0021-7557/04/80-05-Suppl/S199

Jornal de Pediatria
Copyright © 2004 by Sociedade Brasileira de Pediatria
REVIEW ARTICLE

Breastfeeding and early childhood caries:

a critical review
Nilza M. E. Ribeiro,1 Manoel A. S. Ribeiro2

Abstract
Objective: To find scientific evidences that can prove or refute the assumption that nocturnal and on demand
breastfeeding are associated with caries in infants and preschool children.
Sources of data: MEDLINE, Lilacs, and SciELO articles were searched, as well as important internet sites, technical
books and consensus publications of national and international organisms. The following keywords were used: “early
childhood caries”, “dental caries”, “dental decay” and “breastfeeding”. References cited in the articles selected were also
included.
Summary of the findings: Studies associating caries with breastfeeding invariably observe factors associated with
how this disease develops, letting aside those associated with breastfeeding. Many of these factors act as confusing
variables because in the same way as they interfere in breastfeeding, they also influence the development of caries.
Besides, current studies have already demonstrated the cariogenic potential of some types of aliments given to children
against the non-cariogenic potential of the human milk.
Conclusions: There are not scientific evidences proving that the human milk can be associated with the development
of caries. This is a complex relation to be established, as it is often blurred by too many variables.

J Pediatr (Rio J). 2004;80(5 Suppl):S199-S210: Early childhood caries, dental decay, breastfeeding, risk-factors.

Dental caries is still the most common infectious worldwide basis, especially due to fluoridization, its
disease among children. In the United States, its prevalence remains stable in deciduous dentition 5-7 (group
prevalence is estimated to be five times higher than that of twenty teeth that form between 12 and 18 weeks of
of asthma and seven times higher than that of allergic intrauterine life and erupt, on average, between 7 and 30
rhinitis. 1,2 It is a preventable disease and its prevention months of life). 8-10 It is still a serious public health
begins at the pediatrician’s. 3 Although pediatricians are problem and its control should be a priority, since it may
the ones in charge of promoting children’s oral health, lead to malocclusion of permanent teeth, cause phonetic
few scientific studies on this topic have been published in problems and lower self-esteem. 11,12 It also has been
pediatric journals. 2,4 demonstrated that dental caries can gradually reduce
Caries is an infectious disease that is induced by the children’s weight gain, which may be reversed after
diet and, despite its decline in all age groups on a complete oral rehabilitation.13
The prevalence of caries in the general population is
not well-defined, due to different methodologies, which
hamper the comparison of results.11,14 In Brazil, the Oral
Health Project -2003 showed that 27% of children aged
1. Specialist in Pediatric Dentistry, Brazilian Society of Dental Surgeons between 18 and 36 months and nearly 60% of five-year-
(SOBRACID). old children had at least one deciduous tooth that was
2. Neonatologist, Hospital São Lucas, Pontifícia Universidade Católica do
Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil. decayed. On average, a Brazilian child has at least one
decayed tooth up to the age of three years, and three
Suggested citation: Ribeiro NM, Ribeiro MA. Breastfeeding and early
childhood caries: a critical review. J Pediatr (Rio J). 2004;80(5 Suppl):S199- decayed teeth at the age of five years. Large regional
S210. diversities are perceived at all ages, and the rate of

S199
S200 Jornal de Pediatria - Vol. 80, No.5(suppl), 2004 Breastfeeding and caries – Ribeiro NM & Ribeiro MA

healthy lower teeth is lower in the North and Northeast Etiology

Brazilian regions compared with the South and Southeast Caries is regarded as an infectious, contagious and
regions. 15 multifactorial disease produced by three primary individual
In dentistry, there is quasi-consensus that factors: cariogenic microorganisms, cariogenic substrate
breastfeeding on demand, especially at night and if and susceptible host (or tooth).29 These factors interact in
prolonged, produces caries. 10,11,16-18 Likewise, in a certain period of time, causing an imbalance in the
pediatrics, there are publications that share the same demineralization and remineralization between tooth surface
opinion.7,19 The American Academy of Pediatric Dentistry and the adjacent plaque (biofilm).5,30
(AAPD) declared that breastfed and bottle-fed infants are
at a potentially devastating risk for caries due to Cariogenic microorganisms
breastfeeding. This is related to prolonged and repetitive
The main cariogenic microorganisms are the so-called
feeding without proper oral hygiene, and is also related to
mutans streptococci, especially Streptococcus mutans and
the fact that parents are encouraged to offer their infants
Streptococcus sobrinus.7,10,30 These pathogens can colonize
beverages in drinking cups before their first year of life
the tooth surface and produce acids at a faster speed than
and to stop bottle-feeding them between 12 and 14
the capacity of neutralization of the biofilm in an environment
months of life.20 Without an accurate definition, the
below the critical pH value (less than 5.5), which results in
terms “prolonged exposure” and “weaning” had different
the destruction of the tooth enamel.9,10,19 The major
interpretations, which culminated in the recommendation,
reservoir of mutans streptococci is the oral cavity, and
by dentists, of weaning and cessation of breastfeeding
infant infection depends on the level of maternal infection or
before the first year of life . By discouraging prolonged
on the person in closer contact with him or her.7,10,29-31
breastfeeding and breastfeeding on demand,10,19,21 they
Horizontal transmission also has been described in nursery
overlook all the well-documented benefits of breastfeeding
facilities of day-care centers and within families.31,32 The
and also the World Health Organization (WHO)
severity of ECC is directly related to the early establishment
recommendation to maintain breastfeeding up to the
of mutans streptococci in the infant.10,30
second year of life or longer. 22 Similarly, the American
Academy of Pediatrics considers that infants who are put These bacteria admittedly need nondesquamative
to bed with the bottle or who breastfeed during the night surfaces to colonize because their positivity increases with
are at great risk for dental caries.2,23 the number of erupted teeth and with age.30 In the period
known as “window of infectivity”, which corresponds to the
Therefore, the presumable cariogenicity of breastmilk eruption of lower incisors (6 months) and upper molars (24
is an issue of paramount importance because, along with months), the acquisition of streptococci increases. 7,9,10
its substitutes, it is the major nutritional source in the first
Other microorganisms include lactobacilli, which were
years of life.24,25 In the present article, the authors
associated with the progression of an established lesion and
present a review of the literature on the topic, and
not with the development of caries itself.8,30
analyze several epidemiological studies that investigated
a possible relationship between breastfeeding and caries.
Cariogenic diet
Sucrose is the most important cariogenic food and the
one most widely used by people. It turns non-cariogenic
Definitions and anticariogenic foods into cariogenic ones.6,7,19 Other
The expression early childhood caries (ECC) is currently sugars involved in cariogenesis are glucose and fructose,
used to replace the terms baby-bottle tooth decay and found in honey and fruit.6,9,31 A simple exposure to
nursing caries.7,26,27 The literature does not provide a cariogenic foods would not be a risk factor for dental
universally accepted definition for ECC,12,14,28 but the caries, but the frequent and prolonged contact of these
AAPD considers ECC as the presence of any decayed substances with teeth would. 6
deciduous tooth surface (cavitated or non-cavitated),
missing (due to caries) or filled, in children younger than
Susceptible host
six years. Based on this definition, the expression severe
ECC (S-ECC) was adopted in lieu of rampant caries, in the Host risk factors for the development of caries are: yet
presence of at least one of the following criteria: a) any immature post-eruptive enamel; presence of enamel defects,
sign of caries on a smooth surface in children younger characterized mainly by hypoplasia;5,9,11,19,30 morphology
than three years; b) any smooth surface of an and genetic characteristics of the tooth (size, surface, depth
anteroposterior deciduous tooth that is decayed, missing of fossae and fissures) and crowded teeth.9
(due to caries) or filled, in children between three and five Saliva is the major defense system of the host against
years old; c) decayed, missing, and filled teeth index caries, removing foods and bacteria, and providing
(DMFT) equal to or greater than 4 at the age of 3, 5 at the buffering against the acids produced. It functions as a
age of 4 and 6 at the age of 5 years.29 Unlike this mineral reservoir for calcium and phosphate, necessary
definition, the WHO does not consider the presence of for enamel remineralization, containing antibacterial
non-cavitated lesions for the DMFT.22 substances.9,10,19,30 Individual situations that decrease
Breastfeeding and caries – Ribeiro NM & Ribeiro MA Jornal de Pediatria - Vol. 80, No.5(Suppl), 2004 S201

