What do systematic reviews say?

Early childhood caries / severe early childhood caries vs Caries-free controls

The association between baseline caries and declining height-for-age persisted after adjustment (coefficient -0.02); ungraded.

• The bi-directional relationship between growth stunting and early childhood caries: a rapid review. 2023 All outcomes

  ~9.73-month follow-up · China (preschool children) · Shen et al. 2019 (China; adjusted)
  Regression coefficient -0.02 [-0.04, 0.01]
  1 study · 1111 participants
  GRADE not reported

Early childhood caries / severe early childhood caries vs Caries-free controls

One Nepalese cross-sectional study found caries severity significantly correlated with chronic malnutrition/stunting (HAZ; p<0.0001), especially in rural children; ungraded, no effect size reported.

• The bi-directional relationship between growth stunting and early childhood caries: a rapid review. 2023 All outcomes

  Nepal (urban and rural) · Tsang et al. 2019 (Nepal)
  The severity of child caries measured by the dmft index correlated with mouth pain and both chronic (stunting) and acute malnutrition (HAZ score) (p<0.0001).
  1 study · 836 participants
  GRADE not reported
• The bi-directional relationship between growth stunting and early childhood caries: a rapid review. 2023 All outcomes

  Vietnam (south and central; ages 1-6) · Khanh et al. 2015 (Vietnam; pulp-involved caries)
  MD 0.66
  1 study · 593 participants
  GRADE not reported
• The bi-directional relationship between growth stunting and early childhood caries: a rapid review. 2023 All outcomes

  1-year follow-up · Cambodia (children <24 months at baseline) · Renggli et al. 2021 (Cambodia)
  OR 1.8 [1.0, 3.0]
  1 study · 1307 participants
  GRADE not reported

Early childhood caries / severe early childhood caries vs Caries-free controls

One Nepalese cross-sectional study found no significant association between severe ECC and malnutrition risk in children under 6 (mean difference 0.13, p=0.609); ungraded.

• The bi-directional relationship between growth stunting and early childhood caries: a rapid review. 2023 All outcomes

  Nepal · Zahid et al. 2020 (Nepal; children 6 months-6 years)
  MD 0.13 [-0.64, 0.38]
  1 study · 273 participants
  GRADE not reported

Breastfeeding for more than 24 months vs Not breastfed at the same age or breastfed for a shorter duration

Breastfeeding beyond 24 months is associated with an increased risk (incidence) of early childhood caries versus not breastfeeding at the same age (RR 2.44, 95% CI 1.97 to 3.02; low certainty).

• Risk of Early Childhood Dental Caries Associated With Prolonged Breastfeeding: A Systematic Review and Meta-Analysis. 2025 All outcomes

  Up to 71 months of age (study follow-up 1-9 years) · Population/community-based birth and childhood cohort studies; multiple countries (mostly Brazil and Japan; also Thailand, Scotland, Uganda, Spain, Australia, Myanmar, USA, Netherlands, Norway) · More than 24 months
  RR 2.44 [1.97, 3.02]
  2 studies
  Low

Late tooth brushing initiation (>=12 months, or >=2 years in some studies) vs Early tooth brushing initiation (<12 months, or <2 years)

In the primary pooled analysis, late tooth brushing initiation was associated with a non-significant 40% higher odds of early childhood caries (OR 1.40, 95% CI 0.91 to 2.16), with very high heterogeneity (I2=90.5%); ungraded.

• Optimal tooth brushing initiation age and frequency for preventing early childhood caries: a systematic review and… 2025 All outcomes

  Community/population-based; preschool children across Asia, Europe, North America, South America, Africa, and Australia (32 studies; 34,050 children) · Primary analysis (all 10 studies)
  OR 1.40 [0.91, 2.16]
  10 studies · 23200 participants
  GRADE not reported
• Optimal tooth brushing initiation age and frequency for preventing early childhood caries: a systematic review and… 2025 All outcomes

  Community/population-based; preschool children across Asia, Europe, North America, South America, Africa, and Australia (32 studies; 34,050 children) · Leave-one-out sensitivity analysis (Wagner 2017 outlier excluded, k=9)
  OR 1.75 [1.50, 2.03]
  9 studies
  GRADE not reported

Presence of oral Candida albicans vs Absence of oral Candida albicans

RETRACTED. Among studies before 2017, oral C. albicans presence was associated with higher odds of ECC (OR 4.89, 95% CI 2.79-8.58); ungraded subgroup from a retracted review.

