Breastfeeding and Dental Caries Part 1

[Guest guest]

From Mothering Magazine No.41, Fall 1986

Breastfeeding and Dental Caries

Sara Ani

When my daughter Miriam was 20 months old, I noticed what appeared to be

blackened areas between her front four teeth. Our family dentist confirmed

my suspicion of dental decay. Since she was so young, he referred us to a

pedodontist (a dentist specializing in treating children). I was stunned

when the pedodontist blamed breastfeeding for my daughter's decay and

refused to treat her unless I weaned her immediately. Since I was active in

La Leche League, I was aware of White's information sheet,

Breastfeeding and Dental Caries, and knew that breastfeeding could not be

the cause of my daughter's decay.

Bottle-mouth syndrome is a well-documented phenomenon, caused by a child

carrying around a bottle most of the day and falling asleep with it at

nighttime and naptime, allowing the sweetened liquid to pool in the mouth,

coating the teeth and thus causing extensive decay in the front teeth and

first molars. E. N. Fass first described this syndrome in 1962 and called it

" nursing bottle-mouth " . This condition involves rampant decay first

appearing on the primary maxillary incisors and spreading to the molars and

cuspids. Fass proposed that this was caused by stagnation of milk on and

around the teeth for prolonged periods of time, allowing oral microorganisms

to ferment the lactose in the milk and cause cavities. The milk stagnates if

a child sucks from a bottle while sleeping.1

However, as White points out, " Nursing at the breast is different from

sucking on a bottle. The baby draws the mother's nipple well back into the

mouth, the milk is let down and ejected in response to the baby's sucking

action, and this in turn triggers an automatic swallowing reflex in the

infant. When the baby stops sucking, the milk doesn't continue to drip out

as it would from a tilted bottle. " 2 The nursing action deposits the milk in

the region of the posterior soft palate, and when the baby ceases to suckle,

the nipple and breast tissue contract. Milk comes out of the breast only

when the baby is actively suckling. And when the milk is in the baby's

mouth, the child's automatic swallow reflex clears the mouth of milk.

Bottlefeeding, on th other hand, is different. Here, the nipple is in the

forward part of the mouth and the milk continuously drips, even when the

baby is no longer actively suckling. Milk gathers slowly in the mouth and

pools until enough is accumulated for the baby to swallow. When the teeth

are bathed in sweet fluid for a long period of time, bottle-mouth syndrome

(rampant dental decay) can result, especially among babies who sleep with

bottles containing sweetened beverages.

Since Miriam had dental caries and since I didn't believe they were caused

by breastfeeding her for an extended length of time, I was led on a search

for the cause of her caries as well as for the best way to treat the

problem. I am now convinced that dental caries are *multicausal* and cannot

be attributed to any single factor alone, such as night nursing.

In reviewing the dental and medical literature on breastfeeding and dental

caries, I noted that many investigators neglected to differentiate between

breastfeeding with supplemental bottle-feedings and breastfeeding

exclusively. Because of this, comparisons of data are difficult.

For instance, one study on infant-feeding profiles and the dental caries

status of urban Nigerian children attempted to compare caries levels in

breastfed versus bottlefed babies, and to show that the caries rate was high

for both groups that were nursed or bottlefed for a long time. However, it

went on to say, " Nevertheless, it could be argued that, as the breastfeeding

pattern is quite prevalent in the rural areas where caries prevalence is

relatively low, other factors may be involved; and in fact, it is shown that

mothers, especially in developing countries, practice *alloitment mixte*

(both bottle-and breasfeeding)! " 3

Another study attempting to compare bottlefed and breastfed babies with

their respective rate of caries had this to say about the breastfeeding

group: " The black mothers perservered with breastfeeding, in spite of the

fact that many returned to work and had perforce to arrange for

bottlefeeding during the day; but breastfed during the night and morning. " 4

Again, an example of poor differentiaion between a bottlefeeding and a

breastfeeding group of infants.

THE MANY FACTORS

Crawford et al. poited out the multifactorial nature of dental caries. They

reported, however, that an experiment designed to control factors other than

the way in which an infant is fed would be very difficult, if not

impossible, to conduct.5

Many investigators never studied factors other than breastfeeding that could

cause decay. One study of four cases concluded that breastfeeding was

responsible for the children's decay, while also noting that these four

children had no history of oral hygiene!6 Other studies limited to feeding

methods have been unable to establish a clear cause-and-effect relationship.

Several, based on small samples with poor controls, reveal insufficient

evidence for ruling out other possible causes of dental decay.

