AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Policy on Early Childhood Caries (ECC): Classifications,

Consequences, and Preventive Strategies
Review Council
Council on Clinical Affairs

Latest Revision
2016

Purpose ECC is defined as the presence of one or more decayed

Early childhood caries (ECC), formerly referred to as nursing (noncavitated or cavitated lesions), missing (due to caries), or
bottle caries and baby bottle tooth decay, remains a signifi- filled tooth surfaces in any primary tooth in a child under the
cant public health problem.1 The American Academy of age of six. The definition of severe early childhood caries
Pediatric Dentistry (AAPD) encourages healthcare providers (S-ECC) is any sign of smooth-surface caries in a child
and caregivers to implement preventive practices that can younger than three years of age, and from ages three through
decrease a child’s risks of developing this disease. five, one or more cavitated, missing (due to caries), or filled
smooth surfaces in primary maxillary anterior teeth or a de-
Methods cayed, missing, or filled score of greater than or equal to four
This policy was originally developed in a collaborative effort (age 3), greater than or equal to five (age 4), or greater than
of the American Academy of Pedodontics and the American or equal to six (age 5).4
Academy of Pediatrics, and adopted in 1978. This document Epidemiologic data from a 2011-2012 national survey
is a revision of the previous version, last revised by the AAPD clearly indicate that ECC remains highly prevalent in poor and
in 2014. The update used electronic and hand searches of near poor U.S. preschool children. For the overall population
English written articles in the dental and medical literature of preschool children, the prevalence of ECC, as measured by
within the last 10 years, using the search terms infant oral decayed and filled tooth surfaces (dfs), is unchanged from
health, infant oral health care, and early childhood caries. previous surveys, but the filled component (fs) has greatly
Recent references to ECC, along with full text, can be found increased indicating that more treatment is being provided.5
on the Early Childhood Caries Resource Center database The consequences of ECC often include a higher risk of new
(http://earlychildhoodcariesresourcecenter.elsevier.com). When carious lesions in both the primary and permanent denti-
information from these articles did not appear sufficient or tions, 6,7 hospitalizations and emergency room visits, 8,9 high
was inconclusive, policies were based upon expert and con- treatment costs,10 loss of school days,11 diminished ability to
sensus opinion by experienced researchers and clinicians. learn,12 and diminished oral health-related quality of life.13
Microbial risk markers for ECC include MS and Lacto-
Background bacillus species.14 However, new tools for bacterial identifi-
In 1978, the American Academy of Pedodontics and the cation (e.g., polymerase chain reaction [PCR] techniques, 16s
American Academy of Pediatrics released a joint statement rRNA gene sequencing) are revealing the complexity of the oral
“Juice in Ready-to-Use Bottles and Nursing Bottle Caries” to microbiome and other bacterial species that may be associated
address a severe form of caries associated with bottle usage.2 with ECC.15 MS maybe transmitted vertically from caregiver
Initial policy recommendations were limited to feeding habits, to child through salivary contact, affected by the frequency
concluding that nursing bottle caries could be avoided if bottle and amount of exposure.16 Infants whose mothers have high
feedings were discontinued soon after the first birthday. An levels of MS, a result of untreated caries, are at greater risk
early policy revision added ad libitum breast-feeding as a of acquiring the organism earlier than children whose mothers
causative factor. Over the next two decades, however, recog- have low levels.17 Horizontal transmission (e.g., between other
nizing that ECC was not solely associated with poor feeding members of a family or children in daycare) also occurs.17
practices, AAPD adopted the term ECC to better reflect its
multi-factoral etiology. These factors include susceptible teeth
ABBREVIATIONS
due to enamel hypoplasia, oral colonization with elevated levels
AAPD: American Academy Pediatric Dentistry. ECC: Early child-
of cariogenic bacteria, especially Mutans Streptococci (MS), hood caries. MS: Mutans streptococci. PCR: Polymerase chain
and the metabolism of sugars by tooth-adherent bacteria to reaction. S-ECC: Severe early childhood Caries.
produce acid which, over time, demineralizes tooth structure.3

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REFERENCE MANUAL V 39 / NO 6 17 / 18

