Baby bottle tooth decay (early childhood caries) – Causes, prevention, treatment options

Early childhood caries, commonly known as ‘baby bottle tooth decay’, is a common condition among children and can develop from a very young age, as early as a few months old. If left untreated, this condition can have consequences for both oral and general health. From the first white spots on the enamel to advanced tooth decay, understanding how baby bottle tooth decay develops, as well as the specific risk factors, is essential. This article details the causes, early symptoms and effective solutions to protect children’s smiles in the long term. 

Baby bottle tooth decay (Early Childhood Caries – ECC) is a severe, aggressive form of dental caries that affects babies and children up to the age of 5. According to specialists, baby bottle tooth decay refers to any sign of decay on the tooth surface in a child under the age of 3, and in children aged 3 to 5, one or more cavities or missing teeth due to tooth decay.

In the past, it was believed that only children who used a bottle at night were affected, but studies show that the aetiology is much more complex. Baby bottle tooth decay particularly affects the four upper primary incisors, whilst the lower incisors remain healthy. The other teeth may be affected, but to a lesser extent.  

White demineralisation spots on the upper primary incisors are the first signs of baby bottle tooth decay, which may be overlooked by parents. The white spots gradually progress to cavities, appearing as brown or black spots. In contrast, the lower incisors may be unaffected or have only mild decay. In severe cases, the crowns of the upper incisors may be destroyed, leaving only the roots. Children with baby bottle tooth decay usually experience pain and difficulty chewing.  

Risk factors for baby bottle tooth decay include:

• Poor oral hygiene in the baby.
• Prolonged use of a bottle containing sugary liquids at bedtime or during the night without cleaning the mouth afterwards.
• Prolonged night-time breastfeeding without cleaning the teeth afterwards, especially after the age of one.
• Frequent consumption of juices, sweetened drinks or milk between meals.
• The transmission of bacteria from adults to the child.

Why they occur frequently in infants and young children

Early childhood caries occur for several reasons, and genetic factors are the last on the list. The real problem lies in daily feeding and hygiene habits.

In babies, the oral cavity is a fragile environment, as the bacterial flora is still developing and the body’s defence system is still immature. When we add to this a diet rich in sweets, especially from a bottle, the conditions become perfect for the development of tooth decay.

Parents often tend to blame genetic inheritance for the development of tooth decay. However, research clearly shows that the main culprits are, in fact, an unhealthy diet and poor oral hygiene. Early tooth decay is, essentially, the result of the combined action of microorganisms in the mouth, the consumption of carbohydrates (sugars) and tooth enamel that is still fragile.

Most studies have demonstrated a direct link between bottle tooth decay and the habit of letting a child sleep with a bottle filled with milk, juice or other sweet liquids. Sugar remains on the teeth all night, feeding the bacteria that cause tooth decay. Parents play a crucial role in shaping their children’s diet, from the transition from liquid to solid foods, right through to the development of their preferences. Children tend to imitate their parents’ behaviour, so setting a good example of oral hygiene is just as important as a balanced diet. 

A bottle of sweetened milk or tea in the evening or at night

The main cause of bottle tooth decay (rapidly progressing tooth decay) is prolonged exposure of milk teeth to sugary liquids, such as milk (breast milk or formula). This often happens when babies sleep with a bottle in their mouth (containing milk, formula, juice or other sweetened drinks) or when they are breastfed for a very long time during the night, without subsequent oral hygiene.  

The sugars in these liquids ferment under the action of bacteria in the mouth, producing acids that attack the tooth enamel. We can therefore say that tooth demineralisation can be an early sign of baby bottle tooth decay.  

Prolonged exposure of teeth to sugar

A diet rich in sweets, juices, sweetened teas and even certain baby foods (which contain hidden sugars) poses a threat to teeth. If teeth are not cleaned after such meals or snacks, the sugar will act as ‘food’ for the bacteria in the mouth.

Poor hygiene after breastfeeding or bottle-feeding

After every meal, even after breastfeeding, sugars remain on the surface of the teeth and create an ideal environment for bacteria to multiply. If not cleaned, these deposits lead to the formation of plaque and, over time, to tooth decay. It is essential that parents wipe their baby’s gums and first teeth with a sterile gauze pad or a special baby toothbrush to remove food residues. 

