July 25, 2017

Dr. Hardy Limeback BSc PhD (Biochemistry) DDS — Fluoridation and baby bottle tooth decay

Fluoridation and baby bottle tooth decay

Can breast feeding cause early childhood caries (rampant dental decay in toddlers)?
Does fluoride in the drinking water reduce the incidence of early childhood caries?
Can adding fluoride to drinking water reduce the prevalence or severity of baby bottle tooth decay?

Some background

When I first announced that I was publicly opposed to water fluoridation I received many heated phone calls and emails from upset dental care professionals, even from friends. I was distraught. My dental office routine was disrupted. My family was negatively affected (my wife is my dental office manager). I discovered that criticizing fluoridation produced a lot of emotional and negative reactions within the dental community.

I received an email from a dental hygienist working for public health in the province of BC (almost the entire province is unfluoridated). She sent me a picture of baby bottle tooth decay and asked how I could be against fluoridation when there were so many toddlers suffering from rampant dental decay. The reaction was understandable since that dental hygienist probably did not know that fluoridation does little to help toddlers with baby bottle tooth decay (more below…)

When I was invited to Salem, Oregon to help the citizens fight a mandatory water fluoridation bill, a pediatric dentist showed a video of a screaming toddler who was being treated for rampant dental decay. It was a clear attempt to elicit sympathy from the audience … and it did.

Parents don’t want their kids to suffer. Videos intended to pull on the heart strings of parents are effective. Videos and photos of toddlers with rampant dental decay are often shown at hearings where the city council or citizens have to decide on the policy of whether or not to add fluoridation chemicals to the drinking water. In my opinion, the tactic of using a traumatic dental visit where a toddler with baby bottle tooth decay has to have several teeth repaired at once is disingenuous and merely a scare tactic.

Breast vs. bottle milk

Prehistoric dental decay in children

Baby bottle tooth decay and early childhood caries are modern diseases. Dr. Brian Palmer, who recently passed away, was a dentist in Kansas who studied the benefits of breast feeding in relationship to jaw development and early childhood caries. He went to the Smithsonian Natural Museum in Washington D.C. to examine the skulls of prehistoric Native Americans. Out of 1344 ‘baby teeth’, only 1.4% had any signs of decay. Only FOUR teeth had large cavities. The following is a typical image of the prehistoric native infant found in the Plains of South Dakota.

http://www.brianpalmerdds.com

Breast milk never did cause any tooth decay in prehistoric children. It was Dr. Palmer’s contention that “It would be evolutionary suicide for breast milk to cause decay.”

It is now well known that indigenous populations eating processed food (a ‘western diet’) have dental decay problems. Decay rates are extremely high now in some regions where aboriginal people live, largely if not entirely because of the change in diet from the ‘hunter-gatherer’ traditional diet to one of processed food high in sugars and low in nutrition. This was well documented in the book by Weston A. Price, first published in 1939 (Nutrition and Physical Degeneration, 6th edition, Price-Pottenger Nutrition Foundation). I personally experienced how difficult it was to manage dental decay problems in children when I worked as a young dentist in the Sioux Lookout region near James Bay in Ontario. I was told by the local nurse practitioner that families were in the habit of putting their toddlers to bed with a bottle filled with sugar water or cola soft drinks, because they could not afford to purchase fresh cows’ milk or formula powder.

Why the baby bottle damages teeth

Baby bottle tooth decay can be very serious. As shown in this example image, graciously provided with permission from Dr. Palmer’s widow, one can see how every single baby tooth has severe tooth decay. A number of those baby teeth would have to be extracted because they are infected.

Baby bottle tooth decay

Most mothers realize that putting babies to bed with a bottle containing sugary drinks is a mistake. Even milk from a baby bottle can cause severe dental decay because of the natural sugar content. Milk contains the disaccharide lactose. It isn’t as dangerous as table sugar (sucrose) but it still can cause tooth decay.

The difference between breast milk and the baby bottle, according to Dr. Palmer, is that the baby requires some effort to ‘latch on’ and work with a forceful sucking motion to express the breast milk. Breast milk is expressed further in the back of the oral cavity past the teeth. With commercial bottles, there is no effort to drink milk from the rubber nipples, which tend to leak resulting in the pooling of milk on the teeth as baby falls asleep. Once asleep, saliva flow diminishes and does not fight off the acid produced by the metabolism of lactose by plaque bacteria. Furthermore, there are important anti-cavity factors that are in human breast milk (Erickson & Mazhari, 1999).