An associated risk factor to microbial etiology is high con- Evidence increasingly suggests that preventive interven-
sumption of sugars. 18 Caries-conducive dietary practices tions within the first year of life are critical. 31 This may be
appear to be established by 12 months of age and are main- best implemented with the help of medical providers who, in
tained throughout early childhood. 19 Frequent nighttime many cases, are being trained to provide oral screenings, apply
bottle-feeding with milk and ad libitum breast-feeding are preventive measures, counsel caregivers, and refer infants and
associated with, but not consistently implicated in, ECC.20 toddlers for dental care.32
Night time bottle feeding with juice, repeated use of a sippy
or no-spill cup, and frequent in-between meal consumption of Policy statement
sugar-added snacks or drinks (e.g., juice, formula, soda) in- The AAPD recognizes early childhood caries as a significant
crease the risk of caries.21 While ECC may not arise from breast chronic disease resulting from an imbalance of multiple risk
milk alone, breast-feeding in combination with other carbohy- and protective factors over time. To decrease the risk of devel-
drates has been found in vitro to be highly cariogenic.22 Frequent oping ECC, the AAPD encourages professional and at-home
consumption of between-meal snacks and beverages containing preventive measures that include:
sugars increases the risk of caries due to prolonged contact 1. Avoiding frequent consumption of liquids and/or solid
between sugars in the consumed food or liquid and cariogenic foods containing sugar, in particular:
bacteria on the susceptible teeth.23 The American Academy of • Sugar-sweetened beverages (e.g., juices, soft drinks,
Pediatrics has recommended that infants should not be given sports drinks, sweetened tea) in a baby bottle or
juice from bottles or covered cups that allow them to consume no-spill training cup.
juice throughout the day, and intake of 100 percent fruit juice • Ad libitum breast-feeding after the first primary tooth
should be limited to no more than four to six ounces per day begins to erupt and other dietary carbohydrates are
for children one through six years old.24 Additionally, newly- introduced.
erupted teeth, because of immature enamel, and teeth with • Baby bottle use after 12-18 months.
enamel hypoplasia may be at higher risk of developing caries.25 2. Implementing oral hygiene measures no later than the
Current best practice to reduce the risk of ECC includes time of eruption of the first primary tooth. Toothbrush-
twice-daily brushing with fluoridated toothpaste for all chil- ing should be performed for children by a parent twice
dren in optimally-fluoridated and fluoride-deficient commu- daily, using a soft toothbrush of age-appropriate size.
nities.26,27 When determining the risk-benefit of fluoride, the In children under the age of three, a smear or rice-sized
key issue is mild fluorosis versus preventing dental disease. A amount of fluoridated toothpaste should be used. In
smear or rice-sized amount of fluoridated toothpaste children ages three to six, a pea-sized amount of fluori-
(approximately 0.1 mg fluoride; see Figure) should be used dated toothpaste should be used.
for children less than three years of age. A pea-sized amount 3. Providing professionally-applied fluoride varnish treat-
of fluoridated toothpaste (approximately 0.25 mg fluoride) is ments for children at risk for ECC.
appropriate for children aged three to six. 28 Parents should 4. Establishing a dental home within six months of erup-
dispense the toothpaste onto a soft, age-appropriate sized tion of the first tooth and no later than 12 months of age
toothbrush and perform or assist with toothbrushing of to conduct a caries risk assessment and provide parental
preschool-aged children. To maximize the beneficial effect of education including anticipatory guidance for prevention
fluoride in the toothpaste, rinsing after brushing should be of oral diseases.
kept to a minimum or eliminated altogether.29 5. Working with medical providers to ensure all infants and
Professionally-applied topical fluoride treatments also are toddlers have access to dental screenings, counseling, and
efficacious in reducing prevalence of ECC. The recommended preventive procedures.
professionally-applied fluoride treatments for children at risk 6. Educating legislators, policy makers, and third party
for ECC who are younger than six years is five percent so- payors regarding the consequences of and preventive
dium fluoride varnish (NaFV; 22,500 ppm F).30 strategies for ECC.

References
Smear – under 3 yrs. Pea-sized – 3 to 6 yrs.
1. Proceedings of the conference: Innovations in the pre-
vention and management of early childhood caries.
Pediatr Dent 2015;37(3):198-9.
2. American Academy of Pediatrics, American Academy of
Pedodontics. Juice in ready-to-use bottles and nursing
bottle caries. AAP News and Comment 1978;29(1):11.
3. Tinanoff N. Introduction to the conference: Innovations
in the prevention and management of early childhood
Figure. Comparison of a smear (left) with a pea-sized (right) amount caries. Pediatr Dent 2015;37(4):198-9.
of toothpaste.

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 AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

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