First, the development of dental health care for children in the Netherlands is discussed. Caries prevalence among children has declined sharply. The present situation, however, makes clear that the majority of carious cavities in the temporary dentition remain untreated. This has led to the conclusion that the level of restorative care has to increase. On the basis of new insights in cariology gained in recent decades, the authors of this article argue for abandoning the old paradigm of restorative treatment in favour of prevention in the treatment of caries.

In order to gain insight into the development of caries prevalence and caries experience among Dutch youth, a meta- analysis was carried out on epidemiological caries data collected in 5 and 6 and 11 and 12 year-olds between 1980 and 2009. From the present analysis it appears that after the mid-1980’s a halt occurred in the decline of caries experience in the primary dentition among 5 and 6 year-olds. At the same time, the percentage of children with a caries-free primary dentition who were covered by public health insurance or participated in institutions for youth dental care decreased. Among 11 to 12 year-olds there is no indication that the prevalence of caries in the permanent dentition has changed. Considering the high percentage of 12 year-olds with a caries-free permanent dentition, an additional improvement in oral health for this age-group will be difficult to achieve. The average restorative index of the primary dentition in 5-6 year-old children covered by public health insurance and children in The Hague appears not to have changed dramatically in the last 15 years.

Early detection of carious lesions enables the dental professional to interfere in caries development. Visual inspection in combination with bitewing radiographs performed better than new quantitative methods in detecting early noncavitated carious lesions. Once a lesion has been detected assessment of activity (diagnosis) is important in order to distinguish between an active process and a scar developed in the past. The ‘clinical gaze’, an intellectual interpretation of the dental condition, whereby the caries experience of the recent past is used as an important caries predictor, is better able to produce a correct estimate of the caries risk than prediction models based on risk factors. A correct diagnosis of lesion activity in combination with the caries risk of the patient gives us a tool to predict caries development in the future. Subsequently caries activity can be influenced by addressing the factors which cause caries (causal therapy).

For the dental care of parents and children, people in the Netherlands rely especially on the advice of the Ivory Cross. The basis of this advice is plaque removal with fluoride toothpaste. When this offers insufficient protection, one usually finds irregular and careless dental hygiene. Information and instruction concerning daily and careful dental hygiene should receive the highest priority of dental care professionals. If a patient’s own dental care cannot be brought up to standard or if this cannot be done immediately, then (temporary) support can be provided by dental professionals in the form of preventive treatment. Doing this, however, without improving the self care of patients has to be regarded an inadequate treatment modality.

Within modern dentistry, a change from invasive to non-invasive strategies for the treatment of dental caries seems to be apparent. The foundation of on-invasive care is old, but is now interpreted differently as a result of new insights. Caries is a dynamic and multi-factorial process that takes place in the biofilm. There is a growing awareness that dental professionals are better off concentrating on controlling the causes of the disease than merely fighting the symptoms. The most important component seems to be the mechanical cleaning with a toothbrush and fluoride toothpaste. Operative care is only necessary when mechanical cleaning fails to control the caries and when the process proceeds into the dentin or when mechanical cleaning has become impossible due to cavitation. However, a suitable treatment strategy, which takes into consideration the dynamic nature of the caries process, can only be indicated when one has a clear picture of both the caries activity and the specific caries risk of the individual patient.

The traditional restorative approach to active dentin caries in the temporary dentition is questioned. This paper argues in favour of a causal approach. The causal approach focuses on caries management. Restoration is of secondary importance. Delay or replacement of invasive restorative treatment by a causal approach decreases discomfort for children and promotes oral health over time. A form of causal treatment is the so called ‘Non-Restorative Cavity Treatment’. This approach requires that some measures be taken for managing cavitated caries lesions: 1. written informed consent; 2. making the cavity accessible for plaque removal; 3. treating carious dentition with anti-cariogenic agents and/or applying a protective layer to the carious dentition; 4. monitoring the caries process; 5. effective communication about dental health education. Some diagnostic criteria are important for the risk assessment of cavitated lesions: 1. activity of the caries lesion; 2. accessibility of the caries lesion for plaque control; 3. depth of the cavity; 4. condition of the pulp. Conclusion: the causal approach can arrest the caries process even in advanced stages of decay.