1. Protecting All Children’s Teeth
Caries

2. Introduction
used with permission from Ian Van Dinther
Caries is an infectious transmissible disease resulting from tooth
adherent bacteria that metabolize sugars to produce acid which
ultimately demineralize tooth structure and, if left untreated, can
progress to a cavity.
Dental caries is the most common chronic disease of childhood and
disproportionately affects poor and minority populations.
Early Childhood Caries, or ECC, is the presence of 1 or more decayed,
missing (due to caries), or filled tooth surfaces in any primary tooth in
a child under the age of 6.
Notes:
A majority of people in the United States have at least 1 cavity by adulthood.
Dental caries are 5 times more common than asthma (11%) and affect 58.6% of 5- to 17-year-olds; 51.6% of elementary school students (5 to 9 years old); 77.9% of 17 year-olds; and 84.7% of adults.
Glossary:
Cavity: An area of decay in a tooth

3. Learner Objectives
used with permission from Ian Van Dinther
Upon completion of this presentation, participants will be able to:
Define caries and Early Childhood Caries (ECC).
Name the primary bacteria involved in the caries process.
Discuss the contribution of carbohydrate metabolism in caries development.
State the important protective benefits of saliva.
List risk factors and describe the oral manifestations of ECC.
Describe the 5 stages of ECC and identify early lesions on physical exam.
Discuss the impact of ECC on overall health and well-being.
Recall the 5 major methods of preventing ECC.

4. Etiology and Pathophysiology
There are 3 requirements for the formation of
dental caries:
1. Cariogenic bacteria
2. Sugar
3. Teeth
Because dental caries has a microbial
etiology, caries cannot form in the absence of
cariogenic bacteria, regardless of sugar intake.
Cariogenic= cavity-causing
Used with permission from Miller Medical Illustration & Design

5. Etiology and Pathophysiology
Bacteria adhere to the tooth surface in a biofilm called dental plaque. When carbohydrates are consumed, they are metabolized by bacteria and produce acid as a byproduct. The acid causes demineralization of the tooth enamel over time.
Caries
created by AAP Oral Health Staff

6. Etiology and Pathophysiology, continued
The following factors contribute to demineralization:  
High cariogenic bacterial load 
Frequent feedings  
Poor oral hygiene 
Decreased saliva production  
Notes:
A high oral bacterial load results in more acid production.
Frequent feedings allow less time for remineralization.
Poor oral hygiene increases plague and allows sugar to remain longer.

7. Etiology and Pathophysiology, continued
These factors aid in the remineralization process:  
Saliva
Good oral hygiene 
A non-cariogenic diet
However, it is possible to reverse the
demineralization process before
cavitation occurs.
Notes:
Saliva acts as a buffer to return pH above the demineralization level, strengthens tooth enamel, and is a fluoride source.
Good oral hygiene delivers fluoride and removes bacterial energy sources.
Glossary: Non-cariogenic Diet: A diet not contributing to the formation of caries, low in sugar
Used with permission from Giusy Romano-Clarke, MD

8. Bacteria in the pathogenesis of caries is
The primary bacterial species involved
in the pathogenesis of caries is
Streptococcus mutans, but many
other bacteria have also been
implicated, including S sobrinus,
Actinomyces sp, and Lactobacillus sp.
High levels of cariogenic bacteria are
indicative of active caries process and
are associated with increased risk of new caries development
Notes:
Other bacteria implicated in the pathogenesis of caries include S sobrinus, Actinomyces sp, and Lactobacillus sp.
Recent evidence demonstrates that these bacteria can be found in the mouths of predentate infants, having been transmitted from the mouth of the primary caregiver (usually the mother).
Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina

9. Used with permission from Sunnah Kim
Bacteria, continued
Plaque is composed of salivary proteins
that adhere to teeth, as well as
bacteria and their byproducts.
Plaque harbors the bacteria that
initiate the demineralization process. Adequate plaque control can reduce the
likelihood of developing dental caries.
Used with permission from Sunnah Kim

10. S Mutans pits and fissures of teeth, so the
S. mutans is concentrated in the
pits and fissures of teeth, so the
grooved surfaces of the molars
are the most common site for
caries lesions.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospita
Cavity

