In 1999, the Center for Disease Control listed water fluoridation as one of the ten great public health achievements of the 20th century
. Such was its impact on the prevalence of caries that the scourge of dental cavities, and the dreaded shots and drills were poised to be consigned to the annals of history. Despite that optimism, dental caries remains the most common chronic disease of childhood, five times more common than childhood asthma and four times more common than childhood obesity
Even in a developed country like Singapore with 100% water fluoridation, the prevalence of early childhood caries (ECC) is staggering. In a study conducted in 2009, 40% of children in Singapore under six years old were found to have ECC, with over 90% of those caries untreated
. Seeing a child with a mouth full of rotten teeth walking into the practice is unfortunately more common than one may think (Figure 1).
Figure 1: Severe ECC in a four year old
The oral health awareness among parents still leaves a lot to be desired with only 8% of Singaporean children aged three to six years, and 3% aged 18-48 months visiting the dentist regularly . Furthermore, many parents believe that baby teeth are unimportant as they are all due to be replaced anyway. However, that change from baby to adult teeth does not occur all at once but rather it happens over a period of time between six to 12 years old. That means a child requiring a posterior extraction at age three will only have the replacement permanent tooth at 12 years old. This may affect the child's function and jaw development. Moreover, untreated cavities in baby teeth can lead to pain and infection (Figure 2), resulting in visits to the emergency room in the middle of the night and even hospitalisation with the requirement for IV antibiotics.
Figure 2: Swelling from a dental abscess
Although dental caries is very prevalent, it can also be successfully prevented if high risk children are identified early and appropriate preventive measures implemented. The American Academy of Pediatrics and American Academy of Pediatric Dentistry recommend bringing a child for their first dental visit as soon as their first teeth erupts or no later than one year old
. The one year visit is an opportunity for the dentist to provide anticipatory guidance on the prevention of dental caries and establishment of good oral health habits. Caries-causing habits appear to be established by one year and will persist throughout childhood
. Before age one, children visits their physicians very often for well-child and immunisation visits. These are great opportunities for the physicians to identify high risk children for referral, reinforce the importance of oral health and introduce the concept of an age one dental visit.
Risk factors  of early childhood caries:
- The presence of early carious lesions (white spot lesions) (Figure 3)
- The presence of visible plaque build-up (Figure 3)
- Frequent consumption of beverages and foods containing sugar, especially in a baby bottle or no-spill training cup
- Frequent nocturnal and ad-libitum breast-feeding after the first baby tooth begins to erupt and other dietary carbohydrates are introduced
- Use of baby bottle past 12-18 months
- Not starting to brush with a toothbrush after first tooth erupts
- Patients with special needs
Figure 3: A white spot lesion appear as white chalky areas and are usually found under thick plaque It is reversible at this stage, but if not addressed, will progress to a cavitated lesion requiring a filling.
Preventive Recommendations 
- Avoid frequent consumption of beverages and foods containing sugar
- Stop ad-libitum feeding after first baby tooth erupts
- Stop bottle use after one year old
- Implementing oral hygiene measures by the time of eruption of the first baby tooth. Tooth brushing should be done by an adult twice daily, using a soft toothbrush of age-appropriate size
- If using toothpaste, an adequate fluoridated toothpaste (at least 1000 ppm) should be used. For children under the age of three, a smear or rice grain-sized amount of fluoridated toothpaste should be used. In children aged three to six, a pea-sized amount of fluoridated toothpaste should be used. (Figure 4)
- Establishing a dental home (first dental visit) within six months of eruption of the first tooth and no later than 12 months of age
Figure 4: Toothpaste amount
Children with special needs such as autism and complex medical issues can be at higher risk of dental caries. Early referrals are essential for the implementation of effective preventive measures. With the overlying behavioural issues, when these children develop dental caries, advanced pharmacological behaviour management techniques such as sedation and general anaesthesia may be the only way to manage them
. These techniques come with additional risks for the already compromised children.
In conclusion, the old adage of "prevention is better than cure" sure rings true in the case of early childhood caries.
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24(1): p. 32-42.
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122(6): p. 1387-94.
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38(6): p. 52-54.
8. Guideline on Behavior Guidance for the Pediatric Dental Patient. Pediatr Dent, 2016.
38(6): p. 185-198.
Dr Hu Shijia
Division of Paediatric Dentistry
National University Centre for Oral Health, Singapore (NUCOHS)
Dr Hu graduated as the valedictorian from the National University of Singapore (NUS) in 2008 with a Bachelor of Dental Surgery. After receiving the NUS overseas graduate scholarship, he completed his PhD at the University of North Carolina (Chapel Hill) and specialty in Paediatric Dentistry. He is board-certified with the American Board of Pediatric Dentistry and specialist accredited in Singapore. In addition, he also holds an assistant professorship at NUS with research interests in the oral microbiome and early dental preventive care.