Research shows that prolonged nighttime feeding with breast milk does not increase the risk for ‘nursing caries’ (I find the term nursing caries to be a misnomer because some dentists believe that early childhood caries can be caused by nighttime feeding at the breast). The large National Health and Nutrition Examination Survey (NHANES) study in the US concluded: “these data provide no evidence to suggest that breastfeeding or its duration are independent risk factors for early childhood caries, severe early childhood caries, or decayed and filled surfaces on primary teeth.” Iida (2007)

Weerheijm (1998) reported that in Holland “… prolonged demand breast-feeding does not lead to a higher caries prevalence”

In the UK, Cartwright argued that breast milk does not cause dental decay.

Nunes (2012) reported that, “the present results showed that prolonged breast-feeding was not a risk factor for ECC after adjustment for a handful of important confounders.”

In fact, from the largest lactation study ever conducted it was concluded that, “Extended breast feeding (to 12 mo.) did not provide any significant benefit or harm” (Kramer et al, 2007).”

Abbey expressed this position in an article in the Journal of the American Dental Association as early as 1979 and yet the American Dental Association continues to offer the following statement on their website: “Unrestricted, at-will nocturnal breastfeeding after eruption of the child’s first tooth can lead to an increased risk of caries”. http://www.ada.org/2057.aspx

What else causes early childhood tooth decay?

We know breast milk doesn’t cause early childhood dental decay but putting the baby to bed at night with a bottle filled with sugary liquid or even milk can cause rampant dental decay.

What are other reasons why toddlers get rampant tooth decay?

About 5 toddlers/preschoolers out of 100 have severe dental decay (Al-Jewair & Leake, 2010).

This prevalence seems to have increased recently in 2-5 year olds (Kagihara et al. 2009)

There are many risk factors that predispose a preschooler to dental decay in the primary dentition. These include
1. low vitamin D levels (Schroth et al, 2012)
2. enamel defects (Caufield et al, 2012),
3. second hand smoke (Hanioka et al, 2011)
4. social disparities which result in more frequent sugar intake, more soda pop intake, less milk consumption, and less access to dental services (Vadiakas, 2008; Mobley et al, 2009).

Severe dental decay can occur even when the above risk factors are not present

Once the child is weaned off the bottle or breast and introduced to ‘adult’ foods, the risk for caries increases. Substituting milk for juices is the first obvious problem because of the loss of calcium intake and a switch to the more destructive sugars fructose and, in most cases, added sucrose. Allowing the child to have on demand access to drinks sweetened with sucrose through a ‘sippy cup’ increases the risk even further. Lack of oral hygiene and increased consumption of other carbohydrates rather than foods rich in protein and fibre, compounds the problem. Of course, many toddlers who express their dissatisfaction through crying are often ‘comforted’ by treats sweetened with sugar. So often I see parents capitulating to a crying child at the check-out counter in the grocery stores offering that child a candy or chocolate treat to avoid the stress and embarrassment of the child causing a disturbance in a public place. Dentists often report preschoolers coming to the office with chocolate bars in hand. Parents admit to using candy treats at every turn to ‘bribe’ their kids. On top of all this, medications administered at nighttime are laced with sugar (to entice the preschoolers to take them).

No wonder that the dental profession thinks we need fluoridation. But will fluoridation at 0.7 ppm really help early childhood caries? Not according to the research literature.

Fluoridation does little to reduce Early Childhood Caries

Looking at the children in the Head Start Program in the US, Barnes discovered that, “children attending centers showed no significant differences based on fluoride status for the total sample or other variables.” (Barnes et al, 1992).

Howard Pollick, a profluoridation spokesperson for the American Dental Association, has written articles in favour of fluoridation but in this study which he co-authored, it was reported that fluoridated water had no influence on early childhood caries. “Our analysis did not appear to be affected by whether or not children lived in an area with fluoridated water.” (Shiboski et al, 2003).

Community water fluoridation did not appear to provide a cost benefit in the UK (Kowash et al, 2006).

In Brazil, living in a fluoridated community did not make any difference in early childhood caries (Tiano 2009).

However, in a recent small study in Australia, fluoridated water used in infant formula reduced caries risk marginally but only in those infants fed longer than 6 months (Do et al, 2012). It must be remembered that infant formula made with tap water increases the risk of dental fluorosis (see blog on fluorosis) and fluorosis is associated with lowered intelligence (Choi et al, 2012).

Even if there were small positive effects on baby bottle tooth decay by living in a community with fluoridated water, the other health risks from ingesting fluoride are not worth it.

A much more effective way to reduce early childhood caries is to educate low income families on how to prevent it (Feldens et al, 2010)

New moms, once empowered with science-based knowledge, will do everything in their power to properly protect their kids from the pain and suffering that rampant caries brings. No mother wants to see her child placed under general anesthetic and then pay thousands of dollars in dental repair costs.

Rather than put millions of dollars into fluoridation programs, cities would be better off providing oral health education, dietary advice and assistance to families in need.

