Prolonged Breastfeeding And Dental Caries In Ghanaian Children

INTRODUCTION: 
Various authors have studied the effects of breast milk on Infant's deciduous teeth. Whilst some have come to the conclusion that breastfeeding causes caries, others have concluded that breastfeeding is even protective against caries. A review of the literature shows these two schools of thought. The findings of those convinced of an association are as follows.

1. Position of the American Academy of Paediatric Dentistry (AAPD): In 1996 the AAPD stated that, "the risk of potentially devastating nursing-pattern dental decay exists for the breast-fed child as it does for the bottle-fed child." It goes on to say that, "Ad libitum nocturnal breastfeeding should be avoided after the first primary tooth begins to erupt."
2. Hackett et al (1984) quoted several reports from the U.K. and U. S. A. which suggested that under certain rare conditions, breastfeeding may cause rampant dental caries. They gave experimental evidence suggesting that human milk possesses a greater cariogenic potential than bovine milk. The prevalence appears very low and is associated with breast or bottle feeding which has continued for at least two years of age, on many occasions during the day and night.
3. Don Gardner et al (1977) reported based on observing caries in infants whose mothers were adamant about breastfeeding, that breast milk alone or with carbohydrates, can be cariogenic. They recommended mothers discontinue nursing as soon as the child can drink from a cup (approximately 12-15 month). These authors even felt they were the first to make a link between breastfeeding and caries.

For the other school of thought these are their findings:-

1. Irwin Mandel (1996) stated that 1gG and 1gA which retard Streptococcus mutans (one of the major cariogenic organisms) are present in breast milk.
2. Arnold R. et al (1977) stated that Streptococcus mutans is highly susceptible to the bactericidal action of lactoferrin which is present in breast milk
3. Weerheijm (1998) concluded that prolonged demand breastfeeding does not lead to higher caries prevalence.
4. Weber et al (1986) demonstrated by ultrasonographic studies that milk is normally expressed into throat whilst breastfeeding, not around teeth in the mouth.
5. Bruerd et al (1989) studied prehistoric skulls in Native American 
Communities and compared them to modern Native Americans. A decay rate of 57% was observed in modern times compared to 1.4
in the skulls. 
They concluded that babies were breastfed for 92,000 years before the advent of caries only about 8,000-10,000 years ago.
In Ghana, there have always been anecdotal tales about an association between prolonged breastfeeding and burnt teeth. However, there have never been any studies done to find out the truth or otherwise.
The objective of this study was to find out if there is an association between prolonged breastfeeding and dental caries and the nature of such an association.

MATERIALS AND METHODS:
A case-control study was done using a pretested questionnaire. Mothers of children between the ages of 18 months (one case - exposure 12 months) and six years who had all their deciduous teeth intact and were coming to the dental clinic for the first time were interviewed and the children examined. Mothers of 46 children in all were interviewed. 28 of the children were cases whilst 18 were used as controls. A case was defined as rampant caries of the anterior teeth with or without posterior teeth involvement. Exposure to sweets, was defined as those taking sweets and sugary foods and or were given frequent medications in the form of syrups whilst being breastfed. Prolonged breastfeeding was defined as any breastfeeding after the upper anterior teeth were through (1 year). Mothers were asked about how long they breastfed their children for, whether the children were also being given frequent sweets and sugary foods especially with a feeding bottle and whether the children were given frequent medication in the form of syrups and suspensions during the period of breastfeeding. Other data collected was the gender of the children, the age at which caries started appearing in the mouth and the teeth involved. A 95% confidence interval was established for the various groups.

RESULTS:
The mothers of 46 children were interviewed made up of 28 cases and 18 controls. The average age of the children was approximately 4 years and 3 months in both cases and controls and the age range was between eighteen months (one case exposure 12 months) and six years. The average duration of breastfeeding in cases was 23 months whilst that in the controls was 17 months. All the mothers breastfed day and night. Caries according to the mothers, occurred almost immediately after their upper anterior teeth started appearing, that is approximately about when they were 1 year of age. The gender comprised 16 females and 12 males in the cases and 10 females and 8 males in the controls. There was a fair distribution of sexes in exposed and unexposed cases and controls. 35% of the children were exclusively breastfed whilst 65% were being bottle fed or being given sweets or syrups in association with breastfeeding. The average DMFT for cases was 6 whilst that for controls was 0.

LIMITATIONS OF THE STUDY:
1. Controls were especially difficult to find, since in Ghana, patients do not visit the clinic unless there is a problem. This therefore stretched the study over 3 years before enough data could be collected.
2. At the time of seeing the children exposure to the risk had already occurred. Recall could have been a problem for the mothers.
3. It would have been useful for us to look at children who were mainly bottle-fed. Unfortunately, that is also not common in Ghana.

RECOMMENDATIONS AND CONCLUSION:
Breast milk is protective against caries for the first 18 months even in children who are also taking sweets and sugary substances. However, after 18 months, this protective effect is lost. Some reasons have been suggested for further studies to be conducted. The conclusion reached is that breastfeeding after 18 months in association with sugars could be cariogenic. Further work needs to be done using larger samples to establish whether exclusive breastfeeding could lead to Dental Caries. It is recommended however that weaning should be done around 18 months to be on the safer side since about 65% of mothers did not exclusively breastfeed.