In recent years there has been a call to increase access to dental care for children with tooth decay in Maine. New delivery systems have been proposed and developed, from expanding community health centers to permitting dental hygienists to practice outside of dental offices and have the ability to place temporary fillings in children’s teeth. Our public health system should be congratulated for trying to find solutions.

But there are three important things we have forgotten. One is that new health care delivery options cost the public money, a whole lot of money in some instances.

Second, we have forgotten that the most effective measure to reduce the incidence of disease is basic prevention. The adage “an ounce of prevention is worth a pound of cure” has been long lost in our glitzy world of high-priced disease management (i.e. pharmaceuticals, surgical management, diagnostics, etc).

The third issue, the most important issue, is that the delivery of oral health care for children is highly dysfunctional. Dysfunctional because we actually lack evidence that treating dental disease in children has any impact on future disease risk. In fact, if you look at a country like New Zealand, which has universal dental care for all children in public schools, huge disparities still exist between those at high and low risk for tooth- decay experience, even though they all have access to care. Access to dental treatment for children does not eliminate dental disease experience, it simply treats disease experience.

If we step back and look at other basic disease processes, the focus of our state Legislature and many public health advocates does not make sense. Let us consider these questions:

. How did we manage the increase in tobacco-related disease? Did we train more lung surgeons, or did we focus on reducing the use of tobacco?

. When the country was considering automobile fatalities, did we train more trauma surgeons or fight for the installation and use of seat belts?

. When we were managing measles, mumps and rubella, did we expand our health care system’s ability to treat these diseases, or did we find a solution by vaccinating all children?

None of these major public health areas focused on treatment: they all focused on basic prevention, and they have been successful at reducing the burden of disease in all of these populations. Yet we have failed to realize this in dealing with pediatric tooth decay, the most prevalent chronic disease of childhood, which may explain why tooth decay has been and remains the most prevalent disease of childhood.

These comments are a stretch for a pediatric dentist, who spends his days committed to the ideology he believes is dysfunctional. How is it possible that oral health care delivery for children is dysfunctional?

The simple answer is that we generally wait until children are 3 or 4 years of age before they ever have their first dental experience. According to the Centers for Disease Control and Prevention, roughly 60 percent of children already have one or more cavities by age 5. So by the time we see children in a dental office, the tooth decay process has already begun. A recent study from the University of North Carolina showed that children who had an early preventive visit at age 1 could have a reduction in dental costs of close to 50 percent by age 5. This reduction in costs does not measure the reduction in disability, pain, lost school days, lost workdays for parents or sleepless nights that children with severe tooth decay experience.

The number of children receiving preventive dental visits is sobering. In 2002, only 3 percent of children under 3 years of age in Maine who were low-income received a preventive dental visit. Low income is the greatest predictor we have for development of early childhood tooth decay, and the population with the greatest access issues in Maine. The time has come for the dental care delivery system to step up and deliver early preventive dental care to all young children in Maine, particularly those at greatest risk for developing tooth decay.

In discussions and debates about the best venue for such early preventive visits, the state’s Women, Infant and Children program appears to be an ideal first start for addressing early childhood dental prevention. WIC already provides nutritious foods, nutritional counseling and referrals to other health care providers for low-income pregnant women, new mothers and children under 5 years of age. No other public or private program in the nation has contact with 45 percent of infants in this country.

Expanding WIC’s role to include dental education and prevention, which should include the application of fluorides, could have a profound impact on the level of decay in our most at-risk populations. Such an expansion of WIC would require state and private funding, since federal funds cannot be utilized for such an expansion. Other options will likely come about, but few have the logistical benefits of WIC to make them as cost effective. Granters and state legislators need to find ways to best develop these cost-effective programs.

So over the coming years, while the Legislature considers access to dental services and public health advocates consider the most cost-effective options for reducing the burden of dental disease on our population, they should first consider why so many people are developing disease before they start trying to change the way we treat it. Spending more state money on treatment while ignoring the proven impact of prevention on oral health would be immoral.

Dr. Jonathan Shenkin is a pediatric dentist in Bangor and an Assistant Clinical Professor of Health Policy, Health Services Research and Pediatric Dentistry at Boston University.