Dental Caries Prevention Strategies for Children PDF

DTC 200 – KB 3 PREVENTIVE STRATEGIES FOR DENTAL CARIES AT CHILDREN PROF. DR. A.NİL ALTAY [email protected] LEARNING OBJECTIVES: 1. Will be able to list the mainstay of preventive measures 2. Will be able to define tooth brushing techniques in children of different age groups 3. Will be ab...

DTC 200 – KB 3 PREVENTIVE STRATEGIES FOR DENTAL CARIES AT CHILDREN PROF. DR. A.NİL ALTAY [email protected] LEARNING OBJECTIVES: 1. Will be able to list the mainstay of preventive measures 2. Will be able to define tooth brushing techniques in children of different age groups 3. Will be able to explain the reasons for the use of varying fluoride toothpaste in children of different age groups. 4. Will be able to compare the mechanism of action of systemic and topical fluorides 5. Will be able to list the systemic and topical fluoride sources 6. Will be able to list the fluoride tablet usage doses according to the amount of fluoride in drinking water. 7. Will be able to define acute fluorine toxicity values 8. Will be able to list the indications for use of different fissure sealant materials There are four practical pillars to the prevention of dental caries: a) b) c) d) plaque control/ toothbrushing, diet, fluoride, fissure sealing. Each of these will be considered in turn before being brought together in treatment planning and in relation to caries-risk. Prevention of caries is so easy in theory but in practice involves many skills. The main reason for this is that control of the aetiological agents⎯plaque and fermentable carbohydrates⎯involve a change in behaviour. In dentistry there is no doubt that prevention is better than cure. Prevention of dental caries underpins all dental care provided to children. All children require preventive input. The type of input depends on the child and their caries risk. Forming a comprehensive treatment strategy, tailored to the needs of each individual child, is an essential component of all paediatric treatment planning. Consequently two approaches are required to improve dental health. This strategy will involve; A. B. maintaining good dental health in those without dental decay, targeting resources to those that are at risk of developing decay. This means targeting the 'high caries-risk' groups comprising: a. • early childhood caries (nursing bottle caries). b. • the handicapped⎯medical and physical. c. • low socio-economic groups. d. • ethnic minority groups usually residing in inner city areas. Low caries-risk children are those who are caries-free or have well-controlled caries, have good oral and dietary habits, are highly motivated and attend their dental appointments regularly. The mainstay of preventive measures are: (1) plaque control and regular toothbrushing with a fluoride toothpaste; (2) sensible dietary advice; (3) use of fluorides; (4) fissure sealants; (5) regular dental checks with appropriate radiographs. 1) Plaque control and toothbrushing: Plaque disclosing tablets and solutions are available for children. Children need close supervision when using these agents and appropriate advice should be given to parents and guardians. Plaque charts can be used to monitor progress and to identify areas where cleaning is not ideal. After demonstrating the plaque disclosing procedure and performing the charting it is initially advisable to instruct patients to use the disclosing agent prior to toothbrushing. After 1 week it is advisable for patients to brush first and then disclose in order to identify areas that are being missed. Toothbrushing: Advise regular toothbrushing with an appropriate concentration of fluoride toothpaste. Toothbrushing should become a routine and on at least two occasions every day. Manual toothbrushes Electric toothbrushes Toothbrushes should be small head. Young children under 8 years need help with toothbrushing. Children do not have the manual dexterity to brush their teeth effectively until they can tie their own shoelaces. Up to age 8, parents/ caregivings are responsible from the brushing procedures of children. They have to first let the child to brush her/his teeth as she/he knows. Then parents/ caregivings brush the teeth. Dentists should show which brushing tecnique should be used.Fone technique is appropriate for children. The buccal and lingual surfaces should brushed in a circular motion 5 times / tooth. Occlusal surfaces should be brushed same. The toothbrush should be kept in an upright position at labial/ lingual surfaces. parent assiting Only a small smear of fluoride toothpaste should be used up to 3 years of age then pea size could be advised. Fluoride