Early Childhood Caries:

Determining the Risk Factors

And Assessing the Prevention
Strategies
For Nursing Intervention
Jo-Ann Marrs, Sharon Trumbley, Gaurav Malik
Objectives and posttest can be found on page 16.
Jo-Ann Marrs, EdD, APRN-BC, is a
Professor, East Tennessee State University,
Johnson City, TN.
Sharon Trumbley MSN, WHNP, is an
Assistant Professor, East Tennessee State
University, Johnson City, TN.
Gaurav Malik, is a Graduate Assistant, East
Tennessee State University, Johnson City,
TN.
being, and possibly related to many
chronic diseases, as well as loss of productivity
at school and home.
An especially virulent form of
caries is early childhood caries (ECC),
affecting infants and toddlers from 12
to 18 months of age. However, if
appropriate measures are applied early
enough (beginning during pregnancy
and infancy), this painful condition
can be prevented (Douglass, Douglass,
& Silk, 2004; Finn & Wolpin, 2005).
The first dental examination is now
recommended between six months
and one year of age (AAPD, 2010c),
but this is often unrealistic, especially
among the poor and underinsured.
Therefore, there is a huge need for preventive
efforts by nurses and other
health care providers who care for
infants and young children. The purpose
of this article is to review the literature
on the risk factors and prevention
strategies for ECC, and to discuss
the role of nurses in preventing this
disease process.
Dental Caries Overview
Dental caries is an infectious disease
caused by the interaction of bacteria,
mainly Streptococcus mutans (S.
mutans), and sugary foods on tooth
enamel. S. mutans are believed to be
spread from mother to baby in saliva
during infancy and can inoculate even
predentate infants. These bacteria
break down sugars for energy, causing
an acidic environment in the mouth
and results in demineralization of the
enamel of the teeth and dental caries
(Douglass et al., 2004).
ECC in particular is more common
in children from low socio-economic
groups with lower levels of maternal
education (no high school diploma or
GED certificate). It is also associated
with pregnant mothers who have carious
teeth, periodontal disease, high S.
mutans levels, and a high rate of sugar
consumption (National Institutes of
Health Consensus Development
Program, 2001; Peres, Peres, Traebert,
Zabot, & de Lacerda, 2005; Silk,
Douglass, Douglass, & Silk, 2008;
Smith, Badner, Morse, & Freeman,
2002; Wan & Seow, 2001; Zanata,
Gasparetto, & Conrado, 2003).
S. mutans are spread from mothers
to their infants during a discrete window
of infectivity. This period is
believed to be during the time that
teeth are erupting, from seven or eight
months until 36 months, with the
median age being 36 months
(Caulfield, Cutter, & Dasanayake,
1993; Li & Caulfield, 1995). Some
researchers have found bacteria to be
present even before this in as many as
50% of infants six months of age
(Wan et al., 2003), and in infants as
young as three months of age (Wan et
10 PEDIATRIC NURSING/January-February 2011/Vol. 37/No. 1
al., 2003). It is believed that the earlier
the infant or young child contracts
S. mutans, the more likely the child is
to have dental caries (Kohler,
Andreen, & Jonsson, 1988).
The Role of the Mother
As a Risk Factor in ECC
Good oral health during pregnancy
allows for healthy eating habits
and may decrease the childs chance
of having dental caries. However,
experts say that one-fourth of reproductive-
aged women in the U.S. have
dental caries (Silk et al., 2008), with
up to 40% of pregnant women having
some form of periodontal infection
(Boggess, 2008).
The possibility of decreasing dental
caries in the offspring of a pregnant
woman, who herself has severe dental
caries and high S. mutans levels, exists
according to some studies. Three
international groups of researchers
looked at treating pregnant women
and mothers of infants with various
chlorhexidine and fluoride preparations
to decrease S. mutans levels, and
thus, decrease colonization and caries
incidence in their children (Brambilla
et al., 1998; Kohler & Andreen, 1994;
Tenovuo, Hakkinen, Paunio, &
Emilson, 1992). Mothers and infants
were tested for the bacteria after the
interventions and were shown to
have lower levels of S. mutans compared
to control groups. The children
of these mothers were tested late and
were found to have less dental caries
than control groups.