• RETRACTED: Investigating the association between Candida albicans and early childhood dental caries: A comprehensive… 2024 All outcomes

  Exposure and outcome assessed concurrently (observational); children aged ≤6 years · Children aged ≤6 years; multiple countries (Asia, Europe, Americas); dental/clinical and community settings · Time period: before 2017
  OR 4.89 [2.79, 8.58]
  10 studies
  GRADE not reported
• RETRACTED: Investigating the association between Candida albicans and early childhood dental caries: A comprehensive… 2024 All outcomes

  Exposure and outcome assessed concurrently (observational); children aged ≤6 years · Children aged ≤6 years; multiple countries (Asia, Europe, Americas); dental/clinical and community settings · Sample collection: dental plaque
  OR 4.08 [2.65, 6.27]
  13 studies
  GRADE not reported
• RETRACTED: Investigating the association between Candida albicans and early childhood dental caries: A comprehensive… 2024 All outcomes

  Exposure and outcome assessed concurrently (observational); children aged ≤6 years · Children aged ≤6 years; multiple countries (Asia, Europe, Americas); dental/clinical and community settings · Region: Europe
  OR 10.13 [6.01, 17.09]
  5 studies · 635 participants
  GRADE not reported

Growth stunting (linear growth retardation, low height-for-age) vs Children without growth stunting (normal height-for-age)

One Nigerian cross-sectional study reported a significant adjusted association between nutritional (stunting) status and ECC (APR 0.14, 95% CI 0.03-0.69); ungraded.

• The bi-directional relationship between growth stunting and early childhood caries: a rapid review. 2023 All outcomes

  Nigeria (Ile-Ife, sub-urban) · Folayan et al. 2019 (Nigeria; adjusted, model 3)
  APR 0.14 [0.03, 0.69]
  1 study · 370 participants
  GRADE not reported
• The bi-directional relationship between growth stunting and early childhood caries: a rapid review. 2023 All outcomes

  Brazil · Vieira et al. 2020 (Brazil)
  Correlation (r) -0.091
  1 study · 82 participants
  GRADE not reported
• The bi-directional relationship between growth stunting and early childhood caries: a rapid review. 2023 All outcomes

  2-year follow-up · Ecuador (rural) · Sokal-Gutierrez et al. 2016 (Ecuador; pre vs post intervention)
  Pre/post ECC prevalence, dmft, and deep-caries proportion (2-year follow-up) Age 1: prevalence 53.8% to 30.3%, dmft 2.1 to 0.9; Age 2: prevalence 82% to 60%, dmft 5.3 to 3.0, deep caries 19% to 12% (pre vs post)
  1 study · 1575 participants
  GRADE not reported

Analogue (conventional) radiographs vs Reference standard (histology, excavation, or enhanced visual examination)

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies)
  Sensitivity 0.44 [0.38, 0.50]
  51 studies
  GRADE not reported

Radiographic imaging methods (any: analogue radiographs, digital radiographs, or CBCT) vs Reference standard (histology, excavation, or enhanced visual examination)

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Reference standard: enhanced visual (non-CBCT)
  Sensitivity 0.47 [0.29, 0.66]
  8 studies
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Permanent dentition (non-CBCT)
  Sensitivity 0.44 [0.37, 0.51]
  Studies not reported
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Dentine-caries (D3) prevalence medium 15-34% (non-CBCT)
  Sensitivity 0.51 [0.40, 0.61]
  Studies not reported
  GRADE not reported

Cone beam computed tomography (CBCT) vs Reference standard (histology, excavation, or enhanced visual examination)

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Proximal surfaces (CBCT)
  Specificity 0.90 [0.77, 0.96]
  Studies not reported
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies)
  Specificity 0.81 [0.73, 0.88]
  7 studies
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Occlusal surfaces (CBCT)
  Specificity 0.54 [0.31, 0.75]
  Studies not reported
  GRADE not reported

