Oh, this smile. This is the best smile. It is a smile that brings me immense joy. But, when I look closer, that joy is briefly pummeled by a stomach lurching with guilt.
You see, I am a parent of a preschooler with cavities. A lot of cavities. (At least I am in good company, as the rate of dental caries continues to rise across children from all demographics.)
This wasn’t supposed to happen. When she turned one, we delayed a trip to the dentist. We were told by our friends, our pediatrician, and our dentist that those first appointments are to “get them used to the dentist.” To develop a relationship with their dentist and to make it fun. So, we brought her with us to our appointments. She watched us get our teeth clean. And that was that. Our plan was to start the real deal when she turned two. But we didn’t make it that far.
I remember the day so clearly–it was December. We had just visited Santa. A lovely family day. I was playing with her, and dipping her upside down, when I looked into her little upside down face and saw it.
It was small. No bigger than a poppyseed. A yellow-brown divot, settling into one of her upper molars. Before that, I’m not entirely sure I knew what a cavity looked like. But I didn’t need a resume dripping with dentistry to know that an actual HOLE in a tooth was probably something that needed to be addressed. So I did what any reasonable mom would do. I googled it. While Google images failed to produce a match or an explanation, we got the next available dentist appointment and I did my best to stay away from the horrors of Dr. Facebook in the days that followed.
When the appointment rolled around, my child screamed in my arms. Her dentist was amazing, but it’s hard to convince a toddler that having someone pin them down and stick instruments in their mouth is a fun thing. While the exam only lasted maybe five minutes, it felt like hours. I tried to mask my stress, to be calm for my kiddo, but I know she felt it. Especially when the dentist pulled her mask down.
“You were right. She has cavities.” And not just one. It turns out my kid is an overachiever in the cavity department.
My brain started spinning. How did this happen!?? She has never drank from a bottle, never had any juice, sweets are on a short list for special days, we brush her teeth before bed…
The dentist went on to explain the perfect storm going on in my daughter’s mouth. I’m not sure how much I retained that day, as I held my baby and tried to keep from crying, but since then, being the researcher I am, I have, to put it lightly, researched the crap out of cavities in toddlers.
So here are all the things you have to avoid if you want to escape the path we seem to be taking:
- Grazing: Your kid shouldn’t snack all day. Every time you eat, the pH of your saliva increases for up to 30 minutes after you have finished eating. If you snack all day, the pH stays up, weakening the enamel and creating a lovely breeding ground for bacteria. (This shouldn’t be a concern though, since toddlers are known for their ability to abstain from snacking constantly, and instead enjoy settling down to a full meal with lots of broccoli.)
- Carbs: Grazing is worse when it involves carbs. Carb-based snacks, like pretzels and Goldfish not only fuel existing bacteria, but they get stuck in the nooks and crannies of teeth, and hang around for hours. (But, no worries here either, since kids hate Goldfish crackers, right?)
- Bacteria: If you don’t have Streptococcus mutans, the bacteria responsible for cavities, in your mouth, you don’t have cavities. So, as long as your child never puts anything weird in their mouth, licks their friend, swipes at dad’s food, or swaps their cup with a friend at daycare, you’re good to go.
- Genetics: My mom had six brothers and sisters. Growing up, she told me stories about how she brushed and flossed, but still got cavities, while her brother had all the flora and fauna you could hope for on his pearly whites and never had a problem. Then there was me, who had the joy of spending my sixth birthday getting four fillings and two crowns (and not the sparkly purple tiara variety). Sorry kid, I think you’re just screwed here.
- Breastmilk: A dentist friend, who knew about M’s battle with tooth decay, asked in passing one day, “Have you cut out the night feedings yet? That stuff is worse than Mountain Dew for your teeth.” That’s right, apparently, breastmilk is on par with Mountain Dew. He’s not alone in this opinion. There are plenty of dentists who will tell you that breastmilk contributes to cavities. They will instruct lactating parents to “cut out all night feeding” and “limit milk intake” in order to prevent or stop the progression of cavities. But it turns out, this factor is a little complicated.
Physiologically, this doesn’t make sense if the child is actively nursing at the breast. If a child was falling asleep with a bottle of breastmilk, then yes–this is equivalent to “bottle rot”—a constant drip of sweet liquid, washing over teeth, while saliva production is at its lowest (we produce less saliva at night, than we do during the daytime–saliva helps to maintain the pH of our mouth, so with less of it while you are eating something, you are at a greater risk of developing cavities.) But, when a child is actively nursing at the breast, the breast is drawn into the mouth and behind the hard pallet. Any milk drawn out doesn’t have a chance to wash around their mouth a lot, and instead just goes down their throat. Additionally, while a bottle will continue to drip, a breast will not (if that wasn’t the case, I would have had a lot of really awkward public speaking events in the last few years.)