11. Used with permission from Valerie Abbott
S. Mutans, continued
The virulence of S. mutans varies by strain.
The type of S. mutans cannot be modified, but
the amount of bacteria can be altered.
These methods can be used to decrease
bacteria and minimize caries:
Brushing with fluoride toothpaste
Professional dental cleanings
Exposure to topical fluoride
Chlorhexidine mouthrinses and Xylitol use
Flossing
Notes:
Families usually have the same strains of S mutans.
Professional dental cleanings will physically remove the plaque.
Brushing with fluoride toothpaste has the best scientific evidence support of the listed interventions in caries prevention
Flossing has relatively low evidence for caries prevention
Glossary:
Xylitol: A crystalline alcohol C5H12O5 that is a derivative of xylose, used as a sweetener
Used with permission from Valerie Abbott

12. Used with permission from Jamie Zaleski
S Mutans, continued
S mutans is transmitted from the primary
caregiver to infant by saliva.
Transmission rates increase when parents:  
Share utensils or toothbrushes. 
Taste food or drink before serving it.  
“Clean” a dropped pacifier with saliva.
Allow a child to place fingers into
an adult's mouth.
Notes:
Allowing a child to place fingers in the parent’s mouth can result in transmission of S mutans because the fingers eventually go back into the child’s mouth.
Earlier colonization increases a child’s risk for caries.
Used with permission from Jamie Zaleski

13. Sugar The metabolism of carbohydrates
by oral bacteria creates acid that
demineralizes enamel.
The risk of demineralization
and caries development is
directly related to the frequency
with which the teeth are
exposed to sugar.
Notes:
All types of fermentable sugars can be metabolized by bacteria.
Fermentable sugars include sucrose, especially, but also lactose, fructose, and glucose.
Used with permission from Content Visionary

14. Sugar, continued
Caries development is positively associated with the following activities:
Frequent or prolonged contact of the teeth with sugary substances.
 Consumption of sticky foods. 
Dipping a pacifier in sweeteners like honey or corn syrup. 
Regular use of medications that contain sucrose, including some multi-vitamins.
Notes:
Frequent or prolonged contact with sugar substances occurs with frequent bottle or sippy cup use, nocturnal feedings (breast or bottle) once teeth erupts, and frequent snacking between meals.
“Sticky” foods include candy, fruit roll-ups, raisins/dried fruit, and caramel.
Physicians should be mindful when prescribing medications that contain sugar.
Used with permission from ANZ Photography

15. Sugar, continued
Caries risk is reduced when:
Teeth are brushed immediately after eating to remove sticky foods. 
Fresh fruit, vegetables, and whole grain snacks are chosen instead of candy or juice.
Used with permission from Melinda Clark, MD, Associate Professor of Pediatrics, Albany Medical Center

16. Used with permission from Monica Wind
Enamel
Enamel is a physical barrier to bacterial invasion
of the tooth. Acid produced by bacteria on the teeth demineralizes
the enamel.
When the enamel is weakened or less able to
remineralize, the risk for caries is increased.
The health and strength of the enamel can be
modified by changing health behaviors.
Notes:
One risk for the development of caries is enamel hypoplasia. Enamel hypoplasia is common in children, especially among premature infants.
Chronic conditions such as Gastroesophageal Reflux Disease (GERD) and bulimia nervosa weaken enamel. In GERD and bulimia nervosa, gastric acid erodes the enamel.
Glossary:
Enamel: Intensely hard calcareous substance that forms a thin layer partly covering the teeth; the hardest substance of the animal body; consists of minute prisms arranged at right angles to the surface and bound together by a cement substance Hypoplasia: A condition of arrested development in which an organ or part of an organ remains below the normal size or in an immature state
Used with permission from Monica Wind

17. Dental Sealants Outside the Early Childhood
Caries (ECC) age range, the
majority of caries develop on
grooved surfaces of teeth—the
pits and fissures of the molars.
This is why dental sealants are
an effective method of caries
prevention.
Notes:
More information about dental sealants is available at
Used with permission from David A. Clark, MD; Chairman and Professor of Pediatrics at Albany Medical Center

