• Children under 3 years should use a toothpaste containing no less than 1,000 parts per million (ppm) of fluoride.
  • use no more than a smear of toothpaste (a thin film of paste covering less than three-quarters of the brush).
• Children aged 3-6 years should use a pea-sized amount of toothpaste.
• Family fluoride toothpaste (1,350-1,500 parts per million fluoride) is indicated for children age 7 and above and for maximum caries control for all children. Advice must be given about adult supervision and the small amounts to be used.
• For high-risk patients toothpaste with a higher concentration of fluoride can be prescribed (see fluoride section).

• A number of plaque disclosing tablets and solutions are available. Children need appropriate supervision when using these agents and proper advice should be given to parents.
• Disclosing of plaque can be completed in the clinic or at home. Disclosing aims to show patients the plaque present on the teeth in a visual way to aid tooth brushing.
• Plaque charts can be used to monitor progress and identify areas where brushing is being missed. The percentage number of clean surfaces should be recorded so that patients can achieve as close to 100% as possible.
• The disclosing agent should firstly be used in clinic to demonstrate it to the child and the parent. Petroleum jelly should be applied to the lips prior to use to prevent staining. The child should try to remove all stained plaque and you should discuss brushing technique.
• The agent can also be used at home; in the first week it is advisable to instruct the patient to use the disclosing agent prior to brushing. After one week the patient should then brush first and then disclose in order to identify areas being missed.
• Timers can also be used to help the patient brush for the appropriate time

According to a study conducted from 1948 to 1963 at a children’s home (Hopewood House): diet alone can significantly reduce caries without the intervention of fluoride or good oral hygiene.

Healthy eating advice should be given to all patients to promote both good oral and general health. The key messages which should be given to patients are summarised below:

• The amount and most importantly the frequency of food/ drink containing free sugar and fermentable carbohydrates should be reduced.
• The number of times that food or drink containing sugars in one day should not exceed four. By confining food and drinks which contain sugars to mealtimes will reduce the number of acid attacks on the teeth.
• Only milk and water should be consumed in between meals. Drinks containing sugars such as sweetened milk, fruit juices and fizzy drinks increase the risk of caries.
• Ensure that parents are informed about hidden sugars in foods. Many foods such as crisps, yoghurts and cereals contain added sugar which patients and parents maybe unaware of.
• Safer snacks should be encouraged such as carrot sticks and nuts.
• Following tooth brushing at night nothing else should be eaten or drank except for plain water.
• There should be no intake of foods or drinks containing sugars within 1 hour of bed time as the salivary flow, and thus its protective effects are reduced.
• At 6 months children should be introduced to drinking from a free-flow cup and from 12 months drinking from a bottle should be discouraged.

Public Health England (2015) advise that the recommended intake of free sugars is no more than:

• 19g per day =5 sugar cubes for 4 – 6 year olds
• 24g per day = 6 sugar cubes for 6 – 10 year olds
• 30g per day = 7 sugar cubes for 11 and over

The importance of the frequency of sugar intake can be illustrated in the Stephan’s curve. Sugar intake causes a fall in pH level as oral bacteria convert sugar to acid causing demineralisation of tooth surfaces, the buffering action of saliva is also reduced. When sugar intakes are spaced out over hours the teeth can remineralise, which is more effective in the presence of fluoride. However when there are frequent sugar intakes demineralisation occurs more often and there is there is more limited time for the pH to rise to allow remineralisation.

All children should receive the basic dietary advice at their recall appointments and a discussion about how a healthy diet can reduce caries levels should take place.

For children at a high risk of caries a more thorough analysis should take place and more support is required. The diet can be reviewed in the form of a 3-day diet diary.

The diet diary is given to the patients, parents/carers and all food and drinks should be recorded over a 3 day period. One day should be a weekend as the child’s diet may differ at this time. The diet diary should be reviewed and advice should be practical and personal for the patient and the support given should be constructive.

Alternatively, a recall diet diary can be completed in surgery when the patient/ parents/carer recalls the food and drink that the child has consumed over a 24 hour period.

