Tooth Decay Risk Factors In Children

  • Chritish GurungMasters of Biomedical Sciences - MSc(Hons), University of Southampton, England
  • Aranii Nagarajah Master of Science in Pharmacology (2024)
  • Regina LopesSenior Nursing Assistant, Health and Social Care, The Open University

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Tooth decay is a highly prevalent problem within the UK. Despite being preventable, an alarming number of children have experienced tooth decay. Public Health England reported that 23.4% of 5-year-old children in England experienced tooth decay in 2019. Globally, the World Health Organization identified that 514 million children had tooth decay in their primary (baby) teeth in 2022.

What is tooth decay?

Tooth decay is the breakdown of a tooth’s outer surface (enamel) which can result in holes in your teeth (cavities), and if left untreated, it can result in tooth loss. This process primarily occurs due to the accumulation of bacteria which consume various sugars and produce acidic by-products. The acidic environment then causes the loss of key minerals1 from your teeth in a process called demineralisation, which damages the tooth enamel.

Causes of tooth decay

Numerous factors can cause tooth decay; however, these are the key contributors to tooth decay according to the NHS:


The main species of bacteria that causes tooth decay is Streptococcus mutans.2,1 Bacteria consume any sugars such as glucose, sucrose, fructose, and lactose present on your teeth. They break these sugars down into acidic by-products like lactic acid, creating an acidic environment that leads to demineralisation.

Dietary habits

These factors play a pivotal role in causing tooth decay as they directly shape your dental environment. There are three main categories to consider in terms of dietary habits:

  • Sugar and carbohydrates: Diets high in sugary substances provide fuel (substrate) for bacteria. The greater the sugar consumption, the more acidic the environment can become within your mouth, resulting in more enamel erosion
  • Acidic foods and beverages: For example, citrus fruits directly add to the acidic environment and contribute to further enamel erosion
  • Frequency of consumption: Frequent intake of sugary or acidic foods greatly increases the risk of developing tooth decay

Poor oral hygiene

Inadequate oral hygiene practices contribute to the accumulation of dental plaque. Plaque is a biofilm consisting of a complex network of bacteria, saliva, and food particles that adhere to your teeth. A lack of oral hygiene can result in the build-up of plaque, resulting in elevated acid production and enamel demineralisation. 

Fluoride deficiency 

Fluoride is a natural component of tooth enamel and reduces the risk of tooth decay. It strengthens the enamel by promoting remineralisation.3 A lack of fluoride may increase the likelihood of dental cavities.

Dry mouth (Xerostomia)

Saliva can neutralise acids, nullifying the effects of acidic by-products and allowing for healthy oral environments. Several diseases can cause dry mouth, such as Diabetes4 which reduces saliva production and can increase the risk of tooth decay. Several medications such as antihistamines and decongestants, have also been observed to induce dry mouth. 

Genetic factors

An individual’s genetics can also influence the susceptibility to developing dental caries, by affecting the composition of your saliva and tooth structure.5 However, it is the crossover between genetics and environmental and behavioural factors that determines the susceptibility to tooth decay. 

Risk factors of tooth decay in children

Some of the causes of tooth decay can also function as potential risk factors and increase the risk of development: 

  • Poor oral hygiene
  • Dietary habits 
  • Fluoride deficiency 
  • Dry mouth
  • Genetic disposition
  • Age 


Young children and babies are much more susceptible to tooth decay than adults. Primary teeth have much weaker enamel, making them more prone to acid erosion and demineralisation. Hence, it is imperative to identify any signs of tooth decay to initiate timely treatment. If you would like more advice on how to look after your child’s teeth, the NHS has an informative webpage to help guide parents. 

Symptoms of tooth decay

The presentation of dental caries varies for each child. In the early stages, the symptoms may not be noticeable, but as it progresses, some symptoms become more apparent. Identifying these signs can allow for early intervention and treatment if needed. The NHS has listed the following symptoms as the most common symptoms of tooth decay: 

Toothache (tooth pain) 

Persistent or periodic pain or discomfort, especially when chewing or biting. This may occur alongside increased sensitivity to hot, cold, acidic, or sweet foods and drinks. 

Visible cavities

This occurs less so in the initial stages of tooth decay, but as it progresses further, it becomes more evident. The presence of cavities can appear as either holes or pits on the surface of your teeth. 

