Vol. 43. No. 1 March 2010
The frequency of bottle feeding as the main factor of baby bottle tooth
Mochamad Fahlevi Rizal1, Heriandi Sutadi1, Boy M Bachtiar2, and Endang W Bachtiar2
1Department of Pediatric Dentistry
2Department of Oral Biology
Faculty of Dentistry, University of Indonesia
Jakarta - Indonesia
Dental caries remains as main problem in Indonesia and its prevalence is high (90.05%). However, there is no
appropriate data that can be used to analyze dental caries in toddlers, especially baby bottle tooth decay syndrome (BBTD), though
the number of BBTD cases is high in some pediatric dental clinics (90% of patients visiting the clinics). Even though some factors have
already been considered to be the risk factor of BBTD, the main risk factor of BBTD is still unknown, especially BBTD in Indonesia.
This research was aimed to obtain data relating with bottle-feeding habit in 3–5 year old children in Indonesia and its caries
The study was an observational research conducted with clinical examination through caries status (deft) of each child
deserved by pediatric dentists and through questionnaire distributed to parents to examine the risk factor of BBTD. Observation was
conducted on 62 children in the range of age 3 to 5 years old with bottle-feeding habit.
The results revealed that status of caries
was various. The data showed that the frequency of bottle feeding more than twice could trigger BBTD 2.27 times higher than other
factors such as the use of bottle feeding as a pacifier prior sleeping, the period of bottle-feeding, and the breast-feeding experience.
though milk as subtract can possibly become a factor triggering caries, the frequency of bottle-feeding is highly considered
as main factor. Since it could modulated the bacterial colonization on dental surface, which affects its virulence.
the frequency of bottle-feeding, risk factor, baby bottle tooth decay syndrome
Karies masih menjadi masalah utama di Indonesia. Dalam praktek sehari-hari prevalensi karies masih sangat
tinggi (90.05%). Belum ada data yang memadai dalam penelaahan karies yang spesifik pada anak balita selama ini khususnya
kasus sindroma karies botol (SKB) sementara itu kasus SKB ditemukan sangat tinggi di beberapa klinik gigi anak (90% dari jumlah
pasien yang datang ke klinik). Beberapa faktor menjadi resiko kejadian SKB dan belum diketahui faktor resiko utama kejadian karies
khususnya di Indonesia.
Penelitian ini dilakukan guna mendapatkan data yang berhubungan dengan kebiasaan minum susu
botol pada anak usia 3–5 tahun di Indonesia serta resiko kejadian karies yang ditimbulkannya.
Penelitian ini merupakan
penelitian observasional yang dilakukan dengan metode pemeriksaan klinis melalui pencatatan status karies (deft) setiap anak oleh
dokter gigi anak serta pengisian kuesioner yang dilakukan oleh orang tua untuk menentukan faktor resiko kejadian SKB. Pengamatan
dilakukan pada 62 orang anak usia 3–5 tahun yang mempunyai kebiasaan minum susu botol sesuai dengan kriteria inklusi.
Hasil pemeriksaan klinis dan kuesioner memberikan gambaran status karies yang bervariasi. Data yang didapat dari penelitian ini
menjelaskan, bahwa frekuensi minum susu botol lebih dari dua kali menyebabkan SKB 2.27 kali lebih besar dibandingkan dengan
beberapa faktor lain, seperti menjadikannya pengantar tidur, lamanya mengonsumsi, dan riwayat minum ASI.
