Best clinical practice guidance for treating deep carious lesions in primary teeth: an EAPD policy document.

PURPOSE: The European Academy of Paediatric Dentistry (EAPD) has developed this best clinical practice guidance to help clinicians manage deep carious lesions in primary teeth. METHODS: Three expert groups conducted systematic reviews of the relevant literature. The topics were: (1) conventional techniques (2) Minimal Intervention Dentistry (MID) and (3) materials. Workshops were held during the corresponding EAPD interim seminar in Oslo in April 2021. Several clinical based recommendations and statements were agreed upon, and gaps in our knowledge were identified. RESULTS: There is strong evidence that indirect pulp capping and pulpotomy techniques, and 38% Silver Diamine Fluoride are shown to be effective for the management of caries in the primary dentition. Due to the strict criteria, it is not possible to give clear recommendations on which materials are most appropriate for restoring primary teeth with deep carious lesions. Atraumatic Restorative Technique (ART) is not suitable for multi-surface caries, and Pre-formed Metal Crowns (PMCs) using the Hall technique reduce patient discomfort. GIC and RMGIC seem to be more favourable given the lower annual failure rate compared to HVGIC and MRGIC. Glass carbomer cannot be recommended due to inferior marginal adaptation and fractures. Compomers, hybrid composite resins and bulk-fill composite resins demonstrated similar values for annual failure rates. CONCLUSION: The management of deep carious lesions in primary teeth can be challenging and must consider the patient's compliance, operator skills, materials and costs. There is a clear need to increase the use of MID techniques in managing carious primary teeth as a mainstream rather than a compromise option.

Clinical effectiveness of restorative materials for the restoration of carious lesions in pulp treated primary teeth: a systematic review.

PURPOSE: To systematically review the clinical performance of restorative materials after pulp therapy of carious primary teeth. It is part 2 of a systematic review on the clinical effectiveness of restorative materials for the management of carious primary teeth supporting the European Academy of Paediatric Dentistry (EAPD) guideline development. METHODS: Four electronic databases were systematically searched up to December 28th, 2020. Randomised controlled clinical trials (RCTs) on restorative materials for the restoration of carious primary teeth after pulp therapy were included. Failure rate, annual failure rate (AFR) and reasons for failure were recorded. Studies were sorted by restorative materials. The Cochrane Risk of bias tool for randomised trials (RoB 2.0) was used for quality assessment. RESULTS: After identification of 1685 articles and screening of 41 papers from EAPD review group 1, 5 RCTs were included. Restored primary molars with pulpotomy presented the following AFRs: composite resin (CR) 0%, preformed metal crowns (PMCs) 2.4-2.5%, resin-modified glass-ionomer cement combined with CR 3.8%, compomer 8.9%, and amalgam 14.3%. Maxillary primary incisors receiving pulpectomy exhibited AFRs of 0-2.3% for composite strip crowns (CSCs) depending on the post chosen. Reasons for failure were secondary caries, poor marginal adaptation, loss of retention and fracture of restoration. All studies were classified as high risk of bias. Meta-analyses were not feasible given the clinical/methodological heterogeneity amongst studies. CONCLUSION: Considering any limitations of this review, CR and PMCs can be recommended for primary molars after pulpotomy, and CSCs for primary incisors receiving pulpectomy. However, a need for further well-designed RCTs was observed.

Clinical effectiveness of restorative materials for the restoration of carious primary teeth without pulp therapy: a systematic review.

