Not wanting to cause any more trouble, I pocketed the "Free McDonald's Ice Cream Cone" coupon the receptionist gave me as my 18-month-old son's reward for screaming his head off during our visit and retreated to my car. How could my son have developed two cavities, plaque, and so many white lesions (precursors to cavities) on a sugar-free diet, and at such a young age? "Bottle-mouth!" the dentist had proclaimed. But how could my breastfed son have "bottle-mouth"? I decided to look for another dentist and to seek information on Medline, an on-line clearinghouse of dental and medical studies. What I discovered was surprising, validating, and guilt relieving. More than three dozen studies showed that my son's early cavities (also called caries) were not caused by nursing - breastmilk is not cariogenic - but by an infectious disease classified only recently as Early Childhood Caries (ECC).¹ Moreover, according to the National Institute of Dental and Craniofacial Research (NIDCR), breastfed children are less likely to develop this disease than their bottle-fed counterparts, and population-based studies do not support a link between prolonged breastfeeding and ECC.²

The Medline studies were listed by date, an arrangement that made obvious a significant pattern: Only the recent studies distinguished between bottle-fed and breastfed babies, a fact that explains the old names for the disease like "bottle-mouth," "bottle-rot," "baby bottle tooth decay," or "nursing caries." The author of a 1986 Mothering magazine article on dental caries could find no studies that distinguished between bottle-fed and breastfed babies.³

According to La Leche League International (LLLI), "Breastfeeding is typically assumed to be a cause of dental caries because no distinctions are made between the different compositions of human milk and infant formula or cow's milk, and between the different mechanisms of nursing at the breast [with the nipple at the back of the mouth, not allowing for breastmilk to pool around the teeth] and sucking on a bottle with an artificial teat. We have only to consider the overwhelming majority of breastfed toddlers with healthy teeth to know that there must be other factors involved."⁴

The Centers for Disease Control (CDC) discarded the terms "bottle-mouth" and "nursing caries" in 1994, thereby acknowledging ECC as an infectious disease not caused by breast- or bottle-feeding. Most studies now focus on ECC's true causes, contributing factors, and even cures.⁵ It's about time, too. In 1997 the American Academy of Pediatric Dentists (AAPD) declared that ECC was "currently at epidemic proportions in some US populations particularly among racial and ethnic minorities. The caries level in three- to five-year-old US Head Start children may be as high as 90 percent."⁶

Nevertheless, the American Dental Academy (ADA) website continues to caution, "A condition called baby bottle tooth decay can destroy a baby's teeth. Examples of bottle-fed liquids that can cause tooth decay are infant formula, fruit juice, milk, breast milk and any sweetened liquid."⁷ No new or updated policy is forthcoming, according to an ADA spokesperson.

"Most dentists and breastfeeding mothers have an adversarial relationship because dentists are likely to discount academic studies proving breastfeeding does not contribute to caries," says Kevin Hale, a pediatric dentist in Brighton, Michigan. Hale serves on the Section on Pediatric Dentistry for the American Academy of Pediatrics (AAP) and the Counsel on Pre-doctoral Education for the AAPD and is currently one of three people responsible for drafting a policy proposal for the AAP that would recommend educating dentists and pediatricians on ECC's causes and risks factors.⁸

"Breastfeeding is great," Hale told me. "I do health histories on my patients - 80 a month - and it is profound, the difference between the health of the kids who were breastfed and those who were not. If a mother is breastfeeding, which I hope they do, I know it is her flora that is colonizing the child." Unfortunately, Hale asserts, many dentists do not know this, nor do they know the risk factors associated with ECC. "Our biggest weapon against dental decay is education, not fillings."

What Is ECC?

