Dental management of long-term childhood cancer survivors: a systematic review.

PURPOSE: Critically review and summarise existing knowledge on prevalence of oral, dental, and craniofacial side-effects of antineoplastic treatment in childhood cancer survivors (CCS). METHODS: A literature search was conducted for studies reporting on children aged 4-19 years treated for any type of malignancy up to the age of 15 years and for whom, at the time of the examination, more than 8 months have elapsed since the end of treatment. Data regarding dental late effects on teeth and craniofacial complex were collected and mean prevalence of each defect was reported. RESULTS: From the 800 articles identified, 17 studies fulfilled inclusion criteria and were included. A total of 983 CCS were examined, with the total number of healthy controls being 1266 children. Haematological malignancy was the most prevalent diagnosis with the age at diagnosis ranging between 0-15 years. Multiple antineoplastic protocols were implemented with the elapsed time being 8 months up to 17 years. One-third of CCS experienced at least one late effect, with corresponding value for the control group being below 25%. Among the defects identified clinically, microdontia, hypodontia and enamel developmental defects were recorded in 1/4 of CCS. Impaired root growth and agenesis were the two defects mostly recorded radiographically. The effect on dental maturity and on salivary glands was unclear. CONCLUSION: CCS are at risk of developing dental late effects because of their disease and its treatment and therefore, routine periodic examinations are essential to record their development and provide comprehensive oral healthcare.

Association between maxillary canine impaction and other dental anomalies: radiological study of a mixed dentition children's cohort from an orthodontic clinic.

PURPOSE: To investigate the significance of association between maxillary impacted canines and various dental anomalies. METHODS: Files of 874 orthodontic patients were evaluated for the presence of maxillary impacted canines. From this sample, a group of 97 patients (39 males and 58 females) with at least 1 impacted maxillary canine consisted the study group. This group was compared to a control group of 97 patients (42 males and 55 females) that was created by random selection from the initial sample without maxillary canine impaction. The impaction diagnosis was made from the panoramic radiographs. Chi-square test was used to perform the analysis for significant associations. Stepwise discriminant analysis, binary logistic regression and classification tree were used to identify best combinations. RESULTS: Statistically significant difference was found for peg-shaped maxillary lateral incisors and infraoccluded deciduous molars. The presence of peg-shaped upper lateral incisors arises the probability of impacted canine to 83.3%, a distal displaced unerupted second premolar to 63.16% and the impaction of any other teeth to 80% as showed by the classification tree. CONCLUSIONS: The presence of peg-shaped maxillary lateral incisors and infraocclusion of deciduous molars can be considered major valuable early risk indicators for maxillary canine impaction, because they manifest before the maxillary canine eruption. Special consideration should be given on distal displaced unerupted second premolar and the impaction of any other teeth. Patients with these dental anomalies are candidates for future interceptive treatment for canine eruption.

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.

Minimal Intervention Dentistry (MID) mainstream or unconventional option? Study exploring the impact of COVID-19 on paediatric dentists' views and practices of MID for managing carious primary teeth in children across the United Kingdom and European Union.

PURPOSE: To explore the techniques used to manage carious primary teeth during the COVID-19 pandemic by paediatric dentists and dentists with a special interest in paediatric dentistry (DwSI) who are members of the British Society of Paediatric Dentistry (BSPD) and the European Academy of Paediatric Dentistry (EAPD), and their views on the use of minimal intervention dentistry (MID) in children prior to, during and post the COVID era. METHODS: A total of 212 paediatric dentists and DwSI completed an online questionnaire. Six MID techniques were explored: fissure sealants, resin infiltration, Hall Technique (HT), 38% silver diamine fluoride (SDF), atraumatic restorative treatment (ART), stepwise removal and selective caries removal. RESULTS: The majority were specialists (26%) followed by clinical academics (23.1%) working mainly in university teaching hospitals (46.2%). Routine dental treatment for children with carious primary teeth was provided by the majority (92.5%) during the pandemic. HT (96%) and 38% SDF (65.7%) were the most commonly used techniques among the BSPD members whereas conventional restoration of non-selective caries removal and pulp therapy remained the most widely used technique among the EAPD members (66.2%). Most of the MID techniques were used as a treatment option (48.1%) rather than a choice (43.4%), with most of these choices having been affected by the patient's behaviour (82.5%). More than one thirds (39.2%) of the participants were reluctant to adopt MID after the pandemic. Several barriers such as lack of teaching and confidence as well as perceived lack of evidence were identified. CONCLUSION: A range of MID techniques is practiced broadly by a sample of paediatric dentists and DwSI across the United Kingdom (U.K) and European Union (E.U). The majority of clinicians are willing to continue using these techniques going forward after COVID restrictions are lifted. The pandemic served as an opportunity for many dentists to become familiar with various MID practices, such as SDF, which has been already established some time ago.

