Do you also think that “Fluoride” is the gold standard in preventing the prevalence of Early Childhood Caries (ECC)? Well, the clinical reality is a bit different, and studies have proven that fluoride alone is no longer enough! 

As ECC is multifactorial; so, prevention strategy must also be multifaceted and holistic. It must span around education, behaviour change, diet, sealants, probiotics, and even lifestyle factors like screen time.  

Why We Can’t Stop at Fluoride 

Fluoride remains a cornerstone in caries prevention, yet evidence consistently shows it cannot fully eliminate the risk of ECC. 

• Fluoride varnish reduces caries prevalence by 43% in primary teeth and 37% in permanent teeth¹. 
• Fluoride toothpaste lowers caries incidence by 24–30%^1. 

Undoubtedly, these figures are enthralling, but they also point towards the prevalence of the critical gap. The reason fluoride cannot 100% prevent ECC lies in the multifactorial risk factors driving the disease. 

Evidence-Based Prevention Beyond Fluoride 

1. Oral Hygiene Education 

• Educate parents on the significance of brushing right from the eruption of first tooth³.  

• Make parents pro in selecting right toothbrush with soft bristle and in right brushing technique- gentle circular motions, proper flossing once adjacent teeth contact^1,3. 

• Don’t forget to include screen-time counselling. Studies show that excessive screen time is directly linked to higher intake of cariogenic foods. Stats reveal that 22% of meals are consumed in front of screens; in turn, reducing brushing frequency. Thus, both accelerate ECC risk⁴. 

2. Diet & Feeding Practices 

• Educate parents on dietary intervention like sugar intake must be <10% of daily caloric intake while highlighting the ways to identify the hidden sugars in packaged foods and beverages^1,5.  

• Promote healthy snacking in the form of fruits and veggies to enhance salivary flow and natural remineralization. 

Remember just like the fluoride factor; parent factor is equivalently important! 

4. Sealants 

• Resin-based sealants are a great way to reduce caries risk on primary molars among children over 2–7 years and up to 76–85% reduction can be achieved^1. 

• Along with sealants, you can add an extra layer of protection of glass ionomer cement (GIC) sealants especially in challenging moisture conditions because they release fluoride. 

*Recommendation: This is ideal for children between the ages group of 3 to 6 and ones with enamel defects, deep fissures and early demineralization¹.  

5. Probiotics 

• Probiotics have emerged as a valuable adjunct in ECC prevention. They help by targeting and modulating the oral microbiome. Strains such as Lactobacillus rhamnosus and Bifidobacterium lactis have shown inhibitory effects on cariogenic bacteria, especially, Streptococcus mutans¹.  

• Studies reveal that when used as an adjunct to fluoride toothpaste, the intervention reduced early enamel demineralization by 75% ^1. 

6. Silver diamine fluoride (SDF)⁶ 

• Studies have found that 38% SDF, an ammonia solution containing fluoride and silver ions can slow dentine and enamel demineralisation. 

• It is a great option for uncooperative or medically fragile children due to its non-invasive nature. 

7. Xylitol⁷ 

• Xylitol, a naturally occurring and FDA approved nutritional additive.  

• Studies have reported that the consumption of xylitol (5–10 g/day) decreases caries incidence ranging between 30% and 80%. 

8. CPP–ACP (Casein phosphopeptide–amorphous calcium phosphate)⁸ 

• It stabilizes calcium and phosphate ions in plaque, helping to prevent enamel demineralization and promote remineralization during acidogenic challenges.  

• It also reduces the adhesion of Streptococcus mutans, supporting a less cariogenic biofilm.  

• Studies have found that fluoride varnishes enhanced with CPP–ACP provide additional caries protection. This is because CPP–ACP increases the release of fluoride ion from the varnish, further enhancing its remineralization potential. 

9. Risk Assessment⁹ 

• Use tools like CAMBRA to guide decisions.  

• Engage the caregiver, explain simply, and gather key details on health status, fluoride exposure, brushing habits, family caries history, dental visits, feeding practices, and diet. 

• Respectful, culturally sensitive interviews help tailor prevention to each child’s risk. 

Final Takeaway 

ECC prevention demands a layered defense system, in which fluoride acts as the foundation. So, next time when you need to deal with the tiny teeth, do use this holistic way and layer them as per the need of the child. 

References  

1. Aljohani AA, Alarifi AI, Almoain MF, Alrhaimi FF, Alhejji MT, Gazzaz NW, Ali LS, Alammari HD, Alwattban RR, Alharbi HM, Barnawi BM. Managing early childhood caries: a comparative review of preventive and restorative approaches. Cureus. 2024 Nov 28;16(11). 

2. Puspitawati Y, Sulistiani S, Afdilla N. The role of parents in ECC prevention: A cross-sectional study. Journal of International Dental and Medical Research. 2023 Sep 1;16(3):1220-6. 

3. Meyer F, Enax J. Early childhood caries: epidemiology, aetiology, and prevention. International journal of dentistry. 2018;2018(1):1415873. 

4. Robin A, Padmanabhan V, Swaminathan K, Kc V, Haridoss S, Vignesh KC. Association Between Screen Time, Dietary Patterns, and Oral Health Among Children: A Cross-Sectional Study. Cureus. 2025 Mar 28;17(3). 

5. Centers for Disease Control and Prevention. Get the facts: Added sugars. Centers for Disease Control and Prevention; 2024 Jan 5. Available from: https://www.cdc.gov/nutrition/php/data-research/added-sugars.html 

6. Gao SS, Chen KJ, Duangthip D, Wong MC, Lo EC, Chu CH. Preventing early childhood caries with silver diamine fluoride: study protocol for a randomised clinical trial. Trials. 2020 Feb 4;21(1):140. 

7. ALHumaid J, Bamashmous M. Meta-analysis on the effectiveness of xylitol in caries prevention. Journal of International Society of Preventive and Community Dentistry. 2022 Mar 1;12(2):133-8. 

8. Attiguppe P, Malik N, Ballal S, Naik SV. CPP–ACP and fluoride: a synergism to combat caries. International journal of clinical pediatric dentistry. 2019 Mar;12(2):120. 

9. Featherstone JD, Chaffee BW. The evidence for caries management by risk assessment (CAMBRA®). Advances in dental research. 2018 Feb;29(1):9-14. 
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