Tooth decay is a disease of imbalance between Pathogenic Factors and Protective Factors. When the mouth is in a state of health, the pathogenic factors are balanced by protective factors so that no cavities result.

Achieving Primary and Secondary Disease Prevention

Primary disease prevention may be achieved with early intervention and anticipatory guidance:

Anticipatory guidance- In dentistry, this involves informing parents of the conditions that create caries & cavities; its natural progression; and its prevention.Anticipatory guidance is an approach to child care that guides parents to take actions that promote their children’s health in anticipation of conditions that could be deleterious.

Early childhood oral health anticipatory guidance resources:

  • MCHB Oral Health Resource Center: Pediatric Oral Health Guide (Mike: Logo and link are at
  • MCHB Oral Health Resource Center: Open Wide (Mike logo and link are at
  • American Academy of Family Physicians: Anticipatory Guidance in Infant Oral Health (Mike: logo and link are at
  • American Academy of Pediatrics: Oral Health Risk Assessment Training (Logo and link at
  • Bright Futures: Oral Health (Logo and link at
  • The Association of Clinicians for the Underserved: Clinician’s “Pocket Cards”: (Logo and link at
  • American Academy of Pediatric Dentistry: Guidance on Periodicity, Prevention, Anticipatory guidance, and Treatment (Logo at and link at

Dental Home - The concept of the “dental home” by the American Academy of Pediatric Dentistry (Mike: link is is derived from the American Academy of Pediatrics concept of the “medical home” (Mike; Link is (49). It brings together parents, children, and caregivers to offer timely and effective anticipatory guidance, preventive interventions and comprehensive care, including referrals to other providers as needed. affords the opportunity for prevention. The goal is to reduce risk of preventable disease as it provides risk assessment, tailored counseling, anticipatory guidance, emergency plan, and access to comprehensive dental care, including any necessary referrals

Age One Dental Visit Because tooth decay is established as a disease process during a child’s first years of life, early preventive intervention is essential – particularly for children at high risk of ECC. Both AAPD(Mike; The link is ( and AAP

have official policies in support of early dental visits.

- This is an accepted policy of the ADA, Pediatric Dentists, Pediatricians, and the Public Health Association. Its intended to allow for true primary prevention, establishment of dental home, and ongoing anticipatory guidance (50). The Age One Dental Visit consists of history, risk assessment, examination, tailored anticipatory guidance, and counseling.

Secondary Disease Prevention: prevents disease by maintaining a state of balance between disease and health after the risk factors for disease are already present. For dental caries, this is accomplished by maintaining balance between pathologic factors that lead to demineralization of the tooth and protective factors that lead to remineralization of the tooth. A state of oral health is not absence of activity, but rather a balance of activity as t. The teeth are in a constant state of demineralization (loss of mineral) and remineralization (gain of mineral).either de- or re-mineralizing at every moment. When demineralization exceeds remineralization, the tooth will first demonstrate a “white spot lesion” ( the earliest clinical signs of tooth decay). If demineralization continues to exceed remineralization this reversible lesion will continue to a full-fledged cavity and on to a toothache, dental abscess, and abscess of the surrounding bone and face. (“white spot”) begin, however, at this point it is reversible. Remineralization can occur when there is a balance between diet, oral hygiene and fluoride exposure.

What is Disease Management?

When children have not had the benefit of primary prevention and anticipatory guidance, and their ccaries activity has progressed to the point that there is tooth destruction, the following concepts are employed:

Disease Suppression: this is the complete suppression of the disease (caries activity leading to a state of “arrested caries”. Once complete suppression is obtained the disease process is inactive and the teeth “do their best” to remineralize. As a result, the white spot lesions fade away, the decayed tooth material in the cavities turns from a light brown to dark, the edges of the cavities will stop spreading and become very distinct, and the gum tissue becomes firm and pink. Where the decayed tooth structure has been removed by “excavation” (scraping), the healthy dentin (the deeper layer of tooth material below the white enamel) will show through as yellow and glassy. The child will become asymptomatic to stimuli that were previously painful - like air flow (breathing across the affected tooth), and hot and cold foods.

Arrested ECC in a 2 Year Old

(Mike: can we add arrows to “faded white spot,” “dark colored decayed material,” “distinct cavity edge,” “healthy gum tissue,” and “healthy dentin”?)

) before repairing the teeth.Gaining caries arrest It involves intensive diet control to reduce frequency of acid attack on teeth, high-fequency, low-dose fluoride applications to increase remineralization and resistance to attack and gross caries excavation to decrease bacterial load and allow the fluoride to reach the leading edge of the progressing decay.

Disease Arrest: onceOnce caries activity has been completely suppressed, affected teeth will have lost tooth structure (“cavity”) but will be dark or glassy in appearance and will not need to be restored unless it is an issue of function or esthetics.except to restore function and esthetics. If parents are able to sustain a state of caries arrest in their young children, surgical/restorative dentistry can be delayed until a child is old enough to well tolerate dental treatment without use of general anesthesia.

The following two diagrams portray the demineralization and remineralization processes as phenomena fed by the “heat” of a cariogenic diet and reversed by the “cooling” of fluoride and salivary minerals.

Mike: The following two diagrams should be labeled “Demineralization Process” and “Remineralization Process” rather than “tooth decay” The word “tooth repair at the end of diagram two should read “caries arrest”)

Delaying and Reducing Tooth Decay

Delaying and reducing transmission of cariogenic bacteria, delays and can prevent cavities in young children. Among children who do get cavities, these strategies delay timing of the first cavity and reducesthe total amount of tooth decay the child will develop. Studies on controlling infection and colonization of the oral cavity with the primary etiologic agent for early childhood tooth decay (mutans streptococci) have shown promise. Mother-child couples receiving prenatal counseling on oral health and preventive care (dental cleanings and fluoride applications) every 6 months, had a significant improvement in oral health and a reduction of mutans streptococci during the 4 year study period. Children enrolled in the study from before birth to 4 years of age, that received preventive treatment had a reduced caries incidence and delayed S. Mutans colonization (51). In a series of classic Scandinavian reports of a longitudinal case-control study by Bridgette Kohler, reducing mutans reservoirs in mothers delayed children’s acquisition of cariogenic bacteria and lowered their decay experience.

Prevention of oral disease, whether it is periodontal disease or tooth decay, will not work if the populations at risk can not access care.

Barriers to Care

What are the common barriers to care?

  • Low socioeconomic status
  • Lack of community programs (e.g water fluoridation)
  • Lack of accessLogistic barriers (no transportation, inability to get timeconflict withoff work, child care, physical disability)
  • Lack of resources to pay for care/lack of dental insurance
  • Inadequate public dental insurance programs and low provider participation
  • Lack of public awareness and understanding of the importance of oral health

Few dentists accept patients on Medicaid due to low re-imbursement rates, abundance of paperwork, and broken appointments

SBy identifying the barriers to care, specific action steps can be taken to increase oral health awareness and access for high risk populations.

Continue to... Action Steps