sebagai subtrat mungkin dapat dijadikan alasan kejadian karies akan tetapi yang menjadi resiko utama kejadian adalah frekuensi
Rizal et al.: Frequency of bottle-feeding
Dental caries remains as a dental health problem among
children in Indonesia. The prevalence of caries among
toddlers in Indonesia is approximately 85%, while caries
prevalence in general is approximately 90.05%.1-3 The data
indicated that the public health improvement programs
conducted by the government for long time is considered
to be failed. However, this epidemiologic description is
not only found in developing countries, but also found
in industrial countries.4-12 World Health Organization
in 2003 reported that the prevalence of caries among
children reached 60–90%.13 As a result dental caries,
especially nursing bottle syndrome (NBS) or baby bottle
tooth decay (BBTD) syndrome, becomes one of major
concerns for medical experts, and many research have
already been conducted.6 Since baby bottle tooth decay
(BBTD) syndrome usually attacks toddlers, it is also known
as nursing caries, baby bottle tooth decay, rampant caries,
labial caries, and maxillary anterior caries.14
In addition, clinical phenomena found in Jakarta and
surrounding areas indicate that the number of BBTD
patients in pediatric dental clinics is high. The preliminary
research conducted in three hospitals (two in urban area and
one in rural area of Jakarta) showed that the proportion of
children who suffer dental caries was about 95%. Based on
that result, we knew that even though milk is considered
as the source of nutrients for those children, not all of
children with bottle-feeding habit are suffering caries. The
number of tooth decay cases in children who suffer BBTD
is various. Nevertheless, as reported by some researcher,
the patients of BBTD are dominated by toddlers who
consume milk.16, 17
However, there is a controversy that nursing bottle
feeding could cause BBTD. Milk reported could prevent
demineralization process in enamels.18,19 On the other hand
Bowen20 reported that the sugar additional (2% minimum)
can increase the cariogenity of milk. It proved in the
experiment using mice. Those differences then consider
as an obstacle in determining whether milk could cause
BBTD in toddlers who have bottle-feeding habit. Most of
children in urban areas rely on bottle milk as the source of
nutrients.21 Therefore, the further analysis of the condition
in Indonesia, especially in Jakarta, is needed to study baby
bottle tooth decay (BBTD) syndrome that mostly attack
toddlers. The process of tooth decay which started in early
ages could affect the growth and development of children.15
The study was aimed to examine the bottle-feeding habit in
3-5 year old children in Indonesia and its caries risk.
material and method
This research was a cross sectional study. The subject of
study was obtained from non-probability sampling method
with consecutive sampling technique. The subject were 62
children in the range of age 3 to 5 years old, with primary
teeth have erupted and have bottle-feeding habit. Clinical
examination was conducted in children and to obtain
further information, questionnaire was distributed to their
parents. The questionnaire searched the information of the
breast feeding experience (period of breast feeding), and
the bottle-feeding habit (the usage, period, and frequency
of bottle-feeding). Clinical examination was done under
Afterwards, the status of caries was noted based on
World Health Organization standard.22,23 The analysis of
prevalence ratio then was conducted to examine any risk
factors of bottle-feeding habit. The study had been approved
by the research ethic commission of Faculty of Dentistry,
University of Indonesia, and the subjects’ parents had
been informed and asked for their written approval prior
to the study.
Based on consecutive method, 62 children were
considered as the subjects of the research since they met
some inclusion criteria. The distribution of the subjects
as seen in Table 1, showed that the distribution of boys
(61.3%) was bigger than that of girls (38.7%). The age
interval of subjects was in between 3 to 5 years old with
the various numbers of teeth erupted (20 to 24 teeth), but
most of subject had 20 teeth erupted (85.5%).
Most of subjects (72.6%) suffer caries which was
similar to baby bottle tooth decay (BBTD) syndrome, while
the rest (27.4%) was free from caries though they had bottle-
feeding habit. The deft score of all subjects approximately
4.66 teeth. The teeth were classified into some groups based
on the number of decayed tooth, it revealed that 27.4% were
free from caries, 40.3% one to five teeth had caries, and
32.3% had caries in more than five teeth.
The questionnaire result showed that 83.9% subjects
stopped breast feeding since their first year. Most of them
(66.1%) still continue drinking milk with bottle. The
children who drinking 4 times or more a day reach 46.8%
and 53.2% subjects had bottle-feeding once a night, while
32.3% of them had bottle-feeding twice a night. Moreover,
9.7% of them had bottle-feeding three times a night, while
konsumsi susu botol itu sendiri. Kondisi ini dapat dihubungkan dengan modulasi substrat terhadap perkembangan kolonisasi bakteri
di permukaan gigi, sehingga secara tidak langsung juga mempengaruhi virulensinya.
Frekuensi minum susu botol, faktor resiko, sindroma karies botol
Correspondence: Mochamad Fahlevi Rizal, c/o: Bagian Ilmu Kedokteran Gigi Anak, Fakultas Kedokteran Gigi Universitas Indonesia.
Jl. Salemba raya 4 Jakarta, Indonesia. E-mail: email@example.com
46 Dent. J. (Maj. Ked. Gigi), Vol. 43. No. 1 March 2010: 44-481
only 3.2% of them had bottle-feeding four times a night.