Dental health begins even before a baby is born. A mother's prenatal

nutrition is extremely important. Her baby's teeth are formed in the womb,

beginning in the first trimester of pregnancy. If a mothe is very ill - as I

was, with sever nausea, vomiting, and hospitalization for dehydration - her

child's teeth, once they erupt, could possibly be weak and susceptible to

decay. " How resistant these caries' sensitive surfaces wil be depends on how

well these teeth mineralize. The mother, by balancing the necessary calcium,

phosphorus, and vitamins in her bloodstream, contributes to the successful

hardening. " 7

Fevers during pregnancy can also cause the baby's teeth to mineralize

imperfectly, making them more susceptible to decay. " If she gets a fever

from a virus or some other infection (a common occurrence between the fifth

and ninth months of pregnancy), the delicate balance of calcium and

phosphorus salts in her bloodstream could be upset. This would affect the

quality and quantity of tooth structure that is forming in the fetus. The

disruption will continue for as long as it takes the mother's system to

regain the balance. " 8

If a young infant has high fevers prior to tooth erruption, the

calcification proccess can also be interrupted, making the teeth more

susceptible to caries. General health and teeth are closely connected. " An

infectious illness or a high fever affects the adjustment of calcium and

phosphorus salts in the baby's bloodstream. The teeth mineralize

imperfectly. Poor enamel and dentin crystals form, causing the teeth to be

more susceptible to decay. " 9 It is important to keep a record of illnesses

that you and your child have had. Tell the dentist about these illnesses so

that he or she will know that your child has a congenital or early

childhood-related susceptibility to caries.

Premature babies have been known to have a higher rate of decay. " If the

expectant mother gives birth before term, it is possible that the child's

teeth will be affected. There is some evidence today that full-term children

have fewer cavities. This is because those areas of the teeth that are

mineralizing just around the time of birth are the ones most susceptible to

decay. " 10 Premies can have a condition known as anamal hypoplasia, which

mimics bottle-mouth caries. however, it follows the pattern of enamal

formation, is symmetric in nature, and will be evident as soon as the tooth

emerges. This is also common in children with systemic defects like cerebral

palsy.11

One of the most overlooked areas of dental health is the crucial role of

hygiene for infants. I never thought about cleaning my daughter's teeth,

assuming that she would do it herself when she was old enough to hold a

toothbrush. Hence, her decay had already progressed before I introduced any

hygienic measures! Many of the studies citing breastfeeding as the cause for

dental caries were based on case histories; and these do mention lack of

hygiene. This is a crucial factor. Dr. Moss feels that childhood

tooth decay can be wiped out if parents would start cleaning their baby's

mouths from birth onward. He advocates wiping the gums, top and bottom, with

moist gauze pads twice a day so that the teeth can errupt into a

bacteria-free environment. Cleaning the gum tissue can serve to remove food

residue, reduce oral bacteria, and cut down on the overall acidity. He feels

that babies will then have an easier time teething and will be less sick

generally.

Recommendations on positioning the baby for cleaning the gums vary. Dr. Moss

advises placing your baby's head in your lap, feet pointing away from you,

so that you can clearly see into the mouth.12 Dr. Kris, in Boise,

Idaho, says the cleaning program can be a natural outgrowth of the nursing

relationship. Let it be done in the loving, cradled position that you nurse

the child in, he suggests. Regardless of the position you choose, continue

the cleaning program even after the teeth erupt. Using a moist gauze pad,

wash around the gum line and thoroughly clean the surface of each tooth,

front and back. Around 18 months of age, a toothbrush can be gradually and

lovingly introduced.13

Children with allergies are more prone to decay. Food allergies as well as

environmental allergies play a role here. Food allergies can make the mouth

more acidic, which tends to decay teeth. Often the allergic child,

perpetually congested, becomes a mouth-breather. This causes the saliva to

dry up; and since saliva contains an enzyme that protects the teeth against

decay, persistent mouth-breathing can be a contributing factor. Without

sufficient saliva to bathe the teeth, they become more prone to decay.14

Antoher cause of dental decay can be found in medications for children. Many

prearations, from antibiotics to vitamin supplements, contain sugar to make

them taste good. Sweetened medications - especially liquid preparations, and

particularly if they are given at bedtime - promote decay. For a child with

seizures, cardiac ailments, recurrent ear infections, rheumatic fever, and

other conditions often requiring long-term prescriptions, the liquid and

chewable preparations are made more palatable by the addition of sugar as a

sweetener. Sweetened vitamin supplements have been implicated in caries

development in young children. Sucrose has been named as the primary

sweetener, and levels ranging from 25 to 60 percent have been found.15

Throat lozenges and cough syrups are generally given at night, thus

remaining in the mouth for a long period of time. Chewable medications get

lodged in the teeth, and cough drops and throat lozenges bathe the teeth for

as long as they are held in the mouth. Liquid iron supplements are also

sweetened.16 Nearly all pediatric medicines contain sugar. However, a

sugar-free liquid medication list is published annually in American Druggist

and is available to health proffessionals. It would be worthwhile to ask

your child's doctor for a sugar-free substitute for any prescribed

medication.