18. Saliva
Saliva has several important properties that help to protect against the majority of carious lesions:  
Saliva buffers acid.
Saliva is bacteriostatic.  
Saliva aids in remineralizing the teeth.
Notes:
The alkaline properties of saliva allow it to buffer acid and raise the pH, decreasing demineralization. 
Saliva contains many substances that limit the multiplication of oral flora, including lactoferrin, lysozyme, lactoperoxidase, ß-lysin, and immunoglobulins.
Saliva helps remineralize the teeth by supplying calcium, phosphate, and fluoride to help construct enamel.
Glossary:
Bacteriostatic: Causing inhibition of the growth of bacteria without destruction

19. Saliva, continued
Decreased saliva production promotes development of caries. Possible causes of limited saliva production include:
Systemic diseases 
Salivary gland damage from surgery or radiation therapy  
Medication effects
Notes:
Sjogren’s syndrome is one systemic disease that can decrease saliva production.
Glycopyrrolate and Anticholinergic medications can result in decreased saliva.

20. Used with permission from Joe Martinez
Saliva, continued
Medications are the most common cause
of decreased saliva production in children.
Pediatricians need to be aware of this risk
and choose medications carefully.
Notes:
When medications that cause xerostomia cannot be avoided or a condition known to decrease saliva production exists, at-risk children should be screened more closely for caries.
Glossary:
Xerostomia: Abnormal dryness of the mouth due to insufficient saliva production
Used with permission from Joe Martinez

21. Early Childhood Caries (ECC)
ECC is defined as the presence of 1 or more decayed, missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of 6.
ECC typically results in severe tooth morbidity and extensive restorative treatment needs.
Notes:
The previous terminology of “baby bottle tooth decay” and “nursing caries” has been replaced with the term ECC because we now understand that the process of caries is independent of the route of feeding.
Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry, University of Alabama at Birmingham

22. Early Childhood Caries, continued
ECC affects 24.7% of
children in the United States.
ECC is concentrated among poor
and minority children, with 80%
of total tooth decay occurring in
25% of the nation's children.
Notes:
Early Childhood Caries rates are as high as 70% in some Hispanic and Native American populations.
Used with permission from iStock

23. Pattern of primary tooth eruption
The typical pattern of primary tooth eruption is:  
1. Lower central incisors 
2. Upper central incisors  
3. Lateral incisors  
4. First molars  
5. Canines (cuspids) 
6. Second molars
Notes: The diagram is used with permission from the American Dental Association.
Used with permission from the American Dental Association

24. Affected Teeth
ECC tends to affect the upper (maxillary) incisors first because they erupt earliest and are less protected by saliva.
The primary molars are affected next
because of their grooved surfaces.
Plaque stagnates in the molar’s pits
and fissures, which are difficult areas
to clean with a toothbrush.
Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina

25. Affected Teeth, continued
The canines tend to be spared
because they are smooth
teeth that erupt later.
The lower teeth are better
protected by saliva and the
tongue.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

26. Diagnosis and Stages The stages of ECC are as follows:
1. Plaque: This biofilm contains cariogenic bacteria. 
2. Incipient lesions or white spots: Usually begin along the gum line, which is the most important place to examine for ECC. With intervention at this stage, the caries process is entirely reversible. 
3. Enamel caries: A defect in the enamel surface is visible. 
4. Dentine caries: ECC has extended into the dentine layer, where the nerve and pain fibers are located.  
5. Pulpitis: The caries lesion has progressed so that it now affects the pulp.
Notes:
Early lesions are painless and the most difficult to recognize.
During the dentine caries stage, a child develops tooth heat/cold sensitivity and pain.
Pulpitis is very painful and requires a root canal for repair.
Glossary:
Pulp: The highly vascular sensitive tissue occupying the central cavity of a tooth