Tooth discolouration

Changes in the colour of your teeth can also provide signs of tooth decay. Tooth discolouration directly correlates with dental health. The colour of your teeth can provide insight into the different causes of tooth decay, helping dentists identify the root problem. The Cleveland Clinic has identified the following colours as the main colours observed in tooth decay:

  • Yellow teeth: These stains are typically due to diet and consumption of dark foods and drinks. However, this can also be indicative of poor oral hygiene
  • Grey teeth: This may be due to the nerves in your teeth dying which may be caused by an infection or trauma
  • White spot lesions: These lesions are present on your teeth and can be potential signs of early tooth decay.6 They have two main causes; the first is from demineralisation by acidic by-products and the second is excessive exposure to fluoride during development (fluorosis)
  • Black spots: These spots are clear signs of tooth decay or cavities

The causes of dental discolouration can be divided into two main categories: extrinsic (environmental) and intrinsic (specific to an individual) factors. For example, extrinsic factors may include your dietary choices or your quality of oral hygiene. Conversely, intrinsic factors could be a person’s genetics or any underlying health complications you have.

Bad breath

Persistent bad breath, also referred to as halitosis, can be due to the presence of bacteria or decaying food particles in your mouth. 

Unpleasant taste

If there is an infection or decay within your tooth, you may also have an unpleasant or metallic taste in your mouth. 

If you show any of these symptoms, visit your local dentist for a check-up as soon as possible. The sooner the issue is detected, the sooner you can be treated. Ensure to look after your teeth and visit a dental expert if needed. 

Stages of tooth decay 

As with many diseases, tooth decay progresses through various stages that affect deeper layers within the tooth structure. The five main stages of tooth decay are as follows:


These initial stages result in the weakening of your teeth’ enamel. During this phase, white spot lesions become apparent on your teeth. 

Enamel decay

As your enamel continues to wear away, the lesions can deteriorate further into cavities, causing further decay to your enamel. The white spots on your teeth may also turn light brown as well. 

Dentin decay

If the decay progresses deeper into your teeth, it will reach the dentin layer.7 In contrast to enamel, this layer is composed of soft connective tissue that contains nerve endings, resulting in an increased tooth sensitivity.8 The spots on your teeth also darken and turn brown. 

Pulp (Pulpitis)

As the decay worsens, the cavity can reach your tooth pulp. This layer contains even more nerves and blood vessels and can result in inflammation of your dental pulp (pulpitis).9 At this stage, your spots will turn either dark brown or black.


If the affected tooth is not treated, there is a high chance of an infection occurring at the root of your tooth, forming an abscess. Abscesses are pockets of built-up pus which can cause severe pain and swelling. These abscesses can spread to local areas surrounding the affected tissue, potentially causing systemic spread of the infection.


Regular dental check-ups are vital in detecting symptoms of dental caries as early as possible. Individuals experiencing any of the mentioned symptoms should seek dental evaluation. Dentists use both visual examinations and diagnostic tools such as X-rays to aid diagnosis of your teeth. 

Early diagnosis and intervention help maintain oral health. Preventing the progression of further tooth decay is vital in minimising the need for additional dental procedures, so make sure to have regular dental check-ups. 


The severity and stage of tooth decay determine the appropriate treatment required. In the early stages of tooth decay, dentists can prescribe fluoride treatments in the form of varnish or mouthwash, to promote remineralisation.

Fillings and crowns

If you have cavities, then you will require fillings or crowns. The decayed tooth is initially removed and filled in with dental amalgam, composite, or glass ionomer. Your dentist will recommend the appropriate material for your filling.

In contrast to fillings, crowns are for slightly more severe cases. These custom-made caps cover the visible portion of the damaged tooth, allowing for restored functionality. 

Root canals

If the tooth decay has reached the pulp, dentists may recommend root canal treatment. This process involves putting the affected area under local anaesthetic, making it a painless procedure. The infected pulp region is cleaned or removed depending on the severity.

The root canal of the affected tooth is also cleaned, filled, and sealed, creating a healthier environment for the tooth to survive. The tooth is not normally extracted unless there is severe tooth decay and if it is recommended by your dentist. 

Preventing tooth decay

There are several ways to help prevent tooth decay. By incorporating the following actions into your daily routine and regularly visiting your dentist, you can greatly reduce the risk of tooth decay:

Regular brushing and flossing

Brush your teeth twice a day, using either a manual or electric toothbrush. The same applies to your children as well. If your children don’t particularly like brushing their teeth, make it into a game or a race to make the experience more enjoyable for them. Additionally, the NHS also recommends using interdental brushes or dental floss as a part of your dental routine, including children who are 12 or older. Flossing helps remove food stuck between your teeth, as well as also decreasing the risk of gum disease (periodontal disease).10

Fluoride toothpaste

Fluoride treatment through toothpaste is a great way to help the remineralisation process, creating a much healthier oral environment. The specific amounts of fluoride that should be within your toothpaste vary depending on age. The following concentrations are the NHS-recommended amounts of fluoride in your toothpaste:

  • For adults: toothpaste should contain at least 1350 parts per million (ppm) of fluoride
  • For children over the age of 3: a pea-sized amount of toothpaste containing fluoride ranging from 1350 – 1500 ppm
  • For children under the age of 3: a small amount of toothpaste that contains at least 1000 ppm of fluoride 

Healthy diet

Reducing the amount of sugary and acidic foods and drinks, reduces the risk of developing tooth decay.11 These types of food contribute to the formation of acids which contribute to the demineralisation of your enamel, the initial stages of tooth decay. Choosing a balanced diet rich in healthier alternatives promotes your overall health and dental health.

