Content Dam Rdh En Articles Print Volume 37 Issue 3 Contents Put Ecc At A Disadvantage Leftcolumn Article Thumbnailimage File

Put ECC at a disadvantage: Families often struggle to protect infants from early childhood caries

March 14, 2017
Michelle Wood, RDH, writes about the challenges disadvantaged families face with protecting children from early childhood cares.

Disadvantaged families often struggle to protect infants from dental disease

By Michelle Wood, RDH

Childhood is a significant chapter in our lives. For some, events that occur in childhood establish habits and patterns for adulthood. Childhood should be a time of wonder and joy. However, for many, this phase of life is filled with pain and untreated disease. The most common (and preventable) disease that occurs during this time is early childhood caries (ECC). The U.S. Department of Health and Human Services has identified ECC as a chronic condition that can be "harmful to children's growth, development, and academic performance." While ECC affects 41% of children ages six to 11,1 some children are at higher risk. Specifically, Hispanic children, who belong to the largest minority population in the U.S., are among those at highest risk.

The American Dental Association's statement on ECC (see related sidebar) states, "The Association recognizes that early childhood caries is a significant public health problem in selected populations and is also found throughout the general population."

The incidence of severe childhood caries within the Hispanic population is high. According to a study by Mouradian et al., preschool-aged Hispanic children are 2.5 times more likely to develop caries than Caucasian children of the same age.2 Multiple studies have identified factors contributing to this disease phenomenon, such as prolonged bottle feeding, oversight in recognizing decay, and socioeconomics. Understanding the reasons for the risks for ECC is key to reducing the disparity of this disease.

Prolonged bottle feeding

Prolonged bottle feeding, or at-will nursing, is the act of allowing or encouraging a young child to drink from a bottle. This type of feeding is often the beginning of severe early childhood caries because it puts the dentition in direct contact with lactose for extended periods of time. When prolonged bottle feeding is a factor, providers will see multiple areas of decay across the maxillary anterior teeth. There are several reasons why prolonged bottle feeding occurs within the Hispanic population, for example: convenience, buying time, lack of parental awareness, and socioeconomics.3,4

Convenience-Large families often live within the same household. In this living situation, it is essential to keep the toddler quiet so adults can continue with tasks. Pacifying the child by offering a bottle can become a way of appeasing or keeping the child calm.3 In essence, it is easier to allow a toddler to continue bottle feeding as it suits the needs of the family dynamic.3

Buying time-Traditionally, women are the main caregivers of young children. Many women juggle the demands of various roles, which can be exhausting. Finding time to take care of one's self with a demanding child is difficult at best. "Buying time" is another reason why women often choose to prolong bottle feeding. A mother might buy time away from her toddler and with her toddler. Buying time away from the toddler allows the caregiver freedom from the pressures of motherhood, while buying time with the child helps the mother and child fulfill the need for closeness.4

Lack of parental awareness-This is the most widespread reason for prolonged bottle feeding. There is a general lack of clarity about when to stop bottle feeding and the limited research available provides conflicting views. One recommendation is to have the child start drinking from a cup at six months of age and be completely weaned by 15 months.3 Because milk is touted as beneficial for the development of teeth and bones, it is no wonder that families believe it is beneficial to give a toddler as much milk as they want and no harm will be done. Extended bottle feeding places a child at increased risk of ECC. Research indicates other health issues can result as well, including iron deficiency and anemia.3

Recognizing decay

Parents and caregivers often lack the knowledge to recognize decay. From early white spot lesions indicating decalcification to more serious carious lesions, recognizing the appearance of caries takes education. White spot lesions are ignored. These lesions are not recognized as a warning sign of early caries activity.7 Even though these lesions can be remineralized with fluoride and proper home care, failure to recognize the problem allows the decay process to continue.

As a result, treatment often occurs later for children in some lower-income populations. Parents and caregivers understand that baby teeth will eventually fall out and believe it is okay that there are dark spots or holes in the teeth. Parents fail to seek preventive treatment until the child is in such pain that the caries can no longer be managed and restorations or extractions are needed.6 Unfortunately, for these children, the damage has already been done. It is not neglect so much as it is a lack of awareness of the importance of deciduous teeth.7


Many families live below federal poverty income limits. With the financial constraints that are placed on these families, private dental insurance is not an option. Rather, they rely on the public health system to meet their needs. Even with Medicaid dental insurance, preventive dental care is often not initiated.

