Its's access to 'prevention'

March 1, 2004
I met Sebastian on a flight between Dallas and Boston. He was a handsome, young banker married to an attorney and the father of seven-year-old Marcos.

by Trisha E. O'Hehir

I met Sebastian on a flight between Dallas and Boston. He was a handsome, young banker married to an attorney and the father of seven-year-old Marcos. As we chatted before takeoff, it was apparent that Sebastian and his family enjoyed traveling and were comfortable financially. Sebastian had bought himself a midnight blue sports car for his 40th birthday. He confessed it was a frivolous purchase since he didn't really drive much, but he felt it was a well-earned toy. Besides the car, Sebastian's favorite topic was Marcos.

As fellow airline passengers often do, we exchanged travel stories. Over the summer, Sebastian and his wife took Marcos to Amsterdam for his first European trip. Marcos thoroughly enjoyed the wooden shoes, the cobblestone streets, and the encounters with the Dutch language. Sebastian told me that they were walking along one of the canals when Marcos said, "Dad, can I ask you a question? We've been here three days now and I haven't seen any hamsters yet, have you?"

His father replied, "No, I haven't seen any hamsters either. Why are you looking for hamsters?"

Marcos replied, "Well, Dad, why do they call this place Hamsterdam if there aren't any hamsters?"

We both got a good laugh out of that. When our conversation came to a lull, like any good dental hygienist I asked if Marcos had any cavities. I figured that Sebastian's education level and high income would ensure that his son was in a good position to avoid dental disease.

Sebastian's answer surprised me. "No, Marcos doesn't have any cavities, yet." That last word told me he believed tooth decay was inevitable. He had fillings. His wife had fillings. He expected Marcos would also have cavities. It was troubling that dental hygienists hadn't gotten across to Sebastian and people like him that tooth decay can be prevented.

Believe me, Sebastian left the plane with a clear understanding about how his son can avoid tooth decay. I told him about the importance of effective daily plaque control (dry brushing inside first, cleaning between the teeth, and the value of fluoride varnish and sealants) and the importance of regular dental hygiene visits. He was excited his son wouldn't have to suffer tooth decay, and I was delighted to see his perspective change from "tooth decay is inevitable," to "preventive procedures and coaching by a dental hygienist can prevent dental disease."

You and I know that tooth decay and gum disease are completely preventable bacterial infections, but Sebastian didn't. The interaction between bacterial biofilm and fermentable carbohydrates produces acid that demineralizes the enamel. All we have to do is break the equation at one or all of these three key aspects: biofilm, carbohydrates, or tooth surface.

Periodontal disease is slightly more complex when the variations in people's immune systems are considered. But the simple adage "a clean tooth won't decay" usually fits for periodontal disease. A clean tooth and a clean sulcus won't develop periodontal disease. Removing bacterial plaque prior to eating, or eliminating fermentable carbohydrates from the diet will help prevent caries. Strengthening the enamel with fluoride is also beneficial. For periodontal disease, our focus is on the disruption of bacterial biofilm. Many other factors influence a person's immune response to periodontal infection, but a clean tooth is still the best weapon against disease.

If preventing dental disease is so simple, why do we still have what some call an epidemic of dental disease?

There are many reasons, all based on money. "Not enough money for dentists to put in fillings." "Medicaid is under-funded." "Poor people can't afford dental visits so they have a disproportionate level of dental disease." "We have an access to care problem."

If you buy into this "access to care" issue, put your dental hygiene glasses back on and take a closer look.

From our perspective as dental hygienists, providing more money to put in more fillings will never prevent dental disease. A noteworthy risk factor for future tooth decay is the presence of dental restorations that indicate prior caries experience. Why not back up just a couple of years and actually prevent dental disease before it starts?

Why are government and dental professionals locked into "access to care" and failing to address "access to prevention?" It may be due to the perspectives of those involved — dentists rather than hygienists. Dentists specialize in treating disease, while hygienists specialize in preventing disease. When dentists analyze the untreated tooth decay in five-year-olds entering kindergarten, they suggest ways to treat those teeth. They believe the problem is access to restorative care. I'm not saying the dentists don't also include preventive measures in their plan, but it is usually secondary to restorative care.

If hygienists were to analyze this problem, we would intervene before there is evidence of tooth decay, thus avoiding the need for restorative care. Waiting until children have tooth decay to intervene will ensure that tooth decay continues. Dentists often suggest that more money is needed to fund Medicaid so their fees can be reimbursed at their usual rate. What would your solution be?

I trust you would not simply assume the inevitability of tooth decay and thus allocate funds to pay for fillings for these children. Your focus would move intervention from "after decay is present" to "before demineralization even starts." Providing access to prevention just a couple of years earlier would be a wiser investment than waiting until decay is present and more expensive care is needed. Also, once a tooth has been restored, it is more likely to need further restorative care. If we prevent the very first restoration, that tooth has a much better chance of lifetime survival.

So the lifetime survival of a tooth without restorative care is a much better return on investment than placing a filling that is likely to need more work. Dental disease affects more than just teeth. It affects quality of life.

Marcos reached the age of seven without decay. His Dad is now committed to the preventive care necessary to keep Marcos free of dental disease. Whenever you have the chance to refocus the discussion from "access to care" to "access to prevention," do it! If access to prevention gains more attention and more funding, I predict we will see more kids growing up disease-free. You are the preventive specialist who can make that happen. Spread the message not only to friends, family, and patients, but also to legislators and government policy makers. The best solution is access to prevention, not access to care.

Trisha E. O'Hehir, RDH, BS, is a senior consulting editor of RDH. She is also an international speaker, author, instrument designer, inventor, and oral health detective. Her Web sites are and She can be reached at (800) 374-4290 or at [email protected].