is cleared quickly from the oral cavity that many advise to swish the toothpaste saliva slurry around the mouth and not to rinse with water in order to maintain elevated intra-oral fluoride levels for longer periods of time. Smear size pea size The night-brushing should be start half an hour before going to sleep to avoid moodiness. After brushing advice not to eat or drink until sleep. Children between 8-12 years old should be educated by the dentist about toothbrushing technique. Parents/caregivings should observe and control the brushing. Modified Bass Technique: The most commonly recommended method is the Modified Bass technique, which involves holding the toothbrush at an 45 angle so that the bristles point at gum line and making short back-and-forth strokes, followed by sweeping the brush from under the gum toward the edge of tooth. 2) Nutrition and diet in caries control: Advising parents to completely stop their children from eating sugary foods is not achievable. We should advise that only milk or water is given to children in a baby bottle. Many are not aware that no added sugar drinks contain natural sugar. 'Safer foods' have been recommended as alternatives for frequent snackers or nibblers. These alternatives include cheeses that have been shown to raise plaque pH. In addition to fruit and vegetables, crisps and peanuts have also been recommended as safer alternatives. Frequency of eating: Frequency of eating has an important effect on teeth. Eating meals leads to periods of acid attack when tooth mineral is lost. At the end of the meal or snack the acid is buffered by saliva and the mineral loss stops and reverses under favourable conditions. Frequent snackers have predominantly mineral loss and little if any remineralization. Brushing twice per day with a fluoride toothpaste, subjects should safely be able to have five meal moments per day. This is a sensible and achievable dietary message for patients. Non-sugar sweeteners: The intense sweeteners and xylitol are non-cariogenic while the other bulk sweeteners can be metabolized by plaque bacteria but the rate is so slow that these sweeteners can be considered safe for teeth. The use of nonsugar sweeteners is growing rapidly particularly in confectionery and soft drinks. Tooth-friendly sweets are available in many countries with Tooth-friendly (or Mr Happy-Tooth) logo. There is good evidence that sugarless chewing gums are not only non-cariogenic but also positively prevent dental caries, by stimulating salivary flow. Xylitol gums are used in school-based preventive programmes. Dietary advice for the prevention of dental caries: A dentist can make a diet diary for the child patient to give advices to prevent the caries risk. To give a dietary advice dentist have to learn following information. a. Number of intakes of food and drinks b. The number of intakes that contain sugars (excluding sugar in fruit) and how many were consumed between normal mealtimes c. Whether any intakes containing sugars were taken within one hour before bedtime. INSTRUCTIONS ON COMPLETING A DIARY Please write down everything your child eats or drinks and the time during the day when consumed- this will help us to advice you on how best to improve child’s diet. Choose one weekend day and two others. Please bring the diet diary with you to the next appointment. Another problem that effects the existing of ECC is the oral liquid medicines (suspensions) given to baby/child for infection or fever that contains sugar. The parents and the doctors should be warned about the sugar free (SF) medicines. If the medicine does not have SF type then to give water after medicine should be advised. When diet changes are indicated, keep it simple. Make small changes, and let the patient choose one or two goals to practice between dental appointments. As a clinician, be aware of patient’s cultural influence, education, current health status, and any financial restrictions that may inhibit food selection. ADVICES: For children who need the energy provided by between meal snacks, they should be healthy food choices low in cariogenic potential such as cheese, raw vegetables, meat roll-ups, and fresh fruit. When oral hygiene does not follow a meal, suggest ending a meal with cheese or milk, chewing gum with xylitol, or rinsing with water. To stimulate salivary flow, include cool, sour, or tart nutrient dense foods (sugar free), increase water intake, and suck on sugar free mints. Incorporate low-fat, calcium rich foods in the diet, spaced throughout the day for the best absorption rate. When reading a food label, don’t forget to look at the serving size