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Tackling Early Childhood Caries

Interprofessional cooperation is key to effective prevention of tooth decay.

This course was published in the April/May 2024 issue and expires May 2027. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.

AGD Subject Code: 010

Educational ­Objectives

After reading this course, the participant should be able to:

  1. Discuss dental caries as a multifactorial process.
  2. Differentiate between vertical and horizontal transmission of dental caries.
  3. Recognize mother, caregiver, and familial risk factors for childhood dental caries.
  4. Advocate for interprofessional collaboration in addressing early childhood factors that contribute to dental caries.

Dental caries, while preventable, is a chronic condition that continues to globally impact young children. Early childhood caries (ECC) is present when one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces appears in a deciduous tooth among children ages 6 and younger.1 Similarly, severe early childhood caries (S-ECC) is the development of smooth-surface caries lesions before age 3.1

While several preventive measures, such as national policies, school-based programs, and expanded eligibility for public health insurance, have been implemented in the United States, not all children have benefitted at the same rate. For example, disparities exist among certain races, ethnicities, and income groups.

National data from 2011-2016 show that 23% of children ages 2 to 5 had dental caries in primary teeth. Among the same age group, 10% had untreated dental caries in primary teeth.2 Further, Mexican-American children had a higher percentage of dental caries and untreated dental caries (33%, 15%) than Black, non-Hispanic (28%, 15%) and white, non-Hispanic children (18%, 7%), respectively.

In terms of income, children from households < 100% federal poverty level (FPL) had a higher percentage of dental caries (34%) than those from higher FPLs 100% to 199% (24%) and > 200% (16%).2 The same pattern persisted for untreated dental caries, with children from lower income households reporting a higher percentage than children from higher income households.2 While disparities and inequities in childhood dental caries exist among certain demographic groups, the dental caries process and its transmission are complex.

Etiologies of Dental Caries

The Keyes model explains three main intersecting factors related to dental caries: the host (saliva and teeth), microflora (bacteria), and substrate (diet).3,4 It also recognizes confounding factors such as time, plaque, fluoride, sociodemographic characteristics, behaviors, knowledge, and attitudes.5

The Fisher-Owen et al6 conceptual model of children’s oral health incorporates the original Keyes factors while including the level of influences (eg, child, family, community influences) and five domains (eg, genetics and biology, social environment, physical environment, health-influencing behaviors, and medical and dental care).

The microflora is established during the developmental stages and infants are susceptible to Streptococcus mutans from their mother via vertical transmission.7 As the child enters the late infant to toddler stages, feeding practices and the introduction of foods and snacks are additional risk factors for parents and caregivers to consider. For example, research has shown that sleep feedings and the frequency of feedings including, human milk beyond age 12 months, may increase the child’s risk for dental caries.8

Frequent exposure to foods and beverages high in added sugars also increases the risk of dental caries.9 Feeding practices before age 2 are critical to reducing the risk of ECC or S-ECC. For example, frequent bottle feedings of sugary beverages during meals or while sleeping increase the risk of dental caries and most often impact the anterior teeth among children ages 1 to 2.10

As the child ages and tooth eruption occurs, additional primary teeth are susceptible to dental caries. Further, around ages 3 to 4, the maxillary central incisors and mandibular second molars may be susceptible. At age 5, the maxillary central incisors, maxillary second molars, and mandibular first and second molars are at risk. These causes and risk factors should be explained to mothers and caregivers during the perinatal and post-natal periods, in addition to well-child visits.

Modes of Transmission

Dental caries transmission occurs through two primary modes in young children. The most common transmission during infancy and toddler stages are vertical and horizontal. Vertical transmission is the exchange of saliva between the mother/​caregiver and the child.7 Horizontal transmission may occur among groups such as family members or peers. Other modes of transmission may be through utensil sharing, testing food, cleaning of pacifiers, and sharing oral hygiene aids.7

Parents and caregivers play an important role in the transmission of early childhood dental caries. Familial factors, such as education level and socioeconomic status, oral health literacy, and oral health behaviors of caregivers, impact the risk of dental caries among children.11–13

Caregivers with low oral health literacy were found to be less likely to maintain good oral health behaviors for the child.11 A combination of low oral health literacy and lack of resources can increase the risk of dental caries among children.13,14 Caregivers are primarily responsible for the dietary and oral hygiene behaviors of their children. Parental oral health behaviors, such as frequency of brushing, time spent brushing, and frequency of dental visits, contribute to the child’s risk for dental caries.13

Children are more likely to experience dental caries if their parent/​caregiver has a high caries experience.13 Parents/​caregivers who do not engage in caries-prevention behaviors, such as healthy oral health practices or routinely visiting the dental office, may increase their children’s caries risk.

