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Table 2 Results of the recommendations of the adapted guidelines in the two-round Delphi survey

From: Developing clinical practice guidelines for caries prevention and management for pre-school children through the ADAPTE process and Delphi consensus

Topic No. Recommendations First rounda Median Score (%) Second rounda Median Score (%) Final decision
Diagnosis of dental caries (N = 7) 1 Caries should be diagnosed as early as possible to allow management before cavitation and pulpal involvement, and to identify caries-active patients and those at increased risk of caries in the future 8, 100% retained as ‘agreement’
2 New caries detection systems, like Diagnodent, DIFOTI and QLF, can be used as an adjunct diagnostic method in addition to the traditional clinical and radiographic examination 7, 53.7% 7, 52.8% discarded
3 A thorough clinical examination should be carried out on clean dried teeth 8, 87.8% retained as ‘agreement’
4 As thorough a caries diagnostic examination should be performed as the child’s level of cooperation permits 8, 87.8% retained as ‘agreement’
5 The use of bitewing radiography for caries diagnosis should be considered for pre-school children attending for dental care, particularly if they are assessed as being at increased risk of dental caries 6, 48.8% 6.5, 50.0% discarded
6 The timing of subsequent radiographic examinations should be based on the patient’s caries risk status 8, 90.2% retained as ‘agreement’
7 Practitioners should receive training in clinical and radiographic caries diagnosis 8, 87.8% retained as ‘agreement’
Caries risk assessment (N = 9) 8 The use of a practical caries risk assessment tool should be implemented into practice to facilitate the caries risk assessment process 7, 68.3% 8, 86.1% retained as ‘agreement’
9 The caries risk assessment tool should be integrated into the electronic patient record 7, 58.5% 8, 75.0% discarded
10 Public health nurses, practice nurses, general practitioners and other primary care workers who have regular contact with young children should have training in the identification of high caries risk pre-school children 8, 80.5% retained as ‘agreement’
11 Public health nurses or other child healthcare professionals should carry out a caries risk assessment for children as part of their routine overall health assessment and recorded in the child’s health record 7, 73.2% 8, 83.3% retained as ‘agreement’
12 Referral pathways should be developed to allow referral of high caries risk pre-school children from primary, secondary and social care services into dental services 8, 82.9% retained as ‘agreement’
13 A dental practice-based caries risk assessment should be carried out on individual pre-school children and should include the following risk indicators: – evidence of previous caries experience – resident in a deprived area – healthcare worker’s opinion – oral mutans streptococci counts (if accessible) 7, 61.0%  
13 Revised in second round to: A dental practice-based caries risk assessment should be carried out on individual pre-school children and should include the following risk indicators: – evidence of previous caries experience – medically compromised or with special needs – lower socioeconomic family background – resident in a deprived area – healthcare worker’s opinion – oral mutans streptococci counts (if accessible) (revised as some external reviewers suggested that more caries risk factors should be included) 8, 80.6% retained as ‘agreement’
14 A formal caries risk assessment using a structured caries risk assessment tool should be done for children attending the dental clinic for dental assessment or emergency care 8, 68.3% 8, 80.6% retained as ‘agreement’
15 Recall of children for re-assessment of caries risk should be based on the clinician’s assessment of the child’s caries risk status using the caries risk assessment tool, and should not exceed 12 months 8, 78.0% 8, 88.9% retained as ‘agreement’
16 Children whose families live in a deprived area should be considered as at increased risk of early childhood caries when developing preventive programs 7, 70.7%  
  Revised in second round to: Children whose families live in a deprived area or from lower socioeconomic background should be considered as at increased risk of early childhood caries when developing preventive programs (revised as some external reviewers suggested a more detailed socioeconomic background should be assessed, rather than just the residential area of patient) 8, 77.8% discarded
Preventive strategies for pre-school children at population level (N = 25) Oral health education    