and multiply accordingly. FLUORIDE Fluorine (F) is an element of the halogen family. It forms inorganic and organic compounds called fluorides. Living organisms are mainly exposed to inorganic fluorides through food and water. The most relevant inorganic fluorides are hydrogen fluoride (HF), calcium fluoride (CaF2), sodium fluoride (NaF), sulfur hexafluoride (SF6) and silicofluorides. The levels of fluoride in most fruits, vegetables, meats are very low (0.1 – 5 mg/kg) and are unlikely to contribute significantly to daily fluoride exposure. Tea contains relatively high levels of fluoride with the highest concentrations found in mature and fallen tealeaves. Fluoride has both systemic and topical effects on teeth. Systemic fluoride is taken with drinking water, fluoridated milk, foods, salt, and fluoride supplements. Systemic fluorides are those ingested into the body. During tooth formation, ingested fluorides become incorporated into tooth structures. Fluorides ingested regularly during the time when teeth are developing (preeruptively) are deposited throughout the entire tooth surface and provide longer-lasting protection than those applied topically. Systemic fluorides can also give topical protection because ingested fluoride is present in saliva, which continually bathes the teeth providing a reservoir of fluoride that can be incorporated into the tooth surface to prevent decay. Fluoride also becomes incorporated into dental plaque and facilitates further remineralization. According to studies; - Water fluoridation to 1ppm is deemed to provide an optimal balance between reduction of caries and occurrence of fluorosis; – There is no evidence of adverse health effects of water fluoridation at 1ppm; – Increase in caries is evident when there is no sufficient fluoride in water – Water fluoridation at 1ppm provides a 20-40% reduction in caries. Effect of systemic fluoride at development stage Fluoride is regarded as an important trace element, which has a high impact on growth of bone and teeth because it serves as a core of mineralization. When fluoride is taken in during tooth development stage F can substitute into apatite structure as CO3F3- and makes fluorapatite, which is more stable against acid attack. It also has effect on formation stage of tooth where the cusps and the grooves at occlusal surfaces become smoother. Systemic effects of fluoride are not important as topical effects. The types of systemic fluoride are; a. b. c. d. Drinking water Milk Salt Supplements a. Water fluoridation: Water fluoridation is the controlled adjustment of the natural fluoride concentration in drinking water to that recommended for optimal dental health. Water fluoridation is effective at reducing caries and has been hailed as one of the 10 greatest achievements in public health in the 20th century. With the exception of dental fluorosis, no association be- tween adverse effects and water fluoridation has been established. In recent years, the use of bottled drinking waters has become more extensive. These bottled waters, when containing optimal fluoride levels, may play a role in caries prevention. That recommended level is 0.7 parts fluoride per million parts water. b. Fluoride Tablets & Drops, Fluoridated Milk and Fluoridated Salt: Initially their use intended to mimic the consumption of fluoride from naturally fluoridated water in areas without fluoride in drinking water. Now the common view is that it is through the topical effect on tooth surfaces that fluorides have a caries preventive action and the term “supplements” should be avoided. Use of fluoride-containing toothpastes is almost universal, but other fluoride sources may have an additional effect when the caries challenge is considerable according to an individual’s caries- risk assessment. Fluoridated milk: Typically fluoridated milk is used in limited groups of children in kindergartens, but there are insufficient studies of good quality examining the effects of fluoridated milk in preventing dental caries. The fluoride concentration in milk is usually in the range 2.5-5.0 mg F/L. Fluoridated salt: Fluoridated salt is widely used in Germany, France and Switzerland with 30-80% of the marketed salt for domestic use being fluoridated. Salt is most commonly fluoridated at 250 mg of fluoride per kg. Fluoridated salt is probably less effective among small children due to the low salt diet now recommended for this age group. Fluoride tablets/lozenges and fluoride drops: Fluoride for local use has been delivered in drops and in combinations with vitamins. Some caries preventive effect has been reported. Using fluoride drops twice a