rian Palmer, D.D.S., Kansas City, Missouri, USA

The following notes will explain The Infant Caries Presentation and add to your understanding of the numbered slides.  It is suggested that you print this page of notes to read along with the presentation slides.  The Caries Presentation is in Portable Document Format, which requires the free Adobe Acrobat Reader. 

Slide number (bottom left corner)                      Comments 

#2 – Terminology can be confusing because various authors use it inter-changeably.  Example: Nursing caries (cavities) is used when discussing either bottle-feeding or breastfeeding activities that relate to infant caries.  Many assume that both bottle-feeding and breastfeeding can cause the same amount of decay.  Another term is Early Childhood Caries (ECC). 

#3 – The official position of the American Academy of Pediatric Dentistry (AAPD) in 1996.  The AAPD is a great organization, and since it is the national organization for pedodontists, they look to the association for leadership.  Because of new research that has come out since 1996, research that has even been published in their journal, it is hoped the association will consider changing it’s position statement. 

#4 – In 1996, it was the position of the AAPD that nocturnal breastfeeding should be avoided after the first primary tooth began to erupt.   But what options does that give the mother for nurturing the infant?  When the infant starts erupting his/her first primary tooth that infant may not be on an adult 3 meal-a-day schedule.  It is usually best to feed the infant on the infant’s cue, not on a fixed eating schedule contrived by our adult society.  The options would be: 1) Not feed the child or, 2) feed the infant formula.  Both are poor options.  Not feeding the child on cue is not good for the proper development of the child, and feeding the child formula puts that child at greater risk for decay – as discussed later in the presentation (Dr. Pamela Erickson’s research). 

#5 – Examples of infant caries  – Children Mercy Hospital in Kansas City does approximately 10 cases per week.   In a personal conversation with Dr. Cross in Winnipeg, Manitoba, Canada, he stated they do about 1200 cases per year, mainly on the Aboriginals in Manitoba.  He is finding a decay rate of about 89% in that culture. 

#6 – Note abscess above front tooth.  Lower front teeth are usually least affected by decay. 

#9 – Was this infant born with a high palate or was it acquired due to bottle-feeding or        thumb sucking?  Documenting how many infants are born with high palates would be a great research project – because a high palate is a risk factor for sleep apnea and possibly SIDS.  

#17 – In our society today (Year – 2000), infant caries is extremely high in some cultures or areas, especially in areas of poverty.   Prehistoric skulls, on the other hand, have/had minimal decay in their teeth.  They did not have the benefit of fluoride either.  Since breastfeeding was the only way of nurturing infants in the past, breastfeeding cannot be accused of causing dental decay today.   

#18 – Prehistoric infant skulls. These skulls were evaluated at the Smithsonian Natural History Institute in Washington, DC.   Minimal decay was found in teeth of prehistoric skulls.  Malocclusions (bad bites) were also rare.   Anyone in the world can do similar research by going to any museum that has skulls. 

#19 – Also note good width of palate and nice “U” shape of dental arches in these skulls.  Good arch width and shape are important for good occlusions.  High palates as shown in slide #8 were not observed during my evaluation of prehistoric skulls. 

#20 – Skull accidentally cracked in middle of palate.  During rapid palatal expansion in some orthodontic cases today, this is the area that separates during the expansion.  

#21 – Many prehistoric skulls do have flattened teeth due to course diets. 

#24 – Data put together by the staff at the Smithsonian.  Dentist on staff stated she is quite aggressive when she classifies decay.  These numbers, especially 19 lesions, may be over stated. 

#25 – This is a significant slide.  This research of 1989 concluded that the Native Americans in the study had a decay rate of 57%.  That sampling had a similar background genetically as the prehistoric skulls evaluated at the Smithsonian that had a decay rate of 1.4%.  Some of the previous slides in this presentation showing gross decay also had similar backgrounds and had a decay rate of 89%.  

#26 – I encourage others to evaluate skulls in museums around the world for decay and quality of occlusion. 

#27 – In discussions with anthropologists, veterinarians, mammalogists and biochemists, they cannot believe that anyone is actually accusing breastfeeding of causing decay.  It is not scientifically reasonable for a natural process like breastfeeding to cause teeth to decay.  If infants lost their teeth in the past they would die because of their inability to chew food.  They could have died as well from the possible infections that could have occurred when the teeth abscessed. That did not happen in the past. 

#30 – 35 – Defective teeth.  Defects can be due to genetics, malnutrition, disease, accidents, etc. during the time a tooth is developing. 

#37 – This infant was around 11 years of age (2nd molars were about ready to erupt).  Most likely all 4 of the decayed areas (2 cavities shown by one of the arrows) developed after the infant was weaned.     

#38 – #40 – “Pooling”.  During breastfeeding, the majority of milk is expressed into the throat.  During bottle-feeding, the majority of the content of the bottle is dumped into the mouth and “pools” around the teeth, leaving teeth more prone to decay. 