Early Childhood Caries' main culprit, the bacterium Streptococcus mutans, or S. mutans, was suspected as far back as 1986.⁹ These bacteria are transmitted through saliva from mother (or primary caretaker) to child during the child's first 30 months of life, are "site-specific" (so there must be at least one tooth in the infant's mouth), feed on sucrose, and produce acid as a byproduct. In 1996, scientists at the University of Helsinki found that caries-free children had very low levels of these bacteria, whereas children with ECC had extremely high concentrations, more than 100 times the normal levels.¹⁰

ECC appears on teeth as white spots, plaque deposits, or brown decay and can lead to chips and breakage.¹¹ Once the pattern of decay begins, it can be rampant and extensive. Patty Ogden, a mother of three in Norge, Virginia, demand-fed all her children, but only the youngest developed ECC. "When my son was about 18 months old, I noticed a brown line across his teeth," she remembers. "By age two his teeth were fairly discolored and had a possible cavity or two."¹² After two years of wrestling with her insurance company, Ogden found a pediatric dentist and hospital that were covered and would use composite instead of mercury fillings, and her four year-old son underwent anesthetized surgery on his teeth. "He had two extractions, eight fillings with composite material, eight pulpotomies, and six stainless steel crowns on his molars. He also had his bottom front teeth 'slenderized' so that they wouldn't touch, promoting more decay."

The CDC and the dental and medical communities consider ECC to be the most prevalent infectious disease of American children (five to eight times more common than asthma), with 8.4 percent of all children developing at least one decayed tooth by age two, and 40.4 percent by age five. Of these cases, 47 percent of children between the ages of two and nine never receive treatment. "Untreated decay in children can result in chronic pain and early tooth loss…failure to thrive, inability to concentrate at or absence from school, reduced self-esteem, and psychosocial problems," according to the CDC.¹³ Dental caries in primary teeth is one of the major reasons for hospitalization of children and is costly to treat.¹⁴ The total cost of Ogden's son's surgery was nearly $7,000, with out-of-pocket costs exceeding $2,000.

While researchers have recognized S. mutans as the bacteria responsible for ECC, other surprising risk factors have been identified. Significantly high correlations have been found between ECC and pregnancy complications, traumatic birth, cesarean sections, maternal diabetes, kidney disease, and viral or bacterial infection; for the neonate, risk factors seem to be premature birth, Rh incompatibility, allergies, gastroenteritis, malnutrition, infectious diseases, and chronic diarrhea.¹⁵ In addition to sugary foods, studies have implicated a salty diet (such as French fries and chips), iron deficiency, pacifier sucking, and prenatal exposure to lead as ECC risk factors.¹⁶ And even though human breastmilk is not cariogenic, some studies have shown that frequent night nursing may contribute to the development of ECC in the small percentage of children who are at risk for developing the disease.¹⁷ On the other hand, Hale acknowledges that in countries where the American diet isn't a factor and infants sleep at their mother's breast all night, ECC is not the epidemic it is here in the US.

"We're talking about 20 percent of the population of all children who are going to be carriers of the really bad bugs," Hale says. "Some people have none, some have a few, and then a small percentage at the other end have the 'mean flora' [S. mutans]. Some people who eat terribly never get a cavity, and some people who eat well are riddled with cavities. Breastfeeding has nothing to do with creating caries. But if you or your child are one of the people who have the 'mean flora,' you will have to be extremely cognizant and vigilant of the fact that every substance aggravates the flora and contributes to caries formation."

Education, Not Fillings

Hale sees his task as bridging the gap between academia and dentists by writing policy that would educate all health care providers about the risk factors and causes of ECC. The proposed AAP policy would recommend that pediatricians, who are far more likely than dentists to encounter infants, be trained to perform an ECC risk assessment on patients by one year of age. Currently, many at-risk children are not being caught in time for a treatment plan to be implemented before caries become rampant and surgery is inevitable. The reason is twofold. According to a 1998 article in Community Dentistry and Oral Epidemiology, "Most dental providers do not want to treat young children, and most young children are difficult to examine and treat. But early intervention is crucial, since at-risk infants and toddlers with caries in their primary teeth are more likely to develop caries in their permanent teeth."¹⁸ "We need to assess at-risk infants early on and teach their mothers how to give them special care and diets," states Alice Horowitz, a senior scientist at the National Institute of Dental and Craniofacial Research, part of the National Institutes of Health. "Moms are taught how to clean every other orifice in prenatal education classes, but they are not taught how to clean an infant's mouth properly. The gums should be wiped daily with gauze, and teeth should be brushed as soon as they appear."¹⁹

Both Hale and Horowitz hope that, in the future, educated dentists will be more willing to treat their smallest at-risk patients. "It really isn't fair that pediatricians have to look for this; they aren't trained in medical school on what to look for, and there aren't enough pediatric dentists to go around," Hale complains. "The dental community needs to step forward and encourage these early visits."