Challenge to the reader: If there is a new mom in the family, send her the link to this blog so that she can read about how important breast feeding is and how damaging it is to allow babies to sleep with a bottle in their mouth. Confront health care professionals who believe water fluoridation will prevent baby bottle tooth decay, and also send them the link to this blog.

Take home message for the reader: Breast milk does not cause decay in baby teeth and water fluoridation does not prevent baby bottle tooth decay.

References:

Abbey LM (1979) Is breast feeding a likely cause of dental caries in young children? J Am Dent Assoc. 98(1):21-3.

Al-Jewair TS, Leake JL. (2010) The prevalence and risks of early childhood caries (ECC) in Toronto, Canada. J Contemp Dent Pract. 11(5):001-8.

Barnes GP, Parker WA, Lyon TC Jr, Drum MA, Coleman GC. (1992) Ethnicity, location, age, and fluoridation factors in baby bottle tooth decay and caries prevalence of Head Start children. Public Health Rep. 1992.

Cartwright A. (2008) Breast is Best. British Dental Journal 204: 351 – 352.

Caufield PW, Li Y, Bromage TG. (2012) Hypoplasia-associated severe early childhood caries–a proposed definition. J Dent Res. 91(6):544-50.

Choi AL, Sun G, Zhang Y, Grandjean P. (2012) Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis. Environ Health Perspect. Jul 20. (Ahead of print)

Do LG, Levy SM, Spencer AJ. (2012) Association between infant formula feeding and dental fluorosis and caries in Australian children. J Public Health Dent.72(2):112-21.

Erickson PR, Mazhari E. (1999) Investigation of the role of human breast milk in caries development. Pediatr Dent. 21(2):86-90.

Feldens CA, Giugliani ER, Duncan BB, Drachler Mde L, Vítolo MR.(2010) Long-term effectiveness of a nutritional program in reducing early childhood caries: a randomized trial. Community Dent Oral Epidemiol. 38(4):324-32.

Hanioka T, Ojima M, Tanaka K, Yamamoto M. (2011) Does second hand smoke affect the development of dental caries in children? A systematic review. Int J Environ Res Public Health. 8(5):1503-19.

Iida H, Auinger P, Billings RJ, Weitzman M. (2007) Association between infant breastfeeding and early childhood caries in the United States. Pediatrics. 120(4):e944-52.

Kagihara LE, Niederhauser VP, Stark M. (2009) Assessment, management, and prevention of early childhood caries. J Am Acad Nurse Pract. 21(1):1-10.

Kim Seow W. (2012) Environmental, maternal, and child factors which contribute to early childhood caries: a unifying conceptual model. Int J Paediatr Dent. 22(3):157-68.

Kowash MB, Toumba KJ, Curzon ME. (2006) Cost-effectiveness of a long-term dental health education program for the prevention of early childhood caries. Eur Arch Paediatr Dent. 7(3):130-5.

Kramer MS, Vanilovich I, Matush L, Bogdanovich N, Zhang X, Shishko G, Muller-Bolla M, Platt RW. (2007) The effect of prolonged and exclusive breast-feeding on dental caries in early school-age children. New evidence from a large randomized trial. Caries Res 41(6):484-8.

Mobley C, Marshall TA, Milgrom P, Coldwell SE. (2009) The contribution of dietary factors to dental caries and disparities in caries. Acad Pediatr. 2009 9(6):410-4.

Nunes AM Alves CMC, Arau´ jo FB, Ortiz TML, Ribeiro MRC, Silva AAM, Ribeiro CCC. (2012) Association between prolonged breast-feeding and early childhood caries: a hierarchical approach. Community Dent Oral Epidemiol. Online Jun 23 (ahead of print).

Schroth RJ, Jeal NS, Kliewer E, Sellers EA. (2012) The relationship between vitamin D and severe early childhood caries: a pilot study. Int J Vitam Nutr Res. 82(1):53-62.

Shiboski CH, Gansky SA, Ramos-Gomez F, Ngo L, Isman R, Pollick HF. (2003) The association of early childhood caries and race/ethnicity among California preschool children. J Public Health Dent. 63(1):38-46.

Tiano AV, Moimaz SA, Saliba O, Saliba NA. (2009) Dental caries prevalence in children up to 36 months of age attending daycare centers in municipalities with different water fluoride content. J Appl Oral Sci. 17(1):39-44.

Vadiakas G. (2008) Case definition, aetiology and risk assessment of early childhood caries (ECC): a revisited review. Eur Arch Paediatr Dent. 9(3):114-25.

Weerheijm KL, Uyttendaele-Speybrouck BF, Euwe HC, Groen HJ. (1998) Prolonged demand breast-feeding and nursing caries. Caries Res.32(1):46-50.

 

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