22 American Dental Association decay rates between the two communities that are extremely similar in terms of ethnic background and social structure.52 This was attributed to a number of factors. The dental programs exposed the Finnish children to intense topical fluoride regimes and dental sealant programs. Virtually all children and adolescents used the government-sponsored, comprehensive, free dental care. As a result, the effect of water fluoridation appeared minimal. Because of this unique set of factors, it was concluded that these results could not be replicated in countries with less intensive preventive dental care programs.52 No significant decrease in tooth decay was seen after fluoridation was discontinued in 1990 in Chemniz and Plauen, located in what was formerly East Germany.53 The intervening factors in these communities include improvements in attitudes toward oral health behaviors, and broader availability and increased use of other preventive measures including fluoridated salt, fluoride toothpaste and dental sealants.53 A similar situation was reported from the Netherlands. A study was conducted of 15-year-old children in Tiel (fluoridated 1953 to 1973) and Culemborg (nonfluoridated) comparing tooth decay rates from a baseline in 1968 through 1988. The lower tooth decay rate in Tiel after the cessation of fluoridation was attributed in part to the initiation of a dental health education program, free dietary fluoride supplements and a greater use of professionally applied topical fluorides.54 In the preceding examples, communities that discontinued fluoridation either found higher tooth decay rates in their children or a lack of an increase that could be attributed to the availability and use of free dental services for all children or the implementation of wide-spread decay prevention programs that require significant professional and administrative support and are less cost-effective than fluoridation. 10. Is tooth decay still a serious problem in the United States? Answer. Yes. Tooth decay is an infectious disease that continues to be a significant oral health problem. Fact. Good oral health is often taken for granted by many people in the U.S. Yet, while largely preventable, tooth decay, cavities or dental caries (a term used by health professionals) remains a common, debilitating, chronic condition for many children and adults. Tooth decay begins with a weakening and/or breakdown (loss of minerals) of the enamel (the hard outer layer of teeth) caused by acids produced by bacteria that live in plaque. Dental plaque is a soft, sticky film that is constantly forming on teeth. Eating foods or drinking beverages that contain sugars or other refined carbohydrates allow the bacteria in the plaque to produce acids that attack the enamel. The plaque helps to keep these acids in contact with the tooth surface and demineralization (loss of mineral) occurs. After repeated acid attacks, the enamel can breakdown creating a cavity. Left unchecked, bacteria and acid can penetrate the dentin (the next, inner layer of teeth) and then finally the pulp, which contains nerves and blood vessels. Once the bacteria enter the pulp, the tooth becomes infected (abscessed) and, without treatment, the infection can progress and travel into the surrounding tissues. The infection can enter the bloodstream and potentially spread the infection to other parts of the body which, in rare cases, becomes life-threatening. Additional information on this topic can be found in this Section, Question 2. Tooth decay can negatively affect an individual’s quality of life and ability to succeed. Tooth decay can cause pain — pain that can affect how we eat, speak, smile, learn at school or succeed at work. Children with cavities often miss more school and receive lower grades than children who are cavity- free.55 More than $6 billion of productivity is lost each year in the U.S, because people miss work to get dental care.56