Secondly, current research indicates that human milk alone does not cause dental caries (Palmer, 2002). An article on KellyMom nicely details literature supporting this claim. In fact, to the contrary, there is evidence that suggests that “several components of human milk may also protect against the development of caries,” specifically IgA and IgG which “have the potential to retard streptococcal growth; Streptococcus mutans is highly susceptible to the bactericidal action of lactoferrin, a major component of human milk,” (Palmer, 2002). In other words, breastmilk may prevent cavities.
So when your dentist tells you that your magical boob milk caused your kid’s teeth to rot out, you can just tell them to shove it. Right?
Hmmm…not so fast. I did say this was a complicated factor.
Anecdotally, when I look in my child’s mouth, she has some amount of decay on every one of her teeth. Every one of them, except her lower front teeth–the teeth covered by her tongue when she nurses. And the side of her mouth with the worst decay? That’s the side where milk would be most likely to pool while she breastfeeds while lying down.
Palmer was right, breastmilk by itself has protective qualities. But breastmilk mixed with any other carbohydrate, be it pretzel residue or Goldfish cracker, is worse than sugar alone. So, have I stopped night nursing?
Nope. But I have become militant about teeth brushing. We cut down on crunchy carb-based snacks (as much as we can to still survive that is), replaced them with snacks that are more supportive of oral health (things that help maintain pH, like cheese and veggies), and we make sure to wipe (using a towel or xylitol wipes) or brush her teeth frequently throughout the day. We encourage her to drink water with her snacks, and we do our best.
We were also lucky enough to get set up with a dentist who uses silver diamine fluoride (SDF). SDF basically goes after the Streptococcus, and stops the progression of cavities, quickly and without general anesthesia. The downside–it turns any area of decay that it touches black. (That and few insurance companies will cover SDF—that’s right, the lower risk, lower cost approach isn’t covered, but our dental insurance was more than willing to knock our kid out and bring out the drill. But that’s another issue entirely. Delta Dental is one example of an insurance provider who have logic/evidence on their side when it comes to SDF.) While this application of silver diamine fluoride is relatively new to the US, it has been used in Japan for over 80 years, with a great deal of success. It takes moments to “paint” on and has enabled us to avoid the general anesthesia required to fill cavities in a toddler. But it’s been a battle.
Once cavities settle in, it can be tough to get in front of them using a passive approach like SDF. And after six or so treatments with that magical paint, we thought we were gaining ground on her existing cavities. We thought we were in the clear, with our good brushing habits. But cavities spread. And just yesterday, my daughter indicated that we may not be winning after all.
“Teeth hurt.”
“What honey?”
“Mama, teeth hurt. Right here.” She pointed to her mouth, and my heart fell into my stomach.
We have an appointment later this month. Fingers crossed that we can keep this perfect storm at bay a bit longer.
P.S. For more on this application of silver diamine fluoride:
- Peer reviewed article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4778976/
- Great read from the NY Times: http://www.nytimes.com/2016/07/12/health/silver-diamine-fluoride-dentist-cavities.html?_r=0
Milk and Genes 
I presume someone has passed along this suggestion before, but just in case they haven’t, I thought I would suggest you look at the research (scant though it is) on pediatric carries being an indicator for celiac disease in children. Especially when there are high quantities of carries in a situation without significant risk factors.
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As a pediatric dentist who deals with cases similar to this far too frequently (as do all pediatric dentists), thanks for sharing. I spent years writing my book, More Chocolate, No Cavities, to try to help parents prevent situations such as yours. You are correct that crackers and pretzels are nine times stickier than a piece of bread or a bagel, so cutting those out is an awesome start. You are also correct in your proper use of sarcasm that these are henmost common snack foods in all of America. I did an expirement to show how sticky they are on my local news station.
If you are looking for and easy guide that separates what is sticky vs. what is not (or lower in carbs, etc.) mine is at
http://www.TheDentistDad.com/snackguide
You pointed out the lower front teeth are cavity free. This can also be attributed to the salivary glands in combination with gravity. Even at night, those are the only teeth that are still protected by saliva, because gravity keeps saliva there, and they happen to have saliva glands right behind them. The front top teeth are not protected by saliva at night.
If your child breaths through their mouth, the effects of any milk at night are multiplied exponentially because saliva doesn’t rinse away the natural sugars.
You are correct: breast milk helps prevent cavities 95-98% of the time (except the cases where it doesn’t.)
SDF is great, and I have good success with it. I wish you the best of luck. Unfortunately in the healthcare world, nothing has 100% success. Cross your fingers!
Teeth are repaired naturally by saliva by carrying calcium and phosphate to the teeth to patch up the microscopic damage. But teeth need a break from even the healthiest foods in the world to allow saliva to do it’s job. That’s the analogy I use to explain it.
Feel free to reach out to me if I can be of any assistance. I wish you the best.
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Thank you for sharing your thoughts and expertise! It was helpful to do some additional thinking about the role of the salivary glands, and their proximity to those lower teeth. The snack recommendations, the note about mouth breathing, the analogy for giving teeth a break—as a public health researcher I’m intrigued by what it would take to ensure parents get this info before they *need* it…before their kids even have teeth. There seems to be such a narrow window for prevention, yet we often don’t know what we need to know until we find ourselves in the midst of a battle. But isn’t that true for so may health issues?