day compared with the daily sucking of a fluoride tablet (0.25 mg NaF) has more effect on decreasing dental caries. F level < 0.3 ppm 0.3-0.6 ppm 0.7 ppm > None None None 6 months-3 year old 0.25 mg None None 3-6 year old 0.50 mg 0.25 mg None > 6 year old 1 mg 0.50 mg None AGE 0-6 months Fluoride tablet doses for high-risk children (ADA). Important Considerations When Using Dosage Schedule: Determination of dietary fluoride before prescribing supplements can help reduce intake of excess fluoride. Sources of dietary fluoride may include; a) Drinking water from home, day care, and school b) Beverages such as soda, juice, and infant formula c) Prepared food d) Toothpaste. Fluoride supplements require long-term compliance on a daily basis. Conclusion: Fluoridated milk and fluoridated salt could be a public health measure in target groups with high caries prevalence and low compliance for tooth brushing in areas without water fluoridation. Fluoride tablets and fluoride drops could be considered on an individual basis for children at high risk of caries. TOPICAL USAGE OF FLUORIDES: Fluoride has several caries-protective mechanisms of action. 1. Topically, low levels of fluoride in plaque and saliva inhibit the demineralization of sound enamel and enhance the remineralization of demineralized enamel. 2. Fluoride also inhibits dental caries by affecting the metabolic activity of cariogenic bacteria. 3. High levels of fluoride, such as those attained with the use of topical gels or varnishes, produce a temporary layer of calcium fluoride-like material on the enamel surface. 4. The fluoride is released when the pH drops in response to acid production and becomes available to remineralize enamel or affect bacterial metabolism. Calcium fluoride. The main product deposited on the enamel surface and on subsurface carious lesions after the application of topical vehicles with high fluoride content is calcium fluoride, or CaF2. Topical vehicles with low fluoride concentration tend to deposit fluorapatite, or Ca10(PO4)6F2. While fluorapatite remains permanently bound within the crystalline structure of the enamel, most of the CaF2 precipitates on the enamel surface, where it may be lost through exposure to alkaline solutions. Topical usage of fluoride: 1. 2. 3. 4. Toothpaste Fluoride varnish/gels Fluoridated mouth rinses Fluoride supplements (before swallowed, increase the salivary and gingival crevicular fluid fluoride level) 5. Fluoridated dental floss 6. Chewing gums 7. Restorative materials (GIC) Toothpaste: The amount of fluoride contained in fluoride toothpaste should be indicated on the toothpaste tube, although this information may sometimes be hard to locate. Most manufacturers now give fluoride content in ppm F. Amounts in toothpaste: 500/600-1,000-1,500 and 2,800 ppm F Because young infants and children under age 2 years can swallow most, if not all, of the toothpaste when brushing, there has been concern that the use of fluoride toothpaste containing 1,000-1,500 ppm F could give rise to enamel fluorosis of the front permanent incisors. Enamel fluorosis is a condition, which can vary from minor white spots to unsightly yellow/ brown discoloration of the enamel due to excessive intake of fluoride. In response to the concern over enamel fluorosis, some manufacturers now market low fluoride "children's" or "pediatric" toothpastes containing less than 600 ppm F. Toothpastes are used in every age. Fluoride varnish/ gels: Fluoride-containing varnishes were developed during the late 1960s and early 1970s in an effort to improve shortcomings of existing topical fluoride vehicles, such as fluoride gels or mouth rinses, by prolonging contact of the fluoride with tooth enamel. Different brands of fluoride varnishes and their fluoride concentrations: Fluoride varnishes are used in every age. Fluoride gels are used after age 6 to avoid from swallowing excess gel. Gels are applied by special trays or with brushes or cotton pellets on dry teeth. The most commonly used agents for professionally applied fluoride treatments are; 5 % sodium fluoride varnish (NaF; 22,500 ppm F) 1.23 % acidulated phosphate fluoride (APF; 12,300 ppm F). Fluoride mouth rinses: Mouth rinses are used for a variety of reasons: To freshen breath, to help prevent or control tooth decay, to reduce plaque, to prevent or reduce gingivitis (an early stage of gum disease), to reduce the speed that tartar (hardened plaque) forms on the teeth or to produce a combination of these effects. Fluoridated mouth rinses are used after age 6 in children. The recommendations and good practice points for fluoride gels, rinses and varnishes