It revealed that most of subjects (72.6%) rely on bottle-
feeding as pacifier prior sleeping, while the rest (27.4%)
In addition, for profiling those children with bottle-
feeding habit as shown in Table 1, the analysis of prevalence
ratio (PR) was then conducted as seen in Table 2. It showed
that nursing bottle-feeding prior sleep could not always
increase the risk of BBTD since the score of PR was 1.03
times with the interval of reliability was in between 0.91
to 1.15. In details, it showed that the frequency of bottle-
feeding ≥ 2 times a day could increase the risk of BBTD
2.27 times with the interval of reliability between 2.17 to
2.37, while the frequency of bottle-feeding ≥ 2 times a night
could increase the risk of BBTD 1.16 times with the interval
of reliability in between 1.04 to 1.28. Moreover, analysis
based on the age when they stopped bottle feeding, the
prevalence of caries was almost 1. It means that this factor
did not affect the number of caries occurred. Nevertheless,
it appeared that breast feeding could give protection against
Table 2. The estimation of prevalence ratio (PR) as the risk
estimation of BBTD in children who have bottle-
Analyzed Group n
The risk of BBTD in
children having bottle-
feeding as pacifier
The risk of BBTD in
children having bottle-
feeding until in the age of
3 years old or more
The risk of BBTD in
children whose frequency
of bottle-feeding is
twice per day**
The risk of BBDT in
children whose frequency
of bottle-feeding is
twice per night**
The risk of BBTD in
children having breast-
* < 1: causing protection effect
++ 1: causing neutral effect
** once of bottle-feeding equals to 200 cc
The history of BBTD is needed to be examined in this
study in order to categorize kinds of caries occurred in
those children which can possibly be caused by bottle-
feeding habit or by other factors. The categorization is
also needed in this study to analyze further the specific
damage occurred in their primary teeth. Therefore, if the
tooth decay has already attacked their lower anterior teeth,
they could not involve as the subjects of this study since
this condition can cause bias result, which indicates caries
with other pattern.
Moreover, only children in the range of age of 3 to 5
years old were chosen to be the subjects of this study since
their primary teeth were still in the phase of growth,24 thus, it
means that only those whose primary teeth are still persisted
Table 1. Profile of children, as the subjects of the research, who
have bottle-feeding habit
n (person) %
The total number of teeth
Diagnosed BBTD syndrome
Free of caries
Number of caries teeth
Free of caries
> 5 teeth
The length period of breast-feeding
Until 1 year old
Until 2 years old
Until 3 years old
The length period of bottle-feeding
Still on going
Until 2 years old
Until 3 years old
Frequency of bottle-feeding per day*
4 times or more
The role of bottle feeding
Not as pacifier
Frequency of bottle-feeding per night*
4 times or more
*Once of bottle-feeding equals to 200 cc
Rizal et al.: Frequency of bottle-feeding
can involve in this study. It is aimed to obtain the description
of caries caused by bottle-feeding habit. Healthy tooth
reflect sufficient remineralization and demineralization
processes. So we assumed that the unbalancing condition
can be considered as a trigger factor of caries. Caries free
can reflect the balance condition between remineralization
and demineralization processes.
However, the similar condition cannot be expected to
be found in children under three years old. This statement
is also supported by the research using cariostat as the
predictor of caries which found that the increasing of caries
in children around 3–5 years old is not as progressive as that
in children under 3 years old.25 The succession of anterior
teeth in children older than five years old has generally
been occurred,24 thus, the possibility of the involvement
of anterior teeth becomes bias. Based on the analysis result
of prevalence ratio in Table 2, it showed that the period
of bottle-feeding habit was only 0.96. It means that the
period of bottle-feeding is not considered as the only factor
Furthermore, based on the distribution of the data, it
appeared that the number of boys who had bottle-feeding
habit is not the same as that of girls. The result make sense
since caries is not an infectious diseases which affected
by gender.26-29 Even though there is a research that
distinguishes the dental health treatment based on gender,
there is still no significant difference in result.25,30 Actually,
as an infectious disease caused by bacteria, the incubation
and colonization of bacteria tends to be determined by
micro environment inside oral cavity. But, even though this
micro condition is also influenced by internal factors like
hormonal factor, it will not affect too much on children in
the age of 3 to 5 years old.
