How can tooth decay be prevented and treated?

Prevention and Treatment of Tooth Decay

All individuals should drink fluoridated water at optimal concentrations and brush their teeth twice daily with fluoride toothpaste, as frequent exposure to small amounts of fluoride provides the best protection against dental caries across all age groups. 1

Primary Prevention Strategy

Universal Recommendations for All Ages

• Fluoridated drinking water is the foundation of caries prevention—it is safe, effective, inexpensive, and benefits all age groups regardless of socioeconomic status. 1
• Fluoride toothpaste (1,000-1,100 ppm) should be used twice daily, as this reduces caries experience by 15-30% and provides continuous topical fluoride exposure. 2
• The combination of fluoridated water and fluoride toothpaste offers greater protection than either modality alone. 2

Age-Specific Fluoride Toothpaste Guidelines

For children under 2 years:

• Parents must consult a dentist before introducing fluoride toothpaste, weighing the community water fluoride level, other fluoride sources, and individual caries susceptibility. 1

For children aged 2-6 years:

• Use only a pea-sized amount (approximately 0.25 g) of toothpaste to minimize fluorosis risk. 2
• Supervise brushing to limit swallowing, as children under 6 have inadequately developed swallowing reflexes. 1
• Limit brushing to twice daily maximum. 1
• Encourage the child to spit out excess toothpaste rather than swallow. 1

For persons over 6 years:

• Rinse briefly with minimal water or not at all after brushing to retain more fluoride in the mouth. 2

High-Risk Populations Requiring Additional Interventions

Identifying High-Risk Individuals

High-risk factors include: 1

• Active dental caries or history of high caries in siblings/caregivers
• Low socioeconomic status or lack of regular dental care
• Exposed root surfaces from gingival recession
• High levels of cariogenic bacteria
• Impaired oral hygiene ability
• Reduced salivary flow (medications, radiation, disease)
• Orthodontic appliances or dental prostheses

Professional Fluoride Applications for High-Risk Patients

Fluoride varnish is the preferred professional treatment:

• Apply 2.26% sodium fluoride varnish semiannually (twice yearly)—this is as effective as fluoride gel and carries no enamel fluorosis risk even in young children. 1, 2
• Varnish is particularly appropriate for high-risk young children due to its safety profile. 2

Fluoride gel as an alternative:

• 1.23% acidulated phosphate fluoride or 0.9% sodium fluoride gel applied semiannually decreases caries by an average of 26% in children from non-fluoridated areas. 2

Fluoride mouthrinse:

• Target only to high-risk individuals, as its effectiveness has diminished with widespread fluoride toothpaste use. 1

Important Clinical Caveat

• Fluoride paste used during routine dental prophylaxis (4,000-20,000 ppm) is not an adequate substitute for gel or varnish in high-risk patients and is not FDA/ADA-approved for caries prevention. 1, 2
• Professional tooth cleaning before fluoride application is unnecessary—simple toothbrushing and flossing are equally effective for preparation. 2

Mechanism of Action: Why Fluoride Works

Fluoride's primary effect is posteruptive and topical, not systemic: 1

• Fluoride enhances remineralization and inhibits demineralization at the tooth surface when present in small, constant amounts in saliva and plaque. 1, 3
• High-concentration fluoride applications create a temporary calcium fluoride-like layer on enamel that releases fluoride when pH drops during acid attacks. 4
• The systemic incorporation of fluoride into developing enamel plays a minimal role in caries prevention. 3

Special Considerations

In areas with naturally high fluoride (>2 ppm in water):

• Children under 8 years should use alternative drinking water sources to reduce fluorosis risk. 2

Combining fluoride modalities:

• Multiple fluoride sources provide partially additive benefits—the combined effect is greater than any single modality but less than the mathematical sum of individual effects. 1, 2

For stannous fluoride products:

• These provide additional protection against dental erosion through tin-based physical barrier formation, making them preferable for erosion-risk patients over standard sodium fluoride. 4

Treatment of Existing Decay

• Fluoride can slow or reverse the progression of existing early lesions through enhanced remineralization. 1
• A minimally invasive, tissue-preserving approach should focus on managing the caries process over time rather than solely surgical intervention. 5
• Continuous caries prevention throughout life is essential, as caries attacks persist unrelentingly even into adulthood. 6