PURPOSE: To systematically search the available evidence and evaluate the clinical effectiveness of restorative materials for restoration of carious primary teeth. The findings aimed to support the European Academy of Paediatric Dentistry (EAPD) guidelines development. METHODS: Literature search was performed by searching 4 electronic databases for eligible randomised controlled clinical trials (RCTs) comparing restorative materials for the restoration of carious primary teeth up to December 28th, 2020. Quality assessment was performed with the revised Cochrane risk-of-bias tool for randomized trials (RoB 2). RESULTS: Of 1685 identified articles 29 RCTs were finally deemed as eligible for inclusion. Annual failure rates were: Amalgam 1-28%; atraumatic restorative treatment 1.2-37.1%; glass-ionomer cement (GIC) 7.6-16.6%, metal-reinforced GIC 29.9%, resin-modified GIC 1.9-16.9%, high-viscosity GIC 2.9-25.6%; glass carbomer ≤ 46.2%; compomer 0-14.7%; composite resin (CR) 0-19.5%, bulk-fill CR 0-16.9%; zirconia crowns 3.3%, composite strip crowns 15%, and preformed metal crowns (Hall-Technique) 3.1%. Secondary caries, poor marginal adaptation, loss of retention, and fracture of restoration were reported as reasons for failure. Four studies were evaluated at unclear and 25 at high risk of bias. Clinical and methodological heterogeneity, and the diversity of tested materials across included studies did not allow for meta-analyses. CONCLUSIONS: Within the limitations of this systematic review, namely, the heterogeneity and the overall high risk of bias among included studies, clear recommendations based on solid evidence for the best restorative approach in primary teeth cannot be drawn. There is a need for future thoroughly implemented RCTs evaluating restorations in primary teeth to close this knowledge gap.

An update of treatment modalities in children and adolescents with teeth affected by molar incisor hypomineralisation (MIH): a systematic review.

PURPOSE: To systematically review the treatment modalities for molar-incisor hypomineralisation for children under the age of 18 years. The research question was, 'What are the treatment options for teeth in children affected by molar incisor hypomineralisation?' METHODS: An electronic search of the following electronic databases was completed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, Google Scholar and Open Grey identifying studies from 1980 to 2020. The PRISMA guidelines were followed. The studies were screened, data extracted and calibration was completed by two independent reviewers. RESULTS: Of 6220 potential articles, 34 studies were included. Twenty studies investigated management of molars with fissure sealants, glass ionomer cement, polyacid modified resin composite, composite resin, amalgam, preformed metal crowns, laboratory-manufactured crowns and extractions. In four articles management of incisors with microabrasion, resin-infiltration and a combination of approaches was reported. Eight studies looked at strategies to mineralise MIH-affected teeth and/or reduce hypersensitivity. Two studies investigated patient-centred outcomes following treatment. Due to the heterogeneity between the studies, meta-analysis was not performed. CONCLUSION: The use of resin-based fissure sealants, preformed metal crowns, direct composite resin restorations and laboratory-made restorations can be recommended for MIH-affected molars. There is insufficient evidence to support specific approaches for the management of affected incisors. Products containing CPP-ACP may be beneficial for MIH-affected teeth.

Best clinical practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH): an updated European Academy of Paediatric Dentistry policy document.

AIM: To update the existing European Academy of Paediatric Dentistry (EAPD) 2010 policy document on the 'Best Clinical Practice guidance for clinicians dealing with children presenting with Molar-Incisor-Hypomineralisation (MIH).' METHODS: Experts, assigned the EAPD, worked on two different topics: (A) Aetiological factors involved in MIH, and (B) Treatment options for the clinical management of MIH. The group prepared two detailed systematic reviews of the existing literature relevant to the topics and following a consensus process produced the updated EAPD policy document on the 'Best Clinical Practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH).' The GRADE system was used to assess the quality of evidence regarding aetiology and treatment which was judged as HIGH, MODERATE, LOW or VERY LOW, while the GRADE criteria were used to indicate the strength of recommendation regarding treatment options as STRONG or WEAK/CONDITIONAL. RESULTS: (A) Regarding aetiology, it is confirmed that MIH has a multifactorial aetiology with the duration, strength and timing of occurrence of the aetiological factors being responsible for the variable clinical characteristics of the defect. Perinatal hypoxia, prematurity and other hypoxia related perinatal problems, including caesarean section, appear to increase the risk of having MIH, while certain infant and childhood illnesses are also linked with MIH. In addition, genetic predisposition and the role of epigenetic influences are becoming clearer following twin studies and genome and single-nucleotide polymorphisms analyses in patients and families. Missing genetic information might be the final key to truly understand MIH aetiology. (B) Regarding treatment options, composite restorations, preformed metal crowns and laboratory indirect restorations provide high success rates for the posterior teeth in appropriate cases, while scheduled extractions provide an established alternative option in severe cases. There is great need for further clinical and laboratory studies evaluating new materials and non-invasive/micro-invasive techniques for anterior teeth, especially when aesthetic and oral health related quality of life (OHRQoL) issues are concerned. CONCLUSIONS: MIH has been studied more extensively in the last decade. Its aetiology follows the multifactorial model, involving systemic medical and genetic factors. Further focused laboratory research and prospective clinical studies are needed to elucidate any additional factors and refine the model. Successful preventive and treatment options have been studied and established. The appropriate choice depends on the severity of the defects and the age of the patient. EAPD encourages the use of all available treatment options, whilst in severe cases, scheduled extractions should be considered.