Dr. Kenny, Dentist-in-Chief at the Hospital for Sick Children in

Toronto, says, " Any child who is sick during the first three years of life,

whether it be for asthma, gastrointestinal, or cardiac problems, may be

taking large quantities of antibiotics and penicillin. The sucrose in

medications is harmful to their teeth. " 17

Over-the-counter medications are equally menacing, and parents are advised

to exercise great caution in selecting one of these treatments.18 Many

investigators are advocating that sugar in medications be replaced with a

nonsugar sweetener, such as Xylitol.19 This is still in the investigatory

stages. Regardless of their content, the best time to give medications is

with meals, rather than between meals or at bedtime, and afterward the teeth

should be brushed.

The structure of the teeth also plays a role in forming caries. Children who

have malocclusions (bite abnormalities) or very close, overlapping teeth

have a tendancy to more decay than those who do not.

The pros and cons of flouride, and its uses in dentistry and decay

prevention, form a complex subject beyond the scope of this article. It is

important to note, however, that primitive societies with a low incidence of

caries did not use flouride! It may be more valuable to turn our efforts

toward diet and hygiene than to try to cure problems with flouride. Systemic

flouride tablets and vitamins with flouride will not affect existing decayed

teeth. These are only useful for the next set of teeth that are forming

under the gums. One must follow one's heart on the usage of a topical

flouride rinse in order to protect the existing teeth. Since young children

cannot easily expectorate a topical rinse, many parents apply the rinse with

a Q-tip, just dotting it on the decayed area. A topical flouride gel can

also be applied with a Q-tip; some dentists recommend these gels for very

young children in order to delay further decay and postpone the need for

treatment until the child is older. Sometimes the use of a topical flouride

offers the benefit of added time, delaying treatment which may be traumatic

to a toddler, but easy to take for a three year old. These are important

choices to make.

A child also has a certain genetic heritage and susceptibility to caries

that cannot be overlooked. It is important to keep this in mind. Some day we

may have the knowledge and discipline to help overcome this tendency.

Another area of interest is something called the Specific Plaque Hypothesis

(SPH). This hypothesis maintains that Streptococcus mutans, a bacteria,

plays an important role in enamel caries, and that a high salivary count may

be predictive of caries activity. Children with a parent who is highly

infected with Streptococcus mutans may run a genetic risk of also becoming

highly infected. This is now the same bacteria that causes strp throat,

however.

As early as 1924, Killian e described dental caries as an infectious

disease that is tranmissible.20 Strptococcus mutans will initially colonize

on a tooth surface, but sugar plays an important role in augmenting the

total floral cell accumulation of Strp.mutans in plaque. While this bacteria

exists in everybody's mouth to one degree or another, what is crucial is the

total cell count of the Strp. mutans present. And, in order for Strep.

mutans to proliferate, it needs sugar. It thrives on sugar. In 1960, Keyes

and Fitzgerald demonstrated that dental decay was a transmissible infection

due to Streptococcus mutans, and the extent of the infection was found to be

sucrose-dependent. The development of smooth-surface caries on molars or

incisors is most often seen in individuals who consume sucrose frequently or

who have a low salivary flow.21 It is therefore recognized that Strep.

mutans, in the presence of sucrose - which augments the total accumulation

of this bacteria - leads to decay.

Nutrition is probably one of the most important factors in dental decay.

Decay-causing bacteria thrive on sugar. When you eliminate sugar from the

diet, you starve the tooth-decay germs. Primitive man, with his unrefined

diet, had virtually no decay - even without flouride! Weston Price did

marvelous studies on the incidence of dental caries and it's relationship to

diet. Whenever our Western refinied diet was introduced to " primitive "

cultures, decay increased.22 Dr. Ralph Steinman calls decay a " systemic

disease. " It comes from within; yet diet overrules heredity, he noted. Using

stomach tubes, he injected sugar directly into the stomachs of rats; the

control group was given sugar by mouth. This experiment resulted in the same

high rate of decay in both groups. He concluded that what is inside the

teeth - not only what is on the teeth - contributes to decay.23

Many studies have examined the incidence of dental caries and its

relationship to diet. These epidemiological studies are quite impressive.

They reveal many populations in which the rate of caries was low until

exposure to importation and consumption of refined carbohydrates, due to a

gradual change toward a westernized and urbanized diet. Studies were

conducted in Nigeria, Ethiopia, Tristan da Cunha, and among Eskimos, all

with the same results. When the amount of sugar consumption increases, the

caries rate increases.24

These are some of the many factors to consider, if your child has dental

caries. When breastfeeding is implicated, solutions can be found. A

breastfed baby may have a suckling problem, where the last bit of milk is

not swallowed. This can be remedied, says Dr. Mark Mendelsohn, by simply

rolling the baby over in the night after nursing. Movement causes an

automatic swallowing action.25

In addition, Dr. Kriz conducted some small-scale, preliminary studies

on the acidity of mother's milk. He tested various mothers' pH levels in

their milk and found that those with more acidic milk tended to have

children with more tooth decay. He called on professionals to do more

research in this area.26 Perhaps a mother's diet can influence the pH level

of her milk. This is a fascinating area to research, and future studies may

help to explain why a mother who breastfeeds several children can have one

with decay and several who are decay-free.

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