Several researchers have studied
interventions on mothers begun during
pregnancy and continued on the
mother-child pair during their childs
early years and the caries experience
in their children. Study groups in
Germany, Chile, and Brazil evaluated
the dental health, provided dental
prophylaxis, and treated dental problems
of more than 400 pregnant
women. Topical fluoride was provided
in varnishes or toothpaste, and in two
studies, mouth-rinsing with an
antimicrobial mouthwash was recommended.
Pregnant women were
taught about the causes of dental
caries, good dental hygiene for themselves
and their child, and a healthy
diet. The above measures were continued
along with the evaluation of the
children until they were two to four
years of age. In the Chilean and
German studies, teaching during
infancy also involved recommending
measures to avoid salivary transfer
from mother to baby, such as not kissing
the baby on the mouth, not cleaning
pacifiers by putting them in
dental pain/plaque, mothers caries,
low educational level/socioeconomic
status, premature birth, and special
health care needs (Douglass et al.,
2004; Gibson & Williams, 1999;
Harris, Nicoll, Adair, & Pine, 2004;
Jamieson, Thomson, & McGee, 2004;
Mattila et al., 2005; Perinetti, Caputi,
& Varvara, 2005; Smith et al., 2002;
Vanobbergen, Declerck, Mwalili, &
Martens, 2001; Williams, Whittle,
& Blinkhorn, 2004). Proctor and
Gamble provides a diagram of contributing
factors for caries (http://
www.dentalcare.com/soap/olcourse.
htm). Low fluoride concentrations
have also been linked to ECC.
Fluoride
Since the 1970s, the U.S. has seen a
decline in dental caries due to community
water fluoridation; however,
100 million persons in the U.S. still
lack water fluoridation, and only 58%
receive optimal levels through community
water systems (DHHS, 2001).
Fluoridated water continues to be the
most cost-efficient and cost-effective
method of community caries prevention
(Hallett & ORourke, 2002;
Touger-Decker, 2001; Twetman et al.,
2000).
When giving anticipatory guidance
to parents, the amount of fluoride
in the water is an important consideration.
If local fluoride levels are
unknown, the CDC provides information
at state levels (CDC, 2008).
Optimal fluoride levels in drinking
water is 0.7 to 1.2 parts per million. If
fluoride levels are greater than two
parts per million, children need to be
provided with water from other
sources. The American Dental
Association (ADA) (2008) provides the
following guidelines for parents:
Use ready-to-feed formula during
the first 12 months of age.
Use fluoride-free water (purified,
de-mineralized, de-ionized, distilled,
or reverse osmosis) to mix
with liquid concentrate/powdered
infant formula.
Remember sterilization will not
remove fluoride.
Use fluoride supplements daily
(see Table 1 for recommended
dosages).
In the 1980s, fluoride was added to
commercial toothpaste and has be -
come the most common method for
controlling dental caries. Between the
1940s and late 1970s, more than 100
clinical trials were conducted on the
effectiveness of fluoride at reducing
dental caries. Fluoride varnishes
(Marinho, Higgins, Logan, & Sheiham,
2001) and supervised use of fluoride
mothers mouth and then giving
them to the baby, not tasting the
childs food or using the same spoon
for mother and baby, and not drinking
from the same cup. Mothers were
taught to clean the babys teeth as
soon as they began erupting. In all
three studies, children in the experimental
groups had significantly fewer
dental caries than those in the control
groups (Gomez & Weber, 2001;
Gunay, Dmoch-Bockhorn, Gunay, &
Guertsen, 1998; Zanata et al., 2003).
Many experts recommend decreasing
salivary contacts between mother
and infant, as mentioned above, as a
method of decreasing S. mutans transmission
and thus lowering early
childhood S. mutans levels and caries
(Gomez & Weber, 2001; Gunay et al.,
1998; Twetman, Garcia-Godoy, &
Goepferd, 2000). However, the conclusion
of the only readily available
study on this topic was that children
with increased salivary contacts have
significantly lower levels of S. mutans
and significantly fewer dental caries
than children with less salivary contact.
The authors suggested this may
be due to protective immune mechanisms
(Aaltonen & Tenovuo, 1994).