according to EAPD. Modality Recommendation Gels Professional use; 12,500 ppm F) (5,000- Do not use in children < 6 year old age, as risk/benefit ratio is in favor of risk due to danger of swallowing the gel Usage Use 2-4 times per year Obvious deposits of dental plaque should be removed prior to application. Use appropriate size trays, and suction devices during and after treatment. Patient should sit in upright position and not swallow . Allow child to expectorate Teeth should be wiped at the end of the session with gauze. Instruct child not to eat or drink for 20-30 min after application Rinses Home use or at schools; Daily: 0.05% NaF (225ppm F); Do not use in children < 6 year age, as risk: benefit ratio is in favor of risk due to danger of swallowing the rinse Supervised use more efficacious than unsupervised 10 ml of the solution is swished around the mouth for 1 minute Instruct child not to eat or drink 20-30 min after application Should be used for prevention of caries in both primary and permanent teeth Use 2-4 times per year Obvious deposits of dental plaque should be removed prior to application Weekly: 0.2% NaF (900 ppm F) Varnishes Professional use; (1,000 – 56,300 ppm F) In order not to exceed PTD clinicians should take the same precautions as for gels (see above) A thin film using minimal amount should be used Amount could be kept at a minimum by limiting application to surfaces at risk Instruct child not to eat or drink for 20-30 min after application TOXICOLOGY for FLUORIDE: Compared to other substances, which are regularly ingested by humans, fluoride has a higher therapeutic safety. The lethal dose ranges between 32-64 mg F-/ kg. Acute Toxicity: Acute fluoride toxicity occurring from the ingestion of optimally fluoridated water is impossible. The amount of fluoride necessary to cause death for a human adult (70 kg man) has been estimated to be 5-10 grams of sodium fluoride, ingested at one time. This is more than 10,000-20,000 times as much fluoride as is consumed at one time in a single glass of optimally fluoridated water. For children there is a risk of acute toxicity. If a six year-old child with body weight of 20 kg ingests the whole content of a tube of toothpaste with 1500 ppm F sign of toxicity could be seen. If a 10 kg child ingests 3 % toothpaste in a single sitting acute toxicity signs will be seen. Symptoms: (A single ingestion of just 0.1 to 0.3 mg/kg) Gastric pain, Nausea, Vomiting, Headaches, Abdominal pain, diarrhea Excess salivation Generalized weakness Fall in blood pressure Depression of respiratory system Cardiac Arrhythmia Coma and death Management: Less then 5mg/kg: Give calcium orally to relieve GIS symptoms and induce vomiting 5-15 mg/kg: Empty stomach with emetics, give orally soluble calcium, and admit to hospital 15 mg/kg: Admit to hospital immediately, induce vomiting, and begin cardiac monitoring Chronic Toxicity: If fluoride is ingested in elevated doses over longer time periods, changes in teeth and bone can result. These changes are called fluorosis. In bone skeletal fluorosis happens ingestion 10 mg/day at least 10 years. 3. FISSURE SEALANTS The term pit and fissure sealant is used to describe a material that is introduced into the occlusal pits and fissures of caries-susceptible teeth, thus forming a micromechanically-bonded, protective layer cutting access of caries-producing bacteria from their source of nutrients. Tooth surfaces with pits and fissures are particularly vulnerable to caries development observed that although the occlusal surfaces represented only 12.5% of the total surfaces of the permanent dentition, they accounted for almost 50% of the caries in school children. This can be explained by the morphological complexity of these surfaces, which favors plaque accumulation to the extent that the enamel does not receive the same level of caries protection from fluoride (F) as does smooth surface enamel. The plaque accumulation and caries susceptibility are greatest during the eruption of the molars and caries susceptible individuals are therefore vulnerable to early initiation and fast progression of caries in these sites. In fluoridated communities over 90% of dental caries is exclusively pit and fissure caries. DIAGNOSIS: The clinical diagnosis is very important at deciding the type of fissure sealant to primary and young permanent teeth. Diagnosis of fissures and pits at intraoral examination, first the tooth must be isolated and dried with air. The dried surface is then checked with inspection. This gives the dentist the opportunity to see the orifices of the fissures and the chalk appearance that is the early sign