BACKGROUND Dental decay (caries) is a common condition affecting preschool children in Western Australia (WA). Severe dental decay can have significant consequences as indicated by previous data reporting decay as the fifth most common cause of hospitalisation among preschool children in WA. METHODS This study examined the prevalence and severity of decay in preschool children in rural and remote WA and considered some of the factors associated with these rates. RESULTS The study reports on the dental health of 253 children aged between 2 and 4 years within five rural and remote communities in WA. Over 40% of these young children already had one or more decayed teeth with 19% having severe early childhood caries (s-ECC) and 15% having already suffered toothache. The disease burden was far higher among Indigenous children, who comprised one-third of the study group, in comparison with the non-Indigenous children in the study. Among the Indigenous children, decay was far more widespread (69% had decay compared with 25% of non-Indigenous children), and was more severely experienced (34% had s-ECC) and 28% having suffered toothache (vs respective rates of 10% and 7% for the non-Indigenous children). Only half of the Indigenous children brushed their teeth on a daily basis and one-third had never brushed at all (vs rates for non-Indigenous children of 85% and 2%, respectively). CONCLUSIONS Action to improve the prevalence and severity of decay among this group of Indigenous children is linked with promoting core messages for good oral health. A systemic approach to addressing the needs of remote dwelling people, and in particular remote area Indigenous children, must include a sustained, evidence based, primary health focus that is inclusive of oral health.