salivary flow and, consequently, its buffering capacity, as mothers,39 of parents with low educational level, especially
occurs while infants are sleeping, increase tooth of illiterate mothers.7,26,28,33,37,39,40 In this population,
susceptibility to caries.19,30,31 prenatal and perinatal malnutrition or undernourishment
The constant maintenance of fluorine in the oral cavity are the cause of enamel hypoplasia; oral hygiene is usually
is important for enamel resistance, interfering with the poor; exposure to fluorine is probably insufficient 12,39 and
dynamics of caries development, reducing the amount of there is a greater preference for sugary foods. 36,41
minerals lost during demineralization and activating the Several diseases are associated with ECC, among them,
response during remineralization.6,11 In fact, fluorine does malnutrition, 9,24,34,35,42 asthma, recurrent infections,
not prevent caries development, but it is extremely efficient chronic diseases, in addition to medication use. 9,30,40
in minimizing its progression, and control of dental plaque Malnutrition may cause enamel hypoplasia, and just
and diet is also important in order to maximize the effect of
like iron deficiency anemia, it may lead to reduced
fluorine. Daily toothbrushing with fluoridated toothpaste
salivary secretion and low buffering capacity. 7,11,24,35,42,43
and toothbrushing before going to bed are important
Childhood malnutrition is still a major problem in Brazil,
measures for the control of caries, since they maintain the
especially in the North and Northeast regions, 44 which
concentration of fluorine in the saliva for a longer period.6
may contribute to a larger number of decayed teeth in
Thus, caries starts with primary streptococcal infection, these regions. The mean DMFT (number of deciduous
followed by the accumulation of streptococci in the biofilm teeth that are decayed, extracted or indicated to be
at pathogenic concentrations secondary to the frequent and extracted and filled) at the age of five years in the North
prolonged exposure to a cariogenic diet. Finally, fermentation region is approximately 27% higher than the mean for the
of sugars by streptococci inside the dental plaque causes Southeast region.15 It also has been observed that the
enamel demineralization, resulting in cavitation of dental diet of Brazilian infants is poor in iron, monotonous, with
structures.9,11,29-31 regular use of cookies, thickeners, snack foods and
Caries develops from decalcification of upper deciduous sugar, 44 which are highly cariogenic.
incisors immediately after their eruption, affecting the Low birthweight, including preterm births, predisposes
deciduous molars and canines, if not controlled.10,11 While to high levels of streptococcal colonization, 45 in addition
the four upper deciduous incisors are the most severely to favoring the development of enamel hypoplasia and
affected by ECC, lower incisors remain intact because they salivary disorders. 30,43 In these newborns, enamel defects
are protected by the tongue and moistened by the saliva are associated with gestational diseases, such as maternal
from submandibular glands,10,11 as shown in Figure 1. infection, metabolic disorders (hypoxemia, nutritional
disorders, hypocalcemia) and performance of medical
procedures (laryngoscopy and endotracheal intubation). 46
In infants, the presence of infections, metabolic
disorders, chemical toxicity and inherited diseases also
cause the development of enamel hypoplasia. 11,30,43
The severity of ECC increases with the severity of
bronchial asthma, having as major cause the use of beta
2 agonists, which reduce salivary secretion, in addition to
the fact that powder inhalers and oral medications contain
sugar in their formulation. 47 Other situations that reduce
salivary flow and predispose to the appearance of caries
are diabetes mellitus and the use of medications such as
antihistamines, benzodiazepines, antiemetics,
expectorants and antispasmodics. 9

Nipples, pacifiers and bottles

Figure 1 - Typical pattern of carie in infants and preschool Baby bottles predispose to ECC because their nipple
children severely affecting upper teeth and lower
molars, while lower incisors remain intact. Presence of
blocks the access of saliva to the upper incisors, whereas
abscesse in the upper right deciduous incisor. (Picture: lower incisors are close to the main salivary glands and
Brian Palmer, DDS). are protected from liquid contents by the bottle nipple and
the tongue. 11 The use of baby bottles during the night is
associated with the reduction in salivary flow and in the
capacity of salivary neutralization, which would cause
food stagnation in the teeth and prolonged exposure to
Associated risk factors
fermentable carbohydrates. 9,30 Additionally, it has been
ECC is more commonly found in children who live in demonstrated that infants with ECC sleep less at night,
poverty or in poor economic conditions,7,11,24-26,33-37 who wake up more frequently, and receive more bottle-feedings
belong to ethnical and racial minorities,12,38 born to single as a way to manage their sleep problems.48
S202 Jornal de Pediatria - Vol. 80, No.5(suppl), 2004 Breastfeeding and caries – Ribeiro NM & Ribeiro MA

Although the habit of dipping the pacifier in sugar is addition to the fact that there is no information in the
associated with early colonization by Streptococcus mutans literature on what an atypical consumption pattern is for
in predentate infants,49 a systematic review did not find any nursing infants in relation to feeding frequency.44,52 Another
consistent correlation between the use of pacifiers and the argument that is commonly found in the literature is that the
development of ECC, regardless of the length of use of addition of sucrose to human milk makes it cariogenic.7,61
pacifiers and of the introduction of sweeteners or not.50 This statement is arguable because, in practice, this situation
would hardly happen, since such addition should occur
during the breastfeeding session by offering the infant
Cariogenic role of human milk, cow’s milk and something sweet to eat or drink during or immediately after
milk-based formulas in infant feeding breastfeeding.63
Animal studies have shown that cow’s milk does not
The various studies that investigated the association
produce caries and that it has a cariostatic action
between breastfeeding and ECC are shown in Table 1. The
instead. 34,38,51 However, its use is not recommended
most important limitation of these articles is that they do not
before the first year of life.52,53 Nevertheless, milk-based
employ the internationally adopted definitions of
formulas for infant feeding, even those without sucrose in
breastfeeding. Some authors do not present a definition for
their formulation, proved to be cariogenic.54-56 Breastmilk,
ECC,40,64 while others use multiple definitions12 or their
compared with cow’s milk, has a low mineral content,
own definitions.65 As may be observed, most authors did not
higher concentration of lactose (7 versus 3%) and lower
find a correlation between ECC and breastfeeding or with its
protein content (1.2 g/100 ml versus 3.3 g/100 ml), but
duration.12,25-27,40,65-70 The obtained results often are
these differences are probably insignificant in terms of
contradictory and the findings were not always reproduced.
cariogenicity. 30
The same was observed by Valaitis et al. in a systematic
Birkhed et al. demonstrated that human milk and cow’s review of 151 articles. These authors found a moderate
milk can reduce dental plaque pH values, but to a lesser correlation between breastfeeding and ECC in only three
extent than sucrose, and that the fermentation of lactose studies. They verified that the quality of the studies is
and cow’s milk is slower. On top of that, streptococci can relatively poor and that the variables were difficult to
only increase lactose fermentation after frequent contact compare because their essential definitions were weak,
with the milk. According to these authors, this may be one inconsistent, ambiguous or even absent, for instance, the
of the reasons for caries development in deciduous teeth definition of breastfeeding on demand, exclusive
produced by prolonged breastfeeding on demand. However, breastfeeding and breastfeeding at night. Finally, these
for the same authors, the cariogenic potential of milk under authors concluded that: (1) there is no strong and consistent
normal conditions does not have clinical relevance, except evidence between breastfeeding and the development of
when salivary protective factors are reduced, as occurs ECC; (2) there is no specific period for weaning, and women
during sleep and in the presence of xerostomia.57 should be encouraged to continue breastfeeding for as long
as they wish; and (3) rigorous studies are necessary before
issuing any public statements correlating breastfeeding
Breastfeeding versus ECC: reasons and with the development of ECC.21
counterarguments
Gardner et al. 58 , Kotlow 59 and Brams et al. 60 were the In another systematic review involving 73 studies,
first authors to associate ECC with breastfeeding in a Harris et al. identified 106 risk factors significantly associated
report of nine cases, pre-establishing the behavior of with the prevalence or incidence of ECC. Among these, only
dentistry regarding breastfeeding – recommending the three factors are related to breastfeeding (duration,
cessation of breastfeeding as soon as the infant was able frequency and breastfeeding at night) and three to
to drink from a cup, around the twelfth month of life. 10,19 breastfeeding and/or bottle-feeding (when used to feed or
These publications are open to criticism as they deal with to stop the infant from crying at night, to put him/her to
a small number of cases, in addition to the fact that two sleep and duration of breastfeeding longer than 18 months).
infants were bottle-fed and there was no mention of Few articles showed a high methodological quality and used
enamel defects, bacterial medium and dietary validation measures for oral hygiene and eating habits. Most
composition.61 for the remaining seven infants. of these studies showed that variables should be treated as
risk indicators, as they are only probable or putative risk
Most authors argue that caries is associated with
factors and were not able to clearly establish a relation
breastfeeding when the consumption pattern has certain
between exposure and caries. The most consistent
characteristics such as ad libitum feeding, large number of
associations with caries were early streptococcal infection
breastfeedings a day, prolonged breastfeeding and, mainly,
acquisition, highly cariogenic diet, poor toothbrushing
frequent breastfeedings during the night, resulting in
routines and enamel hypoplasia. 5
accumulation of milk in the teeth, which, combined with
reduced salivary flow and lack of oral hygiene, may produce The following arguments refute the association between
tooth decay.10,16,18,19 In opposition to these arguments is breastfeeding and ECC:
the fact that breastmilk expressed directly into the soft – There is substantial evidence that correlates eating
palate62 does not stagnate while being sucked63 and the habits with dental caries, and a common agreement that
volume ingested by the infant is difficult to be quantified, in an increase in the incidence of caries may result from the
Breastfeeding and caries – Ribeiro NM & Ribeiro MA Jornal de Pediatria - Vol. 80, No.5(Suppl), 2004 S203

Table 1 - Studies that investigated the association between breastfeeding and early childhood caries

Authors/ Type of study Results Significant risk factors Notes

country Age group associated with ECC,
Sample size except for human milk

Matee et al.,71 Cross-sectional, Association between Linear enamel hypoplasia Breastfeeding prevalence was not
Tanzania pediatric outpatient S-ECC and prolonged demonstrated. Complementary food
clinic breastfeeding on was introduced between 1 and 9
AG: 1-2.5 years demand. months. Mothers whose children did
n = 442 (47 with ECC) not have S-ECC were not interviewed

Matee et al.,66 Case-control, pediatric Association of ECC Linear enamel hypoplasia There is not reference regarding the
Tanzania outpatient clinic. with nocturnal composition of the other components
AG: 1-4 years breastfeeding; there of the diet, the pre- and perinatal
116 with ECC, was no association of situation and the nutritional status;
243 without ECC ECC with lack of dental hygiene was not taken
breastfeeding into consideration. Other studies show
duration that exclusive breastfeeding is
common and that the early
introduction of food is the rule in this
population, and sorghum or corn
porridge is almost the only
complementary food76,77

Wendt et al.,64 Longitudinal, ECC associated with Nocturnal snacks; Definition of carie is not presented.
Sweden community of breastfeeding for bottle-feeding The study refers to other studies
Jönkönping. children aged < 2 published by these authors. Only 7%
AG: 1 year, seen at 2 months and > 1 year were being breastfed at 1 year. Other
and 3 years. authors suggest that breastfeeding
n = 629 without caries; does not cause caries, but could be
593 seen at 3 years associated with the child’s diet and
(159 with ECC) the educational practice of the family

Matee et al.,72 Case-control, pediatric Breastfeeding allows Counting of The same as for Matee et al., 1994
Tanzania outpatient clinic. the colonization of Streptococcus mutans
AG: 1-2.5 years Streptococcus colonies
17 with S-ECC, mutans
17 without ECC

Wendt et al.,40 Cohort, community of There was no Immigrants; use of bottle There is no definition of carie. The
Sweden Jönkönping. association between with sweetened liquids; study refers to other studies
AG: 3 years breastfeeding and poor oral hygiene; visible published by these authors. Only 14
n = 289 (83 with ECC) ECC plaque; sweets intake children were being breastfed at 1
> once a week year

Li et al.,35 Cross-sectional, Progressive increase Low income population; No reference to the type of
China kindergartens of two of the significance of malnutrition; hypoplasia complementary diet and to the
rural communities. the association prevalence of breatfeeding
AG: 3-5 years between ECC and
n = 1,344 breastfeeding related
(1,106 with caries) to the duration of
breastfeeding

al Ghanim Case-control, Significant Predictive model: visible

et al.,73 three public outpatient association of ECC plaque; first dentist visit
Saudi Arabia clinics and three with breastfeeding at 2 years; use of bottle
schools. duration > 1 year, with sweetened milk;
AG: 3-5 years not confirmed in the frequency of the sweets
231 without ECC, 215 logistic regression intake
with DMFT > 8 analysis

DMFT = decayed, missing, and filled teeth index; ECC = early childhood caries; S-ECC = severe early childhood caries; AG = age group;
n = total number of the sample.
S204 Jornal de Pediatria - Vol. 80, No.5(suppl), 2004 Breastfeeding and caries – Ribeiro NM & Ribeiro MA

Table 1 - Studies that investigated the association between breastfeeding and early childhood caries

Authors/ Type of study Results Significant risk factors Notes

country Age group associated with ECC,
Sample size except for human milk

Weerheijm Cross-sectional, There was no Low use of fluorine Presented different definitions for
et al.,25 La Leche Ligue in 25 association between breastfeeding carie and carie
Neatherland towns. ECC and prolonged
AG: 14-42 months breastfeeding (mean
n = 96 (14 with ECC) 22 months)

Mattos-Graner Cross-sectional, Higher prevalence of Colonization of

et al.,74 random selection in ECC in children who Streptococcus mutans;
Piracicaba, public day care centers. were never breastfed presence of bacterian
Brazil AG: 12-30 months or who were plaque; use of sugar or
n = 142 (27 with ECC) breastfed up to 3 cereal in the bottle; early
months if compared introduction of salty meals
to those breastfed for
longer than 12 months

Oulis et al.,75 Cohort, pediatric dental Breastfeeding for Use of bottle to fall asleep 85% of the group without ECC
Greece clinic, Dental School, longer than 40 days and 95% of the group with ECC
Athenas University. inhibits the occurence used bottle
AG: 3-5 years of ECC
130 with ECC, 130
without ECC

Ramos-Gomez Cross-sectional, There was no Hygiene; frequency of food Five definitions for ECC. Due to
et al.,12 community of Stockton. association between intake this, prevalence of ECC varied
United States AG: < 6 years, n = 220 breastfeeding and ECC between 12.3 and 30.5%

Dini et al.,33 Cross-sectional, Higher risk for Low income population Exclusive breastfeeding definition
Araraquara, 25 public schools. children who were is not clear: children at 3 and 4
Brazil AG: 3-4 years never breastfed or years being exclusively breastfed
n = 245 (112 with ECC) who were being
breastfed for longer
than 24 months

Hallet et al.,38 Cross-sectional, Significant association Use of bottle, mainly after

Australia community. of ECC in children 12 months, in bed, at night,
AG: 4-6 years who were never frequently drinking
n = 3,375 breastfed or in those sweetened liquids
(1,269 with ECC) who were being throughout the day;
breastfed for longer beginning to use cups after
than 2 years if 24 months; introduction of
compared to those solid foods after 9 months;
breastfed for less race (non-Caucasians);
than 24 months single mothers

Rosemblatt Cross-sectional, There was no Cariogenic diet; number of Most children had been breastfed
et al.,67 Outpatient Clinic Amauri association between snacks up to the sixth month of life, the
Recife, Brazil de Medeiros. breastfeeding and ECC exact number of children was not
AG: 12-36 months determined
n = 468 (133 with ECC)

Rajab et al.,26 Cross-sectional, There was no Use of bottle with

Jordan 27 day care centers and association between sweetened liquids after 1
schools. ECC and the duration year old; going to bed with
AG: 1-5 years of breastfeeding the bottle; frequency of the
n = 384 (184 with ECC) intake of sweet snacks
(more often than three times
a day); no toothbrushing; no
dentist visits; low income

DMFT = decayed, missing, and filled teeth index; ECC = early childhood caries; S-ECC = severe early childhood caries; AG = age group;
n = total number of the sample.
Breastfeeding and caries – Ribeiro NM & Ribeiro MA Jornal de Pediatria - Vol. 80, No.5(Suppl), 2004 S205

Table 1 - Studies that investigated the association between breastfeeding and early childhood caries

Authors/ Type of study Results Significant risk factors Notes

country Age group associated with ECC,
Sample size except for human milk

Huntington Case-control in Latin Breastfeeding Food intake while

et al.,28 families, Department of presented lower sleeping, frequency of
United States Pediatric Dentistry, significant risk of toothbrushing up to once
Boston University. ECC; children who a day, toothbrushing
AG: with ECC, up to 5 were not breastfed without parent
years; with no caries, had twice the risk of supervision, last parents’
with age restrictions ECC if compared to dentist visit more than 2
n = 100 with ECC, their siblings who years ago, parents’
60 with ECC were breastfed educational level

Santos et al.,65 Cross-sectional, There was no Visible plaque

Rio de Janeiro, Pediatric Outpatient association between
Brazil Clinic of HUPE-UERJ. breastfeeding and
AG: 0-36 months ECC
n = 80 (32 with ECC)

Cariño et al.,27 Cross-sectional, There was no Toothbrushing was Breastfeeding was a rule,
Philippines community. association between introduced after 1 year but the prevalence
AG: 2-6 years breastfeeding and old; daily frequency of was not determined
n = 993 (586 with ECC) ECC snacks

King et al.,68 Cross-sectional, There was no Only 4% of the sample was being
China 33 day care centers. association between breastfed after 6 months of age
AG: 0-4 years breastfeeding and
n = 353 (65 with ECC) ECC

Jose et al.,69 Cross-sectional, There was no Lack of oral hygiene; low 99% of the children were being
India 13 day care centers. association between income; mothers with breastfed on demand. Even though
AG: 8-48 months breastfeeding and caries; frequent snacks there was no definition of
n = 513 (216 with ECC) ECC breastfeeding, 5% of the sample was
being exclusively breastfed

Vachirarojpisan Cross-sectional, District Significant association Low income; low Breastfeeding was the rule, but the
et al.,37 of U-thong. between ECC and maternal educational prevalence was not determined
Thailand AG: 6-19 months breastfeeding. It was level; high levels of
n = 387 (226 with ECC) not confirmed by the Streptococcus mutans in
multivariate logistic the oral cavity; nocturnal
regression analysis food intake with bottle

Dye et al.,70 Cross-sectional, data of There was no Race (Latin, Non-

United States the health and nutrition association between caucasian); low parental
census. breastfeeding and school level; low income;
AG: 2-5 years ECC low intake of fruits and
n = 4,236 vegetables, frequent
(1,265 with ECC) snacks

DMFT = decayed, missing, and filled teeth index; ECC = early childhood caries; S-ECC = severe early childhood caries; AG = age group;
n = total number of the sample.

civilization of man, producing changes in the most logical studies, in which preneolithic (12,000 a. C.)
natural lifestyles.9,18 Studies involving primitive cul- human skulls did not reveal dental caries and neolithic
tures, in which the rule was to breastfeed on demand, (12,000 to 3,000 a. C.) skulls with decayed teeth
including breastfeeding at night, up to 18-36 months, belonged predominantly to old people.78 The analysis of
show an extremely low prevalence of caries among 1,344 prehistorical human deciduous teeth of native
children.61,78 Classical studies show caries rates of Americans from South Dakota, USA, revealed that only
0.5% in Samoan infants79 and of 1.2% in Eskimo 19 (1.4%) were decayed and only three had extensive
infants.80 Similar results were obtained from anthropo- caries lesions.63 In modern times, the prevalence ob-
S206 Jornal de Pediatria - Vol. 80, No.5(suppl), 2004 Breastfeeding and caries – Ribeiro NM & Ribeiro MA

served in 16 native American communities, with the – Qualitatively, it has been demonstrated that human milk
same culture, was 54%.81 is not cariogenic, as the dental plaque it forms is
– Peoples that maintain ancestral eating habits have a low different from that formed by sucrose. In addition,
prevalence of caries; however, when they come into human milk does not cause clinically visible mineral loss
contact with modern civilization and its eating habits, in the enamel, contrary to what occurs with sucrose.100
the prevalence rate increases drastically.8 – Experimentally, it has been shown that human milk is
– Children’s eating habits have dramatically changed in not cariogenic because it does not decrease the enam-
el pH significantly in breastfed infants, aged between
the last years. Milk consumption has decreased whereas
12 and 24 months; allows moderate growth of Strep-
the consumption of soft drinks, juices, non-citric bever-
ages and carbohydrates has increased.70,82 These hab- tococcus sobrinus (i.e., it does not inhibit or stimulate
the growth of this microorganism); promotes enamel
its have been correlated with a higher prevalence of
remineralization by way of calcium and phosphate
ECC.82
deposition on the enamel surface; has a poor buffering
– The duration of breastfeeding and exclusive breast- capacity; and does not cause in vitro enamel decalci-
feeding is longer in women from upper social classes, fication after twelve weeks. However, when sucrose is
in those who are better educated,83-85 in older moth- added to human milk, caries developed in the dentin
ers and in those with a steady relationship52 and, within 3.2 weeks. 61
dental hygiene is also more appropriate in this
group 12,39 in opposition to underprivileged classes, in In summary, studies that correlated ECC with
which ECC is more common. Early introduction of breastfeeding invariably observed the factors related to
foods, the use of baby bottles and preference for caries development, putting aside those factors related to
sugary foods are more frequently observed in under- breastfeeding. Many of these factors serve as confounding
privileged classes. 36,41,44,52,86,87 variables as they interfere in breastfeeding and in caries
– The prevalence of breastfeeding decreases with age, development as well (Figure 2). Figure 2 shows all the
having very low rates in children aged between 12 and situations that were previously discussed in the present
24 months in Brazil44 and in the world,88 in contrast with paper, where solid arrows stand for a stimulatory effect
the prevalence of ECC.12,27,65,67 and dotted arrows represent an inhibitory effect for each
situation proposed.
– The prevalence of ECC has been constant over the
years6,67,73 even with an increase in the world preva-
lence of breastfeeding89 and a fourfold increase in its Official view of the American Academy of
median in the last three decades in Brazil.90 Pediatric Dentistry (AAPD)
– Preterm and low birthweight infants, who are at great Currently, the AAPD supports the recommendations
risk for ECC, tend to have a shorter breastfeeding made by the American Academy of Pediatrics regarding
period,46,91,92 be bottle-fed for longer periods and breastfeeding (of at least one year). However, it states that
ingest more sugar.46 frequent feeding at night including bottle-feeding,
– Studies have demonstrated that breastmilk reduces the breastfeeding on demand and frequent use of spill-proof
risk of diseases, such as gastroenteritis, infections,93 drinking cups is associated with ECC, but is not consistently
asthma, atopic diseases94 and diabetes mellitus,95,96 implicated. It recommends that infants should not be put to
which have some influence on infant feeding. Therefore, bed with the baby bottle and that ad libitum breastfeeding
breastmilk supposedly protects against caries, due to at night should be avoided after the eruption of the first
the reduced development of disorders that contribute to tooth. Therefore, future research should be conducted
the pathophysiology of caries and due to the reduced use about the effects of breastfeeding and human milk
of cariogenic medications. consumption on oral health and on dentofacial growth. This
– Human milk is characterized by a complex defense view is ambiguous and arguable because the AAPD no longer
system that inhibits the growth of several microorgan- includes breastfeeding among cariogenic factors.29 Moreover,
isms, including mutans streptococci.97,98 The IgA anti- no scientific evidence exists that human milk is cariogenic,61
bodies found in the milk can interfere with the coloniza- even if ingested ad libitum and during the night. 63
tion of pioneer streptococci and consequently with the Concomitantly, the view of the AAPD can also result in
colonization of other bacteria that inhabit the oral cavity. practical problems regarding the counseling and guidance of
Nutrient content, buffering capacity and other defense parents of those infants who wake up crying at night in order
mechanisms found in breastmilk may interfere with the to be breastfed, simply expressing a need that should be
existing microbiota.99
met for infants’ proper development. Finally, given the
– Breastmilk contains a mix of oligosaccharides that is irreversible nature of caries, an actual test involving humans
complex and exclusive to the human species, found in could be regarded as unethical.56
tiny amounts in very few mammals, which may act at
the initial infectious stage by inhibiting bacterial adhe-
sion to epithelial surfaces.99 Therefore, studies that Final remarks
used lactose or milk from other animal species may Although there is no scientific evidence that confirms the
not have their results extrapolated to breastmilk due association between breastfeeding and caries, many
to its distinct composition. professionals still express disbelief at the fact that human
Breastfeeding and caries – Ribeiro NM & Ribeiro MA Jornal de Pediatria - Vol. 80, No.5(Suppl), 2004 S207

Aging

Streptococcus mutans

Genetics

Sugar

Gastroenteritis Use of medication

B Respiratory infection
R Diabetes mellitus
Asthma
E
Salivary alterations
A
S C
T MALNUTRITION Hypoplasia A
F R
E I
Preterm child
E low birth E
D weight Early food introduction
(inadequate habits)
I
Fluorosis
N
Sugar
G Mother:
Low social level
Low educational level Poor dental hygiene
Younger

Streptococcus mutans
Pacifiers

Milk bottles

Anthropological studies

Figure 2 - Breastfeeding and early childhood caries interrelated factors

milk is non-cariogenic, thus cultivating the myth into which caries development. This relationship is complex and contains
this association turned. We believe that breastfeeding at several confounding variables, mainly infection caused by
night should not be discouraged and no strict diet should be mutans streptococci, enamel hypoplasia, intake of sugars in
adopted for a nursing infant. At this age, infants are still varied forms and social conditions represented by parental
adapting to complementary foods, adjusting themselves to educational and socioeconomic level.
new eating patterns and learning to regulate their schedules.
Therefore, exclusive breastfeeding should be encouraged
up to the sixth month of life, maintained at least up to the Acknowledgments
second year of life, with flexibility of schedules or shifts, and Thanks to Dr. Brian Palmer, DDS, for his promptness and
complemented with appropriate weaning foods. kindness in responding to our requests, and also thanks to
This review led us to conclude that there is no scientific Dr. Elsa Giugliani and Dr. Joel Lamounier for their suggestions,
evidence that confirms that breastmilk is associated with which allowed us to improve this paper.
S208 Jornal de Pediatria - Vol. 80, No.5(suppl), 2004 Breastfeeding and caries – Ribeiro NM & Ribeiro MA

References
1. Pierce KM, Rozier RG, Vann WF. Accuracy of pediatric primary 27. Carino KM, Shinada K, Kawaguchi Y. Early childhood caries in
care providers’ screening and refferal for early childhood caries. northern Philippines. Community Dent Oral Epidemiol.
Pediatrics. 2002;109(5):E82-2. 2003;32:81-9.
2. American Academy of Pediatrics. Oral health risk assessment 28. Huntington NL, Kim IJ, Hughes CV. Caries-risk factors for
timing and establishment of the dental home. Pediatrics. hispanic children affected by early childhood caries. Pediatr
2003;111:1113-6. Dent. 2002;24:536-42.
3. Krol DM. Educating pediatricians on children’s oral health: past, 29. American Academy of Pediatric Dentistry. Reference manual
present, and future. Pediatrics. 2004;5:487-933. 2003-2004. Pediatr Dent. 2003;25:1-150.
4. Lewis CW, Grossman DC, Domoto PK, Deyo RA. The role of the 30. Seow KW. Biological mechanisms of early childhood caries.
pediatrician in the oral health of children: a national survey. Community Dent Oral Epidemiol. 1998;26(1 Suppl):8-27.
Pediatrics. 2000;106(6):E84.
31. Berkowitz RJ. Cause, treatment and prevention of early childhood
5. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for dental caries. J Can Dent Assoc. 2003;69:304-7.
caries in young children: a systematic review of the literature.
Community Dent Health. 2004;21(Suppl):S71-85. 32. Mattos-Graner RO, Li Y, Caufield PW, Duncan M, Smith DJ.
Genotypic diversity of mutans streptococci in Brazilian nursery
6. Cury JA. Uso do flúor e controle da cárie como doença. In: children suggest horizontal transmission. J Clin Microbiol.
Baratieri LN, editor. Odontologia restauradora – Fundamentos 2001;39:2313-6.
e possibilidades. São Paulo: Santos; 2001. p. 32-67.
33. Dini EL, Holt RD, Bedi R. Caries and its association with infant
7. Caufield PW, Griffen AL. Dental Caries. An infectious and feeding and oral health-related behaviors in 3-4-year-old Brazilian
transmissible disease. Pediatr Clin North Am. 2000;47:1001-19. children. Community Dent Oral Epidemiol. 2000;28:241-8.
8. Dresti DV, Waes HV. Prevenção coletiva, semicoletiva e individual 34. Petti S, Cairella G, Tarsitani G. Rampant early childhood dental
em crianças e adolescentes. In: Waes HJMV, Stöckli PW, editors. decay: an example from Italy. J Health Dent. 2000;60:159-66.
Odontopediatria. Porto Alegre: Artmed; 2002. p. 133-50.
35. Li Y, Navia JM, Bian JY. Caries experience in deciduous dentition
9. Guedes-Pinto AC, editor. Odontopediatria. 6ª ed. São Paulo:
of rural Chinese children 3-5 years old in relation to the presence
Santos; 1997.
or absence of enamel hypoplasia. Caries Res. 1996;30:8-15.
10. McDonald RE, Avery DR, Stookey GK. Carie dentária na criança
36. Tomita NE, Nadanovsky P, Vieira AL, Lopes E. Preferências por
e no adolescente. In: McDonald RE, Avery DR, editores. 7ª ed.
alimentos doces e cárie dentária em pré-escolares. Rev Saude
Rio de Janeiro: Guanabara-Koogan; 2001. p. 151-77.
Publ. 1999;33:542-6.
11. Davies GN. Early childhood caries- a synopsis. Community Dent
37. Vachirarojpisan T, Shinada K, Kawaguchi Y, Laungwechakan P,
Oral Epidemiol. 1998;26(1 Suppl):S106-16.
Somkote T, Detsomboonrat P. Early childhood caries in children
12. Ramos-Gomez FJ, Tomar SL, Ellison J, Artiga N, Sintes J, Vicuna aged 6-19 months. Community Dent Oral Epidemiol.
G. Assessment of early childhood caries and dietary habits in a 2004;32:133-42.
population of migrant Hispanic children in Stockton, California.
ASDC J Dent Child. 1999;66:395-403. 38. Hallet KB, O’Rourke PK. Early childhood caries and infant
feeding practice. Community Dent Health. 2002;19:237-42.
13. Acs G, Shulman R, Ng MW, Chussid S. The effect of dental
rehabilitation on the body weight of children with early childhood 39. Quiñonez RB, Keels MA, Vann Jr WF, McIver FT, Heller K, Whitt
caries. Pediatr Dent. 1999;21:109-13. JK. Early childhood caries: analysis of psychosocial and biological
factors in a high-risk population. Caries Res. 2001;35:376-83.
14. Ismail AI, Sohn W. A systematic review of clinical diagnostic
criteria of early childhood caries. J Public Health Dent. 40. Wendt LK, Hallosten AL, Koch G, Birkhed D. Analysis of caries-
1999;59:171-91. related factors in infants and toddlers living in Sweden. Acta
Odontol Scand. 1996;54:131-7.
15. Brasil. Ministério da Saúde. Projeto SB Brasil 2003: condições
de bucal da população brasileira 2002-2003: resultados 41. Ruottinen S, Karjalainen S, Pienihäkkinen K, Langström H,
principais. Ministério da Saúde. Secretaria de Atenção à Saúde. Niinikoski H, Salminen M, et al. Sucrose intake since infancy and
Departamento de Atenção Básica. Coordenação de Saúde bucal dental health in 10-year-old children. Caries Res. 2004;38:142-8.
– Brasília: Ministério da Saúde; 2004. 68 p. Série C. Projetos, 42. Johansson I, Saeiinstrom AK, Rajan BP, Parameswaran A .
Programas e Relatórios. Salivary flow and dental caries in Indian children suffering from
16. Nowak A, Crall J. Prevencion de las enfermedades dentales. In: chronic malnutrition. Caries Res. 1992;26:38-43.
Pinkham JR, editor. Odontologia pediatrica. 2ª ed. México: 43. Rugg-Gunn AJ, al-Mohammadi SM, Butler TJ. Malnutrition and
Nueva Editorial Interamericana; 1994. p. 198-215. developmental defects of enamel in 2 to 6 years old Saudi boys.
17. Cameron AC, Widmer RP. Handbook of pediatric dentistry. Caries Res. 1998;32:181-92.
Sydney: Mosby-Wolfe; 1997. 44. Brasil. Ministério da Saúde. Secretaria de Política de Saúde.
18. Theilade E, Birkhed D. Dieta e cárie. In: Thylstrup A, Fejerskov Organização Pan-Americana da Saúde. Guia Alimentar para
O, editors.Tratado de cariologia. Rio de Janeiro: Cultura Médica; crianças menores de dois anos. Séria A Normas e Manuais
1988. p. 117-54. técnicos, no 107. Brasília: Ministério da Saúde; 2002.
19. Schafer TE, Adair SM. Prevention of dental disease. Pediatr Clin 45. Wan AKL, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI.
North Am. 2000;47:1021-42 A longitudinal study of Streptococcus mutans colonization in
20. American Academy of Pediatric Dentistry. Oral health polices. infants after tooth eruption. J Dent Res. 2003;82:504-8.
Baby bottle tooth decay/early childhood caries. Reference 46. Davenport ES, Litenas C, Barbayiannis P, Williams CES. The
Manual 1999-2000. Pediatr Dent. 2000;21:18-9. effects of diet, breast-feeding and weaning on caries risk for
21. Valaitis R, Hesch R, Passarelli C, Sheehan D, Sinton J. A pre-term and low birth weight children. Int J Paediatr Dent.
systematic review of the relationship between breastfeeding 2004;14:251-9.
and early childhood caries. Can J Public Health. 2000;91:411-7. 47. Reddy DK, Hedge AM, Munshi AK. Dental caries status of
22. World Health Organization. Dentition status and criteria for children with bronchial asthma. J Clin Pediatr Dent. 2003;27:
diagnosis and coding (Caries). WHO Oral Health Surveys – Basic 293-5.
Methods. 4th ed. Geneva: WHO; 1997. p. 39-44. 48. Shantinath SD, Breiger D, Williams BJ, Hasazi JE. The relationship
23. Nainar SMH, Mohummed S. Dental health of children. Clin Ped. of sleep problems and sleep-associated feeding to nursing
2004;43:129-33. caries. Pediatr Dent. 1996;18:375-8.
24. Slavkin HC. Streptococcus mutans, early childhood caries and 49. Wan AKL, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI.
new opportunities. J Am Dent Assoc. 1999;130:1787-92. Oral colonization of Streptococcus mutans in six-month-old
25. Weerheijm KL, Uyttendaele-Speybrouck BFM, Euwe HC, Groen predentate infants. J Dent Res. 2001;80:2060-5.
HJ. Prolonged demand breast-feeding and nursing caries. Caries 50. Peressini S. Pacifier use and early childhood caries: an evidence-
Res. 1998;32:46-50. based study of the literature. J Can Dent Assoc. 2003;69:16-9.
26. Rajab LD, Hamdan MAM. Early childhood caries and risk factors 51. Bowen WH, Pearson SK. Effect of milk on cariogenesis. Caries
in Jordan. Community Dent Health. 2002;19:224-9. Res. 1993;27:461-6.
Breastfeeding and caries – Ribeiro NM & Ribeiro MA Jornal de Pediatria - Vol. 80, No.5(Suppl), 2004 S209

52. Giugliani ERJ. O Aleitamento materno na prática clínica. J 77. Serventi M, Dal Lago AM, Kimaro DN. Early cessation of breast
Pediatr (Rio J). 2000;76(Supl 3):S238-52. feeding as a major cause of severe malnutrition in under twos:
53. American Academy of Pediatrics. Work Group on Breastfeeding. a hospital based study- Dodoma Region, Tanzania. East Afr
Breastfeeding and the human milk. Pediatrics. 1997;100: Med J. 1995;72:132-4.
1035-9. 78. Shafer WG, Hine MK, Levy BM. Cárie dentária. In: Tratado de
patologia bucal. 4ª ed. Rio de Janeiro: Interamericana; 1985.
54. Erickson PR, McClintock KL, Green N, LaFleur J. Estimation of
p. 376-442.
the caries-related risk associated with infant formulas. Pediatr
Dent. 1998;20:395-403. 79. Restarski JS. Incidence of dental caries among pure-blooded
Samoans. US Naval Med Bull. 1943;41:1713-15.
55. Peres RC, Coppi LC, Franco EM, Volpato MC, Groppo FC,
Rosalen PL. Cariogenicity of different types of milk: an 80. Rosenbury T, Karshan M. Dietary habits of Kuskokwim Eskimos
experimental study using animal model. Braz Dent J. with varying degrees of dental caries. J Dent Res.
2002;13:27-32. 1937;16:307-9.
56. Sheikh C, Erickson PR. Evaluation of plaque pH changes 81. Bruerd B, Kinney MB, Bothwell E. Preventing baby bottle tooth
following oral rinse with eight infant formulas. Pediatr Dent. decay in American Indian and Alaska Native communities: a
1996;18:200-4. model for planning. Publ Health Rep. 1989;104:631-40.
57. Birkhed D, Imfeld T, Edwardsson S. pH changes in human 82. Marshall TA, Levy SM, Broffitt B, Warren JJ, Eichenberger-
dental plaque from lactose and milk before and after adaptation. Gilmor JM, Burns TL, et al. Dental caries and beverage
Caries Res. 1993;27:43-50. consumption in young children. Pediatrics. 2003 Sep;112(3 Pt
1):e184-91.
58. Gardner DE, Norwood JR, Eisenson JE. At will breast-feeding
and dental caries: Four case reports. ASDC J Dent Child. 83. Venâncio SI, Monteiro CA. A tendência da prática de
1977;44:186-91. amamentação infantil no Brasil nas décadas de 70 e 80. Rev
Bras Epidemiol. 1998;1:40-9.
59. Kotlow LA. Breastfeeding: a cause of dental caries in children.
ASDC J Dent Child. 1977;44:192-3. 84. Kummer SC, Giugliani ERJ, Susin LO, Folleto JL, Lermen JR, Wu
VYJ, et al. Evolução do padrão do aleitamento materno. Rev
60. Brams M, Maloney J. “Nursing bottle caries” in breast-fed Saude Publ. 2000;34:143-8.
children. J Pediatr. 1983;103:415-6.
85. Lawoyin TO, Onadeko MO, Olawuyi JF. Factors associated with
61. Erickson PR, Mazhari E. Investigation of the role of human exclusive breastfeeding in Ibadan, Nigeria. J Hum Lact.
breast milk in caries development. Pediatr Dent.1999;21:86-90. 2001;17:321-5.
62. Escott R. Positioning attachment and milk transfer. Breastfeed 86. Barros FC, Victora CG, Semer TC, Tonioli Filho S, Tomasi E,
Rev. 1989;1:31-7. Weiderpass E. Use of pacifiers is associated with decreased
63. Palmer B [site na Internet]. Kansas city: [atualizado 21 de breast-feeding duration. Pediatrics. 1995;95:497-9.
maio de 2004; Citado 22 de maio de 2004]. Infant dental 87. Marques NM, Lira PIC, Lima MC, Silva NL, Batista Filho M,
decay is it related to breastfeeding? 2000; [aproximadamente Hutlly SRA, et al. Breastfeeding and early weaning practices in
12 telas]. Disponível em: http://www.brianpalmerdds.com/ northeast in Brazil: a longitudinal study. Pediatrics. 2001
caries.htm. Oct;108(4):E66.
64. Wendt LK, Birkhed D. Dietary habits related to caries status in 88. World Health Organization [site na internet]. [atualizado 03
development and immigrant infants. Acta Odontol Scand. setembro de 2003; citado 25 maio de 2004]. Nutrition data
1995;53:339-44. bank. Global data banks on breastfeeding [aproximadamente
65. Santos APP, Soviero VM. Caries prevalence and risk factors 3 telas]. Disponível em: http://www.who.int/nut/db_bfd.hmt.
among children aged 0 to 36 months. Pesqui Odontol Bras. 89. UNICEF [site na internet]. [atualizado 27 maio de 2004; citado
2002;16:203-8. 27 maio 2004]. Trends in exclusive breastfeeding. The state of
66. Matee M, van’t Hof M, Maselle S, Mikx F, Van Palenstein the World’s Children. 2003. [aproximadamente 2 telas].
Helderman WH. Nursing caries, linear hypoplasia, and nursing Disponível em: http://www.unicef.org/sowc02/g11.htm.
and weaning habits in Tanzanian infants. Community Dent 90. Brasil. Ministério da Saúde. Secretaria Executiva. A saúde no
Oral Epidemiol. 1994;22:289-93. Brasil. Estatísticas essenciais-1990-2000. Série G. Estatística
67. Rosemblatt A, Zarzar P. The prevalence of early childhood e informação para a saúde no 22. Brasília: Ministério da Saúde;
caries in 12- to 36-month-old children in Recife, Brazil. ASDC 2001.
J Dent Child. 2002;69:319-24. 91. Gigante DP, Victora CG, Barros FC. Nutrição materna e
duração da amamentação em uma coorte de nascimento de
68. King NM, Wu II, Tsai JS. Caries prevalence and distribution,
Pelotas, RS. Rev Saude Publ. 2000;34:259-65.
and oral health habits of zero- to four-year-old children in
Macau, China. J Dent Child (Chic). 2003;70:243-9. 92. Horta BL, Barros FC, Halpern R, Victora CG. Baixo peso ao
nascer em duas coortes de base populacional no sul do Brasil.
69. Jose B, King NM. Early childhood caries lesions in preschool
Cad Saude Publ. 1996;12(Supl 1):S27-31.
children in Kerala, India. Pediatr Dent. 2003;25:594-600.
93. World Health Organization. Collaborative Study Team on the
70. Dye BA, Shenkin JD, Ogden CL, Marshall TA, Levy SM, Kanellis
Role of Breastfeeding on the Prevention of Infant Mortality:
MJ. The relationship between healthful eating practices and
How much does breastfeeding protect against infant and child
dental caries in children aged 2-5 years in the United States,
mortality due to infections diseases: a pooled analysis of six
1988-1994. J Am Dent Assoc. 2004;135:55-66.
studies from less developed countries. Lancet. 2000;355:451-5.
71. Matee MIN, Mikx FHM, Maselle SYM, Helderman WHVP. Rampant
94. Oddy WH, Peat JK. Breastfeeding, asthma, and atopic disease:
caries and linear hypoplasia. Caries Res. 1992;26:205-8. an epidemiological review of the literature. J Hum Lact.
72. Matee MIN, Mikx FHM, Maselle SYM, Helderman WHVP. Mutans 2003;19:250-61.
Streptococci and Lactobacilli in breast-fed children with rampant 95. Gimeno SG, Souza JM. IDDM and milk consumption. A case-
caries. Caries Res. 1992;26:183-7. control study in Sao Paulo, Brazil. Diabetes Care.1997;20:
73. al Ghanim NA, Adenubi JO, Wyne AA, Khan NB. Caries 1256-60.
prediction model in pre-school children in Riyadh, Saudi 96. Medeiros JS, Rivera MAA, Benigna MJC, Cardoso MAA, Costa
Arabia. Int J Paediatr Dent. 1998;8:115-22. M JC. Estudo de caso-controle sobre exposição precoce ao
74. Mattos-Graner RO, Zelante F, Line RC, Mayer MP. Association leite de vaca e ocorrência de Diabetes Mellitus tipo I em
between caries prevalence and clinical microbiological and Campina Grande, Paraíba. Revista Brasileira de Saúde Materno
dietary variables in 1,0 to 2,5-year-old Brazilian children. Infantil. 2003;3:271-80.
Caries Res. 1998;32:319-23. 97. Calvano LM. O poder imunológico do leite materno. In:
75. Oulis CJ, Berdouses ED, Vadiakas G, Lygidakis NA. Feeding Carvalho MR, Tamez RN, editores. Amamentação. Bases
practices of Greek children with and without nursing caries. Científicas para a prática profissional. Rio de Janeiro:
Pediatr Dent. 1999;21:409-16. Guanabara-Koogan; 2002. p. 88-95.
76. Shirima R, Greiner T, Kylberg E, Gebre-Medhin M. Exclusive 98. Marcotte H, Lavoie MC. Oral microbial ecology and the role of
breast-feeding is rarely practiced in rural and urban Morogoro, salivary immunoglobulin A. Microbiol Mol Biol Rev.
Tanzania. Public Health Nutr. 2001;4:147-54. 1998;62:71-109.
S210 Jornal de Pediatria - Vol. 80, No.5(suppl), 2004 Breastfeeding and caries – Ribeiro NM & Ribeiro MA

99. Kunz C, Rodrigues-Palmero M, Koletzko B, Jensen R. Nutritional Corresponding author:

and biochemical properties of human milk, Part I: General Nilza Margarete Eder Ribeiro
aspects, proteins, and carbohydrates. Clin Perinatol. Av. 15 de Janeiro, 504
1999;26:307-33. CEP 92010-300 - Canoas, RS
100. Araújo FB, Cury JA, Araújo DR, Velasco LFL. Estudo in situ da Brazil
cariogenicidade do leite humano: aspectos clínicos. Revista da Phone: +55 (51) 472-6858
ABO Nacional. 1997;4:42-3. E-mail: [email protected]