Early childhood caries (ECC) is a virulent form of dental caries that can destroy the primary dentition of toddlers and preschool children.

Early Childhood Caries is defined as the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a preschool-age child between birth and 71 months of age. The term "Severe Early Childhood Caries" refers to "atypical" or "progressive" or "acute" or "rampant" patterns of dental caries.

A child's teeth are susceptible to decay as soon as they begin to erupt. Early childhood caries is an infectious disease. There are many aspects of early childhood caries; baby bottle tooth decay is recognized as one of the more severe manifestations of this syndrome.


  • Scheduling the child's first dental visit. It is advantageous for the first visit to occur within six months of eruption of the first tooth and no later than 12 months of age, and
  • Receiving oral health education based on the child's developmental needs (also known as anticipatory guidance).

Role of Bacteria

  • Because cariogenic bacteria (especially mutans streptococci) are transmitted soon after the first teeth erupt, decreasing the mother's mutans levels may decrease the child's risk of developing ECC.


  • Infants and young children should be provided with a balanced diet
  • 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

Bottle Feeding

  • 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.

Breast Feeding

  • Unrestricted, at-will nocturnal breastfeeding after eruption of the child's first tooth can lead to an increased risk of caries.

Use of a Cup

  • Children should be encouraged to drink from a cup by their first birthday.
  • At will, frequent use of a training cup should be discouraged.

Home Care

  • 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.
  • A child's teeth should be periodically checked at home according to the directions of the dentist.


  • Optimal plaque removal

On eruption of the first primary tooth in a child, tooth brushing and cleaning should be performed by an adult. This is important as the plaque that attaches to the surface of the tooth has bacteria that have the ability to cause caries (decay) on the tooth surface. It is recommended to brush children’s teeth using a soft bristled, age and size appropriate toothbrush and age appropriate toothpaste twice daily, however children below the age of two usually don’t require toothpaste.

  • Adequate diet

Dietary habits and the presence of cariogenic bacteria within the oral cavity are an important factor in the risk of ECC. ECC is commonly caused by bottle feeding, frequent snacking and a high sugar diet In regards to preventing ECC through bottle feeding, it is fundamental not to allow the child to sleep using ‘sippy cups’ or bottles as this is a large factor contributing to baby bottle decay/caries.

  • Fluoride

Fluoride is a natural mineral that naturally occurs throughout the world – it is also the active ingredient of many types of toothpaste specifically for its remineralizing effects on enamel, often repairing the tooth surface and reducing the risk of caries. The use of fluoridated toothpaste is highly recommended by dental professionals; whereby studies suggest that the correct daily use of fluoride on the dentition of children has a high caries-preventive effect and therefore prevents has potential to prevent ECC.

  • Pre-natal and peri-natal period

Prevention of early childhood caries begins before the baby is born; women are advised to maintain a well-balanced diet of high nutritional value, especially during the third trimester and within the infants first year of life. This is since enamel undergoes maturation; if the diet is not sufficient, a common condition that may occur is enamel hypoplasia. Enamel hypoplasia is a developmental defect of enamel that occurs during tooth development, mainly pre-natally or during early childhood. Teeth affected by enamel hypoplasia are commonly at a higher risk of caries since there is an increased loss of minerals and therefore the tooth surface is able to breakdown more easily than in comparison to a non-hypoplastic tooth.It is therefore suggested to the mother to maintain a healthy diet since evidence suggests malnourishment during the perinatal period increases the risk of hypoplastic teeth in an infant

  • Dental visits

It is recommended to parents and caregivers to take their children to a dental professional for examination as soon as the first few teeth start to erupt into the oral cavity. The dental professional will assess all the present dentition for early carious demineralization and may provide recommendations to the parents or caregivers the best way to prevent ECC and what actions to take. Studies suggest that children who have attended visits within the first few years of life (an early preventive dental visit) potentially experience less dental related issues and incur lower dental related costs throughout their lives


The current standard of care for Severe Early childhood caries includes restoration and extraction of carious teeth and, where possible, includes early intervention which includes application of topical fluoride, oral hygiene instructions and education. The initial visit is important as it allows dental professionals to flag unfavourable behaviour or eating habits. This will also allow dental clinician, working in a collaborative team, to perform diagnostic testing to determine the rate and progression of the disease. This is done by performing risk assessment based on the child's age, as well as the social, behavioural, and medical history of the child. Children at low risk may not need any restorative therapy, and frequent visits should be made to detect possible early lesions. Children at moderate risk may require restoration of progressing and cavitated lesions, while white spot and enamel proximal lesions should be treated by preventive techniques and monitored for progression. Children at high risk, however, may require earlier restorative intervention of enamel proximal lesions, as well as intervention of progressing and cavitated lesions to minimize continual caries development.

As Early Childhood Caries occurs in children under the age of 5, restorative treatment is generally performed under general anaesthetic to ensure optimal results and prevent a traumatic experience for the child.

Depending on the level of cavitation of the teeth, different types of restorations may be employed. Stainless steel (preformed) crowns are pre-fabricated crown forms which can be adapted to individual primary molars and cemented in place to provide a definitive restoration.They have been indicated for the restoration of primary and permanent teeth with caries where a normal filling may not last.

Another approach of treating dental caries in young children is Atraumatic Restorative Treatment (ART). The ART is a procedure based on removing carious tooth tissues using hand instruments alone and restoring the cavity with an adhesive restorative material. This is useful to prevent trauma and requires less chair time for the young patients. This is used in cases where the teeth are being maintained in the mouth to maintain space for the future teeth to come through. Low quality evidence indicates that ART may have a higher risk of filling failure when compared to usual care. Despite the potential for filling failure, ART is still recommended for children when access to electricity, drills, dentists, or other dental resources are limited.