Public Health England developed an Eatwell plate to give recommendations about a balanced diet for general health. The key messages of the Eatwell plate are:

• Eat at least 5 portions of fruit and vegetables per day.
• Base meals on starchy carbohydrates and choose wholegrain options.
• Ensure that there is some dairy in the diet and choose low sugar and fat options.
• Eat sources of protein such as meat, beans and fish, the diet should include 2 portions of fish per week with 1 portion being oily fish. Processed meats should be limited.
• Choose unsaturated oils and spreads, cutting down on saturated fats.
• Drink at least 1.2 litres of water per day.
• Limit salt and sugar intake. Ideally, no more than 5% of the energy we consume should come from free sugars.

There is abundant evidence that increasing fluoride availability is effective at reducing caries level on an individual and population basis.

Evidence Of Fluoride Summary

• The York review (McDonagh et al., 2000)– fluoridation of drinking water reduces caries but is associated with dental fluorosis. No correlation with bone fractures or human cancers
• Marinho et al., 2003– fluoride toothpaste reduces caries by 24%
• Marinho et al., 2013– fluoride varnish reduces DMFS by 43%
• Marinho et al., 2013– fluoride varnish reduces dmfs by 37% (primary)
• Marinho et al., 2016– fluoride mouthwash reduces DMFS by 27% compared to placebo
• Marinho et al., 2010– fluoride combinations VERSUS single topical fluoride achieved 10% reduction compared to fluoride alone

It is the topical action of fluoride which is essential for caries prevention and it is most effective if it is available at multiple times throughout the day.

The mechanisms of action of fluoride are summarised below:

1 ) It has an effect during tooth formation making the enamel crystals larger and more stable.

2 ) It inhibits plaque bacteria by blocking enzyme enolase during glycolysis.

3) It inhibits demineralisation when in solution.

4) It enhances remineralisation by forming fluorapatite when in solution.

5) It affects the crown morphology making the pits and fissures shallower and hence less likely to create stagnation areas.

Fluoride is widespread in nature and can be found in fish, vegetables, tea and some natural water supplies. In addition there are a great number of fluoride products which are available for systemic and topical use to be used by the patient or delivered by a dental professional.

Water fluoridation is the systemic method of providing fluoride on a community basis. Currently in the UK only approximately 10% of the population benefit from a water supply which is either naturally or artificially at the optimum fluoride level for dental health. There have been multiple studies carried out across the world showing that water fluoridation decreases caries. Water fluoridation is a cheap and cost effective method and can be considered as an effective method to reduce social inequalities in caries level.

Fluoride containing toothpastes were first introduced in the early 1970’s and since then there has been a dramatic decrease in worldwide caries levels. Strong evidence shows that toothpastes containing higher concentrations of fluoride are more effective at controlling caries whereas fluoride toothpastes (containing less than 1,000ppmF) are ineffective at controlling caries.

There should be a balanced consideration between the benefits of topical fluorides in caries prevention and the risk of the development of fluorosis. A research study has shown that the risk of fluorosis from ingesting too much fluoride is linked much more to the amount of toothpaste that is used, than the concentration. Careful brushing by parents/ carers when using toothpastes containing higher levels of fluoride is required.

• For patients aged 10 and above who are at high caries risk 2,800 ppmF toothpaste can be prescribed.
• For patients aged 16 and over who are at high caries risk 5,000 ppmF toothpaste can be prescribed.

Fluoride mouthrinses can be prescribed for patients 8 years and above who are at a high risk of dental caries. It should be used daily in addition to tooth brushing. Rinsing should occur at a different time to brushing to maximise the topical effect. The effect of toothbrushing and rinsing has been shown to be additive. All orthodontic patients should be using fluoride rinses to minimise the risk of demineralisation. Children under the age of 8 should not be recommended to use fluoride mouth rinses because of the increased risk of swallowing the solution.

Fluoride varnish is one of the best options for increasing the availability of levels of fluoride. There is high quality evidence of the preventive effectiveness of fluoride varnish in both the primary and permanent dentition.

The evidence supports that the varnish can also arrest existing lesions. The application is simple and trained dental nurses can also place the varnish on prescription.

Procedure

• Gross plaque should first be removed
• Teeth should be dried with cotton wool rolls or a triple syringe
• The varnish should be carefully applied with a microbrush to pits, fissures and approximal surfaces of teeth.

The patient should then avoid food and drinks for 30 minutes and only soft foods should be eaten up to 4 hours after the application.

Duraphat (5wt% fluoride 22,600 ppm fluoride) is the most widely available fluoride varnish. There is a very small risk of allergy to one component of Duraphat (colophony), so for children who have a history of allergic episodes requiring hospital admission, including asthma, varnish application is contraindicated.