This Finnish study was limited by the
fact that of the 404 mothers interviewed,
only 55 at the extreme ends
of the spectrum were chosen for the
final analysis, skewing the results.
The use of Xylitol, a sugar substitute
found in chewing gum, has been
studied for over 25 years in pregnant
women and new mothers, and has
shown to decrease their S. mutans levels.
Young children up to two years of
age whose mothers regularly chewed
Xylitol gum have less dental caries
when compared to control groups,
probably because of decreased S.
mutans transmission from mother to
child (Lynch & Milgrom, 2005; Silk
et al., 2008, Soderling & Isokangas,
2000).
In summary, possible useful measures
during pregnancy and the postpartum
period exist to decrease childhood
caries, especially in early childhood,
by decreasing maternal S.
mutans. These involve good maternal
dental hygiene, including the use of
fluoride and/or cholorhexidine products
and Xylitol gum, as well as other
measures to limit salivary contact
between mothers and infants.
Risk Assessment for Dental
Caries in Young Children
Risk factors for ECC are multifactorial
and include infrequent tooth
brushing, recent fillings/extractions,
Early Childhood Caries: Determining the Risk Factors and Assessing the
Prevention Strategies for Nursing Intervention
PEDIATRIC NURSING/January-February 2011/Vol. 37/No. 1 11
mouth rinses (Marinho, Higgins,
Logan, & Sheiham, 2003) have supported
the use of fluoride as a decay
preventative.
However, concern has been raised
over dental fluorosis, which are
enamel defects caused by children
ingesting large amounts of fluoride
during the major teeth forming years
(birth to six years of age). ADA (2008)
guidelines state that children two
years of age and younger should not
use fluoride toothpaste. Children over
two years of age should use a peasized
amount of fluoride toothpaste
(0.4 mgm to 0.6 mgm fluoride, which
is equal to daily recommended intake
for children younger than two years
old). Young children can also ingest
enough of a toothpaste tube to
receive a toxic dose. Flossing should
begin when two teeth touch (AAP,
2009). Table 2 includes signs and
symptoms of fluoride toxicity. Be -
cause children as young as six years of
age have not developed a swallowing
reflex, they should not use fluoride
mouthwash. Without fluoridation,
sugar becomes a more potent risk factor.
Sugars
Sugars contained in fermentable
carbohydrates, such as milk, juice,
and starches, are hydrolyzed by salivary
amylase. This process leads to
bacteria-producing acidic end products
with subsequent demineralization
of teeth (Barber & Wilkins, 2002;
Touger-Decker & van Loveren, 2003)
and increased risk for caries on susceptible
teeth (AAPD, 2010a). Bawa
(2005) and Sanders (2004) found a
positive relationship between sugar
intake and the incidence of dental
caries where fluoridation was miniconsumption
(Kiwanuka, Astrom, &
Trovik, 2004). Nurses need to advise
parents to choose and campaign for
sugar-free medicines.
Xylitol
Xylitol, a natural substance found
in fruits, vegetables, and plants, and
produced by the human body by normal
metabolism, has a cool soothing
property that makes it useful in persons
with dry mouth. As an antiplaque
agent in toothbrushes and
gels, Xylitol has been used since the
1960s in such products as chewing
gum, syrup, and mouthwashes. It is in
the Generally Recognized as Safe
category with the Food and Drug
Administration (Life Sciences Re -
search Office, 1986). Xylitol reduces
tooth decay in as low a dose as 15
grams or less (gum and mints contain
about one gram each) if used for at
least five to 20 minutes, three to five
times a day (Xylitol.org, 2010).
Assessment of ECC
Risk assessment tools, such as the
AAPD Caries-Risk Assessment Tool
(CAT) in Table 3, can help in the
determination of reliable predictors
and allow health care professionals to
become more actively involved in
identifying and referring high-risk
children (AAPD, 2002). Beginning at
one year of age, a dental visit should
be performed on all children (Hashim
Nainar & Straffon, 2003). Douglass,
Tinanoff, Tang, and Altman (2001)
found that fissure cavities of the
molars were present as early as 13 to
15 months of age.