17 Oral health education and dietary advice should be incorporated into each child’s general well-being developmental check or at any appropriate opportunity that arises 8, 97.6% retained as ‘agreement’
18 The oral health of young children should be promoted through multiple interventions and multi-sessional health promotion programmes for parents, and if possible, incorporated into relevant general health promotion interventions 8, 97.6% retained as ‘agreement’
19 The dental health team should deliver caries prevention strategies in conjunction with physical prevention techniques such as oral hygiene instruction and the use of fluoride 8, 100% retained as ‘agreement’
20 Oral health promotion programmes for young children should be initiated before the age of 3 years 8, 95.1% retained as ‘agreement’
21 Parents should be encouraged to take their children for regular dental care as soon as the first teeth erupt 8, 90.2% retained as ‘agreement’
22 Teachers, community workers and lay or peer educators can be effective in delivering health promotion interventions and their role should be considered in the development of oral health promotion programmes 8, 82.9% retained as ‘agreement’
23 Non-dental health professionals and lay oral health workers should be provided with adequate educational or training interventions prior to their participation in oral health promotion programmes 8, 90.2% retained as ‘agreement’
24 Multidisciplinary approaches across a range of settings should be taken in the delivery of oral health promotion programmes 8, 87.8% retained as ‘agreement’
25 The use of consistent oral health messages should be promoted to support multidisciplinary approaches within oral health promotion programmes 8, 90.2% retained as ‘agreement’
26 Oral health promotion programmes to reduce the risk of early childhood caries should be available for parents during pregnancy and continued postnatally 8, 97.6% retained as ‘agreement’
Dietary advice    
27 The use of xylitol by parents or carers to reduce caries in their children should be considered 6, 39.0% 6, 36.1% discarded
28 Oral health education on diet to parents/carers and children should start early in life, encouraging balanced healthy eating and a reduction in both frequency and total amount of sugars ingested 8, 100% retained as ‘agreement’
Use of fluoride    
29 Community or home-based oral health promotion interventions should use fluoride-containing agents such as fluoride toothpaste 9, 95.1% retained as ‘high agreement’
30 Community-based tooth-brushing programmes should include fluoride toothpaste with a concentration of 1000 ppm F 8, 80.5% retained as ‘agreement’
31 Community-based tooth-brushing programmes should be undertaken in community-based settings such as nurseries 8, 87.8% retained as ‘agreement’
32 Community-based tooth-brushing programmes should be undertaken with parents to create a supportive environment for oral health behaviour 8, 97.6% retained as ‘agreement’
Tooth-brushing    
33 Parents/carers should brush their child’s teeth as soon as the first tooth appears 9, 95.1% retained as ‘high agreement’
34 All children should be encouraged to brush their teeth under adult supervision 8, 95.1% retained as ‘agreement’
35 All children should be encouraged to brush their teeth under adult supervision with fluoride toothpaste containing at least 1000 ppm F 8, 70.7% 8, 75.0% discarded
36 All children should be encouraged to brush their teeth under adult supervision twice a day 8, 85.4% retained as ‘agreement’
37 All children should be encouraged to brush their teeth under adult supervision at bedtime and one other time during the day 8, 80.5% retained as ‘agreement’
38 All children should be encouraged to brush their teeth under adult supervision using a smear (age < 2) or small pea size (age 2–7) amount of toothpaste 8, 82.9% retained as ‘agreement’
39 Children should be encouraged to spit out toothpaste and not rinse after brushing 8, 70.7% 8, 69.4% discarded
40 Pre-school children should be supervised by an adult when brushing their teeth 8, 100% retained as ‘agreement’
41 Preventive programmes comprising combinations of interventions that include fluoride or fissure sealants should be considered for children based on their caries risk status 8, 100% retained as ‘agreement’
Preventive strategies for pre-school children at high risk (N = 39) Caries risk assessment    
42 A formal caries risk assessment using a structured caries risk assessment tool should be done for children attending the dental clinic for dental assessment or emergency care, and should be re-assessed at certain interval 8, 82.9% retained as ‘agreement’
