Noncommunicable diseases (NCDs), including early childhood caries (ECC), contribute to global public health challenges. Of the world’s population, 26% are under the age of 16 years [1], and approximately 2.1 billion children are affected by NCDs [2]. Untreated dental caries in primary teeth is the tenth most prevalent health condition worldwide [3].

ECC is a common disorder characterized by the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces of primary teeth in children 71 months old or younger. Severe ECC is either any smooth tooth surface decay in children under 3 years old or one or more cavitated, missing (due to caries), or filled smooth tooth surfaces in the primary maxillary anterior teeth in children between the ages of 3 and 5 years [4].

Young children depend on either their parents or caregivers for their health needs and general well-being. For this reason, the responsibility of preventing NCDs such as ECC in this age group lies exclusively with their carers. There are several theoretical frameworks proposing the evolution of ECC [5-8] and an equal number of strategies aimed at preventing the disorder [9-12]. However, the battle against ECC continues.

In the past few decades, several researchers have investigated the etiology of ECC. Like dental caries, ECC occurs as an interplay of at least 4 factors: cariogenic bacteria, fermentable carbohydrates, a susceptible tooth surface, and time. Traditionally, Streptococcus mutans (S. mutans) has been implicated as the key microorganism of dental caries. Recent studies based on DNA and RNA extracted from carious lesions have revealed that S. mutans forms a small part of a diverse biome that interacts synergistically to initiate and enlarge a carious lesion [13]. Oral bacteria can metabolize fermentable carbohydrates such as monosaccharides resulting in an increased production of acids capable of demineralizing dental hard tissue, especially enamel, over a period of time [13]. Apart from the known causative factors, several risk factors are associated with ECC.

Both maternal and infant risk factors have been implicated in the initiation and evolution of ECC. These include socioeconomic status, level of parental education, maternal age, caregiver depression, Vitamin D deficiency, and immigration status. Dental epidemiologists have explored the relationship between ECC and various risk factors for many decades. Despite their efforts, there has been little agreement on the findings, and ECC remains a global challenge affecting countless children.

South Africa has a diverse population in terms of culture, education, income, and occupation. This diversity is due to the consequences of historical racial discrimination, poverty, unemployment, lack of accessibility to health services, and quality of education. Furthermore, there is a distinct divide in the socioeconomic standing of the South African population that results in inequalities in essential health and oral health care [14]. These factors make South Africa unique, and the disease and risk profiles may differ from those of other countries at similar stages of development. In South Africa, children with ECC treated in public state facilities often present for multiple extractions under dental general anesthesia [15]. Apart from the financial costs and long waiting lists, repeated use of general anesthesia in young children poses inherent risks [15].

The aim of this study is to identify the unique maternal and infant risk factors for ECC in a South African context. The authors are confident that the outcome of the present investigation will raise awareness among caregivers, oral health professionals, general practitioners, and other stakeholders [16].

This systematic review will collect and synthesize data to determine the maternal and infant risk factors for ECC in South Africa. This protocol will be conducted according to the PRISMA-P (Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols) guidelines [17]. The search strategy will only be used to identify published studies conducted within South Africa. An initial search was used to identify suitable articles. A search strategy will be developed for each database. The words in the title and abstracts will be screened to determine the initial suitability of the articles. All references of included articles will be perused for more suitable titles. The search strategy will include the following terms: (((“South Africa”) AND (children OR “peri-natal” OR paediatric OR pediatric OR neonatal OR infant)) AND (“risk factor*” OR risk or factor*)) AND (“early childhood caries” OR caries OR decay OR dmft OR dental OR oral OR PUFA).

This review will be conducted from January 2021 to June 2021. The Prospero registration number is CRD42020216455. Two reviewers will be blinded at each stage of the process. Regular team meetings will be held to settle any disputes or differences between the reviewers’ inclusions. This will serve to enhance the reliability and validity of the review process. All discussions will be recorded as evidence. There will be no conflict of interest within the team.