Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Diagnosis
Early Diagnosis of Dental Caries
B - 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.
Diagnostic Techniques
Bitewing Radiographs
D - 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.
D - The timing of subsequent radiographic examinations should be based on the patient's caries risk status.
Other Diagnostic Tools and Training
C - Practitioners should receive training in clinical and radiographic caries diagnosis.
Predicting Caries Risk
Carries Risk Assessment Tool
D - Specialist community public health nurses and child healthcare professionals could consider carrying out a caries risk assessment of children in their first year as part of the child's overall health assessment.
C - 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)
B - Children whose families live in a deprived area should be considered as at increased risk of early childhood caries when developing preventive programmes.
Diet and Nutrition
Maternal Diet and Pregnancy
B - Pregnant women should be advised that there is no benefit to the child of taking fluoride supplements during pregnancy.
Milk Feeding and Caries
Duration and Timing of Feeding
C - Members of the dental team should support and promote breastfeeding according to current recommendations.
C - Parents and carers should be advised that drinks containing free sugars, including natural fruit juices, should never be put in a feeding bottle.
Free Sugars and Dental Caries
Free Sugars in Food
B - Parents and carers should be advised that foods and confectionery containing free sugars should be minimised, and if possible, restricted to meal times.
Free Sugars in Fluids
C - Parents and carers should be advised that drinks containing free sugars, including natural fruit juices, should be avoided between meals. Water or milk may be given instead.
Other Foodstuffs and Caries
C - 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.
Sugar Substitutes
B - Parents and carers should be advised that confectionery and beverages containing sugar substitutes are preferable to those containing sugars.
Toothbrushing with Fluoride Toothpaste
Use of Fluoride Toothpaste
A - Children should have their teeth brushed with fluoride toothpaste.
Fluoride Concentration and Amount of Toothpaste
A - Toothpaste containing 1,000 ppmF +/-10% should be used by pre-school children.
C - Pre-school children should use no more than a smear or small pea-sized amount of toothpaste.
Frequency of Brushing
Supervised Toothbrushing
C - Children should have their teeth brushed, or be assisted with toothbrushing by an adult, at least twice a day, with a smear or pea-sized amount of fluoride toothpaste.
Age at Commencement of Brushing
C -Toothbrushing should commence as soon as the primary teeth erupt
Toothbrushing Practice
Post-brushing Rinsing
A - Children should be encouraged to spit out excess toothpaste and not rinse with water post-brushing.
Use of Powered versus Manual Toothbrushes
A - Children's teeth can be brushed with either manual or powered toothbrushes as an effective means of administering fluoride.
Community Based Prevention
Dental Health Education
B - Dental or dietary health education in isolation should not be undertaken as a community based prevention approach.
Health Promotion
C - The oral health of young children should be promoted through multiple interventions and multisessional health promotion programmes for parents.
D - Oral health promotion programmes to reduce the risk of early childhood caries should be available for parents during pregnancy and continued postnatally.
D- Oral health promotion programmes for young children should be initiated before the age of three years.
D - Oral health promotion programmes should address environmental, public and social policy changes in order to support behaviour change.
Communicating Oral Health Messages
C - Professionals should ensure oral health messages are relevant and applicable to communities and lifestyles.
C - 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.
D - 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.
Health Promotion Programmes Including Fluoride
A - Community or home based oral health promotion interventions should use fluoride containing agents such as fluoride toothpaste.
Toothbrushing Programmes Set in Community or School Venues
Community based toothbrushing programmes should:
A - include fluoride toothpaste with a concentration of 1,000 ppmF (parts per million fluoride)
B - be undertaken in community based settings such as nurseries
B - be undertaken with parents to create a supportive environment for oral health behaviour.
Fluoride Tablets, Salt and Milk
D - Fluoride supplements are not recommended as a public health measure.
D - Fluoride supplements should only be prescribed by dental practitioners on an individual patient basis.
Targeted Prevention
Targeting Specific Groups
B - The impact on inequalities in oral health should be considered when planning population based prevention strategies.
B - Caries prevention measures should target 'at-risk' populations and individuals to reduce oral health inequalities.
Practice Based Prevention
Health Education by the Dental Team
B - The dental health team should deliver caries prevention strategies in conjunction with physical prevention techniques such as the use of fluoride.
B - Parents and their pre-school children should receive oral health education from their dental team. This should include oral hygiene instruction, the appropriate use of fluoride toothpaste and the provision of fluoride agents such as toothpaste.
Topical Fluoride Varnish
B - Topical fluoride varnish should be applied to the dentition at least twice yearly for preschool children assessed as being at increased risk of dental caries.
Practice Based Management
Management of the Active Carious Lesion in Primary Teeth
D - Primary teeth with caries progressing into dentine should be actively managed with a preventive, or a preventive and restorative approach as appropriate to a child's ability to cooperate.
Cavity Preparation Techniques
Extent of Caries Removal
B - If complete caries removal from a vital primary molar is not possible, an indirect pulp capping technique should be considered.
Iatrogenic Damage During Cavity Preparation
B - When preparing a Class II cavity, care must be taken to avoid iatrogenic damage to adjacent proximal tooth surfaces.
The Atraumatic Restorative Technique (ART)
B - Use of the ART approach for cavity preparation in carious primary teeth should be considered as an alternative, where appropriate, to conventional cavity preparation techniques.
Materials for Cavity Restoration
A - Amalgam, composite, resin-modified glass-ionomers, compomer or pre-formed metal crowns should be used as restorative materials for Class II cavities in primary molars.
A - Conventional glass-ionomer should be avoided, where possible, for Class II cavity restoration.
Non-Conventional Caries Management Techniques
B - Copper phosphate cement (black copper cement) should not be used as a restorative material.
Definitions:
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g. case reports, case series)
4: Expert opinion
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