The proposed policy recommends that healthcare providers as well as parents be aware of the following facts: High-caries-index patterns run in families and are usually passed from mother to child (although a small percentage can be passed from a primary caregiver, the father, or siblings), from generation to generation; the children of high-caries-index mothers are at a higher risk of decay; approximately 70 percent of caries are found in 20 percent of our nation's children; a mother's dental hygiene and diet, as well as those of the primary caregiver and entire family, can significantly contribute to the development of ECC in her child.²⁰

Fluoride Versus Nutrition

Currently, because dental providers are largely uneducated about the causes and risk factors of ECC, diagnosis and treatment are tricky. But once ECC has been properly diagnosed, the treatment plan, whether either mainstream or alternative, must be followed aggressively. Horowitz presented the mainstream dental model suggestions for treating ECC: "We have always known that we can re-mineralize teeth with fluoride treatment like fluoride toothpaste, but now we know we can reverse ECC if it is caught and treated at the white lesion stage," she reveals. "This knowledge gives healthcare providers and parents an incentive for early detection and treatment instead of waiting for anesthetized surgery."

Asked about the dangers of using fluoride toothpaste on young children, Horowitz recommended using a "tiny amount" and wiping the child's mouth out afterwards. She does not recommend fluoride varnish as applied at dental offices for young children.

Most dentists agree that fluoride will help to re-mineralize teeth, but given fluoride's controversial reputation, parents may opt for alternative treatments. Ted Spence, a doctor of naturopathy, certified herbalist, and certified nutritionist who has been a family dentist for 25 years on the Eastern Shore of Virginia, disagrees with the NIDCR's recommendation that fluoride be used to re-mineralize children's teeth at the white lesion stage. Instead, he recommends a nutritional approach.²¹

"The health of a baby's teeth begins with conception," Spence emphasizes. "A mother's diet is critical, as is the child's diet after birth." Over the years, Spence has treated tooth decay in young patients with vitamin D therapy. "I have seen soft teeth harden after cod liver oil and lots of butter are added to the diet." Sunshine, cod-liver oil, fortified dairy products, butter, eggs, liver, and oily fish like salmon and tuna are sources of vitamin D. (Since vitamin D is toxic at high levels and is stored in body fat, the RDA of 400 IUs should not be exceeded.)

"Our teeth naturally re-mineralize themselves with the calcium in our own saliva," Spence says. "We can assist this process by eating vitamin D-rich foods, which increase the absorption of calcium." Because fluoride is a neurotoxin and inhibits the absorption of calcium, Spence recommends against fluoride treatments. He also advises his patients to avoid sugar, on which the ECC bacteria thrive.

Spence's nutritional suggestions are supported by a 1996 study that found that a combination of vitamin D, vitamin C, and calcium reversed early decay in children at the white lesion stage.²² And according to the NIDCR website, "Supplementing with vitamins during the first several years of life reduces the prevalence of linear enamel hypoplasia, a caries-associated condition common in lower-income populations that can increase the risk of caries as much as tenfold."²³ According to an article in the Journal of Pediatrics, nutritional rickets, a result of a dietary deficiency of vitamin D, is making a comeback in the US, especially among dark-skinned infants--the same infants who are most at-risk for epidemic levels of ECC, according to the CDC, and the least likely to be breastfed, according to LLLI.²⁴

Asked about using nutrition to reverse ECC, Horowitz replied that the NIDCR has not studied ECC and nutrition, adding, "There's no question we likely could do this with diet alone, but a no-sweets and low-carbs diet is against societal norms. Grandparents are big risks and liabilities here. We know how to prevent this disease, through diet and brushing; we just need to get the information to moms and get them to do it."

