I discussed the arguments raised here with Dr Botser and he supplied me with
a more in-depth explanation which he has given me permission to pass on
here: anyone who wants to see the pictures he sent to me may e-mail me
privately.

Esther Shalom,
I will respond with a long explanation:

In order for a carious lesion to develop, several factors need to
co-exist:
1.Teeth
2.Bacteria
3.Sugar - carbohydrates
These factors need to exist together for a long period of time (or many
short periods of time). During this time the bacteria is using the sugar
and produces organic acids (primarily lactic acid). The organic acids
are capable of dissolving the tooth enamel. First there are
decalcification marks (white stains that can not be wiped off from the
tooth). After that frank cavitations of the enamel occurs.

I will refer now to each factor.
The tooth: the teeth start to develop during pregnancy and keep
developing until eruption. The teeth continue to mature after eruption
when mineral deposits continue to penetrate the porous new enamel.
Systemic insults to the fetus or baby may cause defects in the
developing tooth. These defects can be hypo calcifications or hypoplasia
of the tooth resulting in a tooth surface that is not smooth. A tooth
like that can be easily and rapidly hurt by the carious process.


The bacteria: We get our bacteria from our mother. Our mothers give us
the first stage of the immune system (via the placenta and after birth
via the breast milk by the IgA) since the mother does not have IgAs to
her own bacteria the baby also has no IgAs to the same bacteria.
The "bad" bacteria are the S. Mutans. These are "sticky" bacteria that
can reside only on hard tissues i.e. teeth. The colonization of the
mouth by the bacteria comes therefore only after the first tooth erupts.
The bacteria stick to the tooth by specific glucans that the bacteria
produces from the metabolic substrates. These substrates are the sugars.

Mothers with violent strand of S.Mutans bacteria will transmit the
violent bacteria to their children.
Dentists recommend mothers to undergo dental treatment before the
eruption of the baby's teeth in order to reduce the amount of bacteria
in the maternal saliva. This way the baby's infection by the bacteria
will be postponed.
The bacteria needs time to build up layers on the tooth surface- dental
plaque (several hours). Only after the tooth surface is covered by the
bacteria, does the acid production phase start. By brushing the teeth or
wiping them with gauze or cloth, we remove the sticky bacteria and
prevent them from producing the acid. Bacteria floating in the mouth or
on the gums can not cause caries. It can be swallowed or drift to a
tooth and start forming the dental plaque but it will take hours until
the plaque is actually formed.
A TOOTH WITH NO PLAQUE WILL NOT HAVE CARIES!!!
The nursing caries first attacks the smooth surfaces of the front teeth.
These surfaces can be easily cleaned.
Therefore I recommend (and to my knowledge all of the dental
professionals do) cleaning the teeth twice a day.

Sugar: Many carbohydrates can be used by the bacteria in the oral
environment. Some are highly fermentable and some are not. The breast
milk carbohydrate has low fermentablity but given enough time and amount
can be used by the bacteria to produce lactic acid.

Not every child will develop the same results from the same nursing
habits: a child with severe dental hypoplasia and violent bacteria will
develop a cavity faster than a healthy child with no bacteria and no
hypoplasia.

Caries in young children is termed ECC- Early Childhoods Caries. Before,
it was called baby bottle tooth decay -BBTD. but the term was not good
enough. Few children did not use the bottle but rather were breast fed.
So the term has been changed to Nursing Caries. ECC contains mostly BBTD
and some other cases of caries.
I will copy now the latest oral health policy of the American Academy of
Pediatric Dentistry (2001) referring to early childhood caries:
"The risk of potentially devastating nursing pattern dental caries
exists for the breast-fed child as it does for the bottle fed child, and
is related to extended and repetitive feeding times with prolonged
exposure of erupted teeth to fermentable carbohydrates without
appropriate oral hygiene measures".

To my understanding, lactation consultants see mostly very young
children. The carious lesion develops at older age and breast fed
children manifest lesser severity of the caries. Since not so many
children are only breast fed at this age and not every child will
develop caries (remember, we need all the factors together), there are
only few children with the nursing caries, and pediatric dentists treat
those affected children at the age of about 2 years.
As you know me, I am trying to promote breast feeding as much as I can,
but I think it is bad to dismiss the fact that frequently breast-feeding
a child with very poor oral hygiene can cause damage. This damage can be
easily prevented by good oral hygiene and dental assessment of children
at risk because of dental hypoplasia, violent bacteria or other risk
factors.
In my opinion the lactation consultant should advise the mothers about
oral hygiene and dental exam and not ignore the potential hazard.

Enclosed are pictures of children that I have treated at the O.R. These
children were not bottle fed, no frequent feeding other than breast
feeding and NO ORAL HYGIENE (note the layer of plaque on the teeth).
Let us prevent the next cases together.
Eyal

Esther Grunis, IBCLC
Lis Maternity Hospital
Tel Aviv, Israel

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