Baby Bottle Tooth Decay

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Baby bottle tooth decay (BBTD) is a type of early childhood caries (ECC) that affects primary teeth. BBTD is attributed to prolonged bottle feeding, usually during sleep, of cariogenic liquids, such as milk. It occurs in young children who have inadequate dental plaque removal. Some reports suggest that good oral hygiene can delay or prevent BBTD, even when prolonged feeding occurs. BBTD is alternatively called nursing bottle mouth, baby bottle caries, or baby bottle syndrome.

While the etiology of BBTD is still controversial, animal models suggest that milk alone is not causative. Other liquids such as juices, carbonated drinks, and fruit-flavored drinks can support a pattern of decay identical to BBTD. Most experts would attribute BBTD to the combined precipitating factors of a cariogenic liquid containing sugar, susceptible dentition, and the presence of cariogenic microorganisms such as Streptococcus mutans. Identical caries patterns have been reported to occur with prolonged or frequent breastfeeding or feeding with a transitional container such as a "sippy cup."

BBTD has a characteristic clinical pattern, but a strict definition is not agreed upon. The following are indicators of BBTD:

  1. Decay in two or more of the maxillary primary incisors (top front teeth).
  2. The mandibular incisors (bottom front teeth) are generally not affected.
  3. Other primary teeth, may also show decay.
  4. Dental caries on tooth surfaces usually considered resistant to decay, such as the facial and/or lingual surfaces of the teeth.
  5. Rapid and early occurrence of dental caries in the life of the primary teeth.

The prevalence of BBTD varies among different populations. It ranges from about 5 percent in the general population to well over 50 percent in selected groups such as Native Americans and some immigrant groups. Within low-income groups, prevalence is about 20 percent, according to some studies. Risk factors that predict BBTD are inadequate plaque removal, a diet rich in cariogenic liquids, and prolonged or frequent feedings with cariogenic liquids. Secondarily, studies have implicated parental lifestyles and ignorance of the condition, child behavioral and sleep problems, a need for frequent feedings, and virulent microflora as additional risk factors.

Prevention of BBTD aims to eliminate risk factors and includes education of parents about causality; the use of alternative liquids such as water for night feeding; substituting another object for the bottle, such as a pacifier or toy; weaning a child from the bottle; and daily plaque removal. Secondary prevention involves the use of home-applied topical fluoride in dentifrice or gel form or office-applied fluoride varnish to halt the decalcification of incipient carious lesions, and, if needed, restoration of early lesions with a material such as a dental cement or composite resin. These often have a fluoride-release capability. Once affected with BBTD, a child remains more susceptible to recurrent dental caries throughout the primary dentition. Several studies suggest that even intensive use of existing preventive therapies will not alter a child's susceptibility to recurrent dental caries after having experienced BBTD.

Paul S. Casamassimo

(see also: Caries Prevention; Maternal and Child Health; Oral Health )


Edelstein, B. L., and Douglass, C. W. (1995). "Dispelling the Cavity-free Myth." Public Health Reports 110:552530.

Isman, R. (1988). "Baby Bottle Tooth Decay." California Pediatrician Spring:3942.

Ripa, L. W. (1988). "Nursing Caries: A Comprehensive Review." Pediatric Dentistry 10:268282.

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Baby Bottle Tooth Decay

Baby bottle tooth decay occurs in young children when their teeth or gums are exposed to infant formula, milk, juice, or other sweet drinks for long periods of time. This often happens when infants or toddlers fall asleep while sucking on a bottle. Breastfed infants are usually not at risk, unless they feed for extended periods. The carbohydrates in the drink (lactose in milk, or fructose in fruit drinks) mix with the normal bacteria in the mouth. This bacteria is found in the plaque on teeth and gums. When plaque mixes with carbohydrates, acids are formed that dissolve tooth enamel, causing tooth decay and dental caries . To prevent baby bottle tooth decay, a child should not be put in bed with a bottle; and the bottle should be taken away as soon as mealtime is over. Further, only formula or water should be put in a bottle; juices and sweet drinks should be offered in a cup.

see also Infant Nutrition; Oral Health.

Heidi J. Silver


American Dietetic Association (1996). "Oral Health and Nutrition: Position of the American Dietetic Association." Journal of the American Dietetic Association 96:184189.

Johnsen, D. and Nowjack-Raymer, R. (1989). "Baby Bottle Tooth Decay (BBTD): Issues, Assessment, and an Opportunity for the Nutritionist." Journal of the American Dietetic Association 89:11121116.

Internet Resource

American Academy of Pediatrics. Baby Bottle Tooth Decay. Available from <>

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