#41 – Lactose is a sugar – but it is naturally designed to be digested and broken down into its two sugars while in the lower intestine, not while it is in the mouth.  While in the breastmilk, it is surrounded and protected by antibodies, lactoferrin, etc. which protects it from Strep mutans.  Yes, it can be broken down on paper and on the lab bench to create sugars, but artificial situations do not take info account that the lactose is surrounded by the protective qualities of the breastmilk.   

#42 – Since breastmilk is the best source for calcium, and since calcium is needed for proper development of bones, teeth, etc., why would any health care provider discourage breastfeeding?  Milk is species specific.   Milk from other animals is designed for the young of that species – not the human species.   

#43 – There are 4640 species of mammals (Olaf Oftedal – National Zoological Park in DC).  Humans are but one of those species.  Isn’t it strange that only the human specie has infants with decay in their teeth?  Does that mean that the female of the human specie has inferior breastmilk compared to all other species?  Mammals in the wild rarely have deciduous decay.  Domesticated animals sometimes get decay – but that is mainly due to the fact that they are given food processed by humans.   

#44 – Check with your veterinarian to see if this is true.   Do they see wild infant animals with decay?  

#54 – Currently (2000-2001), Dr. Casamassimo is the president of the AAPD.   

#55 – Research shows that caries can be infectious.  When an infant is born, its mouth is basically sterile.  It does not have decay causing bacteria in its mouth.  The decay causing bacteria is “acquired” or “inoculated” at some point in its life.  It may be the timing and amount of the inoculation that determines the risk of decay. The infant could be inoculated by Strep mutans in many different ways -i.e.- kissing, using same spoon, etc.  Once exposed to Strep mutans, the critical issue then becomes how often the infant is exposed to sugar.  Frequency of exposure to sugar is more important than the amount of sugar.  A low bacteria count with many sugar exposures can be just as cariogenic as a high bacteria count and less sugar exposure. 

#57 – Saliva has a protective effect by bathing or washing the teeth.   Less saliva production at night, or mouth breathing due to nasal congestion, airway obstructions, enlarged tonsils, polyps, etc., can dry the teeth and makes them more prone to decay. 

#59 – This Gardner et al. article may be first article written discussing the relationship between breastfeeding and the risk of infant caries.  The article appears to have logic, and the relationship seems apparent, but the authors did not report doing in-depth evaluation of what went into the infant’s mouth other than breastmilk.  It may have been only the mother’s opinion that the infant did not receive cariogenic food or drink.  The article has been referenced in many other articles on infant caries. This is an example of an article that demonstrates guilt by association.  

#61 – If breastmilk can kill cancer cells, it should be able to kill bacteria that cause decay.  Stomach acid may be the key to the activation of this fantastic benefit of breastmilk. 

#62 – Dr. Slavkin states that population-based studies do not support a link between breastfeeding and caries.  It is a very strong and influential statement coming out of the National Institute of Health.  I strongly agree with his statement.  Many of the articles accusing breastfeeding as a cause of infant decay have been population-based studies.  

#63 – After extensive evaluation of multiple articles, Dr. Joyce Sinton et al also made a similar statement as made by Dr. Slavkin.  They found many of the studies had contradictory findings and weak methodology.  I strongly agree with their research as well.  I have been unable to find any scientific research in which teeth and breastmilk have been placed together which resulted in decay.  If anyone has knowledge of such research, I would appreciate a copy of the article. 

#64 – Dr. Pamela Erickson’s article on infant formula.  This is an important article for those who recommend not breastfeeding and giving formula instead. 

The article concludes that:

– some formulas are quite cariogenic
– some formulas dissolve enamel 
– most reduce pH significantly (this makes the mouth more acidic and teeth more prone to decay)
– some caused dentinal caries within weeks
– some supported significant bacterial growth 

With this kind of scientific research, why would any health care provider recommend formula over breastmilk?   For this research, Dr. Erickson received the AAPD – Educational Foundation Research Award  (first place). 

#65 This is one of the best scientific research articles proving that breastmilk alone does not cause infant caries.   For this research, Dr. Erickson was runner up for the 1998 AAPD award.  

#66 – Conclusions of Dr. Erickson’s research:

1) – Human breastmilk (HBM) actually deposits calcium and phosphorus onto enamel.

2) – HBM does not cause a significant pH drop in plaque

3) – HBM is not cariogenic UNLESS another carbohydrate source is available for bacterial fermentation. 

4) – The buffer capacity of HBM is very poor

5) – HBM supports moderate bacterial growth.

 Comments on these conclusions:

1) – This point demonstrates that HBM actually PREVENTS decay.

2) – This point also helps in the prevention of decay.  A pH drop would increase the risk of decay.

3) – I do not quite understand the reason for linking these two points with an UNLESS.  It states HBM is not cariogenic.  Since nocturnal breastfeeding appears to be the biggest issue as to when decay occurs, is this point suggesting the mother is going to let the infant “sip” on the breast, then “sip” some soda pop, and then alternate back and forth?  When is this OTHER carbohydrate supposed to be introduced during breastfeeding at night?