Interestingly, in the Hispanic community, a child's first dental visit directly correlates to the length of time the mother has lived in the United States and her education level. In other words, mothers who have lived in the U.S. longer and are more educated take their children to the dentist at an earlier age.8 A shortage of Spanish-speaking dental professionals is another reason that families postpone seeking care.8

A lack of convenient hours is also a barrier to seeking preventive care. When a financial deficit exists within the family, work is a priority and missing work to take a child to the dentist is not an option. It is imperative to offer appointments at nontraditional hours to meet the needs of these families.8

Caries is a multifactorial disease. There are many variables that influence the incidence of caries. The convergence of these factors creates a perfect storm for caries to begin. This is especially true in the Hispanic community. These children are at increased risk for developing this disease. Education needs to begin with the expectant mother. If we hope to stop the progression of ECC, then it is clear that more needs to be done. Addressing the family dynamic in regard to feeding children should happen in a continual manner.

Support needs to be in place for these mothers. They must have the education and tools necessary to nurture their young children in a positive manner. The needs of Medicaid insured children who are at higher risk of ECC need to be addressed in a systematic fashion as part of a health-care system.9

Creating multiple opportunities for intervention in the health-care home will help to lessen the disparity that is seen between privately insured children and low income Medicaid children.9 Finally, the socioeconomics of these families must be addressed to stop the progression of severe early childhood caries. RDH

Key points from 2000 ADA statement on ECC

  • Parents and guardians should be "Receiving oral health education based on the child's developmental needs (also known as anticipatory guidance)."
  • "The Association urges its members to educate parents (including expectant parents) and caregivers about reducing the risk for early childhood caries."
  • "Infants and young children should be provided with a balanced diet in accordance with the Dietary Guidelines for Americans published by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services."
  • "Unrestricted, at-will consumption of liquids, beverages and foods containing fermentable carbohydrates (e.g. juice drinks, soft drinks, milk, and starches) can contribute to decay after eruption of the first tooth."
  • "Unrestricted and at-will intake of sugary liquids during the day or while in bed should be discouraged."
  • "Infants should finish their bedtime and naptime bottle before going to bed. "Unrestricted, at-will nocturnal breastfeeding after eruption of the child's first tooth can lead to an increased risk of caries."
  • "Children should be encouraged to drink from a cup by their first birthday."
  • "Proper oral hygiene practices, such as cleaning an infant's teeth following consumption of foods, liquids, or medication containing fermentable carbohydrates, should be implemented by the time of the eruption of the first tooth."

Michelle Wood, RDH, graduated from Central Community College in Nebraska with an associate of applied science in dental hygiene in 2001. Currently, she is enrolled in the bachelor of applied science in dental hygiene program at the Community College of Denver. Since graduating with her AAS, she has practiced clinically in a variety of settings. Most recently, she practices in a public health center, where she is actively involved in serving low socioeconomic at-risk families. Outside of work, she enjoys spending time with her two sons and furthering her education.


1. U.S. Department of Health and Human Services. (2010) Take care of your child's teeth. (Data file). =64&areaID=1 2. Mouradian WE, Wehr E, Crall JJ. (2000) Disparities in Children's Oral Health and Access to Dental Care. Journal of the American Medical Association, 284(20), 2625-2631. Retrieved from: doi:10.1001/jama.284.20.2625.
3. Brotanek JM, Schroer D, Valentyn L, Tomany-Korman S, Flores G. (2009) Reasons for prolonged bottle-feeding and iron deficiency among Mexican-American toddlers: An ethnographic study. Academic Pediatrics 9(1), 17-25. Retrieved from: doi: 10.1016/j.acap.2008.10.005
4. Freeman R, Stevens A. (2008) Nursing caries and buying time: An emerging theory of prolonged bottle feeding. Community Dentistry and Oral Epidemiology 36(5), 425-433. Retrieved from: doi:10.1111/j.1600-0528.2008. 00425.x
5. Boschert S. (2005) Overall improvement in child dental health: Decay rates are down over last 10 years, but there are still disparities by race and income. Pediatric News 39(10), 41. Retrieved from: 10.1016/S0031-398X (05)70666-4
6. Nelson TS, Rogo E, Boyd LD, Cartwright E. (2008) The explanatory model of Mexican American mothers' perception of dental decay. Journal of Dental Hygiene, 82(5), 68-68. Retrieved from:
7. Masterson E, Barker J, Hoeft K, Hyde S. (2014) Shades of decay: The meanings of tooth discoloration and deterioration to Mexican immigrant caregivers of young children. Human Organization 73(1), 82-93. Retrieved from: doi:10.17730/humo.73.1.861831136642q074
8. Kim YOR. (2005) Reducing disparities in dental care for low-income Hispanic children. Journal of Health Care for the Poor and Underserved 16(3), 431-443. Retrieved from: doi:10.1353/hpu.2005.0052
9. Dentistry IQ Editors. (2016) Columbia study focuses on day to day oral health factors of Medicaid pediatric patients. Retrieved from: