Professionally-delivered interventions

Key recommendations

For all children aged 2 years and over, apply sodium fluoride varnish at least twice per year.

(Strong recommendation; moderate certainty evidence)

For all children, consider all factors relevant to the individual patient when deciding whether to place fissure sealants.

(Conditional recommendation; moderate to very low certainty evidence)

In addition to fluoride toothpaste, there is a range of topical fluoride delivery systems that can be used to help prevent caries in children. There is moderate certainly evidence that fluoride varnish is the most effective additional topical fluoride agent for reducing caries incidence in both primary and permanent teeth.^23,67

There is longstanding evidence for the effectiveness of fissure sealants.^23,68 Both resin-based and glass ionomer sealants are effective in preventing caries (moderate and low to very low certainty evidence respectively), with resin-based sealants showing better retention.⁶⁸

More recent very low certainty evidence indicates that the effectiveness of placing fissure sealants and applying fluoride varnish is similar.^69-71 In addition, very low certainty evidence suggests that placing resin‐based fissure sealants as well as applying fluoride varnish works better than applying fluoride varnish alone.⁶⁹

Further details about the development of the recommendations in this guidance can be found in Methodology.

While all children should have fluoride varnish applied to their teeth, the clinician and patient and/or parent/carer should reach a shared decision about whether to additionally place fissure sealants on permanent molars and, when indicated, other teeth. For some children, application of fluoride varnish only might be sufficient.

Relevant factors to consider

The following points should be considered when discussing and agreeing professionally-delivered preventive interventions with children and parent/carers:

The frequency of fluoride varnish application is risk dependent and should be determined individually for each patient.
Applying fluoride varnish has less environmental impact compared to placing fissure sealants.⁷²
Combining fluoride varnish application with examination or another treatment is preferable to delivery at separate appointments because it lessens the environmental impact of travel. Having a child attend a practice for fluoride varnish application only should be avoided, if possible.
Fluoride varnish application is easier for children to tolerate.
The decision to place fissure sealants on permanent molars is risk dependent and should be determined individually for each patient.
Clinical factors might favour the placement of fissure sealants (in addition to fluoride varnish application), such as the presence of caries in other permanent molars, a very deep fissure, an oddly angled tooth or difficulty cleaning.
Patient factors such as cooperation, expectations and preferences influence the choice of the approach used.

Standard Prevention for all children

Apply sodium fluoride varnish (5%) twice a year to children aged 2 years and over (see note below and application technique in Fluoride varnish).

Although a child might additionally receive fluoride varnish twice a year in nursery or school (e.g. via Childsmile), it is acceptable for children to have varnish applied up to four times per year.
If residual varnish is visible or the child has had varnish applied in the past 24 hours (e.g. from Childsmile), leave application until the next visit.

If placing sealants in all pits and fissures of permanent molars do so as soon as possible after eruption.

Resin-based sealants are the first choice of material (see technique in Resin fissure sealant).
Ensure the buccal pits of lower first permanent molars and the palatal fissures of upper first permanent molars are sealed.
On fully erupted teeth where the child is uncooperative, use glass ionomer fissure sealants and ensure that fluoride varnish application is optimal.

Check existing sealants for wear and integrity/leakage at every recall visit.

‘Top up’ worn or damaged sealants.

If it is decided that fissure sealants are not to be placed, ensure that fluoride varnish is applied effectively and at optimal frequency.

Enhanced Prevention for children at increased risk of caries

Ensure that sodium fluoride varnish is applied 4 times per year to children aged 2 years and over (see note and application technique in Fluoride varnish).

Two applications of fluoride varnish may be provided by a community-based programme (e.g. Childsmile) and this should be included in the total number of varnish applications per year.
If recommending use of an alcohol-free sodium fluoride mouthwash for children from 7 years of age in addition to fluoride varnish application, advise that this should be used at a different time from toothbrushing (see SDCEP Drug Prescribing for Dentistry guidance).
It is particularly important to ensure that fluoride varnish application is optimal when placing fissure sealants is not possible.⁷³

Place sealants in all pits and fissures of permanent molars as soon as possible after eruption or if risk status is assessed to have increased.

Palatal pits on upper lateral permanent incisors and the occlusal and palatal surfaces of Ds and Es, can also be fissure sealed if assessed as likely to be beneficial.

If unable to provide fissure sealants (e.g. due to the child being pre-cooperative or having a learning disability), then ensure that fluoride varnish application is optimal and attempt again as cooperation improves.

Consider using glass ionomer as a temporary sealant on partially erupted first and second permanent molars until the tooth is fully erupted.

If at any time you have concerns about attendance, compliance or the child’s wellbeing, be prepared to provide additional support (see Providing additional support).

Note: Many varnishes contain colophony (e.g. Duraphat®). A child who has been hospitalised due to severe asthma or allergy in the last 12 months or who is allergic to sticking plaster may be at risk of an allergic reaction to colophony. In these cases, consider using a colophony-free varnish (licenced for caries prevention in the UK) or suggest the use of alternative age-appropriate fluoride preparations (e.g. fluoride mouthwash or higher concentration fluoride toothpaste).