Nurses using the CAT should be
able to visualize a childs teeth and
mouth, have access to a reliable historian,
be familiar with footnotes,
understand the risk classification system,
and apply the tool periodically.
It is very important to use this tool
properly to be effective in preventing
dental caries.
mal and dental hygiene was poor. The
etiology of dental caries is related to
the length of time of exposure of the
teeth to sugar; it is known that acids
produced by bacteria after sugar
intake persist for 20 to 40 minutes.
Luke, Gough, Beeley, and Geddes
(1999) studied the clearance of glucose,
fructose, sucrose, maltose, and
sorbital rinses, as well as chocolate
bars, white bread, and bananas, from
the oral cavity. Sucrose was removed
the quickest, while sorbitol and food
residues stayed in the mouth longer.
Other factors included the retentiveness
of the food and the presence of
protective factors in foods (calcium,
phosphates, fluoride).
Parents who put their children in
bed with propped milk bottles contributed
to the formation of dental
caries in their infants because almost
no saliva flows during sleep (AAPD,
2009; Hallett & ORourke, 2002; Lin &
Tsai, 1999; Twetman et al., 2000).
Bowen (1992) found that the worst
offenders were bottles that contained
sucrose (sugar water), and the least
cariogenic were bottles filled with
cows milk. Children who were bottle
fed beyond 12 months of age and
babies who are breast fed on demand
and at night may be more prone to
ECC (AAPD, 2009). Food is not the
only source of sugar.
Medicines and Dental Caries
Medicines in general contain sugar
to make them more palatable to
young mouths, but the presence of
sugar has caused some experts to be
concerned about dental caries
(Bigeard, 2000; Perlman, 2005). For
example, in Uganda, the highest rate
of caries was found in children with
the longest periods of cough syrup
Table 1.
Recommended Dosages for Fluoride Supplementation Chart
American Dental Association Recommendation
Dosages for Fluoride Supplementation
Water Fluoride Concentration (ppm)*
Age of Child Less Than 0.3 0.3 to 0.6 Greater Than 0.6
Birth to 6 months 0 0 0
6 months to 3 years 0.25 mg 0** 0**
3 years to 6 years 0.5 mg 0.25 mg 0
6 years to 16 years 1 mg 0.5 mg 0
* 1.0 ppm = 1 mg/liter and 2.2 mg sodium fluoride contains 1 mgm fluoride ion.
** Infants whose nourishment comes exclusively from breast milk need a 0.25
mg
supplement.
Source: ADA, 2008.
Table 2.
Signs and Symptoms
of Fluoride Toxicity*
Nausea Diarrhea
Vomiting Abdominal pain
Increased salivation Increased thirst
*Signs and symptoms can begin in as
little as 30 minutes and last for 24 hours.
Source: Fluoride Action Network, 2008.
12 PEDIATRIC NURSING/January-February 2011/Vol. 37/No. 1
Early Childhood Caries: Determining the Risk Factors and Assessing the
Prevention Strategies for Nursing Intervention
1 Children with special health care needs are those who have a physical, developmental,
mental, sensory, behavioral, cognitive, or emotional impairment or limiting
condition that requires medical management, health care intervention,
and/or use of specialized services. The condition may be developmental or
acquired and may cause limitations in performing daily self-maintenance activities
or substantial limitations in a major life activity. Health care for special
needs patients is beyond that considered routine and requires specialized
knowledge, increased awareness and attention, and accommodation.
2 Alteration in salivary flow can be the result of congenital or acquired conditions,
surgery, radiation, medication, or age-related changes in salivary function. Any
condition, treatment, or process known or reported to alter saliva flow should
be considered an indication of risk unless proven otherwise.
3 Orthodontic appliances include both fixed and removable appliances, space
maintainers, and other devices that remain in the mouth continuously or for
prolonged time intervals and which may trap food and plaque, prevent oral
hygiene, compromise access of tooth surfaces to fluoride, or otherwise create
an environment supporting caries initiation.
4 National surveys have demonstrated that children in low-income and moderateincome
households are more likely to have caries and more decayed or filled
primary teeth than children from more affluent households. Within income levels,
minority children are also more likely to have caries. Thus, socioeconomic
status should be viewed as an initial indicator of risk that may be offset by the
absence of other risk indicators.
