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Clinical Summary

The etiology of dental caries is multifactorial with an interplay between microflora (plaque colonized with Streptococcus mutans), substrate (fermentable carbohydrates from breast milk, formula, or juice), environmental factors (poor parental education, low socioeconomic status), and host (saliva and teeth). Nursing or milk bottle caries result from prolonged and frequent night time breastfeeding or sleeping with a bottle containing milk or sugar-containing juices. The sugars are fermented by the bacteria in plaque, lowering the pH in the mouth and resulting in demineralization of the tooth enamel. The condition generally occurs before 18 months of age and is more prevalent in medically underserved children. Upper central incisors are most commonly involved. Outpatient dental referral is indicated.

Management and Disposition

Parental education and timely referral to a dentist are necessary to prevent complications. If untreated, the caries may destroy the teeth and spread to contiguous tissues. These patients have a high risk for microbial invasion of the pulp and alveolar bone with the subsequent development of a dental abscess and facial cellulitis. In these cases, aggressive treatment with antibiotics (amoxicillin) and pain control, with prompt dental referral for definitive care, is necessary.


  1. The role of the emergency department physician is to recognize this pattern of dental decay (upper incisors most commonly) and initiate dental referral and parental education.

  2. Nursing or milk bottle caries tends to spare the lower front teeth because of the shielding of the lip and tongue and the increased exposure to saliva from the sublingual glands that washes away cariogenic substrates.

  3. The newborn mouth is generally devoid of microorganisms. Newborns and infants are colonized with S mutans from parents and family members. Education on avoidance of sharing utensils and cups may help delay colonization of infants.

FIGURE 14.112

Nursing Bottle Caries. Extensive tooth decay from sleeping with bottle containing milk or sugar-containing juices. (Photo contributor: Lawrence B. Stack, MD.)

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