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Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 7-11

Infant formula and early childhood caries

Department of Public Health Dentistry, KAHE's KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India

Date of Web Publication14-May-2018

Correspondence Address:
Dr. Saudamini Girish More
Department of Public Health Dentistry, KAHE's KLE VK Institute of Dental Sciences, Belagavi - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_11_18

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The prevalence of early childhood caries (ECC) is increasing worldwide. Impaired oral health could have a negative impact on the overall health of infants. ECC can continue to deteriorate the growth and development of the child in preschool stage. Feeding practices largely influence the occurrence of ECC. Infant formula is commonly used as supplements or substitutes for breast milk up to the first 2 years of age. The dietary sugars such as lactose and sucrose, present in the infant formula, could act as a favorable substrate and change the oral microflora. Infant formula constitutes of various minerals which are known to affect tooth mineralization including iron, fluoride, and calcium. A number of in vitro, animal, and human studies have been conducted to understand their effect on oral environment and microbiota. Exploring the scientific literature for different types of infant formula and their role in the etiopathogenesis of dental caries could give us an insight into the cariogenic potential of infant formula. Furthermore, this could be source of information for health practitioners as they are the ones who are first sought by parents for advice related to infant feeding.

Keywords: Dental caries, infant formula, infant oral health, sucrose

How to cite this article:
More SG, Sankeshwari R, Patil PA, Jalihal SS, Ankola AV. Infant formula and early childhood caries. J Dent Res Rev 2018;5:7-11

How to cite this URL:
More SG, Sankeshwari R, Patil PA, Jalihal SS, Ankola AV. Infant formula and early childhood caries. J Dent Res Rev [serial online] 2018 [cited 2023 Jan 31];5:7-11. Available from: https://www.jdrr.org/text.asp?2018/5/1/7/232360

  Introduction Top

Early childhood caries (ECC) is considered to be the most prevalent disease and contributes to unmet health needs among children.[1] ECC is defined as the presence of one or more decayed (noncavitated or cavitated), missing due to caries, or filled tooth surfaces in any primary tooth in a child aged 71 months or younger.[2] Dental caries is a disease of multifactorial etiology.[3] The key microorganisms causing ECC is mutans streptococci (MS) which comprise Streptococcus mutans and Streptococcus sobrinus while the other microorganisms include Lactobacillus and Streptococcus sanguis.[4] Other common factors for causing ECC include feeding during the night, frequency of exposure to foods, and foods having higher sucrose content.

The World Health Organization has recommended feeding infants with human's milk and infant formulas up to the age of 2 years. Bovine milk can only be introduced after 6 months of age.[5] However, there exists a discrepancy of opinion between pediatricians and dentists regarding the duration of infant feeding.[6] This is mainly because the sugars present in breast milk and infant formulas act as favorable substrate for initiation of dental caries. Hence, this review compiles the literature about infant formula and its possible contribution in dental caries formation.

  Methodology Top

A literature search was carried out on infant formula and its role in the causation of ECC. PubMed/Medline and Google Scholar databases were searched using the following keywords: “infant formula,” “dental caries,” “early childhood caries,” and “infant feeding.” A total of ten articles which were found relevant from January 1993 to October 2017 are included in the review.

  Infant Oral Microbiota Top

The microbiota inhabiting in the oral cavity and other parts of the gastrointestinal (GI) tract develops from sterility at birth into the most heavily colonized parts of the human body.[7] Different environmental conditions can lead to distinct bacterial communities at the different anatomical niches of the GI tract. There are over 700 taxa which have been identified in the colon and mouth. However, minimal species overlap between the two sites.[7]

Establishment of stable bacterial ecosystems in the GI tract, including the mouth, evolves during a period of microbial variation chiefly during the first 2 years of life.[8] The initial colonizers are facultatively anaerobic in genera, such as streptococci and Actinomyces. These are succeeded by more strictly anaerobic genera, such as Bifidobaterium in the gut and Veillonella in the mouth.[4]

  Infant Formula Top

It is an alternative to breast milk for feeding the child and is obtained from other human (surrogate mothers) or another mammal. The most frequently used sources include the cow, sheep, and goat.[9]

Numerous health organizations, including the World Health Organization (2002), the American Academy of Pediatrics (1997), the American Academy of Family Physicians (2003), and various others, promote breastfeeding as the ideal form of nutrition for infants during the 1st year of life. Even so, a vast majority of infants in various parts of the world are fed human's milk substitutes since the age of 6 months.[9] Even though these food sources are inferior to human's milk in multiple respects, it promotes more efficient growth, development, and nutrient balance than commercially available cow's milk. It is recommended that infants who are not breastfed should consume iron-fortified infant formulas rather than cow's or goat's milk until 12 months of age by the American Academy of Pediatrics.[8]

Infant formulas can be used as substitutes or supplements for human's milk. Infant formulas are commonly recommended in low birth weight babies, cases of malnutrition, emergency situations such as famines, vulnerable groups, HIV-positive mother, and lactose intolerant babies.[8]

Infant formulas are of two types: cow's milk-based formulas and noncow's milk-based formulas. [Table 1] shows the history and development of infant formula.[8]
Table 1: History of the development of milk formulas

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By the early 20th century, it was clear that cow's milk was most likely the best animal-milk base to work with but that certain modifications were needed to make it safe and palatable for human infants. These modifications included removing animal fat and substituting vegetable oils, diluting the protein content for the newborn's relatively immature renal tubular system, and adding or balancing minerals and vitamins (e.g., adding iron, adjusting the calcium:phosphorus ratio).[8]

  Essential Composition Top

Infant formula is a milk-based product obtained from cows or other animals or a mixture of other ingredients which have been proven to be suitable for infant feeding. All ingredients and food additives should be gluten free. Infant formula prepared ready for consumption in accordance with instructions of the manufacturer should contain per 100 ml not <60 kcal (250 kJ) and not >70 kcal (295 kJ) of energy.[9] The composition of infant formulas includes protein, lipid, carbohydrate, linoleic acid, vitamins, and minerals in standardized ranges. When prepared according to the label directions for use, the product should be free of lumps and of large coarse particles and suitable for adequate feeding of young infants. The ingredients should be clean, of good quality, safe and suitable for ingestion by infants. Furthermore, the normal quality requirements, such as color, flavor, and odor, are assessed. Various thickeners and acidity regulators are also added to it. The product and its component should not have been treated by ionizing irradiation. Thus, the nutritional safety and adequacy of the formula should be scientifically demonstrated to support growth and development of infants.[9]

The carbohydrate content in infant formula is predominantly distributed among lactose, sucrose, maltose, or glucose. Formulas highest in sucrose are alternatives to lactose-containing milk-based formulas. The grams of total sugars per se rving ranged from 1.28 to 11.16 g. Some products are found to be containing 12 g of sugar per se rving.[10]

Various in vitro studies conducted on rat teeth [Table 2] and human teeth [Table 3] have tried to evaluate the cariogenic potential of infant formulas. Some in vivo studies [Table 4] have also tried to compare the cariogenic potential of commercially available infant formulas.
Table 2: Studies conducted on rats

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Table 3: In vitro studies conducted on human teeth

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Table 4: Studies on human participants

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Breast milk provides nutrition for the infant and is a source of lactobacilli, Bifidobacteria, and streptococci.[21],[22] However, components of breast milk inhibit growth and attachment of the cariogenic bacteria, S. mutans in particular.[22] A study conducted by Holgerson et al.[23] revealed that the Lactobacillus counts in the oral cavity were higher in breastfed as compared to formula-fed infants. They also concluded that lactobacilli species had an inhibitory effect on MS. This suggested that formula-fed infants were at higher risk of developing dental caries. A systematic review compared various commercially available infant formulas; however, limited evidence was found regarding the cariogenic effect of infant formulas.[24]

  Effect of Fluoride Top

Fluoride has been established as a caries-preventing agent when used in systemic or topical formulations. Evidence from studies conducted in the USA, Australia, and Brazil suggests that there is a higher concentration of fluoride in infant formulas.[25],[26] Some studies have also reported that formula fed infants had lesser caries prevalence as compared to nonformula fed.[27],[28] However, in a study conducted by Peres et al.,[14] the MS counts were higher in Wistar rats which were given fluoride-supplemented infant formulas as compared to human's or cow's milk. This was mainly attributed to higher concentration of sucrose and reducing sugars present in the infant formulas. A study has shown that the fluoride level in infant formulas available in India is slightly less than the optimal fluoride requirement in milk.[29]

  Cariogenic Potential of Human's Milk and Cow's Milk Top

The prevalence of dental caries caused by cow's milk is relatively low as compared to human's milk. In comparison with cow's milk, breast milk has a low mineral content, higher concentration of lactose (7% vs. 3%), and lower protein content (1.2 g/100 ml vs. 3.3 g/100 ml).[30] Thus, cow's milk could have a better remineralization potential of teeth.

  Cariogenic Potential of Infant Formulas Top

Carbohydrates used in formula are mainly sucrose and lactose. Sucrose is considered to be the most cariogenic dietary carbohydrate, fermentable by the oral bacteria. This process results in reduction of pH in the oral cavity causing dental caries. It also acts as a substrate for the formation of extra- and intra-cellular polysaccharides in dental plaque. These biofilms have more cariogenic potential. Lactose is less readily fermented by S. mutans as compared to sucrose.

  Conclusions Top

Various studies conducted showed that infant formulas containing sucrose and/or corn syrup solids are more acidogenic and hence more cariogenic than lactose-containing formulas. Furthermore, in the study conducted by Erickson et al.[13] which compared the cariogenic potential of different infant formulas, sucrose water, and bovine milk, it revealed that bovine milk was least cariogenic. Formulas containing casein are proven to be less cariogenic than others. Low-iron formulas can cause increase in the S. mutans biofilm formation as compared to normal iron containing at dilution.


Health practitioners should take into consideration the composition of infant formula before recommending them. Since pediatricians and dentists are more likely to see infants and toddlers, they are in a better position to advice parents regarding early initiation of oral hygiene practices for the prevention of ECC.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America's children. Pediatrics 2000;105:989-97.  Back to cited text no. 1
American Academy of Pediatric Dentistry. Definition of Early Childhood Caries (ECC). American Academy of Pediatric Dentistry; 2008. p. 4.  Back to cited text no. 2
Frazão P. Epidemiology of dental caries: When structure and context matter. Braz Oral Res 2012;26 Suppl 1:108-14.  Back to cited text no. 3
Cephas KD, Kim J, Mathai RA, Barry KA, Dowd SE, Meline BS, et al. Comparative analysis of salivary bacterial microbiome diversity in edentulous infants and their mothers or primary care givers using pyrosequencing. PLoS One 2011;6:e23503.  Back to cited text no. 4
Infant and Young Child Feeding. Model Chapters for textbooks for medical students and allied health professionals. World Health Organization; 2009. Available from: http://www.wpro.who.int/nutrition_wpr/publications/infantchildfeeding.pdf. [Last accessed on 2018 Apr 04].  Back to cited text no. 5
Sankeshwari RM, Ankola AV, Tangade PS, Hebbal MI. Feeding habits and oral hygiene practices as determinants of early childhood caries in 3- to 5-year-old children of Belgaum City, India. Oral Health Prev Dent 2012;10:283-90.  Back to cited text no. 6
Costello EK, Lauber CL, Hamady M, Fierer N, Gordon JI, Knight R, et al. Bacterial community variation in human body habitats across space and time. Science 2009;326:1694-7.  Back to cited text no. 7
Adlerberth I, Wold AE. Establishment of the gut microbiota in Western infants. Acta Paediatr 2009;98:229-38.  Back to cited text no. 8
Walker RW, Goran MI. Laboratory determined sugar content and composition of commercial infant formulas, baby foods and common grocery items targeted to children. Nutrients 2015;7:5850-67.  Back to cited text no. 9
Institute of Medicine (US) Committee on the Evaluation of the Addition of Ingredients New to Infant Formula. Executive Summary. Infant Formula: Evaluating the Safety of New Ingredients. Washington (DC): National Academies Press (US); 2004.  Back to cited text no. 10
Bowen WH, Pearson SK. Effect of milk on cariogenesis. Caries Res 1993;27:461-6.  Back to cited text no. 11
Bowen WH, Pearson SK, Rosalen PL, Miguel JC, Shih AY. Assessing the cariogenic potential of some infant formulas, milk and sugar solutions. J Am Dent Assoc 1997;128:865-71.  Back to cited text no. 12
