Early childhood caries (ECC) — sometimes called baby bottle decay or nursing bottle caries — is one of the most common chronic diseases of childhood in Australia, affecting around 1 in 4 children by age 5. It is also one of the most preventable. At Dentist Pymble, we see children with early childhood caries at our practice, and the conversations we have with parents are usually about how it happened and how to stop it from getting worse. This page covers what ECC is, what causes it, the signs to look for, how we treat it, and the practical steps to prevent it.

What is early childhood caries (ECC)?

Early childhood caries is a specific pattern of dental decay that affects the primary (baby) teeth of young children. The most common pattern is decay on the upper front teeth (the ones most exposed to liquids in a bottle or while breastfeeding), often extending to the back teeth. The lower front teeth are usually spared, because the tongue and the lower lip protect them during feeding.

The pattern is so consistent that the diagnosis is usually clinical, without the need for extensive investigation. The child is usually under 5, has visible decay on the upper front teeth, has a history of bottle use or breastfeeding on demand, and often has associated decay on the back teeth. The severity ranges from small white spots (early demineralisation) to extensive decay with pain, infection, and difficulty eating.

What causes baby bottle decay?

The cause is repeated, prolonged exposure of the teeth to sugary or acidic liquids. The most common scenarios:

• Bottle in bed — putting a child to bed with a bottle of milk, formula, juice, or any sweetened liquid means the liquid pools around the teeth for hours. The bacteria in plaque ferment the sugars and produce acid, which dissolves the enamel.
• On-demand breastfeeding — particularly breastfeeding throughout the night after the teeth have erupted. Breast milk contains lactose, which the bacteria can ferment.
• Sippy cups with sugary drinks — using a sippy cup for juice, soft drink, or flavoured milk throughout the day exposes the teeth to repeated acid attacks.
• Sweetened medications — some children’s medications (antibiotics, antihistamines) are sweetened with sugar. Frequent dosing can contribute to decay.
• Bacterial transmission — the bacteria that cause decay (mainly Streptococcus mutans) are usually acquired from the parents or caregivers in the first few years of life. Sharing spoons, cleaning a dummy in the parent’s mouth, or pre-tasting food can transfer these bacteria to the child.

The common thread is prolonged contact between the teeth and fermentable sugars. Anything that reduces that contact (water between meals, ending feeds before sleep, brushing twice a day) reduces the risk.

Signs of early childhood caries

The signs progress as the disease progresses:

• White spots on the upper front teeth near the gum line (the earliest visible sign)
• Yellow or brown discolouration of the enamel as the demineralisation progresses
• Visible holes or pitting in the teeth as the enamel breaks down
• Sensitivity or pain when eating or drinking, particularly sweet, hot, or cold things
• Swelling or abscess in the advanced stages, indicating infection

By the time the child is showing pain or swelling, the disease is well advanced and treatment is more complex. The earlier the disease is caught, the more conservative the treatment can be. This is why the first dental visit by age 1 is so important, even if there are no obvious problems.

How is ECC treated?

The treatment depends on the severity and the age of the child:

• Early stage (white spots only) — fluoride varnish, dietary advice, improved oral hygiene. Often enough to halt the disease and allow the enamel to remineralise.
• Moderate stage (visible decay without pain) — small fillings or stainless steel crowns on the affected teeth, often under local anaesthetic. For very young or anxious children, treatment under general anaesthesia in a day-stay hospital setting is sometimes needed.
• Advanced stage (pain, infection, abscess) — extraction of the affected teeth, with or without a space maintainer to hold the space open for the adult tooth. For very young children with extensive disease, treatment under general anaesthesia is often the kindest and most effective option.

The treatment is always combined with prevention. Without addressing the cause (diet, bottle use, oral hygiene), the disease will recur in the remaining teeth. We will always talk through the underlying causes with you and help you put in place the changes that will stop the cycle.

How to prevent baby bottle decay

The prevention is mostly the unglamorous basics done consistently:

• No bottle in bed — if the child needs a bottle to settle, fill it with water only. Milk, formula, and juice should be finished before the sleep.
• Water between meals — water is the only drink that does not contribute to decay. Juice, soft drink, and flavoured milk are treats, not everyday drinks.
• Brush twice a day — from the eruption of the first tooth, brush with a soft baby toothbrush and a rice-grain amount of fluoride toothpaste. From age 3, a pea-sized amount.
• Fluoride varnish — for high-risk children, fluoride varnish applications every 6 months reduce the risk of decay significantly.
• Limit sugar — particularly between meals. Frequent sugar exposure is worse than the same amount of sugar consumed at once.
• Avoid bacterial transmission — don’t share spoons with the child, don’t clean a dummy in your mouth, and make sure other carers (grandparents, daycare) follow the same approach.

When to start cleaning baby teeth

From the eruption of the first tooth, which is usually around 6 months of age. Before the teeth come through, a clean damp cloth wiped over the gums after feeds is a good habit to establish. Once the teeth erupt, switch to a soft baby toothbrush and a rice-grain amount of fluoride toothpaste. From age 3, increase to a pea-sized amount. From age 6 or 7, the child can start brushing under supervision, with the parent doing a final clean until the child is around 8-10 and has the dexterity to do a thorough job on their own.

Our preventative dentistry service at the Pymble practice includes all of the above, with age-appropriate advice at every stage. We see neighbouring Gordon patients and other nearby families, and the first visit is always a free conversation about what your child needs and when.

Frequently asked questions

At what age should my child first see the dentist? By their first birthday, or within 6 months of the first tooth appearing, whichever comes first. The first visit is mostly about parent education and getting the child comfortable, and it sets the stage for a lifetime of comfortable dental care.

Is bottle decay the parents’ fault? No. Most parents are doing the best they can with the information they have, and the cause of early childhood caries is usually a combination of factors. The honest answer is that the prevention is well understood, and the right support from the dentist and the family can stop the cycle. We are here to help, not to judge.

Can baby teeth with decay be saved? Often, yes, particularly if the decay is caught early. Small fillings and stainless steel crowns are routine in paediatric dentistry. For very advanced cases, extraction may be the best option, particularly if the tooth is due to come out soon anyway.

Will the adult teeth be affected? In most cases, no. The adult teeth develop in a protected environment inside the bone, and the decay in the baby teeth does not usually spread to them. The main risk to the adult teeth is from abscess or infection in the baby teeth, which can damage the developing bud. Early treatment prevents this.

My child won’t let me brush their teeth. What should I do? This is one of the most common challenges of parenting. The most useful tips: make it a game, brush together, let them hold the brush, use a sticker chart, and persist. The alternative — not brushing — leads to decay, which is harder to fix than a few minutes of resistance at the toothbrush. The dentist can also help with strategies at the check-up.