Interventions to Prevent Caries in Children

Overview

This Guidelines summary has been developed for community pharmacy teams to provide advice to patients and members of the public on the prevention of dental caries (tooth decay) in children.

Recommendations are graded [A], [B], [C], [D] to indicate the strength of the supporting evidence. Good practice points [✓] are provided where the guideline development group wishes to highlight specific aspects of accepted clinical practice. 

For the complete set of recommendations, refer to the full guideline.

Reflecting on Your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Caries Risk Assessment

[C] The following factors should be considered when assessing caries risk: 

• clinical evidence of previous disease
• dietary habits, especially frequency of sugary food and drink consumption
• social history, especially socioeconomic status
• use of fluoride
• plaque control
• saliva
• medical history.

[D] Children whose families live in a deprived area should be considered as at increased risk of early childhood caries when developing preventive programmes.

[✓] A child considered by the healthcare professional to be at high caries risk should be referred to the appropriate health service provider. 

Delivery of Dental Brief Interventions

• The most effective and cheapest methods of prevention involving individuals are those carried out regularly at home (for example use of fluoride toothpaste and diet management)
• Interventions are aimed at motivating a client to perform a particular action
• For young children, the intervention is aimed at the parent/carer’s behaviour change, but for older children the brief interventions are targeted directly at the child to support their adoption of dentally healthy behaviours.

[B] Oral health promotion interventions should facilitate daily toothbrushing with fluoride toothpaste 

[B] Oral health promotion interventions should be based on recognised health behaviour theory and models such as motivational interviewing.

Toothbrushing with Fluoride Toothpaste

• The main component of any toothpaste by volume is an abrasive agent, which facilitates the removal of plaque during brushing. The most common active chemical ingredient of toothpastes is fluoride, which has beneficial effects on dental hard tissue. Generally, the available fluoride concentration is recorded as parts per million fluoride (ppmF)
• Over-the-counter toothpaste is currently available in concentrations ranging from around 700–1500 ppmF, while 2800 ppmF and 5000 ppmF toothpastes are available on prescription.

Dental Fluorosis

• Dental fluorosis is a defect in the mineralisation of tooth enamel caused by the ingestion of an excessive amount of fluoride when primary and permanent teeth are developing in the jaws.

[✓] To reduce the risk of mild fluorosis and reinforce good oral health, the amount of toothpaste used by children up to the age of 3 years should be supervised.

• It has been previously recommended that in order to balance the benefits of preventing dental caries against the potential harms of fluorosis associated with ingesting fluoride toothpaste, children under 3 years of age should use no more than a smear of toothpaste
• An average smear is approximately 0.1 ml, which would allow 13 brushing episodes with 1000 ppmF toothpaste per day before breaching the upper tolerable limit of fluoride intake, assuming that 100% of toothpaste used was ingested. For children over the age of 3 years a pea-sized amount (0.25 ml) per brushing is recommended. This would allow eight brushing episodes with 1000 ppmF toothpaste per day before breaching the upper tolerable limit of fluoride intake.

[A] Following risk assessment, children and young people up to the age of 18 years who are at standard risk of developing dental caries should be advised to use toothpastes in the range 1000–1500 ppmF.

[✓] Following risk assessment, children up to the age of 10 years who are at increased risk of developing dental caries should be advised to use toothpastes at 1500 ppmF. 

[A] Following risk assessment, children aged 10–16 years who are at increased risk of developing dental caries should be advised to use toothpastes at a concentration of 2800 ppmF.

Toothbrushing

[A] Toothbrushing with fluoride toothpaste should take place at least twice daily. 

• Toothbrushing for at least 2 minutes is recommended by the Childsmile programme, the SDCEP guidance, and some toothpaste manufacturers. However, there is insufficient evidence on which to recommend a specific duration for an episode of toothbrushing for the prevention of caries.

[A] Supervision of toothbrushing with fluoride toothpaste is recommended as an effective caries prevention measure.

[✓] Children who are unable to brush their teeth unaided should be assisted to do so. 

[✓] Children should be assisted to brush their teeth as soon as they erupt.

[A] Children should be encouraged to spit out excess toothpaste and not rinse with water after brushing

[✓] Children’s teeth should be brushed last thing at night before bedtime and on at least one other occasion.

Children’s teeth can be brushed with either manual or powered toothbrushes as an effective means of administering fluoride.

[✓] There is insufficient evidence to recommend when a worn toothbrush should be replaced.

Other Tooth Cleaning Methods

• Although the toothbrush can effectively clean the occlusal, lingual, and buccal surfaces, the use of dental floss and interdental brushes may be more appropriate methods to achieve good oral health in the mesial and distal surfaces. However, the evidence regarding the effectiveness of flossing, or cleaning with interdental brushes or mishawks in addition to toothbrushing for reducing dental caries in children is of insufficient quality and consistency to make a recommendation.

Topical Anti-caries Interventions

• Topical fluoride interventions or combinations of such interventions are effective in controlling caries in permanent teeth but evidence is sparse in primary teeth
• With the use of daily fluoride toothpaste, the added benefit of topical fluoride interventions (including slow-release fluoride devices, fluoride gels, fluoride drops, or tablets) seems to be minimal or equivocal, with the exception of fluoride varnish

[A] Fluoride varnish should be applied at least twice yearly in all children.

• There appears to be a clear preventive effect of topical fluoride mouthwash on dental caries in permanent teeth in the absence of a daily fluoride toothpaste use, but there were inconsistent results when viewed against the background of fluoride toothpaste use
• There is no robust evidence of additional reduction in caries incidence when using topical chlorhexidine interventions in addition to topical fluoride interventions.