Hale agrees that nutrition is the key to combating ECC. "Diet has the biggest impact of all of the preventive measures for ECC," he says. "If you go back 20,000 years, the bugs are the same, but the difference is the absence of soda machines. By evolutionary design we will always crave sweets and fat and salt, but now we have way too much access to this stuff. Dental decay is just another example of the way our diet choices and sedentary lifestyle are killing us." An article in the newsletter of the Academy of Breastfeeding Medicine states, "It would be evolutionary suicide for breastmilk to cause decay and [some anthropologists believe] that evolution would have selected against it. There are 4,650 species of mammals, all of whom breastfeed their young. Humans are but one species of mammals, but they are the only species with any significant decay."²⁵

Re-mineralizing teeth at the early stage of ECC, with either nutritional support or fluoride, may repair them, but it will not kill the ECC bacteria. Physical removal of the bacteria through brushing or wiping the teeth is still necessary. In pioneering efforts to kill S. mutans, researchers have experimented successfully with chemical antibacterial mouthwashes. Other efforts include a plant-based ECC vaccine, scheduled for release sometime in 2002. Parents who want an alternative route to chemical mouthwashes and vaccines can consult Flora Parsa Stay's Complete Book of Dental Remedies, which recommends using peppermint mouthwashes as an antibacterial treatment for ECC. (Stay cautions that peppermint should never be used on infants.)

Public Policy and At-Risk Children

In the overlapping arenas of science and public policy, the definition and diagnostic criteria agreed upon by NIDCR scientists were needed before ECC could be recognized and acted upon as a public health epidemic. In September 2000, "Congress…passed a children's health bill that, for the first time, authorizes a grant program to promote the oral health of young children. The provision is aimed at preventing dental caries in infants, toddlers, and preschoolers who are covered by Medicaid, SCHIP, or other federal health programs," says Burton L. Edelstein, director of the Children's Dental Health Project, Washington, DC.²⁶ Authorized funding does not translate into guaranteed appropriations for programs that would provide oral intervention and care for at-risk children who have inadequate dental care and are at a greater risk for anesthetized surgery and hospitalization. "Given the severity of the problem, if enough people are willing to make enough noise about it to their congressional representatives, we could get it funded as early as 2003," Edelstein states. "But, given the hundreds of appropriations that come across every senator's desk each year, this may take some public pressure to translate the authorization into a public program."

To Breastfeed or Not?

With scientists only recently agreeing upon ECC's etiology, diagnosis, and treatment, and with nutritional therapies being largely ignored for now, informed parents must take the lead to protect their children's oral and overall health with the preventive measures of regular brushing, healthy diets, and breastfeeding. It is La Leche League International's experience that "a small percentage of at-risk breastfed children develop dental caries in spite of breastfeeding, not because of it. When weaning from the breast is in question, the well-documented long-term lifesaving and enhancing health and emotional advantages of human milk and breastfeeding over infant formula and bottle-feeding must be respected. These benefits must also be weighed against any self-limiting risk of dental caries in the primary teeth in early childhood."²⁷

"Rather than telling a mother to stop nursing, a dentist should praise the mother for giving her child her milk," advises LLLI spokesperson Kim Cavaliero. "If the child has dental problems, the dentist needs to dig deeper and work to find the real cause behind the problem."²⁸ "The benefits of breastfeeding far outweigh the risks for caries," Hale agrees. "But breastfeeding moms with at-risk children need to continue to push to find dentists who will work with them on a treatment plan."

Hale hopes that the forthcoming AAP policy proposals and the push for education in the medical and dental communities will help to ease and correct unwarranted adversarial tensions between breastfeeding moms and their health care providers. "It will take a lot of education of both mothers and healthcare providers, including dentists, to finally allow everyone to work together to serve the overall health interests of the child."

Epilogue

My decision as to whether to sacrifice my son's teeth or continue nursing was always clear. My still breastfeeding-on-demand, co-sleeping four-year-old son is currently caries-free. Our aggressive treatment plan includes brushing daily with a nonfluoride children's toothpaste and an herbal preparation of White Oak Bark, rinsing with Natural Dentist's Herbal Mouthwash for Kids, avoiding sugary foods, and loading up on foods rich in vitamin D. The regimen has halted the progress of the ECC, and no new cavities have developed.