of caries at fissure walls. The dark colored fissures also are considered as early sign of caries for young children and moderate or high-risk caries group. Once the initial lesion has developed, caries may spread laterally such that a small surface lesion may hide a much greater area of destruction below the surface. Types of pit and fissure sealants: Resins. Resin based fissure sealants (FS) are bonded to the underlying enamel by the use of the acid etch technique. Their caries preventive property is based on the establishment of a tight seal, which prevents leakage of nutrients to the microflora in the deeper parts of the fissure. The resin sealants may be pure resin, composites or compomers, and their polymerization may be initiated chemically or by light. Glass ionomer cements (GIC). One of the main clinical advantages of GIC is their ability to bond chemically to dentine and enamel without the use of the acid-etch technique which makes them less vulnerable to moisture. This, in conjunction with active F release into the surrounding enamel has led to the development and evaluation of GIC as an alternative FS system, particularly in cases where moisture control is difficult to achieve. Experiments have established that the F release in distilled water is very high during the first 24 hours (burst effect) and it drops rapidly during the following 48 hours before reaching a relatively constant level during the second week. This pattern of F release is common for all the conventional and resin modified GICs. The use of GIC has been suggested for erupting teeth where isolation is a problem, especially in the high caries risk individuals. In this situation they can be considered more a F vehicle than a traditional FS. Compomers. Compomers are currently being investigated widely in both in vitro and in vivo studies. As the amount of F released in distilled water is considerably less than GIC and as three year clinical results show comparability with resin FS their properties should be estimated as comparable to the resins. Fluoride containing sealants. The durability of F containing FS would now appear to be comparable to conventional resin FS. However, further long-term clinical trials are necessary to determine that the clinical longevity of FS retention is not adversely affected by the presence of incorporated F. Also the clinical importance of the F ion in F containing FS in terms of caries prevention remains to be shown. Technique for resin sealants Time to seal: FS are applied to teeth in 4 years after eruption. If clinician cannot see any sign of early caries lesion or staining at the fissures in that time because of the mastication forces and grinding the occlusal surface will be flattened and the orifices’ of the fissures will not be under risk of caries. Surface cleaning: The need for surface cleaning and the method of cleaning pits and fissures prior to FS placement may seem to be controversial. Some studies suggest the careful removal of plaque and pellicle by the use of pumice or air-polishing instruments in order to obtain optimal acid-etch pattern of the enamel, while another maintains that the effect of acid etching alone is sufficient for surface cleaning provided obvious soft material has been removed. The literature is extensive on the efficiency of different cleaning procedures on bonding including the use of rotating burs in order to remove superficial enamel and open the fissure to have the resin penetrate into it. The early application technique for pit-and-fissure sealant application consisted of cleaning the enamel surface to be treated with pumice and water mixture using a rotary brush, either pointed or flat ended. Later many methods were introduced to clinical processes like air polishing, enameloplasty sealant technique, abrasion with alumina oxide and laser. Isolation. Adequate isolation is the most critical aspect of FS application. If the enamel porosity created by the etching procedure is filled by any kind of liquid, the formation of resin tags in the enamel is blocked or reduced, and the resin is poorly retained. Salivary contamination, during and after acid etching, also allows the precipitation of glycoproteins onto the enamel surface, greatly decreasing bond strength to the FS. The use of rubber dam is obviously the safest way of securing optimal moisture control, but in young and newly erupted teeth this is usually not practical, as it demands the use of local analgesia for placement of the clamp. Additionally, there is sufficient evidence that careful isolation with cotton rolls gives similar retention results. Etchants and conditioners. The