Regular dental check-ups

Dentists, also known as the experts of your teeth, are the most reliable healthcare professionals for maintaining the health of your teeth. So, make sure to visit them regularly for routine check-ups. 


Tooth decay, also known as dental caries, is a highly prevalent issue for children. Without the appropriate treatment, tooth decay progressively worsens and greatly diminishes a person’s oral health. The main causes of tooth decay include poor oral hygiene, dietary habits, fluoride deficiency, genetics, and specific underlying medical conditions. Depending on the severity of the dental caries, appropriate treatments can be implemented to help restore your oral health. 

Multiple preventative methods can be considered to reduce the risk of tooth decay for your children. Some of these include improving your dental hygiene, using fluoride toothpaste, healthier diets, and regular dental check-ups. If you experience any symptoms or stages of tooth decay, consult a dentist for further advice.


  1. Abou Neel EA, Aljabo A, Strange A, Ibrahim S, Coathup M, Young AM, et al. Demineralization-remineralization dynamics in teeth and bone. International Journal of Nanomedicine [Internet]. 2016 Sep 19 [cited 2024 March 10];11:4743-63. Available from:
  2. Forssten SD, Björklund M, Ouwehand AC. Streptococcus mutans, Caries and Simulation Models. Nutrients [Internet]. 2010 Mar 2 [cited 2024 March 10];2(3):290-8. Available from:
  3. Lata S, Varghese NO, Varughese JM. Remineralization potential of fluoride and amorphous calcium phosphate-casein phospho peptide on enamel lesions: An in vitro comparative evaluation. J Conserv Dent [Internet]. 2010 Jan-Mar [cited 2024 March 10];13(1):42-46. Available from:
  4. López-Pintor RM, Casañas E, González-Serrano J, Serrano J, Ramírez L, de Arriba L, et al. Xerostomia, Hyposalivation, and Salivary Flow in Diabetes Patients. Journal of Diabetes Research [Internet]. 2016 Jul 10 [cited 2024 March 10]. Available from:
  5. Tulek A, Mulic A, Runningen M, Lillemo J, Utheim TP, Khan Q, et al. Genetic Aspects of Dental Erosive Wear and Dental Caries. International Journal of Dentistry [Internet]. 2021 Jul 12 [cited 2024 Mar 10]; 5566733. Available from:
  6. Srivastava K, Tikku T, Khanna R, Sachan K. Risk factors and management of white spot lesions in orthodontics. J Orthod Sci [Internet]. 2013 Apr-Jun [cited 2024 Mar 11]; 2​​(2):43-49. Available from:
  7. Goldberg M, Kulkarni AB, Young M, Boskey A. Dentin: structure, composition and mineralization. Front Biosci (Elite Ed) [Internet]. 2011 Jan 1 [cited 2024 Mar 13];3(2):711-735. Available from: 10.2741/e281
  8. Goldberg M, Kulkarni A B, Young M, Boskey A. Dentin: structure, composition and mineralization. Front. Biosci [Internet]. 2011 Jan 1 [cited 2024 Mar 11]; 3(2), 711–735. Available from:
  9. Ghannam MG, Alameddine H, Bordoni B. Anatomy, Head and Neck, Pulp (Tooth) [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan [cited 2024 Mar 13]. Available from:
  10. Marchesan JT, Byrd KM, Moss K, et al. Flossing Is Associated with Improved Oral Health in Older Adults. J Dent Res [Internet]. 2020 Apr 22 [cited 2024 Mar 13];99(9):1047-1053. Available from:
  11. Tungare S, Paranjpe AG. Diet and Nutrition to Prevent Dental Problems. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan [cited 2024 Mar 13]. Available from:

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Chritish Gurung

Masters of Biomedical Sciences - MSc(Hons), University of Southampton, England

Chris is a biomedical sciences graduate starting a career in the biopharmaceuticals industry with experiences in both the research and healthcare industry. After having completed four years at university, he became highly interested in medical writing in a wide range of areas ranging from pharmacology, neurodegenerative diseases, and cardiovascular pharmacology. He is passionate about science communication and simplifying new scientific findings to help bridge the gap between science and the public.

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