Fluoride tablets and drops usually require good compliance from families and often have resulted in under and over-use. The fluoride supplement dose depends upon the age of the patient and also the level of fluoride in the drinking water.

There is a risk of fluorosis if children under the age of 6 take more than the advised dose. Therefore the Delivering better oral health guidance states that other sources of fluoride may be preferable and should be considered first.

Brushing with a toothpaste containing at least 1,000 ppmF or higher is the priority step for prevention of dental caries.

In addition a systematic review of fluoride tablets, drops, lozenges and chewing gums concluded that the evidence of the effect of these additional sources of fluoride ‘was unclear on deciduous teeth’.

The following evidence is from Cochrane systematic reviews which can be read in full in the Cochrane library, a summary of each review is provided below and their references can be found in the recommended reading section:

1. Marinho et al 2003 – Fluoride toothpastes for preventing dental caries in children and adolescents.

• Fluoride toothpastes prevent dental caries by 24%.
• The effect of fluoride toothpaste increased with, higher baseline levels of decayed, missing or filled surfaces (D(M)FS), higher fluoride concentration, higher frequency of use and supervised brushing.

2) Walsh et al 2010 – Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents

• This review confirms the benefits of using fluoride toothpaste in preventing caries in children and adolescents when compared to placebo, but only significantly for fluoride concentrations of 1000 ppm and above.
• The higher the concentration of fluoride the more preventive effect shown.
• The decision of what fluoride levels to use for children under 6 years should be balanced with the risk of fluorosis.

4) Marinho et al 2013 – Fluoride varnishes for preventing dental caries in children and adolescents

• Fluoride varnish is successful in reducing caries.
• In permanent teeth a 43% reduction in D(M)FS was found.
• In primary teeth there was a 37% reduction in d(m)fs.

5) Marinho et al – 2016 (update from original review 2003) Fluoride mouthrinses for preventing dental caries in children and adolescents

• Fluoride mouthrinses showed a 27% reduction in D(M)FS in permanent teeth with fluoride mouthrinse compared with placebo or no mouthrinse.

6) Marinho et al 2004 – Combinations of topical fluoride (toothpastes, mouthrinses,gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents

• Topical fluorides (mouthrinses, gels, or varnishes) used in addition to fluoride toothpaste achieved a 10% reduction in D(M)FS compared to toothpaste used alone.

Pit and fissure sealants are materials applied to the tooth to obliterate the fissures and remove the sheltered environment where caries may develop.

Fissure sealants are an effective measure in preventing caries and a Cochrane review concluded that sealing the occlusal surfaces of permanent molars in children and adolescents reduces caries up to 48 months when compared to no sealant (Ahovuo-Saloranta et al 2013).

Several sealant materials are available, these can usually be grouped into resin materials and glass ionomer sealants. The application of glass ionomer selants is less technique sensitive than for resins but they have poorer retention. Glass ionomer sealants may be indicated if the patient is pre-cooperative, the tooth is partially erupted and the caries risk is very high or there are some concerns over the ability to get good moisture control.

During the placement of fissure sealants isolation is critical to the success. The operator and nurse must work together to ensure appropriate isolation using cotton wool rolls and suction.

Some parties recommend the use of rubber dam due to the superior isolation, however this is often not practical due to the stage of eruption of the tooth or the level of cooperation. It would not be appropriate to delay the placement of the sealant to allow further eruption to place the dam. In addition the placement of fissure sealants is often used as a non-invasive technique to acclimatise the patient. For the placement of rubber dam and clamps local anaesthetic would be required and thus this is not justified if only placing sealants. Placement under rubber dam would be appropriate if isolating the quadrant when placing restorations.

The placement of the fissure sealant should be into all pits and grooves of the tooth, not forgetting the buccal pits of lower teeth and the palatal surfaces of upper teeth. Fissure sealants should be checked visually for wear and physically with a probe for integrity/leakage at every recall visit. In terms of patient selection, fissure sealants should be placed in the permanent teeth of patients with a high caries risk, this includes patients with special needs and patients who are medically compromised.

The British Dental Association Policy document for fissure sealants (2000) gives the following advice in regards to patient and tooth selection:

• Children and young people with caries in their primary teeth (dmfs=2 or more) should have all susceptible sites on permanent teeth sealed.
• Children with caries free primary dentition do not need permanent molars sealed routinely in absence of risk factors.
• Place fissure sealants as soon as teeth have erupted sufficiently for good moisture control.
• Where there is caries in one permanent molar, seal all other permanent molars.

