SINGAPORE - Seven-year-old Shyann Lee slept weekday nights at her grandparents' home because her parents were too busy with work.
Every night without fail, her grandmother would help her brush her teeth.
So when she complained of toothache at the age of four, her mother, Mrs Julie Lee, an associate director of corporate communications at a university, looked in her daughter's mouth and was shocked at what she saw.
Mrs Lee said: "I found stains on a couple of her lower front teeth and some holes in at least three of her molars. The dentist had to remove the stains and fill up the holes. She was in a bit of pain and was put under general anaesthesia. It cost a few hundred dollars."
It turned out that Shyann's grandparents, thinking she needed the calorie boost, had been giving her milk from a bottle three times a day, including once in the middle of the night.
What they did not know was that milk contains sugar which can cling to an infant's teeth for long periods.
Bacteria in the mouth use the sugar as food, producing acid that attacks the teeth. Over months or years, it can cause tooth decay.
Drinking milk at night, when the salivary flow is low, is worse. The milk does not get washed away by the saliva and, hence, stays in the mouth for a longer time.
Shyann's experience is hardly unique and it is certainly not the worst.
A three-year-old boy had all 20 of his milk teeth extracted at National Dental Centre Singapore (NDCS) because they were decayed, leaving only the roots.
Dr Tan Wee Kiat, the head and senior consultant at the centre's paediatric dentistry unit at the department of restorative dentistry, who cited the case, said the boy had slept with a bottle of milk in his mouth from the day he was born.
"The teeth had probably begun to decay the moment they erupted," she said.
High rate of caries in children
Dentists here are seeing more children with early childhood caries - tooth decay before the age of six.
The NDCS, the largest dental specialist centre here, has seen the number of children being treated for early childhood caries at its paediatric dentistry clinics double from about 500 in 2000 to 1,000 a year in 2011 and last year.
At the School Dental Centre at Outram Road, the most common condition was early childhood caries, making up 73.8 per cent of 4,424 cases last year.
A study by the National University of Singapore published in the Community Dental Health in 2009 found that as many as 40 per cent of the 1,782 pre-schoolers aged three to six had early childhood caries; 90 per cent of the caries were untreated.
The rise in early childhood caries has been noticed in other developing countries such as the United States.
The US Surgeon General declared in 2010 that early childhood caries in children aged three years old or younger was a public health problem, accounting for most frequent hospital admissions requiring general anaesthesia in children.
Dr Ng Jing Jing, the deputy director of the School Dental Service at the Health Promotion Board, said more parents are taking their children to the dentist because they are more aware of the importance of oral health.
But at the same time, the large number of children who have tooth decay also reflects parents' ignorance about the risk factors of dental diseases, said Dr Tan.
For instance, they may allow their child to go to bed with a milk bottle or let him suckle and sleep on the breast, without knowing that such practices prolong the time that the teeth are soaked in fermentable carbohydrates, which bacteria can act on.
Dr Tan said some parents may still hold the misconception that baby teeth can be left to rot as they will drop out anyway.
In any case, surveys here show that parents themselves may not visit the dentist regularly. An oral health survey of 6,000 adult Singaporeans in 2006 found that only 45.5 per cent visited the dentist once a year for a check-up. About 31 per cent of Singaporeans will go only when there is pain.
It is safe to assume that parents are even less likely to take their children for dental checks, said Dr Tan.
Studies have also found a link between early childhood caries and lower social income groups.
Dr Tan said this could be due to lower awareness of dental health, less access to care, and other financial and social problems.
Health-care professionals, who could form a first line in identifying the problem, may have outdated knowledge about early childhood caries and its prevention.
For instance, a survey of 78 nurses and receptionists in a health-care setting in 2010 by paediatric dentists at NDCS found only 13 per cent said children should see a dentist by one year of age.
The majority, about 50 per cent, thought seeing a dentist at the ages of three or four was good enough.
In fact, in 2005, the American Academy of Paediatric Dentistry brought forward the age of a child's first dental visit from age two to three, to age one, or shortly after the first tooth erupts, whichever happens first.
Steps taken to fight tooth decay
The NDCS has embarked on an aggressive public awareness campaign to educate more people about early childhood caries and its prevention (see story on the right).
In 2010, it rolled out an oral preventive programme for infants aged up to 18 months and their parents.
Last year, it launched a community outreach programme in which dental surgeons talked to doctors and nurses running family health clinics at 11 polyclinics to identify children at risk of developing caries, such as those who sleep with a milk bottle or on the breast.
It plans to reach out to pre-school teachers and parents next, through a series of public forums on early childhood caries this year.
Paediatric dentists at the National University Hospital (NUH) have gone on the warpath against early childhood caries, one of the top three conditions they see in children, by giving public talks on it in recent years.
As children are more likely to see the paediatrician than the dentist, they have also been reaching out to paediatricians to spread the message.
It is important that the people around children take steps to prevent caries from forming, said Dr Tan.
Children begin to lose their front baby teeth only at the age of six and their back baby teeth when they are about nine to 10 years old.
Baby teeth are important not just for aesthetics. They allow proper chewing, which fosters good nutrition and physical development, said Dr Tan.
They also help speech development and the proper development of permanent teeth by saving space for them, she said. Early loss of primary teeth could compromise the space needed for permanent teeth to erupt into the mouth and result in their overcrowding.
Badly decayed baby teeth pave the way for even more decay in permanent teeth. Children with high decay risks are likely to carry them over to adulthood, said Dr Tan.
More evidence has emerged in recent years to show poor oral health can affect a person's general health.
Early childhood caries can progress quickly and cause pain and discomfort, said Dr Catherine Hong, an NUH consultant in orthodontics and paediatric dentistry.
If the decay in baby teeth is left untreated, the holes get progressively bigger and may cause pain before the teeth are due to fall out, said Dr Hong.
She said some children may develop facial swelling from the bad tooth. This requires immediate medical attention, such as dental surgery, to remove the bad tooth and pus or hospitalisation for the administration of antibiotics through the veins.
And treatment does not come cheap. Treatment for early childhood caries requiring general anaesthesia at NDCS ranges between $1,000 and $3,000.
Mrs Lee has since weaned her daughter from the bottle and makes sure she takes her to the dentist once every six months to a year.
She said: "I don't want to get shocked again by the sight of stains and holes in the teeth of my child."
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