carbohydrates
Acid formation
Demineralization
Tooth destruction
Teeth
Sugar
Decay
Bacteria
Sugar Consumption & Risk of ECC
pH
 Acids persist for 20-40 minutes after eating
 Frequency of sugar ingestion more
important than quantity
Safe
zone
Danger
zone
Time
6
Bottle
7
Breakfast
8
9
Snack
10
11
12
Sippy-cup Sippy-cup
J. Douglass BDS, DDS
1
Lunch
H. Silk MD
A. Douglass MD
Risk Factors for
Early Childhood Caries (ECC)
Bottle-feeding:
Risk of ECC
 Studies show low cariogenicity of bovine milk
 Phosphoproteins in milk inhibit enamel
dissolution
 Cariogenicity increases when bovine milk
serves as a vehicle for sugary substances
Breastfeeding:
Risk of ECC
 Epidemiological studies of breastfeeding
& ECC are rare
 Possibility that deleterious dietary practices other
than breastfeeding cause ECC
 Breast milk alone is not cariogenic
 Breast milk becomes highly cariogenic in the
presence of other sugars
Risk Factor for ECC:
Nocturnal Feeding
 Nocturnal feeding plays a role in caries development
 When practiced for prolonged periods of time
 Related to reduction of salivary flow during sleep
 Highest risk:
 Nighttime sugary liquids and/or prolonged on-demand
nighttime breastfeeding combined with poor oral hygiene
Risk Factors for ECC:
Juice and Sugary Beverages
 Ad lib consumption from bottle or sippy-cup throughout the day
or from a bottle taken to bed:
 Leads to frequent exposure of teeth to carbohydrate,
contributing to caries
 Linked to malnutrition & short stature
 Replaces more nutritious foods & blunts appetite
 Fruit juices offer no nutritional benefits over whole fruit
 Sugary beverages have no nutritional value
 In older children: sugary beverages (especially soda) also
contribute to the epidemic of obesity
Risk Factors for ECC:
Cariogenic (Sugary) Snacks
 Daily frequent exposure to sugary foods is associated with
increased ECC risk.
Sugary foods that are especially cariogenic:
 Sticky foods that are retained in the mouth for prolonged
periods of time & not easily washed out by saliva
 Consumed as between meal snacks (>2X/day)
Risk Factors for ECC:
Transmission of Streptococcus mutans (SM)
 Early contamination with SM increases ECC risk
 Mothers with high levels of SM tend to have:
 High level of decay
 Poor oral hygiene
 Frequent sugar consumption/snacking
 Children with high levels of SM
 High dental caries rates within family members
increases child’s risk
Practices that Allow Transmission of
Streptococcus mutans
Risk Factor for ECC:
Poor Oral Hygiene
 Visible plaque correlated with high levels of
Streptococcus mutans
 Infants & Toddlers:
 Visible plaque is an indication of poor &
inconsistent daily oral hygiene
Risk Factor for ECC:
Inadequate Fluoride
 No regular use of fluoride toothpaste
 Drinking non-fluoridated water
Risk Factor for ECC:
Children with Special
Health Care Needs (CSHCN)
 More caries (treated and untreated)
 More missing teeth
 Poor oral hygiene due to behavior problems
 Higher prevalence of gingivitis and periodontal
diseases
 Inadequate dietary habits
Risk Factor for ECC:
Children with (CSHCN)
Enamel Hypoplasia
 More difficulty obtaining dental care than any other
population
 Frequent exposure to sugary medications
 Medication side effects
 (xerostomia:
salivary flow)
 Compromised immune system
 Enamel hypoplasia
Risk Factor for ECC:
Deleterious Habits During
Pregnancy
 Inadequate prenatal care
 Drug abuse
 Genitourinary or oral infections (periodontal disease)
 Alcohol or tobacco use are associated with:
 Premature and/or Low Birth Weight Baby
 Enamel Hypoplasia
 Prematurity is also associated with Enamel Hypoplasia
Risk Factor for ECC:
Socioeconomic Status
 Ethnic & Cultural factors
 Children from families with:
 Low-income
 Low educational levels
 Low dental health literacy
are more likely to have caries
What Clinical Findings Are
Predictive of High Caries Risk?
Previous Caries Experience
 One of best predictors of future caries (Reisine et. al, 1994)
 For children under age 5, a history of decay should
automatically classify a child as high risk
 Not useful caries-risk predictor for infants and toddlers
(not enough time for ECC to
be expressed)
Visible Plaque
 One of the best predictors of future caries risk in
young children
 Screening for visible plaque is relatively easy and
inexpensive
Dental Plaque
White Spot Lesions
 Initial stage (precursor) of the caries process
 Equivalent to caries for infants and toddlers
 Often observed at the gum line and accompanied by
plaque and bleeding gums
Chalky, white spots on primary teeth are
demineralized areas and are considered early decay
From White Spots to
Frank Caries
Enamel Defects &
Stained Pits and Fissures
 Enamel hypoplasia
 Stained pit and fissure surfaces of primary teeth
 Consider both indicative of increased caries risk
Enamel Hypoplasia
Stained Pits
and Fissures
Perceived Risk by
Health Care Professional
 Experienced practitioners are reasonably able to
predict caries risk with high levels of accuracy
Presence of Braces
and Oral Appliances
Caries Risk Assessment
and Management
 Any observable decay or demineralization (white spots):
- Refer for dental care as soon as possible
 Any factors on the oral screen or parent interview that
increase the child’s risk for caries:
- Refer for dental care
 Uncertain caries risk:
- Refer for dental care
 Refer to I-Smile Coordinator for care coordination & to

ensure that dental care is established
Re-assess to ensure the child has been evaluated by a
dentist & has established regular dental care & a dental
home
I-Smile Coordinators
I-Smile coordinators are dental hygienists who serve as
prevention experts and liaisons between families, health care
professionals, and dental offices to ensure completion of dental
care. Coordinators are located in regional public health
agencies and provide local community support throughout
Iowa. A coordinator can:
• Assist with dental referrals for young children.
• Provide Medicaid dental billing information.
• Offer education for healthcare professionals regarding children’s oral
health, including screening and fluoride varnish training.
I-Smile Coordinator contact information can be found at:
www.idph.state.ia.us/hpcdp/oral_health.asp or
I-Smile hotline 1-866-528-4020
Summary: Oral Health Module 2
 Dental caries develop in the presence of teeth,
bacteria & sugars
 Human & bovine milk have low cariogenicity
 Ad lib use of a sippy cup or bottle filled with juice or
sugary beverages is a significant risk factor
 Previous caries & visible plaque are the best predictors
of future caries for young children
 Enamel defects & stained pits or fissures increase risk
of caries