43 Recall of children for re-assessment of caries risk should be based on the clinician’s assessment of the child’s caries risk status using the caries risk assessment tool, and should not exceed 12 months 8, 82.9% retained as ‘agreement’
Diet    
44 Oral health education on diet to parents/carers and children should start early in life, encouraging balanced healthy eating and a reduction in both frequency and total amount of sugars ingested 8, 97.6% retained as ‘agreement’
45 Parents/carers should be encouraged to limit their child’s consumption of sugar-containing foods and drinks, and when possible, to confine their consumption to mealtimes 9, 100% retained as ‘high agreement’
46 Children should be encouraged to limit their consumption of sugar-containing foods and drinks, and when possible, to confine their consumption to mealtimes 8, 100% retained as ‘agreement’
47 Parents and carers of children should be advised that drinks containing free sugars, including natural fruit juices, should be avoided between meals, and should never be put into a feeding bottle. Water may be given instead 8, 95.1% retained as ‘agreement’
48 Parents and carers should be advised not to let their child sleep or nap with a baby bottle or feeder cup 9, 100% retained as ‘high agreement’
49 Members of the dental team should support and promote breastfeeding according to current WHO recommendations (infants should be breast fed for first 6 months, and after should receive complementary foods with continued breastfeeding up to 2 years or beyond) 8, 78.0% 8, 72.2% discarded
50 Parents and carers should be advised that soya infant formulae are potentially cariogenic and should be used only when medically indicated 7, 70.7% 8, 72.2% discarded
51 Sugar-free formulations of medicines should be used if available and if not parents and carers should be advised to give doses with meals and never after tooth-brushing at night 8, 82.9% retained as ‘agreement’
52 Parents and carers should be advised that cheese is a good high energy food for toddlers as it is non-cariogenic and may be actively protective against caries 8, 85.4% retained as ‘agreement’
53 Parents and carers should be assured that sugar-free snacks are unlikely to be cariogenic 7, 65.9% 7, 63.9% discarded
54 Parents and carers should be advised that confectionery and beverages containing sugar substitutes are preferable, but should be consumed in moderation 7, 68.3% 8, 61.1% discarded
Topical fluoride    
55 The use of fluoride mouthrinse is not recommended for pre-school children due to the risk of fluoride ingestion 8, 95.1% retained as ‘agreement’
56 Topical fluoride varnish application (22,600 ppm F) should be given to pre-school children who are assessed as being at increased caries risk, at intervals of every 3 or 6 months 8, 92.7% retained as ‘agreement’
57 Fluoride varnish should be used in preference to fluoride gel for caries prevention in children who are assessed as being at high caries risk 8, 80.5% retained as ‘agreement’
58 Fluoride gel should not be used in children under the age of 7 7, 53.7% 6, 47.2% discarded
Toothbrush & Toothpaste    
59 Children should have their teeth brushed with fluoride toothpaste 8, 95.1% retained as ‘agreement’
60 Parents/carers should be brush their child’s teeth as soon as the first tooth appears 8, 92.7% retained as ‘agreement’
61 Toothpaste containing 1000 ppm F ±10% should be used by pre-school children 7, 68.3% 7, 58.3% discarded
62 Children should have their teeth brushed, or be supervised/assisted with tooth-brushing by an adult, at least twice a day, with a smear or pea-sized amount of fluoride toothpaste 8, 92.7% retained as ‘agreement’
63 Children’s teeth should be brushed last thing at night, before bedtime and on at least one other occasion 8, 82.9% retained as ‘agreement’
64 Children should be encouraged to spit out excess toothpaste and not rinse with water post-brushing 7, 70.7% 7.5, 63.9% discarded
65 Eating directly after brushing should be avoided to prevent fluoride from being washed out of the mouth prematurely 7, 51.2% 7, 55.6% discarded
66 Brushing children’s teeth with powered toothbrush with a rotation oscillation can be more effective 6, 34.1% 6.5, 50.0% discarded
67 Parents and carers should use a toothbrush with a small head for children 8, 92.7% retained as ‘agreement’
68 For pre-school children age < 2, parents/carers of children should be encouraged to brush their child’s teeth with fluoride toothpaste containing at least 1000 ppm F 5, 34.1% 4, 25.0% discarded