4) – Buffer capacity – (Definition: amount of a liquid required to bring about a pH change).  As stated above, our creator designed HBM to be a perfect food.  I believe it has a poor buffer capacity so that it will not alter the stomach pH, and thus helps with the digestibility of the breastmilk itself.  The acidity of the stomach may also be the key factor that helps breastmilk kill cancer cells as stated in Svanborg’s research.  I do not believe it was designed to contribute to tooth decay as suggested by some.

5) – Reason why stored breastmilk needs to be refrigerated.    

Our ultimate creator designed breastmilk to be the perfect food for the young of all 4640 mammal species.  The young of ALL mammals, except the young of humans, grow, develop and flourish on breastmilk without developing decay in deciduous teeth.  Human breastmilk is not inferior to that of all other species.     

#67 – Exciting conclusion – HBM is not cariogenic.  It is significant that this research was recognized for its importance by the AAPD.   

#69 – Main reason for decay – sugar – frequency is more important than amount – timing and amount of inoculation of Strep mutans – saliva flow  – enamel defects – oral hygiene – eating habits – sugary medicines. 

#70  – “Store bought food has given us store bought teeth”.  Hooton recognized that in 1938. 

#71 – Breastmilk alone does not cause tooth decay – but exclusive breastfeeding does not mean that the infant will be immune from decay.  Anything that is put in the mouth that can be broken down into a sugar can cause decay – even healthy foods.  Many infants start getting supplemental foods around 6 months, often times before many of the deciduous teeth have even started to erupt.  

#73 – It is now time to educate both parents and health care providers that breastmilk does not cause decay.  I understand the position of the AAPD.  Like many other dentists, I have seen or heard of infants who have decay and their mothers have insisted that the infant has only been breastfed.  But are these mothers really aware of what is going into the infant’s mouth?  At what age are these infants started on supplemental foods?  Even formula can cause decay!  So can juices, and so can cereals! 

Here are a few cases I have addressed where the mother insisted her infant had decay even though the child had only been breastfed, or had never been given any foods or snacks that would cause decay: 

1) – After an extensive discussion, I asked the mother if the child had ever been ill.  She replied the infant had a problem with constipation.  For this problem, she had been giving the infant a cup of prune juice every day, with the infant sipping on it all day long.  Source of decay – probably the prune juice.  Mother’s focus had been on the constipation and she never realized the cariogenic potential of the prune juice.  

2) – After an extensive discussion, the mother finally admitted to the child snacking during the day on her homemade bread.  She believed that since she baked the bread herself from scratch, and that it was a healthy food, it would not cause decay.  Bread can cause decay if it is home made or store bought. 

3) – Another mother insisted she only gave her infant diluted juices.  She reasoned that since she diluted the juice, it would not cause decay.  Juice at any concentration has the potential to cause decay if decay causing bacteria is in the mouth. 

4) – A mother was shocked that her infant had decay.  This case was easy.  While I was talking with the mother, the infant was continually snacking on a cereal.  The cereal was a very healthy breakfast cereal – but it can also cause decay if snacked on.  Frequency of exposure was critical here. 

5) – I talked with another mother for quite a while but was unable to find a cause for the infant’s decay based on foods or sickness.  I then inquired about the health of her mouth and that of her husband.  She admitted they both had periodontal and decay problems.  From that statement I felt the parents did not have good home care or good diet – and that being the case – the cleanliness of the infant’s mouth reflected that of the parents.  ANY food put into that infant’s mouth was potentially highly cariogenic.   

I believe the main reason the AAPD has the position it has, is due to the fact that some mothers whose infants have decay insist that the infants have only been breastfed, but in actuality, have given other foods or snacks to the infants.  I believe this happens not from neglect, but because the mothers believe foods or juices, etc. that have been given to the infants are healthy and would not cause decay.  They have not been educated enough to understand that nearly any food, snack, juice, sweetened medications, etc. does have the potential to cause infant decay.  It is also important to understand that parents who are prone to get cavities or have gum disease can also put their infants at risk for caries.  This is NOT a genetic problem, but rather an environmental problem of poor oral hygiene and poor eating habits. 

The solution.  For a better understanding of the true cause of infant caries, the following recommendations are suggested:

 1) – In-depth examinations and evaluations of all care-givers who might possibly contaminate the infant.  It may be necessary to take strep mutans cultures on all.  It is important to note the caries rate and periodontal condition of the parents.  If their hygiene is poor, it is very likely the infant’s hygiene is poor also.  Note hypocalcified areas, possible genetic features, etc. 

2) – In-depth histories as to illnesses, stresses, and other challenges of both the infant and mother all the way back to the time of conception. 

3) – In-depth dietary analyses of the infant and family members.  EVERYTHING that goes into the infant’s mouth needs to be documented, even medicines.  This information needs to be written done as it occurs.  A mother’s recall at the end of the day or week is not good enough. 

Only with these type in-depth evaluations will the issue of infant caries be resolved.  Population based research and guilt by association research are not appropriate for such an important issue.  

The purpose of this presentation:

1) – Help educate anyone in the world who is interested in the oral health of his or her child.

2) – Educate all that breastmilk alone does not cause caries.  Breastfeeding IS the best form of health care (I will prove this with other presentations on this website)


Brian Palmer, D.D.S.