Erickson PR, McClintock KL, Green N, LaFleur J. Estimation of the caries-related risk associated with infant formulas. Pediatr Dent 1998;20:395-403.  Back to cited text no. 13
Peres RC, Coppi LC, Franco EM, Volpato MC, Groppo FC, Rosalen PL. Cariogenicity of different types of milk: an experimental study using animal model. Braz Dent J 2002;13:27-32.  Back to cited text no. 14
Bowen WH, Lawrence RA. Comparison of the cariogenicity of cola, honey, cow milk, human milk, and sucrose. Pediatrics 2005;116:921-6.  Back to cited text no. 15
Peres RC, Coppi LC, Volpato MC, Groppo FC, Cury JA, Rosalen PL. Cariogenic potential of cows', human and infant formula milks and effect of fluoride supplementation. British J Nutr 2008;101:376-82.  Back to cited text no. 16
Hinds LM, Moser EAS, Eckert G, Gregory RL. Effect of Infant Formula on Streptococcus Mutans Biofilm Formation. J Clin Pediatr Dent 2016;40:178-85.  Back to cited text no. 17
Munshi AK, Kavita H, Santhi KP. Acidogenic potential of the infant milk formulas marketed in India. J Indian Soc Pedo Prev Dent 2001:1-8.  Back to cited text no. 18
Masih U, Prabhakar M, Joshi JL, Mahay P. A comparative study of acidogenic potential of milk and commonly used milk formulae. Int J Dent Clin 2010;2:30-2.  Back to cited text no. 19
Raju AS, Hirehal M, Manjunath PG, Reddy VV, Natraj CG. The acidogenic potential of different milk formulas on dental plaque pH. Oral Health Prev Dent 2012;10:225-30.  Back to cited text no. 20
Martín R, Heilig GH, Zoetendal EG, Smidt H, Rodríguez JM. Diversity of the Lactobacillus group in breast milk and vagina of healthy women and potential role in the colonization of the infant gut. J Appl Microbiol 2007;103:2638-44.  Back to cited text no. 21
Danielsson Niemi L, Hernell O, Johansson I. Human milk compounds inhibiting adhesion of mutans streptococci to host ligand-coated hydroxyapatite in vitro. Caries Res 2009;43:171-8.  Back to cited text no. 22
Holgerson PL, Vestman NR, Claesson R, Ohman C, Domellöf M, Tanner AC, et al. Oral microbial profile discriminates breast-fed from formula-fed infants. J Pediatr Gastroenterol Nutr 2013;56:127-36.  Back to cited text no. 23
Tan SF, Tong HJ, Lin XY, Mok B, Hong CH. The cariogenicity of commercial infant formulas: A systematic review. Eur Arch Paediatr Dent 2016;17:145-56.  Back to cited text no. 24
Silva M, Reynolds EC. Fluoride content of infant formulae in Australia. Aust Dent J 1996;41:37-42.  Back to cited text no. 25
Nagata ME, Delbem AC, Kondo KY, de Castro LP, Hall KB, Percinoto C, et al. Fluoride concentrations of milk, infant formulae, and soy-based products commercially available in Brazil. J Public Health Dent 2016;76:129-35.  Back to cited text no. 26
Do LG, Levy SM, Spencer AJ. Association between infant formula feeding and dental fluorosis and caries in Australian children. J Public Health Dent 2012;72:112-21.  Back to cited text no. 27
Hujoel PP, Zina LG, Moimaz SA, Cunha-Cruz J. Infant formula and enamel fluorosis: A systematic review. J Am Dent Assoc 2009;140:841-54.  Back to cited text no. 28
Rahul P, Hegde AM, Munshi AK. Estimation of the fluoride concentrations in human breast milk, cow's milk and infant formulae. J Clin Pediatr Dent 2003;27:257-60.  Back to cited text no. 29
Aarthi J, Muthu MS, Sujatha S. Cariogenic potential of milk and infant formulas: A systematic review. Eur Arch Paediatr Dent 2013;14:289-300.  Back to cited text no. 30


  [Table 1], [Table 2], [Table 3], [Table 4]

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Infant Oral Micr...
Infant Formula
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Effect of Fluoride
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