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.

Dental age estimation in children that have undergone antineoplastic treatment.

OBJECTIVE: Even though many studies have been performed to estimate DA in general population, limited research has been performed concerning medical compromised populations such as childhood cancer survivors. The aims of this case-control study were (a) to estimate dental age in a population of children that have undergone antineoplastic treatment with three different methods and (b) to compare it with the estimates from healthy subjects (control group). MATERIALS AND METHODS: Seventy-three oncology patients and equal number of healthy control subjects from the Pediatric dentistry Department had their dental age estimated through recent orthopantograms using Dermijian's, Willems' and London Atlas methods. All OPGs randomly assessed by two calibrated observers. Mean age difference was calculated. Intraclass Correlation Coefficient was used to assess intra-observer reliability and the Concordance Correlation Coefficient used to assess inter-observer reliability. RESULTS: Concerning the CCS group 35 subjects (48%) were males and 38 (52%) were females, with an overall mean chronological age 10.95 years, ranging between 5.37 and 15.83 years. Intra- and inter-examiner reliability was exceptional for all methods. Mean DA differences in both groups and were not statistically sinificant regardless of the method used. The marginally lower values when males and females were investigated separately is basically due to the corresponding reduction of the sample size. CONCLUSION: An overestimation of DA observed in both groups by all methods was not significant. All three methods produced highly accurate comparable results when it comes to estimate the actual chronological age in both groups (CCS and control subjects) regardless of gender.

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.

Developmental dental anomalies assessed by panoramic radiographs in a Greek orthodontic population sample.

PURPOSE: To assess developmental dental anomalies on panoramic radiographs in a Greek orthodontic population. MATERIALS AND METHODS: The sample consisted of 1200 panoramic radiographs that have been taken as part of routine orthodontic treatment planning in children and adolescents. The following exclusion criteria were applied: systemic disorders such as syndromes or clefts, previous jaw surgery and poor quality of the radiograph. Dental anomalies were classified as anomalies of tooth shape, size, eruption-, position- or number anomalies or root alterations. RESULTS: The age range of the subjects (536 males and 664 females) was 7-17 years with a mean age of 11.78 years. The prevalence of dental anomalies was assessed with a Chi-squared test. The intraobserver agreement was evaluated by calculating Cohen's [Formula: see text]. Among the 1200 digital panoramic radiographs examined, a total of 224 (18.67%) presented dental anomalies, 92 (7.67%) males and 132 (16.67%) females. Moreover, 203 patients (16.92%) had 1 dental anomaly, whereas 19 (1.58%) and 2 (0.17%) patients had 2 or more than 2 dental anomalies, respectively. Oligodontia was the most prevalent dental anomaly and was presented in 6.4% of the subjects, while supernumerary teeth were detected in 1% of the patients. CONCLUSIONS: A significant number of orthodontic patients had at least one DDA. The most common DDA in this sample was oligodontia followed by impaction and supernumerary teeth. Comparison to our data with other studies revealed variation in their prevalence suggesting genetic and environmental influences.

Best clinical practice guidance for local analgesia in paediatric dentistry: an EAPD policy document.