5 Examples of sources of simple sugars include carbonated beverages, cookies,
cake, candy, cereal, potato chips, French fries, corn chips, pretzels, breads,
juices, and fruits. Clinicians using caries-risk assessment should investigate
individual exposures to sugars known to be involved in caries initiation.
6 Optimal systemic and topical fluoride exposure is based on use of a fluoride
dentifrice and American Dental Association/American Academy of Pediatrics
guidelines for exposure from fluoride drinking water and/or supplementation.
7 Unsupervised use of toothpaste and at-home topical fluoride products are not
recommended for children unable to expectorate predictably.
8 Although microbial organisms responsible for gingivitis may be different than
those primarily implicated in caries, the presence of gingivitis is an indicator of
poor or infrequent oral hygiene practices and has been associated with caries
progression.
9 Tooth anatomy and hypoplastic defects (such as poorly formed enamel, developmental
pits) may predispose a child to develop caries.
10 Advanced technologies, such as radiographic assessment and microbiologic
testing, are not essential for using this tool.
Table 3.
American Academy of Pediatric Dentistry Caries-Risk Assessment Tool
(CAT)
Each childs overall assessed risk for developing decay is based on the highest
level of risk indicator circled above. (A single risk
indicator in any area of the high risk category classifies a child as being high
risk.)
Risk Factors to Consider
(For each item below, circle the most accurate
response found to the right under Risk Indicators)
Risk Indicators
Risk Indicators High Moderate Low
Part 1 History (determined by interviewing the parent/primary caregiver)
Child has special health care needs, especially any that impact
motor coordination or cooperation1
Yes No
Child has condition that impairs saliva (dry mouth)2 Yes No
Childs use of dental home (frequency of routine dental visits) None Irregular
Regular
Child has decay Yes No
Time lapsed since childs last cavity Less than
12 months
12 to 24 months Greater than
24 months
Child wears braces or orthodontic/oral appliances3 Yes No
Childs parent and/or sibling(s) have decay Yes No
Socioeconomic status of childs parent4 Low Mid-level High
Daily between-meal exposures to sugar/cavity-producing foods
(includes on-demand use of bottle/sippy cup containing liquid
other than water; consumption of juice, carbonated beverages, or
sports drinks; use of sweetened medications)5
Greater than 3 1 to 2 Mealtime only
Childs exposure to fluoride6,7 Does not use
fluoridated
toothpaste; drinking
water is not
fluoridated; and is
not taking fluoride
supplements
Uses fluoride
toothpaste;
usually does not
drink fluoridated
water; and does
not take fluoride
supplements
Uses fluoride
toothpaste; drinks
fluoridated water;
or takes fluoride
supplements
Times per day that childs teeth/gums are brushed Less than 1 1 2 to 3
Part 2 Clinical Evaluation (determined by examining the childs mouth)
Gingivitis (red, puffy gums)8 Present Absent
Areas of enamel demineralization (chalky white-spots on teeth) More than 1 1
None
Enamel defects, deep pits/fissures9 Present Absent
Part 3 Supplemental Professional Assessment (optional)10
Radiographic enamel caries Present Absent
Levels of Streptococci mutans or Lactobacilli High Moderate Low
PEDIATRIC NURSING/January-February 2011/Vol. 37/No. 1 13
Educational Programs
Educational programs have been
used to decrease the number of dental
caries in children, especially for disadvantaged
and underserved groups
(Gallagher & Rowe, 2001; Gomes,
Fonseca, & Rodriques, 2001) because
they are twice as likely to have dental
caries. Mexican-American children
are also found to have the highest rate
of ECC (CDC, 2005b).
Christensen, Peterson, and Bhambal
(2003), and Sheahan (2000) recommend
the best approach for health promotion
is to develop a population versus
individual approach, a multidisciplinary
approach, and a policy-generating
campaign. One example was a
public health campaign aimed at the
oral health needs of children, Breakers
for Bottles (Andrew, 2004). Families
were encouraged to bring their feeding
bottles and exchange them for
new ones to reduce the bacterial load
the bottles might have due to poor
hygiene practices (Andrew, 2004). A
similar health campaign, Healthy
Smiles, was a multidisciplinary, baby
bottle, tooth decay prevention program
that was very successful (King,
1998). Healthy Smiles, Healthy
Children is the foundation arm of the
AAPD and provides grant monies for
projects that promote good dental
health. Boost Better Breaks, a schoolbased
interdisciplinary event, also
promoted consumption of fruit and
milk at break time. In all instances,
the results were positive (Freeman,
Oliver, Bunting, Kirk, & Saunderson,
2001).
