Nursing caries, also known as early childhood caries, is a pattern of dental decay seen in young children due to prolonged and improper feeding habits. It is caused by transmission of cariogenic bacteria like Streptococcus mutans from mother to child combined with frequent consumption of fermentable carbohydrates like milk, formula, or breastmilk. Nursing caries affects primary maxillary incisors first and progresses through 4 stages from initial reversible demineralization to deep lesions and tooth fracture if left untreated. Treatment involves caries removal, restoration, parental counseling on proper feeding and oral hygiene, and topical fluoride application.

1. NURSING
CARIES

2. Dental caries:-
 “Dental caries is a microbial disease of the
mineralized tissues of the teeth, characterized by
the demineralization of the inorganic portion &
destruction of the organic substances of the tooth.”
• Nursing caries :-
 Nursing caries is a unique pattern of dental
caries seen in very young children due to
prolonged & improper feeding habits.

3. Synonyms
 Nursing bottle caries
 Baby bottle tooth decay
 Nursing bottle syndrome
 Milk bottle syndrome
 Early childhood caries
New name is ……
Maternally derived streptococcus mutans
disease (MDSMD)
 It is seen in infants & toddlers
 It affects the primary dentition only.

4. Classification of early childhood
caries
 Type I ECC ( Mild to moderate)
 Carious lesions involving the molars & incisors
Seen in 2-to-5 year-old children
Cause is usually a combination of cariogenic
semisolid or solid food & lack of oral hygiene
Number of affected teeth usually increases
as the cariogenic challenger persists

5. Type II ECC (Moderate to severe)
 Labiolingual carious lesion affecting the
maxillary incisors with or without molar
caries, depending on age
 Seen soon after the first tooth erupts
 Mandibular incisors are unaffected
 Cause is usually inappropriate use of feeding
bottle or at-will breast feeding or combination
of both with poor oral hygiene
 Unless controlled, it may proceed to an
advanced stage.

6. Type III ECC ( Severe)
 Carious lesions involve almost all the
teeth, including mandibular incisors
 Usually seen at 3-to-5 years of age
 Cause is a combination of factors &
poor oral hygiene
 Rampant in nature & involves immune
tooth surfaces

7. Etiologic agents in nursing caries
1.Food Products:
 Bovine milk
 Milk formulas
 Human breast milk
 Honey
 Fruit juices
 Sweetened beverages
 Pacifiers sweetened with jam & jelly
 Milk or water with added sugar

8. 2.Pathogenic Microorganism
“Streptococcus Mutans ”
It is transmitted to the infants mouth primarily
through mother
 It colonizes the teeth
 It produces large amount of acid
 It provides large amount of extracellular
polysaccharides

9. 3. Substrate
“ Fermentable carbohydrate”
Main sources are
 Bovine milk or milk formulas
 Human milk (breast feeding at will or on demand)
 Fruit juices & other sweet liquid
 Sweet syrups like vitamin preparations
 Pacifiers dipped in honey or sugar solution
 Chocolates or other sweets

10. 4. Host
 Teeth act as hosts for microorganisms
 Hypo-mineralization or hypoplasia of teeth
increases caries-susceptibility of the child
 Thin enamel in primary teeth is one of the
reasons for early spread of lesions
 Developmental grooves also may act as
plaque retentive areas

11. V. Time
 It is an important factor that determines caries
activity
 More the time child sleeps with the bottle in the
mouth the higher is the risk of caries.
 During sleep salivary flow is diminished &
swallowing reflex is absent. Hence milk cannot
be eliminated from the oral cavity & it pools
around the tooth surfaces, providing more time
for accumulation of carbohydrates in the
mouth which are acted upon by microorganisms
to produce acid, leading to caries.

12. Other etiologic risk factors :
 Feeding at night always poses a serious threat
especially if the if the teeth are not cleaned
after feeding.
 Feeding beyond the weaning age i.e. beyond
12 to 15 months
 Single parent households. Child neglect could
also be one of the major reasons for nursing
caries to occur as the parent is too busy.
Camping with financial stress and
responsibilities.

13.  High socio-economic status.it has been seen
that some mother avoid breast feeding.The
children are left to the mercy of the domestic
help who think it their duty to continuously
force a bottle in to the child’s mouth.
 Low socio-economic status. Both the
parents if working, leave the children to be
looked after by the young siblings and the
resultant neglect leads to tooth decay

14.  Immuno compromised children, are at
higher risk due to decreased salivary flow.
 A strong tempered child such as the only
child or on over protected one world always
demand and force the parents to give in to its
wishes.
 Children who present sleep disorders are
found to be affected by nursing caries.
 Low birth- weight infants (less than 2500 G.)

15. Despite, its cariogenic potential mother’s milk remains
the ideal food for a child. It is sweeter as compared to
bovine milk because of its higher lactose content. It is:-
 a) The perfect food at the perfect temperature
 b) It provides a natural transfer of immuno-globulins by
way of colostrums
 c) The continuous sucking leads to development of
orofacial structures
 d) A bond of love and affection is formed between the
infant and the mother which provides the child with a much
needed security and warmth
It is important to realize and educate mothers
about the importance of proper feeding habits.

16. CLINICAL FEATURES:-

17. The intra-oral decay pattern of nursing caries affects
the primary teeth in the following sequence:
Primary maxillary incisors are first to
get affected.
a) Maxillary central incisors: facial, lingual,
mesial & distal surfaces
b) Maxillary lateral incisors: facial, lingual,
mesial & distal surfaces
n Maxillary first molars: facial, lingual and
occlusal, prominent surfaces.