Radiographic imaging methods (any: analogue radiographs, digital radiographs, or CBCT) vs Reference standard (histology, excavation, or enhanced visual examination)

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Permanent dentition (non-CBCT)
  Specificity 0.90 [0.85, 0.93]
  Studies not reported
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Sensitivity analysis: low risk of bias for index test
  Specificity 0.88 [0.82, 0.92]
  Studies not reported
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Dentine-caries (D3) prevalence high >=35% or unreported (non-CBCT)
  Specificity 0.89 [0.82, 0.93]
  Studies not reported
  GRADE not reported

Analogue (conventional) radiographs vs Digital radiographs (direct within-person / paired comparison); reference standard: histology, excavation, or enhanced visual examination

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Analogue
  Specificity 0.91 [0.86, 0.94]
  15 studies
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Digital
  Specificity 0.88 [0.83, 0.92]
  15 studies
  GRADE not reported

Analogue (conventional) radiographs vs Reference standard (histology, excavation, or enhanced visual examination)

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies)
  Specificity 0.90 [0.86, 0.93]
  51 studies
  GRADE not reported

Cone beam computed tomography (CBCT) vs Reference standard (histology, excavation, or enhanced visual examination)

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies)
  Sensitivity 0.60 [0.51, 0.68]
  7 studies
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Proximal surfaces (CBCT)
  Sensitivity 0.68 [0.42, 0.86]
  Studies not reported
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Occlusal surfaces (CBCT)
  Sensitivity 0.76 [0.55, 0.89]
  Studies not reported
  GRADE not reported

Cone beam computed tomography (CBCT) vs Digital radiographs (direct within-person / paired comparison); reference standard: histology

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Digital
  Specificity 0.76 [0.43, 0.93]
  6 studies
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · CBCT
  Specificity 0.69 [0.35, 0.90]
  6 studies
  GRADE not reported

Cone beam computed tomography (CBCT) vs Digital radiographs (direct within-person / paired comparison); reference standard: histology

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · CBCT
  Sensitivity 0.76 [0.65, 0.85]
  6 studies
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Digital
  Sensitivity 0.69 [0.57, 0.80]
  6 studies
  GRADE not reported

Analogue (conventional) radiographs vs Digital radiographs (direct within-person / paired comparison); reference standard: histology, excavation, or enhanced visual examination

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Digital
  Sensitivity 0.47 [0.36, 0.59]
  15 studies
  GRADE not reported
• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies) · Analogue
  Sensitivity 0.41 [0.30, 0.53]
  15 studies
  GRADE not reported

Digital radiographs vs Reference standard (histology, excavation, or enhanced visual examination)

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies)
  Sensitivity 0.49 [0.42, 0.56]
  40 studies
  GRADE not reported

Digital radiographs vs Reference standard (histology, excavation, or enhanced visual examination)

• Imaging modalities to inform the detection and diagnosis of early caries 2021 · Cochrane All outcomes

  Up to 3 months between index test and reference standard (in vivo studies)
  Specificity 0.87 [0.82, 0.91]
  40 studies
  GRADE not reported

Early childhood caries (ECC) vs Caries-free controls

Veillonella spp. mean relative abundance was higher in ECC children, without a comparative effect estimate or CI.

• A systematic review of Streptococcus Mutans and Veillonellae species interactions in dental caries progression:… 2025 All outcomes

  Indonesia
  Mean relative abundance (%) ECC 3.29 (SD 6.83) vs caries-free 2.13 (SD 2.30)
  1 study · 87 participants
  GRADE not reported
• Meta-Analysis Using NGS Data: The Veillonella Species in Dental Caries. 2022 All outcomes

  Saliva and supragingival biofilm (pooled) · Overall (all sample types)
  MD 2.22 [0.54, 3.90]
  6 studies · 319 participants
  Very low
• Meta-Analysis Using NGS Data: The Veillonella Species in Dental Caries. 2022 All outcomes

  Saliva · Saliva
  MD -1.05 [-7.67, 5.57]
  2 studies · 161 participants
  GRADE not reported