Prevention During Perinatal Period Through Early Childhood

Prevention of dental caries among children begins during the perinatal period. The World Health Organization Expert Consultation on Public Health Intervention Against Early Childhood Caries recommends that the most appropriate time to prevent ECC is pregnancy through the child’s first 2 years.10 Mothers must be educated about the importance of continued dental care both during pregnancy and after birth. Further, providers should promote continued dental care during the perinatal period and stay up-to-date with the national guidelines and policies.11

Preventive dental care is safe and encouraged during the perinatal and post-natal periods. Data from the 2016-2020 Pregnancy Risk Assessment Monitoring System showed that in 2020, 40% of pregnant women had a prophylaxis by a dentist or dental hygienist.12 Preventive oral health behaviors should start during pregnancy and continue with the child after birth. Parents and caregivers need to be provided with educational materials related to good oral health and caries prevention.13

When the child’s first tooth erupts or the first birthday occurs, a dental visit and dental home should be established. The American Academy of Pediatric Dentistry recommends parents and caregivers establish a dental home for the child by the age of 12 months.14

Preventive dental visits with oral health professionals aid in providing age-appropriate anticipatory guidance for parents/​caregivers. These recommendations include assisting the child with oral hygiene behaviors until age 10, role modeling oral behaviors, and promoting healthy dietary behaviors.14 Moreover, an assessment of the child’s and parent’s/​caregiver’s dental caries risk should be conducted to determine the need for at-home fluoride or professional treatment. The preventive dental visits and anticipatory guidance should continue throughout the child’s development. Table 1 provides a list of resources for caries risk assessment forms.

Treatment Options for Dental Caries

Even with prevention strategies, children may develop caries. Therefore, the conversation of secondary (eg, early detection, fluoride varnish, sealants) and minimally invasive tertiary prevention (eg, atraumatic restorative treatment [ART]) should occur with the parent/​caregiver.10 ART is restorative treatment completed without the use of electric drills and local anesthesia.15

The most common nonrestorative treatment options are dental sealants and 5% NaF varnish. The American Dental Association (ADA) recommends the use of dental sealants plus the application of 5% NaF varnish every 3 to 6 months to arrest or reverse noncavitated carious lesions on the occlusal surfaces of primary and permanent teeth.16 For noncavitated lesions on facial and/​or lingual surfaces, the application of 1.23% APF or 5% NaF varnish every 3 to 6 months is recommended.16 Early detection of carious lesions in children can prevent the need for restorative treatment.


Growing research supports the efficacy of silver diamine fluoride (SDF) as an additional nonrestorative treatment option for dental caries in children.16–18 The silver in SDF has antibacterial effects that target the cariogenic bacteria, while the fluoride provides remineralizing effects to arrest and sometimes reverse the caries process (Figure 1).18

SDF should be considered, especially for children and those with special health­care needs, because the ap­pli­cation process is not as invasive as traditional restorative treatments. The ADA recommends the use of 38% SDF twice a year to arrest advanced cavitated lesions on the coronal surfaces of primary and permanent teeth.16

No acute adverse side effects have been noted; however, the silver byproducts in SDF stain dental tissues black, impacting the esthetic appearance.18 Clinicians must be cautious when applying SDF to ensure staining does not occur on the skin and gingival tissues.19

Role of Oral Health and Medical Professionals in Caries Prevention and Management

The child’s risk for developing dental caries must be determined to implement patient-centered preventive strategies. One tool commonly used to assess dental caries risk is caries management by risk assessment (CAMBRA). It analyzes an individual’s risk for dental caries based on disease indicators, biological and pathological risk factors, and protective factors.20 The balance of these factors determines if the individual is at a low, moderate, high, or extreme risk for dental caries.

CAMBRA should be used on all new patients to determine initial caries risk. Subsequent assessments can be conducted at recare visits based on the clinician’s judgment and patient considerations. Multiple studies have been conducted on the validity of CAMBRA and found it to be a valid tool to determine future caries experience at follow up visits.20

The efforts of oral health professionals alone are not sufficient to decrease the prevalence of dental caries among young children. An interprofessional approach is needed among all professionals and stakeholders who provide care or services for women, families, and children.

The US Department of Health and Human Services developed core clinical competencies for primary care clinicians to integrate oral health into primary care practice, one of which is the importance of interprofessional collaborative practice.21 Oral health professionals are encouraged to build relationships and increase communication with medical providers, especially pediatricians, obstetricians, and school nurses.

Pediatricians and obstetricians also need to collaborate with oral healthcare professionals to prevent ECC and S-ECC.22 Pediatricians and primary care providers see pediatric patients for well-child visits more frequently and sooner than oral healthcare professionals, making them ideal collaborators to address ECC.

These medical professionals can apply fluoride varnish and prescribe dietary fluoride supplements if indicated.22 Therefore, collaboration with oral health professionals is essential to enhance pediatricians’ and primary care providers’ comfort with implementing these services into their daily practice.

Obstetricians also play an important role in providing oral health education to expectant mothers about the importance of their oral health, as well as the oral health of their children. These collaborations are important to ensuring mothers, caregivers, and family members are aware of the contributing factors to dental caries to minimize risk.