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Thanks for the imformative article. However, I am a bit confused too. In one paragraph you say drinking a bottle of breastmilk leads to decay as it coats the teeth. But in the next paragraph you say that breastmilk is not cariogenic due to its antibacterial properties. Can you pleas explain this? Thanks!
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As Dr. Lucas pointed out in an earlier comment and as my article touches on, research suggests that in most cases breastmilk protects against cavities, but doesn’t always. Drinking breastmilk from a bottle, versus breast, complicates the matter, since drinking anything from a bottle presents some issues (particularly in the presence of other risk factors).
First off, breastmilk from a bottle enters the mouth differently than breastmilk directly from the breast. A bottle will continue to drip into the child’s mouth, even when they are not actively sucking, which continues to wash over the teeth. This also occurs further towards the front of the mouth, rather than more directly into the throat (which is what happens when a child is nursing directly from the breast—they draw the breast tissue behind the hard palette.) In other words, a child who is actively nursing at the breast, may not have any breastmilk actually contact their teeth.
Secondly, “grazing” raises an individual’s risk for cavities. When someone eats, the pH of their mouth increases and stays higher for up to 20-30 minutes after they eat. If a child is eating constantly, the pH in their mouth stays higher for a longer period of time, eventually breaking down the enamel. This is what happens when a child is consuming a liquid, even breastmilk, from a bottle–a constant slow drip as long as the bottle is in their mouth. So if they fall asleep at night with a bottle of anything, that slow drip keeps the pH up higher at a time when the teeth are more vulnerable (we produce less protective saliva at night, than we do during the daytime). Breastmilk from the breast doesn’t pose the same level of risk, as breasts typically don’t continue to leak like a bottle does.
Finally, when a child is breastfeeding directly from the breast, they create a vacuum which draws the breastmilk out. Angela Garbes addresses this mechanism in an article published in The Stranger: “Within that vacuum, the infant’s saliva is sucked back into the mother’s nipple, where receptors in her mammary gland read its signals. This “baby spit backwash” … contains information about the baby’s immune status. Everything scientists know about physiology indicates that baby spit backwash is one of the ways that breast milk adjusts its immunological composition.” So, in theory, breastmilk directly from the breast, as opposed to breastmilk from a bottle, would be able to better adapt to the needs of the child—presumably better accommodating their oral health.
I would imagine there are other factors at play, but these were the first three things that came to mind.
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Thanks again for the additional information. I used a slow flow nipple with my daughter so she had to actively suck in order to get breastmilk out of her bottle. Each feed lasted a few minutes and there was no dripping afterwards. My understanding is that the lactose in breastmilk does not break down into a sugar until it reaches the intestines in the presence of lactase. So…it doesn’t digest like other foods in the mouth leading to sugar eating away at the enamel. However, if there are food particles left on the teeth breastmilk can coat them not allowing saliva to do its job in neutralizing the mouth’s pH. My daughter is a fussy brusher so it is hard to get her teeth totally clean. At eighteen months she developed four cavities in her upper incisors. Her decay arrested six months later after following the Cure Tooth Decay protocol. I am still befuddled how it all happened though and am constantly searching for ways to prevent the same issues with her permanent teeth (she is now three). Also, the reverse vacuum created while nursing that you mentioned is fascinating. However, the mother and baby can get the same immunity benefits through touch and saliva if they are breastfeeding with a bottle. Again, thanks for all of your insight!
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In any case—there’s a rather interesting, and fairly complicated relationship between breastmilk and pediatric oral health! I continue to be interested in learning more. 🙂
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Very true indeed!
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Have you looked into healing her teeth with nutrition? We have been following the “Cure Tooth Decay” protocol by Ramiel Bagel and have had great success with it.
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I’m very aware of Nagel’s work. We’re taking a holistic approach to addressing her dental issues, through diet and working closely with a trusted dentist.
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You mentioned that constant snacking raises the mouth’s pH leading to enamel breakdown. My understanding is that saliva buffers the acid attack created by foods. And if one snacks often the saliva can no longer keep up so the acid takes over. This leads to a lower pH, not a higher pH. Can you please explain your reasoning? Thanks!
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Hah. Good catch. No reasoning—I was just responding too late at night, when I should have been sleeping. You are spot on.
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Glad we are on the same page here. Thanks again for all of the information. Good luck on your healing journey!
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hi
we hav the same cavities problems with our daughter.
Did you continue breastfeeding after the SDF treatment and did it left stains on your skin?
cheers
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I did–still breastfeeding in fact. 🙂 It didn’t stain any skin on my breast (you’re encouraged to wait about an hour after SDF application typically, because any food or drink, so we just waited a while after the application before she fed again). While I’m not a medical professional, I would be happy to answer any other questions you have about it, from the perspective of our experience with SDF. Cheers!
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