69 For pre-school children age < 2, parents/carers of children should be encouraged to brush their child’s teeth twice a day 8, 90.2% retained as ‘agreement’
70 For pre-school children age < 2, parents/carers of children should be encouraged to brush their child’s teeth at bedtime and one other time during the day 8, 82.9% retained as ‘agreement’
71 For pre-school children age < 2, parents/carers of children should be encouraged to brush their child’s teeth using a smear of toothpaste 8, 82.9% retained as ‘agreement’
72 For pre-school children age > 2, all children should be encouraged to brush their teeth under adult supervision 8, 100% retained as ‘agreement’
73 For pre-school children age > 2, all children should be encouraged to brush their teeth under adult supervision with fluoride toothpaste containing at least 1000 ppm F 8, 63.4% 8, 72.2% discarded
74 For pre-school children age > 2, all children should be encouraged to brush their teeth under adult supervision twice a day 8, 90.2% retained as ‘agreement’
75 For pre-school children age > 2, all children should be encouraged to brush their teeth under adult supervision at bedtime and one other time during the day 8, 82.9% retained as ‘agreement’
76 For pre-school children age > 2, all children should be encouraged to brush their teeth under adult supervision using a small pea size amount of toothpaste 8, 82.9% retained as ‘agreement’
Fissure sealants    
77 Children who are assessed as being at high caries risk should have resin-based fissure sealant applied and maintained in vulnerable pits and fissures of permanent teeth 8, 97.6% retained as ‘agreement’
78 Routine application of sealants on primary molar teeth is not recommended, but may be considered for selected high caries risk children 8, 85.4% retained as ‘agreement’
Anti-microbial agent    
79 The use of chlorhexidine for caries prevention is not recommended 8, 68.3% 8, 75% discarded
Re-mineralising product    
80 The use of re-mineralising products (e.g. CPP-ACP) can help caries prevention 8, 78% 8, 88.9% retained as ‘agreement’
Management strategies (N = 11) 81 Primary teeth with caries progressing into dentine should be actively managed with a preventive, or a preventive and restorative, approach as appropriate with the child’s ability to cooperate 8, 90.2% retained as ‘agreement’
82 Restorative treatment should always be provided in conjunction with a course of preventive treatment 8, 90.2% retained as ‘agreement’
83 If complete caries removal from a vital primary molar is not possible an indirect pulp capping technique should be considered 8, 87.8% retained as ‘agreement’
84 A calcium hydroxide containing lining material, followed by an adhesive restoration or a pre-formed metal crown, should be used 7, 65.9% 6, 47.2% discarded
85 When preparing a Class II cavity, care must be taken to avoid iatrogenic damage to adjacent proximal tooth surfaces 9, 100% retained as ‘high agreement’
86 Use of the Atraumatic Restorative Treatment approach for cavity preparation in carious primary teeth should be considered as an alternative, where appropriate, to conventional cavity preparation techniques 8, 90.2% retained as ‘agreement’
87 Minimal amount of formocresol for doing pulpotomy in primary teeth should be used 8, 80.5% retained as ‘agreement’
88 Amalgam, composite, resin-modified glass-ionomers, compomer or preformed metal crowns should be used as restorative materials for cavities in primary molars; conventional glass-ionomer should be avoided, where possible, for Class II cavity restoration 8, 95.1%  
88 Revised in second round to: Composite, resin-modified glass-ionomers, compomer or preformed metal crowns should be used as restorative materials for cavities in primary molars; conventional glass-ionomer should be avoided, where possible, for Class II cavity restoration (revised as some external reviewers commented that amalgam should better not to be used in children) 8, 86.1% retained as ‘agreement’
89 Conventional glass-ionomer should be avoided, where possible, for Class II cavity restoration 7, 56.1% 8, 63.9% discarded
90 Tooth bonding adhesives allows more conservative preparation and should be used according to manufacturer’s instruction 8, 95.1% retained as ‘agreement’
91 Clinical management protocols, based on a child’s age, caries risk, and level of patient/parent cooperation, provide health providers with criteria and protocols for determining the types and frequency of diagnostic, preventive, and restorative care for patient specific management of dental caries 8, 92.7% retained as ‘agreement’
  1. aNumbers are median score; ratings percentages by external reviewers with an overall median score within the top tertile (7–9)