goal of etching is to produce an uncontaminated, dry, frosted surface. The most frequently used etchant is orthophosphoric acid. In non-invasive FS applications 30 sec of etching is optimum time. In invasive FS applications 15 sec of etching is preferable. If the clinician is going to apply FS to primary tooth with non-invasive technique the etch time should be 60 sec, and at invasive 30 sec. Washing and drying. The tooth is usually irrigated vigorously with air and water for about 10 seconds and then dried with uncontaminated compressed air for 10 seconds. Both washing and drying are thorough enough to remove all etchant from the surface of the tooth to give a chalky, frosted appearance. Cost effectiveness of fissure sealants Pits and fissures are generally recognized as highly susceptible to caries and least likely to benefit from systemic or topical F. FS can prevent caries and are therefore considered cost effective. FS should not be routinely used in all children and all teeth, but based on an individual risk evaluation will play a significant role in improving even further the cost effectiveness of sealants. Recommendations for using FS The decision to apply a FS should be made on clinical grounds based on a thorough clinical examination, supported by radiographs where appropriate, and taking into account risk factors such as medical and social history as well as past caries experience and present caries activity. FS may be used to prevent caries in teeth estimated to be at risk, or to arrest the progression of caries lesions limited to enamel. Patient and tooth selection. This should be based on the following. - Children and young people with medical, physical or intellectual impairment: The application of FS to all susceptible sites of primary and permanent teeth should be considered, especially when systemic health could be jeopardised by dental disease or the need for dental treatment. - Children and young people with signs of acute caries activity: All susceptible pit and fissure sites should be considered for FS, including the buccal fissures of permanent molars. - Children and young people with no signs of caries activity: Only deeply fissured (extremely plaque retaining fissures) and thus potentially susceptible surfaces should be considered for sealing. Clinical considerations 1. When there is an indication for placement, then FS should be placed as soon as possible, as the tooth is most caries susceptible during the post eruption period. However, susceptible sites of teeth can be sealed at any age depending on assessment of risk factors. 2. The choice between resin/composite and glass ionomer FS should be based on adequacy of moisture control. As the resins are most durable they should generally be preferred, while GIC should be used in cases where moisture control is difficult, e.g. in erupting or newly erupted teeth. GIC sealants in these cases are regarded more as a temporary FS or F release vehicle, rather than a true FS. 3. Where there is a real doubt about the caries status of a susceptible site on clinical examination, e.g. a stained fissure, then a bitewing radiograph should be obtained. If there is unequivocal evidence that the lesion is confined to enamel then the surface can be sealed and monitored clinically and radiographically. When the evidence is equivocal, then removal of the stained areas in the fissures (enamel biopsy) should be performed, using rotating instruments. 4. If the lesion extends into dentine after removal of staining, then a sealant restoration (“preventive resin/GIC restoration”) may be placed. A more extensive cavity will require a conventional restoration. Follow-up and review: - All sealed surfaces should be regularly monitored clinically and radiographically. Bitewing radiographs should be taken at a frequency consistent with the patient’s risk status, especially where there has been doubt as to the caries status of the surface prior to sealant placement. The exact intervals between radiographic review will depend not only on risk factors, which may change over time, but also on monitoring of other susceptible sites, for example proximal surfaces. - Defective FS and/or preventive resin or GIC restorations should be investigated and the FS reapplied in order to maintain the marginal integrity, provided the surface is caries free. REFERENCES: 1) McDonald and Avery’s ( 2016). Dentistry for the Child and Adolescent. 10th ed. Elsveir, Holland. 2) Welbury R, Duggal MS, Hosey MT ( 2018). Paediatric Dentistry. 5th Ed. Oxford, England. 3) F. Meyer, J. Enax . Early Childhood Caries: Epidemiology, Aetiology, and Prevention. Volume 18.