Early Childhood Caries

This is Joao. He is six years old. He lives with his grandparents in a little house just down the way, and he regularly comes over to our casita to play. He talks incessantly, asks a lot of random questions, and has some interesting ideas about the US that he picked up from movies he is way too young to watch. These include a belief that Godzilla is real (for real, real) and that zombies regularly roam the streets of the US. I cannot even tell you how many times he and I have discussed these two topics.

Joao loves our walkie talkies and Friday pizza night. He also enjoys the Legos and art supplies. He asks for help to do simple drawings and to put together a basic Lego creation; I think he lacks confidence and experience to try himself. He drives Jonah a bit crazy because he can be reckless. He tends to destroy things, not out of malice, but some combination of clumsiness and carelessness.

His adorable puppy is Lulu. Joao loves Lulu deeply, and the feeling is quite obviously mutual. Joao calls to her, and she comes bounding up the little hill below our house as soon as she hears him, tackling him with kisses and nibbles until he picks her up. Today, she fell asleep within seconds of being in his arms sitting in our hammock. We're pretty sure she's responsible for a number of missing shoes from our front porch.

Joao is a sweet kid with terrible teeth.

Joao has early childhood caries or ECC -- extensive dental decay of his baby teeth. I did my Master's thesis years ago on early childhood caries in rural communities in El Salvador, small communities not unlike the one we are currently living in Ecuador. Unfortunately, ECC is a worldwide phenomenon. In fact, ECC is the most common pediatric infectious disease in the world. ECC is caused by the trifecta of 1) streptococcus mutans, a virulent bacteria in the mouth, generally transferred from mothers' mouths in infancy to their babies 2) a diet high in simple sugars, and 3) vulnerable teeth, caused by many factors including poor perinatal and early childhood nutrition and erratic (or non-existent) fluoride exposure.

You can see in Joao's mouth that almost all of his baby teeth are rotten; several are broken and cracked. ECC is not benign. It causes pain, difficulty eating, and poor self-esteem. In fact, Joao smiles a ton when he's at my house, but when I tried to snap a photo of him for this post, he very self-consciously closed his mouth and kept his teeth covered. This tells me he is very much aware of the rotten teeth on display in his beautiful smile.

It's kind of crazy to think of cavities as an infectious disease, but it's very much true. Strep mutans are found in most mouths that contain teeth (there is nowhere for the bacteria to adhere until there are teeth in the mouth); higher bacterial loads and certain strains are more likely to cause extensive tooth decay. The best way to keep the strep mutans burden low is to regularly care for your teeth (brushing and flossing) and have any cavities attended to promptly.

Sugar consumption contributes largely to dental caries for children all over the world. Unfortunately, both breast milk and formula are both very high in sugars, and it is not uncommon to see ECC even in exclusively breastfed infants, particularly those who nurse on demand overnight. I have seen this in pediatric patients in the US. In addition, it's fairly typical for very young children and toddlers in Latin America to consume a surprising amount of simple sugars on a regular basis, often in the form of lollipops, sugared candies, gelatin drinks and sodas. Cola, ironically, is safer drinking water than tap water; it is often cheaper than bottled water, and on a hot day the only beverage kept cold. Just last night, a six-year old came over to our house holding a full bottle of Inka Cola she had just purchased with the spending money her mom gave her.

Since much of the world lacks fluoridated water, plus infant toothpastes are explicitly made without fluoride so as to avoid flurosis (or fluoride poisoning), most children do not have adequate enamel support. Application of fluoride varnishes have become increasingly popular in community health centers in the US and are used in some health centers globally at the time of childhood vaccinations, but they are not as widely available as they should be, particularly in under-resourced areas.

One final contributor, maternal nutrition during the perinatal period, surely contributes to early dental decay in young children.

Some people might believe that, because baby teeth are temporary, they don't matter that much; after all, they will all fall out in a few years Unfortunately, however, a high bacterial load in a child's mouth with ECC makes permanent teeth vulnerable to early cavities, even as they are just erupting. So, yes, Joao will lose these carious teeth and get new ones, but his adult teeth, even before they are visible, are at unbelievable risk for cavities. I often tell my children -- when I am nagging them about teeth brushing -- that I want them to have their teeth long after I am gone, and I mean it. My mom lost most of her teeth before she turned 30 for many of the same reasons: poverty and poor nutrition.

There is evidence that if mothers receive routine dental care during pregnancy (e.g. cleaning, fillings), it not only improves her dental health, and decreases her bacterial load, but decreases the bacteria transferred to her vulnerable infant and improves her baby's dental health. Also, it's a no-brainer to decreasing simple sugars for toddlers (there is a LOT of simple sugar consumption here in Ecuador), having mothers wipe infants' mouths after breastfeeding, and decreasing night time feeding decreases the tooth's exposure to the sugars necessary to cause decay. Finally, adding fluoride (either via water, fluoridated toothpaste or fluoride varnish) gives strength to the enamel to make the teeth less vulnerable.

I have lots more I could say on the topic, but I'll leave it here for now. I felt inspired to write about ECC from the moment I met Joao and saw his terrible teeth, but I was particularly motivated this week because Dr. Karen Sokal-Gutierrez, my friend/teacher/mentor from the Joint Medical Program, who happens to have also been a Peace Corps Volunteer in Ecuador, is coming to Ecuador this week to visit a friend she has remained connected to since Peace Corps. She's then on her way to Bolivia to do work on ECC. She and I are trying to figure out if we can meet up next week. This post is dedicated to her.