A needs assessment has also been
an important precursor to educational
programs. The administration of
cross-sectional surveys to determine
needs (Szoitko, 2004; Wierzbicka,
Peterson, Szatko, Dybizbanska, &
Kalo, 2002), identification of slogans
(Koelen, Hiekema-de Meij, & van der
Sanden-Stoelinga, 2000), and evaluation
of effectiveness (Kallista, 2005)
have all been used to improve the
effectiveness of educational programs.
Health promotion programs to
stimulate tooth brushing have been
among the most successful educational
programs (Curnow et al., 2002; de
Almeida, Petersen, Andr, & Toscano,
2003; Jackson et al., 2005).
Populations (1450 to 1545 children)
studied in cross-sectional surveys,
clinical trials, and experiments for
tooth brushing research studies have
found that tooth brushing with flossing
twice a day resulted in increased
tooth retention (Curnow et al., 2002).
Access to primary care health care
providers (AAPD, 2010c).
Prevention of transmission of S.
mutans from caregiver to infant
(Silk et al., 2008).
A review of the literature with
regard to ECC identifies some risk factors,
prevention strategies, and nursing
interventions needed to assist
children and their families to remain
caries-free. However, much research
remains to be undertaken to identify
additional predictors of caries, as well
as establish clinical application
(including customized periodicity
schedules, preventive regimens, and
treatment strategies) and clinical trials
for fluoride varnish as a caries preventative.
Pediatric nurses are in the best
position to assist in research and the
establishment of best practices that
will make a difference in the lives of
our most precious resource, children.
References
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Pediatric Nursing
Implications
The pediatric nurse is often the
first person parents and children
encounter when they enter the health
care environment. Pediatric nurses
have several roles in the prevention of
ECC. As educators, nurses can make
children and parents aware of the
causative agents for dental caries,
ensuring they understand that dental
caries is a communicable disease (von
Burg et al., 1995).
Nurses should examine childrens
teeth as early as six months of age so
they can refer them for appropriate
care. High-risk groups (Hispanic and
African-American children) should be
given special attention (DHHS Office
of Disease Prevention and Health
Promotion, 2001). Caries initially
appear as white spots on the surface
area of the tooth near the gum margin,
later becoming yellow and turning
to brown and then black in color.
Caries affect teeth as they erupt, with
molars being the last affected (AAPD,
2010a; Barber & Wilkins, 2002;
Twetman et al., 2000).
In addition to caries, pediatric
nurses should assess for the presence
of plaque, tooth eruption/exfoliation,
dental irregularities, and alignment of
teeth. When performing an oral
health risk assessment, nurses should
also assess the mothers/caregivers
oral health, the childs exposure to
fluoride, and provide education on
oral hygiene and diet (AAP, 2009).
Nurses also have a case manager
role of assisting families to navigate
the system to access dental care. Only
20% of children eligible for dental
insurance under Medicaid received a
preventive dental service, and only
9% are covered by public dental insurance
(DHHS, 2001). Nationally, nurses
also have an advocator role to fulfill
by becoming involved in the political
system to advocate for funding of
programs to assist families in the prevention
and treatment of dental
caries. The advocacy role is continuous
and needed.
Conclusions
Given the literature review, the
most effective measures for children
who are vulnerable to dental caries are:
Fluoride toothpaste and fluoridated
water (Hallett & ORourke,
2002).
Supervised tooth brushings twice a
day (Curnow et.al., 2002).
Educational programs (Szoitko,
2004).
14 PEDIATRIC NURSING/January-February 2011/Vol. 37/No. 1
Andrew, L. (2004). Beakers for bottles: A
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Barber, L., & Wilkins, E. (2002). Evidencebased
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Bowen, W. (1992). Wither or whither caries
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