BACKGROUND: The European Academy of Paediatric Dentistry (EAPD) proposes this best-practice guidance to help practitioners to decide when and how to use local analgesia to control pain in children, adolescents, and medically compromised individuals during the delivery of oral health care. METHODS: A search of different databases was conducted using all terms relevant to the subject. Relevant papers were identified after a review of their titles, abstracts or full papers. Three workshops were held during the corresponding EAPD interim seminar in Torino (Italy) in 2017. Several statements were agreed upon and, furthermore, knowledge gaps were identified. RESULTS: An important outcome was that when local analgesia administered appropriately-correct choice of agent(s) and dosage, proper route of administration-it is, firstly, clinically effective for pain-control in treating children and, secondly, it carries a very low risk of morbidity including adverse or side-effects. Furthermore, several gaps in knowledge were identified during the workshop which indicates future research needs. Most importantly it remains unsatisfactory that in several European countries the most frequently used injectable local analgesic agent, articaine, is not approved for usage in children below the age of 4 years. CONCLUSION: When considering the dental demand to treat vulnerable (medically compromised) children and adolescents in a safe, painless, less-invasive and effective way, there seems to be an urgent need to close these gaps in knowledge.

Knowledge of preschool teachers in the prefecture of Attica of early childhood oral health. Association with their demographic and personal characteristics.

AIM: To investigate the knowledge of preschool teachers of early childhood oral health (OH) and its association with demographic and educational characteristics as well as with personal oral health habits and attitudes. METHODS: Teachers (594) of preschool children were invited to complete a questionnaire with 40 questions on demographic data, knowledge of early childhood OH issues, personal OH habits and attitudes, and participation in OH educational programmes at preschools. Statistical analysis included descriptive statistics, Spearman correlation coefficients, multiple linear and logistic regression modelling (p ≤ 0.05). RESULTS: The mean age of participants was 40.9 years (SD 7.5), 68.5% of them had children of their own, 72.6% had not attended any OH educational course during their studies, 70% believed that they had insufficient knowledge to implement an OH educational programme, 44.6% had implemented such a programme, 26.8% knew that the first dental visit should be at a child's first birthday and 36.7% knew the correct age that tooth brushing should start. The most significant factors that influenced overall teachers' knowledge on early childhood oral health were: their participation in OH educational programmes (p < 0.001), their belief that OH courses during their studies were necessary (p = 0.01), their confidence on OH knowledge (p = 0.03) and parenthood (p = 0.05). CONCLUSIONS: Based on the results of this study, there was a lack of knowledge among preschool teachers in significant OH issues for that age. Moreover, limitations in implementing OH educational programmes at preschools were attributed mainly to lack of self-confidence in relevant knowledge. Nevertheless, participants acknowledged the significance of OH and were willing to participate in relevant teacher training.

Best clinical practice guidance for management of early caries lesions in children and young adults: an EAPD policy document.

BACKGROUND: The European Academy of Paediatric Dentistry (EAPD) encourages prevention and arrest of active dental caries. Therefore, the present guidance provides evidence- and clinically-based recommendations for detecting and diagnosing early/non-cavitated caries lesions, risk assessment and disease management. METHODS: A search of different databases was conducted using all terms related to the subject. Relevant papers were identified after a review of their titles, abstracts or full texts. Three workshops were held during the corresponding EAPD interim seminar in Brussels in 2015. Several statements were agreed upon and, furthermore, gaps in our knowledge were identified. RESULTS: Following the systematic reviews and outcomes of the seminars, it was concluded that visual and radiographic caries detection should be utilised as a basic diagnostic approach to locate, assess and monitor non-cavitated caries lesions in primary and permanent teeth. As another important evaluation step, a caries risk assessment should be performed at a child's first dental visit, and reassessments should be performed on a regular basis. It is widely accepted that non-cavitated caries lesions can be managed non-invasively in the majority of cases. The spectrum of measures includes a low cariogenicity tooth-friendly diet, daily and appropriate management of the biofilm, home and within the dental office/surgery usage of fluorides as well as sealing techniques. CONCLUSION: The detection and management of non-cavitated caries is an essential aspect of preventive dentistry. Therefore, the EAPD encourages oral health care providers and caregivers to implement preventive practices that can arrest early caries and improve individual and public dental health.

Effect of a chlorhexidine/thymol and a fluoride varnish on caries development in erupting permanent molars: a comparative study.