Eighty five point five percents of the subjects have
met the criteria to become the samples of the study since
the total number of their teeth was 20 (Table 1). The rest
of them (14.5%) had more than 20 teeth. However, this
condition did not affect the study since the erupted teeth
were permanent molars, and it did not affect the diagnosis
of baby bottle tooth decay syndrome.
The examination conducted on children who have
bottle-feeding habit showed that 72.6% of them suffer baby
bottle tooth decay with various numbers of caries (1–15)
teeth and with the mean score of deft 4.66 teeth. It means
that every child has caries in their four teeth. Pattern of baby
bottle tooth decay syndrome which is linier with the order of
dental eruption, concluded that most of children with baby
bottle tooth decay syndrome get caries in their four anterior
teeth of upper jaw, and it is not different from what happens
with non Caucasian children in the age of 4–5 years old in
countries with good health program.31 However, caries in
the upper incisive can not only cause infection for those
children, but can also affect their aesthetics, especially
concerning with their self-esteem.
If compared with the research involving five year old
children in China which population is similar to Indonesia’s
in the term of biosocioculture, the mean score of deft is
almost similar (the mean of deft 3 from 780 children).26
Similarly, the mean score of deft in Riyadh, Saudi Arabia
is 5.27 Nevertheless, the mean score of deft in 0–5 year old
children is different as shown in the research conducted in
Brazil, which is 1.53. This condition can possibly occur
since based there is a correlation between the length of
age interval and caries occurred, which means that the
increasing of caries occurs as the increasing of age.32 It is
also supported by the result of a research involving toddlers
in Depok in 1992 which mean score of deft is 4.67 teeth.25
It indicates that there has not been significant change in the
mean of deft for the last two decades.
Actually, tooth decay suffered by most of children
(72.6%) is possibly caused by many factors. One of them
is related with the activity of parents in urban areas that
tends to be busy and have not enough time to meet their
children. Like in Indonesia, this phenomenon also occurs
in some countries, except in developed countries in which
promotion and prevention programs that have already
been developed can reduce the unawareness of parents
toward their children.33 Therefore, it can be concluded that
bottle-feeding habit is considered to be an important factor
The result showed that 66.1% of the subjects in this
study have bottle-feeding habit. The proportion of children
who use bottle-feeding prior sleep is the same with the
proportion of children who suffer caries. In general, it is
known that 45 children (72.6%) have this bottle-feeding
habit, but, not all of the children who have bottle-feeding
habit prior sleep get caries. Based on the result of prevalence
ratio in Table 2 it is known that those who rely on bottle-
feeding as pacifier when falling asleep do not always get
caries since the interval of reliability is between 0.91–1.15.
Nevertheless, based on the observation of 55 kindergarten
students in Italia, it is known that bottle-feeding habit
can cause caries.28 Similarly, researches conducted in
North Brisbane and Montreal is also showed that BBTD
emerged in children who rely on bottle-feeding when falling
asleep.34,35 Moreover, based on the research conducted in
Australia, it is known that the frequency of bottle-feeding
twice or more a day can increase the risk of caries for about
2.27 times, while the frequency of bottle-feeding twice
or more a night can increase the risk of caries for about
The occurence of BBTD can be examined from the
experience of bottle-feeding habit. Most of the children
got breast feeding until they were one year old (83.9%).
It means that the weaning of breast feeding start after first
primary tooth erupted or just before the eruption of primary
tooth. Therefore, the correlation between breast feeding
and BBTD can be eliminated. It is also supported by the
score result of the prevalence ratio, which is about 0.716.
It means that 60–83% of subjects have breast feeding as
a protection against caries or breast feeding did not affect
caries occurrence during the study. This result is similar
to the result of the cross sectional research conducted on
children in the age of 2–5 years old in the United States of
48 Dent. J. (Maj. Ked. Gigi), Vol. 43. No. 1 March 2010: 44-481
America in 1576 which concludes that the length period
of breast feeding cannot be considered as the single risk
factor of caries.4
Therefore, it can be concluded that though milk as
subtract can possibly become a factor triggering caries, the
frequency of bottle-feeding is highly considered as main
factor. Since it could modulated the bacterial colonization
on dental surface, which affects its virulence.
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