Early detection of baby bottle tooth decay is crucial to preventing its rapid progression and associated complications. Parents should look out for the following signs:

• White, dull spots on the surface of the teeth: These are the first signs of tooth decay, with the demineralisation stage indicating a loss of minerals from the enamel. They are most often visible on the upper front teeth.
• Brown or black spots: Their appearance indicates that the decay process in the enamel is progressing.  
• Formation of cavities: Without intervention by a paediatric dentist in the early stages and without parents’ involvement in ensuring proper oral hygiene, baby bottle tooth decay progresses rapidly and cavities (holes) appear on the surface of the teeth.
• Sensitivity and pain: When cavities become deep, they affect the dental pulp (nerve), and the child may become irritable, refuse to eat certain foods (especially cold, hot or sweet ones); teeth may fracture, leading to dental abscesses as well as gum inflammation.  
• Functional and aesthetic problems: The presence of advanced cavities and infections can lead to difficulties with eating and speaking, whilst older children may be bothered by the unsightly appearance of their teeth. 

Complications of baby bottle tooth decay

• Premature loss of milk teeth has negative effects not only on the primary dentition but, sometimes, on the development of the permanent teeth
• Untreated abscesses in milk teeth can affect the development of the enamel of the permanent teeth still in the bone, causing them to erupt with discolouration, enamel defects or even decay.
• Loss of space in the dental arch affects the eruption of permanent teeth.
• Problems with chewing, speech and aesthetics. 

Preventing demineralisation and bottle tooth decay is essential for maintaining children’s oral health and stopping the development of tooth decay. Parents play a crucial role in taking protective measures.  

“Parents can take numerous steps to protect their children’s tooth enamel, from ensuring good oral hygiene – especially after feeding milk to babies – to limiting the consumption of sweet foods and drinks. Equally important are regular visits to the dentist for fluoride treatments and dental sealants,” says Dr. Alexandra Nițu, a paediatric dentist.

Preventive measures include:

• Removing the milk bottle once the child has fallen asleep: If the baby needs a bottle to fall asleep, fill it with water only.
• Cleaning the teeth after every meal, and especially after the evening meal, with an age-appropriate toothbrush and toothpaste.
• Start brushing early: Even before the first tooth appears, clean your baby’s gums with a damp gauze pad after every meal. Once teeth have come through, brush them twice a day with a soft toothbrush and fluoride toothpaste (a rice-grain-sized amount for children under 3 years old and a pea-sized amount for those between 3 and 6 years old).
• Avoid sweetened liquids, including those sweetened with honey, agave syrup and highly concentrated natural fruit juices, even if they are homemade.  
• Early dental check-ups: The first visit to the dentist should take place after the first tooth appears or at the latest by the age of one. 

When baby bottle tooth decay is diagnosed, prompt and appropriate treatment is crucial to halt its progression and restore the child’s dental health. Treatment strategies vary depending on the stage of the condition.

Early intervention by a dentist

Fluoride plays a crucial role in strengthening tooth enamel, through its antibacterial effect, but also by promoting the remineralisation of tooth enamel and increasing its resistance to acid attack.

Fluoride is applied topically in the dental surgery in the form of varnishes and gels in various concentrations. This procedure is quick, safe and completely painless, and is recommended periodically to keep children’s teeth strong and protected.

Dental sealants, remineralisation

Dental sealants are also one of the most effective methods of protecting teeth in children and teenagers. The procedure is simple, quick and painless: a special material is applied to deep grooves and pits, particularly on molars, premolars and, in exceptional cases, on incisors, where a toothbrush does not clean effectively. This material prevents the accumulation of food debris and bacterial plaque, significantly reducing the risk of tooth decay.

Remineralisation treatment involves the use of gels or varnishes with a high concentration of fluoride or other compounds that help rebuild the structure of the enamel. These solutions, available at DENT ESTET 4 KIDS clinics, combined with effective oral hygiene carried out at home, can halt and even reverse the process of demineralisation.

The benefits of advanced technologies in the treatment of baby bottle tooth decay

In modern paediatric dentistry, we have access to advanced technologies, such as intraoral scanners and dental lasers, which help prevent or treat dental conditions.  

“With the help of scanners, we obtain clear and detailed images of the child’s teeth and gums. These images are displayed on a screen, so that parents and children can see exactly what the dentist sees. On the other hand, the dental laser allows procedures to be carried out without the vibrations and noise associated with the dental drill, thereby reducing anxiety and discomfort for young patients. “The laser also offers greater precision in removing affected tissue, preserving the healthy structure of the tooth and minimising the risk of damage to surrounding tissue,” explains Dr. Alexandra Nițu, a paediatric dentist at the DENT ESTET 4 KIDS clinics.

In conclusion, these technologies help to establish an accurate diagnosis, monitor treatments and improve communication with parents and children, offering greater comfort and efficiency. 

Early Childhood Caries, 2023