AIM: To compare the caries preventive effect of a chlorhexidine/thymol-containing antibacterial varnish with a fluoride varnish when topically applied during the eruption of permanent molars. METHODS: The study group consisted of 189 patients, 5-14 years of age, with one 1st or 2nd permanent molar in the process of eruption. After stratification for type of molar and stage of eruption, the patients were randomised to either quarterly topical applications with an antibacterial varnish (Cervitec(®) Plus; CV group) or biannual applications with a fluoride varnish plus biannual treatments with placebo varnish (Fluor Protector; FV group). The duration of the study was 2 years. The primary endpoint was caries incidence (initial and cavitated) in the erupting molars and the secondary outcome was salivary mutans streptococci (MS) counts. RESULTS: The groups were balanced with respect to socio-economy, oral hygiene, dietary habits and caries experience at baseline. The dropout rate was 11.6 %. The caries incidence was low (< 10 %) in both groups and there was no significant difference between the CV and FV groups with respect to occlusal caries development in the erupting molars (relative risk 1.08, 95 % CI 0.94-1.25). Significantly lower levels of salivary MS were disclosed in the CV group at the end of the study (p < 0.05). CONCLUSIONS: No difference in occlusal caries development in young permanent molars was displayed after topical applications of either a chlorhexidine/thymol varnish or a fluoride varnish during tooth eruption.

Long-term outcome of oral health in patients with early childhood caries treated under general anaesthesia.

AIM: Reports on the long-term outcome of oral health in children with early childhood caries (ECC) treated under general anaesthesia (GA) are lacking. The aim of this study was to assess oral health in adolescents with history of ECC treated under GA at young age. METHODS: A total of 98 children treated under GA because of ECC at the University Hospitals of Leuven (Belgium) (1995-1996) were included in a follow-up study. Information was collected at baseline (GA) and 1 and 12 years after treatment. The children were examined clinically [oral hygiene, caries experience (CE)] and oral health behaviour was recorded using a questionnaire. RESULTS: At second recall, 46 (48 %) adolescents could be contacted; 21 of these attended the dental clinic. Their mean age was 17.5 years (SD 1.4) with mean time span since GA of 13.1 years (SD 0.8); 91 % presented with CE. Mean D3MFT was 8.2 (SD 5.6) (median 7; range 0-18); 71 % showed untreated decay. A considerable gap between knowledge of content and actual use of fluoride in toothpaste was evident. CONCLUSIONS: Individuals with a history of ECC remained at high risk for caries in their permanent dentition. There is a need for well-designed long-term studies to explore associated factors.

Therapeutic management of a case of generalised aggressive periodontitis in an 8-year old child: 18-month results.

BACKGROUND: Generalised aggressive periodontitis (GAP) is a rare condition associated with rapid periodontal destruction, in multiple teeth. The paper aims to present a case of an 8-year old with GAP and discuss his response to treatment. CASE REPORT: An 8-year old male was referred to the postgraduate clinic of paediatric dentistry of the University of Athens due to increased mobility in his primary dentition. At initial clinical examination, plaque accumulation, gingival inflammation and temporary restorations were noted. Detailed periodontal examination revealed bleeding on probing, pocket depths of up to 9 mm and second degree mobility in primary teeth. Radiographic examination showed advanced bone loss and carious lesions. Microbiological analysis revealed increased percentages of peri-opathogens in pooled subgingival samples. Final diagnosis of GAP was made after ruling out any underlying systemic disorder. TREATMENT: Periodontal therapy involved non-surgical subgingival debridement, systemic administration of antibiotics and retention of periodontally involved teeth. FOLLOW-UP: This was based on a monthly recall program for the first 6 months and a 3-monthly regime thereafter. At 18-months after initial examination, a substantial improvement in clinical parameters was seen, while levels of periodontal pathogens were sustained at low levels. CONCLUSION: Non-surgical root debridement along with systemic administration of antibiotics and retention of the periodontally involved teeth, can be successful in achieving improvement and maintenance of periodontal health in the mixed dentition.

Oral health status and behaviour of Greek patients with cleft lip and palate.