27. Impact and Effects on Health
ECC increases the risk of caries lesions developing in permanent teeth.
Other health effects include:  
Pain
Difficulty chewing, which may lead to poor weight gain 
Difficulty speaking
Oral infections
Loss of sleep, difficulty concentrating, and interrupted learning
Destruction and loss of teeth
Damage to permanent teeth
Notes:
Oral infections include abscesses that can spread and lead to cellulitis or fistula formation. More information about abscesses is available online at
ECC can impact a child's education. According to a 1992 study (see Reference, below), approximately 51 million school hours per year are missed because of dental problems, most of which result from caries.
Destruction and loss of teeth can lead to decreased self-esteem and impaired socialization. 
Glossary:
Abscess: A localized collection of pus surrounded by inflamed tissue
Reference:
Gift HC, Reisine ST, Larach DC. The Social Impact of Dental Problems and Visits. Am Journal of Public Health. 1992; 82(12):

28. Impact and Effects on Health, continued
ECC results in increased office, dental,
and ER visits.
These costs far exceed those of
preventive dental care.
It is 10 times more expensive to provide inpatient care for caries-related symptoms than to provide that same patient the recommended periodic preventive care.
Notes:
More school is missed by poor, Hispanic females without dental insurance than any other children. Missed school for children also translates into missed work and lost wages for caregivers.
The following studies have investigated the cost of prevention versus treatment of disease and confirm that it is significantly more expensive to treat caries than to prevent them: - Pettinato ES, Webb MD, Seale NS. A comparison of Medicaid reimbursement for non-definitive pediatric dental treatment in the emergency room versus periodic preventative care. Pediatr Dent. 2000; 22(6): Savage MF et al. Early preventative dental visits: effects on subsequent utilization and costs. Pediatrics. 2004; 114(4):
Paper Permission on file from Mayra Patino

29. Risk Factors for ECC Ethnicity, minority or low socioeconomic status
Social/Environmental Characteristics  
Ethnicity, minority or low socioeconomic status
Parents with less than a high school education
Limited or no dental insurance
Limited or no access to dental care
Inadequate fluoride exposure
Caries in a parent or sibling (especially in the past 12 months)
High levels of S mutans in parents

30. Risk Factors for ECC, continued
Physical Characteristics
Children with special health care conditions
Low birth weight (less than 2500 grams)  
Gingivitis 
Chronic conditions that weaken enamel, promote gingivitis, or cause
decreased saliva production 
Visible plaque on the teeth 
Notes:
The presence of even a single cavity in a young child is a strong risk factor for future decay.
More information about oral health in children with special needs is available online at
Glossary:
Gingivitis: Inflammation of the gums

31. Risk Factors for ECC, continued
Behavioral Risk Factors
Poor nutritional/feeding habits
Poor oral hygiene
Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina

32. Preventing ECC Physicians who care for children
Should teach the following methods
to prevent or delay caries: 1. Improve oral hygiene
2. Alter feeding/eating practices
3. Delay colonization of the teeth
4. Ensure adequate fluoride
5. Establish dental care, such as a dental home
In older high-risk children, encourage dental sealants
Notes:
Improve oral hygiene through regular brushing and flossing.
Altering feeding practices includes less frequent eating and choosing healthier, less sticky snacks.
Fluoride is effective in the prevention of caries and should be provided topically (toothpaste, mouthrinse, gel, varnish) and systemically (drinking water, fluoride supplementation). More information about fluoride is available at
Dental care includes oral health examinations, cleanings, anticipatory guidance, and definitive treatment of existing disease. The American Academy of Pediatrics recommends that all children have their first dental visit at or around the age of 1. See for AAP referral guidelines.
More information about dental sealants is available at
An more in-depth discussion of each preventive measure is available online at
Used with permission from Melinda Clark, MD, Associate Professor of Pediatrics, Albany Medical Center

33. Question #1
Through which of the following mechanisms does saliva inhibit caries formation?
A. Supplying fluoride to aid in tooth remineralization
B. Removal of dietary carbohydrates from tooth surfaces
C. Buffering of acid
D. Providing calcium and phosphate to aid in remineralizing the teeth
E. All of the above

34. Answer
Through which of the following mechanisms does saliva inhibit caries formation?
A. Supplying fluoride to aid in tooth remineralization
B. Removal of dietary carbohydrates from tooth surfaces
C. Buffering of acid
D. Providing calcium and phosphate to aid in remineralizing the teeth
E. All of the above

35. Question #2
True or False? The risk of caries development is directly related to the frequency with which the teeth are exposed to sugar.  
A. True 
B. False

