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Breastfeeding and Dental Health
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Janna L. Cataldo, MD
Wellstart International
July 15, 1998

Exclusive breastfeeding is the preferred method of infant feeding in the first six months of life, and continued breastfeeding throughout the first year and into the second year carries with it a multitude of advantages for both the mother and the infant.1,10,27,28 Both the American Academy of Pediatrics and the American Academy of Pediatric Dentistry have as primary goals the promotion of optimal health for children. The issue of dental caries in infants and young children is one that both pediatricians and pediatric dentists are intimately concerned with. 18 When discussing dental caries in young children, a clear association between inappropriate bottle feeding (prolonged use of the bottle, carrying it in the mouth all day, and being put to bed with it at night) 8,11 and an increased incidence of caries involving the upper incisors starting on the smooth surfaces, exists. This has been variously termed nursing caries, baby bottle tooth decay and early childhood caries. 19 However, when discussing breastfeeding, the association is not as clear. A debate has emerged over the last twenty years over whether breastfeeding ad lib through the night , or prolonged breastfeeding beyond 12 months of age, are causes of "nursing caries" in a similar fashion as "baby-bottle tooth decay".3,4,5,8,9,10,14,17,20 A review of the current literature gives us a better understanding of this issue.

Nursing caries is caused by the fermentation of sugars present in liquids fed to the infant by bacteria present in the mouth. 7,22,25 It has been shown that streptococcus mutans is present at much higher concentrations in the mouths of infants and young children with caries than in those without.11,19,22 The streptococcus mutans bacteria is most commonly transferred to the infant from his/her mother. 7,25,27 The mothers with the highest levels of streptococcus mutans and usually an associated history of dental caries are the most likely to do this. 11,13,31 In addition, there are other genetic factors which may predispose an infant to dental caries. 5,11,21 Research on dental caries in adults has shown that factors present in the saliva may be protective. 21 These include factors which cause decreased bacterial aggregation and adherence to tooth surfaces and plaque pH regulation to inhibit breakdown of tooth enamel. The absence of these substances is associated with increased rates of dental caries. 21 The occurrence of early childhood caries also appears to vary significantly with race, culture and socioeconomic status. 11,13,34,36


In studies comparing bottle-fed to breast-fed babies, bottle-fed babies have been found to have a higher incidence of dental caries overall.4,9,10,18,26,30,32 This has been attributed to bottle-propping and giving the baby a bottle of formula, milk or juice to sleep with at night.11,14,24 However, nursing caries has been identified in babies that have been exclusively breastfed without receiving any bottles.14,19,23,28 How can this occur?

Infants who sleep with their mothers and nurse all night long have been reported to have an increased risk of nursing caries.8,23,36 The breastfed baby while actively suckling has the nipple at the junction of the hard and soft palates, with the tongue filling the oral cavity, and very little if any remaining milk present after swallowing.2,5,12 It is important to remember that isolated feedings from the breast at night in addition to daytime feedings are essential in the first few months of life to initiate a good milk supply and to ensure adequate growth for the infant.1,29 When the baby falls asleep at the breast, the nipple retracts.2 If the mother is also asleep and the baby does not completely remove the breast from his mouth, milk can pool in the babies mouth, coming into contact with the lingual surface of the upper incisors.29 In addition, during sleep there is a decrease in the amount of saliva produced, which decreases the clearance of the milk.11,15 In a baby with a family history of caries and a high streptococcus mutans count, this can lead to rampant nursing caries.