An update of the aetiological factors involved in molar incisor hypomineralisation (MIH): a systematic review and meta-analysis.

PURPOSE: To systematically review the aetiological factors associated with molar incisor hypomineralisation (MIH). To this day, the aetiology remains unknown. Determining risk factors would allow risk assessment and enhance early diagnosis of MIH in young patients. The aim was to assess, evaluate and summarise the relationship between MIH and reported aetiological hypotheses. METHODS: Electronic database searches of MEDLINE, EMBASE, EBSCO, LILACS and Cochrane Library were conducted. Authors conformed to PRISMA guidelines. Studies were screened, data extracted, assessment of risk of bias and calibration was completed by two independent reviewers. Meta-analyses with heterogeneity calculations were performed. RESULTS: Of the potential 8949 studies, 64 studies were included in the qualitative analysis whilst 45 were included in the quantitative analysis. Prenatal factors: results are inconclusive as only unspecified maternal illnesses appear to be linked to MIH. Perinatal factors: prematurity (OR 1.45; 95% CI 1.24-1.70; p = 0.0002) and caesarean delivery (OR 1.45; 95% CI 1.09, 1.93; p < 0.00001) are associated with an increased risk of developing MIH. Birth complications are also highlighted. These three factors can lead to hypoxia, and children with perinatal hypoxia are more likely to develop MIH (OR 2.76; 95% CI 2.09-3.64; p < 0.0001). Postnatal factors: measles, urinary tract infection, otitis media, gastric disorders, bronchitis, kidney diseases, pneumonia and asthma are associated with MIH. Fever and antibiotic use, which may be considered as consequences of childhood illnesses, are also associated with MIH. Genetic factors: an increasing number of studies highlight the genetic and epigenetic influences in the development of MIH. CONCLUSION: Several systemic and genetic and/or epigenetic factors acting synergistically or additively are associated with MIH, revealing a multifactorial aetiology model. Peri- and postnatal aetiological factors are more likely to increase the odds of causing MIH than prenatal factors.

The effect of different liners on the bond strength of a compomer to primary teeth dentine: in vitro study.

OBJECTIVE: This in vitro investigation should identify the effect of protective liners on dentine bond strength of a polyacid modified resin composite to dentine of primary teeth. METHODS: Forty-two extracted caries-free primary molars were randomly assigned to seven groups (n = 6) and flattened. Six test groups were centrally covered with different protective liners/base materials: Kerr Life (KL), IRM zinc oxide eugenol cement (IRM), Ketac Bond (KB), Vitrebond (VB), Dycal (DY), and mineral trioxide aggregate (MTA). Specimens were bonded with Prime&Bond NT (PB) and restored with Dyract eXtra. The control group (C) did not receive liner pretreatment. After 24-h storage in Aqua dest. (37 °C), specimens were cut and regional microtensile bond strengths of the uncovered areas were tested. Fractography was conducted under a light microscope and further interface/surface analyses were performed under a SEM. Statistical appraisal was carried out using oneway ANOVA (mod. LSD test; p < 0.05). RESULTS: Independent of the distance to the applied liner, all groups exhibited inferior µ-TBS to dentine of primary teeth compared to the control group (p < 0.05). The results were as follows in MPa(SD) x:significance level/percentage of adhesive fractures: PB: 34 (10)A/72%; KL: 23 (25)B/64%; KB: 15 (12)C/76%; DY 15 (13)C/55%; IRM: 14 (10)C/68%; VB: 12 (10)C/61%; MTA 12 (10)C/69%. CONCLUSIONS: Protective liners significantly reduced µ-TBS to dentine of primary teeth.

Regenerative endodontic therapy of immature permanent molars with pulp necrosis: a cases series and a literature review.