Childhood dental caries is a complex process that requires education and prevention during the perinatal period and throughout the child’s lifetime. Interprofessional collaboration among oral health and medical professionals is essential to increasing awareness of early childhood caries among caregivers and families. Through this partnership, the goal of reducing caries prevalence among all age groups can be achieved.


  1. American Academy of Pediatric Dentistry. Definition of early childhood caries (ECC). Available at: aapd.org/​​assets/​䁯/​䁵/​​d_​​ecc.pdf. Accessed April 16, 2023.
  2. United States Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. Available at: nidcr.nih.gov/​​research/​​data-statistics/​​dental-caries/​​children. Accessed April 16, 2023.
  3. Keyes PH, Jordan HV. Factors influencing the initiation, transmission, and inhibition of dental caries. Publ American Assoc Advan Science. 1963;75:261-283.
  4. Research Gate. Increased Salivary Fluoride Concentrations After Post-Brush Fluoride Rinsing not Reflected in Dental Plaque. Available at: researchgate.net/​​figure/​​Keyes-model-1963_​​fig1_​�. Accessed April 16, 2024.
  5. Cate JM. The need for antibacterial approaches to improve caries control. Adv Dent Res. 2009;21:8-12.
  6. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Influences on children’s oral health: a conceptual model. Pediatrics. 2007;120:e510-e520.
  7. Berkowitz RJ. Mutans streptococci: acquisition and transmission. Pediatr Dent. 2006;28:106-198.
  8. Tham R, Bowatte G, Dharmage SC, et al. Breastfeeding and the risk of dental caries: a systematic review and meta-analysis. Acta Paediatrc. 2015;104:62-84.
  9. Barzel R, Holt K. Promoting oral health in children: a resource guide. National Maternal and Child Oral Health Resource Center. Available at: mchoralhealth.org/​​PDFs/​​resguideyoungchildren.pdf. Accessed April 16, 2024.
  10. World Health Organization. WHO Expert Consultation on Public Health Intervention Against Early Childhood Caries. Available at: who.int/​​publications/​​i/​​item/​​who-expert-consultation-on-public-health-intervention-against-early-childhood-caries. Accessed April 16, 2024.
  11. National Maternal and Child Oral Health Resource Center. Oral Health Care During Pregnancy Consensus Statement. Available at: mchoralhealth.org/​​PDFs/​​OralHealthPregnancyConsensus.pdf. Accessed April 16, 2024.
  12. United States Centers for Disease Control and Prevention. Prevalence of Selected Maternal and Child Health Indicators for All PRAMS Sites, Pregnancy Risk Assessment Monitoring System, 2016-2020. Available at: cdc.gov/​​prams/​​prams-data/​​mch-indicators/​​states/​​pdf/​떔/​​all-sites-prams-mch-indicators-508.pdf. Accessed April 16, 2024.
  13. Shimpi E, Gulrich I, Maybury C, et al. Knowledge, attitudes, behaviors or women relate to pregnancy and early childhood caries prevent: a cross-sectional pilot study. J Prim Care Community Health. 2021;2:1-6.
  14. American Academy of Pediatric Dentistry. Policy on the Dental Home. Available at: aapd.org/​​media/​​policies_​​guidelines/​​p_​​dentalhome.pdf. Accessed April 16, 2024.
  15. Dorri M, Martinez-Zapata MJ, Walsh T, Marinho VC, Sheiham A, Zaror C. Atraumatic restorative treatment versus conventional restorative treatment for managing dental caries (review). Cochrane Database Syst Rev. 2017;12:1-66.
  16. Slayton RL, Urquhart O, Araujo MWB, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: a report from the American Dental Association. J Am Dent Assoc. 2018;149:837-849.
  17. Urquhart O, Tampi MP, Pilcher L, et al. Nonrestorative treatments for caries: Systematic review and network meta-analysis. J Dent Res. 2019;98:14-26.
  18. Crystal YO, Niederman R. Evidence-based dentistry update on silver diamine fluoride. Dent Clin North Am. 2019;63:45-68.
  19. American Dental Hygienists’ Association. State Specific Information on Silver Diamine Fluoride. Available at: adha.org/​​wp-content/​​uploads/​떖/​葘/​​Silver_​​Diamine_​​Fluoride_​​State_​​by_​​State_​​Information.pdf. Accessed April 16, 2024.
  20. Featherstone JDB, Chaffee BW. The evidence for caries management by risk assessment (CAMBRA). Adv Dent Res. 2018;29:9-14.
  21. United States Department of Health and Human Services Administration. Integration of Oral Health and Primary Care Practice. Available at: hrsa.gov/​​sites/​​default/​​files/​​hrsa/​​oral-health/​​integration-oral-health.pdf. Accessed April 16, 2024.
  22. Horowitz A, Kleinman D, Child W, et al. Perception of dental hygienists and dentists about preventing early childhood caries: A qualitative study. J Dent Hyg. 2017;91:29-36.

From Decisions in Dentistry. April/May 2024; 10(3):42-45

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