Fissure sealants can also be used in some cases for the management of carious pits and fissures in permanent teeth. For fissure caries conventional restorations should be placed when there is:

• Microcavitation
• Shadowing visible under the enamel adjacent to the fissure after cleaning and drying the tooth.
• Dentinal caries clearly visible on a bitewing radiograph

Otherwise place a fissure sealant alone, and review the tooth at every recall visit.

1) Clean the tooth if obvious debris is present.

2) Isolate the tooth surface with cotton wool rolls, use high volume suction and a dry guard may be beneficial.

3) Apply etch 37% phosphoric acid for 20-30 seconds

4) Wash and dry the surface, maintaining isolation, dry the tooth until there is a frosty appearance.

5) Apply bond using a microbrush, lightly dry with the triple syringe and light cure.

6) Apply resin to the pits and fissures using a spoon excavator.

7) Light cure the resin.

8) Check for adequacy with a probe, if the sealant comes away with the probe it will need to be replaced.

The use of bonding agent between etching and the resin sealant is now supported in literature. It has been shown that adding a bonding layer may improve the retention of fissure sealants, especially when contaminated with saliva. In most studies the bond and resin are applied in one layer to reduce treatment time, however it is recommended that if moisture control allows it that the separate layers are cured separately.

1) Ahovuo-Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington H. Pit andfissure sealants for preventing dental decay in permanent teeth. Cochrane Databaseof Systematic Reviews. 2017;.

2) Bentley E, Ellwood R, Davies R. Fluoride ingestion from toothpaste by young children.British Dental Journal. 1999;186(9):460-462.

3) British Dental Association. A Policy document on fissure sealants in paediatricdentistry. BSPD; 2000.

4) Dental checks: intervals between oral health reviews. London: NICE; 2004.

5) Department of Health. Delivering Better Oral Health: An Evidence based toolkit forprevention. 2014.

6) Marinho V, Worthington H, Walsh T, Clarkson J. Fluoride varnishes for preventingdental caries in children and adolescents. Cochrane Database of Systematic Reviews.2013;.

7) Marinho V, Chong L, Worthington H, Walsh T. Fluoride mouthrinses for preventingdental caries in children and adolescents. Cochrane Database of Systematic Reviews.2016;.

8) Marinho V, Higgins J, Sheiham A, Logan S. Combinations of topical fluoride(toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride forpreventing dental caries in children and adolescents. Cochrane Database ofSystematic Reviews. 2004;.

9) Mc Cafferty J, O Connell A.A randomised Controlled Clinical Trial on The use ofIntermediate Bonding on the retention of Fissure Sealants in Children.InternationalJournal of Paediatric Dentistry 2016; 26: 110–115.

10) Prevention and Management of Dental Caries in Children Dental Clinical Guidance.Dundee: SDCEP; 2010.

11) Public Health England. Water fluoridation: health monitoring report for England.London: Public Health England; 2014.

12) Public Health England. The Eatwell Guide. 2016. Public Health England.

13) Selection Criteria for Dental Radiography. 3rd ed. 2013.

14) Welbury R, Duggal M, Hosey M. Paediatric dentistry. 4th ed. Oxford: OxfordUniversity Press; 2012.

15) Tubert-Jeannin S, Auclair C, Amsallem E, Tramini P, Gerbaud L, Ruffieux C et al.Fluoride supplements (tablets, drops, lozenges or chewing gums) for preventingdental caries in children. Cochrane Database of Systematic Reviews. 2011;.

16) Walsh T, Worthington H, Glenny A, Appelbe P, Marinho V, Shi X. Fluoride toothpastesof different concentrations for preventing dental caries in childrenand adolescents.Cochrane Database of Systematic Reviews. 2010;

17) Wong M, Glenny A, Tsang B, Lo E, Worthington H, Marinho V. Cochrane review: Topicalfluoride as a cause of dental fluorosis in children. Evidence-Based Child Health: ACochrane Review Journal.2011;6(2):388-439.

18) Yaacob M, Worthington H, Deacon S, Deery C, Walmsley A, Robinson P et al. Poweredversus manual toothbrushing for oral health. Cochrane Database of SystematicReviews. 2014;.