36. Answer
True or False? The risk of caries development is directly related to the frequency with which the teeth are exposed to sugar.  
A. True 
B. False

37. Question #3
Which of the following helps to prevent or delay dental caries?  
A. Limiting snacks between meals 
B. Ensuring adequate fluoride
C. Improving oral hygiene
D. Establishing a dental home 
E. All of the above

38. Answer Which of the following helps to prevent or delay dental caries?
A. Limiting snacks between meals
B. Ensuring adequate fluoride
C. Improving oral hygiene
D. Establishing a dental home 
E. All of the above

39. Question #4
Which teeth does Early Childhood Caries tend to affect first?  
A. Mandibular molars 
B. Maxillary incisors 
C. Mandibular incisors
D. Maxillary molars 
E. All teeth are equally affected

40. Answer Which teeth does Early Childhood Caries tend to affect first?
A. Mandibular molars 
B. Maxillary incisors 
C. Mandibular incisors 
D. Maxillary molars
E. All teeth are equally affected

41. Question #5
Which of the following bacterial species is the primary pathogen implicated in the development of dental caries?  
A. Streptococcus salivarius 
B. Streptococcus mutans 
C. Bacteroides sp. 
D. Streptococcus viridans
E. Actinomyces sp.

42. Answer
Which of the following bacterial species is the primary pathogen implicated in the development of dental caries?  
A. Streptococcus salivarius 
B. Streptococcus mutans 
C. Bacteroides sp. 
D. Streptococcus viridans 
E. Actinomyces sp.

43. References
1. American Academy of Pediatrics Policy Statement. Oral health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics. 2003; 111(5): Available online at Accessed November 20, 2006.
2. Anderson M. Risk assessment and epidemiology of dental caries: review of the literature. Pediatr Dent. 2002; 24(5):
3. Berkowitz RJ. Causes, Treatment and Prevention of Early Childhood Caries: A Microbiologic Perspective. J Can Dent Assoc. 2003; 69(5):
4. Berkowitz RJ. Mutans Streptococci: Acquisition and Treatment.Pediatr Dent. 2006; 28(2):
5. Gift HC, Reisine ST, Larach DC. The Social Impact of Dental Problems and Visits. Am Journal of Public Health. 1992; 82(12):
6. Holt K and Barzel R. Open Wide: Oral Health Training for Health Professionals. Available online at Accessed November 20, 2006.

44. References, continued
7. Isokangas P et al. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0-5 years of age. J Dental Res. 2000; 79(11):
8. Kaste LM et al. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, J Dental Res. 1996; 75:
9. Keyes PH. Research in Dental Caries. JADA. 1968; 76:
10. Lai PY et al. Enamel hypoplasia and dental caries in VLBW children: a case-controlled, longitudinal study. Pediatr Dent. 1997; 19(1): 42-9.
11. Lee JY et al. Examining the cost-effectiveness of early dental visits. Pediatr Dent. 2006; 28(2):102-5.
12. Li Y, Caufield PW. The fidelity of initial acquisition of mutans streptococi by infants from their mothers. J Dent Res. 1995, 74(2):
13. Linnett V et al. Oral health of children with gastroesophageal reflux disease: a controlled study. Aust Dent J. 2002; 47(2):

45. References, continued
14. Oral health in America: A Report of the Surgeon General. Rockville MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; Available online at SurgeonGeneral. Accessed November 20, 2006.
15. Pettinato ES, Webb MD, Seale NS. A comparison of Medicaid reimbursement for non-definitive pediatric dental treatment in the emergency room versus periodic preventative care. Pediatr Dent. 2000; 22(6):
16. Savage MF et al. Early preventative dental visits: effects on subsequent utilization and costs. Pediatrics. 2004; 114(4):
17. Seow WK. Enamel hypoplasia in the primary dentition: a review. ASDC J Dent Child. 1991; 58(6):
18. Soderling E at al. Influence of maternal xylitol consumption on mother-child transmission of mutans streptococci: 6-year follow-up. Caries Res. 2001; 35(3):173-7.
19. Vargas CM et al. Sociodemographic Distribution of Pediatric Dental Caries: NHAANES III, JADA. 1998; 129: