What Is Early Childhood Caries (ECC)? Helpful Advice & Treatment

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Dr. Matthew Hannan | My Dental Advocate
Early Childhood Caries | My Dental Advocate

Early childhood caries (ECC) is a destructive oral health disease that affects infants and preschool children worldwide.

What’s involved? ECC is the presence of one or more decayed, missing, or filled primary teeth in children five and younger.

Did you know that 85% of disadvantaged groups are affected by ECC? Helpful advice and treatment are necessary for diagnosis and healing.

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What Is Early Childhood Caries? (ECC)

Early Childhood Caries (ECC) begins when white spots appear on the surface of the teeth, commonly along the gum line.

If the disease progresses, decay will occur, leading to further damage and loss of teeth. Several factors contribute to the development of early childhood caries.

These include microorganisms (bacteria), poor oral hygiene practices (home care), and an unhealthy diet.

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One of the leading causes of early childhood caries (ECC) is improper feeding habits.

Poor nutrition leads to poor teeth hygiene which increases the risk of developing tooth decay. Children who grow up without proper nutrition may be unable to eat properly because of poor oral health, including decayed or lost teeth.

In addition, they may suffer from malnutrition and stunted physical growth. Teeth serve an important function, especially in children.

Therefore, preventing cavities and severe early childhood caries is essential for health.

Although it is largely preventable, ECC remains one of the most common childhood diseases.

What Causes ECC?

Despite the decline in the prevalence of cavities in western developed countries, cavities in preschool children remain a significant problem in both developed and developing countries.

The majority of ECC varies widely with several factors.

Risk Factors

  • Culture
  • Ethnicity
  • Socio-economic status
  • Lifestyle
  • Dietary pattern
  • Oral hygiene practices
  • Living location
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According to research, in most developed countries, the prevalence rate of ECC is between 1 and 12%.

However, in less developed countries, the prevalence has been reported to be as high as 85%. In addition, according to a study, the highest prevalence of ECC is found in the 3- to 4-year-old age group, and boys are significantly more affected than girls.

Oral hygiene behaviors during childhood are related to early childhood caries (ECC) among children. These include nighttime breastfeeding, frequent use of sugary drinks, and eating foods high in sugar.

ECC affects deprived families disproportionately more.

Cavity-Causing Bacteria

Streptococcus Mutans (SM), Streptococcus Sobrinus, and Lactobacillus bacteria are the most common microorganism associated with early childhood caries.

They metabolize sugar into acid, contributing to the demineralization and subsequent cavities in teeth. In addition, these bacteria can be transmitted from mother to child.

Preschool children with high levels of SM have higher cavity prevalence and a greater risk of developing new cavities. In addition, children with high SM levels were five times more prone to tooth decay.

SM is the primary bacteria associated with dental caries, whereas the other oral bacteria in the dental plaque could be involved in the initiation and progression of caries.

The primary source of acquiring cavity-causing bacteria is from the mother during the first 12–24 months.


Dietary practices also play an essential role in the development of EEC.

The child is at greater risk for tooth decay, mainly if it includes high levels of fermentable carbs. Inappropriate feeding practices can prolong the exposure to fermentable carbs, which may aggravate EEC’s chances.

Bottle feeding during bedtime or sleeping has been linked to children’s onset and development of rampant caries. S. mutans convert fermentable carbs into acid, which can demineralize enamel and dentin.

Systematic review studies have found that breastfeeding for more than a year and at night might be related to an increased prevalence of ECC.

Risk Factors

  • Frequent exposure to sucrose
  • Frequent snacking
  • Drinking sugary beverages to bed
  • Sharing food with adults
  • Caries risk of mother
  • Oral hygiene habits
  • Diet habits

Environmental Factors

Lack of good oral health practices promotes the development of ECC.

Children should start getting oral health care soon after the emergence of their baby teeth. Family social status, poverty risk, ethnic origin, years of schooling, and dental insurance coverage can also affect the oral health habits of youngsters and the severity of EEC.

Saliva and the enzymes excreted with it are essential to maintaining healthy teeth. Without it, your teeth will quickly begin to rot.

In addition, while eating, your tongue moves inside your mouth, helping you break down foods into smaller pieces.

Kids from lower socio-economic status are twice as likely to have dental carious compared to kids from higher income groups.


Early Childhood Caries (ECC) is an infectious process affecting the developing dentition of infants and toddlers.

The formation of cavities within the enamel surface of the teeth characterizes it. The etiology of ECCL is complex and involves multiple risk factors, including poor nutrition, lack of dental care, and inadequate parental supervision.

In addition, certain genetic predispositions may also play a role in the prevalence of ECC.

Although the exact cause of ECC remains unknown, it is believed that the combination of these factors leads to the initiation of the disease process. Once initiated, the progression of ECC can lead to severe consequences, including pain, infection, abscess formation, and ultimately loss of teeth.

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Dietary habits and feeding practices also play a significant role in acquiring the disease and the progression of dental caries. In addition, low fluoride levels in drinking water and poor dental care may contribute to the disease.

Children from lower socio-economic backgrounds, those living in refugee camps, and those born outside of developed nations are at increased risk of acquiring the disease.

These groups often suffer from malnutrition, social isolation, and cultural barriers to accessing adequate dental care.

ECC is a severe oral health issue, especially in underserved populations in both developed and undeveloped regions around the globe.

AAPD Caries Risk Assessment

The AAPD Caries Risk Assessment is based on systematic research reviews and expert panel recommendations that provide a better understanding of and recommendations for diagnostic, preventive, and therapeutic treatments.

Cavity risk is assessed at both the individual level and the tooth level. In addition, active surveillance (prevention therapies and close monitoring) of enamel lesions is possible when conditions are favorable.


  1. Dental caries-risk assessment should be a routine component of new and periodic examinations by oral health and medical providers based on a child’s age, social/behavioral/medical factors, protective factors, and clinical findings.
  2. While there needs to be more information to analyze risk assessment, children are grouped into different categories based on cavity risk.
  3. Based on a child’s age and caries risk, care pathways provide health providers with criteria and protocols for determining the types and frequency of diagnostic, preventive, and restorative care for patient-specific management of dental caries.

Source: AAPD Caries Risk Assessment


ECC consists of rampant tooth decay, and the diagnosis is a continuum. The initial cavity appears as a soft spot on the tooth surface. If the cavity is not remineralized (healed), it will progress into the dentin and pulp layer, causing irreversible harm.

ECC is recognized when rampant tooth decay occurs in children five years and younger. ECC is classified into three categories.


  1. Type I (mild to moderate) The existence of ‘isolated carious lesion(s)’ involving incisors and molars. The most common causes are a combination of semisolid or solid food and lack of oral hygiene.
  2. Type II (moderate to severe) ECC was described as ‘labiolingual lesions’ affecting maxillary incisors, with or without molar caries, depending on the child’s age and stage of the disease. Typically, the mandibular incisors are unaffected. The cause is an inappropriate use of a feeding bottle, at-will breastfeeding, or a combination of both, with or without poor oral hygiene.
  3. Type III (severe) ECC was described as carious lesions affecting almost all teeth, including the mandibular incisors. A combination of cariogenic food substances and poor oral hygiene causes this ECC.
Early Childhood Caries Management | My Dental Advocate
Source AAPD


Maintaining primary teeth in a healthy condition is essential for the infant’s overall health.

Primary teeth are needed for proper chewing, esthetic appearance, speech development, and preventing bad eating and drinking behavior.

Preventing the progression of ECC can be done through various methods, including restoratives, modifying dietary practices, educating the parent about decay-causing behaviors, maintaining good oral care, and applying fluoride products.

Treatment of ECC requires extensive restorative work and extractions of decayed teeth.

Anesthesia or sedation may be used during these procedures due to the inability of infants to tolerate the pain associated with them.

Antimicrobial rinses and varnishes containing chlorhexidine have demonstrated beneficial outcomes.

Fluoride has proven to be an effective method of preventing cavities.

It can be taken orally, topically, or professionally administered. Brushing teeth with fluoridated dentifrice (toothpaste) shows the most substantial benefit.

In addition, professional application of topical fluoride varnish shows similar results. Supervised use of fluoride rinse reduces dental caries in children.

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Prenatal care is an essential part of preventing early childhood caries. Clinicians should educate parents about keeping their child’s teeth healthy during pregnancy.

They should brush their baby’s gums daily and regularly clean their tongue. In addition, avoid feeding the baby sugary drinks and high-fermentable foods that will readily stick to teeth.

Early childhood cavities caused by bottle feeding are most often apparent in the top front teeth, as the nipple of the bottle prevents saliva from washing away the sugars from the top incisors.

However, the bottom front teeth may also be affected, though they are more protected by saliva and the tongue.

This condition is called “baby bottle syndrome.”

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Preventing “Baby Bottle Syndrome”

Putting your child to bed with a bottle filled with milk may give him some comfort and help him sleep, but it can also seriously damage his teeth.

Baby bottle tooth syndrome is the name given to tooth decay caused by using a baby bottle to soothe the child to sleep.

In addition, when a child falls asleep with a bottle full of milk or juice, some liquid from the bottle pools behind the sleeping child’s front teeth.

The bacteria that cause cavities then have all the time and sugars they need to erode the enamel on those tiny teeth.

According to the American Dental Association, these early childhood cavities are entirely preventable by doing a few simple things to ensure your child’s teeth are clean, healthy and robust.


  • If your child needs a bottle to fall asleep, or if you’re using a bottle as a pacifier during the day, fill it with water rather than milk, juice or any other beverage.
  • If your child falls asleep while feeding, remove the bottle as soon as you notice he’s no longer sucking.
  • Begin brushing your child’s teeth as soon as they erupt. Begin flossing his teeth as soon as he has two primary teeth touching.
  • Teach your child to drink from a cup rather than a bottle by about six months. Children should be weaned from the bottle by about one-year-old.
  • Bring your child to a pediatric dentist after his first tooth erupts. Your dentist can warn you of potential problems with your child’s teeth and gums.

Source: Colgate.com

Frequently Asked Questions (FAQ)


Early childhood caries typically affects the front teeth, especially the upper front teeth. This is because these teeth are the first to come in, and because they are used for biting and tearing food. However, early childhood caries can also affect other teeth, including the molars, which are the teeth in the back of the mouth used for grinding and chewing food. If left untreated, early childhood caries can lead to tooth decay in multiple teeth.

Some of the symptoms that a child with early childhood caries (ECC) may experience include the following:

  • Tooth pain or sensitivity
  • Difficulty with eating, speaking or learning
  • Swelling or redness of the gums
  • Bad breath
  • Visible holes or cavities in the teeth
  • White, brown, or black spots on the teeth

If your child is experiencing any of these symptoms, it is important to contact your dentist as soon as possible. Your dentist can diagnose the condition and recommend appropriate treatment, including filling cavities, removing decayed teeth, or providing other forms of care. Early treatment is important to prevent the condition from worsening and ensure that your child’s teeth and overall health are unaffected.

A dentist will first clean the affected teeth and remove any decay to treat ECC. The dentist may also apply a fluoride treatment to help strengthen the teeth and prevent further decay. Sometimes, a dentist must fill or crown the tooth to repair the damage. Good oral hygiene habits, such as brushing twice a day with fluoride toothpaste and limiting sugary foods and drinks, can help prevent ECC from developing in the first place.

My Experience & Expertise

ECC is a destructive childhood condition that affects millions of children worldwide. It is caused by bacteria that feed on sugar found in foods and drinks.

These bacteria cause cavities (holes) in your baby’s teeth. Cavities can make eating hard work and may lead to tooth loss. However, early diagnosis and treatment can help stop cavities from worsening and prevent them from causing problems later in life.

Need a second opinion? We can help! Learn more. Knowledge is power when cultivating healthy dental habits. The more informed you are, the better positioned you’ll be to prevent avoidable and potentially costly dental procedures for you and your family. Watch for future blog posts, where we’ll continue sharing important information, product reviews and practical advice!


About the Author

Dr. Matthew Hannan, also known as “Dr. Advocate,” is a board-certified dentist on a mission to provide accurate dental patient education. He attended Baylor University before completing dental school at UT Health San Antonio School of Dentistry. He now lives in Arizona with his beautiful wife and 4 kids. Dr. Hannan believes everyone should access easy-to-read dental resources with relevant, up-to-date dental research and insight to improve their oral health.

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