AIM: This was to record the oral health profile and more specifically the prevalence of carious and hypoplastic lesions in children and adolescents with cleft lip and palate (CLP). STUDY DESIGN AND METHODS: The study group consisted of 41 children and adolescents (4-18 years-old) with CLP group while a similar number of non-cleft persons (HLP) matched for sex, age and orthodontic treatment (75.6%), was used as the control group. Information regarding the oral health habits, medical and dental history were collected using a questionnaire. Stimulated saliva was collected to evaluate the flow rate and buffering capacity as well as the levels of mutans streptococci and lactobacilli using the chair-test CRT(R) (Ivoclar -Vivadent). Oral hygiene (OH) was assessed using the index of Silness and Loe [1964]. The prevalence of initial/white spot and cavitated carious lesions as well as hypoplasia was evaluated based on the criteria by ICDAS [2005] and Nyvad et al [2008] as well as Koch et al [1987] respectively. The statistical analysis was carried out using the t-test and the chi- square test. RESULTS: Approximately half of the CLP and HLP subjects were brushing their teeth 2 x per day. Both groups reported an average of 3 main and 2 snack meals per day. Levels of mutans streptococci and lactobacilli as well as the quality of the saliva were similar for both groups. The plaque index score was significantly higher in the CLP than in the control group (p=0.0003). The prevalence of cavitated carious lesions was similar in both groups but that of the initial/white spot lesions, especially at the area of maxillary incisors, was higher in the CLP group (85%, p=0.000). CONCLUSIONS: The increased numbers of initial/ white spot lesions combined with poor OH found in the CLP group predispose for an increased risk of further development to carious cavitated lesions. Taking into consideration that the majority of those patients were under orthodontic treatment, the application of an intensive individualized oral health preventive program, focused on remineralisation of the initial caries, is imperative.

The microbiota on different oral surfaces in healthy children.

INTRODUCTION: Knowledge of the early oral colonization patterns could provide a better understanding of oral biofilm development and disease initiation that in turn could be the basis for early preventive programmes. METHODS: Microbial samples were collected from five different oral habitats from a total of 93 children (age 3-12 years), attending the Dental School of the University of Athens, who were split into three age groups. A total of 38 microbial species were sought out by the checkerboard DNA-DNA hybridization technique. RESULTS: All of the test species, except Parvimonas micra and Porphyromonas gingivalis, differed significantly among sample locations providing quite distinct microbial profiles for the different oral surfaces. Supragingival and subgingival plaque had similar profiles and exhibited higher proportions of Actinomyces species and Green complex while soft tissue samples were dominated by streptococci of the Yellow complex. The profiles of the tongue dorsum and saliva were also similar. Many of the species were in similar proportions in all three age groups for a given location. Periodontal pathogens showed increases in proportions with increasing age. Specifically, the Red complex species (Tannerella forsythia, P. gingivalis, Treponema denticola) showed a significant increase in proportion with age (P < 0.05) in all sample locations. CONCLUSIONS: The results showed a pattern of colonization in children similar to that previously found in adults. Differences in the profile between age groups suggest a gradual maturation of the oral microbiota, with it being made up of an increasing number of Orange and Red complex species.

Progression of proximal caries in children with different caries indices: a 4-year radiographic study.

AIM: This was to investigate survival rate, median survival time and differences in the progression of different stages of proximal caries in 196 children, aged 6 to 8 years old, with different caries index at baseline examination. METHODS: Based on DMFS/dmfs values, children were categorized as low, moderate and high caries index groups. Subjects with DMFS/dmfs smaller or equal to half of a child's age were classified as low caries index group, children with DMFS/dmfs greater to half and smaller than or equal to the child's age as moderate, while those with DMFS/dmfs greater than the child's age as high. Proximal caries and its progression were diagnosed from bitewing radiographs taken at 1-year intervals over a period of 4 years. The mesial surface of the first permanent molars, mesial and distal surfaces of the first and second primary molars and distal surfaces of the primary canines were examined. Sound surfaces, caries lesions in the external and internal half of the enamel and external, middle, internal third of the dentine as well as filled, extracted and exfoliated teeth were recorded. STATISTICS: A life table analysis was performed to estimate survival rate and median survival time of each state of proximal caries and differences between the groups in the progression of the proximal lesions were tested with the Wilcoxon pairwise comparison statistic. RESULTS: There were statistically significant differences in the caries rate of the sound proximal surfaces of the primary teeth between the low and high caries index groups. Also, statistically significant differences between these two groups were found in the progression of the external half of the enamel caries in the first permanent molars and in the primary teeth. CONCLUSIONS: A high caries index increases the risk of developing caries in the sound proximal surfaces of posterior primary teeth and causes faster progression of the external half of the enamel lesions in the first permanent molars and posterior primary teeth.