Other contributing factors, not explored in most articles reporting nursing caries in the breastfed babies are: what constitutes the rest of the baby’s diet, since most babies presenting with caries are older than 12 months;12,35 is fluoride supplementation being given;10 and, what is the hygiene practice in this baby's family?2,4,5,10,35 There are no good studies comparing breast-fed babies that are matched for appropriate solid food diet and excellent hygiene practices, and matched for streptococcus mutans colonization and family history of caries.24 Before we say that night-time breastfeedings are a problem, we need to look at all of the factors present in each case, and maintain the breastfeeding relationship as much as possible. 31,33

In summary, it is true that some breastfed babies have been reported to have nursing caries.15,16 However, breastfeeding itself does not need to be stopped in order to prevent further caries.16,33 Further research is needed before we should ever say to a parent that they need to stop breastfeeding because of caries in the infant, as we know from case reports that further caries can be prevented while breastfeeding is maintained.15,16 The following steps are recommended:10,14,15,16,19,27,29,36

  • breastfeeding as the preferred method of infant feeding
  • exclusive breastfeeding for the first six months of life, and continued breastfeeding with appropriate introduction of solids for the rest of the first year and into the second year
  • proper attention to dental hygiene at the first tooth eruption
  • early dental evaluation of infants with a family history of dental caries (6 to 12 months of age) with regular follow-up
  • never allow a baby to be propped with a bottle
  • never allow a baby to go to bed with a bottle containing anything other than water
  • dental evaluations for infants without a family history of caries should begin at 12 months
  • breastfeedings at night should not be continuous, and the baby should be removed from the breast when the feeding is complete
  • fluoride recommendations from the AAP and ADA should be followed
    If all of these steps are followed, a much healthier population of infants will exist.


From San Diego County Breastfeeding Coalition
http://breastfeeding.org/References

  1. American Academy of Pediatrics. Work Group on Breastfeeding (1997) Breastfeeding and the use of human milk. Pediatrics 100(6); 1035-1039.
  2. Abbey, LM (1979) Is breast feeding a likely cause of dental caries in young children? J of the American Dental Association 98; 21-23.
  3. Abbey LM (1979) Night breast feeding and dental caries Pediatrics 64(5); 701.
  4. Al-Dashti AA, Williams SA, and Curzon MEJ (1995) Breast feeding, bottle feeding and dental caries in Kuwait, a country with low-fluoride levels in the water supply. Comm Dental Health 12(6); 42-47
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  6. Aspis LJ (1996) Early childhood caries-a prescription for prevention. CA Pediatrician ; 26, 28.
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  9. California Society of Pediatric Dentists (1988) Baby bottle tooth decay. California Pediatrician ; 39-42.
  10. Degano MP and Degano RA (1993) Breastfeeding and oral health. NYSDJ ; 30-32.
  11. Duperon DF (1995) Early childhood caries: A continuing dilemma. CDAJ ; 23(2); 15-25.
  12. Eronat N, Eden E (1992) A comparative study of some influencing factors of rampart on nursing caries in preschool children. J Clin Ped Dentistry; 16(4):275-279.
  13. Febres C, Echeverri EA, Keene HJ (1997) Parental awareness, habits, and societal factors and their relationship to baby bottle tooth decay. Amer Acad of Ped Dentistry; 19(1);22-26.
  14. Gardner, D (1977) At will breastfeeding and dental caries: four case reports. J of Dentistry for Children ; 18-23.
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  16. Hale, KJ (1997) A pediatric dentist’s perspective. New Beginnings; 11-12.
  17. Jelliffee DB and Jelliffee EFP (1983) Breastfeeding could be a cause of the type of dental caries. J Dent 11(4); 361.


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  12. Roberts GJ, Cleaton-Jones PE, Fatti LP, Richardson BD, Sinwel RE, Hargreaves JA, et al (1992) Patterns of breast and bottle feeding and their association with dental caries in 1-to 4-year-old South African children. 2. A case control study of children with nursing caries. Community Dent Health 11(1); 38-41.
  13. Roberts GJ, Cleaton-Jones PE, Fatti LP, Richardson BD, Sinwel RE, Hargreaves JA, et al (1993) Patterns of breast and bottle feeding and their association with dental caries in 1- to 4-year old South African children 1. Dental caries prevalence and experience. Community Dent Health 10(4); 405-413.
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