AIM: To present the application and the outcome of the regenerative endodontic therapy (RET) in a series of symptomatic immature mandibular molars with pulp necrosis and apical periodontitis and to review the relevant literature for the documentation of the procedure as a potential treatment option. METHODS: Three young male patients were referred with pain in the left mandibular region resulting from pulp necrosis and apical periodontitis of the first permanent molar. Regenerative endodontic approach was performed for the complete resolution of the lesions and the thickening of the apical root canal walls. The databases of Medline, Pubmed and Google Scholar were also searched for articles in which a regenerative approach has been undertaken for the endodontic management of immature permanent molars with pulp necrosis and apical periodontitis. RESULTS: Follow-up examinations showed that the teeth remained functional without any signs or symptoms. Final radiographic examination at 12, 18 and 36 months, respectively, revealed complete resolution of the lesions and complete apical closure in the two out of three cases. The search of the literature revealed the existence of only 25 clinical articles in which necrotic immature molars were treated by the regenerative approach. The total number of the treated teeth were 46. CONCLUSIONS: Regenerative endodontic approach may be applied in posterior non-vital molar teeth with a possible favorable outcome. However, the literature support for the documentation of the procedure as a predictable and reproducible treatment option in posterior immature molar teeth is at present limited.

Guidelines on the use of fluoride for caries prevention in children: an updated EAPD policy document.

AIM: To update the exisitng European Academy of Paediatric Dentistry (EAPD) 2009 fluoride guidelines. METHODS: Experts met in Athens, Greece duirng November 2018 for the following groups: I Fluoride toothpastes, II Fluoride gels, rinses and varnishes, III Fluoridated milk, fluoridated salt, tablets/lozenges and drops, IV Water fluoridation. Systematic reviews and meta-analyses were reviewed and discussed for each of the groups. The GRADE system was used to assess the quality of evidence which was judged as HIGH, MODERATE, LOW or VERY LOW based on the assessment of eight criteria which can influence the confidence of the results. Following the quality assessment, GRADE was then used to indicate the strength of recommendation for each fluoride agent as STRONG or WEAK/CONDITIONAL. RESULTS: Parents must be strongly advised to apply an age-related amount of toothpaste and assist/supervise tooth brushing until at least 7 years of age. The EAPD strongly endorses the daily use of fluoride as a major part of any comprehensive programme for the prevention and control of dental caries in children. Regardless of the type of programme, community or individually based, the use of fluoride must be balanced between the estimation of caries-risk and the possible risks of adverse effects of the fluorides. Fluoride use is considered safe when the manufacturer's instructions are followed. Preventive programmes should be re-evaluated at regular intervals and adapted to a patient's or population's needs and risks. CONCLUSIONS: For the majority of European Countries, the EAPD recommends the appropriate use of fluoride toothpaste in conjunction with good oral hygiene to be the basic fluoride regimen.

Molar incisor hypomineralisation (MIH) training manual for clinical field surveys and practice.

BACKGROUND: Despite clear assessment criteria, studies of molar incisor hypomineralisation (MIH) and hypomineralised second primary molars (HSPM) are marked by inconsistency in outcome measurements. This has detracted from meaningful comparisons between studies and limited interpretation. AIM: To provide a comprehensive manual as a companion to assist researchers in planning epidemiological studies of MIH and HSPM, with particular reference to outcome measurement. METHODS: This manual begins with a succinct review of the clinical problems and evidence for management of the conditions. The subsequent sections guide researchers through diagnosis of MIH and HSPM and implementation of both the long and short forms of a recently proposed grading system. MIH and HSPM can often be confused with fluorosis, enamel hypoplasia, amelogenesis imperfecta, and white spot lesions but can be distinguished by a number of unique clinical features. Based on the grading system, a standardised protocol is proposed for clinical examinations. Intra and inter-examiner reliability is of key importance when outcome measurement is subjective and should be reported in all epidemiological studies of MIH. The manual concludes with an exercise forum aimed to train examiners in the use of the grading system, with answers provided. CONCLUSION: The use of a standardised protocol, diagnostic and grading criteria will greatly enhance the quality of epidemiological studies of MIH.

A novel approach for building up infraoccluded ankylosed primary molars in cases of missing premolars: A case report.

