Sir, I am grateful for your persisting interest in epidemiology and for pointing us to the fascinating report of Public Health England on the prevalence and severity of dental decay of 5-year-old children in 2012 (BDJ 2013; 215: 313). You highlight the painful finding, that, in spite of a moderate general decline in prevalence, unacceptable differences in caries experience between deprived and better-off regions remain, which are symptoms for, or results of, broader social and economic inequalities within British society.

Your editorial prompted me to read the full text of the report, which contains even more revealing facts: the average care index across England for 5-year-olds was 11.2%, meaning that 88.8% of decayed teeth remained untreated. Unfortunately, the UK figure of untreated decay in children is not unusual and very much in line with other countries, be it high-, middle- or low-income countries.1

The concept that dental care can 'treat away' disease is short-sighted, outdated, and addresses only the tip of the iceberg. There will always be more cavities than professionals to fill them. This situation is even worse in low- and middle-income countries, where oral care is either not available or not affordable. Still, many countries are trying to address the problem by training more and more dentists. Sure, many regions of the world are in desperate need of more trained oral health professionals, but the crux is not their mere number, but the type of work they do and the balance between prevention and clinical care. The FDI World Dental Federation's Vision 2020 document states that 'the approach to oral health has focused overwhelmingly on treatment rather than on disease prevention and oral health promotion. This approach has, however, limitations. Globally, the burden of oral diseases remains high and the traditional curative model of oral health care is proving too costly, in terms of both human and financial resources, to remain viable in the light of the increasing demand.'2

The Editor's questions as to whether we (as a dental profession) 'can [...] treat our way towards eradicating the problem' and if we have 'been at the vanguard of preventing the vast majority of dental decay' are simple to answer, as there is clear evidence that dental care alone only contributed little to improvements in oral health status that we have seen over the last decades across Europe and other regions.3 It is a recognised fact that we owe much of the decline of dental decay to the widespread use of fluoride toothpaste or other ways of exposure to appropriate fluorides, as well as to changes in the broader determinants of oral health.

Interestingly, the report of Public Health England also suggests three reasons for the modest decline in overall prevalence from 2008 to 2012. All of them revolve around fluoride: following official NHS recommendations toothpastes containing levels below 1,450 ppm of fluoride were phased down; dentists are prescribing fluoride containing products more often or apply fluoride varnish; and, lastly, the impact of public dental health programmes may be reflected in the statistics (though there is no evidence as yet for this assumption).

In order to control the current caries burden, to prepare for the future and to maintain professional credibility, the shift from curative to preventive dentistry – announced already decades ago – needs to finally become a reality and find its way into contemporary dental education, remuneration systems and the professional culture of every oral health professional. Without such a profound change, all ambitions to prove that dentistry is more than the drilling and filling of teeth will be seriously challenged.