18. d) Maxillary canine and second molars facial,
lingual and proximal surfaces.
e) Mandibular molars: At later stage.
The Mandibular incisors are usually
because of spared:
 They are protected by the mechanical
cleansing action of the tongue
 Cleansing action of saliva due to presence of
the orifice of the duct of the sublingual glands
very close to lower incisors

19. Developmental process:
4 Stages:-
 Stage I : Initial (reversible) Stage
 Stage II: Damaged ( Carious) Stage
 Stage III: Stage of deep lesions
 Stage IV: Traumatic stage

20. Stage I : Initial (reversible) Stage:
 Cervical and interproximal opaque white chalky
demineralization seen on maxillary anterior
teeth
 Pain or toothache does not occur
 The dentist is the only one who can make the
diagnosis, by using the air syringe and thus
drying the teeth properly

21. Stage II: Damaged ( carious) Stage:
 Caries extends in to dentin and marked
discolorations are seen
 Discontinuity of enamel surface is seen
penetration of carious lesions occurs. Parents can
now spot the decay
 Children start complaining of toothache on
ingestion of extremely cold food for e.g..
Ice- creams.

22. Stage III: Deep Lesions:
 This stage is reached in 10-14 months.
 Complaints of pain during tooth brushing or
eating especially while biting are frequent.
 Complaints of pain during intake of hot or cold
drinks.
 Diagnosis is facilitated if patient complaints of
pain during eating, brushing or if the child uses
his canines to incise food.

23. Stage IV: Traumatic Stage:
 Fracture of one or more carious teeth,
cerivcally are a frequent occurrence.
 A toddler learns to walk when his protective
reflexes have not developed fully, the child falls
on its face and sometimes the incisors fracture,
as they are already weakened the parents do not
notice the fracture at times.

24. Fracture of primary
teeth are rare because they are
frequently displaced or intruded Hence
when weakened by nursing caries,the
tooth will tend to fracture in the
weakest spot cervically.At times, only
root stumps remain in the oral cavity.

25. Management
Aims:
 Management of existing emergency
 Arrest and control of the carious process
 Institution of preventive procedure
 Restoration and Rehabilitation

26. Factors affecting management:-
 Extent of the lesion
 Age of the patient
 Behavioral problems of the child due to
young age of the child.

27. Treatment :-
Divided in to three visits:-
First Visit:-
This phase of treatment constitutes
treatment of the lesion identification of the
cause for counseling of the parent
 All lesions should be excavated and restored.
 Indirect pulp capping or pulp therapy
procedures can be evaluated by further
investigation.

28.  It the abscess is present it can be treated
through drainage.
 X-rays are advised to assess the condition
of the succedaneous teeth.
 Collection of saliva for determining the
salivary flow and viscosity.
 Also, the application of fluoride topically.

29. Parent Counseling
 The Parent should be questioned about the
child’s feeding habits, specially regarding the
use of nocturnal bottles, demand the breast
feeding, pacifiers dipped in sweetening agents
 The parents should be asked to try weaning the
child from using the bottle as a pacifier while in
bed
 In case of considerable emotional dependence
on the bottle suggest the use of plain or
fluoridated water

30.  The parents are should be instructed to clean
the child’s teeth after every advised to
maintain a direct record of the child’s teeth
after every feed
 Parents are advised to maintain a diet record
of the child for one week which include the
time, amount of food given to the child, the
type of food and the number of sugar exposure

31. SECOND VISIT
It Should be scheduled one week after the first
visit.
 Analysis of diet chart and explanation of the
disease process of the child’s teeth should be
undertaken by a simple question.
 Isolate the sugar factors from the diet chart and
control sugar exposure by intelligent use.
 Caries activity tests can be started and repeated
at monthly intervals to monitor the success of
treatment.

32. Third and subsequent visits:-
 Restoring all grossly decayed teeth.
 Endodontic treatment
 In case of unrestorable teeth extractions
can be done followed by space
maintenance
 Crowns can be given for grossly decayed
or endodontically treated teeth.
 Review and recall after every 3 months.

33. Complications:-
 Nursing caries is a severely disabling condition. It
can result in a severely painful, unaesthetic
appearance. Due to loss of tooth structure, the
child may not be able to chew food properly and
subsequent malnutrition may ensue Hence these
children may show retarded growth as compared to
normal children
 Prolonged bottle feeding often displaces other
components of staple diet hence this can result in
nutritional deficiencies for e.g. anemia, etc. The
child who has nursing caries has an increased risk
of developing caries in the permanent dentition

34.  Rapid destruction of teeth may affect a child
psychologically when he compares himself to
other children
 Early extraction of maxillary incisors can
create speech problems
 Loss of primary teeth can cause space
problems, which may result in malocclusion

35. PREVENTION
 The main strategies for the prevention of nursing
caries should be to create awareness and alert
prospective parents and new parents about the
condition and its causes
 Information on nursing caries can be distributed
to new parents through obstetricians or
gynecologist, pediatricians, paramedical staff,
health workers and maternal and child health
care centers
 Sealing of all caries free pits and fissures
 Professional fluoride programs

36. Use of antimicrobial therapy topically
Supervised home care should be taught
Systemic fluoride program if there is sub optimal
fluoride concentration in drinking water
Parents should be educated:
• How and when to feed the child during
the earliest stages of the child
• When and how to introduce solid foods

37. • Breast feeding should be encouraged as
human breast milk is highly adapted to the
human infant and is almost a complete
source of all required nutrients
 Broadly based committees at government level to
address the tissue of caries and the risk factors in
young children and how to recognize early signs
of the condition and promote early intervention.