BACKGROUND: In cases of infraoccluded primary molars associated with agenesis of premolars, any treatment plan occasionally includes retention of the primary teeth for space preservation and future implant placement if needed. In these cases, building up the crowns to the occlusal line is necessary to prevent various clinical problems. The present case report describes in detail a novel but simple clinical approach for retention and building up of the crown of infraoccluded primary molars. CASE REPORT/TECHNIQUE PRESENTATION: The technique is presented in a 14-year-old girl with nine missing permanent teeth. Orthodontic evaluation indicated space closure for five teeth and space maintenance in the remaining four second primary molars, three of them being infraoccluded. The technique included the following clinical steps: (a) elastic separators were placed proximally to the primary molars for few days to create space; (b) proximal minimal reduction of the crown width was performed; a direct hand composite resin core was made to increase crown height facilitating the selection of a preformed metal crown (PMC). The selected PMC was filled with self-curing composite resin and placed on the primary tooth following an acid etch and adhesive procedure; excess cervical material was removed; (c) after polymerisation, the PMC was carefully removed using cutting and hand instruments, revealing the composite resin fabricated crown which was adjusted for occlusion and polished. Radiographic evaluation confirmed the result. CONCLUSION: This simple method for infraoccluded primary molars crown building up to occlusion using conventional instruments and materials, appears to be a valuable clinical tool for paediatric dentists who frequently find themselves dealing with primary teeth that need to be retained and which can produce serious clinical problems if left untreated.

Εvaluation of a treatment protocol for unerupted maxillary central incisors: retrospective clinical study of 46 children.

AIM: To evaluate the clinical outcome of a treatment protocol performed in children with unerupted permanent maxillary central incisors, including surgical removal of any related obstruction and traction initiation in one stage, under fully repositioned flap, combined with pre- and post-operative orthodontics for space creation and final alignment. METHODS: Forty-six patients aged 7.3-12.7 years (mean = 9.44 ± 1.36) having 54 impacted maxillary central incisors were reviewed. The study group included 37 patients fully treated by us and nine referrals with eruption failure of impacted incisors following previous surgical removal of various obstructions. Detailed patient's clinical and radiographic data were recorded. RESULTS: Aetiology of unerupted incisors included 9 patients with odontomas, 24 with supernumerary teeth, 1 with skeletal lack of space, 1 with a dentigerous cyst, 4 with dilaceration, 1 with severe incisor MIH, 5 with luxation injuries to primary predecessors and 1 with coexisting dilaceration and odontoma. The total treatment time following the standardised protocol ranged from 5 to 21 months (mean 9.88 ± 3.10), while the time needed using different approaches (no pre-operative orthodontics or obstruction removal and then to wait over an assessment period) ranged from 12 to 18 months (mean 15 ± 2.12) and 17 to 30 months (mean 23.73 ± 5.14), respectively (p < 0.05). The time needed for full alignment depended on the inclination, the height of the impacted tooth (p = 0.001) and the patient's age (p = 0.002). Additionally, the absence of pre-operative orthodontics for space creation dramatically increased treatment time (p = 0.018). In contrast, the maturity of the impacted tooth and the developmental stage of the anterior teeth did not affect treatment time. Finally, when the location of the impacted tooth and the space availability allowed waiting for spontaneous eruption, treatment time was not statistically different from that of the main treatment protocol (p = 0.545). CONCLUSIONS: The studied treatment protocol appears ideal for successful results and minimum treatment time. Space creation followed by surgical removal of any obstruction together with orthodontic traction initiation produces excellent results, while waiting for spontaneous eruption is indicated only in cases of favourable patient's age and tooth location. Treatment initiation with operation in the absence of the required eruption space is not recommended, whereas in unfavourable cases obstruction removal without simultaneous orthodontic traction increases dramatically the total treatment time and requires an unnecessary second operation for traction.

Solitary median maxillary central incisor syndrome (SMMCI) with congenital nasal puriform aperture stenosis: literature review and case report with comprehensive dental treatment and 14 years follow-up.

BACKGROUND: Solitary median maxillary central incisor syndrome [SMMCI] is an extremely rare anomaly, especially when no other abnormalities are present. The defect is often found together with various nasal abnormalities and short stature with or without decreased levels of growth hormone. In more severe cases, SMMCI has been associated with holoprosencephaly, the CHARGE and the VACTERL association. Also, published sporadic cases have been related with rare variants of ectodermal dysplasia, chromosomal abnormalities, precocious puberty, hypothalamic hamartoma, congenital heart defects, physical/mental retardation, genital hypoplasia and ear abnormalities. For these reasons when the initial diagnosis is made by the paediatric dentist, ENT, neurological and paediatric evaluations are essential. CASE REPORT: A 4-year-old boy with SMMCI was referred for dental treatment. Clinical/radiographic examination revealed a symmetrical primary and permanent SMMCI, a skeletal Class I and a unilateral crossbite. Medical history indicated respiratory distress and surgery soon after birth due to congenital nasal puriform aperture stenosis. Gradual orthodontic treatment started at the age of 4 years and completed at the age of 13 years. Following maxillary expansion, upper lateral segments were moved backwards and anterior space was created for accommodating a second central incisor. Retainers with a supplementary acrylic incisor were provided for aesthetic and functional replacement until the age of 16 years, when a fixed Maryland ceramic bridge was placed. FOLLOW-UP: Two years recall, at the age of 18 years, revealed a satisfactory and stable aesthetic and functional result. CONCLUSION: Successful dental management of SMMCI patients is possible, following a detailed long-lasting treatment plan requiring multidisciplinary paediatric dental, orthodontic and prosthetic approach.

Oro-facial tumours and tumour-like lesions in Greek children and adolescents: an 11-year retrospective study.

OBJECTIVE: To determine the epidemiology, histological diagnosis and treatment outcome of oro-facial tumours and tumour-like lesions in Greek children and adolescents. MATERIAL AND METHODS: The medical records of patients with oro-facial lesions who presented at the Department of Oral and Maxillofacial Surgery at "A. & P. Kyriakou" Children's Hospital from 2000 to 2010 were reviewed. Data was analyzed in relation to age, gender, location, histology, treatment choice and outcome. RESULTS: Two hundred and eleven oro-facial lesions were identified. Age ranged from 14 days to 15 years (mean 8 years); the male-to-female ratio was 1.09: 1; 90.05% of the lesions were benign and 9.95% malignant. Vascular anomalies were the most common benign lesion (22.1%) and rhabdomyosarcoma was the most prevalent malignancy (28.57%). One hundred and ten lesions (52.1%) involved soft tissue, most commonly the tongue and 96 cases (45.5%), involved hard tissue, most frequently the mandible; 5 lesions (2.4%) involved both hard and soft tissue. Surgery was performed under general anaesthesia in 198 cases (93.84%). Some malignant lesions were treated with chemotherapy and/or radiotherapy. CONCLUSIONS: Oro-facial tumours and tumour-like lesions are not uncommon in the Greek paediatric population; although most frequently benign, these may cause considerable morbidity. As such early diagnosis and treatment are imperative.

Attitudes, knowledge and utilization of fissure sealants among Greek dentists: a national survey.

AIM: This was to evaluate the attitudes and knowledge of Greek Dentists concerning fissure sealants (FS) and other preventive measurements, together with the extent and the reasons for using or not using FS in their clinical practice. METHODS: 1,221 general dental practitioners (GDPs) including 50 Paediatric Dentists (PD) were randomly selected from 35 local dental societies of Greece and asked to answer a telephone questionnaire regarding their attitudes to prevention, use of FS and variables influencing their placement. Non parametric Pearson's Chi square test and multifactorial logistic regression models were used for analysing the data. RESULTS: Although 87.6% of all Greek dentists believe and apply prevention, only 35.8% are using them routinely. Factors highly correlated with FS usage for all dentists were using fluoride regimens (p<0.001), being in practice for 5-14 years (p=0.004) and practicing in urban areas (p<0.001). By contrast, all PD were using FS, regardless of any parameter (p>0.01). Concerning the type of surfaces sealed, 45.6% of GDP used FS on intact surfaces and 41.1% on questionable, while only 15% of them sealed incipient caries. Overall, fewer GDPs compared with PD sealed premolars, primary teeth, questionable surfaces, incipient enamel caries and molars in high risk patients (p<0.001), while fewer PD sealed intact surfaces (p<0.001). The reasons mentioned for not using FS were: 76.3% that parents were unwilling to pay, 61.9% did not know how to use them, while 43.0% believed that oral hygiene was sufficient in order to reduce caries. CONCLUSIONS: Insufficient knowledge and lack of clinical practice guidelines for the use of FS by GDPs in Greece, leads to low usage rates. Appropriate professional and scientific authorities should join efforts to improve knowledge of GDP and instil confidence in using FS.